Every finding on record at Austin Wellness & Rehabilitation

Based on observation, interview, and record review, the facility failed to assure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #1) of 4 residents reviewed for peri-care. CNA A failed to position Resident #1 safely on the bed prior to performing peri care on 08/06/2026 at 9:24 p.m. CNA A failed to use proper measures to assure Resident #1 had privacy during peri- care on 08/06/2026 at 9:24 a.m. This failure could place residents at risk of not receiving care and services to meet their needs. Record review of Resident #1's face sheet dated 08/24/2026 reflected a [AGE] year-old female resident admitted to the facility on [DATE] with a diagnoses which included Cerebral Infarction (a stroke ), Paralytic Syndrome ( a group of conditions that cause a loss of muscle function and voluntary movement due to a disruption in the nervous system) affecting right, dominant side, Mild Cognitive impairment ( trouble with a person's ability to think, learn, remember, use judgment, and make decisions.) and Major Depressive Disorder (a common mental health condition that causes a lasting low mood, deep sadness, and a loss of interest in normal activities for at least two weeks). Record review of Resident #1's annual MDS assessment dated [DATE] reflected she had a BIMS score of 00 and indicated severe cognitive impairment, placing her at the lowest end of the 0-15 scale and signaling major difficulties with memory, orientation, and recall. She required dependence on staff for toileting hygiene and toileting transfer and showering/bathing, and personal hygiene. She required assistance with set up or clean-up while eating and substantial assistance with rolling from left to right, sitting to lying, lying to sitting on the side of the bed. She was independent when using a manual wheelchair. Record review of Resident #1's Comprehensive Care Plan initiated on 03/16/2025 and last revised on 06/29/2026 reflected Resident #1 had been identified as having an ADL Self Care Performance Deficit. The goal was for the residents to maintain a current level of function in bed mobility, transfers, eating, dressing, personal hygiene and ADL score through the review date. Interventions indicated, Resident #1 required (X1-2) staff participation with transfers and bed mobility. Resident #1 is totally dependent on staff for repositioning and turning in bed. During an interview and observation on 08/24/26 at 9:43 a.m., Resident # 2 revealed a photo she had taken of Resident #1 on 08/06/2026 at 9:24 p.m. The photo documented R#1 lying on her bed with her torso sideways and her feet hanging off the right side of the bed. Photo documented that R#1 was partially undressed exposing her brief and bare legs. R#2 stated she overheard R#1 crying so she entered the residents room to see what was happening, R#2 stated CNA A told her to exit the room. During an interview and observation on 08/24/26 at 10:42 a.m., R#1 was independently mobilizing in her manual wheelchair on the facility's first floor. R#1 revealed that she did not recall an incident where she was crying and CNA A attended to her. R#1 did not recall R#2 taking a photo of her. During a phone interview on 08/24/26 at 11:06 a.m., Resident #1's Surrogate / Proxy revealed he had not been to see R#1 in the last few months however, he speaks with her on the phone daily. He stated he provides Resident #1 with the needed toiletries. He said she is paralyzed on the right side, and it is his understanding that Resident #1's peri care required 2 staff members to change her. During an interview on 08/24/26 at 2:00 p.m., it was revealed that CNA B arrived at the facility at around 9:30 p.m. on 08/06/2026 for his scheduled night shift of 10 p.m. to 6 a.m. He stated, I do not recall anything happening regarding R#1 on that evening. CNA B stated, I am the one who changes R#1, and she cooperates with me. he stated, if R#1 is in pain or if she needs to be changed, she will say 222. He stated if a resident was hanging off the bed, they would feel bad and I would not attempt to change the resident without repositioning them first. CNA B stated we should protect the residents' dignity when giving them care or changing them by closing the curtain and by closing the door. During an interview on 08/24/26 at 2:47 p.m., it was revealed that CNA A had been trained on Abuse, Neglect and Exploitation and Resident Rights. CNA A stated residents have a right to dignity and for staff to respond to the calls for care immediately. CNA A stated she recalls having an in-service on ANE and RR in May of this year. She stated if a resident has behavior issues we must wait till they calm down before we perform peri- care. CNA A stated on 08/06/2026 she recalled R#1 was yelling because she wanted to be changed immediately. CNA A stated when I responded to R#1's call light I saw R#1 sitting in her wheelchair next to the bed. CNA A stated she told R#1 that she needed to finish up with another resident and she would be back to assist R#1 shortly. CNA stated, R#2 was at R#1's door and she was yelling at me, and she shouted at me you bitch. CNA A stated, when I returned to R#1's room I transferred her to the bed by myself. She said, R#1 is a big woman, but I can do the transfer by myself. She said, RN C entered the room, and she asked R#2 to leave while we perform peri care for R#1. CNA A did not know how R#2 got a picture of R# 1 lying in her bed in a state of partial undress. CNA A stated, I had prepped R#1 for peri- care by taking her pants off before I changed her brief. CNA A stated R#2 was outside the room in the hallway not in the room when I transferred R#1 to the bed. CNA A stated, we should protect the residents' dignity when giving care or changing them by closing the door and by pulling the curtain to give them privacy. During a phone interview on 8/24/26 at 3:35 p.m., it was revealed that RN C was on staff and she was present in the room when R#2 was instructed to exit R#1's room on 08/06/2026 at 9:24 p.m. RN C stated she worked the night shift from 6 p.m. to 6 a.m. and she was the Charge Nurse for the 2100 hallway that night. She stated it is her expectation that the nursing staff will safely position the residents and they will provide privacy during peri care. She stated that the door should be shut and curtain pulled to protect the residents from view. She said, guests should not be present while staff is performing peri care to a resident. RN C stated it is not appropriate for anyone to take a photo of a resident in a partially dressed state. RN C stated she does not recall seeing the resident sideways on the bed. RN C stated she told R#2, that she may speak with R#1 for a moment, then she would have to leave the room so R#1 could have privacy during her care. R#2 said she wanted me to stay in the room when R#1 was being changed. RN C said, I stayed and CNA A changed R#1, then we allowed R#2 to go back in the room. RN C said, after R#1 was changed, she stayed in the room to supervise R#2 because R# 2 has been known to take things from other residents. During an interview on 08/24/26 at 4:42 p.m., the DON revealed it was her expectation that all nursing staff would treat all residents with dignity. She stated all nursing staff are trained in peri care procedures, and they are expected to provide the residents with privacy during peri care. She stated privacy can be obtained by closing the door and by pulling the curtain closed before starting peri care. She stated if the staff member must stop or pause the peri care before it is completed and if a resistant is partially undressed, then the staff member should cover them with a blanket or towel. She stated, a resident could feel emotionally down if they are not treated with dignity. The DON stated residents should not be allowed to take a photo of another resident if they are not fully dressed. She stated residents should be properly positioned on the bed to ensure they are safe and that the staff is able to reach them to perform pre-care. The DON stated if a staff member tried to perform pericare when a resident was only partially on the bed, the staff member should be re- trained in ADL and peri- care. During an interview on 08/24/26 at 5:30 p.m., the ADM revealed it is his expectation that residents be provided with privacy and that they are treated with dignity. The ADM stated, we drill that into our staff in our training on resident rights. He stated residents have a right to privacy. Nursing staff should shut the door and pull curtains closed and to be aware of their surroundings before performing peri care on a resident. The ADM stated it was inappropriate for Resident #2 to take a photo of R#1 or of any other resident and he will train the staff on this subject immediately. Record review of facility In- service training titled Abuse, Neglect, Exploitation and Resident Rights revealed an in-service on these topics was conducted on 05/27/2026. CNA A's signature was confirmed to be on the in-service sign in sheet for that date. Record review of the facility policy, titled Staffing, sufficient and competent nursing, revised 08/2022, revealed . 2. All nursing staff must meet the specific competency requirements of their respective licensure and certificate requirement defined by state law. Record review of the facility policy title Resident Rights revised on 08/2020 indicated: Purpose: To promote and protect the rights of all residents at the facility.Policy All residents have a right to a dignified existence, Sefl - determination, and communication with an access to persons and services inside and outside the facility including those specified in this policy. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of the residents and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source.The Facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. Record review of the facility policy titled: Perineal Care, Nursing Care dated 06/2020 indicated:Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.ProcedureVII. Turn resident to side.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse.The facility failed to closely supervise and monitor after Resident #1 was involved in a physical altercation with Resident #2 on [DATE]. Resident #1 was hospitalized and received staples to his scalp and ear and a laceration to his face.An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:30 PM. A plan of removal was requested. While the IJ was removed on [DATE], the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systemsThis failure could place residents at risk for physical, mental, and/or psychosocial harm.Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed a sixty-nine-year-old male who was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels, marked by emotional highs (mania) and lows (depression), schizophrenia (a serious mental illness marked by delusions, hallucinations, and disorganized thinking), and depression (a common, serious mood disorder that causes persistent sadness, low energy, and a loss of interest in activities). Record review of Resident #1's care plan reflected a focus dated [DATE] that Resident #1 had potential to demonstrate physical behaviors specify related to anger and poor impulse control. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] indicated Resident Assessment and Care Screening contained only Section A - Identification Information, no additional information completed and no information indicating Resident #1 BIMS score. Record review of Resident #1's BIMS assessment dated [DATE] reflected a BIMS score of 0 indicating severe cognitive issues. Record review of Resident #2's face sheet, dated [DATE], revealed a seventy-year-old male who was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (the brain completely loses its supply of oxygen, causing brain cells to start dying within four to five minutes), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms (such as hallucinations or delusions) and a major mood disorder (such as depression or mania), and major depressive disorder (a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy lasting at least two weeks). Record review of Resident #2's care plan reflected a focus dated [DATE] of Resident #2 had potential to demonstrate physical behaviors related to anger and poor impulse control, anxiety, major depressive disorder. Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated [DATE] Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 15 indicating no cognitive issues. Record review of facility self-report to HHSC dated [DATE] reflected Resident #1 was trying to go into Resident #2's room. Facility staff assumed Resident #1 thought he was entering his own room. Resident #2 would not let Resident #1 in the room. Resident #1 became upset and the residents began pushing at each other. Resident #1 grabbed a pill crusher off the top of a medication cart. A PT intervened and was able to diffuse the situation and redirect Resident #1 to put down the pill crusher and leave with her to the nurses' station. Around 5 minutes later Resident #1 returned down the hall and Resident #2 saw Resident #1 coming so Resident #2 picked up the pill crusher to defend himself and to prevent Resident #1 from grabbing it and using it as a weapon. Resident #1 attempted to go in Resident #2's room again thinking it was his room and Resident #2 hit Resident #1 with the pill crusher in his head. Resident #1 fell down. Facility staff intervened and sent Resident #1 to the emergency room and called the police. Resident #2 told the police that he saw Resident #1 coming back down the hall and he was worried Resident #1 would pick up the pill crusher again and hit him with it, so Resident #2 grabbed the pill crusher first and defended himself with it so that Resident #1 could not hit him with it. Review of facility non-audio video #1 dated [DATE] of hallway outside of Resident #1's room reflected Resident #2 in his wheelchair at the doorway to his room. Resident #1 attempted to enter Resident #2's room. Resident #2 did not move out of the way to make for Resident #1 to enter his room. Resident #1 used his right hand to slap in a downward motion at Resident #2 maybe hitting Resident #2's right hand and Resident #2 used his right arm to punch Resident #1 maybe hitting Resident #1 in the chest. Resident #1 backed away from Resident #1 and both residents made slapping motions towards each other without contact. Resident #2 made a fist with his right hand with arm laying on the arm of Resident #2's wheelchair but did not punch Resident #1. Resident #1 walked around Resident #2 to the right of Resident #2 and picked up a metal pill crusher that weighs approximately 4 pounds. Resident #2 moved out of his room, turned towards Resident #1 who was holding the pill crusher. Resident #1 walked towards Resident #2's room with the pill crusher in his hand. Resident #2 backed up to his previous position at the doorway to his room and blocked Resident #1's entrance to his room. A PT came into view while Resident #1 was holding the pill crusher standing in front of Resident #2 and Resident #2 was in the doorway to his room. The PT pointed down the hallway directing Resident #1 to move away from Resident #2 down the hallway. Resident #1 moved away from Resident #2 and walked down the hallway still holding the pill crusher. Resident #1 walked about 9 steps down the hallway with the PT with the pill crusher in his right hand by his side and stopped. Resident #1 and the PT appeared to be speaking to each other for a few seconds but no audio. Resident #2 turned and walked towards Resident #2 and the medication cart and placed the pill crusher back on the medication cart. After placing the pill crusher back on the medication cart, Resident #1 walked down the hallway away from Resident #2 towards the PT who was standing several feet down the hallway. Review of facility non-audio video #2 dated [DATE] of the hallway outside of Resident #1's room reflected Resident #2 in his wheelchair at the doorway to his room. Resident #1 walked down the hallway towards Resident #2. Resident #2 moved out of the door of his room to the medication cart to his right and took the pill crusher from the top of the medication cart. Resident #1 stopped in front of Resident #2 and turned towards Resident #2. Resident #1 attempted to enter Resident #2's room. Resident #2 used the metal pill crusher weighing approximately 4 pounds and hit Resident #1 on the left side of Resident #1's head three times. Resident #1 fell backwards to the floor and the back of Resident #1's head hit the floor. Record review of Resident #1's hospital discharge records dated [DATE] reflected Resident #1 was evaluated in the Emergency Department for a laceration to his scalp and cheek. Your laceration was repaired in the Emergency Department with sutures and staples. Record review of Resident #1's order dated [DATE] reflected Wander guard (a small, wearable safety device, when the wearer gets close to a door or exit, the device sends a warning to staff) had been placed on Resident #1's left ankle. Record review of Resident #1 Psychiatric Nurse Practitioner Notes dated [DATE] reflected Resident #1 was seen to establish care. Resident #1 was admitted to the facility on [DATE] from a hospital after an extended hospital stay after being struck by a car on [DATE]. Resident #1 suffered TBI (damage to the brain caused by an external force, most commonly from falls, vehicle crashes, or sports impacts). On [DATE] Resident #1 was looking for his room when he tried to go into a peer's room. Resident #1 was carrying a pill crusher and the peer found this to be threatening. Staff intervened and Resident #1 was removed from the situation. Later, Resident #1 approached same room, and the peer took the pill crusher off the medication cart and hit Resident #1 with it across his face. CT scan was negative. Resident #1's cognition tends to wax and wane, and mood varies between agitation and cooperation with care. Depakote (can be used to manage acute manic or mixed episodes in bipolar disorder) was started and Seroquel (an atypical antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) increased on [DATE]. PRN Lorazepam (short-term relief of anxiety, trouble sleeping caused by stress, and active seizures) used 11 times since admission. Resident is a very marginal and imprecise historian. Resident #1 was English/Spanish speaking. He was seen in his room, resting in bed. He was alert but guarded and distracted by looking for his TV remote. When new remote was provided, he continued with an angry facial expression. He had poor understanding of his circumstances and the events leading to his admission. When asked about the bandage to his face, he could not explain when or how he was injured. He did not recall hospitalization last weekend. He became very angry with questions and cursed at this nurse in Spanish. Exam reflected bandage and bruising noted to left side of face. Psychiatric: speech is mumbled, affect was angry, insight was poor, judgment was poor, unable to determine resident's mood, cognitive screening has been elusive due to patient's refusal to participate, oriented to self, thought content is impoverished and confused, executive functioning (ability to analyze, interpret, plan, organize and execute tasks) was limited, resident had a very low tolerance for frustration and is easily annoyed. Discussion: medication regimen reviewed and was appropriate. Depakote started yesterday for impulsivity and mood. Seroquel was increased and changed to every night at bedtime. Suggestion, but not limited to: 1:1 (a dedicated staff member is assigned to continuously monitor and assist a single resident at all times. This high-intensity intervention provides uninterrupted, direct observation and immediate physical or verbal intervention for resident safety) monitoring. During an interview on [DATE] at 1:27 PM, Resident #2 said Resident #1 kept coming in his room and he told Resident #1 that it this was not his room. Resident #2 said that Resident #1 was going to hit him with the pill crusher, but he hit Resident #1 with the pill crusher. Resident #2 said when Resident #1 came back down the hallway he picked up the pill crusher because he thought Resident #1 was coming back down the hallway to hit him. During an interview on [DATE] at 1:39 PM, the SW said that she understood that over the weekend Resident #1 attempted to enter Resident #2's room. The SW said Resident #1 grabbed the pill crusher from the medication cart. The SW said the PT intervened, deescalated the situation, and escorted Resident #1 away from Resident #2. The SW said Resident #1 went back later and Resident #2 saw Resident #1 approaching and Resident #2 grabbed the pill crusher and when Resident #1 tried to again enter Resident #2's room Resident #2 raised the pill crusher and hit Resident #1 three times. The SW said she was not sure if Resident #1 fell to the floor. The SW said that after Resident #1 was hit, staff intervened and Resident #1 was sent to the hospital. The SW said Resident #2 had not had any previous altercations with other residents. The SW said for the most part, Resident #2 did not leave his room. The SW said Resident #1 was interviewable with a Spanish speaking interpreter. The SW said she did not believe either resident was affected psycho socially and she said both residents were doing okay. The SW said part of the problem was that Resident #1 did not know where his room was. The SW said the PNP came to the facility and did an evaluation of the residents on Tuesday, [DATE]. The SW said that her report had not been uploaded into the residents' EMR yet. During an interview with the assistance of a Spanish speaking interpreter on [DATE]-026 at 1:58 PM, Resident #1 said someone hit him he did not know who hit him. Resident #1 said it happened a long time ago when he had to leave. During an interview on [DATE] at 2:49 PM, RN B said the PT came and told her about the altercation that she witnessed between Resident #1 and Resident #2. RN B said the PT was explaining to her about what happened and then she saw Resident #1 fall. RN B said it was just a few minutes between when the PT told her about the incident between Resident #1 and Resident #2 and when Resident #1 fell. RN B said she immediately assessed Resident #1 and then called EMS. RN B said it happened so fast. During an interview on [DATE] at 2:55 PM, the PT said she passed by Resident #1, and he was holding a pill crusher and sounded agitated and she got alarmed. The PT said she observed there was a potential threat and she redirected Resident #1 away from Resident #2. The PT said Resident #1 was holding on to the pill crusher and she was trying to get him to put it down. The PT said it was a scary situation, and she was not trained to handle things like that. The PT said she brought Resident #1 down the hallway, directed him to the nurses' station and told the RN that Resident #1 looked agitated and he was headed toward Resident #1. The RN said she was aware that Resident #1 had been anxious all day and they would take care of it. The PT said that the RN was in the middle of something else when she said she would take care of the situation. The PT said she had other resident responsibilities and left Resident #1 at the nurses' station. During an interview on [DATE] at 3:39 PM, the Administrator he said the PT redirected Resident #1 and there were a couple of minutes between when Resident #1 calmed down and when he wandered back to Resident #2. The Administrator said you cannot predict what a resident will do. The Administrator said he did not feel like Resident #1 came back to Resident #2 in a mischievous manner. The Administrator said Resident #1 probably did not recognize what happened. The Administrator never put Resident #1 on 1:1 because it seemed like the problem was resolved within minutes. The Administrator said Resident #1 had never said he did not want anyone in his room. The Administrator said there was about 5 minutes between the time the PT told the RN about the incident and when Resident #1 headed back down the hallway again. The Administrator said he felt like the residents were separated and things were defused. The Administrator said you cannot completely predict anyone. During an interview on [DATE] at 5:04 PM, h RN C said the facility tried to avoid any residents having an altercation but if there was an altercation, the residents were immediately separated. RN C said after residents were separated, the incident was reported to the Administrator. RN C said she heard about this situation with Resident #1 and Resident #2. RN C said Resident #2 was usually in his room. RN C said she heard Resident #1 was trying to get into Resident #2's room. She said she received an in-service that any equipment that could cause harm to a resident should be kept inside the medication cart, RN C said she does not know if Resident #1 had any other interventions except a psychiatric intervention. During an interview by phone on [DATE] at 5:13 PM, the PNP said she visited with Resident #1 on [DATE] and he was pretty riled up when she saw him. She said when she saw him, she asked him simple questions and he got agitated. The PNP said she sensed that he got easily agitated and had a problem with impulsivity. She said his past behavior of his interaction with Resident #2 could be indicative of his future behavior. The PNP said Resident #1 had just gotten to the facility and they did not know him very well. The PNP said she had a concern about him wandering and going into other residents' rooms. The PNP said many of the residents at the facility might became upset if other residents wandered into their room and many of the residents are able bodied and have a lot of psychiatric issues. She said the facility should keep an eye on Resident #1, 24 hours a day until they are sure he has the correct medication levels. She said you really need to keep an eye on him because he can walk and he can move fast. During an interview on [DATE] at 5:34 PM with CNA A she said when residents are in an altercation, they should be separated and the charge nurse should be informed. CNA A said to always make sure the residents are safe first. CNA A said she was not aware of the altercation between Resident #1 and Resident #2. She said she had a recent in-service about making sure the pill crusher was always hidden and not on top of the medication cart. She said she was not aware of any interventions regarding Resident #1 and Resident #2. During an interview on [DATE] at 2:23 PM, CNA D said she did not recall anyone tell her to make sure Resident #1 did not go down Resident #2's hallway. CNA D said she worked a couple of days after the incident but unsure if she worked the day of the incident. During an interview on [DATE] at 2:28 PM, RN B said the PT was walking with Resident #1 to the nurses' station. RN B said that she did not recall that the PT told her that Resident #1 almost got into it with Resident #2 or that Resident #1 tried to strike Resident #2 with a pill crusher. RN B said they saw Resident 1 slip back down the hallway after the PT left. RN B said the PT did not come to her with any urgency and initially she did not know it was a serious problem. RN B said they had been dealing with Resident #1 all day and had given him medication for his agitation as often as his PRN prescription allowed. RN B said she noticed Resident #1's agitation and wandering as soon as he arrived and she put the Wander guard on Resident #1 within an hour of him arriving at the facility. During an interview on [DATE] at 12:39 PM, the Administrator said he was not at the facility when the incident between Resident #1 and Resident #2 occurred. The Administrator said he learned about it from RN B. RN B told him there was an incident with a pill crusher and he looked on the facility video for what happened. The Administrator was told that Resident #1 was sent to the hospital and when the Administrator arrived at the facility he spoke with the police who told him, after the police watched video #1 and video #2, that Resident #2 acted in self-defense. The Administrator spoke with Resident #2 and Resident #2 told him he was okay and he felt safe at the facility. The Administrator said he did not put Resident #1 on 1:1 because he knew his residents and he did not feel like Resident #1 was a threat. The Administrator said that Resident #1 was so tiny, and he felt that staff could redirect him and alleviate and situations involving Resident #1. The Administrator said that Resident #1 did but the pill crusher down when the PT told him to do so and the staff had just given Resident #1 medication for his anxiety. The Administrator said you can always have should have could have situations. The Administrator did not see Resident #1 as a threat because he wandered. The Administrator said the initial situation when Resident #1 walked back down the hallway happened so fast and there have been no incidents since the incident on [DATE] and therefore he believes he was correct that Resident #1 would not have been aggressive again. Record review of facility policy Violence Between Resident dated [DATE] reflected Purpose - To protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by facility. Policy - the facility acts promptly and conscientiously to prevent and address altercations between residents. Facility staff monitors residents for aggressive or inappropriate behavior toward other residents. Response to an altercation - separate the residents and institute measures to calm the situation, determine what happened including what might have led to the aggressive conduct on the part of one or more of the residents involved in the altercation, notify each residence representative and the attending physician of the incident, review the events with the charge nurse and director of nursing services including interventions staff can take to prevent additional incidents, consult with the attending physician to identify treatable conditions Such as acute psychosis that may have caused or contributed to the problem, make any necessary changes to the care plan for all or any involved residents as necessary, Document in the residence interventions and their effectiveness in the resident's medical record, consult with psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management is necessary or as may be recommended by the attending physician or interdisciplinary team, complete the incident report and document the incident, , findings, and any corrective measures taken in the resident's medical or clinical record, if after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident, report incidents, findings, and corrective measures to appropriate agencies. The ADM was notified on [DATE] at 8:30 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 10:25 AM: The POR included: Immediate Jeopardy On [DATE] an abbreviated survey was initiated at the facility. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility failed to keep the resident free from abuse, by not implementing monitoring/interventions for aggressive behaviors, this deficient practice has the potential to effect all residents. Action: Resident #2 was immediately placed on continuous 1:1 supervision on [DATE] at 8:33 p.m. and remains on continuous 1:1 supervision. The Psychiatric Nurse Practitioner evaluated Resident #2 following the resident-to-resident altercation and confirmed that medication adjustments initiated after the [DATE] incident remain appropriate. The Psychiatric NP recommended that Resident #2 continue on 1:1 supervision for approximately 10 days following the altercation and will re-evaluate the resident on or around [DATE], to determine whether 1:1 supervision can be safely discontinued based on the resident's response to treatment and absence of further aggressive behaviors. Prior to discontinuing 1:1 supervision, the interdisciplinary team, including the Psychiatric NP, Nursing, Social Services, and the attending physician, will review the resident's behaviors, response to medication, and effectiveness of interventions. If 1:1 supervision is discontinued, the resident will remain on enhanced behavioral monitoring, continue all psychiatric recommendations and individualized care plan interventions, and staff will immediately notify the nurse and psychiatric provider of any signs of escalating behaviors for prompt reassessment and implementation of additional interventions as clinically indicated. All direct care staff will receive education on resident-to-resident abuse prevention, identification of escalating behaviors, de-escalation techniques. All new staff will receive in-service upon hiring during onboarding process, Prn Staff will be called and in serviced by Admin, DON, ADON, or Designee. Start Date: [DATE] @ 833pmCompletion Date: [DATE]Responsible: DON, ADON, ADMIN, Designee staff member Action: Safety Survey will be conducted for all residents for this incident, and as needed as identified in future incidentsStart Date [DATE]Completion [DATE]Responsible: DON Admin, ADON, SW, Designee Monitoring: Action: Resident #2 was immediately placed on continuous 1:1 supervision on [DATE] at 8:33 p.m. and remains on continuous 1:1 supervision. The Psychiatric Nurse Practitioner evaluated Resident #2 following the resident-to-resident altercation and confirmed that medication adjustments initiated after the [DATE] incident remain appropriate. The Psychiatric NP recommended that Resident #2 continue on 1:1 supervision for approximately 10 days following the altercation and will re-evaluate the resident on or around [DATE], to determine whether 1:1 supervision can be safely discontinued based on the resident's response to treatment and absence of further aggressive behaviors. On [DATE] at 8:40 PM observed Resident #1 monitored 1:1 by a CNA E with no issues.On [DATE] at 11:15 AM observed Resident #1 monitored 1:1 by CNA E with no issues. On [DATE] at 4:25 PM observed Resident #1 monitored 1:1 by CNA F with no issues. On [DATE] at 11:02 AM observed Resident #1 monitored 1:1 by CNA G with no issues.On [DATE] at 2:42 PM observed Resident #1 1:1 monitored by CNA F with no issues.On [DATE] at 11:35 AM observed Resident #1 monitored 1:1 by CNG H with no issues. Record review of QAPI Committee Meeting Minutes dated [DATE] reflected handwritten signatures of the ADON, BOM, Rehabilitation Designee, Medical Director, and the PNP reflected an IDT meeting was held to discontinue 1:1 monitoring for Resident #1 and cognitive psychiatric accommodations and staff was to notify management of any behaviors During an interview on [DATE] at 12:13 p.m., the PNP said Resident #1 looked significantly better and was much more coherent than her visit with him on [DATE]. She said Resident #1 did not exhibit agitation or aggression and was speaking a lot more English. The PNP said she was fine with removing Resident #1 from 1:1. During an interview on [DATE] at 2:09 PM, the Administrator said all direct care staff received education, either in-person or by telephone, on resident-to-resident abuse prevention, identification of escalating behaviors, de-escalation techniques and the facility abuse and neglect policy. During an interview on [DATE] at 1:07 PM, the SW said she conducted safety surveys for all residents about this incident. The SW said she asked each resident if they felt safe. The SW said one resident said she did not want to stay at the facility and the SW was working on finding another safe placement for that resident. During interviews on [DATE] from 12:27 PM - [DATE] 1:58 PM, a Physical Therapy Assistant, the Director of Rehabilitation, 1 person from housekeeping, 3 RNs, 3 LVNs and 6 CNAs from different shifts all stated they were in-serviced before working their shift on the facility policy for handling resident to resident altercations stating that they would immediately separate residents who appeared as if were engaged or were going to engage in any type of resident to resident incident, all staffed described ways to deescalate resident to residents incidents, and all staff said they would report any incidents of abuse, neglect, or exploitation including resident to resident incidents immediately to the Administrator who was the Abuse and Neglect Coordinator. While the IJ was removed on [DATE] at 4:40 PM, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately.The failure could affect residents by placing them at risk for food-borne illnesses and food contamination.Findings included:Observations of the facility's kitchen refrigerator on 05/05/2026 at 9:23 a.m., revealed there was 1 sealed plastic container with cheese, it was not labeled or dated.Observation on 05/05/2026 at 9:36 a.m., revealed the ADS removing a cell phone from her pocket, she then placed it directly on the food preparation counter. Neither the cell phone nor the counter was sanitized before or after the cell phone was placed on the counter. Observation of the kitchen refrigerator on 05/07/2026 at 8:31 a.m., revealed there were 2 sealed plastic containers with cheese, they were not labeled or dated.Interview with the DS on 05/05/2026 at 9:18 a.m., revealed staff have been trained in food safety and prevention of cross contamination. The DS stated it is his responsibility to make sure food storage requirements are met. He stated, the facility guidelines require that food is to be labeled and dated to include the date it was received and the expiration date. He stated that it is his expectation that proper hand sanitation is done by all staff members while they are performing kitchen tasks. He stated if staff fails to follow hands sanitization procedures or food storage and labeling requirements it could cause cross contamination and residents are at risk for food borne illness. The DS stated, staff have been trained regarding use of cell phones in the kitchen. He said this could be a cause of cross contamination. During an interview on 05/05/2026 at 9:30 a.m., the ADS said she had been trained in food safety and she was in-serviced on hand sanitation. The ADS stated, I must wash my hands between tasks to prevent foodborne illness from spreading. During a phone interview on 05/06/2026 at 8:35 a.m., the RD revealed she had worked as a Dietary Consultant for 10 months. She stated, my scope of practice is the clinical side. She stated, I work with the care team, doctors and nurses, I provide education and diagnoses. She stated, I believe the facility does an excellent job of training staff on cross contamination. The RD stated staff cell phones should not be put on the food preparation surfaces as this could cause cross contamination. The RD was unaware that there was a cheese container that was undated in the refrigerator, she stated, undated food should not be used as it could be expired and it could cause someone to get sick. During an interview on 05/07/2026 at 8:35 a.m., the DA stated, when food is delivered to the facility, I label and date the food with the date it arrives and the day it expires. The DA was unaware that the cheese container in the refrigerator was not labeled and dated. She stated she was responsible for loading food on the trays per the resident's food plan. She stated that she had been trained to wash hands to the count of 20 seconds between tasks and she was to wear gloves when performing tasks in the kitchen. She stated residents could get sick if the staff does not use proper hand sanitation and / or if expired food is used.Record review of Dietary Safety Training Certificates revealed that 8 of 8 staff members had current food safety certifications. Review of facility Food Storage Guidelines last revised on 12/2020, revealed All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date) .Record review of Hand Hygiene Policy revised 6/2020, revealed, The facility considers hand hygiene the primary means to prevent the spread of infections.Procedure:Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Hand hygiene observation may be observed and recorded by the Infection Control Designee monthly and results reported to QA.Facility Staff follow the hand hygiene procedure to help prevent the spread of infections to other staff, residents, and visitors.Hand hygiene products and supplies (sinks, soap,. ) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy.Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too.Wash hands with soap and water:After contact with. Environmental surfaces.Was the cheese addressed specifically with the DSnoNoRemove name from document

Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 (ADON ) staff reviewed for staff qualifications. The facility failed to ensure ADON had a valid nursing license to practice and was not expired on [DATE].This failure could place residents at risk for not receiving nursing services by a licensed nurse.The findings included:Record review of the staff roster for the facility indicated ADON had been employed at the facility since [DATE].Record review of the TBON license verification dated [DATE] indicated ADON was originally issued an LVN/LPN license on [DATE] and current expiration date was [DATE]. Record review of the license renewal application receipt issued by TBON indicated that the application for renewal was submitted by ADON with the required late fee, on [DATE]During an interview on [DATE] at 3:45pm the ADON stated she was notified by the facility on [DATE] that her license had expired. She stated she never thought she was practicing with an expired license and applied for renewal as soon as she came to know about it. She stated the license was not renewed yet by the TBON though the application and the fee for renewal was submitted at the end of [DATE]. She stated she rarely did bedside nursing tasks and mostly did administrative work. She stated her responsibility included providing in-services and training to the nursing staff and managing the nursing work force . She stated there were two to three occasions when she had to administer medications and assessments when nurses were not around, during the inactive licensure period. The ADON stated she did not believe her expired license impacted on her ability to do her job because of the expertise and experience she gained over the past 45 years.During an interview on [DATE] at 4:30pm the DON stated she was not aware that the licensure of ADON had expired and in the process of renewal. She stated , it was every nurse's responsibility to ensure that they have a valid active licensure. She added that it was a requirement as per the rule of the TBON to ensure the competency of the nurses. The DON stated as her assistant ADON was resourceful and did not notice any concerns or competence issues. During an interview on [DATE] at 4:50pm the ADM stated that the ADON had not notified him about her delinquent nursing license. He stated that he confirmed with the facility office that an application for renewal with late fee was processed on [DATE] and expecting the renewal anytime . He stated the ADON would not be doing any nursing tasks until her license has been activated . He stated he would create a system to track the expiry dates of the licenses of all the professionals who work at the facility so that their licenses could be renewed well in advance before they got lapsed. He stated ADON had wealth of experience as LVN and did not receive any alarm about any competency concern.The facility did not provide any policies related to licensure and credentialing staff.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment for 1 of 8 (Resident #13) residents reviewed for homelike environment. The facility failed to ensure that shower curtains did not contain brown, unidentifiable substances and that the shelf in the shower room did not contain a yellow unidentifiable substance. These findings could place residents at risk for living in an environment that is not homelike. Findings included:A record review of Resident #13's face sheet dated 5/07/2026 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of bipolar disorder (manic depression), peripheral vascular disease (reduced blood flow), schizophrenia (mental health condition), generalized anxiety, heart failure, hypertension (high blood pressure), and mild cognitive impairment. A record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated minimally impaired cognition. Resident #13's MDS assessment reflected that he was independent with personal hygiene ADLs. A record review of Resident #13's care plan revised on 9/08/2023 reflected that he had potential to demonstrate verbally abusive behaviors related to infective coping skills. Interventions included that staff were to assess resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation. During an observation and interview on 5/05/2026 at 2:45 PM, Resident #13 was observed in the hallway. Resident #13 stated that the shower rooms had shit on the floor. Observations of the shower room between 2300 and 2200 halls revealed there was an unidentifiable brown substance on the floor and on the curtain. There was also an unidentifiable yellow substance on the shower room shelf. During an observation on 5/06/2026 at 9:29 AM revealed that there was still a yellow unidentifiable substance on the shower room shelf and a brown unidentifiable substance on the shower curtain. During an observation and interview on 5/07/2026 at 2:44 PM, RN E stated that the shower rooms were cleaned every day on every shift and that the brown substance on the curtain could be poop. During an interview on 5/07/2026 at 2:50 PM, RN C stated that the yellow unidentifiable substance on the shower shelf could be something that spilled. RN C stated the brown stain on the shower curtain was either food or poop. During an interview on 5/07/2026 at 3:25 PM translated by HHSC's translating services, HK D stated that the process of cleaning the showers involved taking garbage out, disinfecting, sweeping and washing up with the mop. HK D stated that shower curtains were cleaned every time she cleaned the shower room. HK D stated that maybe she needed to try cleaning the curtain with something stronger. During an interview on 5/07/2026 at 4:27 PM, the DON stated, we're supposed to make it as similar as it can be to living at home. The DON stated she had not walked into the shower rooms in the past couple of days, but after each resident finished receiving a shower, staff were supposed to disinfect the shower rooms. The DON stated if the shower curtains had stained, staff needed to let maintenance know so housekeeping could launder them. The DON stated she was not sure when the last time the curtains were cleaned. When asked how the stained cabinet and curtains could affect residents'' environment, the DON stated, I don't think it's very inviting and bacteria could grow. During an interview on 5/07/2026 at 4:37 PM, the ADM stated that if there were any issues related to homelike environment, staff should report it to the respective department. The ADM stated that his expectation was, if they see it, they should say something. When asked how yellow and brown stains in the shower room could affect residents, the ADM stated, you don't want to see it. A record review of the facility's policy titled Resident Rights dated August 2020 reflected the following: PurposeTo promote and protect the rights of all residents at the Facility.PolicyAll residents have a right to a dignified existence, self-determination, and communication with andaccess to persons and services inside and outside the facility including those specified in thispolicy. The Facility must treat each resident with respect and dignity and care for each residentin a manner and in an environment, that promotes maintenance or enhancement of his or her qualityof life, recognizing each resident's individuality.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication (Med) carts (Med cart 2100 and Med cart 2400) reviewed for storage.The facility failed to ensure MA B did not store his personal belongings in the Med cart 2100 and Med cart 2400on 05/06/26.These deficient practices could place residents at risk of receiving cross-contaminated medications.Findings included:During an observation and Interview on 05/06/26 at 11:35 AM MA B facilitated the surveyor in reviewing medication labelling and storage in the medication carts. During the inspection, it was revealed that a one-dollar currency notes and a pair of sunglasses belonging to MA B were stored in one of the drawers of Med Cart 2400. Observation of Med Cart 2100, a black backpack belonging to MA B was found stored in the bottom drawer. The backpack contained assorted personal belongings, including a personal medication organizer box. MA B stated it was a blunder on his part and stated that, as a responsible medication aide, he should not have stored his personal belongings in a medication cart designated exclusively for residents' medications. He said that storing personal items in the cart increased the risk of cross-contamination of the medications stored there.During an interview on 05/07/26 at 4:30 p.m. , the DON stated that staff should not place any personal items in the medication carts, as this could pose a risk of cross-contamination. She said that the medication storage room and medication carts were intended solely for storing residents' medications, and nothing else should be kept there. She highlighted that this practice was important for the proper management of medications to minimize errors and prevent infections caused by contamination.

Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 3 of 8 residents (Residents #30, #56 and #90) reviewed for hydration, in that: The facility failed to ensure R #30, R# 56, R #90 had access to water and/or beverages in their rooms between meals. These deficient practices could affect resident's hydration and lead to discomfort, dehydration, and/or a diminished quality of life. Record review of R# 30's face sheet dated 05/07/2026 revealed a [AGE] year-old male with an admission date of 09/02/2025 with diagnoses which included: Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms vary from person to person and generally include unexplained fatigue and headache.) VASCULAR DEMENTIA, (A condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), and TYPE 2 DIABETES (A condition results from insufficient production of insulin, causing high blood sugar.) Record review of R #30's quarterly MDS dated [DATE] revealed a BIMs score of 4 which indicated severe cognitive impairment. The MDS indicated R #30 required supervision or touching assistance - helper provides verbal cues and/or touching / steadying and/or contact guard assistance as resident completes activity and ADLs such as Oral hygiene. And R#30 was independent with ADLS such as eating and toileting. Record review of R #30's care plan last revised on 03/06/2026 revealed he was able to hold a cup and feed himself. The care plan revealed R#30 had nutritional problems or potential nutritional problems. R#30's goal is the resident will maintain adequate nutritional status through review date. During an observation and interview on 05/6/2026 at 10:51 a.m., revealed R # 30 did not have a water cup available or within reach. Resident #30 said that he did not know where the cup was and that he would like to have a water cup. Resident #56 Record review of R # 56 's face sheet dated 05/07/2026 indicated a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Dementia (confusion due to aging with inability to remember), HEART FAILURE, (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen.) and RHEUMATOID ARTHRITIS,( a chronic, autoimmune disease where the immune system mistakenly attacks the lining of joints (the synovium), causing painful inflammation, swelling, stiffness, and potential joint deformity.) Record review of a quarterly MDS assessment dated [DATE] for R #56 indicated a BIMS score of 9 indicating he had moderate cognitive impairment. The assessment of R #56's mobility indicated he needed supervision or touching assistance- helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity. Record review of the Care Plan dated 03/17/2026, for R # 56 indicated the staff was to be sure the resident's call light was within reach and encourage the resident to use it. During an observation and interview of R #56 on 05/06/2026 at 10:49 a.m., it was revealed that R# 56 was sitting on his bed, and no water cup or water pitcher was seen in R#56's room. R# 56 stated he does not know why he does not have water, he said he did not know that he was supposed to have water between meals. Resident #90 Record review of R #90's face sheet dated 05/07/2026 revealed a [AGE] year-old male with an admission date of 03/21/2025 with diagnoses which included: EPILEPSY, (A neurological disorder that causes seizures or unusual sensations and behaviors.), DYSPHAGIA, (difficulty swallowing) and PARKINSON'SDISEASE, (A progressive disorder that affects the nervous system and the parts of thebody controlled by the nerves.) Record review of R #90's quarterly MDS dated [DATE] revealed a BIMs score of 11 which indicates moderate problems with thinking and memory. The MDS indicated R #90 required assistance for set up or clean- up regarding ADLS such as eating and bringing food and/or liquid to the mouth. During an observation and interview on 05/06/2026 at 10:50 a.m., R #90's room did not have any water, beverages, or water pitcher at bedside. R #90 said, he was not sure why he didn't have water by his bedside. R# 90 said, I like water. During an interview on 05/07/2026 at 12:05 p.m., CNA F revealed all residents should be provided with adequate hydration. She stated that CNAs are responsible for providing water to each resident. She stated the water should be within arm's length of the resident and if they don't have enough water they could suffer from dehydration. CNA F Said she did not know why R# 90 did not have a water cup by his bedside. She said he is a new patient, and I don't know him very well. During an interview on 05/07/2026 at 12:34 p.m., RN E revealed that staff are responsible for performing rounds every 2 hours. She said, every resident will have their cup filled up with ice and water every time it is needed. She said, water is an essential, they need water for life. During an interview and interview on 05/07/2026 4:05 p.m., the DON stated, staff are supposed to follow protocol regarding hydration. She stated that every resident should have their cup filled up frequently. She said no one should have an empty cup of water. She said if they do not get enough water, they may become dehydrated. During an interview on 05/07/2026 at 4:49 p.m., the ADM revealed that every staff member is expected to follow policies and procedures regarding hydration for residents. He stated all staff have been in-serviced on policies for hydration and call lights. He stated they should know they are supposed to place water within each residents reach and they should assess the residents' need for water when they do rounds to each room. The ADM does not know why # R #30, R# 56, R #90 do not have water available in their rooms. Record review of the facility's policy titled Hydration revised 10/05/16 indicated . The facility provides each resident with sufficient fluid intake to maintain proper hydration and health. The residents will receive enough fluid based on assessed need to prevent dehydration and promote optimum physiological functions Staff should offer hydration, unless contraindicated at the following intervals: prior to, during, and following meals .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3of 4 residents (Resident #45 Resident # 28 and Resident #56) reviewed for incontinence care and infection control.The facility failed to ensure that :CNA G and CNA H handling personal care items with clean gloves while providing incontinent care for Resident #45. MA I sanitized the blood pressure monitor before and in-between use on Resident #56and Resident #28, while obtaining blood pressure.This failure could place the residents at the facility at risk of transmission of disease and infection.Findings included:Resident #45Record review of Resident #45's face sheet, dated 05/07/26, reflected Resident #45 was admitted to the facility on [DATE]. Resident #45 was an [AGE] year-old female, diagnosed with cerebrovascular disease, cognitive communication deficit, muscle weakness, and dementia. Record review of Resident #45's quarterly MDS dated [DATE] revealed BIMS 10 indicating her cognition was moderately impaired. The Resident was dependent on ADL support Record review of Resident #45's care plan revealed she had ADL self-care performance deficit . provide care and the intervention was providing required ADL care. During an observation on 05/07/26 at 1:40 p.m., CNA G and CNA H provided incontinent care to Resident #45. CNA G and CNA H entered Resident #45's room, they did not perform hand hygiene, and both donned disposable gloves. After removing the soiled brief, CNA G proceeded to clean the resident's front and back while CNA H maintained appropriate positioning of the resident. CNA G applied a new brief without changing the contaminated gloves. CNA G operated the bed's remote control to adjust the height using unclean gloves, and CNA H tidied the bed and pulled up the blanket with the soiled gloves. CNAs removed their gloves, collected waste materials, and left the room. In an interview at 1:55 p.m., CNA H stated that she contaminated her gloves by touching the resident's body and handling dirty materials. She stated that she should have changed her gloves before handling clean items to prevent contamination. CNA H further indicated that she had been trained in performing incontinence care and was aware of the risk of germ transmission when infection control practices are not properly followed. In a phone interview at 2:20 p.m., CNA G stated she contaminated clean items with soiled gloves. She stated that she should have changed her gloves after completing the cleaning process and before handling the new brief. CNA G reported that the facility provided infection control and peri-care training during her job orientation four months prior. She said that her actions could pose a risk of disease transmission through contamination, which could potentially impact on residents' health. Resident #28 Record review of Resident #28's face sheet, dated 05/06/26, reflected Resident #28 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #28 was a [AGE] year-old male, diagnosed with hypertension.Record review of Resident #28's quarterly MDS dated [DATE] revealed BIMS 0 indicating his cognition was severely impaired.Record review of Resident #28's care plan had not addressed his diagnosis of hypertension.Record review of Resident #28's physician's order reflected Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate): Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold for BP less than 110/55 or Pulse less than 60. - Order Date-03/30/2026Resident #56 Record review of Resident #56's face sheet, dated 05/06/26, reflected Resident #56 was admitted to the facility on [DATE]. Resident #56 was a [AGE] year-old male, diagnosed with hypertension.Record review of Resident #56's initial MDS dated [DATE] revealed BIMS 09 indicating his cognition was moderately impaired.Record review of Resident #56's care plan had not addressed the diagnosis of hypertension.Record review of Resident #56's physician's order reflected:* Lisinopril Tablet 10 MG :Give 1 tablet by mouth one time a day for hypertension hold forsystolic less than 110 -Order Date- 04/17/2026* Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG: Give 1 tablet by mouth two times a day for blood pressure control hold for systolic less than 110 or HR less than 60.-Order Date-04/17/2026 0637During an observation on 05/06/26 at 10:50 a.m., MA -I measured Resident #56's blood pressure with the wrist monitor without prior sanitization. After administering medications to Resident #56, she proceeded to use the same monitor on Resident #28 without sanitizing it first. She only sanitized the monitor after Resident #28 when the investigator pointed out the omission.During an interview on 05/06/26 at 11:25 a.m. MA I stated that she had been employed at the facility for approximately two months and had 16 years of experience as a medication aide. She reported that she had not received any training on the importance of sanitizing medical equipment between patients at the facility. She stated was aware of the significance of sanitizing medical equipment, from her experience as med aide, forgetting to do so due to being in a hurry. MA I stated that sanitizing blood pressure cuffs between residents helps reduce the risk of transmitting infectious diseases through contamination.During an interview on 05/07/26 at 4:30 p.m. the DON stated that her expectation was for all staff to sanitize medical equipment, including blood pressure cuffs, between residents. She reported observing deficiencies in infection control practices during routine rounds. The DON said that, based on MA I's comment about not receiving specific training on sanitizing medical equipment after starting employment, sanitization procedures are considered part of standard precautions for infection control and were included in initial orientation. The DON indicated that additional topics related to sanitizing medical equipment had not been routinely included in in-service sessions. She further stated that CNA G and CNA H also did not follow infection control protocols during incontinent care, which increased the risk of contamination of clean items. The DON concluded that the improper practices of MA I, CNA G, and CNA H heightened the potential for the spread of infectious diseases.Record review of facility policy Infection prevention and control program revised in 06/2020 reflected :Purpose: To ensure the facility establishes 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 in accordance with federal and state requirements .Record review of facility policy Cleaning & Disinfection of Environmental Surfaces revised in October 2024 reflected :Policy : Environmental surfaces are cleaned and disinfected per current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard .Procedure:C. Non-critical items are those that come in contact with intact skin but not mucous membranes.The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in the resident's environment.Non-critical items are those that come in contact with intact skin but not mucous membranes. i. Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors.ii. Most non-critical items can be decontaminated where they are used, as opposed to being transported to a central processing location.iii. Some items that can come in contact with non-intact skin for a brief period of time are usually considered non-critical surfaces as well and are disinfected with intermediate-level disinfectants.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 8 residents (Resident #12, Resident #45 , Resident #86 , Resident #95 and Resident#57, ) reviewed for respiratory care. The facility failed to ensure that :The oxygen cannula, nebulizer masks and tubing of Resident #36 and Resident #95 were stored safely in protective bags. 'oxygen in use sign board displayed in the rooms of Resident #12, Resident #57, and Resident #86These failures placed residents at risk for fire safety and respiratory infections through contamination.Findings included:Resident #36Record review of Resident #36's face sheet, dated 05/06/26, reflected Resident #36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #36 was a [AGE] year-old female, diagnosed with acute respiratory failure with hypoxia ( low oxygen intake) and COPD(breathing difficulty). Record review of Resident #36's quarterly MDS dated [DATE] revealed BIMS assessment could not be completed as the resident rarely/never understood the assessment questions. The MDS indicated of oxygen therapyRecord review of Resident #36's care plan had not addressed her diagnosis of COPD and respiratory failure with hypoxia .Record review of Resident #36's physician's order reflected Oxygen @ 2-4 l/m via nasal canula to reach saturation 90% or higher/hypoxia every shift for as needed for SOB/hypoxia related to acute respiratory failure with hypoxia . Monitor O2 saturation.-Order Date- 11/29/2025.Record review of the April and May 2026 MAR of Resident #36 revealed Resident#36 received Oxygen via nasal cannula 2 times every day.During observation and interview on 05/05/26 at 10:35am Resident #36 was in her room and resting in wheelchair. Her oxygen cannula from the concentrator was on the ground and the water bottle on the oxygen concentrator had a sticker 4/19/26 written on it. There was no protective bag available in the room for keeping the cannula when it was not in use. Resident #36 stated she received the oxygen two times every day . She said the staff were helpful and provided the oxygen and medications without fail.Resident #95Record review of Resident #95's face sheet, dated 05/05/26, reflected Resident #95 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #95 was a [AGE] year-old female, diagnosed with acute respiratory failure with hypoxia, COPD and moderate persistent asthma Record review of Resident #95's quarterly MDS dated [DATE] revealed BIMS 14 indicating her cognition was intact. The MDS indicated oxygen therapy.Record review of Resident #95's care plan dated 09/04/25 reflected the resident had asthma r/tCOPD. The relevant intervention was providing medications as ordered and monitoring /documenting side effects and effectiveness.Record review of Resident #95's physician's order reflected:* Umeclidinium Bromide Inhalation Aerosol Powder Breath Activated 62.5 MCG (Umeclidinium Bromide) : 1 inhalation inhale orally as needed for COPD -Order Date- 06/23/2023. * Respiratory evaluation before Nebulizer treatment every 2 hours as needed for SOB.-Order Date- 07/05/2023.* Respiratory evaluation after Nebulizer treatment every 2 hours as needed for SOB.-Order Date- 07/05/2023.During an observation and interview on 05/05/26 at 10:50am it was revealed that the nebulizing mask of Resident #95 was not in a protective bag and was lying on the side table exposed to the open air. Resident #95 stated she uses nebulizer for shortness of breath on PRN basis and could not remember when she had it last. She stated her respiratory issue improved recently however staff provided the medication via nebulizer when in need as per her request.Resident #86Record review of Resident #86's face sheet, dated 05/05/26, reflected Resident #86 was admitted to the facility on [DATE]. Resident #86 was a [AGE] year-old female, diagnosed with chronic respiratory failure with hypoxia. Record review of Resident #86's quarterly MDS dated [DATE] revealed her BIMS assessment could not be completed as she rarely/never understood the assessment questions. MDS indicated oxygen therapy.Record review of Resident #86's care plan dated 04/05/26 reflected the resident had oxygen therapy r/t CHF and ineffective gas exchange.Record review of Resident #86's physician's order reflected Oxygen @ 2-4 liters via nasal cannula every shift related to chronic respiratory failure with hypoxia.Order Date- 04/10/2026During an interview and observation on 05/05/26 at 11:00am it was revealed that Resident #86 was connected to the oxygen concentrator via nasal cannula for continuous oxygen supply however there was no Oxygen in use sign board on her room. Resident #86 stated her respiratory condition was very bad and needed continuous supply of oxygen. Resident #12Record review of Resident #12's face sheet, dated 05/05/26, reflected Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 was a [AGE] year-old male, diagnosed with chronic respiratory failure. Record review of Resident #12's quarterly MDS dated [DATE] revealed BIMS 14 indicating his cognition was intact. MDS indicated oxygen therapyRecord review of Resident #12's care plan dated 03/20/26 reflected he had emphysema/COPD and the relevant intervention was administering aerosol or bronchodilators as ordered and monitoring for any side effects.Record review of Resident #12's physician's order reflected Oxygen 1-5 LMP via NC as needed for SOB.-Order Date- 09/23/2025During an observation and interview on 05/05/26 at 11:30am Resident #12 was resting in his bed. There was an oxygen concentrator in his room without an 'oxygen in use' signboard. Resident #12 stated he was improving with his breathing capacity, needed oxygen occasionally and the staff provided when requested.Resident #57Record review of Resident #57's face sheet, dated 05/05/26, reflected Resident #57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #57 was a [AGE] year-old female, diagnosed with acute and chronic respiratory failure, COPD, emphysema (a progressive, chronic lung disease ) and shortness of breath.Record review of Resident #57's quarterly MDS dated [DATE] revealed BIMS 13 indicating her cognition was intact. MDS indicated oxygen therapy. Record review of Resident #57's care plan reflected she was on Oxygen Therapy r/t ineffective gas exchange and COPD. The relevant intervention was administering oxygen as per physician's order.Record review of Resident #57's physician's order revealed O2 @ 2.5 liters per minute via nasal cannula every shift-order date 12/23/2025.During an observation and interview on 05/05/26 at 11:45am Resident #57, she was in her bed . She had continuous supply of oxygen via a cannula that was connected to an oxygen concentrator. There was no oxygen in use sign board in her room. She stated she has severe breathing issue and needed continuous supply of oxygen. Resident said the staff was supportive in providing care.During an observation and interview conducted with LVN J on 05/05/26, at 11:15 a.m., LVN J observed that the oxygen cannula belonging to Resident #36 was lying on the floor. She promptly picked it up for disposal, noting that it should have been stored in a protective bag. LVN J stated that she would immediately change the water bottle of the oxygen concentrator, which had been sitting in place since 04/19/26. She stated that, according to facility protocol, the cannula and water bottle were to be replaced weekly to minimize the risk of respiratory infection. LVN J indicated that the purpose of these interventions was to reduce the potential for respiratory infections among residents. She said she would make arrangements to display Oxygen in Use signage for Resident #12 and Resident #86 to enhance safety precautions.During an observation and interview conducted on 05/05/26 at 11:35 a.m., RN E noted that the nebulizing mask belonging to Resident #95 was found lying on the side table. RN E stated that the mask should have been stored in a protective bag when not in use. She removed the unprotected mask and tubing. RN E explained that failure to protect respiratory equipment from external environmental factors poses a risk of cross-contamination and microorganism colonization, which could potentially lead to serious respiratory infections and other health complications. She said that it was the responsibility of nursing staff to ensure proper storage of respiratory equipment in protective bags. RN E stated that she should have identified this noncompliance earlier and taken corrective action. RN E stated that she would immediately display an Oxygen in Use signage for Resident #57 to warn staff and visitors of the fire hazard associated with oxygen therapy. In an interview conducted on 05/07/26 at 4:30 p.m., the DON stated that nebulizer masks, tubing, and oxygen nasal cannulas should be cleaned and stored in a clean protective bag after use. She explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The DON further clarified that it was the nurses' responsibility to ensure that this process was completed following medication administration. She highlighted that residents sometimes remove their respiratory equipment and forget to replace it in the protective bags, emphasizing the importance of regular rounds by nursing staff to verify proper storage of respiratory devices. Additionally, the DON addressed the challenge related to maintaining Oxygen in Use signage, noting that one resident at the facility had taken down the signage displayed on the board. She said that staff recently discovered a bundle of various signage types stored among that resident's belongings. The DON stated that staff should have been more vigilant regarding the disappearance of the signage and emphasized the need for daily rounds to ensure that signage boards remain undisturbed and properly displayed.Record review of the in-service since [DATE] revealed there were no in services on safe handling of respiratory equipment.Review of the facility policy Oxygen Administration revised on 06/2020 reflected: . III. Infection ControlA. All oxygen tubbing, humidifiers, masks, and cannulas used to deliver oxygen:i. Are for single resident use only.ii. Will be changed weekly and when visibly soiled, or as indicated by stateregulation.B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect theequipment from dust and dirt when not in use.IV. Safe Handling of Oxygen/EquipmentA. Residents using oxygen will have an Oxygen in Use sign placed on the door frame oftheir room.

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff work area from each resident's bedside for 4 of 34 residents (Residents # 3, # 36, #46 and # 56) reviewed for call lights.The facility failed to ensure the call light system was accessible to Residents # 3, # 36, #46 and #56.These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life.Record review of a face sheet dated 05/07/2026 indicated that R #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Spastic Diplegic Cerebral Palsy, (a neurological movement disorder characterized by high muscle tone (spasticity) causing severe stiffness and tightness, primarily affecting the legs more than the arms.) Aneurysm of Unspecified Site , (a localized, abnormal widening or ballooning of an artery wall that has not been definitively localized to a specific artery (such as the brain or aorta) in medical documentation.) Hypertension, (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms vary from person to person and generally include unexplained fatigue and headache.) Record review of a quarterly MDS assessment dated [DATE] for R #3 indicated a BIMS score was unable to be determined. Resident # 3 was rarely/never able to be understood and he had short term and long-term memory problems. Resident # 3 had limitations in range of motion, and he was impaired on both upper and lower extremities. Review of R #1 care plan dated 12-23-2025, had a behavior problem related to dementia. Her behavior is to hoard napkins, food and spoons. Interventions include anticipating and meeting the residents' needs. R# 1 participates in exercise. Interventions including the activity director will encourage and remind R # 1 of current activities. Record review of R # 3 's comprehensive care plan with a revision date 11/05/2025, revealed the R #3 had impaired cognitive function/dementia or impaired thought processes r/t neurological symptoms. R#3's goal is to maintain current level of cognitive function. Interventions are to Engage the resident in simple, structured activities that avoid overly demanding tasks. The resident has had an actual fall with No Injury, Unsteady gait. Therapy will work with R#3 regarding use of call light and safety awareness. During an observation and interview on 05/05/2026 12:46 p.m., R #3's call light was observed hanging off the right side of the bed, it was not within reach of R#3. R#3 stated that she did not know where the call light was. Resident #36 Record review of a face sheet dated 05/07/2026 indicated that R #36 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including: PULMONARY HYPERTENSION, (high blood pressure), SCHIZOPHRENIA, (a chronic, severe brain disorder that affects how a person thinks, feels, and acts, often causing them to lose touch with reality) and BIPOLAR DISORDER(includes bouts of hypomania or mania and sometimes major depression.) Record review of a Quarterly MDS assessment dated [DATE] for R #36 indicated that her BIMS score could not be determined. The MDS assessment for Resident # 36's mobility indicated she required Supervision or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Record review of the Care Plan dated 04/14/2026, indicated that R# 36 had an ADL Self Care Performance Deficit r/t Impaired balance. R#36's interventions are to Encourage the resident to use bell to call for assistance. During an observation and attempted interview of R# 36 on 05/06/2026 at 10:50 a.m., R# 36 was lying in her bed, she was sleeping and the call light was located out of R#36's reach on the floor, near the foot of her bed. Resident #46 Record review of R # 46's face sheet dated 05/07/2026 indicated that R #46 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including: ACUTE RESPIRATORY FAILURE WITH HYPOXIA ( a sudden, life-threatening condition where the lungs cannot adequately oxygenate the blood, resulting in a low partial pressure of oxygen.) TYPE 2 DIABETES, a chronic condition characterized by insulin resistance and high blood sugar levels.) And REFLUX DISEASE, (the backward flow of liquid, specifically when stomach acid or contents travel up into the esophagus (throat). Record review of a Quarterly MDS assessment dated [DATE] for R #46 indicated a BIMS score of 6 indicating he had a severe problem with thinking and memory. The assessment of R #46's mobility indicated he was dependent, and he needed 2-person assistance using a Mechanical lift. Record review of the Care Plan dated 04/10/2026, for R # 46 indicated the resident's call light was to be within reach and encourage the residents to use it for assistance as needed. In an observation and interview on 05/05/2026 at 12:40 p.m., R#46's call light button was resting on the bedside table, and it was out R #46's reach. The RP stated R#46 needed assistance with ADLs. The RP said R#46 does not know how to get in touch with the staff. Resident #56 Record review of R# 56 's face sheet dated 05/07/2026 indicated that R #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Dementia (confusion due to aging with inability to remember), HEART FAILURE, (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen.) and RHEUMATOID ARTHRITIS,( a chronic, autoimmune disease where the immune system mistakenly attacks the lining of joints (the synovium), causing painful inflammation, swelling, stiffness, and potential joint deformity.) Record review of a Quarterly MDS assessment dated [DATE] for R #56 indicated a BIMS score of 9 indicating he had moderate cognitive impairment. The assessment of R #56's mobility indicated he needed supervision or touching assistance- helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity. Record review of the Care Plan dated 03/17/2026, for R # 56 indicated the staff was to be sure R#56's call light was within reach and encourage the him to use it. During an observation and interview on 05/06/2026 at 10:49 a.m., R# 56 was sitting on his bed, and no call light was seen in R#56's room. R# 56 stated he does not know how he would contact staff for help, he said he was not sure how often the staff came into his room and checked on him. During an interview on 05/07/2026 at 12:05 p.m., CNA F stated she had been in-serviced regarding call light location, and CNAs are responsible for making sure the location of call lights are within reach of each resident. She stated, Residents call lights are important for them to be able to reach out for help. If a resident has a fall, they will need immediate assistance. And she stated, Call lights should be pinned to the resident's bed, it should be close to the residents hand. During an interview on 05/07/2026 at 12:34 p.m., RN E stated, everyone on staff is responsible for checking the call light button locations. She said, the type of call light used for a resident is determined when the resident is assessed for functional abilities. The IDT including the Therapy team will have input as to the type of call light that is best for that person. RN E said, per the policy, a residents call light must be within reach of the resident. She said if a call light is not within residents' reach, the residents may not be able to get the help they need. During an interview on 05/07/2026 at 4:05 p.m., the DON revealed that call lights should be clipped on to the bed and it should be within each residents' reach. The DON stated, residents who have problems with dexterity may need a specialized call light. The DON stated, it is not acceptable for call light to be on the floor. The DON stated that CNAs are responsible for checking on the call light locations. During an interview on 05/07/26 at 04:49 p.m., the ADM said that he expects that staff will follow the policies and procedures regarding call lights. He stated that staff have been in-serviced on placement of call lights. The ADM stated, each resident should have a call light within reach of residents. Record review facility policy titled Communication- Call System date revised 10-24-2022 indicated: The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities.The call system should be accessible to a resident lying on the floor in toileting and bathing facilities.ProcedureII. Call cords will be placed within the resident's reach in the resident's roomIII. Nursing staff will answer call bells promptly, in a courteous manner.IV. Upon responding to request, if item is requested is questionable, assistance will be obtained from the Charge Nurse.

Based on observation, interview, and record review, the facility failed to ensure that residents had the right to manage their financial affairs and to know in advance what charges a facility may impose against a resident's personal funds for 1 of 8 (Resident #70) residents reviewed for personal funds. The facility failed to distribute Resident #70's personal needs allowance in full. This failure placed residents at risk of not having access to their funds and a decreased quality of life.Findings included: A record review of Resident #70's face sheet dated 5/07/2026 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of dementia (neurocognitive disorder), muscle weakness, chronic obstructive pulmonary disorder (progressive lung disease), major depressive disorder, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and chronic kidney disease. A record review of Resident #70's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated moderately impaired cognition. A record review of Resident #70's care plan revised on 3/30/2026 reflected that she experienced increased agitation and anxiety related to environmental stimuli. Interventions included that staff would provide gentle redirection and reassurance to resident as needed to promote calm behavior. During an observation and interview on 5/06/2026 at 10:04 AM, Resident #70 stated that she had problems with her money. Resident #70 stated that she was only getting $60 per month and she was supposed to received $75. Resident #70 stated that it had been going on for the past couple of months. Resident #70 stated that she had talked with the Receptionist about this issue, and the Receptionist told her no she could not get her money. A record review of the facility's document titled Customer Balance Detail dated April 30, 2026 reflected that Resident #70 received petty cash payments of $60.00 on 1/05/2026, 2/05/2026, 3/06/2026, and 4/03/2026. During an interview on 5/07/2026 at 8:50 AM, the BOM stated that Resident #70 should be getting $75 and that the Receptionist handed out funds for residents' personal needs allowance. The BOM stated that the CFO gave the money to the Receptionist and the Receptionist gave it to residents. The BOM stated that she was not involved with the process. During an interview on 5/07/2026 at 8:55 AM, the BOM stated that she would fix Resident #70's account, that's an easy fix and that she believed it was an error that she was only receiving $60 per month because the guideline was that everyone got $75. The BOM stated yes that if there were complaints about the personal needs allowance, she would expect those concerns to be communicated to her. When asked how not receiving the correct amount of money each month could affect Resident #70, the BOM stated she did not think it would affect her because she was not sure whether Resident #70 picked up her money every month. The BOM stated that residents had to request their PNA each month. During an interview and record review on 5/07/2026 at 8:56 AM, the Receptionist stated that Resident #70 complained that she was not receiving as much money each month as she should. The Receptionist stated that she had not brought up this concern with the BOM, but I should have. The Receptionist pulled a sheet of paper that had a table with resident names listed next to an amount, the document reflected that Resident #70's name was listed and next to her name , it said 60 under a column titled amount. During an interview on 5/07/2026 at 12:14 PM, the BOM stated that petty cash listed on Resident #70's ledger was her PNA. During an interview on 5/07/2026 at 4:27 PM, the DON stated that her understanding of the policy on PNA was that residents talked with the Receptionist, told her how much they wanted, signed it out, and then had a witness sign. The DON stated yes she would expect a resident complaint to be escalated to the BOM or to the ADM. The DON stated I guess it would be against her rights if residents did not receive their full PNA. During an interview on 5/07/2026 at 4:37 PM, the ADM stated he believed residents were allowed $75 per month for their PNA. The ADM stated no it had not been brought to his attention that Resident #70 was not receiving her PNA in full. The ADM stated it was a resident right and that's her right to get it. A record review of the facility's policy titled Resident Funds - Handling & Reporting dated August 2020 reflected the following: PurposeThe objectives of this policy are to: Provide a means to protect resident funds managed by the Facility;.ProcedureManagement of Resident Funds.No licensee, owner, Administrator may act as an authorized representative of resident funds, unless the resident is a relative within the second degree of relation.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #1) reviewed for privacy.The facility failed to ensure CNA G and CNA H provided privacy by closing the door and drawing the privacy curtain during incontinent care for Resident #45.This failure could place residents at risk of lack of privacy and not having residents' rights acknowledged.The findings include:Record review of Resident #45's face sheet, dated 05/07/26, reflected Resident #45 was admitted to the facility on [DATE]. Resident #45 was an [AGE] year-old female, diagnosed with cerebrovascular disease (stroke), cognitive communication deficit, muscle weakness, and dementia.Record review of Resident #45's quarterly MDS dated [DATE] revealed BIMS 10 indicating her cognition was moderately impaired.Record review of Resident #45's care plan revealed the resident had an ADL self-care performance deficit and the intervention was providing required ADL care. During an observation on 05/07/26 at 1:30 p.m., CNA G and CNA H provided incontinent care to Resident #45 in her room. CNA G and CNA H closed the door but they did not fully draw the privacy curtain during the procedure. Resident #45 shared the room with another resident, with her bed positioned near the door. Her roommate was not present at that time, the incontinent care was potentially fully visible to anyone entering the room or to her roommate if she or others entered during the care.In an interview at 1:45 p.m., Resident #45 stated that she believed CNA G and CNA H performed the care satisfactorily and was pleased with the service. She also noted that she did not observe whether the privacy curtain was fully closed or if the door to her room was shut. Resident #45 expressed that she would not feel comfortable if an unidentified visitor or her roommate observed her during personal care activities.During an interview on 05/07/26 at 1:55 p.m., CNA H stated that she should have drawn the privacy curtain but admitted she was nervous and forgot to do so. She emphasized that providing privacy during nursing care was essential because privacy and dignity are fundamental resident rights.During a telephone interview on 05/07/26 at 2:20 p.m. CNA G stated that incontinent care was a routine part of her responsibilities. She said that it was a mistake that the privacy curtain was not fully closed. CNA G explained that she believed it was unacceptable to keep the curtain partially or fully open, as the peri-care could have been visible to Resident #45's roommate or anyone entering the room at that time. She recognized that her oversight compromised Resident #45's right to privacy and dignity during the procedure.During an interview on 05/07/26 at 2:30 p.m., RN E stated that closing the door and drawing the privacy curtain were crucial to ensuring the privacy and dignity of residents. She indicated that CNA G and CNA H should have been diligent in maintaining compliance with this aspect of resident rights.During an interview on 05/07/26 at 4:30 p.m., the DON stated that respecting and upholding residents' privacy and dignity during nursing care, including incontinent care, involves closing doors, windows, and privacy curtains. The DON acknowledged that the door and privacy curtain of Resident #45 should have been fully closed prior to initiating care. She said that Resident #45's privacy could be violated if anyone entered the room during care. The DON further stated that resident rights are part of ongoing staff training, with all nursing staff required to complete an annual evaluation to ensure competence in respecting residents' rights and maintaining proper nursing practices.Record review of facility policy Resident Rights-Quality of life revised in 08/2020 reflected: Purpose: To ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility.Policy: Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. X. Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 8 (Resident #9 and Resident #34) residents reviewed for activities of daily living. The facility failed to ensure Resident #9 and Resident #34's nails were trimmed and clean. This failure placed residents at risk for poor hygiene and decreased quality of life.Findings included: A record review of Resident #9's face sheet dated 5/07/2026 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of Alzheimer's disease (neurocognitive disorder), cerebral infarction (stroke), dysphagia (difficulty swallowing), weakness, unspecified lack of coordination, other reduced mobility, other lack of coordination, muscle weakness, and need for assistance with personal care. A record review of Resident #9's MDS assessment dated [DATE] reflected that he was not assessed for a BIMS score. Resident #9's MDS assessment reflected that he had not been assessed for his ability to maintain personal hygiene. A record review of Resident #9's care plan revised on 1/31/2026 reflected that he had ADL self-care performance deficit related to dementia (neurocognitive disorder). Interventions included 1 staff participation with personal hygiene and oral care. A record review of Resident #9's progress notes dated 4/07/2026-5/07/2026 reflected no documented refusals of care. A record review of Resident #34's face sheet dated 5/07/2026 reflected an [AGE] year-old male readmitted on [DATE] with diagnoses of muscle weakness, dementia (neurocognitive disorder), Parkinson's disease (progressive neurological disorder), unspecified lack of coordination, hypertension (high blood pressure), and history of falling. A record review of Resident #34's MDS assessment dated [DATE] reflected that he was not assessed for a BIMS score. A record review of Resident #34's care plan revised on 5/07/2026 reflected that he had ADL self-care performance deficit related to dementia (neurocognitive disease). Interventions included check nail length and trim and clean on bath day and as necessary. During an observation and interview on 5/05/2026 at 2:16 PM, Resident #34 was observed sitting in a wheelchair. Resident #34's nails were observed to have about 3 mm of white showing and there was a dark, unidentifiable substance underneath his nails. Resident #34 stated no his nails were not long for him. A record review of Resident #34's progress notes dated 4/07/2026-5/07/2026 reflected no documented refusals of care. During an observation and interview on 5/05/2026 at 2:36 PM, Resident #9 was observed lying in bed. Resident #9's fingernails had about 4 mm of whites showing. Resident #9 stated no that staff had offered to trim his nails and that he did not have nail clippers. During an interview and observation on 5/07/2026 at 2:15 PM, LVN A stated that CNAs did nail care as needed or daily. LVN A looked at Resident #9's nails and stated that his nails were very long, she did not know when the last time they were trimmed , and that his nails were a little dirty. During an observation and interview on 5/07/2026 at 2:22 PM, LVN A was observed walking into Resident #34's room. LVN A then walked out and stated that Resident #34's nails were very long and on a scale of 0-10, which 10 being the dirtiest, they were a 6. LVN A stated that Resident #9's were a 7 out of 10. During an interview on 5/07/2026 at 4:27 PM, the DON stated that if residents were not diabetic, CNAs could do nail care. The DON stated that nail care was done once a week on Sunday and as needed. The DON stated that she had not seen Resident #9's or Resident #34's nails. When asked how having long nails could impact residents, the DON stated they could scratch themselves and I wouldn't want dirty fingernails [when] eating. During an interview on 5/07/2026 at 4:49 PM, the ADM stated that the nail care policy depended on whether the resident was diabetic and that he did not know whether Resident #9 or Resident #34 were diabetic. The ADM stated, we do get some residents that refuse and said if residents refused nail care, it should be documented in a progress note. When asked how long nails could impact residents, the ADM stated it could lead to bacteria buildup and many things. A record review of the facility's undated policy titled Grooming Care of the Fingernails and Toenails reflected the following: PurposeNail care is given to clean and keep the nails trimmed.PolicyFingernails are trimmed by Certified Nursing Assistants except for residents with the following conditions:A. Diabetes or circulatory impairment of the handsB. Ingrown, infected, or painful nailsC. Nails that are too hard, thick, or difficult to cut easily

Based on observation, interview, and record review, the facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers for 1 of 8 residents (Resident #97) reviewed for skin assessments. The facility failed to assess Resident #97's skin weekly, as required by the facility's policy, from December 2025 to May 2026 This failure placed residents at risk for unidentified skin issues.Findings included: A record review of Resident #97's face sheet dated 5/07/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of sequelae of cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis), morbid (severe) obesity, and rhabdomyolysis (rapid breakdown of skeletal muscle). A record review of Resident #97's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated moderately impaired cognition. A record review of Resident #97's care plan dated 5/07/2026 reflected that she had potential for pressure ulcer development related to immobility. A record review of Resident #97's TAR/MAR dated May 2026 reflected an order dated 5/20/2023 for weekly skin assessments every evening shift every Wednesday. There were no orders for barrier cream. A record review of Resident #97's chart on 5/06/2026 reflected that her last skin assessment was on 12/08/2026. A record review of Resident #97's skin assessment dated [DATE] reflected that she did not have any skin impairments. During an observation and interview on 5/05/2026 at 10:23 AM, Resident #97 was observed lying on her back. Resident #97 stated no she did not have any wounds. During an interview on 5/07/2026 at 11:03 AM, RN C stated that Resident #97 was bedbound and most of the time she did not want to be touched. When asked if Resident #97 refused skin assessments, RN C stated, not really. RN C stated that she saw Resident #97's backside about two weeks ago and there wasn't anything. RN C stated, we have weekly skin assessments for patients who are bedbound and for ones who refuse hygiene-I can check if she is one. RN C stated that Resident #97 received barrier cream. During an interview on 5/07/2026 at 9:49 AM, the DON stated that all skin assessments should be under the 'assessments' tab in [the EHR]. The DON stated that skin assessments were done weekly and every resident had a specific day they were supposed to have them. The DON stated the nurse or Wound Care RN did skin assessments. The DON stated that Resident #97 did not have any pressure injuries to her knowledge. When asked how not receiving regular skin assessments could impact Resident #97, the DON stated she could have skin issues we're not aware of. During an interview on 5/07/2026 at 4:49 PM, the ADM stated if the policy said that all residents needed skin assessments weekly, his expectation was to adhere to policy. When asked how Resident #97 could be affected by not receiving regular skin assessments, the ADM stated, she could get a bed sore or pressure ulcer. A record review of the facility's undated policy titled Wound management reflected the following: PurposeTo provide a system for the treatment and management of residents with wounds including pressureand non-pressure injury.ProcedureI. AssessmentA. A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly,and as needed for each resident.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plan revisions.The facility failed to ensure that Resident #1's care plan was comprehensive and complete, reflecting his complex active medical conditions.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet dated 03/20/26 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Coronary Artery Disease (Limited blood flow in the arteries of the heart) , End-Stage Renal Disease (kidney failure), Heart Failure, Hypertension, Diabetes Mellitus , Peripheral Vascular Disease( blood circulation issues), Gastroesophageal Reflux Disease(acid reflux), Pneumonia, Chronic Obstructive Pulmonary Disease ( breathing difficulty) , Hyperlipidemia (high cholesterol), Depression, Post Traumatic Stress Disorder ( a mental disorder) , Anemia(tiredness) and Pain.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the cognition of the resident was intact. Further review of the MDS reflected that Resident #1 was actively diagnosed with medically complex conditions. They were Coronary Artery Disease, End-Stage Renal Disease, Heart Failure, Hypertension, Diabetes Mellitus, Peripheral Vascular Disease( blood circulation issues), Gastroesophageal Reflux Disease, Pneumonia, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Depression, Post Traumatic Stress Disorder, Anemia and Pain.Record review of Resident #1's March 2026 MAR revealed resident was receiving medications for all his complex medical conditions.Record review of Resident #1's comprehensive care plan, initiated on 03/05/26, revealed that there were no care plans for any of his active complex medical conditions.During an interview on 03/20/26 at 10:20am Resident #1 stated he was not happy with the nursing he received at the facility. He stated that he and his family member are in the process of looking for a better facility. Resident #1 said the staff at the facility were not doing their job properly . He mentioned that he received his medications sometimes not on time. He also said that recently he missed his watch and suspects that one of the staff members took it. Overall, he said his experience at the facility was not good.During a phone interview on 03/20/26 at 11:30am , the MDSC stated that he was responsible for initiating, updating, and completing care plans. He indicated that he was aware of the timing parameters for completing care plans. The MDSC also mentioned that he received information about residents' medical conditions or changes during the daily IDT meetings and made updates accordingly. He said he was under the impression that he had completed the care plan for Resident #1 following the completion of his MDS assessment on 02/05/26. The MDSC stated that care plans were an integral part of nursing care, providing relevant information about residents and their conditions, as well as appropriate interventions to address them.On 03/20/26 at 12:45pm , RN A stated she worked at the facility as a PRN nurse. She reported that she uses the Kardex (a concise summary of essential patient information and daily care needs, updated each shift) for resident care. RN A added that she had not referred to care plans ever, as the Kardex was available at the facility. When asked about the importance of care plans, she stated she was not aware of their relevance. RN A also mentioned that she had never received any in-service training on care plans.On 03/20/26 at 2:30 p.m., RN B stated she had been employed at the facility since December 26 and had not referred to care plans for any reason. She explained that she did not rely on care plans, instead depended on the 24-hour report and other assessment tools. When asked about the implementation of person-centered care listed in the care plan, she stated she was not familiar with the concept of person-centered care plan and did not know how the care plans were implemented using the interventions listed. RN B stated she noted down the relevant interventions required during daily IDT meetings and perform the nursing care on day-to-day basis , based on the IDT meeting outcomes. During a phone interview on 03/20/26 at 3:50 p.m., LVN C stated she worked with Resident #1 and had not noticed the absence of care plans for his conditions. She stated that care plans were very important as they contain relevant information about residents' short- and long-term goals and the interventions needed to achieve them. LVN C stated she refer to care plans in the EHR when required, however, never received any in- services on careplan. During an interview on 03/20/26 at 4:00 p.m. the DON stated she was new to the facility and was unaware of the lack of a proper care plan for Resident #1. She said care plans were an essential part of nursing care, providing a person-centered perspective of residents' issues, goals, and interventions. She explained that nurses were expected to work according to the care plan to promote residents' maximum well-being. The DON added that care plans offer direction and serve as tools to achieve the goals of residents' stays, supported by the IDT team.During an interview on 03/20/26 at 4:20pm , the ADM stated that the MDSC worked remotely and was responsible for creating and updating care plans. He mentioned that Resident #1 was out of the facility for a while before re admitted on [DATE] and that, according to records, there were care plans in the past for Resident #1 . However, he indicated that the MDSC failed to transfer the care plan with the necessary updates after Resident #1's readmission. He described the process as straightforward and expressed uncertainty as to why Resident #1's conditions were not reflected in the current care plan, suggesting a possible system glitch. The ADM stated he would work with the MDSC to resolve this issue, emphasizing that an active, valid care plan is essential and an integral part of nursing care. The ADM stated it was the responsibility of the IDT and other staff members who were using the care plan to see if the care plan was complete and report to the ADM or DON if there was any shortfall. Record review of the facility's policy Care Planning revised on 10/24/2022 reflected : Purpose:To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.Policy:The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines.The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases. VIII. A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on interview and record review the facility failed to develop the comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans.The facility failed to ensure that Resident #1's comprehensive care plan was completed within 7 days after completion of the comprehensive assessment, completed on 02/05/26.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet dated 03/20/26 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Coronary Artery Disease (Limited blood flow in the arteries of the heart) , End-Stage Renal Disease (kidney failure), Heart Failure, Hypertension, Diabetes Mellitus , Peripheral Vascular Disease( blood circulation issues), Gastroesophageal Reflux Disease(acid reflux), Pneumonia, Chronic Obstructive Pulmonary Disease ( breathing difficulty) , Hyperlipidemia (high cholesterol), Depression, Post Traumatic Stress Disorder ( a mental disorder) , Anemia(tiredness) and Pain.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the cognition of the resident was intact. Further review of the MDS reflected that Resident #1 was actively diagnosed with medically complex conditions. They were Coronary Artery Disease, End-Stage Renal Disease, Heart Failure, Hypertension, Diabetes Mellitus , Peripheral Vascular Disease( blood circulation issues), Gastroesophageal Reflux Disease, Pneumonia, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Depression, Post Traumatic Stress Disorder, Anemia and Pain.Record review of Resident #1's comprehensive care plan initiated on 03/05/26 revealed there was care plan only for Resident #1's noncompliance with facility smoking policies . The care plan included interventions to achieve the goal of compliance with facility smoking policy through the review date.There were no other care plans for Resident #1's medical, nursing, mental and other psychosocial needs.During an interview on 03/20/26 at 10:20am Resident #1 stated he was not happy with the nursing he received at the facility. He stated that he and his family member are in the process of looking for a better facility. Resident #1 said the staff at the facility were not doing their job properly . He mentioned that he received his medications sometimes not on time. He also said that recently he missed his watch and suspects that one of the staff members took it. Overall, he said his experience at the facility was not good.During a phone interview on 03/20/26 at 11:30am , the MDSC stated that he was responsible for initiating, updating, and completing care plans. He indicated that he was aware of the timing parameters for completing care plans. He said he was under the impression that he had completed the care plan within 7 days after the completion of Resident #1's MDS assessment on 02/05/26. The MDSC stated that care plans were an integral part of nursing care, providing relevant information about residents and their conditions, as well as appropriate interventions to address them. He stated a timely care plan was essential for the staff to understand what Resident #1's specific needs were, the goals, and the nursing interventions to be implemented to achieve these goals.During an interview on 03/20/26 at 4:00 p.m., the DON stated she was new to the facility and was unaware that there was no proper care plan for Resident #1 based on the quarterly MDS assessment that was completed on 02/05/26. She said timely completed care plans were an essential part of nursing care, providing a person-centered perspective of residents' issues, goals, and interventions. The DON added that care plans offer direction and serve as tools to achieve the goals of residents' stays, supported by the IDT team. The DON stated that Resident #1's missing care plan related to his medical conditions was a concern as careplan was an integral part of nursing care.During an interview on 03/20/26 at 4:20pm the ADM stated that the MDSC worked remotely and was responsible for creating and updating care plans. He mentioned that Resident #1 was out of the facility for a while before re-admitted on [DATE] and that, according to records, there were care plans in the past for Resident #1. However, he indicated that the MDSC failed to transfer the care plan with the necessary updates after the completion of the recent quarterly MDS assessment. He described the process as straightforward and expressed uncertainty as to why Resident #1's conditions were not reflected in the current care plan, suggesting a possible system glitch. The ADM stated he would work with the MDSC to resolve this issue, emphasizing that a timely completed care plan was essential and was an integral part of nursing care. The ADM stated he would work with the MDSC to resolve this issue, emphasizing that a timely completed care plan was essential and was an integral part of nursing care.Record review of the facility's policy Care Planning revised on 10/24/2022 reflected : Purpose:To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for 1 of 8 residents (Resident #1) reviewed for care plan. The facility failed to develop Resident #1's care plan to reflect refusals of showers and interventions which included skin assessment and reduction of risk for skin breakdown. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings include: During an interview with the DON on 01/10/2026 at 10:48 a.m., she said she was trained on completing care plans. She said the residents' participation in ADLs and if they refused care, this information should go on the care plan. She said the care plan should be updated and she did not know why Resident #1's care plan was not updated. She said if something was not on the care plan it could affect the quality of care for the residents. She said the DON, ADON and the social worker were responsible to ensure the care plan was updated continuously when new problem care area was identified. She said it was monitored through IDT care plan meetings. She said she did not know why Resident #1's care plan did not have risk/goals/interventions for her refused care including showers and changing briefs. She stated that not updating her care plan could increase Resident #1's risk for skin breakdown and infection (UTI). During an interview with the ADM on 01/10/2026 at 12:44 p.m., he said he was trained on residents' care plans. He said the training covered the overall protocol for the care plan. He said the care plan should be person centered. He said if a resident refused services often then it should be in the care plan so staff would know she refused. He said the facility had an IDT team that put information in the care plan. He said the care plan if not revised could cause the residents to have inadequate care. He said the DON monitored to ensure the care plan was correct. The ADM said he did not know how the DON monitored the revision of care plans. He said he had asked the DON at the time to care plan Resident #1's care refusals back in September 2025 and he did not care plan it himself. Record review of Resident #1's face sheet, dated 1/09/2026, revealed an 80-years-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Cerebral infarction (the death of brain tissue [infarct] due to a blocked artery, cutting off oxygen and nutrients, typically from a blood clot), chronic pain, depression (a serious mood disorder causing persistent sadness and loss of interest, affecting how you feel, think, and behave, interfering with daily life), morbid obesity (a severe form of obesity defined by a Body Mass Index [BMI] of 40 or higher), altered mental status (a general term for a sudden change in brain function, causing confusion, disorientation, decreased alertness, or unusual behavior), hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body, often affecting an arm, leg, or face, resulting from brain damage) following cerebral infarction affecting right dominant side. Record review of Resident #1's comprehensive care plan reflected it consisted of the last revisions to Resident #1's ADL self-care performance goals, dated 8/30/2023, which did not include her refusal of care. Record review of the facility's Care Planning Policy, dated 10/24/2023, revealed the purpose of care planning is to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will need to be reflected on updated Care Plan. Record review of Resident #1's nursing progress notes, dated 11/26/2025, 11/20/2025, 11/19/2025, 11/14/2025, 11/13/2025, 11/11/2025, 10/15/2025 and, 10/3/2025, revealed Resident #1 refused to be changed and take showers from nurses and CNAs. Resident #1 has incontinence urine, chronic refusal of ADLs, and getting out of bed. Record review Psychiatric subsequent assessment, dated 05/07/2025, revealed the collateral information: Staff say patient has a hx of refusing care and often isolates to her room. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 7, which indicated severe cognitive impairment.

Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included: During an Observation of the nurses station on 01/10/2026 at 07:39a.m., revealed MC#1 was unlocked and unattended. RN A was sitting inside the nurses station out of view of the medication cart. Another RN walked past MC #1 and went into the nurses station and did not lock MC #1. Residents were walking by the unlocked medication cart. MC #1 contained residents prescribed creams, residents prescribed drugs, over the counter medication, narcotics, and injectable antibiotics. During an interview with RN A on 01/10/2026 at 07:43a.m., revealed that she had been trained on medication storage. She said the medication cart policy was the medication cart was to be locked any time staff stepped away from it. She said that the nurse was responsible for locking the medication cart. She said if the medication cart was left unlocked and unattended a resident might get into the medication. She said all staff monitored to ensure the medication carts were locked. She said staff monitored by locking the medication cart if they saw the cart unlocked. She said she was told state was in the building, so she walked around the nurses station to grab something. She said she did not see the surveyor open the drawers and take pictures. During an interview with the DON on 01/10/2026 at 10:48a.m., revealed she had been trained on medication storage. She said the medication cart policy was that the medication cart must be locked when not in use or the nurse was not around the cart. She said the medication aide and the nurses who passed the medication were responsible for locking the carts. She said if the cart was left unlocked the residents could get into the cart and take medications that are not prescribed to them. She said the DON monitors to ensure the cart were locked, She said the DON monitored through observations. She said if she saw a medication cart unlocked she would tell the staff to lock the medication cart and start an in-service. She said she did not know why RN A left her cart unlocked. During an interview with the ADM on 01/10/2026 at 12:44p.m., he was not clinical, but his expectation was for staff to lock the medication cart. He said the medication cart must be locked when staff were not using the medication cart. He said the person who was on the cart was responsible for locking the cart, but any staff can lock it. He said if the medication cart was left unlocked and unattended it could cause a drug diversion, or a resident could get into the medication cart. He said all staff monitored to ensure the medication carts were locked. He said if staff saw a medication cart unlocked the staff member should lock the cart. He said he did not know why RN A left her medication cart unlocked. Record review of Storage and Expiration Dating of Medications and Biologicals Policy dated 6/30/2025, revealed Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for one (1) (Resident #1) of six (6) residents reviewed for abuse and neglect.The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #1 on 09/15/2025. The facility did not notify law enforcement.This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuse.Findings Include: Record review of Resident #1's face sheet, dated 09/16/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Major Depressive Disorder ( is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life.), Borderline Personality Disorder (unstable moods, behavior, intense relationships, distorted self-image), Unspecified Psychosis (a psychiatric diagnosis used when a person experiences symptoms of psychosis but does not meet the full criteria for a specific psychotic disorder, such as schizophrenia or delusional disorder.) not due to a substance or unknown physiological condition. Face sheet also reflected Resident #1 is her own RP.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Review of Resident #1's care plan revised 05/25/2025 reflected Resident #1 had history of trauma, history of making false allegations/inaccurate statements as evidence by previously accusing with intervention of staff will investigate allegations/statements as per facility policy.Review of Resident #1's progress notes written by the DON dated 09/15/2025 at 1:00 pm reflected: I was called to patient's room by staff regarding an allegation of possible abuse. When I asked [Resident #1] what happened, she stated that a Tall black man touched her vagina last night. She stated that the incident occurred around 3 am last night. She reported no injury, pain or irritation to the vaginal area, I instructed her staff nurse to do a complete skin survey. I then requested statements from staff who were present on that hall last night. I also suspended the black aide who worked that hall pending an investigation.Review of Resident #1's progress note written by RN A dated 9/15/2025 at 2:38 pm reflected: [MD] informed to this nurse that [Resident #1] want to talk to you about her concern. When this nurse went to see [Resident #1], she stated someone black aide came to my room and touched my vagina at night. This nurse informed DON and ADON immediately. On floor NP and ADON with this nurse went to do assessment on resident. On assessment [Resident #1] mentioned that black guy touched my upper pubis area (mons pubis) and there were no signs of skin discoloration. [Resident #1] refused for any pain or discomfort.Review of Resident #1's Progress notes and clinical records reflected no evidence of Resident #1 being offered to speak to Law Enforcement and Resident #1 refused. A review in TULIP reflected on 09/15/2025 at 2:48 pm the facility reported to HHSC: Description of the Allegation: [Resident #1] reported that a tall black man came into her room and touched her vaginal area.Other Pertinent History: Resident has history of verbal aggression and making false accusations.Actions and Notifications.Review of facility's in-services reflected an in-service titled Abuse and Neglect Reporting dated 09/15/2025.Review of facility's investigation document reflected safety check of residents on the hall with Resident #1 was completed on 09/16/2025 and it reflected no concerns regarding abuse. A review of facility's Provider investigation Report dated 09/22/2025 reflected CNA B denied the allegation. Assessment: Complete skin assessment was performed by the ADON, and no injury, bruising or irritation was found.Were other parties notified? Example: physician, family, ombudsman: NP, RP, Admin, DON, MD.Provider Action Taken Post-Investigation: in services conducted abuse, neglect, reporting incidents, staff member suspended pending investigation.During an interview on 09/16/2025 at 11:30 am, Resident #1 stated the other night to the morning hours, there was a tall dark man in her room, he had grabbed her on her vagina, and she said NO! STOP! Resident #1 stated the tall dark man was wearing a tank top and a pajamas like pants with flag on it. Resident #1 said she had never seen the tall dark guy in the facility before, but he kept holding her vagina and about 10 minutes into it, another male voice came from her doorway. Resident #1 stated she did not see the other male because her bathroom door was opened and it prevented her from seeing the person at the door. Resident #1 stated she didn't tell anyone at the time of the incident because she thought the male voice that came from the doorway had taken care of it by reporting the incident. Resident #1 stated later that day she reported the incident and stated she was raped but that was not the right word to use, the right terminology was she was sexually molested. Resident #1 stated she had been raped before in the past that is why the word rape came out. Resident #1 stated RN A, the NP and the ADON came into her room and assessed her, and she explained what had happened. Resident #1 stated she also spoke with the DON and explained the incident. Resident #1 stated the DON had asked her to write a statement after she had already explained the incident to him and she refused to write the statement.During an interview on 09/16/2025 at 11:55 am RN A stated she was called by the MD to Resident #1's room due to Resident #1 having a concern. RN A stated she went into Resident #1's room while the MD was present and Resident #1 stated a black man touched her private part and she screamed. RN A stated she called the ADON and the DON and explained what Resident #1 had said. RN A stated the NP was in the facility and was notified. RN A stated she, the ADON and the NP went into Resident #1's room and assessed Resident #1. RN A stated there were no bruises, no indication of vaginal penetration so Resident #1 was not sent to the hospital. RN A stated when they went to assess Resident #1, Resident #1 said she was touched on the pubic area, not the vagina. During an interview on 09/16/2025 at 12:18 pm, LVN C stated she was the nurse assigned to Resident #1 on the night of the alleged abuse. LVN C stated her assigned CNA was CNA B. LVN A stated she was not made aware of the alleged abuse by Resident #1 who was usually vocal and was able to express her needs. LVN C stated CNA B was wearing scrub pants with the American flag and black t-shirt on the night of the alleged abuse. LVN A said she was called by the DON to come to the facility and write a statement regarding the incident. During an interview on 09/16/2025 at 2:11 pm CNA B stated he worked the hall with Resident #1 on the night of the alleged abuse. CNA B stated he worked with CNA D, they teamed up to provide care for the residents assigned to both of them. CNA B stated during his final shift rounds by about 4am in the morning, he checks on every resident to make sure they were still alive and breathing. CNA B stated he never went into Resident #1's room by himself, he was with CNA D.CNA B stated he did not have to check and change Resident #1 because she went to the restroom on her own. CNA B stated he was called by the DON to come and write a statement and that he was suspended pending investigation.During an interview on 09/16/2025 at 2:41 pm the DON stated he heard about the alleged abuse on the afternoon of 09/15/2025. The DON stated the MD was rounding at the time when Resident #1 made the allegation. The DON stated RN A notified him and he immediately went to speak to Resident #1 to find out what had happened. The DON stated the female nurses (ADON, RN A and the NP) went and assessed Resident #1 and found nothing. The DON stated he then called HR to suspend CNA B because that was his assigned hall and Resident #1 had described the pants he was wearing the night of the allegation. The DON stated the Administrator was out on vacation and he was responsible for completing the investigation regarding the alleged abuse. The DON stated he had initiated an in-service on abuse and neglect, reported the alleged allegation to HHSC, completed head-to-toe assessment on Resident #1, spoke with the night nurse and so far, that was thorough and there was nothing else that needed to be done, even though Resident #1 has a history of false accusations. The DON stated he did not notify law enforcement/police because Resident #1 did not describe anything other than he was touching her there, on top of her stomach. The DON stated Resident #1 only wanted the facility to know what had happened and did not want to press charges. The DON later stated, it was hours later, the AP was not here, I didn't necessarily believe her [Resident #1]. During a phone interview on 09/16/2025 at 2:59 pm CNA D stated he worked the night of the alleged abuse. CNA D stated usually he and CNA B would make rounds together on their shift but on the night of the alleged abuse, he did not make rounds with CNA B. CNA D stated he went to help CNA B on the morning of 9/15/2025 at about 4:30 am and CNA B was already done with Resident #1's room. CNA D stated he did not see CNA B when he entered Resident #1's room. During an interview on 09/25/2025 at 11:45 am, Resident #1 stated, they pull down my pants, they used multiple phones flashlights to assess me. I wanted to make a police report, but the police were not called. They did not offer or promise to call the police after being molested by a guy.During an interview on 09/25/2025 at 12:34 pm the NP stated she, RN A and the ADON assessed Resident #1 after Resident #1 alleged she was abused. The NP stated Resident #1 stated that someone had touched her in her peri area. The NP stated she looked for bruising and open areas and there were none, there was no sign that someone penetrated her, no discharge, no bruising, no marking, nothing internal, it was external. The NP stated Resident #1 stated she didn't want [CNA B] in her room anymore. The NP stated Resident #1 did not ask to talk to the police and she did not hear anything about the police.During an interview on 09/25/2025 at 12:41 pm the Social Worker stated she spoke with Resident #1 after the alleged abuse and Resident #1 stated she used the word rape which was a strong word to use but she was angry and upset of the incident, so she said rape. The Social Worker stated Resident #1 did not express wanting to talk to the police, if she [Resident #1], she would have called the police. The Social worker stated she completed a safety check on 09/16/2025 with all the residents on the hall with Resident #1 to ensure they all felt safe.During an interview on 09/25/2025 at 2:30 pm the Administrator stated if there was an allegation the staff needed to report to him, if he was not available, the staff needed to go to the DON. The Administrator stated, in his absence, the DON takes over investigations. The Administrator stated when Resident #1 alleged abuse, he was on vacation. The Administrator stated if there was an allegation of abuse, the expectation was to make sure the resident was safe, assess the resident, interview staff and anyone with knowledge of the incident, in-service staff, ask other Residents of anything in-appropriate, follow up on the investigation, monitor depending on what is going on, report to HHSC, complete the 5 days investigation report. The Administrator stated the facility follows the provider letter from HHSC regarding abuse and neglect and he was going to look at it to confirm if he was supposed to notify law enforcement. The Administrator stated he was made aware of Resident #1 allegation of abuse, but he did not participate in the investigation. The Administrator stated he spoke with Resident #1 on 09/18/2025, and Resident #1 stated she didn't say it right; it was not rape. The Administrator stated Resident #1 said a tall black man came in her room and touched her, she didn't see who it was, said she didn't like it. The Administrator stated he told Resident #1 the facility will provide female CNAs only for her care to be safe. The Administrator stated, for Resident #1 it was hard with her because of her delusion and hallucination. The Administrator stated the AP was suspended pending investigation. The Administrator stated, I was not here, I don't know who was notified, she [Resident #1] did not ask for the police, we want to investigate first before calling the police. I did not know we had to notify law enforcement The Administrator stated the DON completed the investigation, he looked at it after the DON had completed the investigation and he felt it was thorough. Review of facility's policy titled Abuse Prevention and Prohibition Program dated 08/2020 reflected: Purpose- To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Ill. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems.VI. InvestigationA. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.i. The Facility has protocols for investigations of theft/misappropriation of resident property abuse. See Policy No. -AP - 11-Theft Prevention.B. If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee may appoint a member of the Facility's management team (theInvestigator) to investigate the alleged incident.i. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident.IX. Reporting/Response D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. See AN - 01- Form E - Initial Report - Facility Reported Incidents.i. Immediately, but no later than 2 hours after forming suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).

Based on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. The facility failed to develop Resident #1's comprehensive care plan to address all Resident #1's care needs. Resident #1's comprehensive care plan did not address the need for pain medication / management, risks for pressure ulcer development, assistance needed for ADL care, incontinence to bowel and bladder, medications Resident #1 was taking to manage disease processes, Hospice care, reason for oxygen therapy, DNR status, fall risk, elopement risks. This deficient practice could place residents at risk for not receiving necessary care and services. Findings included:Review of Resident #1's face sheet printed [DATE] reflected a [AGE] year-old male who was admitted on [DATE]and readmission of [DATE] with the following dx: Chronic Obstructive Pulmonary Disease ( is a condition caused by damage to the airways or other parts of the lung), Type 2 Diabetes Mellitus without complication (happens when the body cannot use insulin correctly and sugar builds up in the blood) , Pneumonia ( an infection in one or both of your lungs. It causes the air sacs of your lungs to fill up with fluids and pus), Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), bipolar disorder ( is a mental health condition that causes extreme mood swings), Depression (also known as Depressive Disorder, is a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. It is different from regular mood changes), chronic kidney disease (is characterized by the presence of kidney damage. It is a stat of progressive loss of kidney function), Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms (refers to the non-malignant growth or hyperplasia of prostate tissue and a common cause of lower urinary tract symptoms in older men), Low back pain, Jaw pain, Age related decline, Asthma (a chronic lung disease affecting people of all ages. It is caused by inflammation and muscle tightening around the airway which makes it harder to breathe.). Review of Resident#1's Significant change MDS assessment dated [DATE] reflected a BIMS score of 11, indicating moderate cognitive impairment. *Section H-Bladder and Bowel reflected Resident #1 was occasionally incontinent to bladder and frequently incontinent to bowels. *Section I- Active Diagnoses reflected the following diagnoses: Bipolar Disorder, Depression, Respiratory failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus without complication, Pneumonia, Essential (Primary) Hypertension, chronic kidney disease, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms, Low back pain, Jaw pain, Age related decline. *Section J-Health Conditions reflected Resident #1 received scheduled pain medication and PRN pain medication. Section-J also reflected Resident #1 pain frequency was frequently at a numeric rating of 7 on the scale 0-10 with 10 being the highest. *Section-M-Skin Condition reflected Resident #1 was at risk of developing pressure ulcers and pressure reducing device for bed was needed. *Section N-Medication reflected Resident #1 was taking the following medication: antipsychotic, antianxiety, antidepressant, opioid, antiplatelet, anticonvulsant. *Section O-Special Treatments reflected Resident #1 was on oxygen therapy and on Hospice care. Review of Resident #1's comprehensive care plan initiated [DATE] reflected only 2 care areas were addressed: The resident has Pneumonia. Azithromycin ordered and the resident has a behavior problem r/t smoking while oxygen is flowing. Further review revealed Resident #1's comprehensive care plan did not address the need for: *pain medication / management, *risks for pressure ulcer development, *assistance needed for ADL care, *incontinence to bowel and bladder,* medications Resident #1 was taking to manage disease processes, *Hospice care, *reason for oxygen therapy, *DNR status, *fall risk, and *elopement risks. Review of Resident #1's clinical assessments reflected the following:*Fall Risks evaluation completed [DATE] reflected a score of 15 indicating high fall risk.*Elopement Risks evaluation completed [DATE] reflected a score of 9 indicating imminent risk for elopement. Review of Resident #1's physician orders reflected the following orders: *Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 6 hours for wheezing, shortness of breath given while awake dated [DATE].*DILTIAZEM 24HR ER (CD) 240MG CAP ER 24H Give 1 tablet by mouth one time a day for blood pressure dated [DATE] *Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 2 capsules by mouth one time a day for benign prostatic hyperplasia dated [DATE].*Mirtazapine Tablet 7.5 MG Give 7.5 mg by mouth at bedtime for appetite dated [DATE] *Montelukast Sodium Tablet 10 MG Give 10 mg by mouth in the morning for Asthma dated [DATE] *Nicotine Transdermal Patch 24 Hour (Nicotine) Apply 14 mg transdermally one time a day for tobacco cessation apply every morning dated [DATE] *traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 4 hours as needed for painOxygen at 3-4 l/m via nasal canula every shift related to CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA (occurs when oxygen is insufficient at the tissue level to maintain adequate homeostasis) OR HYPERCAPNIA (when you have too much carbon dioxide in your blood) dated [DATE]*predniSONE Oral Tablet 20 MG (Prednisone) Give 1 tablet orally one time a day for allergic reaction dated [DATE] *Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia dated [DATE] *OXcarbazepine ER Oral Tablet Extended Release 24 Hour 150 MG (Oxcarbazepine) Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, UNSPECIFIED dated [DATE] *QUEtiapine Fumarate Tablet 100 MG Give 1 tablet by mouth two times a day related to BIPOLAR DISORDER, UNSPECIFIED dated [DATE] *Admit pt. to hospice Dx: COPD dated [DATE] *DNRCC (DNR Comfort Care)-dated [DATE]. Review of Resident #1's progress notes dated [DATE] at 09:45 p.m., written by LVN A reflected Resident #1 had expired on hospice services. During an interview on [DATE] at about 11:33 a.m., the ADON stated the MDS nurse was responsible for developing and updating comprehensive care plan. The ADON stated she had never done any updates on care plans. The ADON stated sometimes the DON made adjustments and update care plans when there was a change in condition. During a telephone interview on [DATE] at 12:15 p.m., the MDS Nurse stated he had worked part-time at the facility for about a year as the MDS Nurse. The MDS Nurse stated he was responsible for care plans and MDS assessments. The MDS Nurse stated MDS assessments were done every 90 days, and care plan should be updated after each MDS assessment whenever there were changes. The MDS Nurse stated the DON, ADON and floor Nurses could also update the care plan wherever there were changes in the Resident's care, not just the MDS Nurse. The MDS Nurse stated it was important to update the care plan to reflect the care that the resident was receiving. He stated residents would be impacted if the care plan was not updated. The MDS Nurse stated if a resident signs a DNR, the social worker could update the care plan. The MDS Nurse stated if a Resident code status change from full code to DNR and he was not aware, whoever changed the code status could update the care to reflect it. The MDS Nurse stated he was aware Resident #1 was placed on hospice care, and his code status had changed, and it should have been care planned. The MDS Nurse stated Resident #1 diagnoses for which he was being treated should have been care planned. The MDS Nurse reviewed Resident #1's only comprehensive care plan and stated he did not know why Resident #1 comprehensive care plan had only two (2) care areas (Pneumonia and smoking with Oxygen). During an interview on [DATE] at 1:17 pm the Social Worker stated she has never updated care plan. The Social Worker stated If a resident was not on hospice, she would help with the DNR documents and upload the document into the Resident's electronic records and alert the MDS nurse. The Social Worker stated Resident #1 hospice handled the DNR process. The Social Worker stated DNR should be care plan because that was what decided the proper procedure the facility should go through keeping in mind Resident's preferences. During an interview on [DATE] at 1:30 pm the DON stated baseline was due within 24 hours and Comprehensive care plans should be developed within the first week of admission and periodically. The DON stated he sometimes made adjustments and updates to like care plan when there were changes like a resident starting an antibiotic. The DON stated he usually reviews the dashboard for medication related changes, if there was a risk management issue such as falls. The DON stated it was important to update a care plan because care plans should reflect the residents' care needs. The DON stated he expected care plan to be updated when the MDS was done. The DON stated, if a resident was DNR, it should be reflected in the care plan. The DON stated the floor nurses should be updating the care plan for DNR and Hospice care. The DON stated a lot of times the nurses let him know if a Resident's code status had changed. The DON stated, he would look into Resident #1's care plan, he did not know Resident #1's care plan was not fully developed. The DON stated, ultimately, there was a negative outcome if a resident's care plan was not fully developed, the care plan should reflect what care was being provided or should be provided. During an interview on [DATE] at 2:16 p.m., the Administrator stated he had to review the care plan policy, look at protocols and know the timeline for care plan development. The Administrator stated he was aware that everything that a resident needed should be reflected in their care plan, it gave the story of the resident. Review of facility's policy revised [DATE], titled Care Planning reflected: Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA (Omnibus Budget Reconciliation Act-requires that each state establishes a pre-admission assessment program for any nursing home facility participating in Medicare and Medical Assistance Program) and MDS guidelines.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases. Procedure:VIII. A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative.B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan.IX. Each resident's Comprehensive Care Plan will describe the following:A. Services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being.B. Any services that would be required but are not provided due to the residents' exercise of rights, which includes the right to refuse treatment.C. Any specialized services including rehabilitative serviceD. The residents' goals for admission and desired outcomes. X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including comprehensive and quarterly review assessments.XI. The Comprehensive Care Plan must be prepared by the IDT team.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for two (Resident #1 and Resident #2) of five residents reviewed for accidents and hazards. The facility failed to: - Address or put in place new interventions when Residents #1 and #2 had a change-in-condition and began experiencing more frequent falls in a short time-frame. - Implement the new intervention of a helmet that was documented in a nursing noted for Resident #2 after a fall on 07/27/24. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 09/18/24 at 9:15 AM. While the IJ was removed on 09/19/24 at 3:55 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of harm, injuries, or hospitalization . Findings included: Resident #1 Review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including COPD (a chronic lung disease), morbid obesity, TBI, and a risk of falling. Review of Resident #1's quarterly MDS assessment, dated 07/17/24, reflected a BIMS of 8, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had not experienced any falls since admission. Review of Resident #1's quarterly care plan, dated 09/03/24, reflected she was a moderate risk for falls related to gait/balance problems with an intervention of evaluation and treating as ordered or PRN. The care plan was not revised or updated to include additional interventions after she experienced falls on 08/21/24, 08/23/24, and 08/24/24. Review of Resident #1's progress notes, dated 08/21/24 at 8:28 PM and documented by LVN A , reflected the following: [Resident #1] noted lying on her right side in front her wheelchair I missed my bed while transferring myself I just sled [sic] off the chair I have no pain from the fallstated [sic] assessed for injuries none noted assisted to the bed . Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/21/24. Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/21/24 at 7:23 PM. Review of Resident #1's progress notes, dated 08/23/24 at 3:22 PM and documented by RN B , reflected the following: [Resident #1] had an unwitnessed fall in her room. She denied hitting her head on the floor. Head to toe examination was done and no obvious injuries were noted . Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/23/24. Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/23/24 at 5:52 PM. Review of Resident #1's Fall Risk Evaluation, dated 08/23/24, reflected she was a high risk for falls. Review of Resident #1's progress notes, dated 08/24/24 at 7:34 AM and documented by LVN C , reflected the following: CNA called this nurse. This nurse entered room and found [Resident #1] lying on the bathroom floor in prone position. Put [Resident #1] back to wheelchair with 3 people assistant [sic]. [Resident #1] able to explain the situation. I was self-transferred [sic] to use toilet and fell . [Resident #1] complained pain on left hip and forehead 10 out of 10. [Resident #1] has a big bump on top of left eye. It's getting bigger. Sent to (hospital) . Review of Resident #1's progress notes, dated 08/24/24 at 1:32 PM and documented by LVN C, reflected the following: [Resident #1] came back with EMS stretcher. [Resident #1] companied [sic] of pain left hip and left side of forehead. Gave pain medication. CT scan is cleared . Review of Resident #1's ER discharge documentation, dated 08/24/24, reflected she was seen for a hematoma of scalp. Review of Resident #1's Fall Risk Evaluation, dated 08/24/24, reflected she was a moderate risk for falls. Review of Resident #1's progress notes, dated 09/02/24 at 9:37 AM and documented by LVN C, reflected the following: [Resident #1] was found on the floor at 8:20 AM, face down and bleeding from the forehead. [Resident #1] was unresponsive and without a pulse . Review of Resident #1's hospice note, dated 09/02/24, reflected the following: .ME contacted at 10:37 AM spoke with the investigator (name), gave ME all information on [Resident #1] and past falls that occurred. ME stated that they will be picking up the body d/t falls . [Resident #1]'s left eye is dark purple d/t fall last weekend. On 09/03/24 at 11:27 AM, all neurological checks for Resident #1 for the past month were requested from the ADM. During an interview on 09/03/24 at 12:00 PM, the ADM stated he was being told that there was only one neurological check conducted and had a copy of the one from 08/23/24. During an interview on 09/03/24 at 5:03 PM, the DON stated the last time she saw Resident #1 was on 08/30/24. She stated she remembered she had bruising from a fall by her left eye but could not remember the color. She stated it was the nurses' responsibility to document bruising in the residents' progress notes and skin assessments. The DON was asked if it met her expectations that the bruise was not documented and she stated, Well, it was fading . Resident #2 Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including mild intellectual disabilities, age-related physical debility, unsteadiness on feet, and other lack of coordination. Review of Resident #2's significant change in status MDS assessment, dated 07/26/24, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had experienced a fall since admission that resulted in a major injury. Review of Resident #2's quarterly care plan, dated 06/12/24, reflected she had an actual fall with an intervention of checking range of motion daily. The care plan was not revised or updated to include additional interventions after she experienced falls on 06/14/24, 07/21/24, and 07/27/24. Review of Resident #2's progress notes, dated 06/14/24 at 7:17 PM and documented by LVN B , reflected the following: [Resident #2] was transferred to the hospital post fall. The documentation did not reflect what/how the fall occurred. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 06/14/24. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected six neurological checks were conducted; 06/14/24 at 10:14 PM and 06/15/24 at 6:27 AM, 6:34 AM, 6:42 AM, 1:24 PM, and 11:37 PM. Review of Resident #2's ER documentation, dated 06/14/24, reflected the primary impression was a scalp contusion. Review of Resident #2's progress notes, dated 06/19/24 at 12:44 PM and documented by the DON, reflected the following: [Resident #2] was sent to the hospital for further evaluation . There was no documentation reflecting why further evaluation was needed. Review of Resident #2's progress notes, dated 07/21/24 at 1:25 PM and documented by LVN E , reflected the following: . [Resident #2] was found kneeling on the floor, using her hands to hold the upper body up. She was morning [sic] in pain, while bleeding from the back of her head . 911 was called . Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/21/24. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted on 07/21/24 12:00 PM. Review of Resident #2's progress notes, dated 07/27/24 at 12:39 AM and documented by LVN A, reflected the following: [Resident #2] returned from (hospital) . [Resident #2] has dx of L1 fracture and well as seventh left side rib fracture . Review of Resident #2's progress notes, dated 07/27/24 at 5:14 PM and documented by LVN B, reflected the following: [Resident #2] fell in the hallway while using her walker to ambulate . Review of Resident #2's progress notes, dated 07/30/24 at 9:34 AM and documented by LVN B, reflected the following: . history of falls. Intervention for frequent falls will include use of helmet as an intervention. The helmet was not listed as an intervention in her care plan, nor was there a physician order for a helmet. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/27/24. During an observation and interview on 09/03/24 at 12:36 PM, Resident #2 was in the dining room eating lunch. She was unable to answer questions appropriately and was fixated on missing clothes. She was not wearing a helmet. Observation on 09/03/24 at 12:42 PM revealed the helmet was not able to be located in Resident #2's room. A telephone call was made on 09/03/24 at 12:48 PM to LVN B to ask about the documentation of the helmet. A returned call was not received prior to exiting. During an interview on 09/03/24 at 12:50 PM, LVN F stated if a resident had an unwitnessed fall, a head-to-toe assessment would need to be conducted. She stated she would document the fall and conduct neuros every 15 minutes X4, every 30 minutes X4, and so on for 72 hours. She stated neuro checks were documented in the residents' EMR, not on paper. LVN F stated she did not believe Resident #2 had a helmet as she had never seen her wearing one. During an interview on 09/03/24 at 2:37 PM, the DON stated after a resident has a fall the nurse is to complete an assessment. She stated after the assessment is complete, if there was no injury, the nurse would get the resident up. She stated the nurse then had to monitor the resident for three days. She stated if it was an unwitnessed fall you had to treat it as a head injury so neuro checks would need to be documented for 72 hours, a fall assessment would need to be completed, and one more thing, but I cannot remember what it was. She stated she was responsible for ensuring neuro checks were done and to complete any missing items. She stated it would not meet her expectations if neuro checks were not documented after a fall and maybe the nurses did them on paper - I am sure it is there. When asked why fall risk assessments were not completed accurately, why new interventions were not put into place when both Residents #1 and #2 began experiencing more frequent falls in a short time period, and why Resident #2's helmet intervention was never implemented, the DON just shook her head and said it probably all happened before she started working at the facility. She stated resident falls were discussed in the morning meetings and if need be, the IDT would get together to discuss new interventions for safety, but could not answer why this was not done for Residents #1 and #2. During an interview on 09/03/24 at 2:44 PM, LVN G stated neuro checks and fall assessments were documented in the residents' EMR, not on paper. During an interview on 09/03/24 at 2:50 PM, RN H stated neuro checks and fall assessments were documented in the residents' EMR, not on paper. During an interview on 09/03/24 at 4:17 PM, the ADM stated if an aide found a resident on the ground, they should notify the nurse immediately who would conduct a fall assessment and beigin doing neuros. He stated all falls were discussed in the morning meetings and the DON was responsible for ensuring all assessments were being completed. He stated a negative outcome of not completing all proper assessments could be that an injury could go missed, or if they hit their head, they could have a brain bleed. During an interview on 09/03/24 at 4:52 PM, the DON stated she started an in-service (that day) on neurological checks being documented on an observation sheet (paper). She stated she started the in-service because she could not find the missing neuro checks in the computer for Resident #1 and #2. During a telephone interview on 09/04/24 at 9:39 AM, Resident #1 and #2's MD stated he was notified of their increase in falls. He stated if a resident had an unwitnessed fall or hit their head, he would expect neurological checks to be conducted for 72 hours to ensure there was not a change in condition. He stated he would have expected the facility to have put new interventions in place when the falls increased. Review of the in-service entitled Falls, dated 09/03/24, reflected the following: Neurological checks must be done on all falls, witnessed and unwitnessed falls. Neuro checks will be done: Q 15 minutes X 4 Q 30 minutes X 4 One hour X 4 Every 8 hours until completion of 72 hours Review of the facility's Fall Evaluation and Prevention Policy, revised 08/2020, reflected the following: Purpose: To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility will evaluate residents for their fall risk and develop interventions for prevention . The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. Following a fall, the following steps should be undertaken: -Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status. - If there was a loss of consciousness or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours. - Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of injury. The ADM and DON were notified on 09/18/24 at 9:15 AM that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/19/24 at 7:40 AM: The notification of Immediate Jeopardy states as follows: F689 -The facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision. Action: DON and ADON in-serviced by CNO on Inservice on Fall Documentation and interventions, Assessments and interventions, on Fall policy and procedure, and on Abuse and Neglect. Start Date: 9/18/24 Completion Date: 9/18/24 Responsible CNO Action: In-service on Fall policy and procedure implemented to all nursing staff- Ongoing until 100% completion. All Nursing Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any nursing staff not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible: DON, ADON , Administrator Action: Inservice on Abuse and Neglect implemented to all staff, ongoing until 100% completion. Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any staff not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible DON, ADON, Administrator Action: Inservice on Fall Documentation, Assessments, and fall intervention, has been implemented with all Nurses, Ongoing until 100% completion. Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any Nurse not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible DON, ADON, Administrator Action: Audit all resident with fall risk to ensure interventions are in place and documented Start Date: 9/18/2024 Completion Date: 9/18/2024 Responsible DON, ADON, MDS, Administrator Action: ADHOC Qapi meeting conducted by IDT Team on fall events. Attending staff Admin, DON, ADON, SW, DOR, Activities Director will attend. Start Date: 9/18/2024 Completion Date: 9/18/2024 Responsible Administrator, DON, ADON, SW, DOR, Activities Director. The Surveyor monitored the POR on 09/19/24 as followed: During interviews on 09/19/24 from 11:56 AM - 3:20 PM, staff from all shifts were interviewed (one RN, four LVNs, four CNAs, and two MAs ). The CNAs and MAs all stated they were in-serviced before their shifts on abuse and neglect and the facility's fall policy. They all stated if they witnessed a resident on the floor, they would press the call light or call for a nurse so they could be assessed. They stated they would not move the resident nor would they leave the resident alone. The nurses all stated they were in-serviced before their shifts on abuse and neglect and falls. They all stated if a resident fell , they would immediately assess them with a head-to-toe assessment and ensure they were not bleeding. They would conduct a fall assessment, fall risk assessment, and start neurological checks if they hit their head or if the fall was unwitnessed. They all stated that neurological checks needed to be documented and continued for 72 hours. They all stated neuro checks popped up in the EMR when the next one was due. They stated the importance of documentation was to ensure all assessments had been completed and all of the nursing staff were aware of the fall. They stated if a resident began having more frequent falls, it was important to put further interventions in place to attempt to lessen the number of falls. During an interview on 09/19/24 at 3:06 PM, the DON stated she, the ADON, and ADM received training by their CNO. She stated fall risk assessments should be done on admission, quarterly, and after a fall. She stated neuro checks were to be done every 15 minutes x4, every 30 minutes x4, every hour for 24 hours, and completed after 72 hours. She stated she was completing daily audits after resident falls of nursing documentation of neuro checks, fall assessments, and fall risk assessments. Review of the facility's QAPI Meeting Agenda, dated 09/18/24, reflected the ADM, DON, ADON, SW, DOR, AD, and MD were in attendance. Review of an in-service, dated 09/18/24 and conducted by the CNO, reflected the ADM, DON, and ADON were in-serviced on the Fall Management Policy and Procedure. Review of an in-service, dated from 09/18/24 - 09/19/24 and conducted by the DON, reflected all staff were in-serviced on abuse and neglect. Review of an in-service, dated from 09/18/24 - 09/19/24 and conducted by the DON, reflected all nursing staff were in-serviced on frequent rounding, documentation of falls, conducting neuros, and fall and skin assessments, and their fall policy. Review of nine residents' EMRs that experienced a fall in September 2024, on 09/19/24, reflected updated care plans, a fall assessment, a fall risk assessment, and neuro checks as needed. While the IJ was removed on 09/19/24 at 3:55 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on record review, observations and interviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) experiencing falls. The facility failed to include frequent falls as a focus area to provide possible preventive interventions despite the resident having serious injuries from falls in his recent history, prior to admission and multiple falls since his admission. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. While the IJ was removed on 06/04/24 at 4:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at an increased risk for falls, injury, or death, due to an interdisciplinary team not having included interventions in the care plan developed specifically to meet the needs of each resident. Findings include: Review of Resident #1's Face sheet, undated, revealed he was admitted to the facility on [DATE] from a local hospital. Resident #1's admitting diagnoses included traumatic subdural hemorrhage (brain injury resulting in a bleed from a vessel causing blood to collect between the brain and skull), epileptic seizures, fracture of skull and facial bones, unspecified fall. Review of Resident #1's Local Hospital Discharge Summary dated 4/29/24 revealed Resident #1 had been admitted on [DATE] with a problem list of 1.Fall with Injury (Acute, Onset:3/13/24) 2. Intercranial subdural hemorrhage (Acute, Onset:03/13/24) discharge date [DATE] Discharge diagnosis: Found down with TBI Pt condition on discharge: stable. Review of Resident #1's 5-day MDS assessment, dated 5/3/24 revealed a BIMs score of 10 indicating moderate cognitive impairment. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is yes. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.). Review of Resident #1's Admission MDS assessment, dated 5/3/24 revealed a BIMs score of 10 indicating moderate cognitive impairment. Section GG notes Resident #1 is dependent on staff helper does all the effort to walk ten feet. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is No . For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.) Review of Resident #1's Care Plan revealed falls are not included in the areas addressed. The only area addressed with a goal and interventions is elopement initiated on 4/29/24. Another focus area listed was the resident requires antidepressant medication. There are instructions to include the medication and the diagnosis, however, neither are included. There are no goals and no interventions. The focus area was initiated 5/1/24. The third and final focus area states the resident has impaired cognitive function/dementia or impaired thought processes. The goal is the resident will maintain his current level of cognitive functioning. No interventions are listed. Review of Resident #1's Care Plan Conference, dated 5/6/2024 revealed that other than the resident's name and date the form is blank . Review of Resident #1's Nursing Progress Notes reveals falls documented on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/10/24, 5/15/24, and 5/30/24. The fall on 5/1/24 required a trip to the hospital for a CT scan after Resident #1 complained of hitting his head. The fall on 5/30/24 required overnight hospitalization after the facility nurse found Resident #1 on the floor in his bathroom with a knot to the back of his head. Observations and interview on 6/1/24 at 9:40 AM of Resident #1's room revealed he was sitting in the room attempting to put on his shoes. Resident #1's bed was noted to be neatly made with the call light attached to the top cover of the bed which was at a normal bed height. A fall mat was noted to be folded against the wall on the opposite side of the room near an empty bed. When asked what the call light was for Resident #1 was unsure. When asked if he could use it to call for help such as when going to the bathroom, Resident #1 denied that he needed help and began to stand from his wheelchair. Resident #1 was able to read a sign on his wall that said his family did his laundry but there were no other signs in the room including any to prompt him to call for help. Observation on 6/1/24 at 1:40 PM of Resident #1's room revealed the bed remained at a normal height and fall mat remained in the same position against the wall on the other side of the room. Interview on 6/1/24 at 10:25 AM with Resident #1's FM revealed there is a concern that he will reinjure his head with all these falls he has been experiencing at the facility. The FM stated he had a TBI in 2004 and recently a few months ago was found wandering around after a fall at his apartment and his brain bled again causing the damage to his brain to be worse. They were told that he does not need to be getting any further injuries to his head. The FM stated the facility is frequently calling family saying that he has fallen but they will lower his bed and use a mat beside his bed. It does not seem to have worked. The FM stated I wish they would understand that he is probably trying to take himself to the bathroom when he falls, does anyone ever ask him if he needs to go to the bathroom and offer to help. He frequently is urinating in clothes baskets and trash cans. He has brain damage he cannot remember to call for help, they say they are reminding him but that is not helping either. The FM stated they have not been asked to meet with a team to discuss a plan of care about him they have just been telling ideas to random people that they meet one time then the next time they go it will be somebody new in that position. The FM has tried explaining to staff Resident #1 is left-handed and gets up from the bed easier if he can use that side, but they have the bed positioned so that is not possible . The FM stated it seems as though it is just a matter of time before he has a fall that will hospitalize him again. Interview on 6/1/24 at 1:45 PM with CNA A who had worked the 6am to 2pm shift, revealed that she was unable to speak English. When the surveyor pointed to the mat folded against the wall and asked if it was for Resident #1, MA B came in from the hallway and said CNA A did not understand what the surveyor was asking but it was a mat for Resident #1 and the bed was supposed to be in a low position but Resident #1 must have moved the mat and lowered the bed. MA B was asked to ask CNA A if she was aware the bed was to be low and fall mat was to be beside his bed, and CNA A shook her head No. MA B stated CNA A knows now because she just explained it to her. Interview on 6/1/24 at 1:47 PM with MA B revealed she had been aware of fall precautions were to be in place for Resident #1 but had not noticed today that they were not in place. When asked how she and the CNAs learn who is on fall precautions she stated the nurse for the hall would tell the staff in the morning rounds. Interview on 6/1/24 at 1:58 PM with RN C revealed he is the nurse for Resident #1's hall working the 6 AM to 6 PM shift. RN C stated he was made aware this morning during report, from the previous nurse, that Resident #1 had returned from the hospital yesterday after a fall during which he had hit his head. RN C stated the nurse had written on the 24-hour report that the resident was a high fall risk, but RN C was not aware that included the use of the fall mat and bed in lowest position, therefore he was not checking for those things this shift and had not told CNA A anything other than Resident #1 was a high fall risk. Interview on 6/1/24 at 2:04 PM with the facility DON revealed the mat and bed in low position would normally be in place, but the hospital had returned Resident #1 last night without giving them a heads up that he was returning and therefore the staff had probably not been prepared for him. Interview on 6/1/24 at 2:23 PM with CNA E revealed she is working the 2-10 shift tonight on Resident #1's hall. CNA E stated she has worked with Resident #1 multiple times during the month he has been here, but he has not fallen while she was working with him. She stated until today when she came into work, she was not aware that they were to be having the bed in the lowest position and a fall mat in place. CNA E stated she has seen Resident #1's bed low and fall mat in place but she did not know they were always supposed to have those precautions in place. CNA E stated there is not a place where the CNAs can look to see interventions/ care plan or what they are to do but the nurses will tell them when they come to work. If they have a question they can ask the nurse if they are available. CNA E stated the area where the CNAs document does say Resident #1 is high fall risk. But does not say anything about the bed position or fall mat. Interview on 6/1/24 at 3:07 PM with NP Q revealed she normally would be the NP for Resident #1. She stated she did not know about any of the falls except the one recently when he hit his head of the floor, so she sent him to the hospital. Her expectation is that if a resident has more than one fall, fall precautions are put in place. Interview on 6/2/24 at 9:56 AM with LVN F revealed that she had just come to work at 6 AM and was told Resident #1 was a 1:1 now because of the number of falls he had since his admission. LVN F stated she knew about his falling before today but felt like the nursing staff was doing all they could to protect him. If he falls, they lower his bed and put the mat down next to the bed. Now they will be adding the soft helmet. When asked how long the bed is to stay on low and fall mats should be in place, she said it probably should stay that way but if not, then they do it each time he falls. Interview on 6/2/24 at 10:04 AM with CNA G revealed today is her first day to work with Resident #1. She stated she is providing the 1:1 and was told to make sure she uses the fall mat and document every 30 minutes what he is doing. She stated he mostly has been sleeping but when she asks him if he wants to go to the dining room or if he needs to go to the bathroom he does so without problems. CNA G stated she is trying to teach him to use the call light, and he seems to understand. Interview on 6/2/24 at 2:20 PM with CNA E revealed she will be providing Resident #1's 1:1 supervision tonight. She knows he needs to have the helmet, the bed in low position and the mat on the floor in front of the bed when he is in bed. When asked how she was aware of all that she said the nurse let her know and there is an in-service she read today. When asked if she is always able to remember each person's needs, she stated usually but if she does not, she can ask the nurse, and she has heard it is being added to the CNA's POC . When asked if she could show the surveyor the plan of care that CNAs use, she agreed. We went to the nurse's station, and she showed the surveyor where they document the amount of meals eaten and if the resident had been checked on every 2 hours. When asked where the mat, bed, 1:1 and helmet info was she initially was not sure and asked another staff to show her. The other staff found where there is a check off for whether the resident is incontinent and the use of the helmet, which was added today. There is no mention of the low bed or the fall mat use. Interview on 6/2/2024 at 11:49 AM with the MDS Nurse revealed he does at times add needed items to the care plans of residents, but he works as needed and part time. The MDS nurse stated that the DON and SW can also add anything needed. He does not recall developing a care plan for Resident #1, but he may have. He stated when someone was admitted it is usually the nursing staff or DON that will initiate a care plan. The MDS nurse stated when they are answering the section in the MDS assessment about falls they are only looking at the previous 7 days. If Resident #1 had as many falls as you are describing it should have been added to the care plan by the DON since he is usually only at the facility on weekends. The MDS nurse was asked if there is a purpose for the CNAs to see the interventions in the POC and he stated so that they can know those things need to be done for the residents. He stated he went over the Care Plan for Resident #1 yesterday and they added falls and the use of a fall mat and soft helmet. Interview on 6/3/24 at 3:30 PM with the facility DON revealed that when asked if he could provide any documentation regarding interventions and/or precautions put in place to prevent further falls he stated when a fall occurred, they put out a fall mat and have the bed in lowest position, that is the interventions. The nurses do so after every fall. When asked about documentation of these interventions the DON stated the nurse's progress notes will contain that information. When asked if the falls are being tracked for patterns which may provide additional interventions, the DON stated other interventions are listed on internal documents that could not be shared with the surveyor, and the falls are reviewed in the morning meetings. Investigations are performed by the nursing staff and are included in the progress notes. Additionally, the facility's written Incident Reports are internal documents that also could not be provided. He suggested the surveyor look at the progress notes of the nurses to obtain information needed. The DON stated he just became aware yesterday that he can add areas of focus to the care plan, he had not known before, and he agrees it should be added for this resident. Interview on 6/3/24 at 3:35 PM with the Administrator revealed he is aware there is a problem with the care plans. They have hired a new SW and have the MDS nurse so plan to make all corrections soon. The ADM stated they review all investigations that the nurse writes in the progress notes, during the morning meeting and are considering that as an interdisciplinary meeting for everyone who had an incident and/or accident. All department heads, administrators, nursing, wound care nurse, the DON, the activities person, and rehab medical director will sign off if there are any orders as a result of the meeting. The Administrator stated the fall precautions were put in place after each fall by the nursing staff. Each time a fall was documented it automatically populated the fall risk assessment, the bed being lowered to the lowest position and a fall mat being placed at the bedside. The Administrator stated they cannot prevent a person from falling that is an unrealistic expectation. The Administrator confirmed knowing that investigations at times provided other interventions such as the possibility of a toileting program to prevent Resident #1 from attempting to get up without assistance. He was not aware that Resident #1's family felt falls could be related to him trying to get to the toilet. Review of the facility policy titled Care Planning, undated, revealed, the Purpose of the policy is: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The policy includes that each resident's plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. I. The facility Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS Guideline II. The Care Plan serves as a course of action where resident (resident family and/or guardian or other legally authorized representative), resident's attending physician, and IDT work to help the resident move toward resident specific goals that address the resident's medical nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems resolution of current problems and as deemed appropriate by clinical assessment and judgement on an as needed bases . The ADM was notified on 06/01/2024 at 06:03 PM, that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/04/2024 at 12:35 PM, and included: Plan of Removal Immediate Jeopardy On 06/01/2024 an abbreviated survey was initiated at the facility. On 06/01/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F656 -The facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1's care plan did not include interventions to possibly prevent falls despite a history of falls with serious injuries. Action: A Fall reassessment for Resident #1 was completed by DON on 6/1/24 and the Care Plan was updated on 6/1/24 for Resident #1 to reflect the appropriate interventions to try to help prevent injury from further falls. Resident #1 and room was reviewed to ensure that documented interventions were in place as documented in the plan of care. Intervention for safety helmet placement and fall monitoring rounds was implemented. An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions during shift change and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: 06/01/2024 Completion Date: 06/01/2024 Responsible: DON Action: A full house fall risk reassessment was implemented and completed by DON for all residents to ensure no additional residents are at risk, and Care Plans will be updated to reflect appropriate fall interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON was reeducated on the facility fall management program policy and procedure along with communicating updated interventions. Start Date: 6/1/24 Completion Date: 6/1/24 Responsible: Clinical Nurse Consultant Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON will monitor that clinical staff is compliant with following the Policy and Procedure for the facility's Fall Management Program and their responsibilities which include communication during shift change, review of 24-hour report and implementation of interventions for any resident that is a fall risk. 24-hour report will be reviewed by DON during morning clinical meetings. DON will report progress with monitoring to the QAPI team for review to implement any needed changes or updates to ensure compliance. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: New system implementation of tracking resident falls and interventions in a fall tracking binder for daily review by charge nurses which will help identify residents with multiple falls and appropriate interventions. DON will audit binder for updates and completeness. DON will audit the binders daily for a week, biweekly for a month, monthly for QAPI. Audit results will be reviewed and shared with QAPI team. Start Date: 06/02/2024 Completion Date: 06/03/2024 Responsible: DON Action: An Ad-[NAME] QAPI meeting was held by DON, MD, and Administrator regarding facility fall management program policy and procedure along with communicating updated interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON The Surveyor monitored the POR on 06/04/24 as followed: During an interview on 6/4/24 at 9:35 AM with the Facility DON revealed. In-serviced staff on falls and ANE. Monitoring fall risk residents' daily and documenting to ensure interventions implemented and for any new incidents. No new incidents. Resident #1 family aware Resident #1 would get out of bed independently without asking for assistance and aware of Resident #1's impulsiveness, which was why Resident #1's family placed him in facility because they could not manage how often Resident #1 would fall. During an interview on 6/4/24 at 9:40 AM with the ADM, he said the facility updated Resident #1's care plan, implemented a new binder system on fall risk, put helmet on Resident #1, removed electronic control from bed, and ordered a PVC bed that would go on the floor for Resident #1 when the order arrived. Observation and interview on 6/4/24 at 10:16 AM of Resident #1 revealed he was lying in bed. Resident #1 was clean, dressed, and comfortable. Resident #1 had a fall mat next to his bed. Resident #1's bed was in low position. CNA J was sitting in a chair with 1:1 monitoring sheets across Resident #1. Resident #1 had two postings on the wall behind his bed that stated he was to wear a helmet when he got out of bed at all times and that he must have a fall mat next to his bed at all times. During an interview, Resident #1 stated he was doing fine, staff checked on him often, he had some falls in the past, staff were monitoring him, he wore a helmet whenever he got out of bed, his fall mat was always next to his bed, his bed was always in lowest position, and he had no concerns or issues. On 6/4/23 at 10:23am the facility POR for F656 was approved. During an interview on 6/4/24 at 10:21AM, CNA J revealed she was 1:1 monitoring Resident #1. CNA J stated she filled out a monitoring form that was submitted to the Charge Nurse at the end of her shift reflecting she monitored Resident #1 every 30 minutes. CNA J stated Resident #1 had no falls since her shift. CNA J also stated Resident #1's bed had been in the lowest position, had a fall mat next to his bed, and Resident #1 had been wearing a helmet for a while. CNA J did not know how long Resident #1 had the interventions that were previously mentioned or when the interventions started. She was in-serviced on falls and ANE before she started her shift. She learned how to prevent falls, listening to call lights, ensuring beds were at lowest position, ensuring fall mat on floor, ensuring belongings within reach, ensuring Resident #1 wore safety helmet, who and how to report ANE, and ADM was the abuse and neglect coordinator. During an interview on 6/4/24 at 10:30 AM, RN H revealed she had conducted 1:1 monitoring for Resident #1. RN H stated she documented the 1:1 monitoring every 30 minutes on a log. RN H also stated CNAs are 1:1 monitoring Resident #1 and logging their monitoring during their shift every 30 minutes. RN H stated she was in-serviced on falls and ANE. RN H also stated Resident #1 had a helmet on anytime he was out of bed, had a fall mat next to his bed at all times, and bed was in lowest position. RN H was in-serviced on how to respond to falls, resident rights, who and how to report ANE, and ADM was the abuse and neglect coordinator. Reviewed fall tracking binder daily. During an interview on 6/4/24 at 12:33 PM, ADM stated DON completed Resident #1's fall reassessment on 06/01/24. ADM also stated Resident #1's care plan was updated by the facility MDS Coordinator on 06/01/24. ADM stated DON reviewed Resident #1's room to ensure care plan interventions were implemented on 06/01/24. ADM also stated Resident #1's fall monitoring rounds conducted by clinical staff (nurses and CNAs) started every 30 minutes on 06/02/24 and ongoing. Resident #1's safety helmet placement was implemented. DON in-serviced clinical staff on fall management and ANE started on 06/01/24 and ongoing before staff started shifts. ADM stated he did not know CNA M was not in-serviced prior to starting his work shift on ANE and falls. DON conducted fall risk reassessment on all residents started on 06/01/24 and completed 06/02/24. He was not sure if there were any other residents identified as at risk and if there were any other residents who required updated care plans to reflect appropriate fall interventions. Clinical Nurse Consultant reeducated DON on fall management policy and procedure on 06/01/24. DON started daily monitoring clinical staff to ensure compliant with fall management by auditing the new system implementation of tracking resident falls and interventions in a fall tracking binder that was daily reviewed by charge nurses on 06/02/24. DON started reviewing all residents' 24-hour reports during morning clinical meetings started on 06/01/24 and completed 06/02/24. On 06/02/24, him, DON, and MD had QAPI meeting. DON reported progress with monitoring during the meeting. No changes or updates to ensure compliance needed to be done following QAPI meeting to discuss 24-hour reports. Charge nurses daily reviewed new system implementation of tracking falls and interventions from fall tracking binder started on 06/02/24 and ongoing. Observation on 6/4/24 at 1:17 PM of Resident #1 revealed he was sitting in his wheelchair and wore a safety helmet while watching tv in his room. During an interview on 6/4/2024 at 1:48 PM with the MDS Coordinator revealed he updated Resident #1's care plan on 06/02/24. He and the DON updated residents' care plans to reflect fall interventions on 06/01/24 and was ongoing. During an interview on 6/4/24 at 2:08 PM with the Clinical Nurse Consultant revealed she reeducated DON on 06/01/24 on fall management policy and procedure. During an interview on 6/4/24 at 2:11 PM, the ADM revealed Resident #1's safety helmet was implemented on 06/02/24. Review of the facility's in-services revealed clinical staff were trained on fall prevention protocol and interventions on 06/01/24-06/03/24. Review of Resident #1's care plan revealed his care plan was reviewed and revised on 06/01/24 to reflect new interventions. Review of Resident #1's progress notes revealed the following: On 6/1/24 at 7:57 PM RN H documentation included that Resident #1 was a high fall risk having had more than four falls the previous month. Resident #1's Care Plan was updated with fall risk prevention and management in-service was conducted regarding fall risk management and prevention. 1:1 sitter was implemented for his safety, other fall safety prevention was carried out including the bed in the lowest position, call light within reach and a fall mat next to his bed. On 6/2/24 at 10:53 AM LVN F documented Resident #1 remained with a 1:1 sitter, call light was within reach and resident was educated several times to use call light for help. During an interview on 6/4/24 at 2:18 PM, DON revealed he completed fall reassessment on Resident #1 on 06/01/24. MDS Coordinator and him sat and revised Resident #1's care plan on 06/01/24. He conducted fall risk assessment again on all residents on 06/02/24. There were some residents who were flagged as fall risks and nurses flagged some residents because nurses believed they were fall risks. He and the MDS Coordinator updated PCC profile to reflect residents were fall risks and the nurses and MDS coordinator updated care plans to reflect fall interventions started on 06/01/24 and ongoing. Clinical Nurse Consultant reeducated him over the phone on fall program policy and procedure on 06/01/24. She taught him on pulling fall reports, fall risk assessments, bed positioning, fall mat implementation, safety helmets, binder to track falls, ANE, and wander guards. He reviewed 24-hour reports during morning clinical meetings since his employment. He did not have anything to report to QAPI during meeting that needed changes or updates to ensure compliance. He started auditing the fall tracking binder daily since 06/02/24. 1:1 monitoring on the night of 06/01/24. He, ADM, and MD attended QAPI meeting on 06/02/24. Review of residents who were high risk for falls in PCC revealed care plans revised for fall risk, interventions, and PCC profile noted they were fall risks. Review of the facility's QAPI meeting, dated 06/02/24, revealed ADM, DON, and MD attended. The ADM was notified on 06/04/2024 at 03:50 PM that the Immediate Jeopardy was lowered. While the IJ was removed on 06/04/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

Based on record reviews, observations and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have repeated falls without attempts to decrease the severity and frequency of falls that continued to occur despite the same two interventions used each time a fall occurred. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. While the IJ was removed on 06/04/24 at 4:00 PM, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for falls possibly resulting in injuries including traumatic brain injury, hospitalization and/or death. Findings included: Review of Resident #1's Face sheet, undated, revealed he was admitted to the facility on [DATE] from a local hospital. Resident #1's admitting diagnoses included traumatic subdural hemorrhage (brain injury resulting in a bleed from a vessel causing blood to collect between the brain and skull), epileptic seizures, fracture of skull and facial bones, unspecified fall. Review of Resident #1's Local Hospital Discharge Summary dated 4/29/24 revealed Resident #1 had been admitted on [DATE] with a problem list of 1.Fall with Injury (Acute, Onset:3/13/24) 2. Intercranial subdural hemorrhage (Acute, Onset:03/13/24) discharge date [DATE] Discharge diagnosis: Found down with TBI Pt condition on discharge: stable Review of Resident #1's 5-day MDS, dated [DATE] revealed a BIMs score of 10 indicating moderate cognitive impairment. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is yes. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.). Review of Resident #1's Admission MDS, dated [DATE] revealed a BIMs score of 10 indicating moderate cognitive impairment. Section GG notes Resident #1 is dependent on staff helper does all the effort to walk ten feet. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is No. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.) Review of Resident #1's Care Plan revealed falls are not included in the areas addressed. The only area addressed with a goal and interventions is elopement initiated on 4/29/24. Another focus listed was the resident requires antidepressant medication there are instructions to include the medication and the diagnosis, however, neither are included. There are no goals and no interventions. The focus area was initiated 5/1/24. The third and final focus states the resident has impaired cognitive function/dementia or impaired thought processes. The goal is the resident will maintain his current level of cognitive functioning. No interventions are listed. Review of Resident #1's Nursing Progress Notes reveals falls on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/10/24, 5/15/24, and 5/30/24, which detail the following: 5/1/24 at 2:14 PM [Physician name] told this nurse resident fell on the floor. This nurse went in his room. Resident lying down on the right side of the bed. Resident complained of pain on both knees, has old scabs, said hit his head. [Physician Name] also assessed resident and got order to send resident out for CT scan. Took a set of vital signs and called non-emergent transportation. DON aware of it. 11pm resident returned from hospital scan was clear, denied pain no signs or symptoms of distress. 5/2/24 at 1:16 PM Resident was found on floor of his room, no visible injuries were noted he denies pain, and said he fell on the left knee. The administrator was notified, voice message left on MD on call number and the [family member] was notified. 5/5/24 at 2:44 PM Staff reports to the nurse that the resident is lying on the floor, Nurse walks into the resident room and see the resident lying between both beds, head on floor, resident reports I fell out of my chair, Intervention: Head to toe assessment, pain medication, on call NP notified, family aware. Plan to initiate neuros , Nursing will notify NP of any change of condition. 5/6/24 at 9:40 PM Resident noted on the floor by the bathroom door in his room, wheelchair beside him assessed for injuries none noted assisted to the bed, resident able to move extremities. 5/13/24 at 3:53 AM Resident noted on the floor in his room on his stomach by the window, bed on the lowest position. Resident stated he rolled off the bed. Assessed for injuries assisted to bed, NP/DON notified. Resident continues neuros as per facility protocol denied pain. 5/16/24 at 7:02 PM Resident was found lying on floor beside his wheelchair, no injuries noted at time of assessment. Resident was safely assisted back in wheelchair. Vitals and neuro checks conducted on him. NP notified of his condition, [family member] notified, all fall safety protocol carried out on him, fall mat next to his bed, bed in lowest position and call light within reach. Encouraged him to use call light if needs assistance, he verbalized understanding. DON notified of the incident. 5/30/24 at 4:35 PM Resident was found on the floor in his room close to the bathroom door he had a bump at the back of his head, he denies pain. Resident was transferred to hospital for further assessment. The [family member] was notified, and the NP was also notified. 5/31/24 at 7:36 PM Resident returned from hospital. Hospital admission for unwitnessed fall with impact to back of head. No new findings at the hospital. Review of an Incident Report summary for the month of May 2024 revealed Resident #1 listed as having falls on 5/1, 5/2, 5/5, 5/6 and 5/13. The summary consist of the resident's name, date, time, and the words fall, no injury. A review of the actual detailed Incident Reports was attempted but the documents were not provided, due to being considered internal documents. Review of Resident #1's Fall Risk Evaluations revealed an initial admission evaluation dated 4/29/24 with a score of 20 indicating high fall risk. Resident #1 was noted to be chair bound and requires assistance with toileting, having balance problems while standing, walking, or sitting, unable to stand independently. On 5/2/24 a post fall assessment shows Resident #1's fall risk score is noted to be twelve indicating high risk. On 5/5/24 a post fall assessment shows a score of 11 indicating high risk. On 5/6/24 a post fall assessment shows a score of 9 which does not indicate a high risk. On 5/16/24 a post fall risk assessment shows a score of 20 indicating high risk. Observations on 6/1/24 at 9:40 AM of Resident #1's room revealed he was sitting in the room attempting to put on his shoes. Resident #1's bed was noted to be neatly made with the call light attached to the top cover and the bed was a normal bed height. A fall mat was noted to be folded against the wall on the opposite side of the room near an empty bed. When asked what the call light was for Resident #1 was unsure . When asked if he could use it to call for help such as when going to the bathroom, Resident #1 denied that he needed help and began to stand from his wheelchair. Resident #1 was able to read a sign on his wall that said his family did his laundry but there were no other signs including any to prompt him to call for help. Observation on 6/1/24 at 1:40 PM of Resident #1's room revealed the bed remained at a normal height and fall mat remained in the same position against the wall on the other side of the room. Observation on 6/2/24 at 9:53 AM revealed Resident #1 was in his room in bed and appeared to be asleep. Resident #1's bed was in the lowest position; a fall mat was next to his bed and there was a 1:1 staff sitting in his room. Interview on 6/1/24 at 1:45 PM with CNA A who had worked the 6am to 2pm shift, revealed that she was unable to speak English. When the surveyor pointed to the mat folded against the wall and asked if it was for Resident #1. MA B came in from the hallway and said CNA A did not understand what the surveyor was asking but it was a mat for Resident #1 and the bed was supposed to be in a low position but Resident #1 must have moved the mat and lowered the bed. MA B was asked to ask CNA A if she was aware the bed was to be low and fall mat was to be beside his bed, and CNA A shook her head No. MA B stated CNA A knows now because she just explained it to her. Interview on 6/1/24 at 1:47 PM with MA B revealed she had been aware of fall precautions were to be in place for Resident #1 but had not noticed today that they were not in place. When asked how she and the CNAs learn who is on fall precautions she stated the nurse for the hall would tell the staff in the morning rounds. Interview on 6/1/24 at 1:58 PM with RN C revealed he is the nurse for Resident #1's hall working the 6 AM to 6 PM shift. RN C stated he was made aware this morning during report, from the previous nurse, that Resident #1 had returned from the hospital yesterday after a fall during which he had hit his head. RN C stated the nurse had written on the 24-hour report that the resident was a high fall risk, but RN C was not aware that included the use of the fall mat and bed in lowest position, therefore he was not checking for those things this shift and had not told CNA A anything other than Resident #1 was a high fall risk. Interview on 9/1/24 at 2:04 PM with the facility DON revealed that the mat and bed in low position would normally be in place but the hospital had returned Resident #1 last night without giving them a heads up that he was returning and therefore the staff had probably not been prepared for him. Interview on 6/1/24 at 2:23 PM with CNA E revealed she is working the 2-10 shift tonight on Resident #1's hall. CNA E stated she has worked with Resident #1 multiple times during the month he has been here, but he has not fallen while she was working with him. She stated until today when she came into work, she was not aware that they were to be having the bed in the lowest position and a fall mat in place. CNA E stated she has seen Resident #1's bed low and fall mat in place but she did not know they were always supposed to have those precautions in place. CNA E stated there is not a place where the CNAs can look to see interventions/ care plan or what they are to do but the nurses will tell them when they come to work. If they have a question they can ask the nurse if they are available. CNA E stated the area where the CNA's document does say high fall risk. But does not say anything about the bed position or fall mat. Interview on 6/1/24 at 3:07 PM with NP Q revealed she normally would be the NP for Resident #1. She stated she did not know about any of the falls except the one recently when he hit his head of the floor, so she sent him to the hospital. Her expectation is that if a resident has more than one fall, fall precautions are put in place. Interview on 6/2/24 at 9:56 AM with LVN F revealed that she had just come to work at 6 AM and was told Resident #1 was a 1:1 now because of the number of falls he had since his admission. LVN F stated she knew about his falling before today but felt like the nursing staff was doing all they could to protect him. If he falls, they lower his bed and put the mat down next to the bed. Now they will be adding the soft helmet. When asked how long the bed is to stay on low and fall mats should be in place, she said it probably should stay that way but if not, then they do it each time he falls. Interview on 6/2/24 at 10:04 AM with CNA G revealed today is her first day to work with Resident #1. She stated she is providing the 1:1 and was told to make sure she uses the fall mat and document every 30 minutes what he is doing. She stated he mostly has been sleeping but when she asks him if he wants to go to the dining room or if he needs to go to the bathroom he does so without problems. CNA G stated she is trying to teach him to use the call light, and he seems to understand. Interview on 6/2/24 at 2:20 PM with CNA E revealed she will be providing Resident #1's 1:1 supervision tonight. She knows he needs to have the helmet, the bed in low position and the mat on the floor in front of the bed when he is in bed. When asked how she was aware of all that she said the nurse let her know and there is an in-service she read. When asked if she is always able to remember each person's needs, she stated usually but if she does not, she can ask the nurse, and she has heard it is being added to the CNAs POC . When asked if she could show the surveyor the plan of care that CNA's use, she agreed. We went to the nurse's station, and she showed the surveyor where they document the amount of meals eaten and if the resident had been checked on every 2 hours. When asked where the mat, bed, 1:1 and helmet info was she initially was not sure and asked another staff to show her. The other staff found where there is a check off for whether the resident is incontinent and the use of the helmet, which was added today. There is no mention of the low bed or the fall mat use. Interview on 6/2/2024 at 11:49 AM with the MDS Nurse revealed he does at times add needed items to the care plans of residents, but he works as needed and part time. The MDS nurse stated that the DON and SW can also add anything needed. He does not recall developing a care plan for Resident #1, but he may have. He stated when someone was admitted it is usually the nursing staff or DON that will initiate a care plan. The MDS nurse stated when they are answering the section in the MDS assessments about falls they are only looking at the previous 7 days. If Resident #1 had as many falls as you are describing it should have been added to the care plan by the DON since he is usually only at the facility on weekends. The MDS nurse was asked if there is a purpose for the CNAs to see the interventions in the POC and he stated so that they can know those things need to be done for the residents. He stated he went over the Care Plan for Resident #1 yesterday and they added falls and the use of a fall mat and soft helmet. Interview on 6/1/24 at 10:25 AM with Resident #1's FM revealed there is a concern that he will reinjure his head with all these falls he has been experiencing at the facility. The FM stated he had a TBI in 2004 and recently a few months ago was found wandering around after a fall at his apartment and his brain bled again causing the damage to his brain to be worse. They were told that he does not need to be getting any further injuries to his head. The FM stated the facility is frequently calling family saying that he has fallen but they will lower his bed and use a mat beside his bed. It does not seem to have worked. The FM stated I wish they would understand that he is probably trying to take himself to the bathroom when he falls, does anyone ever ask him if he needs to go to the bathroom and offer to help. He frequently is urinating in clothes baskets and trash cans. He has brain damage he cannot remember to call for help, they say they are reminding him but that is not helping either. The FM stated they have not been invited to meet with a team to discuss a plan of care about him they have just been telling ideas to random people that they meet one time then the next it will be somebody new in that position. The FM has tried explaining to staff Resident #1 is left-handed and gets up from the bed easier if he can use that side, but they have the bed positioned so that is not possible . The FM stated it seems as though it is just a matter of time before he has a fall that will hospitalize him again. Interview on 6/3/24 at 3:30 PM with the facility DON revealed that when asked if he could provide any documentation regarding interventions and/or precautions put in place to prevent further falls he stated when a fall occurred, they put out a fall mat and have the bed in lowest position, that is the interventions. The nurses do so after every fall. When asked about documentation of these interventions the DON stated the nurse's progress notes will contain that information. When asked if the falls are being tracked for patterns which may provide additional interventions, the DON stated other interventions are listed on internal documents that could not be shared with the surveyor, and the falls are reviewed in the morning meetings. Investigations are performed by the nursing staff and are included in the progress notes. Additionally, the facility's written Incident Reports are internal documents that also could not be provided he suggested the surveyor look at the progress notes of the nurses to obtain information needed. Interview on 6/3/24 at 3:35 PM with the Administrator revealed he stated they review all investigations that the nurse writes in the progress notes, during the morning meeting and are considering that as an interdisciplinary meeting for everyone who had an incident and/or accident. All department heads, administrators, nursing, wound care nurse, the DON, the activities person, and rehab medical director will sign off if there are any orders as a result of the meeting. The Administrator stated the fall precautions were put in place after each fall by the nursing staff. Each time a fall was documented it automatically populated the fall risk assessment, the bed being lowered to the lowest position and a fall mat being placed at the bedside. The Administrator stated they cannot prevent a person from falling that is an unrealistic expectation. The Administrator confirmed knowing that investigations at times provided other interventions such as the possibility of a toileting program to prevent Resident #1 from attempting to get up without assistance. He was not aware that Resident #1's family felt falls could be related to him trying to get to the toilet. Review of the facility policy titled Response to Falls, undated, revealed the purpose of the policy is To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. The policy includes that after each fall the nurse will complete a post fall assessment and investigation. The investigation will help identify circumstances or factors contributing to the resident's fall. Any identified findings and the Facility's response will be documented in the resident's medical record as appropriate. The IDT will review the investigative reports on a regular basis, as they occur and make systemic changes to reasonably limit future occurrences, consider change in POC interventions, system changes, etc. Review of Facility Nursing Manual/Policy titled Fall Evaluation and Prevention, undated, revealed the purpose of the document is To ensure the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy is listed as The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/ interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. And in a section under procedure, titled Risk Factors Associated With A Fall, Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of intrinsic risk factors including incontinence and previous falls. Interventions include evaluate and implement toileting program if indicated, provide adequate lightening , and remove obstacles in path. Evaluate medications to determine if any can be discontinued or administration times can be changed. The ADM was notified on 06/01/2024 at 06:03 PM, that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/04/2024 at 12:35 PM, and included: Plan of Removal Immediate Jeopardy On 06/01/2024 an abbreviated survey was initiated at [the facility]. On 06/01/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F689 the facility failed to ensure adequate supervision and assistive devices to prevent Resident #1 from repeated falls. Action: A Fall reassessment for Resident #1 was completed by DON on 6/1/24 and the Care Plan was updated on 6/1/24 for Resident #1 to reflect the appropriate interventions to try to help prevent injury from further falls. Resident #1 and room was reviewed to ensure that documented interventions were in place as documented in the plan of care. Intervention for safety helmet placement and fall monitoring rounds was implemented. An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions during shift change and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: 06/01/2024 Completion Date: 06/01/2024 Responsible: DON Action: A full house fall risk reassessment was implemented and completed by DON for all residents to ensure no additional residents are at risk, and Care Plans will be updated to reflect appropriate fall interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON was reeducated on the facility fall management program policy and procedure along with communicating updated interventions. Start Date: 6/1/24 Completion Date: 6/1/24 Responsible: Clinical Nurse Consultant Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON will monitor that clinical staff is compliant with following the Policy and Procedure for the facility's Fall Management Program and their responsibilities which include communication during shift change, review of 24-hour report and implementation of interventions for any resident that is a fall risk. 24-hour report will be reviewed by DON during morning clinical meetings. DON will report progress with monitoring to the QAPI team for review to implement any needed changes or updates to ensure compliance. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: New system implementation of tracking resident falls and interventions in a fall tracking binder for daily review by charge nurses which will help identify residents with multiple falls and appropriate interventions. DON will audit binder for updates and completeness. DON will audit the binders daily for a week, biweekly for a month, monthly for QAPI. Audit results will be reviewed and shared with QAPI team. Start Date: 06/02/2024 Completion Date: 06/03/2024 Responsible: DON Action: An Ad-[NAME] QAPI meeting was held by DON, MD, and Administrator regarding facility fall management program policy and procedure along with communicating updated interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON The Surveyor monitored the POR on 06/04/24 as followed: During an interview on 6/4/24 at 9:35 AM with the Facility DON revealed In-serviced staff on falls and ANE. Monitoring fall risk residents' daily and documenting to ensure interventions implemented and for any new incidents. No new incidents. Resident #1 family aware Resident #1 would get out of bed independently without asking for assistance and aware of Resident #1's impulsiveness, which was why Resident #1's family placed him in facility because they could not manage how often Resident #1 would fall. During an interview on 6/4/24 at 9:40 AM with the ADM, he said the facility updated Resident #1's care plan, implemented a new binder system on fall risk, put helmet on Resident #1, removed electronic control from bed, and ordered a PVC bed that would go on the floor for Resident #1 when the order arrived. Observation and interview on 6/4/24 at 10:16 AM of Resident #1 revealed he was lying in bed. Resident #1 was clean, dressed, and comfortable. Resident #1 had a fall mat next to his bed. Resident #1's bed was in low position. CNA J was sitting in a chair with 1:1 monitoring sheets across Resident #1. Resident #1 had two postings on the wall behind his bed that stated he was to wear a helmet when he got out of bed at all times and that he must have a fall mat next to his bed at all times. During an interview, Resident #1 stated he was doing fine, staff checked on him often, he had some falls in the past, staff were monitoring him, he wore a helmet whenever he got out of bed, his fall mat was always next to his bed, his bed was always in lowest position, and he had no concerns or issues. On 6/4/23 at 10:23am the facility POR for F689 was approved. During an interview on 6/4/24 at 10:21AM, CNA J revealed she was 1:1 monitoring Resident #1. CNA J stated she filled out a monitoring form that was submitted to the Charge Nurse at the end of her shift reflecting she monitored Resident #1 every 30 minutes. CNA J stated Resident #1 had no falls since her shift. CNA J also stated Resident #1's bed had been in the lowest position, had a fall mat next to his bed, and Resident #1 had been wearing a helmet for a while. CNA J did not know how long Resident #1 had the interventions that were previously mentioned or when the interventions started. She was in-serviced on falls and ANE before she started her shift. She learned how to prevent falls, listening to call lights, ensuring beds were at lowest position, ensuring fall mat on floor, ensuring belongings within reach, ensuring Resident #1 wore safety helmet, who and how to report ANE, and ADM was the abuse and neglect coordinator. During an interview on 6/4/24 at 10:28 AM, CNA K revealed he had not conducted 1:1 monitoring for Resident #1 yet. CNA K stated Resident #1 was impulsive and often tried to get out of bed independently without asking for help and would end up on his fall mat. CNA K also stated Resident #1 was reeducated by staff to use his call light for assistance, but Resident #1 still would not use it and often tried to get out of bed independently. He was in-serviced on falls and ANE before he started his shift. Learned how and who to report ANE to, ADM was the abuse and neglect coordinator, and how to respond to falls. During an interview on 6/4/24 at 10:30 AM, RN H revealed she had conducted 1:1 monitoring for Resident #1. RN H stated she documented the 1:1 monitoring every 30 minutes on a log. RN H also stated CNAs are 1:1 monitoring Resident #1 and logging their monitoring during their shift every 30 minutes. RN H stated she was in-serviced on falls and ANE. RN H also stated Resident #1 had a helmet on anytime he was out of bed, had a fall mat next to his bed at all times, and bed was in lowest position. RN H was in-serviced on how to respond to falls, resident rights, who and how to report ANE, and ADM was the abuse and neglect coordinator. Reviewed fall tracking binder daily. During an interview on 6/4/24 at 10:35 AM, CNA M stated he was not in-serviced on falls and ANE. During an interview on 6/4/24 at 10:40 AM, Nurse L revealed she was in-serviced on falls and ANE. She learned about fall preventative devices, monitoring, safety protocols, ADM was the abuse and neglect coordinator, and how and who to report. Nurse L stated Resident #1 was impulsive and often tried to get out of bed without asking staff for assistance by call light. Nurse L also stated staff had reeducated Resident #1 on multiple occasions and Resident #1 still would try to get out of bed independently. Nurse L stated Resident #1's family was aware of Resident #1 trying to independently get out of bed. She reviewed the resident fall tracking documentation daily and have reported to CNAs any updates on fall risk. Observation on 6/4/24 at 11:07 AM of 2400 hall revealed residents who were fall risks had fall preventative devices in their rooms, such as fall mats and lowered beds. During an interview on 6/4/24 at 12:33 PM, ADM stated DON completed Resident #1's fall reassessment on 06/01/24. ADM also stated Resident #1's care plan was updated by the facility MDS Coordinator on 06/01/24. ADM stated DON reviewed Resident #1's room to ensure care plan interventions were implemented on 06/01/24. ADM also stated Resident #1's fall monitoring rounds conducted by clinical staff (nurses and CNAs) started every 30 minutes on 06/02/24 and ongoing. Resident #1's safety helmet placement was implemented. DON in-serviced clinical staff on fall management and ANE started on 06/01/24 and ongoing before staff started shifts. ADM stated he did not know CNA M was not in-serviced prior to starting his work shift on ANE and falls. DON conducted fall risk reassessment on all residents started on 06/01/24 and completed 06/02/24. He was not sure if there were any other residents identified as at risk and if there were any other residents who required updated care plans to reflect appropriate fall interventions. Clinical Nurse Consultant reeducated DON on fall management policy and procedure on 06/01/24. DON started daily monitoring of clinical staff to ensure compliance with fall management by auditing the new system implementation of tracking resident falls and interventions in a fall tracking binder that was daily reviewed by charge nurses on 06/02/24. DON started reviewing all residents' 24-hour reports during morning clinical meetings on 06/01/24 and completed 06/02/24. On 06/02/24, him, DON, and MD had QAPI meeting. DON reported progress with monitoring during the meeting. No changes or updates to ensure compliance needed to be done following QAPI meeting to discuss 24-hour reports. Charge nurses daily reviewed new system implementation of tracking falls and interventions from fall tracking binder started on 06/02/24 and ongoing. Review of the facility's Behavior Rounds 06/01/24-06/04/24 revealed staff monitored Resident #1 every 30 minutes and there were no behaviors observed. Observation on 6/4/24 at 1:17 PM of Resident #1 revealed he was sitting in his wheelchair and wore a safety helmet while watching tv in his room. During an interview on 6/4/24 at 1:18 PM MA N revealed he was in-serviced on ANE and falls. He learned any ANE to report to the ADM because he was the abuse and neglect coordinator and he learned to notify a charge nurse if he observed a resident on the ground and ensure resident safety. During an interview on 6/4/24 at 1:21 PM with Translator #9603, CNA O revealed she was not in-serviced on ANE and falls before her shift. She learned to report to her nurses and DON when she observed a resident on the ground and to report ANE. [TRUNCATED]

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for elopement. Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk. Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on 03/08/24 and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility. During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. Review of undated facility policy Elopement Risk Reduction Approaches reflected. Planning: As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment . Ensure that residents are able to move freely, are monitored and remain safe . .Training: Facility staff needs to know: . The resident's propensity to wander and the triggering conditions The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost . Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them .Environment: Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible After conferring with fire and other appropriate officials, minimize the risk of elopement. An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following: Plan of Removal Immediate Jeopardy On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. Start Date: 3/17/2024. Completion Date: 3/17/2024 Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: DON or Designee Action: Medical Director notified of IJ on 3/25/2024 Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: Administrator Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents Start Date: 3/25/2024. Completion Date: 3/26/2024 Responsible: Medical Director or Designee Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. Start Date: 3/25/2024 Completion Date: 3/26/2024 Responsible Human Resources or Administrator Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. Start Date: 3/26/2024 Completion Date: 3/26/2024 Responsible Human Resources or Administrator Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. Start Date: 3/26/2024. Completion Date: 3/26/2024 Responsible Administrator Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: Regional Clinical Specialist The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: 1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. 2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist 3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. 4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. 5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk. 6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for five (Resident #1, Resident #2 Resident #3, Resident #4, Resident #5, and Resident #11) of 91 residents reviewed for quality of care, in that: A.) The facility failed to get physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was sent to the hospital on 1/25/2022 and diagnosed with severe [CONDITION(S)] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) resulting in actual harm. B.) The facility failed to conduct and document appropriate weekly skin assessments, including documentation, for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #11. An Immediate Jeopardy (IJ) was identified on 2/01/2022 at 4:30 p.m. While the IJ was removed on 2/04/2022 at 5:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and need to evaluate the effectiveness of their Plan of Removal. This failure resulted in Resident #1 and Resident #11 sustaining pressure injuries which required hospitalization and caused severe [CONDITION(S)]. It also placed other residents with pressure injuries at risk of skin breakdown, pain, decreased quality of life, hospitalization , and/or death. Findings included: A Health Complaint Investigation of TX 035 and an Investigation of Facility Self-Reported Incident TX 460 was conducted 01/27/2022 through 02/04/2022. Immediate Jeopardy was identified. An acceptable Immediate Jeopardy removal plan was obtained 02/04/2022. Initial implementation of the plan was verified, and the Immediate Jeopardy was removed on 02/04/2022. Upon administrative review, the survey was reopened on 02/11/22. Additional findings of noncompliance that occurred before the IJ removal actions were obtained. Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated [DATE], reflected a BIMS of 8 indicating mild cognitive impairment. Review of Resident #1's care plan dated 12/17/21, reflected she had the potential for impairment to skin integrity and pressure ulcers related to fragile skin with interventions of following facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated 12/21/21 reflected she had a diabetic ulcer to the left heel and left second toe related to diabetes and PAD with interventions of treating the wound per facility protocol and upcoming appointment with vascular surgeon consult. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's January 2022 TAR reflected documentation that the foam dressing was not placed between the toes on ten occasions (shifts) once on 1/5/22, once on 1/7/22, twice on 1/8/22, twice on 1/9/22, once on 1/11/22, once on 1/18/22, once on 1/22/22, and once on 1/24/22. Review of Resident #1's Weekly Wound Progress Assessments reflected there was not an assessment completed from 12/21/21 until 1/21/22. Review of Resident #1's Weekly Wound Progress Assessment per Nurse Practitioner dated 1/21/22, reflected an arterial ulcer to her left heel, arterial ulcer to her great toe on her left foot, and an arterial ulcer to her second toe on her left foot. Review of Resident #1's hospital progress notes dated 1/25/22, reflected she was admitted with a completely ischemic left second toe and large ischemic areas on first and third toes as well, revealing tendon and bone, with mold growing on the tendon. Both heels had unstageable pressure injuries and she had a stage IV sacral decubitus. There was no record of Resident #1's right heel wound in her records. Review of Resident #1's NP progress note dated 12/10/21, reflected he would make a referral to vascular given the severity of the PAD of her toe. He stated he spoke to the ADON regarding the urgency of the referral and would like the appointment scheduled ASAP. Review of Resident #1's NP progress note dated 1/3/22, reflected he would reorder the referral to vascular as he was unsure if an appointment had been scheduled. Review of Resident #1's NP note dated 1/25/22, reflected Resident #1 was seen by vascular on 1/17/22. The wound looked progressively worse and was now necrotic, noting signs of possible wet gangrene, the wound bed was previously dry. During an interview on 1/27/2022 at 2:30 PM with the ADM, he stated the facility received a phone call from the facilities liaison regarding the hospital's identification of Resident #1's wounds on admission to the hospital. The facility immediately started an investigation upon notification on 1/26/2022. The DON initiated a facility-wide skin assessment on 1/27/2022 at approximately 10:30 AM and it was completed on 1/27/2022 at approximately 7:00 PM. The skin sweep weekly skin assessment was documented in the individual residents' chart over the course of 1/27/22 - 2/01/22. The DON initiated in-services on 1/27/2022. The facilities PA completed rounds on 1/28/2022 on all residents with pressure on non-pressure areas to ensure proper treatment and assessment was in place. During an interview on 1/27/2022 at 4:30 PM, with LVN A she revealed she discovered the sacral wound on Resident #1 on 1/25/2022 while assisting with incontinent care. LVN A stated she reported the discovered sacral wound to the DON and did not officially document in the electronic medical record until 1/28/2022. During an interview on 1/27/2022 at 4:42 PM, the DON stated all nurses do skin assessments, not just the DON. She stated skin issues should be documented on all weekly skin assessments and on shower sheets by the aides. The DON stated the previous wound care nurse had quit, and their new wound care nurse had started on Monday, 1/24/2022. The DON stated there were no further findings from facility-wide skin assessments conducted on 1/27/2022, and the wound care doctor made rounds for residents with wounds on Friday 1/28/2022. During an interview on 2/01/2022 at 9:30 AM, with the DON, she stated LVN A reported the sacral wound found on Resident #1 she stated she would expect newly discovered wounds and other skin issues to be documented in a nursing progress note. When asked why the DON was unable to tell the surveyor why Resident #1 did not have progress notes regarding their skin issues, she had no answer. She stated it was her responsibility to ensure skin assessments and shower sheets were being completed regularly and accurately. Resident #1 was sent to the hospital on 1/25/2022 for respiratory distress and altered mental status. Observation was conducted on 2/01/2022 at 10:25 AM with RN A for Resident #6's wound care. RN A reviewed physician orders, performed hand hygiene, and gathered supplies. RN A sanitized the surface to be used for wound care, sanitized hands, and set up supplies. RN A sanitized hands and donned gloves, cleansed skin laceration on the right lower leg with wound cleanser and gauze. RN A sanitized hands and donned gloves and applied petroleum dressing to wound and covered with a dry adhesive dressing. No concerns were noted. During an interview on 2/01/2022 at 10:47 AM, with the DON, she stated the wound care doctor makes rounds once weekly. DON revealed the ADONs make rounds and are tasked with making sure skin assessments and shower sheets are up to date. DON also revealed ADON A had scheduled Resident #1's appointment with a vascular surgeon. The DON stated a negative outcome of not doing a weekly skin assessment would be something could be missed. During an interview on 2/01/2022 at 2:30 PM, with ADON A, she stated she called the vascular surgeon's office and faxed the requested paperwork for Resident #1 in December 2021 regarding an appointment for Resident #1's left second toe. ADON A stated the vascular surgeon's office told her they would call back with an appointment for Resident #1 in a few days. ADON A stated the vascular surgeon's office insisted they did not receive Resident #1's paperwork. ADON A stated she re-sent Resident #1's paperwork to the vascular surgeon. ADON A stated the vascular surgeon's office did not contact her for a week. ADON A stated she went on vacation during the end of December 2021 and returned to work on January 7, 2022. ADON A stated she was responsible for ensuring skin assessments were being done weekly. ADON A stated each nurse had assigned rooms on each shift and was to complete a weekly skin assessment and skilled notes for each resident. ADON A stated many weekly skin assessments had been missed while she was on leave from late December 2021 to January 7, 2022. During an interview on 2/01/2022 at 3:05 PM, LVN A, stated the nurses were responsible for weekly skin assessments. During an interview on 2/01/2022 at 3:10 PM, with CNA A, she stated if she noticed a skin issue during a shower, she would show it to the nurse. CNA A stated she would document on the resident's shower sheet. During an interview on 2/02/2022 at 5:15 PM, with LVN B, he stated recent training topics were resident skin assessments. He stated the nurses were asked to complete skin assessments during each shift. Review of Resident #2's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan, revised 12/9/21, reflected he had a diabetic ulcer to his left lateral metatarsal and an ulcer to his right foot with interventions of treating the wound as per facility protocol. Review of Resident #2's physician order, dated 12/22/21, reflected an order to clean the left foot ulcer with cleanser, apply collagen, cover with [MEDICATION(S)] blue dressing, and wrap with kerlix gauze every Monday/Wednesday/Friday and PRN. Review of Resident #2's TAR, January 2022 TAR, reflected documentation that the left foot ulcer was not treated on four occasions, 1/7/22, 1/10/22, 1/17/22, and 1/24/22. Review of Resident #2's physician order, dated 12/2/21, reflected an order to clean the wound on the right heal with wound cleanser and apply wound vac at 125 mmHG continuous suction every Monday/Wednesday/Friday and PRN. Review of Resident #2's TAR, January 2022 TAR, reflected the wound on the right heel was not treated on four occasions, 1/7/22, 1/10/22, 1/17/22, and 1/24/22. Review of Resident #2's Weekly Wound Progress Assessments reflected there was not an assessment completed from 12/21/21 until 1/21/22. Review of Resident #3's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan, revised 9/15/21, reflected he had a stage 3 pressure ulcer on his left lateral heel with an intervention of administering treatment as ordered and to monitor for effectiveness. Review of Resident #3's physician order, dated ordered 12/26/21, reflected an order to cleanse the wound on his left heel with wound cleanser, pat dry, apply collagen, and cover with dry dressing every evening shift. Review of Resident #3's TAR, January 2022 TAR, reflected the wound was not treated on six occasions, 1/5/22, 1/6/22, 1/7/22, 1/11/22, 1/13/22, and 1/27/22. Review of Resident #3's Weekly Wound Progress Assessments reflected there was not an assessment completed from 12/21/21 until 1/21/22. Observation on 1/27/2022 at 3:25 PM, RN B provided wound care for Resident #3. RN B reviewed the physician orders, performed hand hygiene, and gathered supplies. RN B sanitized the surface prior to wound care, sanitized hands, and set up supplies. RN B cleansed left heel with wound cleanser and patted dry with gauze, applied collagen, and covered with a dry adhesive dressing that included the time and date. Hand hygiene was performed. No concerns noted. The wound was an abrasion and measured 1.5 cm x 3 cm, and there were no other wounds visible on the resident. Review of Resident #4's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's care plan, revised 2/1/22, reflected he had the potential for pressure ulcer development related to having a wound to his sacral area with an intervention to apply triad paste to sacral wound BID. Review of Resident #4's physician order, dated ordered 1/27/22, reflected an order to apply triad paste to sacral wound every day and evening shift. Review of Resident #4's TAR, January 2022 TAR, reflected the wound was not treated on one occasion, 1/31/22. Review of Resident #4's Weekly Wound Progress Assessments reflected there was not an assessment completed from 12/21/21 until 1/21/22. Review of Resident #5's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's care plan, revised 1/12/22, reflected he had an unstageable pressure ulcer to the sacral coccyx which extended to both buttocks with interventions to assess wound healing at least weekly and to administer treatments as ordered. Review of Resident #5's Weekly Wound Progress Assessments reflected there was not an assessment completed upon admission (1/5/22) or until 1/21/22. Review of Resident #11's face sheet revealed a [AGE] year-old-male DOB 07/14/1949 with an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's admission MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Review of Resident #11's Care Plan dated 02/04/2022 revealed the resident has [CONDITION(S)] of knees, had impaired cognitive function/dementia or impaired thought processes related to admission BIMS assessment of 10, had potential for pressure ulcer development related to limited mobility, incontinent of bowel and bladder. Date Initiated: 02/04/2022, is high risk for falls related to unaware of safety needs, [CONDITION(S)], physical debility, has an ADL Self Care Performance deficit related to general weakness, limited mobility, has a nutritional problem or potential nutritional problem related to a history of [CONDITION(S)]. Review of Resident #11's skin assessment reflected the following: Skin assessment dated [DATE] indicated redness to coccyx with a size of 2x2 cm. Skin assessment dated [DATE] indicated pressure ulcer to coccyx area, right lateral vertebrae opened area, and dry skin. Skin assessment dated [DATE] indicated DTI at left outer lateral foot with a size of 10.3 x 3.3 cm; left outer ankle wound with the size of 3 x3.5 cm; left inner ankle wound with the size of 1.5 x 2.3 cm; DTI at left inner lateral foot with the size of 1.5 x 2 cm; wound located on the right posterior knee the size of 1.5 x 0.5 cm; pressure ulcer at vertebrae the size of 3 x 3 x 0.1 cm. Review of Resident #11's wound progress notes dated 01/21/2022 reflected the following: Sacro coccyx wound with the size 9 x 6 cm; it was also noted on the wound progress notes to carry on the following order-cleanse with wound cleanser, Santyl, and calcium alginate, cover with a dry dressing Review of Resident #11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Treatment Administration Records for January 2022 and February 2022 reflected no orders for wound care until 02/08/2022. There was no evidence wound care was being done on Resident #11 from 01/21/2022 to 02/08/2022. Review of Resident #11's hospital records dated 02/09/2022 reflected the following: Skin-multiple areas of skin breakdown, sacral decubitus stage IV, thoracic decubitus stage II, left ankle stage II, right thigh stage II, deep tissue injury to the left heel and forefoot, skin with extensive dry flaky skin on the abdomen and lower extremities, sick oncotic toenails, left foot for redness. In an interview on 02/11/2022 at 12:22 PM, ADON B stated skin assessments are supposed to be done on admission and weekly thereafter. She also stated, when the resident has skin problems, it is documented on the wound progress notes. She stated she was the one who admitted Resident #11 and did his admission skin assessment. She stated Resident #11 had redness to his coccyx when he was admitted . She also stated she saw Resident #11 on 01/21/2022 due to a pressure ulcer in his coccyx area. She stated, she, the DON, and RN A assessed Resident #11 on 01/21/2022 and there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #11 was seen by the wound doctor on 01/21/2022 and there were orders written for wound care. LVN A made rounds with the wound doctor. She stated Resident # 11's next skin assessment should have been done on 01/28/2022 but he was moved to the COVID unit on 01/24/2022. She stated the order for Resident #11's wound care was on the wound progress notes and not transcribed on the TAR. She stated, when the facility was in the IJ, we revamped the system, we were auditing continuously and later realized on 02/08/2022 that there were no orders on the TAR for Resident #11's wound care. We did a full skin assessment and added the treatment on the TAR. At the end of the day, we had a responsibility to care for this Resident. We failed to give a verbal report that wound care was being done. Every step has been done to correct the problem. We did a complete audit to compare the skin assessment with the orders in PCC yesterday for station 1. I did a skin sweep on 01/27/2022 on station 2 and another on 02/04/2022. I rearrange the showers to correspond with the skin assessment so it can trigger on the same day. In an interview on 02/11/2022 at 1:46 PM, RN A stated skin assessments are done for residents weekly according to the schedule. He stated he usually works Monday to Friday on station 1 where Resident #11 was. He stated, he cannot recall doing skin assessments on Resident #11. He stated, he was alerted by the CNA on 01/21/2022 that Resident #11 had a wound to his coccyx and the resident was seen by the wound doctor the same day. He stated, he did wound care on Resident # 11 on 01/24/2021 before he went to on the COVID unit and on 02/07/2022 when Resident #11 came back from the COVID unit and there was not a dressing on his coccyx prior to me doing wound care. He stated, Resident #11 did not have orders on the TAR for wound care, it was noted on his wound progress notes and he also got a report. He stated, he did not work on 02/08/2022 but noticed Resident #11 had lots of wound care orders on his TAR on 02/09/2022. In an interview on 02/11/2022 at 2:24 PM, ADON A stated she is responsible for station 1 but she did not work with Resident #11 firsthand. She stated she was alerted by the CNA on 02/08/2022 while Resident #11 was getting his bath and he had wounds to his sacrum, mid back, both lower extremities, DTI to both lower extremities. She stated she is not sure if Resident #11 was admitted with all those wounds. She stated skin assessment was done on Resident #11 on 02/28/2022 and orders were put in the computer system for wound care. She stated, Skin assessment are supposed to be done weekly by the charge nurses. She stated, I know when we were in the IJ on wounds, we put a system in place to audit skin assessments daily, we scheduled skin assessment for Monday through Friday to be able to ensure it is being done, we have it set to where it is done on the Residents shower days. She stated, whoever makes rounds with the wound doctor is responsible to put the orders on the TAR. She also stated LVN A was the one that made rounds with the wound doctor on 01/21/2022. In an interview on 02/11/2022 at 3:35 PM, LVN A stated she usually makes rounds with the wound doctor. She stated she made rounds with the wound doctor on 01/21/2022 and Resident #11 was seen by the wound doctor and there were orders for wound care. She also stated she did not transcribe the orders for Resident #11 to the TAR because she documented it on the wound progress notes and thought it would automatically transfer to the TAR. She stated she just learned on 02/08/2022 that she is supposed to do a wound progress note and transcribe the orders on the TAR whenever she makes rounds with the wound doctor. She stated she did wound care on Resident #11 and gave report to staff regarding wound care for Resident #11. She stated the only missing piece was the TAR. In an interview on 02/11/2022 at 4:08 PM, the DON stated she was alert on 02/08/2022 when Resident #11 was getting a bath and she went to look at his shin. She stated she was about to do wound care on Resident #11 and noted there were no orders on the TAR for Resident #11, but the nurse was able to tell me what the order was. She stated, Skin assessments is where we fell off, that is what the IJ was about, we were not doing skin assessment. when we implemented the POR, I felt something was missing, according to the UDAs, I couldn't match up and I knew something was missing. Then we started to take the charts one at a time. I had the 2 ADONs and LVN A sharing the duty and that was the problem and so I had to have one person to do just the skins. She stated Resident #11 had an up-to-date dressing on his coccyx on 02/08/2022, his skin was really dried, and his legs were contracted. She stated the nurses were doing wound care to Resident #11 from the cheat sheet they had and the 24 hours report. She ended by saying, she did not think the wound doctor saw Resident #11 while he was on the COVID unit because there was no documentation to indicate. The ADM and DON were notified on 2/01/2022 at 4:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on 2/01/2022 at 4:30 PM. The following A Plan of Removal (POR) was first submitted by the ADM and was on 2/01/2022 at 5:30 PM and the following POR was accepted on 2/04/2022 at 2:08 PM: Date: 2/1/22 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Summary of Details which lead to outcomes On 2/1/22, an abbreviated survey was initiated at Austin Wellness and Rehab at Rustic Rock Dr, Austin, TX . On 2/1/22, A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: Pressure Injuries The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Identify residents who could be affected. All Residents have the potential to be affected. The facility currently has 5 residents with pressure injuries. All 5 residents are currently receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Problem 1: Review of Resident #1's EMR reflected her last Weekly Skin Assessment was completed on 12/22/21 documenting a wound to her left toe and left heel. There were no skin assessments completed after 12/22/21. There were orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation of a wound on her right heel or her sacrum. There are four other residents in the facility with pressure ulcers. They also went a month without a weekly skin assessment being completed. They also had many instances of treatments being missed. The DON stated that skin assessments had not happened for a month because their treatment nurse left. She stated it was the ADON's jobs to ensure they were being done. The ADON stated she knew she was responsible for ensuring skin assessments are getting done. She stated they were missed because she was out on vacation and then she had COVID. Action Taken: The Director of Nursing initiated an in-service with the Licensed nurses on completing resident skin assessment upon admission, readmission and every seven days and as needed thereafter starting on 1/27/22 and completion date is 2/3/22 and for any staff unavailable they will be in serviced prior to working their next shift. This required skin assessment will be documented in PCC on the weekly skin assessment form. The Director of Nursing initiated an in-service with the Licensed nurses on following all MD orders regarding treatments for wounds and completing correct documentation on the treatment record on 2/1/22 and for any staff unavailable they will be in serviced prior to working their next shift. The Director of Nursing initiated an in-service on 1/27/22 with the licensed nurses on completing the Weekly Wound Progress Assessment for all residents with impaired skin integrity every seven days. Completion date was 2/3/22 and for any staff unavailable they will be in serviced prior to working their next shift. Monitoring: The Director of Nursing, or Assistant Director of Nursing will review and verify skin assessments have been completed for all new admissions, readmissions and have been completed every 7 days per facility schedule and that they have been documented on the weekly skin assessment in PCC. The monitoring will be documented on a monitoring tool form daily x 30 days and prn. The Director of Nursing or Assistant Director of Nursing will monitor resident treatment records for completion of ordered treatments daily x 30 days and prn. Director of Nursing, or Assistant Director of Nursing will monitor weekly any resident with impaired skin integrity for the completion of a weekly wound assessment. Monitoring will be documented on a verification form weekly x 30 days and prn. The Physician and IDT will be notified of new and worsening pressure wounds, complaints of pain, signs and symptoms of infection or [CONDITION(S)] and residents who refuse care or treatment. The effectiveness of current treatment will be documented in resident medical record on a weekly basis. Problem 2: Review of NP note, dated 12/10/21, reflected he would make a referral to vascular given the severity of Peripheral Artery Disease (of her toe). He stated he spoke to the ADON regarding the urgency of the referral and would like the appointment scheduled for ASAP. Review of NP note, dated 1/3/22, reflected he would reorder the referral to vascular as he was unsure if an appointment had been scheduled. Review of NP note, dated 1/25/22, reflected Resident #1 was seen by vascular on 1/17/22. The wound looked progressively worse and was now necrotic, noting signs of possible wet gangrene, wound bed was previously dry. Action Taken: The Director of Nursing initiated an in-service on 2/1/22 with the licensed nurses on the procedure of making resident appointments in an acceptable time frame. Completion date is 2/3/22. For any staff unavailable they will be in serviced prior to working their next shift. Monitoring: Director of Nursing/Assistant Director of Nursing will complete a monitoring tool Monday-Friday x30days and prn to ensure all resident referrals have been followed through on and an appropriate appointment has been made in the acceptable time frame. Problem 3: Review of shower sheets reflected the aides are to mark if there are any new skin issues on the resident. The last shower sheet for Resident #1 is from 1/18/22 with bruises marked on the back of her left foot, left thigh, and front of the left foot. Action Taken: The Director of nursing initiated an in-service on 2/1/22 with the nursing staff regarding the completion of resident showers and the documentation and notification when an area of impaired skin integrity is identified. Completion date is 2/3/22. For any staff unavailable they will be in serviced prior to working their next shift. The Director of Nursing initiated an in-service on 2/1/22 with the nursing staff on the procedure when the CNA identifies any skin issues while providing ADL care including peri care and bathing. Negative findings will be documented on the Stop and Watch form and reported to charge nurse. Charge nurse will report findings to the Director of Nursing. Completion date is 2/3/22 and for any staff unavailable they will be in serviced prior to working their next shift. Monitoring: Director of Nursing or Assistant Director of Nursing will verify all new findings that have been identified have appropriate orders and treatments in place daily x 30days and prn. The Director of Nursing or Assistant Director of Nursing will monitor daily that residents are receiving showers as scheduled by the facility and all documentation on the stop and watch have been addressed appropriately x 30day and prn. The Physician and IDT will be notified of new and worsening pressure wounds, complaints of pain, signs and symptoms of infection or [CONDITION(S)] and residents who refuse care or treatment. The effectiveness of current treatment will be documented in resident medical record on a weekly basis. Any staff on PTO/vacation/PRN status/agency staff who have not been trained on resident skin assessment during admission and readmission and completing weekly skin assessments every seven days, completion of wound progress assessment for residents with skin impairment, and the Stop and Watch procedure will not be allowed to work until they have undergone training. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 2/1/22. The Director of Nursing will review the weekly pressure injury and no pressure injury report with the Medical Director. Involvement of QA On 2/1/22 an Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/ system will be started on 2/1/22. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 2/1/22. The survey team monitored the plan of removal on 2/02/2022 and 2/04/2022 as follows: During interviews on 2/01/2022 between 9:30 a.m. and 5:00 p.m., two LVNs and one RN reported they received training on nurses performing weekly skin assessments, CNAs are responsible for reporting any skin changes to nurse and documenting on resident shower sheet. During interviews on 2/02/2022 between 3:30 p.m. and 5:00 p.m., three LVNS and two CNAs reported they received training on reporting skin issues and skin b [TRUNCATED]

Based on interview, and record review, the facility failed to consult with the resident's physician and notify the resident ' s interested family member when there was a significant change in the resident's physical and mental status for one (1) of five (5) residents reviewed for significant change in condition (Resident #1). The facility failed to notify Resident #1 ' s physician and RP between 05/08/14 and 05/17/14 when Resident #1 experienced an 8.9% weight loss in seven days (05/04/14 to 05/11/14) and refused 20 out of 30 of her liquid diet meals in 10 days (05/08/14 to 05/17/14). This deficient practice could place 17 residents identified as high nutritional risk at risk for severe weight loss and malnutrition. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s most recent MDS dated [DATE] reflected the following active Diagnoses: [REDACTED]. The MDS indicated that the resident had moderately impaired cognitive skills for daily decision making. It also indicated that Resident #1 required extensive assistance of one staff person with eating. It was indicated that the resident was on a Mechanically Altered Diet. It was documented that the resident did not have a swallowing disorder. Resident #1 was indicated to have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months while not on a physician prescribed weight loss regimen. Review of Resident #1 ' s Care Plan dated 02/10/14 reflected the following: " Focus: Nutritional status as evidenced by: weight loss textured and therapeutic diet. Goals: Will tolerate diet and texture/consistency. Interventions: Encourage and assist as needed to consume foods and/or supplements and fluids offered; Provide diet as ordered; Report signs or symptoms of diet and/or texture intolerance; Review weights and notify physician and responsible party of significant weight change. " Review of Resident #1 ' s weekly weight records dated 01/27/14-05/11/14 reflected that Resident #1 weighed 151.8 lbs. on 01/27/14 (date close to admitted ). Further review reflected the following weights: 05/04/14: 134.8 lbs. 05/11/14: 123.6 lbs. 05/11/14: 122.8 lbs. Using the latest recorded weight of 122.8 lbs., it was found that Resident #1 lost 8.9% of her weight (12 lbs.) in seven days (between 05/04/14 and 05/11/14). Review of the MDS 3.0 reflected that significant weight loss is defined as loss of 5% body weight or more within a month. Review of Resident #1 ' s meal intake records dated March 2014-May 2014 reflected that from 05/08/14 to 05/17/14, Resident #1 was offered 30 meals. The resident did not eat 20 of those meals. Of those 20 meals, 14 were documented as refused and six were documented as " 0% eaten. " Out of the ten meals that were consumed by Resident #1, nine of those meals were documented as only 25% meal consumption. According to the meal intake records for March and April 2014, the resident did not have a history of refusing meals in a row for this long of a time period. In March, the resident ' s average intake was between 25-50% with sporadic meal refusals. In April, the resident ate an average of 0-25% for the first half of the month, and after 04/16/14, her intake increased to about 50% with only one meal refusal. During an interview on 06/04/14 at 10:15 am, the LD stated that Resident #1 was having problems eating enough food at the facility related to her Dementia diagnosis. The LD stated that the facility had started providing her with a nourishing liquid diet with Ensure Plus at all three meals (a liquid nutritional supplement). The LD stated that Resident #1 would only drink liquids at the facility, and would not eat solid foods. This was why they tried the nourishing liquid diet with enhanced liquid foods to provide her nutrition. The LD stated that Resident #1 also had a prescription for [MEDICATION NAME] (a medication used to stimulate appetite). The LD stated that other interventions that were in place for Resident #1 included house shakes in between meals, monitoring her weekly weights, and adding Resident #1 to the weekly weight meeting. She stated that Resident #1 was also on the red napkin program (a program that utilizes red napkins in the dining room to alert staff of residents with significant weight loss or nutritional risk). She stated that Resident #1 received assistance from staff members at all meals. Review of Resident #1 ' s admission nutrition assessment dated [DATE] reflected that her calorie needs were 1900-2100 calories per day and her protein needs were 68 grams of protein per day. Review of the Nourishing Liquid Diet sample meal plan dated January 2010 reflected if a house supplement was added to the nourishing liquid diet two times per day (between meals) then the diet provided approximately 3000 calories and 113 grams of protein daily. The sample meal plan consisted of the following food items: Breakfast consisted of 8 ounces of orange juice, 6 ounces fortified cooked cereal, 8 ounces whole milk, half a cup of yogurt, and coffee, tea, or hot chocolate. The morning snack consisted of a house supplement equivalent to 200 calories. The noon meal consisted of 8 ounces of juice, 6 ounces of fortified pureed soup, house supplement, ice cream, 8 ounces of whole milk, and coffee, tea, or hot chocolate. The afternoon snack consisted of a house supplement equivalent to 200 calories. The evening meal consisted of 8 ounces of juice, 6 ounces of fortified pureed soup, house supplement, fortified pudding, 8 ounces whole milk, and coffee, tea, or hot chocolate. The evening snack consisted of a house supplement equivalent to 200 calories. Review of Resident #1 ' s medical record reflected that the following nutritional interventions were put in place at the following times to address weight loss: 02/20/14: House supplements two times per day (documented on diet telephone order form) 02/20/14: Monitor weekly weights, add to weight loss committee, and add to red napkin program (documented in the progress notes) 04/14/14: Full liquid nourishing diet, [MEDICATION NAME] 400 mg PO twice daily, and Multivitamin liquid solution 10 ml PO daily (documented on physician ' s telephone order form). 04/25/14: Ensure plus on all meal trays (documented on diet communication form). This was the latest nutritional intervention that was put in place. During an interview on 06/04/14 at 10:47 am, RN A stated that Resident #1 had lost weight because she had stopped eating and drinking as much as normal. RN A stated that the physician had been made aware of the weight changes and had ordered [MEDICATION NAME] (on 04/14/14). During an additional interview on 06/04/14 at 1:46 pm, RN A stated that she noticed that Resident #1 had not been drinking as much of her liquid diet as usual during the last week of her stay at the facility. RN A stated that she informed Resident #1 ' s RP about the change to the full liquid diet and the [MEDICATION NAME] medication (started on 04/14/14). RN A did not mention Resident #1 ' s weight loss in May 2014 (which occurred after [MEDICATION NAME] was prescribed on 04/14/14) when asked about Resident #1 ' s appetite and weights. During an interview on 06/04/14 at 11:04 am, RN B stated that Resident #1 had been losing weight because she was not eating well, but she was put on a liquid diet (on 04/14/14) because she would still drink fluids. RN B did not specifically mention that she knew about Resident #1 ' s most recent significant weight loss from 05/11/14 (which occurred after the resident started the full liquid diet on 04/14/14 to improve intake) when asked about Resident #1 ' s appetite and weights. During an interview on 06/05/14 at 1:30 pm, the DON, when asked when physicians should be notified of meal refusals, stated that if there is a " trend " of meal refusals that develops that does not seem to correct itself, then the physician should be notified. Review of Resident #1 ' s progress notes reflected the last note written by the LD was dated 05/07/14 and reflected the following information: " (weight) wt. 134.5 lb. Wt stable times one month. 11.2% wt loss since admission (4 months). Dr. aware of wt loss 4/24/14 noted. Resident tolerates full nourishing liquid diet. Rx (prescription) [MEDICATION NAME]. Intake noted 25-50%. Continue (plan of care) POC. Inform MD of wt trends. Monitor weekly weights, and weekly wt committee. LD remains available as needed. " Review of Resident #1 ' s LD to Physician communication form dated 05/07/14 reflected " 11.2% (17 lb.) wt loss since admission (4 months). Wt trend stable times one month. 4/14/14- 131.2 lbs. 5/4/14- 134.5 lb. " The physician responded with " noted. " This was the most recent LD to physician communication. Further review of Resident #1 ' s progress notes from 05/08/14 to 05/17/14 reflected no documentation of physician notification of meal refusals and/or weight loss. Also, there were no notations or comments regarding Resident #1 ' s weekly weight of 122.8 lbs (from 05/11/14). During an additional interview on 06/05/14 at 4:00 pm, the DON, stated that she did not know why the physician was not notified of Resident #1 ' s meal refusals between 05/08/14 and 05/18/14. When the surveyors showed the DON the resident ' s meal intake sheet for May 2014, she stated that she would have expected the physician to be notified of the trend of meal refusals. The DON stated that especially for a resident who was being monitored for nutrition, the physician and the RP should have been notified of the trend of meal refusals. The DON stated that she was on vacation during this time period. She stated that when CNAs document a meal refusal in the computer system, the computer generates an alert documentation that the nurses read. During an interview on 06/05/14 at 1:06 pm, the Administrator stated that the facility used the Interact 3 tool as a guideline for when to notify the physician. Review of the Interact 3 tool titled " Change in Condition: When to report to the MD/NP/PA " dated 2011 reflected the physician should be notified of the following on the next business day: " New onset of anorexia with or without weight loss " , " significant decline in food and fluid intake in resident with marginal hydration and nutritional status " , and a weight loss of 5% or more within 30 days. During an interview on 06/05/14 at 12:35 pm, Resident #1 ' s physician stated he did not recall if the staff members contacted him regarding Resident #1 ' s meal refusals. When the surveyors showed Resident #1 ' s physician the resident ' s meal intake percentages, he stated that missing meals over that long of a period would be concerning. He then stated, " What would I do past that ([MEDICATION NAME])? " He stated that he would not have recommended a feeding tube for the resident. The physician then stated that Resident #1 is now on hospice services (after admission to the hospital). He stated that he sent Resident #1 to the hospital on [DATE] due to respiratory distress. Observation of Resident #1 on 06/03/14 at 4:10 pm revealed that the resident was still at a local hospital. During an interview on 06/04/14 at 1:18 pm, RN C, Unit Manager, stated that Resident #1 ' s family member who attended the care plan meetings was not the RP, but the RP ' s spouse. RN C stated that at the last care plan meeting on 05/07/14 the family member had asked what the liquid diet consisted of and how Resident #1 ' s weight had been since the [MEDICATION NAME] and liquid diet had been initiated. RN C stated that Resident #1 ' s weight had been stable. When RN C was asked when Resident #1 began to stop eating and drinking, RN C stated that, according to the nurse's notes (also know as "progress notes" at this facility), Resident #1 stopped drinking on 05/18/14, the day before she was sent to the hospital. RN C referred to the nurse ' s notes for documentation regarding meal and fluid refusals. The nurse ' s notes did not reflect all of the resident ' s meal refusals between 05/08/14 and 05/17/14 and did not reflect the 8.9% weight loss from 5/11/14. The nurses notes also did not reflect that the physician had been notified of the 8.9% weight loss or the meal refusals. Review of Resident #1 ' s progress notes dated 05/07/14 reflected " Care plan meeting today with IDT present. Resident (family member) in attendance. Continue POC (plan of care). " This was the last documented time that the family was notified of the resident ' s nutritional status until 05/18/14. During an interview on 06/05/14 at 10:04 am, Resident #1 ' s RP stated that the only contact he received from the facility was regarding the change to the full liquid diet. He stated that the facility staff told him that Resident #1 ' s appetite had decreased so they were asking for his permission to start a liquid diet. He stated that he was not informed after that point that the resident was refusing to eat and was not drinking fluids. Resident #1 ' s RP stated that he saw the resident on 05/11/14 and it seemed like " she was looking through me. " He stated that he talked to a nurse about it and the nurse agreed that she seemed different and gave him an Ensure (liquid nutritional supplement) to give to her. He stated that Resident #1 was not drinking the Ensure like she normally did. He stated that he was informed that the doctor would be seeing her the next weekend. Resident #1 ' s RP stated that it was ok for the facility to talk to his wife regarding Resident #1 because she shares the information with him. The RP stated that he had told the facility that they could always call him, and he wondered why they did not. During an interview on 06/04/14 at 11:04 am, RN B stated that she worked with Resident #1 on 05/18/14 and that Resident #1 was not drinking that day. She stated that the resident appeared lethargic but her vital signs were normal. RN B stated that she called Resident #1 ' s physician to notify him of the changes to Resident #1, and the physician ordered stat labs to be drawn. She also stated that she notified Resident #1 ' s RP ' s spouse that the resident was not drinking and that labs were going to be drawn. RN B stated that this occurred around breakfast time on 05/18/14. During an interview on 06/05/14 at 1:55 pm, the LD, when asked when nurses notified her of meal refusals, stated that if meal refusals were a change from the resident ' s baseline, then she would usually be notified. When asked if she was notified of or aware of Resident #1 ' s meal refusals, the LD responded that several interventions had been put in place to address Resident #1 ' s weight loss including Ensure supplements, [MEDICATION NAME], and changing her to a liquid diet. She stated that the next step would have been to evaluate with the family how aggressive they wanted the nutritional therapy. The LD gave an indirect answer to the question and did not answer if she had been notified of Resident #1 ' s meal refusals or significant change in weight from 05/11/14. During an interview on 06/05/14 at 6:00 pm, the Administrator and DON were informed that if they had any additional information or documentation showing that Resident #1 ' s significant weight loss and meal refusals were addressed and the physician and/or family was notified, to please provide the information. No additional information was provided. During an interview on 06/05/14 at 1:06 pm, the Administrator stated that the facility did not have a specific policy for significant change in condition, but that they followed the state guidelines and used the Interact 3 tool as a guideline, but not as a policy. Review of a Documentation guideline form provided by the Administrator dated November 2013 reflected that the Administrator hand wrote a note on the bottom of the form to the surveyors with the following information: " Follow State Regulatory Guidelines regarding notification of Physician and Responsible Party for Significant Change in Condition. " There was no specific policy for notifying the physician or RP. During an interview on 06/06/14 at 10:45 am, the DON stated that there were 12 residents identified with significant weight loss and 5 residents identified as being at high nutritional risk.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being, in accordance with the comprehensive assessment and plan of care, for one (1) of five (5) residents reviewed for change in condition (Resident #1). The facility failed to appropriately assess and address Resident #1 ' s change in condition when she experienced an 8.9% weight loss in seven days (05/04/14 to 05/11/14) and refused 20 out of 30 of her liquid diet meals in 10 days (05/08/14 to 05/17/14). On 05/19/14, Resident #1 was sent to the ER with critical lab values and [DIAGNOSES REDACTED]. This deficient practice could place 17 residents identified as high nutritional risk at risk for severe weight loss and malnutrition. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s weekly weight record dated 01/27/14 reflected that the resident weighed 151.8 lbs. on 01/27/14. The weekly weight record further indicated that the resident weighed 122.8 lbs on 05/11/14. Review of Resident #1 ' s most recent MDS dated [DATE] reflected the following active Diagnoses: [REDACTED]. The MDS indicated that the resident had moderately impaired cognitive skills for daily decision making. It also indicated that Resident #1 required extensive assistance of one staff person with eating. It was indicated that the resident was on a Mechanically Altered Diet. It was documented that the resident did not have a swallowing disorder. Resident #1 was indicated to have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months while not on a physician prescribed weight loss regimen. Review of Resident #1 ' s Care Plan dated 02/10/14 reflected the following: " Focus: Nutritional status as evidenced by: weight loss textured and therapeutic diet. Goals: Will tolerate diet and texture/consistency. Interventions: Encourage and assist as needed to consume foods and/or supplements and fluids offered; Provide diet as ordered; Report signs or symptoms of diet and/or texture intolerance; Review weights and notify physician and responsible party of significant weight change. " Review of Resident #1 ' s weekly weight records dated 01/27/14-05/11/14 reflected that Resident #1 weighed 151.8 lbs. on 01/27/14 (date close to admitted ). Further review reflected the following weights: 03/16/14: 137.8 lbs. 03/23/14: 136 lbs. 04/08/14: 131.4 lbs. 04/20/14: 132 lbs. 04/27/14: 132 lbs. 05/04/14: 134.8 lbs. 05/11/14: 123.6 lbs. 05/11/14: 122.8 lbs. Using the latest recorded weight of 122.8 lbs., it was found that Resident #1 lost 8.9% of her weight (12 lbs.) in seven days (between 05/04/14 and 05/11/14). Review of the MDS 3.0 reflected that significant weight loss is defined as loss of 5% body weight or more within a month. Review of Resident #1 ' s meal intake records dated March 2014-May 2014 reflected that from 05/08/14 to 05/17/14, Resident #1 was offered 30 meals. The resident did not eat 20 of those meals. Of those 20 meals, 14 were documented as refused and six were documented as " 0% eaten. " Out of the ten meals that were consumed by Resident #1, nine of those meals were documented as only 25% meal consumption. According to the meal intake records for March and April 2014, the resident did not have a history of refusing meals in a row for this long of a time period. In March, the resident ' s average intake was between 25-50% with sporadic meal refusals. In April, the resident ate an average of 0-25% for the first half of the month, and after 04/16/14, her intake increased to about 50% with only one meal refusal. During an interview on 06/04/14 at 10:15 am, the LD stated that Resident #1 was having problems eating enough food at the facility related to her Dementia diagnosis. The LD stated that the facility had started providing her with a nourishing liquid diet with Ensure Plus (a liquid nutritional supplement) at all three meals (supplement started on 04/25/14). The LD stated that Resident #1 would only drink liquids at the facility, and would not eat solid foods. This was why they tried the nourishing liquid diet with enhanced liquid foods to provide her nutrition (started on 04/14/14). The LD stated that Resident #1 also had a prescription for [MEDICATION NAME] (a medication used to stimulate appetite, started on 04/14/14). The LD stated that other interventions that were in place for Resident #1 included house shakes in between meals (started on 02/20/14), monitoring her weekly weights (started on 02/20/14), and adding Resident #1 to the weekly weight meeting (started on 02/20/14). She stated that Resident #1 was also on the red napkin program (a program that utilizes red napkins in the dining room to alert staff of residents with significant weight loss or nutritional risk, started on 02/20/14). She stated that Resident #1 received assistance from staff members at all meals. During an interview on 06/04/14 at 11:04 am, RN B stated that Resident #1 had been losing weight because she was not eating well, but she was put on a liquid diet (on 04/14/14) because she would still drink fluids. RN B did not specifically mention that she knew about Resident #1 ' s most recent significant weight loss from 05/11/14 (which occurred after the resident started the full liquid diet on 04/14/14 to improve intake) when asked about Resident #1 ' s appetite and weights. During an interview on 06/04/14 at 10:47 am, RN A stated that Resident #1 had lost weight because she had stopped eating and drinking as much as normal. RN A stated that the physician had been made aware of the weight changes and had ordered [MEDICATION NAME] (on 04/14/14). During an additional interview on 06/04/14 at 1:46 pm, RN A stated that she noticed that Resident #1 had not been drinking as much of her liquid diet as usual during the last week of her stay at the facility. RN A stated that she informed Resident #1 ' s RP about the change to the full liquid diet and the [MEDICATION NAME] medication (started on 04/14/14). RN A did not mention Resident #1 ' s weight loss in May 2014 (which occurred after [MEDICATION NAME] was prescribed on 04/14/14) when asked about Resident #1 ' s appetite and weights. During an interview on 06/05/14 at 4:16 pm, LVN E stated that Resident #1 had been eating less and starting spitting out her food sometimes. When asked about Resident #1 ' s meal refusals, LVN E stated that she thought that the meal refusals were something that the nurses were aware of. She stated that she was aware of the meals that Resident #1 had refused during her shift (3:00 pm to 11:00 pm) but was not aware of the meals Resident #1 refused in the mornings. LVN E stated that if a resident refused meals " more than a couple days in a row " , then the physician should be notified. LVN E stated that Resident #1 ' s intake had declined toward the end of her stay, but she was not sure about the resident ' s weight changes. LVN E stated that Resident #1 was being treated for [REDACTED]. During an interview on 06/04/14 at 1:18 pm, RN C, Unit Manager, stated that Resident #1 ' s family member who attended the care plan meetings was not the RP, but the RP ' s spouse. RN C stated that at the last care plan meeting on 05/07/14 the family member had asked what the liquid diet consisted of and how Resident #1 ' s weight had been since the [MEDICATION NAME] and liquid diet had been initiated. RN C stated that Resident #1 ' s weight had been stable. When RN C was asked when Resident #1 began to stop eating and drinking, RN C stated that, according to the nurse's notes (also know as "progress notes" at this facility), Resident #1 stopped drinking on 05/18/14, the day before she was sent to the hospital. RN C referred to the nurse ' s notes for documentation regarding meal and fluid refusals. The nurse ' s notes did not reflect all of the resident ' s meal refusals between 05/08/14 and 05/17/14 and did not reflect the 8.9% weight loss from 5/11/14. The nurses notes also did not reflect that the physician had been notified of the 8.9% weight loss or the meal refusals. During an interview on 06/05/14 at 1:30 pm, the DON, when asked when physicians should be notified of meal refusals, stated that if there is a " trend " of meal refusals that develops that does not seem to correct itself, then the physician should be notified. Review of Resident #1 ' s progress notes reflected the last note written by the LD was dated 05/07/14 and reflected the following information: " (weight) wt. 134.5 lb. Wt stable times one month. 11.2% wt loss since admission (4 months). Dr. aware of wt loss 4/24/14 noted. Resident tolerates full nourishing liquid diet. Rx (prescription) [MEDICATION NAME]. Intake noted 25-50%. Continue (plan of care) POC. Inform MD of wt trends. Monitor weekly weights, and wetly wt committee. LD remains available as needed. " Review of Resident #1 ' s LD to Physician communication form dated 05/07/14 reflected " 11.2% (17 lb.) wt loss since admission (4 months). Wt trend stable times one month. 4/14/14- 131.2 lbs. 5/4/14- 134.5 lb. " The physician responded with " noted. " This was the most recent LD to physician communication. Review of Resident #1 ' s progress notes from 05/08/14 to 05/17/14 reflected that the following notations were made regarding Resident #1 ' s meal refusals: 05/08/14: " Pt ate 25% of dinner, took meds ... encouraging fluids 05/11/14: " Refused breakfast and lunch. Accepted milk shake snack and consumed 100%. " Further review of Resident #1 ' s progress notes from 05/08/14 to 05/17/14 reflected no documentation of physician notification of meal refusals and/or weight loss. Also, there were no notations or comments regarding Resident #1 ' s weekly weight of 122.8 lbs (from 05/11/14). During an additional interview on 06/05/14 at 4:00 pm, the DON, stated that she did not know why the physician was not notified of Resident #1 ' s meal refusals between 05/08/14 and 05/18/14. When the surveyors showed the DON the resident ' s meal intake sheet for May 2014, she stated that she would have expected the physician to be notified of the trend of meal refusals. The DON stated that especially for a resident who was being monitored for nutrition, the physician and the RP should have been notified of the trend of meal refusals and weight changes. The DON stated that she was on vacation during this time period. She stated that when CNAs document a meal refusal in the computer system, the computer generates an alert documentation that the nurses read. During an interview on 06/05/14 at 1:06 pm, the Administrator stated that the facility used the Interact 3 tool as a guideline for when to notify the physician. Review of the Interact 3 tool titled " Change in Condition: When to report to the MD/NP/PA " dated 2011 reflected the physician should be notified of the following on the next business day: " New onset of anorexia with or without weight loss " , " significant decline in food and fluid intake in resident with marginal hydration and nutritional status " , and a weight loss of 5% or more within 30 days. During an interview on 06/05/14 at 12:35 pm, Resident #1 ' s physician stated he did not recall if the staff members contacted him regarding Resident #1 ' s meal refusals. When the surveyors showed Resident #1 ' s physician the resident ' s meal intake percentages, he stated that missing meals over that long of a period would be concerning. He then stated, " What would I do past that ([MEDICATION NAME])? " He stated that he would not have recommended a feeding tube for the resident. The physician then stated that Resident #1 is now on hospice services (after admission to the hospital). He stated that he sent Resident #1 to the hospital on [DATE] due to respiratory distress. During an interview on 06/05/14 at 10:04 am, Resident #1 ' s RP stated that the only contact he received from the facility was regarding the change to the full liquid diet. He stated that the facility staff told him that Resident #1 ' s appetite had decreased so they were asking for his permission to start a liquid diet. He stated that he was not informed after that point that the resident was refusing to eat and was not drinking fluids. Resident #1 ' s RP stated that he saw the resident on 05/11/14 and it seemed like " she was looking through me. " He stated that he talked to a nurse about it and the nurse agreed that she seemed different and gave him an Ensure (liquid nutritional supplement) to give to her. He stated that Resident #1 was not drinking the Ensure like she normally did. He stated that he was informed that the doctor would be seeing her the next weekend. Resident #1 ' s RP stated that it was ok for the facility to talk to his wife regarding Resident #1 because she shares the information with him. The RP stated that he had told the facility that they could always call him, and he wondered why they did not. Observation of Resident #1 on 06/03/14 at 4:10 pm revealed that the resident was still at a local hospital. During an interview on 06/04/14 at 11:04 am, RN B stated that she worked with Resident #1 on 05/18/14 and that Resident #1 was not drinking that day. She stated that the resident appeared lethargic but her vital signs were normal. RN B stated that she called Resident #1 ' s physician to notify him of the changes to Resident #1, and the physician ordered stat labs to be drawn. RN B stated that she called the lab to order the lab work. She also stated that she notified Resident #1 ' s RP ' s spouse that the resident was not drinking and that labs were going to be drawn. RN B stated that this occurred around breakfast time on 05/18/14. Review of Resident #1 ' s progress notes dated 05/18/14 reflected the following: " Resident refused all am meds, did not drink anything, fluids offered with spoon, called (physician). (Family member) notified, awaiting a call back from (physician). " " New order received for stat lab CBC, BMP, UA with C&S, (lab) contacted, left message for (RP) will continue to monitor. " During an interview on 06/04/14 at 2:07 pm, CNA D stated that she worked with Resident #1 on 05/18/14, and the CNA had noticed that she was not drinking very much (compared to her usual intake), even when they tried to spoon feed her fluids. CNA D stated that she reported this to the nurse (RN B). CNA D also stated that she worked with Resident #1 on 05/19/14, and that Resident #1 was not herself and she was not looking around at the CNAs to watch them like she normally did. CNA D stated that she reported this to the nurse (RN A) who assessed the resident and called Emergency Medical Services (EMS). During an interview on 06/04/14 at 10:47 am, RN A stated that she was the nurse working with Resident #1 on the morning of 05/19/14. RN A stated that when she came to work on 05/19/14, she went to Resident #1 ' s room because the Certified Nursing Assistants (CNAs) told her that she did not look good and they did not want to get her up for breakfast. RN A stated that Resident #1 appeared to be breathing rapidly, so she assessed the resident and found that her blood pressure was low and her respirations were about 42 breaths per minute. RN A stated that it looked like the resident was in respiratory distress. She also stated that she noticed mottling to the resident ' s knees, which is something she has seen on people who are about to die. RN A also noticed that Resident #1 had right sided facial drooping and was not tracking with her eyes. RN A stated that she called Resident #1 ' s physician who ordered for Resident #1 to be sent to the ER. RN A stated that the resident had stat labs drawn on 05/18/14, and her sodium levels were within normal limits. She stated that these events occurred between 8:00 am and 8:30 am on 05/19/14. RN A stated that when she returned to work on 05/19/14 (a Monday), it was reported to her that Resident #1 had stopped drinking as much over the weekend. Review of Resident #1 ' s Acute Transfer Form (facility documentation) dated 05/19/14 reflected that this was an unplanned transfer and the resident was full code status. The resident ' s BP was 95/67 mm Hg (normal is 120/80 mm Hg) and respirations were 42 breaths per minute (normal is 12-18 breaths per minute). The transfer form indicated that the physician and RP were notified. Review of Resident #1 ' s progress notes dated 05/19/14 reflected at 8:20 am that the resident was not tracking and had BP on 95/67 mm Hg and respirations of 42 breaths per minute. Bilateral knee mottling was noted. The physician was contacted and there was a new order to send the resident to the ER for respiratory distress. The RP was notified. At 8:40 am it was noted that " Pt left for (ER) via stretcher accompanied by 4 EMS personnel." Review of the Emergency Medical Services (EMS) narrative dated 05/19/14 reflected " Arrive on scene to find female lying in bed unresponsive with a respiratory rate of approx. 40. Nurse states yesterday she was up in the wheelchair and that today she has facial droop and decreased alertness and this is different from her normal. Nurse states Dr. ordered blood work yesterday along with a urinalysis yesterday. ... Pt. has some mottling to her mid leg area. Lung sounds reveal rhonci in her upper lobes. Pt. is a full code ....(Intravenous drip) IV attempt x4 (four times) without success. ... (Blood pressure) BP increased to 90 systolic from 68. Pt. placed in trendelenburg to assist with BP. " Review of Resident #1 ' s lab work at the hospital dated 05/19/14 reflected a sodium level of 180 mmol/L (with a normal range of 134-145 mmol/L). Review of Resident #1 ' s emergency department records dated 05/19/14 reflected that the resident was positive for fever and altered mental status and appeared dehydrated. Preliminary [DIAGNOSES REDACTED]. The resident ' s weight was 121.7 lbs. It was documented that "condition is serious." Review of Resident #1 ' s history and physical from the hospital dated 05/19/14 reflected in the general exam that the resident had altered mental status and appeared cachectic (severe weight loss, emaciation, and muscle mass and tissue wasting). The plan was to admit the resident to the ICU. Review of Resident #1 ' s physician consultation from the hospital dated 05/19/14 reflected that " several laboratory results are pending, however, a serum sodium was 180 and 184 on the subsequent draw. Lab also reflected an initial creatinine of 6.1 and a BUN of 157. I spoke with the nursing staff and per reports, she received a total of 1.1 L of normal saline from the field to the emergency room and at least 500 to 800 cc of [MEDICATION NAME] saline in the ER after her first sodium value was obtained. " " There is a lab report from her nursing home, that indicates a sodium from May 18, 2014 of 141. In my view, this is difficult to believe given that that would indicate the development of over an 8 to 9 L of free water deficit in less than 24 hours without polyuria. As such, I am not sure what to make of her ' lab value ' from yesterday, but I believe it is erroneous. " " This patient is critically ill and I believe her poor prognosis is somewhat grim. " Resident #1 was admitted to the ICU. (BUN - normal range of 7-17 mg/dL) (creatinine- normal range of 0.5-1.0 mg/dL). Review of the Food-Medication Interactions book, 16th Edition, dated 2010 reflected the following causes or significances of abnormal laboratory values: BUN may be increased with [MEDICAL CONDITION], and if the lab value is over 50 it may indicate serious impairment. BUN may be increased with shock, dehydration, infection, and/or excessive protein catabolism. Creatinine may be increased with acute [MEDICAL CONDITION] or starvation. Sodium may be increased with dehydration and/or low fluid intake. During an interview on 06/05/14 at 1:55 pm, the LD, when asked when nurses notified her of meal refusals, stated that if meal refusals were a change from the resident ' s baseline, then she would usually be notified. When asked if she was notified of or aware of Resident #1 ' s meal refusals, the LD responded that several interventions had been put in place to address Resident #1 ' s weight loss including Ensure supplements, [MEDICATION NAME], and changing her to a liquid diet. She stated that the next step would have been to evaluate with the family how aggressive they wanted the nutritional therapy. The LD gave an indirect answer to the question and did not answer if she had been notified of Resident #1 ' s meal refusals. During an interview on 06/05/14 at 1:30 pm, the DON stated the staff members were aware that Resident #1 was nutritionally compromised due to her cognitive status. She stated that the facility had weight loss interventions in place for Resident #1 and that they had discussed the use of [MEDICATION NAME] (a medication used to stimulate appetite) with the physician. She stated that " at some point " the facility would need to have a conversation with the family about how aggressive they wanted to be with the nutritional treatments. During an interview on 06/05/14 at 4:00 pm, the DON stated that tube feedings for Resident #1 were an intervention that had been discussed between staff members, but had not been discussed yet with the family. The DON stated that talking to the family about a tube feeding would have been the next step, and that this was documented in the weight meeting notes. Review of Resident #1 ' s medical chart from the facility reflected no documentation of a palliative care consult or hospice care consult for Resident #1. Resident #1 was a full code status. During an interview on 06/05/14 at 6:00 pm, the Administrator and DON were informed that if they had any additional information or documentation showing that Resident #1 ' s significant weight loss and meal refusals were addressed and the physician was notified, to please provide the information. No additional information was provided. During an interview on 06/05/14 at 1:06 pm, the Administrator stated that the facility did not have a specific policy for significant change in condition, but that they followed the state guidelines and used the Interact 3 tool as a guideline, but not as a policy. Review of a Documentation guideline form provided by the Administrator dated November 2013 reflected that the Administrator hand wrote a note on the bottom of the form to the surveyors with the following information: " Follow State Regulatory Guidelines regarding notification of Physician and Responsible Party for Significant Change in Condition. " There was no specific policy for notifying the physician or RP. During an interview on 06/06/14 at 10:45 am, the DON stated that there were 12 residents identified with significant weight loss and 5 residents identified as being at high nutritional risk.