Every finding on record at Avir at Cotulla

Based on interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, of the 6-month review period for (25 of 184 days), reviewed for RN coverage.The facility failed to ensure the facility maintained the required RN coverage for 25 days between July 2025 to December 2025.The dates are: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.Findings included:Record review of CMS CASPER Report (a confidential, that analyzes internal data to measure the quality of patient care) reflected the facility prompted for no RN hours for FY 4th Quarter 2025 (July 2025 to September 2025), for the following dates: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025. Record review of the facility RN schedule from July 2025 to December 2025 revealed that the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day for the 6-month review period for the following dates: 7/3/2025 - 7/7/2025, 8/4/2025 - 8/8/2025, 9/8/2025 - 9/12/2025, 10/9/2025- 10/12/2025, 11/10/2025-11/12/2025 and 12/16/2025 - 12/18/2025. Staff interview on 1/7/2026 at 2:09 p.m. with the Administrator, she stated the previous DON had to be released from employment, and during the hiring process, there were no RN applicants due to the location and population making it difficult to attract a sufficient number of qualified candidates. She stated that if RNs did not work at the facility, it could lead to improper care for residents. Record review of the facility policy, titled Staffing, Sufficient, and Competent Nursing, revised 08/2022, revealed 3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week. Registered nurses may be scheduled more than eight (8) hours depending on the acuity needs of the residents.

Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 9 residents (Resident #6, Resident #41, and Resident #52) who were reviewed for resident assessments. 1.The facility failed to document Resident #6's lack of use of scheduled pain medication on the quarterly MDS assessment. 2.The facility failed to document Resident #41's diagnosis of anxiety on the quarterly MDS assessment. 3. The facility failed to document Resident #52's use of an antidepressant on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care or of not receiving services necessary for their physical, mental, and psychosocial well-being.The findings included: 1.Record review of Resident #6's admission sheet dated 6/30/2025 with an original admission date of 4/15/2013 documented a [AGE] year-old female resident with diagnoses including multiple sclerosis (a disease that causes breakdown of the protective covering of nerves causing numbness, weakness, trouble walking, and vision changes), dementia, peripheral vascular disease (when arteries in the limbs are narrowed, limiting blood flow), depression, and epilepsy (seizure disorder). Record review of Resident #6's quarterly MDS assessment dated [DATE] documented a BIMS could not be conducted due to the resident rarely or never being understood and recorded the use of antidepressant, anticoagulant (blood thinner), and anticonvulsant (antiseizure) medications. Further review of Resident #6's MDS in Section J – Health Conditions J0100. Pain Management revealed the assessment documented the resident had received scheduled (routine) pain medication in the last five days, despite the resident having no order for scheduled pain medication. Record review of Resident #6's order summary documented active orders for the as needed pain-relieving medications Acetaminophen with an order date of 11/14/2025 and Ibuprofen with an order date of 11/14/2025. Acetaminophen was ordered as Acetaminophen 325mg, give 2 tablet via G-Tube (a soft tube inserted through the abdomen directly into the stomach, used to provide nutrition, fluids, and medicine when a person can't eat or drink enough by mouth) every 6 hours as needed for pain. Ibuprofen was ordered as Ibuprofen 200mg, give 1 tablet via G-Tube every 8 hours as needed for pain. Further review of Resident #6's order summary revealed the resident had no order for a scheduled pain medication. Record review of Resident #6's November 2025 and December 2025 MARs revealed the resident did not receive any scheduled pain medication during the months of November and December. Record review of Resident #6's care plan with an initiation date of 1/30/2023 documented the resident was at risk for experiencing discomfort or pain r/t MS with a goal of the resident will exhibit a comfortable/relaxed appearance without facial grimacing or signs of distress. 2.Record review of Resident #41's admission sheet dated 6/16/2025 with an original admission date of 7/21/2021 documented a [AGE] year-old female resident with diagnoses including neurocognitive disorder with Lewy bodies (a disorder characterized by the presence of abnormal protein deposits called Lewy bodies in the brain, leading to cognitive decline, movement issues, and various other symptoms), depression, anxiety, hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone), and type 2 diabetes mellitus. Record review of Resident #41's quarterly MDS dated [DATE] documented that a BIMS could not be conducted due to the resident rarely or never being understood and recorded the use of antipsychotic, antianxiety, antiplatelet, and hypoglycemic medications. Further review of the MDS under Section I – Active Diagnoses Psychiatric/Mood Disorder revealed the assessment did not include a diagnosis of anxiety in the box next to I5700 Anxiety Disorder. Record review of Resident #41's October 2025 MAR documented the resident had been receiving monitoring every shift for the following behaviors including 1=Agitation, 2=anxiety, 3=nervousness, 4=compulsiveness, 5=aggression, 6=verbal aggression, 7=hallucinations, 8=delusions, 9=repetitive verbalizations that affect function. with anxiety documented on 10/17/2025. Record review of Resident #41's psychiatric services progress note dated 3/28/2025 documented in the Reason for Visit section, the resident was seen for evaluation and management of their anxiety, depression, and dementia. Further review of the psychiatric note documented in the PMHx section a past medical history with conditions including HTN, M/S injury, hypothyroidism, Type II DM, anxiety, dementia. Under the Assessment/DSM section of the psychiatric note the diagnoses of Anxiety disorder, generalized and Depressive disorder were included in the diagnosis list. Record review of Resident #41's care plan with a problem start date of 10/19/2025 documented the resident has Behavioral Symptoms with approaches including Maintain a calm environment. and Maintain a calm, slow, understandable approach with the resident. During an interview with the MDS Nurse on 01/08/2025 at 9:26 AM, the MDS Nurse stated she was responsible for verifying MDS assessments were accurate before submission. Regarding scheduled pain medications received in the last five days, the MDS Nurse stated she included medications from the anticonvulsant drug class as scheduled pain medications on the MDS. Regarding active diagnoses, the MDS Nurse stated she only included an active diagnosis on the MDS if a resident was receiving medication or psychiatric services to manage the diagnosis, because that is how she was taught. The MDS Nurse stated it was important for the MDS to be accurate. The MDS Nurse stated she did not think there could be any danger to a resident if the MDS is inaccurate or missing items, unless they missed a behavior like suicidal ideations. 3. Record review of Resident #52's admission sheet dated 03/22/2023 with an original admission date of 01/01/2021 documented a [AGE] year-old male resident with diagnoses including hemiplegia (paralysis on one side of the body), mood disorder, dementia, anxiety disorder, major depressive disorder (depression), and schizoaffective disorder (mental health condition). Record review of Resident #52's quarterly MDS assessment dated [DATE] documented a BIMS of 15 indicating intact cognition and recorded the use of antipsychotics, antianxiety, and diuretic (promote production of urine) medications but not the use of an antidepressant. Record review of Resident #52's order summary documented active orders for an antidepressant, Trazodone, with an order date of 11/24/2025. Trazodone was ordered as Trazodone HCI oral tablet 150mg, give 1 tablet by mouth two times a day, related to schizoaffective disorder, unspecified. Record review of Resident #52's December 2025 and January 2026 MARs revealed the resident did receive an antidepressant medication, Trazodone, during the months of December and January. Record review of Resident #52's care plan with an initiation date of 12/22/2025 documented the resident was at risk for complications related to psychotropic drug use due to a DX of schizoaffective disorder, mood disorder, anxiety disorder and dementia. I am on routine antianxiety medication, routine anti antipsychotics, and routine antidepressants with a goal of the resident benefit without side effects. During an interview on 01/08/2026 at 9:46 a.m., the MDS nurse confirmed Resident #52 was currently taking an antidepressant which was Trazadone 150mg. The MDS nurse stated the MDS was not reflecting Resident #52's use of an antidepressant but that it should have. The MDS nurse stated she would have to modify the MDS in order for it to accurately reflect Resident #52's use of an antidepressant. The MDS nurse was unsure of the risk to a resident if their medications were incorrectly coded on the MDS assessment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 noted in section N: Medications in section N0415: High-Risk Drug Classes: Use and Indication states 1. Is taking: check if the resident is taking any medications by pharmacologic classification, not how it is used, during the last 7 days. Further review shows section N0415B2. Antidepressant : Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period. Record review of an email from the Administrator on 01/08/2026 at 11:55 AM, documented the Administrator stated there was no MDS policy, they follow the RAI manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 noted in section J0100: Pain Management, the definition of scheduled pain medication regimen as Pain medication order that defines dose and specific time interval for pain medication administration. For example, 'once a day,' 'every 12 hours.' Further review of the RAI noted in Section I: Active Diagnoses that One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. and Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to date items after receiving/opening them located in the kitchen pantry. 2. The facility failed to take temperatures for both breakfast and lunch meals on 01/05/2026. This deficient practice could place residents at risk for food borne illness.The findings include: Observation on 01/06/2026 at 10:00 a.m., of the kitchen pantry revealed 1 box of food thickener with no date, 1 bag of lime gelatin, opened, in a Ziploc bag, which was sealed, with no date, 1 container of chicken flavored base with no date, and 1 container of beef flavored base with no date. Record review of the Food Temperature Chart document, dated 01/04/2026 to 01/10/2026, reflected under breakfast and lunch for Monday, 01/05/2026, no temperatures for any of the entrees served. During an interview on 01/06/2026 at 10:16 a.m., the Dietary manager stated food temperatures should be taken as soon as food items were put on the steam table, for every meal, and every day. The dietary manager stated the cook and dietary manager were responsible for dating products as they got food deliveries. The dietary manager stated the risk to the residents for not dating food products or taking temperatures of food could be food items building bacteria and risk of expiration. The Dietary manager stated they were not aware of any food borne illness outbreaks within the facility. During an interview on 01/07/2026 at 10:48 a.m., the DON stated they were not aware of any food borne illness outbreaks since being employed at the facility. During an interview on 01/08/2026 at 11:47 a.m., the [NAME] stated they were supposed to take the temperature of all foods before every meal. The [NAME] stated the purpose was to check to see if the temperature is appropriate to serve to residents. The [NAME] stated they would have to get back with what the risk could be to residents if they are not checking the food temperatures of food items. Record review of the facility's policy, Food Storage, dated 2023, reflected: 8. All containers or storage bags must be legible and accurately labeled and dated. Record review of the facility's policy, Food Temperatures, dated 2023, reflected: The temperatures of all food items will be taken and properly recorded prior to service of each meal

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 2 medication carts (Med Cart 2) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during hand off of the cart key for Med Cart 2 during lunch. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: During an observation of Med Cart 2 on 1/07/2026 at 3:06 PM, a sample of controlled medications was inventoried for accuracy with LVN A. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit revealed the log had not been signed when LVN B gave control of her key to Med Cart 2 to LVN A before lunch. During an interview with LVN A on 1/07/2026 at 3:06 PM, LVN A stated it was important to count the controlled medications for inventory accuracy and document on the controlled medication reconciliation log to make sure the count is correct when taking supervision of a medication cart. LVN A stated if they did not count and document the counting of the controlled medications, a pill could be missing, and they would not know when the loss occurred. LVN A stated if a resident was missing a pill, they might not get the benefit of their medication. During an interview with the DON on 01/07/2026 at 4:24 PM, the DON stated staff responsible for medication carts had never counted the controlled medications when handing off their key to another staff member before lunch. The DON stated moving forward, her expectation was for staff to count and document the count of controlled medications when they hand off their key to another staff member before lunch or anytime they relinquish their key. The DON stated if staff did not reconcile the controlled medications in their carts before handing over their key to another staff member, something could go missing and they would not know where or when a medication was lost. During an interview with LVN B on 01/08/2026 at 8:10 AM, LVN B stated when they hand over their medication cart key to another staff member before lunch it was important that they count and document the controlled medications in their cart, because medications could go missing. LVN B stated moving forward, they will sign the new log developed for documenting the count of controlled substance when handing off their key to another staff member before lunch. Record review of the facility policy titled Controlled Substances with a revision date of November 2022, noted Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection/follow-up. The policy further stated, The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage handling, and consumption of residents' food items for 1 (refrigerators in resident room [ROOM NUMBER]-A) of 4 residents' refrigerators reviewed in that: The personal refrigerator in resident's room [ROOM NUMBER]-A contained unlabeled, undated food items. This deficient practice could place residents at risk of foodborne illness due to consuming foods which could be spoiled.The findings were: Observation on 01/06/2026, at 10:44 a.m. revealed that the personal refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard, which had been previously opened, with expiration dates not legible, which were unlabeled and undated. During an interview on 01/06/2026 at 10:44 a.m. the resident in room [ROOM NUMBER]-A stated staff had not been labeling their food items located in their personal fridges, but that staff had been checking for the fridge's temperature. The resident in room [ROOM NUMBER]-A stated the food items were brought in by himself and family. Observation on 01/07/2026, at 7:53 a.m. revealed that the personal refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard, which had been previously opened, with expiration dates hard to obtain, which were unlabeled and undated. During an interview on 01/07/2026, at 10:33 a.m., CNA C stated housekeeping usually checks resident's fridges, but those items should be labeled and dated. CNA C confirmed that the refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard which were unlabeled and undated. CNA C stated if items in residents' fridges are not labeled staff would not know whose items were whose. During an interview on 01/07/2026, at 10:39 a.m., LVN D stated nurses and CNAs were responsible for checking residents' personal fridges nightly for at least expirations dates and if the item is open then staff should date the item. LVN D stated staff check the fridges for their temperature as well. LVN D stated items should be dated in residents' personal fridges. LVN D confirmed that the refrigerator in resident room [ROOM NUMBER]-A contained two bottles of mayonnaise and one bottle of mustard which were unlabeled and undated. LVN D stated if items in residents' fridges are not labeled there could be a risk for residents to get sick if the item is expired. During an interview on 01/07/2026, at 10:48 a.m., the DON stated the housekeeping checks residents' personal fridges for temperatures and in case anything needs to be thrown away. The DON stated staff would not know whose items were whose in residents' fridges if they were not labeled. The DON stated if items in residents' fridges are not labeled there could be a risk for residents to have an upset stomach if they were unsure how long the item had been opened. During an interview on 01/07/2026, at 11:06 a.m., HSKP stated they check residents' personal fridges for temperatures but was unsure if they were supposed to be checking for labels or dates. HSKP stated if an item in a resident's personal fridge has been out for a while and there weren't sure if the item was still good, they would just throw it out. Record review of the facility policy, Food Brought in by Family/Visitors, revised March 2022, revealed,Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food.Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 of 5 residents (Resident #6) reviewed for infection control. The facility failed to ensure LVN B wore a PPE gown while administering medication to Resident #6 via PEG tube (a flexible feeding tube inserted through the abdominal wall into the stomach that allows for the delivery of nutrition, fluids, and medications directly into the stomach). This failure could place residents at risk for cross contamination and infection.The findings included: Record review of Resident #6's admission sheet dated 6/30/2025 with an original admission date of 4/15/2013 documented a [AGE] year-old female resident with diagnoses including multiple sclerosis (a disease that causes breakdown of the protective covering of nerves causing numbness, weakness, trouble walking, and vision changes), dementia, peripheral vascular disease (when arteries in the limbs are narrowed, limiting blood flow), depression, and epilepsy (seizure disorder). Record review of Resident #6's quarterly MDS assessment dated [DATE] documented a BIMS could not be conducted due to the resident rarely or never being understood and recorded the use of a feeding tube in Section K - Swallowing/Nutritional Status K0520 Nutritional Approaches. Record review of Resident #6's order summary documented an active order for ENHANCED BARRIER PRECAUTIONS G Tube with an order date of 11/30/2025 and no end date. Record review of Resident #6's care plan with an initiation date of 6/06/2024 documented the resident required Enhanced Barrier Precautions r/t use of my G tube for all my nutritional, hydration, and medication needs. with interventions including Follow Facility policy. During an observation of g-tube medication administration on 01/08/2026 at 7:05 AM, LVN B was observed wearing gloves while administering medications through Resident #6's g-tube. LVN B did not wear a protective gown while administering the medications. A sign regarding information for EBP was observed posted on Resident #6's door. During an interview with LVN B on 01/08/2026 at 8:10 AM, LVN B stated Resident #6 did not have a specific order to wear a gown, and that she only wore gloves when she administered medications through the resident's g-tube. LVN B stated it was important to wear EBP to protect both staff and residents from contamination during care. During an interview with the DON on 01/08/2026 at 9:08 AM, the DON stated her understanding regarding EBP was that it was important because you do not want to spread infection between staff and residents. The DON stated her expectation was for staff to wear gowns and gloves any time they provided care which indicated the use of EBP. The DON stated she had already begun instructing her staff on proper EBP usage. During an interview with the ADON on 01/08/2026 at 9:55 AM, the ADON stated she had been the facility IP since 2022. The ADON stated her expectation was that staff should be wearing EBP during care, whenever a resident is under isolation, or any time it is indicated including care provided with a g-tube. The ADON stated with any use of the g-tube she expected her staff to wear gowns and gloves, and that the wearing of these items was important to prevent transmission of infections between staff and residents. The ADON stated she had been working with the DON to reeducate staff on proper EBP procedures. Review of facility policy Enhanced Barrier Precautions with a revision date of February 2025 noted Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. and Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 residents (Resident #6) reviewed for infection control, in that: While providing incontinent care for Resident #6, CNA A did not change her gloves or wash her hands after touching the bed remote before starting to provide care. CNA B did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. CNA A changed gloves multiple times and did not sanitize between change of gloves. These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: Record review of Resident #6's face sheet, dated 05/09/2025, revealed an admission date of 09/12/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure) Record review of Resident #6's MDS Quarterly assessment, dated 03/23/2025, revealed the resident had a BIMS score of 7, indicating severe cognitive impairment. Resident #6 required total care with her activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #6's care plan revealed a care plan initiated 09/15/2023 with a problem of Resident is incontinent of bowel and bladder d/t impaired mobility., and an intervention of Check for incontinence routinely and PRN. Assist with incontinent care with each episode w/ use of skin barrier salve to promote skin integrity. Observation on 05/09/25 at 9:48 a.m., revealed while providing incontinent care for Resident #6, CNA A touched the bed remote with her gloved hands. CNA B touched the privacy curtain with her bare hands. Neither CNA A or CNA B changed their gloves or wash their hands, then, started to provide care for Resident #6. CNA A changed gloves multiple time while providing care but did not sanitize or wash her hands in between change of gloves. During an interview on 05/09/2025 at 10:05 a.m., CNA A and CNA B stated the privacy curtain and bed remote were considered dirty and they should have changed gloves and sanitize their hands. They revealed they did not realize they had to change their gloves and sanitize their hands before starting to provide the care. CNA A stated she did not use sanitizer between change of gloves multiple times and was unclear when to use sanitizer or wash her hands. They confirmed receiving training on infection control within the year. During an interview on 05/09/2025 at 10:30 a.m., the DON stated the staff should have changed their gloves and sanitize their hands prior to start providing care for the resident. She stated they should sanitize their hands between change of gloves. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS. Record review of the facility's CNA A competency check titled, CNA proficiency audit, dated 09/13/24 revealed CNA A demonstrated competency in hand washing and incontinent care. Record review of the facility's CNA B competency check titled, CNA proficiency audit, dated 09/13/24 revealed CNA B demonstrated competency in hand washing and incontinent care. Review of facility policy, titled Handwashing/Hand Hygiene, dated 01/20/23, revealed Hand hygiene must be performed prior to donning (put on) and after doffing (remove) gloves.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #46) of 17 residents reviewed for range of motion. The facility failed to have interventions and monitoring in place to address Resident #46's left hand contracture. This failure could place residents with ROM issues at risk for decline in range of motion, decreased mobility, and worsening contractures. Findings included: Record review of Resident #46 admission face sheet dated 10/24/24 revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and recent admission from hospital on 08/09/24. His diagnosis included (but not limited to) Parkinson's disease without dyskinesia and without mention of fluctuations (a neurodegenerative disease of mainly the central nervous system that affects both the motor and non-motor systems of the body); personal history of transient ischemic attack (a brief stroke-like attack) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) without residual deficits. Record review of Resident #46's Quarterly MDS dated [DATE] Section C revealed BIMS Score 12 indicating moderate cognitive impairment. Record review of Resident #46's Quarterly MDS dated [DATE] Section GG 0130 A5 Eating is coded 02 indicating Substantial / Maximal assistance needed in eating; Section GG 0015 A revealed impairment to one side upper extremity and B. one side lower extremity. Quarterly MDS 07/22/24 & Quarterly MDS 06/21/24 Section G revealed Partial / Moderate assistance in eating. Quarterly MDS dated [DATE] & 02/11/24 revealed Supervision in eating. Record review of Resident #46 Occupational Therapy (OT) Discharge Summary 02/10/24 revealed Left upper extremity (LUE) palm protector to reduce risk of contracture and that resident required set-up or clean-up assistance with eating. OT Discharge Summary 06/24/24 revealed Minimal assistance with personal hygiene. Record review of Resident #46's Focused assessment dated [DATE] revealed contracture to LUE (Left upped extremity), LLE (Left lower extremity), RLE (Right lower extremity). Record review of Resident #46 OT evaluation dated 04/02/24 revealed resident required set-up assistance with self-feeding, LUE ROM impaired at shoulder, elbow, wrist, hand, thumb and fingers and that limitations were not related to contracture. Record review of Resident #46 OT Evaluation and Plan of Treatment dated 09/19/23 revealed goals to increase sitting balance, increase Right elbow/forearm flexion strength, to improve ability to safely and efficiently perform upper body dressing with partial / moderate assistance and to improve ability to safely and efficiently perform grooming and hygiene tasks with supervision or touching assistance. OT Evaluation and Plan of Treatment does not address left hand contracture. Record review of Resident #46 Care Plan dated 09/18/23 revealed use of divided plate and built-up utensils with all meals under nutritional status problem and ADL functional problem. Care plan does not identify left hand contracture. Record review of the physician's orders (print/save date 10/24/24) revealed no orders in place for preventative measures to left hand contracture. Resident #46 observation 10/22/24 at 11:05 a.m. revealed resident sitting up in bed. Left hand was in fist position with no preventative measures in place. Resident #46 observation and staff interview with CNA A on 10/23/24 at 1:22 p.m.: CNA at bedside feeding resident with built up spoon. CNA A stated, I work night usually, but he does not try to hold the spoon with me, and his left hand is contracted, so I feed him. There were no preventative measures to his left hand. Interview with LVN B on 10/23/24 at 1:20 p.m. revealed Resident #46 will try to hold the utensils at times and that staff tend to help him with feeding. LVN B was asked if any assistive device was in place for his left hand to aid in contracture management. LVN B stated, I am part-time, and I have never seen any device for his left hand. Resident #46 observation and interview on 10/23/24 at 2:48 pm revealed Resident #46 sitting up in bed. Resident stated he was unable to open his left hand or lift his left hand and arm. Upon observation, left hand was in closed fist position with no preventative measures in place. Resident #46 observation and interview on 10/24/24 at 9:43 a.m. revealed resident sitting up in bed. The call light was attached to the bed sheet on left side. Resident was able to reach call light with his right hand and demonstrated ability to push call button. Resident stated he was unable to open his left hand and that, In a couple of days it will smell nasty, and that he will try to clean it myself because it smells nasty, and that he will have the girls clean is about every three days. There were no preventative measures in place to left hand. Interview with CNA C stated resident #46's shower is scheduled for today on the 2nd shift (after 6pm). When asked what type of care was provided to resident's left hand, she stated, I will put a towel inside, dry it down, apply lotion. Interview with the DON and DOR on 10/24/24 at 10:43 a.m.: DON stated, resident has been followed by Dermatology, Ortho and Neurology and contracture is addressed but no recommendations were made. DON stated resident had recent hospitalization (08/05/24-08/09/24 due to seizure activity with recommendations to follow up with neurology. Record review of Neurology progress note dated 08/19/24 revealed neurological condition to include spastic left hemiplegia, generalized weakness, no visible hypertrophy or atrophy to upper and lower extremities, and under Assessments #5. Hemiplegia following cerebral infarction affecting left non-dominant side. Record review of Ortho consult dated 10/10/24 revealed residual left hemiparesis with progressive low back pain, lumbosacral radiculitis with degenerative disc disease and facet arthropathy. Neurology progress note and Ortho consult note did not address contracture as stated by DON. Record review of the facility provided policy on Resident Examination and Assessment (Revised February 2014) revealed the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical assessment #4 Neurological d. strength and equality of the hand grasps; #5 Musculoskeletal b. mobility and range of motion of extremities & e. contractures.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 4 (Resident #3, Resident #35, Resident #45, and Resident #47) of 16 residents reviewed for MDS transmission, in that: 1. The facility failed to correct and resubmit incorrect MDS assessments for Resident #3, Resident #45, and Resident #47. 2. The facility failed to transmit a completed MDS assessment for Resident #35. These deficient practices placed residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of Resident #3's clinical record as of 10/23/2024, revealed a quarterly MDS assessment, dated 06/21/2024, with a status of production accepted w/[with] warning. Record review of Resident #35's clinical record as of 10/23/2024, revealed a quarterly MDS assessment, dated 09/04/2024, with a status of in process. Record review of Resident #45's clinical record as of 10/23/2024, revealed a quarterly MDS assessment, dated 10/10/2024, with a status of production accepted w/[with] warning. Record review of Resident #47's clinical record as of 10/23/2024, revealed a quarterly MDS assessment, dated 09/07/2024, with a status of production accepted w/[with] warning. During an interview on 10/24/2024 at 10:30 a.m., the MDS Coordinator stated she was responsible for completing and submitting MDS assessments, and confirmed that assessments for Resident #3, Resident #45, and Resident #47 had been returned by the CMS system due to error(s). The MDS Coordinator stated she was aware that the assessments had been returned by the CMS system and that they had not been corrected due to an oversight. The MDS Coordinator further stated that Resident #35's assessment had been completed but not transmitted due to an oversight. Record review of the facility policy, Electronic Transmission of the MDS, revised November 2019, revealed All MDS assessments .are completed and electronically encoded into our facility's MDS information system and transmitted to CMS .in accordance with current OBRA regulations .

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 3 of 23 (Residents #4, #22, #36) residents reviewed for call lights: 1. Resident # 4's call light was connected to the light string hanging behind her bed on the opposite side of the bed she was sitting on and not within reach. 2. Resident #2's call light was attached to the privacy curtain, out of reach. 3. Resident #36's call light was not within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Review of Resident #4's face sheet dated 09/07/23 revealed the resident was admitted on [DATE] with the diagnoses which included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), history of falling, rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body. RA mainly attacks the joints, usually many joints at once), dysphagia (swallowing difficulties), major depression- single episode (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #4's quarterly MDS Resident Assessment Instrument (RAI) dated 08/28/23 revealed a BIMS score 06, indicating severe impaired cognition, ADL's which included walking with supervision with one-person physical assistance. Review of Resident #4's Comprehensive Care Plan dated 12/23/22 revealed call lights were addressed in problems for Falls due to rheumatoid arthritis, general bilateral extremity weakness, unsteady gait, decline in condition and impulsiveness with approaches to educate/encourage Resident #4 to call light usage and keep the call light within reach. Observation on 09/06/23 at 10:10 a.m. and on 09/06/23 at 11:57 a.m. in Resident #4's room revealed the call light both times was connected to the light string hanging behind the resident's bed on the opposite side of the bed in which the resident was sitting. When this surveyor told the resident where the call light was, the resident turned and looked but, the resident did not respond. During an interview on 09/06/23 at 10:22 a.m. with the DON, confirmed Resident #4's call light was attached to the light string on the opposite side of the bed and not within Resident #4's reach. Record review of Resident #22's face sheet dated 09/07/23 revealed the resident was admitted on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance (can be feelings of distress, sadness or symptoms of depression, and anxiety), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), cerebral palsy (abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of Resident #22's quarterly MDS dated [DATE] revealed the resident has a BIMS score of 07 indicating the resident has severe cognitive impairment. The MDS indicated their ADL's to include walking did not occur during the 7 day period. Review of Resident #22's comprehensive care plan dated 01/20/23 with revision date of 09/06/23 revealed the call light to be kept within reach for urinary incontinence. There were no other problems addressing call lights. Observation on 09/07/23 at 11:30 a.m. during Resident #22's peri care revealed the call light was clipped to the privacy curtain and not within the resident's reach. Further observation of Resident #22 after peri care the call light continued to remain out of reach for the resident. CNA A and CNA B did not replace the call light within Resident #22's reach. During interview on 09/07/23 at 11:30 a.m. with CNA A and CNA B after completing peri care for Resident #22, both CNAs said they had finished with Resident #22. This surveyor took both CNA A and CNA B back into Resident #22's room and both CNA A and CNA B confirmed the call light was attached to the privacy curtain and the call light was not within Resident #22's reach. CNA A then took the call light and unclipped it from the privacy curtain and placed the call light beside Resident #22 so she could reach it. When this surveyor asked what might happen if Resident #22 was not able to reach the call light CNA A and CNA B stated she may fall out of the bed. Review of Resident #36's face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), kidney disease stage 3 (your kidneys are damaged and can't filter blood the way they should), glaucoma- bilateral (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), muscle weakness, unsteadiness on feet. Review of Resident #36's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 08, indicating moderate impairment of cognition and ADL's to include walking which requires extensive assistance of 1 person. Review of Resident #36's comprehensive care plan revised on 07/26/23 revealed falls, visual function and urinary incontinence were addressed and one of the approaches was to keep the call light within reach. Observations on 09/05/23 at 11:50 a.m. of Resident #36 reclining in his recliner revealed call light was stretched across the bed but, not within resident #36's reach. Observation on 09/06/23 at 10:00 a.m. of Resident #36 was reclined in his recliner and the call light was observed on the opposite side of the bed next to the upper bed rail and was not within the resident's reach. The DON was observed taking the call light from behind the resident's bedside dresser and stretching the cord over to the resident and attaching the call light to the side of the recliner within the resident's reach. During an interview and observation on 09/06/23 at 10:20 a.m. the DON confirmed Resident#36's call light was not within reach. During the interview on 09/06/23 at 10:24 a.m. with the DON, when asked what could happen if the resident could not reach the call light, the DON stated the resident could fall or something worse could happen to them. Review of the facility Policy and Procedure for Answering the Call Light dated 2001 and revised on 2021 sated in part: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the Facility Policy and Procedure for Perineal Care (incontinent care) dated 01/20/23 revealed on page 2, numbers 14. and 15., States reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident.

Based on observation, interviews, and record review, the facility failed to ensure nursing staff was able to demonstrate competency in skills and techniques for 1 of 2 (RN C) RNs observed during medication pass. The facility failed to prevent RN C from following: 1. Established Infection Control Procedures while passing medications to Resident #5 and Resident #10. 2. HIPAA privacy requirements to lock and close the laptop while passing medications to Resident #7. 3. The procedure to lock the medication cart before walking away during the medication pass. 4. The procedure to prime an Insulin Pen before administering the medication to Resident #7. These deficient practices could affect residents who were receiving medications leaving them at risk for infection, not receiving the proper amount of insulin and exposure of confidential information. The findings were: Review of Resident #7's face sheet dated 09/07/23, revealed Resident #5 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #7's quarterly MDS assessment dated [DATE], revealed Resident #7 had severely impaired cognition skills for decision making and a BIMS score was 99 indicating unable to complete the interview. Further review of the quarterly MDS revealed ADL's for Resident #5 required supervision of 1 staff person. Review of Resident #7's care plan dated 04/04/23 and revision dated 08/29/23 revealed the care plan addressed the resident's medications including monitoring the side effects and to administer the medications as ordered. Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. Further review revealed Resident #7 was to also receive Divalproex 125 mg capsule, 2 po tid.; Famotidine 20 mg tab give 1 po bid; Furosemide 20mg tab, give 1 po qd;, Metformin 500mg tab 1 po qd; Quetiapine 300 mg extended release tab, give 1 po qd; Docusate Na 100mg tab give 1 po qd; D3 2000IU capsule, give 1 po qd; Farxiga 10 mg tab give 1 po qd; Lisinopril 5 mg tab, give 2 (10mg) po qd; Lorazepam o.5mg tab give 1 po tid. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 11, indicating moderate impairment and ADL's required supervision with setup by 1 person. Review of Resident #10's comprehensive care plan dated 12/01/23 with revision date of 08/30/23 under medications reveals an approach of administer medications as ordered. Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the following medications to be given Buspirone 5 mg tab give 1 po bid; D3 1000 IU 25mg cap give 1 po qd; Eliquis 5 mg tab give 1 tab po bid; Lisinopril 10mg tab give 1 po qd; metoprolol tar 25 mg tab give 1 po bid; lactulose solution 10 mg/15ml give 30 ml po qd; dorszao/tinol Sol 22.3-4.68 1 gtt o.u. bid; alphagn p sol 1% give 1 gtt o.u. tid; terbinafine hcl 1% cream on toenails qd; lorazepam 0.5mg give 0.25mg tab po bid. Observations from 09/07/23 at 8:15 a.m. to 9:10 a.m. for Resident #7 and #10 during the medication pass revealed RN C placed his finger in the medication cup then took the blister packs and either popped the resident's medications into his thumb and index finger or popped the pill(s) into the palm of his hand and then placed the medication into the medication cup. When asked how many pills he was giving, he would pour the medication into the palm of his hand and take his thumb and index finger and pick up each pill and place back into the medication cup. Resident #10 refused her eye drops and her toenail cream. As RN C was setting up the medication for Resident #7, RN C left the keys in the lock on the medication cart and went into Resident #10's bathroom to wash his hands. Later as RN C was setting up Resident #5's medications he walked away from the medication cart without locking and closing the top on the laptop, exposing Resident #7's picture, name and some of the medications Resident #7 was taking. Observation on 09/07/23 at 9:10 a.m. for Resident #7 revealed RN C was preparing to give Resident #7 her insulin with an insulin pen. RN C picked up the new insulin pen, placed the needle on the end of the barrel and dialed up the 42 units he was to give. RN C did not prime the insulin pen prior to setting the dosage in which the resident might have not received all her insulin as ordered. Interview on 09/07/23 at 9:20 a.m. to 9:26 a.m. with RN C revealed he did not wear gloves as he setup the medications for Resident #7 and #10 or ensure his hands were clean while picking up blister packs, opening drawers on the medication cart and while opening over the counter medications used on multiple residents. Stated he did not remember if he left the keys in the medication cart or leave the laptop open exposing Resident #7's picture, name, and some of her medications. RN C stated he did not know he was handling the medications incorrectly and thought he could pick the pills up with his thumb and index finger and place them into the palm of his hand. When asked what could happen in the different situations, RN C stated he could have caused the resident to develop an infection. RN C stated, the keys anyone could have come along and opened the medication cart and taken the medications. RN C stated the personal information of Resident #7 could have been taken and used against the resident. Interview on 09/07/23 at 12:25 p.m. with RN C concerning the insulin given to Resident #7 stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. Interview on 09/07/23 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the medication pass with RN C but, when asked about his training, the DON stated RN C was trained and also had the pharmacist consultant do medication passes with the nurses and medication aides. When asked what could have happened in each of the incidents with RN C during the medication pass, the DON stated, infection control- not cleaning his hands and using proper procedure to handle pills could lead to infection. The keys left in the lock on the medication cart- the DON stated someone could have come along and gotten into the medication cart and taken medications. The laptop not locked and lid closed-the DON stated no one else was to see the medications or issue of the resident and the information could be used against the resident or they could sell the information to someone else. The insulin pen- the DON stated it was an infection control issue and also not primed Resident #7 might not have gotten the right dose. Review of RN C's Clinical Nursing Validation Review Checklist revealed on 02/28/23, RN C was checked off for his skills by the DON. The checklist included hand washing and on 07/16/23 handwashing and F tags for infection control with the facility Core Clinical Compliance 2023. Review of the facility Policy and Procedure dated 2001 with a revision on 04/19 for Administering Medications revealed in part the following: 16. During administration of medications, the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide a. When using a tablet or laptop, maintain HIPAA privacy requirements by covering or closing the computer screen 21. Staff follows established infection control procedures (e.g. handwashing, antiseptic technique, gloves, ) for the administration of medications, as applicable.

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67%, based on 2 errors out of 30 opportunities, which involved 2 of 5 residents (Resident #7 and #10) reviewed for medication administration in that: The facility to ensure RN C ensured the Insulin Pen was purged to ensure Resident #7 received her insulin as ordered. The facility failed to prevent RN C from giving Resident #10 the wrong dosage of Lorazepam 0.25mg tablet as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. The findings included: 1. Review of Resident #7's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. (Start date was 08/18/23) Review of Resident #7's Medication Administration Sheet dated 08/07/23 to 09/07/23 revealed the Lantus Solostar (insulin glargine) pen was started on 08/18/23 and was receiving the insulin twice a day at 8:00 a.m. and 8:00 p.m. Review of Resident #7's comprehensive care plan, dated 04/24/23 and revised 08/19/23 revealed the resident was on Insulin and Administer medication as ordered. Observation on 09/07/23 at 9:10 a.m. RN C was observed taking a new Lantus Solostar pen for Resident #5 and placing a new needle on the barrel. RN C dialed up 42 units of insulin and did not purge the pen before ensuring Resident #7 was given the insulin and receiving the dose on the left side of the abdomen. Interview on 09/07/23 at 12:25 p.m. with RN C after the medication pass concerning not priming the Lantus Solostar pen before dialing the correct dosage and giving the insulin to Resident #7, stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. Interview on 09/07/23 from 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the issues found with the Medication Pass with RN C. She stated concerning the insulin pen for Resident #7 should have been primed before dialing up the dosage for Resident #7. The DON stated Resident #7 may have not gotten the correct dosage of insulin. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 1/2 tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for 1/2 mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23, when it was found to be wrong during reconciliation of the Lorazepam for Resident #10. Observation on 09/07/23 at 8:15 am during Medication Pass RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and the Lorazepam was to be given twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so as to give 1/2 (equals 0.25 mg) of the tablet. Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could have happened to Resident #10 by receiving the wrong amount, the DON stated Resident #10 could of had an adverse reaction to the medication. Record review of the facility policy and procedure titled, Administering Medications dated 2001 and revised on 04/19, revealed in part, . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation and interview the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for 1 of 5 residents (Resident #10) reviewed during the medication pass in that: The facility failed to prevent Resident #10 from being given 0.5mg of Lorazepam instead of 0.25mg tab. This deficient practice placed residents receiving medications at risk for receiving the wrong dosage as prescribed. The Findings include: Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 1/2 tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for 1/2 mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23, when it was found to be wrong during reconciliation of the Lorazepam for Resident #10. Observation on 09/07/23 at 8:15 am during Medication Pass RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and was to receive twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so, as to give 1/2 (equals 0.25 mg) of the tablet. Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could have happened by Resident #10 receiving the wrong amount, the DON stated Resident #10 could have had an adverse reaction to the medication. A facility Policy and Procedure for Medication Storage, Dating and Labeling of all Biologicals requested from the DON was not provided.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #7 and #10) reviewed for infection control practices, in that: The facility failed to prevent RN C from doing the following during medication pass: 1. Setup pills from the blister packs and bottles by using his bare thumb and index finger or palm of his hand to place the medication into the medication cups. 2. Administered by mouth medications for Resident #7 and #10 by placing his bare fingers inside the medication cups These failures could place residents at risk for infection, transmission for communicable diseases and or a decline in health. The Findings include: Review of Resident #7's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident #7's quarterly MDS assessment dated [DATE], revealed Resident #7 had severely impaired cognition skills for decision making and a BIMS score was 99 indicating unable to complete the interview. Further review of the quarterly MDS revealed ADLs for Resident #5 required supervision of 1 staff person. Review of Resident #7's comprehensive care plan dated 04/04/23 and revision dated 08/29/23 revealed the care plan addressed the resident's medications including monitoring the side effects and to administer the medications as ordered. Review of Resident #7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Divalproex 125 mg capsule, 2 po tid.; Famotidine 20 mg tab give 1 po bid; Furosemide 20mg tab, give 1 po qd;, Metformin 500mg tab 1 po qd; Quetiapine 300 mg extended release tab, give 1 po qd; Docusate Na 100mg tab give 1 po qd; D3 2000IU capsule, give 1 po qd; Farxiga 10 mg tab give 1 po qd; Lisinopril 5 mg tab, give 2 (10mg) po qd; Lorazepam o.5mg tab give 1 po tid. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the following medications to be given Buspirone 5 mg tab give 1 po bid; D3 1000 IU 25mg cap give 1 po qd; Eliquis 5 mg tab give 1 tab po bid; Lisinopril 10mg tab give 1 po qd; metoprolol tar 25 mg tab give 1 po bid; lactulose solution 10 mg/15ml give 30 ml po qd; dorszao/tinol Sol 22.3-4.68 1 gtt o.u. bid; alphagn p sol 1% give 1 gtt o.u. tid; terbinafine hcl 1% cream on toenails qd; lorazepam 0.5mg give 0.25mg tab po bid. Review of Resident #10's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS of 11, indicating moderate impairment and ADLs require supervision with setup by 1 person. Review of Resident #10's comprehensive care plan dated 12/01/23 with revision date of 08/30/23 under medications reveals an approach of administer medications as ordered. Observations from 09/07/23 at 8:15 am to 9:10 am for Resident #7 and #10 during the medication pass revealed RN C placed his finger in the medication cup then took the blister packs and either popped the resident's medications into his thumb and index finger or popped the pill(s) into the palm of his hand and then placed the medication into the medication cup. When asked how many pills he was giving he would pour the medication into the palm of his hand and take his thumb and index finger and pick up each pill and place them back into the medication cup. Interview on 09/07/23 at 9:20 a.m. to 9:26 a.m. with RN C revealed he did not wear gloves as he setup the medications for Resident #7 and #10 or ensure his hands were clean before picking up blister packs, popping pills and retrieving them with his thumb and index finger or popping them into the palm of his hand, opening drawers on the medication cart and while opening over the counter medications used on multiple residents. When asked what could happen in this situation, RN C stated he could cause the resident to develop an infection. Interview on 09/07/23 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the medication pass with RN C but, when asked about his training, stated he had been trained (medication pass) and she also had the pharmacist consultant do medication passes with the nurses and medication aides. When asked what could happen in each of the incidents with RN C during medication pass the DON stated, infection control- not cleaning their hands and using proper procedure to handle pills could lead to infection. Review of RN C's Clinical Nursing Validation Review Checklist revealed on 02/28/23, RN C was checked off for his skills by the DON. The checklist included hand washing and on 07/16/23 handwashing and F tags for infection control with the facility Core Clinical Compliance 2023. Review of the Facility Policy and Procedure for Administering Medications dated 2001 and revised on 04/19 revealed in part: 21. Staff follows established facility infection control procedure (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable.

Based on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for 1 of 42 [Resident #7) residents reviewed for confidentiality of records during the survey in that: The facility failed to ensure RN C locked and closed the laptop during the medication pass exposing Resident #7's personal information to include some of her medications. This failure could affect residents by placing them at risk for loss of privacy and dignity. The Findings included: Review of Resident #7's face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (a nerve damage that is caused by diabetes), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions) and depression ( A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) Observation on 09/07/23 at 8:27 a.m. of RN C's medication cart revealed the medication cart was left unattended for approximately 3 minutes while RN C went into Resident # 10's bathroom to wash his hands. RN C was setting up medications for Resident #7. The screen showed Resident #7's picture, name and medications RN C was about to setup. Interview on 09/07/23 at 9:26 a.m. with RN C stated he did not remember leaving the laptop open. When asked what could have happened if someone sees the information? RN C stated well, I guess someone could use the information against the resident. Interview on 09/07/23 at 10:25 a.m. with the DON revealed she was not aware of the issues found during medication pass. She stated no one else was supposed to see the meds or issues of the resident. When asked what could have happened if the resident's information was open and no one around. She stated the information could be used against the resident or they could sell the information to someone else Record review of a facility's policy and procedure titled Resident Rights dated 2001 and revised in February 2021 revealed in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: f. Privacy and confidentiality. 3. The unauthorized release, access, or disclosure of resident information is prohibited.

Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #7 and #10) out of 5 residents reviewed for medication administration in that: The facility failed to ensure RN C ensured the Insulin Pen was purged before giving Resident #7 her insulin. The facility failed to prevent RN C from giving Resident #10 Lorazepam 0.5mg tab instead of 0.25mg tab. These deficient practices could affect residents with medications and place residents at risk for not receiving the proper dosage. The findings included: Review of Resident #5's face sheet dated 09/07/23, revealed Resident #7 was admitted on [DATE] and diagnoses which include type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), Schizoaffective disorder, bipolar type (a mental illness that can affect your thoughts, mood and behavior with episodes of mania and sometimes depression), diabetic neuropathy (nerve damage that is caused by diabetes), Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anxiety ( a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday actions), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident#7's Physician's Order Report dated from 08/07/23 to 09/07/23 revealed Resident #7 was to receive Lantus Solostar (insulin glargine) U 100, 100 units/ml (3ml) give 42 units subcutaneous and give twice a day 8:00 a.m. and 8:00 p.m. (Start date was 08/18/23) Review of Resident #7's Medication Administration Sheet dated 08/07/23 to 09/07/23 revealed the Lantus Solostar (insulin glargine) pen was started on 08/18/23 and the resident was receiving the insulin twice a day at 8:00 a.m. and 8:00 p.m. Observation on 09/07/23 at 9:10 a.m. RN C was observed taking a new Lantus Solostar pen for Resident #7 and placing a new needle on the barrel. RN C dialed up 42 units of insulin and did not purge the pen before ensuring Resident #7 was given the insulin and receiving the dose on the left side of the abdomen. Interview on 09/07/23 at 12:25 p.m. with RN C after the medication pass concerning not priming the Lantus Solostar pen before dialing the correct dosage and giving the insulin to Resident #5, stated he was not aware of priming the insulin as long as there were no bubbles in the insulin barrel. Interview on 09/07/23 from 10:20 a.m. to 10:25 a.m. with the DON revealed she was not aware of the issues found with the Medication Pass with RN C. She stated concerning the insulin pen for Resident #5 should have been primed before dialing up the dosage for Resident #7. Stated Resident #5 may have not gotten the correct dosage of insulin. Review of Resident #10's Face sheet dated 09/07/23 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), cardiomegaly (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), glaucoma, bilateral, severe stage (eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), depression with psychotic symptoms (mood disorder). Review of Resident #10's Physician Order Report date from 08/07/23 to 09/07/23 revealed the Lorazepam order reflected Lorazepam - Schedule IV tablet; 0.5mg. Special instructions: administer 0.25 mg tablet by mouth two times a day; 08:00 a.m.- 10:00 a.m., 08:00 p.m. - 10:00 p.m. (Starting on 08/17/23). Review of Resident #10's Controlled Substance Administration Record from 07/19/23 to 09/08/23 revealed the resident was to receive from 07/19/23 to 08/16/23 1/2 tab of Lorazepam once a day. The order description was Lorazepam- Schedule IV 0.5 mg tablet and to give 0.25 mg (1/2 of the 0.5mg tablet) by mouth once a day. Then on 08/16/23 the order for 1/2 mg tablet of Lorazepam was to be given twice a day starting on 08/17/23 and had continued to 09/08/23. Observation on 09/07/23 at 8:15 a.m. during Medication Pass revealed RN C gave Resident #10 Lorazepam 0.5mg tab 1 by mouth, and was to receive twice a day. Observation again on 09/08/23 at 12:45 p.m. of the Resident #10's blister pack of Lorazepam revealed the medication was refilled on 08/20/23 and to take a 0.5mg tablet twice a day. There was nothing on the blister pack indicating the dosage had been changed and further observation of the 0.5 mg tablet revealed the tablet was not scored so as to give 1/2 (equals 0.25 mg) of the tablet. Completed as part of the medication reconciliation to verify the orders against the medication given and the blister pack medication was taken from. Interview on 09/08/23 at 2:22 p.m. with the DON after informing her of the medication discrepancy with Resident #10's Lorazepam she stated it was called into the Pharmacist. The order was not transcribed electronically. The Lorazepam was originally ordered for a gradual dose reduction (GDR) on 07/19/23 to 0.25 mg. The pharmacy kept sending out 0.5 mg of Lorazepam and the staff continued to give 0.5 mg. The original order from 09/14/22 for Resident #10's Lorazepam was for 0.5 mg to be given twice a day. Interview on 09/08/23 at 4:23 p.m. with the DON confirmed Resident #10 was given the wrong amount of the Lorazepam for 15 days. When asked about what could happen by receiving the wrong amount, she stated Resident #10 could have an adverse reaction. Record review of the Facility Policy Administering Medications dated 2001 with a revision date of 04/19 stated in part: 4. Medications are administered in accordance with prescriber orders .

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 6 Residents (Resident #1) whose records were reviewed for abuse; failed to report an outbreak of COVID for 1 of 1 incident. 1. CNA A allegedly pulled Resident #1's pants down out of anger because Resident #1 was flirting with CNA A's husband. The allegation of Resident abuse was not reported until 2 days after the incident. 2. The facility failed to report a COVID outbreak within 24 hours after DA E tested positive for COVID. These deficient practices could affect any resident and could contribute to continued resident abuse and reporting inaccurate data after a COVID outbreak. The findings were: 1. Review of Resident #1's face sheet, dated 2/16/23, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia unspecified severity, without behavior disturbance and Major Depressive Disorder. Review of event, dated 12/13/22, revealed Resident #1 and CNA A were playing around and Resident #1's pants fell down (to ankles). The event included Resident #1's BIMS score of 8 (out of 15) indicative of moderate cognitive impairment. Review of Provider Investigation Report #394216, dated 12/13/22 revealed incident date was 12/11/22 alleging Resident abuse involving Resident #1. It was reported to HHSC on this same date. Housekeeper B reported CNA A and Resident #1 were playing around. CNA A tugged on the Resident #1's blouse/pants and her pants fell off. ADON C assessed Resident #1 who did not appear to be in distress. Staff was in-serviced on 12/13/22 re: abuse including all allegations to administrative staff right away, customer service and resident rights. CNA A received one on one in-service. Safe surveys were conducted with 4 residents with no reported concerns related to abuse. The findings were unfounded. Review of complaint intake, dated 12/19/23, revealed the complainant reported overhearing multiple staff members discussing their concern about CNA A who pulled Resident #1's pants down and CNA A remained working at the facility. Further review revealed CNA A was sitting in the area where the residents were eating. CNA A pulled down Resident #1's pants because Resident #1 was too close in proximity. Housekeeper B witnessed the incident but was afraid to speak out for fear of CNA A retaliating, showing up at her home, if she said anything to the ADM. Interview on 2/15/23 at 3:47 PM with Housekeeper, B, revealed CNA A's husband came to visit around Christmas time. She stated the husband liked Resident #1. Resident #1, CNA A and her husband were sitting in the dining room on the 300 hall located at the CNA desk. She stated Resident #1 was flirting with CNA A's husband. CNA A told Resident #1 to go to her room several times but Resident #1 refused. CNA A was upset and pulled down Resident #1's pants to her ankles exposing her brief. Housekeeper B stated Resident #1 commented to her; it's a good thing he didn't turn around to see me. Resident #1 was going around telling other residents what happened. Housekeeper B stated the husband was busy on his phone and was not paying attention. She stated she did not report it until a couple of days later after thinking about the incident. She stated she initially thought they were playing around because they often teased each other and did not note any animosity amongst them on the date of the incident. Housekeeper B stated she reported the incident to LVN D because she spoke primarily Spanish and felt comfortable talking with LVN D. Housekeeper B stated LVN D told her it was a serious incident and she should have reported the incident right away. Housekeeper B stated the DON took her statement and she signed it. Housekeeper B stated she was afraid CNA A would find out she reported the incident and would retaliate against her. She stated CNA A was very aggressive. Interview on 2/15/23 at 4:34 PM with the DON revealed another staff reported Resident #1 and CNA A were playing and joking around. While playing around Resident #1's pants fell down because the pants were too big on her. She had another resident's clothes on. The DON stated she investigated the incident and learned the CNA's boyfriend might have been visiting or dropping off lunch for CNA A. She stated Resident #1 commented about CNA A's boyfriend being [NAME]. The DON stated both Resident #1 and CNA A told her they were playing around. She stated Resident #1 did not express being afraid or that she was in any distress. The DON stated Resident #1 was discharged home some time after the incident. Interview on 2/16/23 at 9:28 AM with CNA A revealed she had worked at the facility for 1 year and had worked on all halls. She remembered the incident with Resident #1 and stated she was suspended pending the investigation. CNA A stated she knew the Resident from the community and at times they would joke around. On the date in question, her husband came to the facility to pick her up from work. Resident #1 also knew her husband; she approached him and started talking to him. Then suddenly she started making inappropriate comments like, You're so [NAME], I wanna suck your dick. CNA A stated her husband immediately turned away from Resident #1 and never looked back at her. CNA A stated she then reached over and tugged on Resident #1's shirt and told her to settle down. She stated Resident #1 was wearing big clothes and when she tugged on the Res' shirt her pants fell down because Resident #1 was holding her pants up. She stated Resident #1 picked them up right away; she laughed and walked away. CNA A stated she was not upset, did not purposely pull Resident #1's pants down to intentionally embarrass Resident #1. CNA A stated she was removed from working on 300 hall at that time. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed that Housekeeper B should have reported the incident right away and in turn the ADM should have reported the incident within 2 hours. The DON stated she reported the incident to the ADM on 2/13/23 and the incident was reported to HHSC on 2/13/23. She stated she reiterated to Housekeeper B that she should report all allegations of resident abuse right away. The DON stated Housekeeper A told her she understood the expectation. 2. Review of Provider Investigation Report, dated 10/4/22, revealed non-direct staff member tested positive for COVID on 9/26/22. It was reported to HHSC on 9/27/22. Review of facility line testing for September 2022 revealed on 9/23/22 DA E tested positive for COVID and then on 9/26/23 DA F also tested positive for COVID. Therefore, the outbreak onset date was 9/23/22. The outbreak was reported to HHSC on 9/27/22. Interview on 2/15/23 at 3:08 PM with the DON and ADON revealed DA E, tested positive for COVID on 9/23/22. This was the actual start of the outbreak date and not as reported which was on 9/26/23 when DA F tested positive for COVID. The DON stated the facility was required to report the outbreak within 24 hours. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed the facility had at least a couple of traveling Interim Administrator's in the last year or so. The ADM stated he recognized that the reporting deadlines were not always met and understood the regulation required the facility to report any allegation of abuse within 2 hours and to report all other allegations within 24 hours. Review of a facility policy, Abuse Prevention Program, dated 1/9/23 read: Policy Statements: 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for 1 of 6 Residents (Resident #1) whose record were reviewed for abuse and failed to report an outbreak of COVID for 1 of 1 incident. 1. CNA A allegedly pulled Resident #1's pants down out of anger because Resident #1 was flirting with CNA A's husband. The allegation of Resident abuse was not reported until 2 days after the incident. 2. The facility failed to provide a report of a COVID outbreak within 24 hours after DA E tested positive for COVID. These deficient practices could affect any resident and could contribute to continued resident abuse and reporting inaccurate data after a COVID outbreak. The findings were: Review of a facility policy, Abuse Prevention Program, dated 1/9/23 read: Policy Statements: 1. The Administrator is responsible for the overall coordination and implementation of our Center ' s abuse prevention program policies and procedures in accordance with the Elder Justice Act. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 1. Review of Resident #1's face sheet, dated 2/16/23, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia unspecified severity, without behavior disturbance and Major Depressive Disorder. Review of event, dated 12/13/22, revealed Resident #1 and CNA A were playing around and Resident #1's pants fell down (to ankles). The event included Resident #1's BIMS score of 8 (out of 15) indicative of moderate cognitive impairment. Review of Provider Investigation Report #394216, dated 12/13/22 revealed incident date was 12/11/22 alleging Resident abuse involving Resident #1. It was reported to HHSC on this same date. Housekeeper B reported CNA A and Resident #1 were playing around. CNA A tugged on the Resident #1's blouse/pants and her pants fell off. ADON C assessed Resident #1 who did not appear to be in distress. Staff was in-serviced on 12/13/22 re: abuse including all allegations to administrative staff right away, customer service and resident rights. CNA A received one on one in-service. Safe surveys were conducted with 4 residents with no reported concerns related to abuse. The findings were unfounded. Review of complaint intake, dated 12/19/23, revealed the complainant reported overhearing multiple staff members discussing their concern about CNA A who pulled Resident #1's pants down and CNA A remained working at the facility. Further review revealed CNA A was sitting in the area where the residents were eating. CNA A pulled down Resident #1's pants because Resident #1 was too close in proximity. Housekeeper B witnessed the incident but was afraid to speak out for fear of CNA A retaliating, showing up at her home, if she said anything to the ADM. Interview on 2/15/23 at 3:47 PM with Housekeeper, B, revealed CNA A's husband came to visit around Christmas time. She stated the husband liked Resident #1. Resident #1, CNA A and her husband were sitting in the dining room on the 300 hall located at the CNA desk. She stated Resident #1 was flirting with CNA A's husband. CNA A told Resident #1 to go to her room several times but Resident #1 refused. CNA A was upset and pulled down Resident #1's pants to her ankles exposing her brief. Housekeeper B stated Resident #1 commented to her; it's a good thing he didn't turn around to see me. Resident #1 was going around telling other residents what happened. Housekeeper B stated the husband was busy on his phone and was not paying attention. She stated she did not report it until a couple of days later after thinking about the incident. She stated she initially thought they were playing around because they often teased each other and did not note any animosity amongst them on the date of the incident. Housekeeper B stated she reported the incident to LVN D because she spoke primarily Spanish and felt comfortable talking with LVN D. Housekeeper B stated LVN D told her it was a serious incident and she should have reported the incident right away. Housekeeper B stated the DON took her statement and she signed it. Housekeeper B stated she was afraid CNA A would find out she reported the incident and would retaliate against her. She stated CNA A was very aggressive. Interview on 2/15/23 at 4:34 PM with the DON revealed another staff reported Resident #1 and CNA A were playing and joking around. While playing around Resident #1's pants fell down because the pants were too big on her. She had another resident's clothes on. The DON stated she investigated the incident and learned the CNA's boyfriend might have been visiting or dropping off lunch for CNA A. She stated Resident #1 commented about CNA A's boyfriend being [NAME]. The DON stated both Resident #1 and CNA A told her they were playing around. She stated Resident #1 did not express being afraid or that she was in any distress. The DON stated Resident #1 was discharged home some time after the incident. Interview on 2/16/23 at 9:28 AM with CNA A revealed she had worked at the facility for 1 year and had worked on all halls. She remembered the incident with Resident #1 and stated she was suspended pending the investigation. CNA A stated she knew the Resident from the community and at times they would joke around. On the date in question, her husband came to the facility to pick her up from work. Resident #1 also knew her husband; she approached him and started talking to him. Then suddenly she started making inappropriate comments like, You're so [NAME], I wanna suck your dick. CNA A stated her husband immediately turned away from Resident #1 and never looked back at her. CNA A stated she then reached over and tugged on Resident #1's shirt and told her to settle down. She stated Resident #1 was wearing big clothes and when she tugged on the Res' shirt her pants fell down because Resident #1 was holding her pants up. She stated Resident #1 picked them up right away; she laughed and walked away. CNA A stated she was not upset, did not purposely pull Resident #1's pants down to intentionally embarrass Resident #1. CNA A stated she was removed from working on 300 hall at that time. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed that Housekeeper B should have reported the incident right away and in turn the ADM should have reported the incident within 2 hours. The DON stated she reported the incident to the ADM on 2/13/23 and the incident was reported to HHSC on 2/13/23. She stated she reiterated to Housekeeper B that she should report all allegations of resident abuse right away. The DON stated Housekeeper A told her she understood the expectation. 2. Review of Provider Investigation Report, dated 10/4/22, revealed non-direct staff member tested positive for COVID on 9/26/22. It was reported to HHSC on 9/27/22. Review of facility line testing for September 2022 revealed on 9/23/22 DA E tested positive for COVID and then on 9/26/23 DA F also tested positive for COVID. Therefore, the outbreak onset date was 9/23/22. The outbreak was reported to HHSC on 9/27/22. Interview on 2/15/23 at 3:08 PM with the DON and ADON revealed DA E, tested positive for COVID on 9/23/22. This was the actual start of the outbreak date and not as reported which was on 9/26/23 when DA F tested positive for COVID. The DON stated the facility was required to report the outbreak within 24 hours. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed the facility had at least a couple of traveling Interim Administrator's in the last year or so. The ADM stated he recognized that the reporting deadlines were not always met and understood the regulation required the facility to report any allegation of abuse within 2 hours and to report all other allegations within 24 hours.

Based on observation, interview and record review revealed the facility failed to report the results of all investigations to the State Survey Agency within 5 working days of the incident for 1 of 6 Residents (Resident #2) whose records were reviewed for abuse and for 1 of 1 COVID incident outbreak. 1. Resident #2 fell on [DATE] which resulted in an acute fracture of the left wrist. The Provider Investigation Report was not provided to HHSC until 1/4/23, 11 working days after the incident. 2. DA E tested positive for COVID on 9/23/23, the onset of a COVID outbreak, the Provider Investigation Report was not provided on 10/4/22, 7 working days after the incident. These deficient practices could result in reportable events not being investigated timely contributing to resident abuse/neglect. The findings were: 1. Review of Resident #2's face sheet, dated 2/16/23, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and history of falling. Review of event dated 1/3/23 revealed Resident #2 fell on [DATE] and was observed lying on the floor on left side in dining room. Resident had been escorted to the dining room and then ambulated to the hallway and observed on floor. There were no witnesses. Review of Stat X-Ray on 12/16/22 revealed an acute intra articular fx of left distal radial metaphysis; left wrist fracture. Review of Provider Investigation Report revealed the investigation was completed and reported to HHSC on 1/4/23. Further review revealed on 12/16/22 nurse observed Resident #2 on the floor when exiting another resident's room. Resident #2 had an abrasion to upper lip and swelling to left hand. There were no witnesses and no safety hazards were observed. X-Ray results received on 12/16/22 at 12:30 PM revealed Resident #2 sustained an acute intra articular fx of left distal radial metaphysis; fracture of left wrist. The findings were confirmed on 1/4/23. Interview on at 10:05 AM with CNA A revealed Resident #2 would have good days (was clear minded and able to converse) and other days she appeared very confused. She stated Resident #2 had not fallen since she broke her wrist and stated she was on duty at the time. CNA A stated she had escorted Resident #2 to the common area and then the nurse saw Resident #2 on the floor. She busted her lip and broke her left wrist. Observation and interview on 2/16/23 at 1:20 PM revealed Resident #2 was located in the secured unit sitting in her wheelchair in the common area in front of the TV. She smiled when called her name but did not engage in conversation. She did not have any bruising to her face, arms and legs. Her left wrist appeared to have healed. CNA A stated the charge nurse would round during med pass and prior to lunch time. Interview on 2/16/23 at 3:15 PM revealed with the DON and ADON revealed Resident #2 had a fall and fractured her left wrist. The ADON stated she assessed Resident #2 after the fall and the Resident could not tell her what happened. She was confused. She stated she did not believe Resident #2 had any other falls. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed the facility had at least a couple of traveling Interim Administrator's in the last year or so. The ADM stated the investigation for the self-report involving Resident #2 was completed on 1/4/23. The ADM stated they were required to complete and provide a copy of the investigation no later than the 5th working day. 2. Review of Provider Investigation Report revealed Staff tested positive for COVID on 9/26/22. However, the onset date was on 9/23/22 when DA E tested positive. The outbreak was reported to HHSC on 9/27/22 and the PIR was completed and provided to HHSC on 10/4/22. Interview on 2/16/23 at 5:15 PM with the ADM and DON revealed the facility had at least a couple of traveling Interim Administrator's in the last year or so. The ADM stated he reviewed the Provider Investigation Report for the COVID outbreak on 9/23/22 and confirmed the investigation report was completed and reported to HHSC on 10/4/22; which was past the 5th working day. Review of a facility policy, Abuse Prevention Program, dated 1/9/23 read: Policy Statements: 1. The Administrator is responsible for the overall coordination and implementation of our Center ' s abuse prevention program policies and procedures in accordance with the Elder Justice Act. Reporting: 4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within the state requirement. (Usually 5 business days).

Based on observation, interview, and record review, the facility failed to ensure residents who were at risk for pressure injuries received appropriate treatment and services to prevent pressure injuries for 1 of 1 Resident (Resident #35) reviewed for pressure injuries in that: LVN B did not provide proper care to Resident #35's DTI (deep tissue injury) and failed to utilize hand hygiene during wound care. This deficient practice could place residents at risk for infection, skin break down due to improper care practices and result in cross contamination and infection related illnesses. The findings were: Record review of Resident #35's face sheet, dated 7/19/22 revealed an [AGE] year old admitted on [DATE] and re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's most recent quarterly MDS assessment, dated 6/15/22 revealed the resident was severely cognitively impaired for daily decision-making skills, required one-person physical assist with bed mobility, two-person physical assist with transfers and was at risk for pressure ulcers and had an unstageable deep tissue injury. Record review of Resident #35's care plan, revision date 7/17/22 revealed the resident had a DTI to the left heel with interventions that included to administer treatments as ordered. Record review of Resident #35's Order Summary Report, dated 7/19/22 revealed an order to Cleanse Left Heel with NS (normal saline). Pat dry. Paint area with Skin Prep and [MEDICATION(S)] to Left heel. Cover with non-adherent dressing and wrap with Kerlix (gauze dressing/bandage) and secure with tape every day shift for DTI, with order date 7/18/22 and no end date. Observation on 7/19/22 at 11:39 a.m., during wound care, LVN B took a 4 inch by 4 inch gauze soaked with normal saline and cleansed Resident #35's DTI to the left heel improperly by wiping the area in a back and forth scrubbing motion at least 6 times with the same gauze. LVN B then took a dry 4 inch by 4 inch gauze and wiped the DTI to Resident #35's left heel at least 3 times with the same gauze. During an observation of wound care to Resident #35 on 7/19/22 at 11:49 a.m., LVN B removed the bandage from Resident #35's left ankle/foot, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN B then cleaned the wound, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN B then applied the treatment to the wound as ordered, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN B then covered the wound with gauze, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. During an interview on 7/19/22 at 12:12 p.m., LVN B stated confirmed she had not provided proper care to Resident #35's left heel DTI because the wound should have been cleaned from the inner part of the wound away from the center and should have used one 4 inch by 4 inch gauze for each pass. LVN B stated, having wiped the wound in a scrubbing motion and using the same gauze on multiple passes was cross contamination and could results in the wound getting worse or becoming infected. LVN B stated she had received training on the computer for wound care about a month ago. LVN B further confirmed she had not performed hand hygiene between gloves changes. LVN B stated she should have had sanitizer at the bedside. LVN B stated it was important to perform hand hygiene between gloves changes to prevent cross contamination. LVN B stated, not performing hand hygiene between glove changes could cause Resident #35's wound to become infected or delay healing. LVN B stated she had received competency training on wound care a month ago. During an interview on 7/19/22 at 3:31 p.m., the DON stated, Resident #35's wound should have been cleaned from the inner part of the wound to the outer part and with one pass. The DON stated, the gauze should have been tossed after one pass and not used in a back and forth motion because it did not create a clean area and it was cross contamination. The DON stated, cleaning the wound in that manner would put the resident at risk for infection. The DON stated, nursing staff were provided training on the computer at least monthly and was in the process of setting up skills clinics for nursing to practice wound care. The DON further stated it was the expectation of the nursing staff to perform hand hygiene between glove changes to prevent cross contamination. The DON stated, washing or sanitizing hands between glove changes was part of proper infection control practice. The DON stated, improper infection control practices could result in the resident's wound to become infected or delay the healing process. The DON stated nursing staff received on-line training on wound care and infection control practices at least monthly. Record review of the competency training titled, Wound Dressing Change for LVN B, dated 6/24/22 revealed LVN B satisfied the requirements for performing wound dressing changes and under Comments was noted, Still requires more teaching, gets nervous and redirected. Further review of the competency training revealed in part, .Wipe in one direction once and then repeat technique with new gauze, etc .If using a circular motion start at the center and working outward in a circular motion . Record review of the facility policy and procedure titled, Handwashing/Hand Hygiene, revision dated August 2015 revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infections .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations .g. Before handling clean or soiled dressings, gauze pads, etc .h. Before moving from a contaminated body site to a clean body site during resident care .m. After removing gloves .

Based on interviews and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 (Resident #1) of 6 residents reviewed for pain management in that: Resident #1 was not provided with pain medication for a fractured right hip for a period of 7 hours due to [MEDICATION NAME] not being available. This deficient practice could affect residents with traumatic injuries and could result in unnecessary pain. The findings were: Review of Resident #1's electronic face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with that [DIAGNOSES REDACTED]. Observation on 12/3/19 at 10:30 a.m. of Resident #1 revealed she was sitting in a tall back wheel chair in her room and was not able to ambulate. Review of the facility self-report investigation of Resident #1's fall on 10/19/19 at 6:00 p.m. revealed she had a witnessed fall when she was redirected by CNA B after wandering in other residents rooms. Resident #1 fell back onto her bottom and she yelled in pain and laid down holding her right hip. LVN A checked Resident #1, made required notifications to Hospice and the RN Case Manager who arrived at the facility at 7:45 p.m. Review of Resident #1's MAR indicated [REDACTED]. He also administered [MEDICATION NAME] (antianxiety) 0.5 mg by mouth as needed for anxiety and agitation. Further review of the MAR indicated [REDACTED] Review of Resident #1's progress notes written by LVN A on 10/19/19 at 7:00 p.m. post fall revealed Resident complained of pain to right hip. No redness or swelling, tenderness to touch.resident log rolled onto bed sheet, and transferred on to bed in the hallway. Resident #1 unable to give a description of events, only verbalizes pain. Review of Resident #1's of RN - Skilled Nursing Visit Notes dated 10/19/19 Time in: 7:45 p.m., Time Out: 8:30 p.m. revealed RN B wrote reports that pt is in a lot of pain and taken to room and placed back to bed, she was also given [MED] and [MEDICATION NAME] at that time, pt fidgeting and guarding right hip area with covers and speaking word salad in [REDACTED].pt also noted rubbing right hip, facility CNA asked patient if she was in pain but pt was unable to answer, on assessment.when covers removed right leg noted with shorter than left and with outer rotation of leg with swelling of hip and thigh, facility staff place a cold compress on top of area but pt unable to tolerate, CM place compress on bed next to hip pt tolerated there, talked to Hospice about giving patient something stronger for pain, facility stated that pt has order for [MEDICATION NAME] but doesn't have any at facility otherwise patient has order for [MED] suppository, talked with staff to see if they had medication in ER box, he stated it doesn't.pt noted during visit work on trying to get out of bed.pain. Further review of Resident #1's RN - Skilled Nursing Visit Notes dated 10/19/19 written by RN B revealed Pain intensity-6, and What Makes Pain Worse-movement, Psychological Status-Anxious. Review of Resident #1's progress notes written by LVN A on 10/19/19 at 11:28 p.m. revealed that the [MEDICATION NAME] and the [MED] ([MEDICATION NAME]) was effective which brought the pain level down from a 7 to a 2. Review of Resident #1's progress notes written by LVN A on 10/19/19 at 11:39 p.m. revealed contacted Hospice RN on right hip X-ray result.Acute Intertrochanteric [MEDICAL CONDITION].DON notified of right hip X-ray results. Review of Resident #1's X-ray report dated 10/19/19 revealed Findings.moderately displaced intertrochanteric [MEDICAL CONDITION]. Review of Resident #1's Comprehensive Plan of Care dated 12/4/17 revealed I am able to ambulate with no assistance and no difficulties. Review of Resident #1's Comprehensive Plan of Care revised on 10/21/19 revealed I had a fall on 10/3/19 and 10/19/19. Review of Resident #1's Physician Orders dated 10/2019 revealed she was placed on Hospice services housed in San Antonio on 10/17/19 for Senile Degeneration of the Brain. Review of Resident #1's Significant Change MDS with an ARD of 10/20/19 (pre-fall) revealed she ambulated and performed all other ADL's with supervision and required limited assistance with dressing and personal hygiene. Review of Resident #1's Quarterly MDS with an ARD of 11/1/2019 (post-fall) revealed she sometimes understood and usually understands. She scored a 3 of 15 on her BI[CONDITION] making her severely cognitively impaired. Review of Resident #1's mobility status revealed it did not occur and she was dependent on staff for her ADL's. Further review of Resident #1's Physician Orders dated 10/2019 revealed she had an order initiated on [DATE] from Hospice for [MEDICATION NAME] ([CONDITION]04) (concentrate) Solution 20 Mg/Ml.Give 5 mg by mouth every 3 hours as needed for pain. This order was written 2 days prior to the fall, and the [CONDITION]O4 from Hospice had not been delivered because at that time she did not need it and the triplicate was held up at the physician's office. Review of Resident #1's MAR indicated [REDACTED]. Review of Resident #1's progress note written by LVN A on 10/20/19 at 1:14 a.m. revealed [MEDICATION NAME] Solution 20 mg/ml, give 5 mg by mouth every 3 hours as needed for pain.resident unable to convey pain intensity due to poor cognitive skills. Review of Resident #1's pain assessment (LVN A) from October 19th from 6:00 p.m. to October 20th 09:45 a.m. revealed: 6:45 on the 19th a 7 later reassessed to be a 2 on a scale of 1 to 10 and at 04:19 a.m. a 5 (after the [CONDITION]O4) Hospice RN B's initial pain assessment score at 7:45 p.m. on 10/19/19 revealed a 6 (prior to the [CONDITION]O4). After the two doses of [CONDITION]O4, and antianxiety medications administered, LVN E (the day shift nurse the morning after the fall) rated Resident #1's pain as a 10 when they transferred her to the gurney to go to the hospital at 09:45 a.m. Review of Resident #1's MAR indicated [REDACTED]. She received [MEDICATION NAME] [MED] 50 mg tablet by mouth in the morning for depression on October 19th. 10/19/19: She received [MEDICATION NAME] [MED] (for anxiety and agitation) tablet 10 mg at mid day on October 19th. She received [MEDICATION NAME] [MED] 10 mg at 01:39 a.m. on the morning of October 20th along with 5 mg of [MEDICATION NAME], she had another 5 mg of [CONDITION]O4 at 4:19 a.m., and at 07:20 a.m. her a.m. dose of [MEDICATION NAME] 1mg was given. She was administered another 5 mg of [CONDITION]O4 at 09:45 a.m. when the ambulance arrived on October 20th. Review of Resident #1's Emergency Department assessment dated [DATE] at 10:40 a.m. revealed her pain was rated as a 6 out of 10 and she was give 2 mg of [CONDITION]O4 IVP. Further review revealed the individual has been provided with a medical screening examination, and an emergency medical condition exists.the patient requires specialty or higher level of care not available at the facility. She was stabilized and sent to a hospital for surgery. Review of Resident #1's initial hospital visit Medical Records dated 10/20/19 revealed Emergency medical screening exam conducted.physician first contact with patient time: 10:30 a.m. Date: 10/20/19.Chief Complaint, right hip pain.aching.right hip tenderness, right leg shortened and rotated. Review of Resident #1's History and Physical dated 10/21/19 at the hospital revealed she was admitted for a fracture with pain. Further review of the X-ray report revealed Acute, markedly displaced right intertrochanteric fracture with displacement of the lesser trochanter. The fracture appears to extend from the medial cortex to the lateral cortex distally, consistent with a reverse obliquity intertrochanteric femoral fracture. Lateral angulation associated with approximately 4 cm's (centimeter) shortening. Interview on [DATE] at 10:35 a.m. with Hospice RN B revealed she came in to the facility and assessed Resident #1 after her fall, and she rated her pain as a 6, and when asked by the surveyor if she felt like the resident needed something stronger than [MED] she said Yes. RN B was asked by the surveyor 2 more times with the same response. Resident #1 was moaning and had some facial grimaces but was fine if you didn't touch her. She stated that she was lying in bed mumbling in [REDACTED] and Resident #1 couldn't speak English. She stated that the resident was administered [MED], and she asked LVN A if they had any narcotics in the E-kit (emergency storage of medication) and he said that he couldn't get narcotics out of the E-kit. LVNA said he did not have access to the E-kit narcotics. Hospice RN B stated that she decided to go back to San Antonio to get the resident's [CONDITION]O4 that was ordered. She said, I told LVN A.it's gonna be awhile. Interview with the DON on [DATE] at 10:00 a.m. revealed that all the nurses including LVN A had access to the E-kit and narcotics. Observation with the DON on [DATE] at 2:00 p.m. of the facility ER medication kit revealed the availability of [MEDICATION NAME] and [MED] #3 for pain. Interview on [DATE] at 08:15 a.m. with CNA C who took care of Resident #1 all night on 10/19/19 revealed that she helped to log roll Resident #1 onto the bed. Resident #1 was crying and in pain. You could see her bone, hip was dislocated and when we transferred her she was yelling. CNA C stated that she was with Resident #1 and watching her. She was telling me that she had pain all the way up until she got the [MEDICATION NAME] and then she went to sleep. Resident #1 was in pain because the guy couldn't take more x-rays, he only took one. The X-ray technician said, I am not going to move her anymore because she was in pain. I felt bad because Resident #1 was in pain. When Resident #1 was on the floor she was in pain, she was yelling, crying and showing us where it hurt. CNA C stated that Resident #1 said in [REDACTED], It hurts. CNA C stated that Resident #1 kept trying to get up and everytime she tried and moved she was in pain. Interview on [DATE] at 2:00 p.m. with CNA C revealed that she told LVN A several times Resident #1 was in pain, but he seemed preoccupied with paperwork. Interview on 12/5/19 at 07:02 a.m. with LVN A revealed he did not try to move the resident because she was in pain when she moved. He stated that when he checked on the resident she appeared to be still and resting. When asked by the surveyor why he did not recommend something stronger from the Emergency Kit he stated that the RN from Hospice did not ask for anything and that she managed the case. Interview on [DATE] at 09:50 a.m. with CNA D (who witnessed the fall) revealed that Resident #1 had always been very anxious. She was always going into other residents' rooms and she was combative earlier that day with me. CNA D stated she was trying to redirect her, and Resident #1 had her back to the wall and I turned to close the door behind me and she started doing a squat and she fell back onto her bottom and as soon as she fell she screamed back in pain. Resident #1 laid back and sat up and she screamed out in pain again. Resident #1 had a grimace when she tried to sit up. Whenever Resident #1 moved, her pain appeared to increase, and she would yell and then lay back down. Her right hip appeared popped out and her right leg was turned outward. Interview on [DATE] at 3:30 p.m. with LVN E (the nurse working the next morning after Resident #1's fall) revealed that LVN A had told her that Resident #1 was given [MEDICATION NAME] for pain and was resting comfortably. She stated she was told to send her out to the hospital Emergency Department. She was screaming when they tried to put her on the gurney and I rated her pain as a 10 and I medicated her prior to her leaving. If she did not move she was ok, but when she moved it was painful for her. Review of the facility policy and procedure on Pain Management dated 4-2011 revealed The community recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities leading to an impaired quality of life.

Based on observation, record review and interview, the facility failed to develop and implement written policies and procedures that prohibit the neglect of 1 of 13 residents (#2) whose care was reviewed for elopement from the secure unit; and the neglect of 1 of 4 residents (#1) whose care was reviewed for community acquired pressure sores in that: 1. The facility failed to assign a staff member to monitor Resident #2 after 1 attempt to elope and succeeded on the second attempt on the same day by removing screws from his window with his belt buckle, climbing over a 6-8 foot wrought iron fence and leaving the facility grounds; 2. The facility failed to conduct head-to-toe skin assessments on Resident #1 for 18 days and developed multiple Stage 2 pressure sores to both feet, Deep Tissue Injuries (DTI) to both hips and a potential Stage 3 to the coccyx. The facility failed to obtain treatment clarification and was late 2 days in beginning treatment to the pressure sores after returning from the hospital. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway and placed 4 residents at risk for pressure sores, [MEDICAL CONDITION] and death from lack of assessments and treatment. The findings were: 1. Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated Physician's Orders dated 8/1/16 revealed the resident had an anti-anxiety medication, [MEDICATION NAME] tablet 0.5 mg, 1 tablet every 6 hours as needed for anxiety/agitation ordered on admission on 6/30/16. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the [MEDICATION NAME]: Called MD and RP and made aware that [MEDICATION NAME] had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the [MEDICATION NAME] order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room [ROOM NUMBER]. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. 2. Review of Resident #1's admission face sheet dated 8/2/16 revealed the resident was admitted on [DATE], 6/18/16 and 7/23/16. Resident #1's initial [DIAGNOSES REDACTED]. Review of a care plan dated 4/24/16 instructed the staff to observe the skin and assist in turning and repositioning and report any abnormal findings to the nurse. Further review revealed a care plan dated 7/13/16 documenting that the resident had an actual impairment to skin integrity of the left and right feet, the left and right hip and the sacral area and right hand due to fragile skin, mobility issues and incontinent issues. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Review of Resident #1's initial MDS dated [DATE] revealed the resident's BIMS could not be assessed and that his cognitive skills for daily decision making were severely impaired. The resident had trouble maintaining concentration for reading or watching television and was occasionally physically aggressive towards others. Resident #1 required extensive support with ADLs, including eating and toileting and incontinence of bowel and bladder. The resident ambulated by wheelchair and required staff assistance due to his lower extremities including hip, knee, ankle and foot being impaired on both sides. Resident #1's skin was intact and was not assessed at risk for developing pressures. Review of a nursing note dated 6/14/16 revealed Resident #1 was transported to a hospital due to a low grade fever of 100.8 for 2 days, decrease alertness and increasing weakness. After a surgical procedure, lap. chole. (removal of a gall bladder by laparoscopy), the resident was readmitted on [DATE] with additional [DIAGNOSES REDACTED]. Review of Resident #1's re-entry MDS dated [DATE] assessed the resident with unclear speech, which was slurred or mumbled words, with no change in cognition, ADLS and both upper and lower extremities had functional limitations in range of motion. The resident continued to be incontinent of bowel and bladder and weighed 142 pounds. The resident was assessed at risk for developing pressure ulcers. Review of Resident #1's consolidated physician's orders for 7/1/16 to 7/31/16 revealed an order to conduct weekly skin assessments. Review of the weekly skin assessment log for Resident #1 revealed that the resident's head-to-toe skin assessment had not been performed for 18 days, 6/22/16 to 7/10/16. A non-pressure assessment had been conducted on 6/18/16 by LVN G. Review of a head-to-toe skin assessment by LVN G on 6/18/16 assessed the resident with non-pressure bruises to bilateral upper extremities and hands and a 3 cm x 1 cm sutured area to the abdomen with steri. strips from the lap. chole. The site was clean and dry. Subsequent non-pressure skin assessments were performed by LVN G on 6/22/16, 6/30/16 and 7/4/16. On 7/4/16, a skin assessment documented a non-pressure bruise to the right contracted hand and index finger and tip was assessed by LVN G. On 7/7/16, a partial body skin assessment documented that the palm of the right hand, which included the thumb and index finger were contracted by LVN G and that the abdomen (lap. chole.site) had no redness or warmth to the site. The first head-to-toe skin assessment was conducted on 7/10/16 and was documented in the nursing notes and the skin assessment. Review of the facility's provider investigation report dated 7/10/16 revealed that upon completion of the investigation, the facility had identified 10 CNAs and nurses that should have identified and reported the skin breakdown either during showers, changing clothes or conducting skin assessments. The report revealed that the resident resided in the secured memory care unit and was an Adult Protective Services referral/order due to the resident's unsanitary living conditions and inability to care for himself due to dementia, behavioral disturbance, [MEDICAL CONDITION] and very limited communication abilities. Review of Resident #1's nursing note for 7/10/16 revealed that night CNA A had reported an open wound to the left inner heel. When the day shift's licensed staff, RN B, LVN H and LVN K, conducted a total body assessment, they found several areas of breakdown, including several Stage 2 pressure ulcers (partial thickness loss of dermis presenting in a shallow open ulcer with a red pink wound bed): a. Left inner heel, 5 cm x 7 cm; b. Left outer heel reddened area 1 cm x 2 cm; c. Right ankle 1.5 cm x 1.5 cm. d. Right mid outer aspect of foot (blackened skin) 2 cm x 2 cm; e. Right outer aspect of foot towards toes reddened area 3 cm x 2 cm. f. Right inner aspect of heel 4 cm x 4.5 cm. The assessment findings were documented and reported to the responsible party, DON and physician. Pending a call back from the physician, the staff cleansed the areas with wound cleanser; pat dried the wounds and applied clean dry gauze with Kerlix wrap. All opened areas were assessed Stage 2. Further description in the nursing note described the wound beds with granulation tissue, without exudate and slight odor. The surrounding skin colors were white/gray pallor and wound edges were macerated (injury accompanied by soft, white, deteriorating skin around the site due to exposure to moisture for extended periods of time). Review of the nursing notes for Resident #1 on 7/10/16 revealed that the physician responded to the facility's notification at 6:00 p.m. and ordered the treatment protocol for Stage 3 (decubital care to bilateral legs. LVN H documented that she verbally notified the incoming nurse LVN C for the 7 p.m. to 7 a.m. on 7/10/16 nurse to follow up on care and input (transcribe) orders to the PCC, or computerized orders system. Review of nursing notes for Resident #1 for 7/12/16 revealed that the treatment orders were not transcribed. LVN K performed a second head to toe skin assessment and then transcribed the physician's orders from 7/10/16. Further review of assessments on 7/13/16 revealed a non-pressure assessment was conducted on the sacrum (tail bone) and documented finding shearing (friction causes shear) and excoriation (raw irritated lesion) to the sacrum and buttock site. The left and right hips were assessed with [REDACTED]. Review of nursing notes dated 7/19/15 revealed Resident #1 was hospitalized for [REDACTED]. The nursing note documented that the resident had facility acquired pressure sores to both feet and coccyx (tailbone area), which developed since the 6/18/16 admission. While hospitalized from [DATE] to 7/23/16, Resident #1 was also diagnosed with [REDACTED]. Review of the facility's weekly pressure ulcer log dated 7/26/16 revealed that in addition to the multiple pressure ulcers on both Resident #1's feet and hips, a Stage 2 pressure ulcer, 12.0 cm x 6 cm, was identified to the sacrum on 7/13/16. On 7/19/16, the facility received an order from the attending physician to transfer the resident to a hospital for evaluation and treatment due to multiple skin infections with [MEDICAL CONDITION] to upper and lower extremities, dementia and to rule [MEDICAL CONDITION] (blood infection). Review of the hospital's physician's orders dated 7/19/16 revealed that the resident's condition was guarded and the physician ordered intravenous fluids and 2 antibiotics [MEDICATION NAME] (broad spectrum antibiotic) 1 Gm every 12 hours be initiated and [MEDICATION NAME] (antibiotic) 3.375 Gm by IV every 6 hours. Review of the hospital's skin assessment and physician's discharge summary revealed the following: a. Right hand, 3rd finger, necrotic (dead) tissue 1 cm x 1 cm. b. Right hip, non-blanchable redness with broken skin surface, superficial 6 cm x 5 cm. c. Left hip, non-blanchable redness, superficial broken skin 6 cm x 7 cm. d. Left shin, non-blanchable redness, skin intact, 2 cm x 1.5 cm. e. Coccyx, broken skin extending to underlying tissue, necrotic tissue, 8 cm x 12 cm. f. Left, medial heel, 6 cm x 5 cm, broken skin, extending into lower tissue levels, necrotic edges. g. Left 5th toe, dark, skin intact. h. Right foot, lateral surface, 1 cm x 2 cm, 1.5.cm x 1.75 cm, 4 cm x 2.5 cm medial heel. Review of the hospital's H&P for Resident #1 dated 7/19/16 revealed documentation that the resident was significant for weakness, poor appetite and increasing lethargy. The physician's assessment of the resident's skin was: significant for pale, senile, atrophic skin with multiple ulcers on various parts of his extremities and some ulcers are stage II, some are stage I and some are progressing to Stage 3 probably. The physician also noted that the resident had increasing confusion and lethargy lately and was also showing extrapyramidal (EPS - signs and symptoms with increasing rigidity of all extremities and tremors). Review of a hospital physician's progress note dated 7/21/16 revealed that the patient is still not doing well and having stage 3 and 4 decubitus ulcer in the sacral area. The physician documented increased rigidity with tremors/signs of [MEDICAL CONDITION]; dementia progressing fast; [MEDICAL CONDITION]; and multiple decubital ulcers as source of infection. The physician also documented that he would discuss with the family or his power of attorney person of the poor prognosis and referral to Hospice care in view of his poor prognosis and reduced chances of recovery based upon his progressive dementia and multiple decubital ulcers. The physician's discharge orders on 7/23/16 included returning the resident to the nursing facility, discontinuing antipsychotic medications ([MEDICATION NAME] and [MEDICATION NAME]), a referral for hospice care, and continuation of wound care and included a new medication to control EPS, [MEDICATION NAME] 2 mg by mouth TID. Review of skin assessments performed by LVN H upon readmission on 7/23/16 were described as follows: a. Stage 2, sacrum with granulation tissue (pink or red with shiny moist granular appearance) with serosanquinous (containing blood, especially mixed with other fluids) and top portion of wound has eschar (dry, dark scab or falling away of dead skin). b. Stage 2, left heel, with slough (yellow or white tissue that adheres to the ulcer bed in strings, clumps or mucinous); serosanquinous drainage; scant exudate with black/brown surrounding skin color with macerated edges. c. Stage 1 (intact skin with non-blanchable redness), left hip; d. DTI, right side of outer foot; Stage 1, right side of outer foot; e. Stage 1, left outer heel, left outer pinky; f. Stage 1, right hand thumb discoloration, index finger discoloration and middle finger discoloration. g. Stage 2, right outer ankle with [MEDICATION NAME] tissue (new skin), bright red and scant serous exudate. h. Stage 1, right inner heel; i. Stage 1, right heel; j. Stage 1, right hip, skin intact, discoloration; Review of the July 2016 TAR for Resident #1 revealed that the resident was discharged from the hospital on [DATE] and treatment was begun 2 days later on 7/25/16. During initial observations within the facility on 8/2/16 at 10:25 a.m., Resident #1 was observed lying on his left side on an air mattress with a Duoderm (Foam dressings to protect against skin breakdown caused by excess moisture and shear force) to the right hip dated 7/31/16. An anchored indwelling urinary catheter was draining yellow clear urine He was clean and asleep and the left hand was tremulous. During an observation of wound care on 8/2/16 at 1:46 p.m., LVN K and CNA M performed wound care on the resident's multiple areas. The coccyx wound area was large and extended between the buttock approximately 9 cm long. There was a large area of slough (dead tissue) in the center of the wound and grayish skin surrounding the slough. The outer edges were pink and red. A reddish area approximately 3 cm in circumference was located on the edge of the left buttocks and the center was pink with red edges. A small area to the outer edge was black with extended scar tissue. The right buttocks had a small opening that was grayish and pink. During the wound care, the resident made no signs of discomfort or pain. Review of a witness statement from LVN G, ADON, dated 8/8/16 at 7:25 p.m. revealed that the LVN was in charge of the secure unit and hall 200. LVN G reported that after Resident #1 returned from a surgical incident for gall bladder removal on 6/23/16, the resident began to decline and was no longer ambulatory and became more quiet and withdrawn. LVN G reported that head to toe skin assessments were conducted on Wednesdays on the memory unit and that she had not been able to conduct any skin assessments for 2 to 3 weeks, because of the many hats she wore. Resident #1 was not assessed for 2 weeks. LVN G stated that she had depended on CNAs and nurses to report any skin breakdowns on any residents. LVN G stated that she took the word of the staff to assess and report findings. Review of a witness statement from LVN K, Charge Nurse, dated 8/8/16 at 4:50 p.m. revealed that she did not perform head-to-toe skin assessments unless she noted skin breakdown, or if the day was Wednesday, on which the assessments were scheduled. LVN K stated that she was not aware of what the facility's Stage 3 wound care protocol was and did not ask for clarification. Review of a witness statement from RN B, Weekend Supervisor, dated 8/8/16 at approximately 1:30 p.m. revealed that she never performed head to toe skin assessments, even when acting as charge nurse, because the facility had specific days scheduled for assessments. While writing the statement, RN B reported that she noted a lot of irritation and excoriation to the Resident #1's buttock and some of the pressure sores were unstageable. RN B stated that the resident was being turned and repositioned and that the resident had declined after returning from the hospital after the lap. chole. RN B stated that the physician had given an order on 7/10/16 for Resident #1 to follow the facility's Stage 3 wound care protocol, but the charge nurse, LVN H, and RN B did not know what the order meant. RN B reported that the physician was not contacted for clarification. On 7/10/16, RN B and 2 other staff nurses conducted a complete skin assessment of Resident #1, and noted that the buttocks was excoriated (a scratch or abrasion of the skin). Review of a witness statement from LVN C, MDS Coordinator, dated 8/3/16 at 2:55 p.m. revealed that she had worked the night shift (7 p.m. to 7 a.m.) on 7/9/16 and did not conduct a head to toe skin assessment on the morning of 7/10/16, because CNA A had reported finding a broken blister to one of Resident #1's feet during report to the on-coming day shift at 7:00 a.m LVN C stated that upon returning on 7/10/16 at 7:00 p.m., she was not aware that a physician's order for Resident #1 had not been transcribed, but was surprised when the day shift informed her of the multiple pressure ulcers. LVN C stated that CNA A had reported only 1 area of skin breakdown. LVN C reported while writing the statement that she had performed treatments to both feet during the night shift that included cleansing with normal saline and applying [MEDICATION NAME] cream and covering the feet with Kerlix gauze during the shift (unspecified), but did not document the treatment in the nurse progress notes and/or the TAR. During an interview on 8/2/16 at 11:48 a.m., CNA A reported that she didn't usually work in the secure unit, but when Resident #1 returned from his gall bladder surgery, she showered him and did not notice any skin breakdown, including the coccyx area. She stated that she usually did a more thorough examination of residents ' feet by taking their socks off, but did not take both socks off during the night shift of 7/9/16. During a second interview on 8/2/16 at 4:21 p.m., LVN C, MDS Coordinator, stated that she wasn't able to complete Resident #1's MDS to reflect pressure ulcers because she was waiting for the measurements from the nurses. LVN C stated that she thought the nurses were performing skin assessments as scheduled on all the residents. During an interview by phone on 8/2/16 at 5:30 p.m., the DON confirmed that weekly skin assessments (head to toe) had not been performed on Resident #1 and other residents on the secure unit and hall 200 for at least 2 weeks. The physician order given to LVN H on 7/10/16 had not been clarified and transcribed. On Monday, 7/11/16, the Weekend Supervisor acted as charge nurse for the secure unit, and Resident #1 was not provided wound care. On Tuesday, 7/12/16, LVN K was informed of the multiple areas of skin breakdown on Resident #1 and no physician orders were found in the facility's computerized system (PCC). Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and conduct weekly head to toe skin assessments. For Stage 3 (full thickness loss. Subcutaneous fat may be visible but bone, tendons or muscle are not exposed) and 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough (dead tissue) or eschar (dry, dark scab or falling away of dead skin) ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provided by the Administrator on 8/9/16 at approximately 12:45 p.m. and included the follow steps taken by the facility: a. The Investigator confirmed that the facility all Phillip's screws in the secure unit were replaced with traditional bolt pattern requiring a nut drive or socket to remove. Three exits were identified on the secure unit in the event of an emergency exit. The admission process to the secure unit was revised to include assessing for triggers for

Based on observations, record review and interviews, the facility failed to implement the facility's written policies and procedures that prohibit the neglect of 1 of 13 residents (#2) whose care was reviewed for elopement from the secure unit; and the neglect of 1 of 4 residents (#1) whose care was reviewed for community acquired pressure sores in that: 1. The facility failed to assign a staff member to monitor Resident #2 after 1 attempt to elope and succeeded on the second attempt on the same day by removing screws from his window with his belt buckle, climbing over a 6-8 foot wrought iron fence and leaving the facility grounds; 2. The facility failed to conduct head-to-toe skin assessments on Resident #1 for 18 days and developed multiple Stage 2 pressure sores to both feet, Deep Tissue Injuries (DTI) to both hips and a potential Stage 3 to the coccyx. The facility failed to obtain treatment clarification and was late 2 days in beginning treatment to the pressure sores after returning from the hospital. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway and placed 4 residents at risk for pressure sores, [MEDICAL CONDITION] and death from lack of assessments and treatment. The findings were: 1. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated Physician's Orders dated 8/1/16 revealed the resident had an anti-anxiety medication, [MEDICATION NAME] tablet 0.5 mg, 1 tablet every 6 hours as needed for anxiety/agitation ordered on admission on 6/30/16. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the [MEDICATION NAME]: Called MD and RP and made aware that [MEDICATION NAME] had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the [MEDICATION NAME] order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room [ROOM NUMBER]. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. 2. Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and weekly head to toe skin assessments. For Stage 3 and 4 ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. Review of Resident #1's admission face sheet dated 8/2/16 revealed the resident was admitted on [DATE], 6/18/16 and 7/23/16. Resident #1's initial [DIAGNOSES REDACTED]. Review of a care plan dated 4/24/16 instructed the staff to observe the skin and assist in turning and repositioning and report any abnormal findings to the nurse. Further review revealed a care plan dated 7/13/16 documenting that the resident had an actual impairment to skin integrity of the left and right feet, the left and right hip and the sacral area and right hand due to fragile skin, mobility issues and incontinent issues. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Review of Resident #1's initial MDS dated [DATE] revealed the resident's BIMS could not be assessed and that his cognitive skills for daily decision making were severely impaired. The resident had trouble maintaining concentration for reading or watching television and was occasionally physically aggressive towards others. Resident #1 required extensive support with ADLs, including eating and toileting and incontinence of bowel and bladder. The resident ambulated by wheelchair and required staff assistance due to his lower extremities including hip, knee, ankle and foot being impaired on both sides. Resident #1's skin was intact and was not assessed at risk for developing pressures. Review of a nursing note dated 6/14/16 revealed Resident #1 was transported to a hospital due to a low grade fever of 100.8 for 2 days, decrease alertness and increasing weakness. After a surgical procedure, lap. chole. (removal of a gall bladder by laparoscopy), the resident was readmitted on [DATE] with additional [DIAGNOSES REDACTED]. Review of Resident #1's re-entry MDS dated [DATE] assessed the resident with unclear speech, which was slurred or mumbled words, with no change in cognition, ADLS and both upper and lower extremities had functional limitations in range of motion. The resident continued to be incontinent of bowel and bladder and weighed 142 pounds. The resident was assessed at risk for developing pressure ulcers. Review of Resident #1's consolidated physician's orders for 7/1/16 to 7/31/16 revealed an order to conduct weekly skin assessments. Review of the weekly skin assessment log for Resident #1 revealed that the resident's head-to-toe skin assessment had not been performed for 18 days, 6/22/16 to 7/10/16. A non-pressure assessment had been conducted on 6/18/16 by LVN G. Review of a head-to-toe skin assessment by LVN G on 6/18/16 assessed the resident with non-pressure bruises to bilateral upper extremities and hands and a 3 cm x 1 cm sutured area to the abdomen with steri. strips from the lap. chole. The site was clean and dry. Subsequent non-pressure skin assessments were performed by LVN G on 6/22/16, 6/30/16 and 7/4/16. On 7/4/16, a skin assessment documented a non-pressure bruise to the right contracted hand and index finger and tip was assessed by LVN G. On 7/7/16, a partial body skin assessment documented that the palm of the right hand, which included the thumb and index finger were contracted by LVN G and that the abdomen (lap. chole.site) had no redness or warmth to the site. The first head-to-toe skin assessment was conducted on 7/10/16 and was documented in the nursing notes and the skin assessment. Review of the facility's provider investigation report dated 7/10/16 revealed that upon completion of the investigation, the facility had identified 10 CNAs and nurses that should have identified and reported the skin breakdown either during showers, changing clothes or conducting skin assessments. The report revealed that the resident resided in the secured memory care unit and was an Adult Protective Services referral/order due to the resident's unsanitary living conditions and inability to care for himself due to dementia, behavioral disturbance, [MEDICAL CONDITION] and very limited communication abilities. Review of Resident #1's nursing note for 7/10/16 revealed that night CNA A had reported an open wound to the left inner heel. When the day shift's licensed staff, RN B, LVN H and LVN K, conducted a total body assessment, they found several areas of breakdown, including several Stage 2 pressure ulcers (partial thickness loss of dermis presenting in a shallow open ulcer with a red pink wound bed): a. Left inner heel, 5 cm x 7 cm; b. Left outer heel reddened area 1 cm x 2 cm; c. Right ankle 1.5 cm x 1.5 cm. d. Right mid outer aspect of foot (blackened skin) 2 cm x 2 cm; e. Right outer aspect of foot towards toes reddened area 3 cm x 2 cm. f. Right inner aspect of heel 4 cm x 4.5 cm. The assessment findings were documented and reported to the responsible party, DON and physician. Pending a call back from the physician, the staff cleansed the areas with wound cleanser; pat dried the wounds and applied clean dry gauze with Kerlix wrap. All opened areas were assessed Stage 2. Further description in the nursing note described the wound beds with granulation tissue, without exudate and slight odor. The surrounding skin colors were white/gray pallor and wound edges were macerated (injury accompanied by soft, white, deteriorating skin around the site due to exposure to moisture for extended periods of time). Review of the nursing notes for Resident #1 on 7/10/16 revealed that the physician responded to the facility's notification at 6:00 p.m. and ordered the treatment protocol for Stage 3 (decubital care to bilateral legs. LVN H documented that she verbally notified the incoming nurse LVN C for the 7 p.m. to 7 a.m. on 7/10/16 nurse to follow up on care and input (transcribe) orders to the PCC, or computerized orders system. Review of nursing notes for Resident #1 for 7/12/16 revealed that the treatment orders were not transcribed. LVN K performed a second head to toe skin assessment and then transcribed the physician's orders from 7/10/16. Further review of assessments on 7/13/16 revealed a non-pressure assessment was conducted on the sacrum (tail bone) and documented finding shearing (friction causes shear) and excoriation (raw irritated lesion) to the sacrum and buttock site. The left and right hips were assessed with [REDACTED]. Review of nursing notes dated 7/19/15 revealed Resident #1 was hospitalized for [REDACTED]. The nursing note documented that the resident had facility acquired pressure sores to both feet and coccyx (tailbone area), which developed since the 6/18/16 admission. While hospitalized from [DATE] to 7/23/16, Resident #1 was also diagnosed with [REDACTED]. Review of the facility's weekly pressure ulcer log dated 7/26/16 revealed that in addition to the multiple pressure ulcers on both Resident #1's feet and hips, a Stage 2 pressure ulcer, 12.0 cm x 6 cm, was identified to the sacrum on 7/13/16. On 7/19/16, the facility received an order from the attending physician to transfer the resident to a hospital for evaluation and treatment due to multiple skin infections with [MEDICAL CONDITION] to upper and lower extremities, dementia and to rule [MEDICAL CONDITION] (blood infection). Review of the hospital's physician's orders dated 7/19/16 revealed that the resident's condition was guarded and the physician ordered intravenous fluids and 2 antibiotics [MEDICATION NAME] (broad spectrum antibiotic) 1 Gm every 12 hours be initiated and [MEDICATION NAME] (antibiotic) 3.375 Gm by IV every 6 hours. Review of the hospital's skin assessment and physician's discharge summary revealed the following: a. Right hand, 3rd finger, necrotic (dead) tissue 1 cm x 1 cm. b. Right hip, non-blanchable redness with broken skin surface, superficial 6 cm x 5 cm. c. Left hip, non-blanchable redness, superficial broken skin 6 cm x 7 cm. d. Left shin, non-blanchable redness, skin intact, 2 cm x 1.5 cm. e. Coccyx, broken skin extending to underlying tissue, necrotic tissue, 8 cm x 12 cm. f. Left, medial heel, 6 cm x 5 cm, broken skin, extending into lower tissue levels, necrotic edges. g. Left 5th toe, dark, skin intact. h. Right foot, lateral surface, 1 cm x 2 cm, 1.5.cm x 1.75 cm, 4 cm x 2.5 cm medial heel. Review of the hospital's H&P for Resident #1 dated 7/19/16 revealed documentation that the resident was significant for weakness, poor appetite and increasing lethargy. The physician's assessment of the resident's skin was: significant for pale, senile, atrophic skin with multiple ulcers on various parts of his extremities and some ulcers are stage II, some are stage I and some are progressing to Stage 3 probably. The physician also noted that the resident had increasing confusion and lethargy lately and was also showing extrapyramidal (EPS - signs and symptoms with increasing rigidity of all extremities and tremors). Review of a hospital physician's progress note dated 7/21/16 revealed that the patient is still not doing well and having stage 3 and 4 decubitus ulcer in the sacral area. The physician documented increased rigidity with tremors/signs of [MEDICAL CONDITION]; dementia progressing fast; [MEDICAL CONDITION]; and multiple decubital ulcers as source of infection. The physician also documented that he would discuss with the family or his power of attorney person of the poor prognosis and referral to Hospice care in view of his poor prognosis and reduced chances of recovery based upon his progressive dementia and multiple decubital ulcers. The physician's discharge orders on 7/23/16 included returning the resident to the nursing facility, discontinuing antipsychotic medications ([MEDICATION NAME] and [MEDICATION NAME]), a referral for hospice care, and continuation of wound care and included a new medication to control EPS, [MEDICATION NAME] 2 mg by mouth TID. Review of skin assessments performed by LVN H upon readmission on 7/23/16 were described as follows: a. Stage 2, sacrum with granulation tissue (pink or red with shiny moist granular appearance) with serosanquinous (containing blood, especially mixed with other fluids) and top portion of wound has eschar (dry, dark scab or falling away of dead skin). b. Stage 2, left heel, with slough (yellow or white tissue that adheres to the ulcer bed in strings, clumps or mucinous); serosanquinous drainage; scant exudate with black/brown surrounding skin color with macerated edges. c. Stage 1 (intact skin with non-blanchable redness), left hip; d. DTI, right side of outer foot; Stage 1, right side of outer foot; e. Stage 1, left outer heel, left outer pinky; f. Stage 1, right hand thumb discoloration, index finger discoloration and middle finger discoloration. g. Stage 2, right outer ankle with [MEDICATION NAME] tissue (new skin), bright red and scant serous exudate. h. Stage 1, right inner heel; i. Stage 1, right heel; j. Stage 1, right hip, skin intact, discoloration; Review of the July 2016 TAR for Resident #1 revealed that the resident was discharged from the hospital on [DATE] and treatment was begun 2 days later on 7/25/16. During initial observations within the facility on 8/2/16 at 10:25 a.m., Resident #1 was observed lying on his left side on an air mattress with a Duoderm (Foam dressings to protect against skin breakdown caused by excess moisture and shear force) to the right hip dated 7/31/16. An anchored indwelling urinary catheter was draining yellow clear urine He was clean and asleep and the left hand was tremulous. During an observation of wound care on 8/2/16 at 1:46 p.m., LVN K and CNA M performed wound care on the resident's multiple areas. The coccyx wound area was large and extended between the buttock approximately 9 cm long. There was a large area of slough (dead tissue) in the center of the wound and grayish skin surrounding the slough. The outer edges were pink and red. A reddish area approximately 3 cm in circumference was located on the edge of the left buttocks and the center was pink with red edges. A small area to the outer edge was black with extended scar tissue. The right buttocks had a small opening that was grayish and pink. During the wound care, the resident made no signs of discomfort or pain. Review of a witness statement from LVN G, ADON, dated 8/8/16 at 7:25 p.m. revealed that the LVN was in charge of the secure unit and hall 200. LVN G reported that after Resident #1 returned from a surgical incident for gall bladder removal on 6/23/16, the resident began to decline and was no longer ambulatory and became more quiet and withdrawn. LVN G reported that head to toe skin assessments were conducted on Wednesdays on the memory unit and that she had not been able to conduct any skin assessments for 2 to 3 weeks, because of the many hats she wore. Resident #1 was not assessed for 2 weeks. LVN G stated that she had depended on CNAs and nurses to report any skin breakdowns on any residents. LVN G stated that she took the word of the staff to assess and report findings. Review of a witness statement from LVN K, Charge Nurse, dated 8/8/16 at 4:50 p.m. revealed that she did not perform head-to-toe skin assessments unless she noted skin breakdown, or if the day was Wednesday, on which the assessments were scheduled. LVN K stated that she was not aware of what the facility's Stage 3 wound care protocol was and did not ask for clarification. Review of a witness statement from RN B, Weekend Supervisor, dated 8/8/16 at approximately 1:30 p.m. revealed that she never performed head to toe skin assessments, even when acting as charge nurse, because the facility had specific days scheduled for assessments. While writing the statement, RN B reported that she noted a lot of irritation and excoriation to the Resident #1's buttock and some of the pressure sores were unstageable. RN B stated that the resident was being turned and repositioned and that the resident had declined after returning from the hospital after the lap. chole. RN B stated that the physician had given an order on 7/10/16 for Resident #1 to follow the facility's Stage 3 wound care protocol, but the charge nurse, LVN H, and RN B did not know what the order meant. RN B reported that the physician was not contacted for clarification. On 7/10/16, RN B and 2 other staff nurses conducted a complete skin assessment of Resident #1, and noted that the buttocks was excoriated (a scratch or abrasion of the skin). Review of a witness statement from LVN C, MDS Coordinator, dated 8/3/16 at 2:55 p.m. revealed that she had worked the night shift (7 p.m. to 7 a.m.) on 7/9/16 and did not conduct a head to toe skin assessment on the morning of 7/10/16, because CNA A had reported finding a broken blister to one of Resident #1's feet during report to the on-coming day shift at 7:00 a.m LVN C stated that upon returning on 7/10/16 at 7:00 p.m., she was not aware that a physician's order for Resident #1 had not been transcribed, but was surprised when the day shift informed her of the multiple pressure ulcers. LVN C stated that CNA A had reported only 1 area of skin breakdown. LVN C reported while writing the statement that she had performed treatments to both feet during the night shift that included cleansing with normal saline and applying [MEDICATION NAME] cream and covering the feet with Kerlix gauze during the shift (unspecified), but did not document the treatment in the nurse progress notes and/or the TAR. During an interview on 8/2/16 at 11:48 a.m., CNA A reported that she didn't usually work in the secure unit, but when Resident #1 returned from his gall bladder surgery, she showered him and did not notice any skin breakdown, including the coccyx area. She stated that she usually did a more thorough examination of residents ' feet by taking their socks off, but did not take both socks off during the night shift of 7/9/16. During a second interview on 8/2/16 at 4:21 p.m., LVN C, MDS Coordinator, stated that she wasn't able to complete Resident #1's MDS to reflect pressure ulcers because she was waiting for the measurements from the nurses. LVN C stated that she thought the nurses were performing skin assessments as scheduled on all the residents. During an interview by phone on 8/2/16 at 5:30 p.m., the DON confirmed that weekly skin assessments (head to toe) had not been performed on Resident #1 and other residents on the secure unit and hall 200 for at least 2 weeks. The physician order given to LVN H on 7/10/16 had not been clarified and transcribed. On Monday, 7/11/16, the Weekend Supervisor acted as charge nurse for the secure unit, and Resident #1 was not provided wound care. On Tuesday, 7/12/16, LVN K was informed of the multiple areas of skin breakdown on Resident #1 and no physician orders were found in the facility's computerized system (PCC). Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and conduct weekly head to toe skin assessments. For Stage 3 (full thickness loss. Subcutaneous fat may be visible but bone, tendons or muscle are not exposed) and 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough (dead tissue) or eschar (dry, dark scab or falling away of dead skin) ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provid

Based on observation, interview and record review the facility failed to complete a Comprehensive Assessment for 2 of 5 residents (Residents #1 and 2) reviewed for comprehensive assessments in that: 1. The facility failed to assessment on Resident #1 at risk for developing pressure sores. 2. The facility failed to assess Resident #2 at risk for elopement. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway and placed 4 residents at risk for pressure sores, [MEDICAL CONDITION] and death from lack of assessments and treatment. The findings were: 1. Review of Resident #1's admission face sheet dated 8/2/16 revealed the resident was admitted on [DATE], 6/18/16 and 7/23/16. Resident #1's initial [DIAGNOSES REDACTED]. Review of a care plan dated 4/24/16 instructed the staff to observe the skin and assist in turning and repositioning and report any abnormal findings to the nurse. Further review revealed a care plan dated 7/13/16 documenting that the resident had an actual impairment to skin integrity of the left and right feet, the left and right hip and the sacral area and right hand due to fragile skin, mobility issues and incontinent issues. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Review of Resident #1's initial MDS dated [DATE] revealed the resident's BIMS could not be assessed and that his cognitive skills for daily decision making were severely impaired. The resident had trouble maintaining concentration for reading or watching television and was occasionally physically aggressive towards others. Resident #1 required extensive support with ADLs, including eating and toileting and incontinence of bowel and bladder. The resident ambulated by wheelchair and required staff assistance due to his lower extremities including hip, knee, ankle and foot being impaired on both sides. Resident #1's skin was intact and was not assessed at risk for developing pressures. Review of a nursing note dated 6/14/16 revealed Resident #1 was transported to a hospital due to a low grade fever of 100.8 for 2 days, decrease alertness and increasing weakness. After a surgical procedure, lap. chole. (removal of a gall bladder by laparoscopy), the resident was readmitted on [DATE] with additional [DIAGNOSES REDACTED]. Review of Resident #1's re-entry MDS dated [DATE] assessed the resident with unclear speech, which was slurred or mumbled words, with no change in cognition, ADLS and both upper and lower extremities had functional limitations in range of motion. The resident continued to be incontinent of bowel and bladder and weighed 142 pounds. The resident was assessed at risk for developing pressure ulcers. Review of Resident #1's consolidated physician's orders for 7/1/16 to 7/31/16 revealed an order to conduct weekly skin assessments. Review of the weekly skin assessment log for Resident #1 revealed that the resident's head-to-toe skin assessment had not been performed for 18 days, 6/22/16 to 7/10/16. A non-pressure assessment had been conducted on 6/18/16 by LVN G. Review of a head-to-toe skin assessment by LVN G on 6/18/16 assessed the resident with non-pressure bruises to bilateral upper extremities and hands and a 3 cm x 1 cm sutured area to the abdomen with steri. strips from the lap. chole. The site was clean and dry. Subsequent non-pressure skin assessments were performed by LVN G on 6/22/16, 6/30/16 and 7/4/16. On 7/4/16, a skin assessment documented a non-pressure bruise to the right contracted hand and index finger and tip was assessed by LVN G. On 7/7/16, a partial body skin assessment documented that the palm of the right hand, which included the thumb and index finger were contracted by LVN G and that the abdomen (lap. chole.site) had no redness or warmth to the site. The first head-to-toe skin assessment was conducted on 7/10/16 and was documented in the nursing notes and the skin assessment. Review of the facility's provider investigation report dated 7/10/16 revealed that upon completion of the investigation, the facility had identified 10 CNAs and nurses that should have identified and reported the skin breakdown either during showers, changing clothes or conducting skin assessments. The report revealed that the resident resided in the secured memory care unit and was an Adult Protective Services referral/order due to the resident's unsanitary living conditions and inability to care for himself due to dementia, behavioral disturbance, [MEDICAL CONDITION] and very limited communication abilities. Review of Resident #1's nursing note for 7/10/16 revealed that night CNA A had reported an open wound to the left inner heel. When the day shift's licensed staff, RN B, LVN H and LVN K, conducted a total body assessment, they found several areas of breakdown, including several Stage 2 pressure ulcers (partial thickness loss of dermis presenting in a shallow open ulcer with a red pink wound bed): a. Left inner heel, 5 cm x 7 cm; b. Left outer heel reddened area 1 cm x 2 cm; c. Right ankle 1.5 cm x 1.5 cm. d. Right mid outer aspect of foot (blackened skin) 2 cm x 2 cm; e. Right outer aspect of foot towards toes reddened area 3 cm x 2 cm. f. Right inner aspect of heel 4 cm x 4.5 cm. The assessment findings were documented and reported to the responsible party, DON and physician. Pending a call back from the physician, the staff cleansed the areas with wound cleanser; pat dried the wounds and applied clean dry gauze with Kerlix wrap. All opened areas were assessed Stage 2. Further description in the nursing note described the wound beds with granulation tissue, without exudate and slight odor. The surrounding skin colors were white/gray pallor and wound edges were macerated (injury accompanied by soft, white, deteriorating skin around the site due to exposure to moisture for extended periods of time). Review of the nursing notes for Resident #1 on 7/10/16 revealed that the physician responded to the facility's notification at 6:00 p.m. and ordered the treatment protocol for Stage 3 (decubital care to bilateral legs. LVN H documented that she verbally notified the incoming nurse LVN C for the 7 p.m. to 7 a.m. on 7/10/16 nurse to follow up on care and input (transcribe) orders to the PCC, or computerized orders system. Review of nursing notes for Resident #1 for 7/12/16 revealed that the treatment orders were not transcribed. LVN K performed a second head to toe skin assessment and then transcribed the physician's orders from 7/10/16. Further review of assessments on 7/13/16 revealed a non-pressure assessment was conducted on the sacrum (tail bone) and documented finding shearing (friction causes shear) and excoriation (raw irritated lesion) to the sacrum and buttock site. The left and right hips were assessed with [REDACTED]. Review of nursing notes dated 7/19/15 revealed Resident #1 was hospitalized for [REDACTED]. The nursing note documented that the resident had facility acquired pressure sores to both feet and coccyx (tailbone area), which developed since the 6/18/16 admission. While hospitalized from [DATE] to 7/23/16, Resident #1 was also diagnosed with [REDACTED]. Review of the facility's weekly pressure ulcer log dated 7/26/16 revealed that in addition to the multiple pressure ulcers on both Resident #1's feet and hips, a Stage 2 pressure ulcer, 12.0 cm x 6 cm, was identified to the sacrum on 7/13/16. On 7/19/16, the facility received an order from the attending physician to transfer the resident to a hospital for evaluation and treatment due to multiple skin infections with [MEDICAL CONDITION] to upper and lower extremities, dementia and to rule [MEDICAL CONDITION] (blood infection). Review of the hospital's physician's orders dated 7/19/16 revealed that the resident's condition was guarded and the physician ordered intravenous fluids and 2 antibiotics [MEDICATION NAME] (broad spectrum antibiotic) 1 Gm every 12 hours be initiated and [MEDICATION NAME] (antibiotic) 3.375 Gm by IV every 6 hours. Review of the hospital's skin assessment and physician's discharge summary revealed the following: a. Right hand, 3rd finger, necrotic (dead) tissue 1 cm x 1 cm. b. Right hip, non-blanchable redness with broken skin surface, superficial 6 cm x 5 cm. c. Left hip, non-blanchable redness, superficial broken skin 6 cm x 7 cm. d. Left shin, non-blanchable redness, skin intact, 2 cm x 1.5 cm. e. Coccyx, broken skin extending to underlying tissue, necrotic tissue, 8 cm x 12 cm. f. Left, medial heel, 6 cm x 5 cm, broken skin, extending into lower tissue levels, necrotic edges. g. Left 5th toe, dark, skin intact. h. Right foot, lateral surface, 1 cm x 2 cm, 1.5.cm x 1.75 cm, 4 cm x 2.5 cm medial heel. Review of the hospital's H&P for Resident #1 dated 7/19/16 revealed documentation that the resident was significant for weakness, poor appetite and increasing lethargy. The physician's assessment of the resident's skin was: significant for pale, senile, atrophic skin with multiple ulcers on various parts of his extremities and some ulcers are stage II, some are stage I and some are progressing to Stage 3 probably. The physician also noted that the resident had increasing confusion and lethargy lately and was also showing extrapyramidal (EPS - signs and symptoms with increasing rigidity of all extremities and tremors). Review of a hospital physician's progress note dated 7/21/16 revealed that the patient is still not doing well and having stage 3 and 4 decubitus ulcer in the sacral area. The physician documented increased rigidity with tremors/signs of [MEDICAL CONDITION]; dementia progressing fast; [MEDICAL CONDITION]; and multiple decubital ulcers as source of infection. The physician also documented that he would discuss with the family or his power of attorney person of the poor prognosis and referral to Hospice care in view of his poor prognosis and reduced chances of recovery based upon his progressive dementia and multiple decubital ulcers. The physician's discharge orders on 7/23/16 included returning the resident to the nursing facility, discontinuing antipsychotic medications ([MEDICATION NAME] and [MEDICATION NAME]), a referral for hospice care, and continuation of wound care and included a new medication to control EPS, [MEDICATION NAME] 2 mg by mouth TID. Review of skin assessments performed by LVN H upon readmission on 7/23/16 were described as follows: a. Stage 2, sacrum with granulation tissue (pink or red with shiny moist granular appearance) with serosanquinous (containing blood, especially mixed with other fluids) and top portion of wound has eschar (dry, dark scab or falling away of dead skin). b. Stage 2, left heel, with slough (yellow or white tissue that adheres to the ulcer bed in strings, clumps or mucinous); serosanquinous drainage; scant exudate with black/brown surrounding skin color with macerated edges. c. Stage 1 (intact skin with non-blanchable redness), left hip; d. DTI, right side of outer foot; Stage 1, right side of outer foot; e. Stage 1, left outer heel, left outer pinky; f. Stage 1, right hand thumb discoloration, index finger discoloration and middle finger discoloration. g. Stage 2, right outer ankle with [MEDICATION NAME] tissue (new skin), bright red and scant serous exudate. h. Stage 1, right inner heel; i. Stage 1, right heel; j. Stage 1, right hip, skin intact, discoloration; Review of the July 2016 TAR for Resident #1 revealed that the resident was discharged from the hospital on [DATE] and treatment was begun 2 days later on 7/25/16. During initial observations within the facility on 8/2/16 at 10:25 a.m., Resident #1 was observed lying on his left side on an air mattress with a Duoderm (Foam dressings to protect against skin breakdown caused by excess moisture and shear force) to the right hip dated 7/31/16. An anchored indwelling urinary catheter was draining yellow clear urine He was clean and asleep and the left hand was tremulous. During an observation of wound care on 8/2/16 at 1:46 p.m., LVN K and CNA M performed wound care on the resident's multiple areas. The coccyx wound area was large and extended between the buttock approximately 9 cm long. There was a large area of slough (dead tissue) in the center of the wound and grayish skin surrounding the slough. The outer edges were pink and red. A reddish area approximately 3 cm in circumference was located on the edge of the left buttocks and the center was pink with red edges. A small area to the outer edge was black with extended scar tissue. The right buttocks had a small opening that was grayish and pink. During the wound care, the resident made no signs of discomfort or pain. Review of a witness statement from LVN G, ADON, dated 8/8/16 at 7:25 p.m. revealed that the LVN was in charge of the secure unit and hall 200. LVN G reported that after Resident #1 returned from a surgical incident for gall bladder removal on 6/23/16, the resident began to decline and was no longer ambulatory and became more quiet and withdrawn. LVN G reported that head to toe skin assessments were conducted on Wednesdays on the memory unit and that she had not been able to conduct any skin assessments for 2 to 3 weeks, because of the many hats she wore. Resident #1 was not assessed for 2 weeks. LVN G stated that she had depended on CNAs and nurses to report any skin breakdowns on any residents. LVN G stated that she took the word of the staff to assess and report findings. Review of a witness statement from LVN K, Charge Nurse, dated 8/8/16 at 4:50 p.m. revealed that she did not perform head-to-toe skin assessments unless she noted skin breakdown, or if the day was Wednesday, on which the assessments were scheduled. LVN K stated that she was not aware of what the facility's Stage 3 wound care protocol was and did not ask for clarification. Review of a witness statement from RN B, Weekend Supervisor, dated 8/8/16 at approximately 1:30 p.m. revealed that she never performed head to toe skin assessments, even when acting as charge nurse, because the facility had specific days scheduled for assessments. While writing the statement, RN B reported that she noted a lot of irritation and excoriation to the Resident #1's buttock and some of the pressure sores were unstageable. RN B stated that the resident was being turned and repositioned and that the resident had declined after returning from the hospital after the lap. chole. RN B stated that the physician had given an order on 7/10/16 for Resident #1 to follow the facility's Stage 3 wound care protocol, but the charge nurse, LVN H, and RN B did not know what the order meant. RN B reported that the physician was not contacted for clarification. On 7/10/16, RN B and 2 other staff nurses conducted a complete skin assessment of Resident #1, and noted that the buttocks was excoriated (a scratch or abrasion of the skin). Review of a witness statement from LVN C, MDS Coordinator, dated 8/3/16 at 2:55 p.m. revealed that she had worked the night shift (7 p.m. to 7 a.m.) on 7/9/16 and did not conduct a head to toe skin assessment on the morning of 7/10/16, because CNA A had reported finding a broken blister to one of Resident #1's feet during report to the on-coming day shift at 7:00 a.m LVN C stated that upon returning on 7/10/16 at 7:00 p.m., she was not aware that a physician's order for Resident #1 had not been transcribed, but was surprised when the day shift informed her of the multiple pressure ulcers. LVN C stated that CNA A had reported only 1 area of skin breakdown. LVN C reported while writing the statement that she had performed treatments to both feet during the night shift that included cleansing with normal saline and applying [MEDICATION NAME] cream and covering the feet with Kerlix gauze during the shift (unspecified), but did not document the treatment in the nurse progress notes and/or the TAR. During an interview on 8/2/16 at 11:48 a.m., CNA A reported that she didn't usually work in the secure unit, but when Resident #1 returned from his gall bladder surgery, she showered him and did not notice any skin breakdown, including the coccyx area. She stated that she usually did a more thorough examination of residents ' feet by taking their socks off, but did not take both socks off during the night shift of 7/9/16. During a second interview on 8/2/16 at 4:21 p.m., LVN C, MDS Coordinator, stated that she wasn't able to complete Resident #1's MDS to reflect pressure ulcers because she was waiting for the measurements from the nurses. LVN C stated that she thought the nurses were performing skin assessments as scheduled on all the residents. During an interview by phone on 8/2/16 at 5:30 p.m., the DON confirmed that weekly skin assessments (head to toe) had not been performed on Resident #1 and other residents on the secure unit and hall 200 for at least 2 weeks. The physician order given to LVN H on 7/10/16 had not been clarified and transcribed. On Monday, 7/11/16, the Weekend Supervisor acted as charge nurse for the secure unit, and Resident #1 was not provided wound care. On Tuesday, 7/12/16, LVN K was informed of the multiple areas of skin breakdown on Resident #1 and no physician orders were found in the facility's computerized system (PCC). Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and conduct weekly head to toe skin assessments. For Stage 3 (full thickness loss. Subcutaneous fat may be visible but bone, tendons or muscle are not exposed) and 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough (dead tissue) or eschar (dry, dark scab or falling away of dead skin) ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. 2. Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated Physician's Orders dated 8/1/16 revealed the resident had an anti-anxiety medication, [MEDICATION NAME] tablet 0.5 mg, 1 tablet every 6 hours as needed for anxiety/agitation ordered on admission on 6/30/16. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the [MEDICATION NAME]: Called MD and RP and made aware that [MEDICATION NAME] had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the [MEDICATION NAME] order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room [ROOM NUMBER]. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provided by the Administrator on 8/9/16 at approximately 12:45 p.m. and included the follow steps taken by the facility: a. The Investigator confirmed that the facility all Phillip's screws in the secure unit were replaced with traditional bolt pattern requiring a nut drive or socket to remove. Three exits were identified on the secure unit in the event of an emergency exit. The admission process to the secure unit was revised to include assessing for triggers for exit seeking behaviors such as a history of wandering, exit seeking, verbalization and confusion. Exit seeking assessment forms are to be completed and both the DON and Administrator were to be notified of who were exit seekers. Staff received 1-on-1 in-services on identifying and reporting triggers and at the time of the submission of the Plan of Removal, 80 % of the staff had been in-serviced. Four exit seeking notebooks identifying assessed exit seeking residents were prepared to be placed within the secure unit, receptionist desk, therapy department and nurses station that included a picture of the resident, admission face sheet

Based on observations, record review and interviews, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores and a resident with pressure sores receives the necessary treatment and services to promote healing, prevent infection and prevent new sores form developing for 1 of 4 residents (#1) whose care was reviewed for community acquired pressure sores in that: The facility failed to conduct head-to-toe skin assessments on Resident #1 for 18 days and developed multiple Stage 2 pressure sores to both feet, Deep Tissue Injuries (DTI) to both hips and a potential Stage 3 to the coccyx. The facility failed to obtain treatment clarification and was late 2 days in beginning treatment to the pressure sores after returning from the hospital. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 4 residents at risk for pressure sores, [MEDICAL CONDITION] and death from lack of assessments and treatment. The findings were: Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and weekly head to toe skin assessments. For Stage 3 and 4 ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. Review of Resident #1's admission face sheet dated 8/2/16 revealed the resident was admitted on [DATE], 6/18/16 and 7/23/16. Resident #1's initial [DIAGNOSES REDACTED]. Review of a care plan dated 4/24/16 instructed the staff to observe the skin and assist in turning and repositioning and report any abnormal findings to the nurse. Further review revealed a care plan dated 7/13/16 documenting that the resident had an actual impairment to skin integrity of the left and right feet, the left and right hip and the sacral area and right hand due to fragile skin, mobility issues and incontinent issues. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Review of Resident #1's initial MDS dated [DATE] revealed the resident's BIMS could not be assessed and that his cognitive skills for daily decision making were severely impaired. The resident had trouble maintaining concentration for reading or watching television and was occasionally physically aggressive towards others. Resident #1 required extensive support with ADLs, including eating and toileting and incontinence of bowel and bladder. The resident ambulated by wheelchair and required staff assistance due to his lower extremities including hip, knee, ankle and foot being impaired on both sides. Resident #1's skin was intact and was not assessed at risk for developing pressures. Review of a nursing note dated 6/14/16 revealed Resident #1 was transported to a hospital due to a low grade fever of 100.8 for 2 days, decrease alertness and increasing weakness. After a surgical procedure, lap. chole. (removal of a gall bladder by laparoscopy), the resident was readmitted on [DATE] with additional [DIAGNOSES REDACTED]. Review of Resident #1's re-entry MDS dated [DATE] assessed the resident with unclear speech, which was slurred or mumbled words, with no change in cognition, ADLS and both upper and lower extremities had functional limitations in range of motion. The resident continued to be incontinent of bowel and bladder and weighed 142 pounds. The resident was assessed at risk for developing pressure ulcers. Review of Resident #1's consolidated physician's orders for 7/1/16 to 7/31/16 revealed an order to conduct weekly skin assessments. Review of the weekly skin assessment log for Resident #1 revealed that the resident's head-to-toe skin assessment had not been performed for 18 days, 6/22/16 to 7/10/16. A non-pressure assessment had been conducted on 6/18/16 by LVN G. Review of a head-to-toe skin assessment by LVN G on 6/18/16 assessed the resident with non-pressure bruises to bilateral upper extremities and hands and a 3 cm x 1 cm sutured area to the abdomen with steri. strips from the lap. chole. The site was clean and dry. Subsequent non-pressure skin assessments were performed by LVN G on 6/22/16, 6/30/16 and 7/4/16. On 7/4/16, a skin assessment documented a non-pressure bruise to the right contracted hand and index finger and tip was assessed by LVN G. On 7/7/16, a partial body skin assessment documented that the palm of the right hand, which included the thumb and index finger were contracted by LVN G and that the abdomen (lap. chole.site) had no redness or warmth to the site. The first head-to-toe skin assessment was conducted on 7/10/16 and was documented in the nursing notes and the skin assessment. Review of the facility's provider investigation report dated 7/10/16 revealed that upon completion of the investigation, the facility had identified 10 CNAs and nurses that should have identified and reported the skin breakdown either during showers, changing clothes or conducting skin assessments. The report revealed that the resident resided in the secured memory care unit and was an Adult Protective Services referral/order due to the resident's unsanitary living conditions and inability to care for himself due to dementia, behavioral disturbance, [MEDICAL CONDITION] and very limited communication abilities. Review of Resident #1's nursing note for 7/10/16 revealed that night CNA A had reported an open wound to the left inner heel. When the day shift's licensed staff, RN B, LVN H and LVN K, conducted a total body assessment, they found several areas of breakdown, including several Stage 2 pressure ulcers (partial thickness loss of dermis presenting in a shallow open ulcer with a red pink wound bed): a. Left inner heel, 5 cm x 7 cm; b. Left outer heel reddened area 1 cm x 2 cm; c. Right ankle 1.5 cm x 1.5 cm. d. Right mid outer aspect of foot (blackened skin) 2 cm x 2 cm; e. Right outer aspect of foot towards toes reddened area 3 cm x 2 cm. f. Right inner aspect of heel 4 cm x 4.5 cm. The assessment findings were documented and reported to the responsible party, DON and physician. Pending a call back from the physician, the staff cleansed the areas with wound cleanser; pat dried the wounds and applied clean dry gauze with Kerlix wrap. All opened areas were assessed Stage 2. Further description in the nursing note described the wound beds with granulation tissue, without exudate and slight odor. The surrounding skin colors were white/gray pallor and wound edges were macerated (injury accompanied by soft, white, deteriorating skin around the site due to exposure to moisture for extended periods of time). Review of the nursing notes for Resident #1 on 7/10/16 revealed that the physician responded to the facility's notification at 6:00 p.m. and ordered the treatment protocol for Stage 3 (decubital care to bilateral legs. LVN H documented that she verbally notified the incoming nurse LVN C for the 7 p.m. to 7 a.m. on 7/10/16 nurse to follow up on care and input (transcribe) orders to the PCC, or computerized orders system. Review of nursing notes for Resident #1 for 7/12/16 revealed that the treatment orders were not transcribed. LVN K performed a second head to toe skin assessment and then transcribed the physician's orders from 7/10/16. Further review of assessments on 7/13/16 revealed a non-pressure assessment was conducted on the sacrum (tail bone) and documented finding shearing (friction causes shear) and excoriation (raw irritated lesion) to the sacrum and buttock site. The left and right hips were assessed with [REDACTED]. Review of nursing notes dated 7/19/15 revealed Resident #1 was hospitalized for [REDACTED]. The nursing note documented that the resident had facility acquired pressure sores to both feet and coccyx (tailbone area), which developed since the 6/18/16 admission. While hospitalized from [DATE] to 7/23/16, Resident #1 was also diagnosed with [REDACTED]. Review of the facility's weekly pressure ulcer log dated 7/26/16 revealed that in addition to the multiple pressure ulcers on both Resident #1's feet and hips, a Stage 2 pressure ulcer, 12.0 cm x 6 cm, was identified to the sacrum on 7/13/16. On 7/19/16, the facility received an order from the attending physician to transfer the resident to a hospital for evaluation and treatment due to multiple skin infections with [MEDICAL CONDITION] to upper and lower extremities, dementia and to rule [MEDICAL CONDITION] (blood infection). Review of the hospital's physician's orders dated 7/19/16 revealed that the resident's condition was guarded and the physician ordered intravenous fluids and 2 antibiotics [MEDICATION NAME] (broad spectrum antibiotic) 1 Gm every 12 hours be initiated and [MEDICATION NAME] (antibiotic) 3.375 Gm by IV every 6 hours. Review of the hospital's skin assessment and physician's discharge summary revealed the following: a. Right hand, 3rd finger, necrotic (dead) tissue 1 cm x 1 cm. b. Right hip, non-blanchable redness with broken skin surface, superficial 6 cm x 5 cm. c. Left hip, non-blanchable redness, superficial broken skin 6 cm x 7 cm. d. Left shin, non-blanchable redness, skin intact, 2 cm x 1.5 cm. e. Coccyx, broken skin extending to underlying tissue, necrotic tissue, 8 cm x 12 cm. f. Left, medial heel, 6 cm x 5 cm, broken skin, extending into lower tissue levels, necrotic edges. g. Left 5th toe, dark, skin intact. h. Right foot, lateral surface, 1 cm x 2 cm, 1.5.cm x 1.75 cm, 4 cm x 2.5 cm medial heel. Review of the hospital's H&P for Resident #1 dated 7/19/16 revealed documentation that the resident was significant for weakness, poor appetite and increasing lethargy. The physician's assessment of the resident's skin was: significant for pale, senile, atrophic skin with multiple ulcers on various parts of his extremities and some ulcers are stage II, some are stage I and some are progressing to Stage 3 probably. The physician also noted that the resident had increasing confusion and lethargy lately and was also showing extrapyramidal (EPS - signs and symptoms with increasing rigidity of all extremities and tremors). Review of a hospital physician's progress note dated 7/21/16 revealed that the patient is still not doing well and having stage 3 and 4 decubitus ulcer in the sacral area. The physician documented increased rigidity with tremors/signs of [MEDICAL CONDITION]; dementia progressing fast; [MEDICAL CONDITION]; and multiple decubital ulcers as source of infection. The physician also documented that he would discuss with the family or his power of attorney person of the poor prognosis and referral to Hospice care in view of his poor prognosis and reduced chances of recovery based upon his progressive dementia and multiple decubital ulcers. The physician's discharge orders on 7/23/16 included returning the resident to the nursing facility, discontinuing antipsychotic medications ([MEDICATION NAME] and [MEDICATION NAME]), a referral for hospice care, and continuation of wound care and included a new medication to control EPS, [MEDICATION NAME] 2 mg by mouth TID. Review of skin assessments performed by LVN H upon readmission on 7/23/16 were described as follows: a. Stage 2, sacrum with granulation tissue (pink or red with shiny moist granular appearance) with serosanquinous (containing blood, especially mixed with other fluids) and top portion of wound has eschar (dry, dark scab or falling away of dead skin). b. Stage 2, left heel, with slough (yellow or white tissue that adheres to the ulcer bed in strings, clumps or mucinous); serosanquinous drainage; scant exudate with black/brown surrounding skin color with macerated edges. c. Stage 1 (intact skin with non-blanchable redness), left hip; d. DTI, right side of outer foot; Stage 1, right side of outer foot; e. Stage 1, left outer heel, left outer pinky; f. Stage 1, right hand thumb discoloration, index finger discoloration and middle finger discoloration. g. Stage 2, right outer ankle with [MEDICATION NAME] tissue (new skin), bright red and scant serous exudate. h. Stage 1, right inner heel; i. Stage 1, right heel; j. Stage 1, right hip, skin intact, discoloration; Review of the July 2016 TAR for Resident #1 revealed that the resident was discharged from the hospital on [DATE] and treatment was begun 2 days later on 7/25/16. During initial observations within the facility on 8/2/16 at 10:25 a.m., Resident #1 was observed lying on his left side on an air mattress with a Duoderm (Foam dressings to protect against skin breakdown caused by excess moisture and shear force) to the right hip dated 7/31/16. An anchored indwelling urinary catheter was draining yellow clear urine He was clean and asleep and the left hand was tremulous. During an observation of wound care on 8/2/16 at 1:46 p.m., LVN K and CNA M performed wound care on the resident's multiple areas. The coccyx wound area was large and extended between the buttock approximately 9 cm long. There was a large area of slough (dead tissue) in the center of the wound and grayish skin surrounding the slough. The outer edges were pink and red. A reddish area approximately 3 cm in circumference was located on the edge of the left buttocks and the center was pink with red edges. A small area to the outer edge was black with extended scar tissue. The right buttocks had a small opening that was grayish and pink. During the wound care, the resident made no signs of discomfort or pain. Review of a witness statement from LVN G, ADON, dated 8/8/16 at 7:25 p.m. revealed that the LVN was in charge of the secure unit and hall 200. LVN G reported that after Resident #1 returned from a surgical incident for gall bladder removal on 6/23/16, the resident began to decline and was no longer ambulatory and became more quiet and withdrawn. LVN G reported that head to toe skin assessments were conducted on Wednesdays on the memory unit and that she had not been able to conduct any skin assessments for 2 to 3 weeks, because of the many hats she wore. Resident #1 was not assessed for 2 weeks. LVN G stated that she had depended on CNAs and nurses to report any skin breakdowns on any residents. LVN G stated that she took the word of the staff to assess and report findings. Review of a witness statement from LVN K, Charge Nurse, dated 8/8/16 at 4:50 p.m. revealed that she did not perform head-to-toe skin assessments unless she noted skin breakdown, or if the day was Wednesday, on which the assessments were scheduled. LVN K stated that she was not aware of what the facility's Stage 3 wound care protocol was and did not ask for clarification. Review of a witness statement from RN B, Weekend Supervisor, dated 8/8/16 at approximately 1:30 p.m. revealed that she never performed head to toe skin assessments, even when acting as charge nurse, because the facility had specific days scheduled for assessments. While writing the statement, RN B reported that she noted a lot of irritation and excoriation to the Resident #1's buttock and some of the pressure sores were unstageable. RN B stated that the resident was being turned and repositioned and that the resident had declined after returning from the hospital after the lap. chole. RN B stated that the physician had given an order on 7/10/16 for Resident #1 to follow the facility's Stage 3 wound care protocol, but the charge nurse, LVN H, and RN B did not know what the order meant. RN B reported that the physician was not contacted for clarification. On 7/10/16, RN B and 2 other staff nurses conducted a complete skin assessment of Resident #1, and noted that the buttocks was excoriated (a scratch or abrasion of the skin). Review of a witness statement from LVN C, MDS Coordinator, dated 8/3/16 at 2:55 p.m. revealed that she had worked the night shift (7 p.m. to 7 a.m.) on 7/9/16 and did not conduct a head to toe skin assessment on the morning of 7/10/16, because CNA A had reported finding a broken blister to one of Resident #1's feet during report to the on-coming day shift at 7:00 a.m LVN C stated that upon returning on 7/10/16 at 7:00 p.m., she was not aware that a physician's order for Resident #1 had not been transcribed, but was surprised when the day shift informed her of the multiple pressure ulcers. LVN C stated that CNA A had reported only 1 area of skin breakdown. LVN C reported while writing the statement that she had performed treatments to both feet during the night shift that included cleansing with normal saline and applying [MEDICATION NAME] cream and covering the feet with Kerlix gauze during the shift (unspecified), but did not document the treatment in the nurse progress notes and/or the TAR. During an interview on 8/2/16 at 11:48 a.m., CNA A reported that she didn't usually work in the secure unit, but when Resident #1 returned from his gall bladder surgery, she showered him and did not notice any skin breakdown, including the coccyx area. She stated that she usually did a more thorough examination of residents ' feet by taking their socks off, but did not take both socks off during the night shift of 7/9/16. During a second interview on 8/2/16 at 4:21 p.m., LVN C, MDS Coordinator, stated that she wasn't able to complete Resident #1's MDS to reflect pressure ulcers because she was waiting for the measurements from the nurses. LVN C stated that she thought the nurses were performing skin assessments as scheduled on all the residents. During an interview by phone on 8/2/16 at 5:30 p.m., the DON confirmed that weekly skin assessments (head to toe) had not been performed on Resident #1 and other residents on the secure unit and hall 200 for at least 2 weeks. The physician order given to LVN H on 7/10/16 had not been clarified and transcribed. On Monday, 7/11/16, the Weekend Supervisor acted as charge nurse for the secure unit, and Resident #1 was not provided wound care. On Tuesday, 7/12/16, LVN K was informed of the multiple areas of skin breakdown on Resident #1 and no physician orders were found in the facility's computerized system (PCC). Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and conduct weekly head to toe skin assessments. For Stage 3 (full thickness loss. Subcutaneous fat may be visible but bone, tendons or muscle are not exposed) and 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough (dead tissue) or eschar (dry, dark scab or falling away of dead skin) ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and require attention to resident specific needs. Notify the physician for treatment orders. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provided by the Administrator on 8/9/16 at approximately 12:45 p.m. and included the follow steps taken by the facility: The Investigator confirmed that the facility had initiated and completed a full head-to- toe skin assessment on 100 % of the residents on 7/12/16 and no new areas were identified. Medical records were audited to ensure residents with pressure areas had the appropriate treatment orders from their physicians, that the treatments were being carried out and that all orders had been transcribed. 100 % of the review was completed on 7/13/16. The DON and ADON provided training to licensed staff on conducting weekly skin assessments, which included documentation of any findings, measurements, staging, notification of family/physician and transcription of treatment orders. The old wound care protocol was deleted and was replaced by the corporation's current policies on assessment, treatment and obtaining and following physician orders. The weekly skin assessment schedule was revised to accommodate the nurses' workload and all residents were to be assessed by a nurse on their shower days and as needed. Any findings were to be brought to the monthly QAPI (Quality Assurance & Performance Improvement Meetings. On 8/9/16 at 1:45 p.m., the Regional Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor residents at risk for developing pressure sores. The CMS Form 672 dated 8/2/16 reported there were 4 residents with pressure sores.

Based on observations, record review and interviews, the facility failed to ensure residents were provided adequate supervision for 1 of 13 residents (Resident # 2) to prevent elopement from the facility in that: The facility failed to assign a staff member to monitor Resident #2 after 1 attempt to elope and succeeded on the second attempt on the same day by removing screws from his window with his belt buckle, climbing over a 6-8 foot wrought iron fence and leaving the facility grounds. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway and placed 4 residents at risk for pressure sores, septicemia and death from lack of assessments and treatment. The findings were: Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated physician's orders [REDACTED]. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the Ativan: Called MD and RP and made aware that Ativan had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the Ativan order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room 313. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provided by the Administrator on 8/9/16 at approximately 12:45 p.m. and included the follow steps taken by the facility: The Investigator confirmed that the facility all Phillip's screws in the secure unit were replaced with traditional bolt pattern requiring a nut drive or socket to remove. Three exits were identified on the secure unit in the event of an emergency exit. The admission process to the secure unit was revised to include assessing for triggers for exit seeking behaviors such as a history of wandering, exit seeking, verbalization and confusion. Exit seeking assessment forms are to be completed and both the DON and Administrator were to be notified of who were exit seekers. Staff received 1-on-1 in-services on identifying and reporting triggers and at the time of the submission of the Plan of Removal, 80 % of the staff had been in-serviced. Four exit seeking notebooks identifying assessed exit seeking residents were prepared to be placed within the secure unit, receptionist desk, therapy department and nurses station that included a picture of the resident, admission face sheet and assessment form. Staffing on the secure unit was increased by 1 for the night shift to ensure that a staff member was always on the unit to monitor residents and answer call lights. The Exit Seeking Guidance was updated to include guidance as to what to do when exit seeking was attempted but not successful. The Administrator and DON began training team members regarding the update and staff was not permitted to start their scheduled shifts until completion of the training. Any findings of exit seeking were to be brought to the monthly QAPI (Quality Assurance & Performance Improvement Meetings. The Administrator reported that there were 13 residents on the secure unit.

Based on observations, interviews and record reviews, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with resident assessments and individual plans of care for 1 of 5 residents (Resident #2) reviewed for care, services and neglect in that: The facility did not provide one-on-one supervision for Resident #2 after attempting to elope from the secure unit, because there was only 1 licensed nurse and 2 nurse aides to provide care for 55 residents during the night shift, 6:00 p.m. and 6:00 a.m. and the secure unit with 13 residents was left unattended. The facility failed to assign a staff member to monitor Resident #2 after 1 attempt to elope and succeeded on the second attempt on the same day by removing screws from his window with his belt buckle, climbing over a 6-8 foot wrought iron fence and leaving the facility grounds; These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway. The findings were: Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated physician's orders [REDACTED]. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the [MEDICATION NAME]: Called MD and RP and made aware that [MEDICATION NAME] had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the [MEDICATION NAME] order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room [ROOM NUMBER]. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. The Administrator was notified on 8/8/16 at 1:35 p.m. of an Immediate Jeopardy for above failures and a Plan of Removal was requested. A final draft of the facility's Plan of Removal was provided by the Administrator on 8/9/16 at approximately 12:45 p.m. and included the follow steps taken by the facility: The Investigator confirmed that the facility all Phillip's screws in the secure unit were replaced with traditional bolt pattern requiring a nut drive or socket to remove. Three exits were identified on the secure unit in the event of an emergency exit. The admission process to the secure unit was revised to include assessing for triggers for exit seeking behaviors such as a history of wandering, exit seeking, verbalization and confusion. Exit seeking assessment forms are to be completed and both the DON and Administrator were to be notified of who were exit seekers. Staff received 1-on-1 in-services on identifying and reporting triggers and at the time of the submission of the Plan of Removal, 80 % of the staff had been in-serviced. Four exit seeking notebooks identifying assessed exit seeking residents were prepared to be placed within the secure unit, receptionist desk, therapy department and nurses station that included a picture of the resident, admission face sheet and assessment form. Staffing on the secure unit was increased by 1 for the night shift to ensure that a staff member was always on the unit to monitor residents and answer call lights. The Exit Seeking Guidance was updated to include guidance as to what to do when exit seeking was attempted but not successful. The Administrator and DON began training team members regarding the update and staff was not permitted to start their scheduled shifts until completion of the training. Any findings of exit seeking were to be brought to the monthly QAPI (Quality Assurance & Performance Improvement Meetings. On 8/9/16 at 1:45 p.m., the Regional Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor for exit seeking residents and resident at risk for developing pressure sores. The Administrator reported that there were 13 residents on the secure unit at the time of the elopement and the CMS Form 672 dated 8/2/16 reported there were 4 residents with pressure sores.

Based on interview and record review, the Administrator and Director of Nurses failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 2 of 5 (Residents # 1 and 2) whose care was reviewed in that: The Administrator and DON did not ensure the facility's policies and procedures were current and implemented to prevent Resident #2 from eloping from the secure unit and Resident #1 from developing pressures sores. The Administrator did not implement a 1-on-1 monitoring and supervision of Resident #2 after the resident attempted to climb over a fence and eloped from the facility ground within 24 hours of the same day. The Administrator did not ensure there was sufficient staff to supervise 13 residents within the secure unit. The Administrator did not supervise the DON and the Nursing staff to perform weekly skin assessments resulting in Resident #1 developing multiple pressure sores. The DON did not ensure the licensed nurses were performing weekly skin assessments and did not ensure that weekend staff had current guidelines in assessing, reporting, transcribing and following physician orders in the care of residents with skin breakdown. The DON did not ensure charge nurses and the weekend supervisor were performing their duties in reporting skin breakdown, reporting, transcribing and following physician orders in the care of Resident #1. The Weekend Supervisor (RN B) did not clarify a facility guideline in performing treatments to residents with pressure sores and did not clarify the physician's orders. The Weekend Supervisor did not perform the wound care prescribed by the physician while acting as charge nurse. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/8/16. While the IJ was removed on 8/9/16, the facility remained out of compliance with the potential for more than minimal harm with a scope identified as pattern until all staff was in-serviced and staff was increased. These deficient practices placed 13 residents in the secure unit at risk for elopement and injury from being run over by a nearby heavily traveled highway and placed 4 residents at risk for pressure sores, [MEDICAL CONDITION] and death from lack of assessments and treatment. The findings were: 1. Review of Resident #2's admission face sheet dated 8/2/16 revealed that the resident was admitted on [DATE] from home with multiple medical [DIAGNOSES REDACTED]. The resident was discharged to another facility on 8/8/16. Review of a facility's investigation report (Incident # 6) dated 8/2/16 revealed that Resident #2 eloped before midnight on 8/1/16. Earlier in the day, a therapist reported observing the resident in the backyard of the secure unit standing on top of 2 chairs and trying to pull himself over the wrought iron fence. After the resident was brought back into the building on 8/1/16, Resident #2 was taken to a dentist and a tooth was pulled. Further review of the report revealed that on the evening of 8/1/16, Resident #2 used his belt buckle to remove the screws keeping his (bedroom) window from opening completely. He removed the window screen, exited the window, and used lawn furniture to climb over the wrought iron fence. He walked to a nearby motel and began to solicit a ride to Laredo (approximately 75 miles) from the hotel. The manager called the Sheriff's office and the officers escorted the resident back to the facility at 12:55 a.m. on 8/2/16. The resident was moved to another room and assigned a staff member to watch the resident for the rest of the shift. The maintenance department replaced all Philips head screws to the windows in the secured unit with hexagonal bolts that required a wrench to unscrew. Review of Resident #2's Consolidated Physician's Orders dated 8/1/16 revealed the resident had an anti-anxiety medication, [MEDICATION NAME] tablet 0.5 mg, 1 tablet every 6 hours as needed for anxiety/agitation ordered on admission on 6/30/16. However, the MAR for July and August 2016 revealed that the anti-anxiety medication was never administered. Review of Resident #2's nursing notes instead revealed a note dated 7/29/16 that discontinued the [MEDICATION NAME]: Called MD and RP and made aware that [MEDICATION NAME] had not been administered since admission. MD gave orders to DC r/t not in use. After the resident's elopement, the [MEDICATION NAME] order was reinstated on 8/2/16 at 7:16 p.m. but the facility could not administer the medication until the pharmacy delivered it to the facility later that evening. Review of Resident #2's initial MDS dated [DATE] revealed that the assessment had not been completed as of 8/2/16 and did not document the resident was an elopement risk prior to admission although the initial nursing assessment conducted by LVN K documented the resident displayed exit seeking behavior. Further review of Resident #2's initial nursing note dated 6/30/16 revealed documentation that the resident had a history of exit seeking behaviors and wandering at home and requires supervision. Review of Resident #2's care plans between 7/20/16 and 8/2/16 revealed the resident was assessed for impaired cognitive function and dementia, impaired thought process and required questions to be asked yes/no in order to determine the resident's needs. The care plan also did not document that the resident was maintained in the secure unit and was a wanderer and elopement risk. Review of an exit seeking risk tool dated 8/2/16 confirmed that Resident #2 was physically able to exit on foot, and that this was the first time the resident (had) exhibited the possibility of elopement. He's usually about the common area alone with other residents. Further review of a nursing note dated 8/1/16 revealed that at approximately 11:30 a.m. the Physical Therapist was on the secure unit and witnessed Resident #2 standing on top of 2 stacked chairs next to the metal fence and was attempting to lift himself over the fence. The nursing staff was alerted and the resident was brought back into the facility. When questioned, the resident reported that he had a tooth ache. During the initial entrance conference on 8/2/16 at approximately 9:45 a.m., the Administrator reported that Resident #2 had made 2 attempts on 8/1/16 to leave the facility grounds and succeeded on the second attempt before midnight on 8/1/16. The Administrator stated that the night staff had discovered the resident missing from the building and that the window to the resident's room was wide open. The staff immediately searched the grounds and notified the Administrator, who called 911. During the conference, the Administrator was asked if there had been staff on the secure unit when the resident climbed out of the window and he responded that he hadn't asked that question, but assumed there had been. Review of the staff sign-in sheet for the 7 p.m. to 7 a.m. shift on 8/1/16 revealed that LVN G, CNA A and CNA E had worked the shift and that CNA E was primarily assigned to provide care and supervision of the secure unit with 13 residents and hall 200 with approximately 13 residents. During initial observation rounds on 8/2/16 at approximately 10:59 a.m., all the windows on the secure unit were assessed for Philips screws to the window frames that prevented the windows from being opened wide enough to prevent residents from sliding out of the windows. Two windows were located in room [ROOM NUMBER]. Resident #2 was observed sitting in his area on the left side of the room and the screws to his window had been replaced. The resident was alert and oriented to self, fully dressed and groomed and responded in Spanish. The window on the right side of the room belonging to Resident #4 was missing a screw and a second screw had been partially unscrewed. No staff was present conducting 1-on-1 monitoring and Resident #2 was allowed to move around the unit unattended. During an interview on 8/3/16 at 10:30 a.m., CNA E reported that Resident #2 was not on a 1-on-1 monitoring status prior to the resident's elopement. CNA E stated that she had been in and out of the secure unit during her shift (6 p.m. to 6 a.m.) to assist CNA A with her residents and to take care of the residents on hall 200. CNA E stated that at approximately 9:45 p.m. on 8/1/16, Resident #2 asked for a cup of juice and upon retrieving a cup, the resident closed the door to his room. CNA E reported that at approximately 10:30 p.m., she checked the resident's roommate, Resident # 4, but did not check Resident #2, whose privacy curtain was pulled closed. CNA E stated that she firmly believed the resident was asleep and did not check him. CNA E stated that she was unaware of the resident's elopement until LVN G reported it on the night of 8/1/16. CNA E further reported that staffing was a problem during the 6 p.m. to 6 a.m. shift and on many nights there was only 3 persons in the building to provide care to all the residents. CNA E stated that after assuring that the residents on the secure unit were asleep, she would leave the unit unattended and help the other CNA to perform incontinent care, put residents to bed and answer call lights on the other 3 halls. During an interview on 8/2/16 at 5:41 p.m. and also while writing a statement on 8/8/16 at 7:25 p.m., LVN G reported that she had worked the 7 p.m. to 7 a.m. on 8/1/16 and had been busy administering medications and performing treatments on the secure unit between 11:00 p.m. and 11:30 p.m. LVN G stated that she had not observed Resident #2 at the start of the shift, because she had begun her tasks at the other end of the hall. LVN G stated that at approximately 11:45 p.m. she observed the door to Resident #2's room open and the bathroom light on and the door closed. LVN G stated that she assumed that Resident #2 was in the bathroom. Then, she noticed that Resident #2's privacy curtain was partially open; the TV was on; the window was open and a chair had been placed in front of the window to enable the resident to climb over the air conditioner. LVN G immediately alerted the 2 other CNA's and a hunt was started within and around the facility. LVN G reported that she was the ADON during the day and charge nurse for all 4 halls during the night shift. LVN G stated that she was aware that the CNA assigned to the secure unit would leave the unit unattended to assist on the other halls and if time permitted, LVN G would work on the secure unit to monitor the residents while passing out medications and performing treatments. During an interview on 8/2/16 at 6:19 p.m., CNA A reported that she usually worked halls 100 and 400 and worked the night shift, 6 p.m. to 6 a.m. on 8/1/16. CNA A stated that she did not see Resident # 2 and that CNA E had helped her with her residents. During an interview on 8/2/16 at 7:18 p.m., the Administrator reported that the facility could use another person on the night shift, but was unable to find additional staff. He stated that he was budgeted for an additional LVN, and had actively sought additional staff. During an interview on 8/2/16 at 7:25 p.m., LVN J reported that she also worked the night shift and often only had 2 other CNA's to work. She stated that there was too much work to do on the shift and that staff turnover was high. She stated that she tried to cover the secure unit when both CNAs were on the main halls, but because there were no medication aides employed, she had to pass the evening medications and could not cover the secure unit. During an interview on 8/9/16 at approximately 10:00 a.m., PT Q reported that he was standing in the secure unit on 8/1/16 at approximately 11:46 a.m. when he saw Resident #2 through the activity area window standing on top of 2 lawn chairs trying to pull himself up. PT Q stated that he alerted the staff and when he approached the resident, he jumped down off the chairs. During an interview on 8/9/16 at approximately 10:15 a.m., CNA F reported that he was on duty in the secure unit on 8/2/16 and when he started his shift at 6:00 a.m., he was told to keep an eye out for Resident #2, because he had eloped during the night. No one was assigned as 1-on-1 monitoring. Review of the facility's policy dated 2015 on exit seeking revealed the following: B. Resident located - First Steps: (2) Place resident on 1:1 for at least 24 hours (or longer than 24 hours if needed to monitor safety of resident or place in MSU (memory support unit) for monitoring; have an IDT to discuss if your are able to move monitoring up to every 15 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident); then have an IDT to discuss if you are able to move monitoring up to every 30 minutes x 24 hours (or longer than 24 hours if needed to monitor safety of resident). D. Identifying exit seeking residents: (1). Determine which residents are identified on the risk assessment for exit seeking/wandering/elopement behaviors. (3) Team members will be in-serviced on the notebook, exit seeking behaviors and actions to be taken to prevent as well as actions to be taken if exit seeking occurs. 2. Review of Resident #1's admission face sheet dated 8/2/16 revealed the resident was admitted on [DATE], 6/18/16 and 7/23/16. Resident #1's initial [DIAGNOSES REDACTED]. Review of a care plan dated 4/24/16 instructed the staff to observe the skin and assist in turning and repositioning and report any abnormal findings to the nurse. Further review revealed a care plan dated 7/13/16 documenting that the resident had an actual impairment to skin integrity of the left and right feet, the left and right hip and the sacral area and right hand due to fragile skin, mobility issues and incontinent issues. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Review of Resident #1's initial MDS dated [DATE] revealed the resident's BIMS could not be assessed and that his cognitive skills for daily decision making were severely impaired. The resident had trouble maintaining concentration for reading or watching television and was occasionally physically aggressive towards others. Resident #1 required extensive support with ADLs, including eating and toileting and incontinence of bowel and bladder. The resident ambulated by wheelchair and required staff assistance due to his lower extremities including hip, knee, ankle and foot being impaired on both sides. Resident #1's skin was intact and was not assessed at risk for developing pressures. Review of a nursing note dated 6/14/16 revealed Resident #1 was transported to a hospital due to a low grade fever of 100.8 for 2 days, decrease alertness and increasing weakness. After a surgical procedure, lap. chole. (removal of a gall bladder by laparoscopy), the resident was readmitted on [DATE] with additional [DIAGNOSES REDACTED]. Review of Resident #1's re-entry MDS dated [DATE] assessed the resident with unclear speech, which was slurred or mumbled words, with no change in cognition, ADLS and both upper and lower extremities had functional limitations in range of motion. The resident continued to be incontinent of bowel and bladder and weighed 142 pounds. The resident was assessed at risk for developing pressure ulcers. Review of Resident #1's consolidated physician's orders for 7/1/16 to 7/31/16 revealed an order to conduct weekly skin assessments. Review of the weekly skin assessment log for Resident #1 revealed that the resident's head-to-toe skin assessment had not been performed for 18 days, 6/22/16 to 7/10/16. A non-pressure assessment had been conducted on 6/18/16 by LVN G. Review of a head-to-toe skin assessment by LVN G on 6/18/16 assessed the resident with non-pressure bruises to bilateral upper extremities and hands and a 3 cm x 1 cm sutured area to the abdomen with steri. strips from the lap. chole. The site was clean and dry. Subsequent non-pressure skin assessments were performed by LVN G on 6/22/16, 6/30/16 and 7/4/16. On 7/4/16, a skin assessment documented a non-pressure bruise to the right contracted hand and index finger and tip was assessed by LVN G. On 7/7/16, a partial body skin assessment documented that the palm of the right hand, which included the thumb and index finger were contracted by LVN G and that the abdomen (lap. chole.site) had no redness or warmth to the site. The first head-to-toe skin assessment was conducted on 7/10/16 and was documented in the nursing notes and the skin assessment. Review of the facility's provider investigation report dated 7/10/16 revealed that upon completion of the investigation, the facility had identified 10 CNAs and nurses that should have identified and reported the skin breakdown either during showers, changing clothes or conducting skin assessments. The report revealed that the resident resided in the secured memory care unit and was an Adult Protective Services referral/order due to the resident's unsanitary living conditions and inability to care for himself due to dementia, behavioral disturbance, [MEDICAL CONDITION] and very limited communication abilities. Review of Resident #1's nursing note for 7/10/16 revealed that night CNA A had reported an open wound to the left inner heel. When the day shift's licensed staff, RN B, LVN H and LVN K, conducted a total body assessment, they found several areas of breakdown, including several Stage 2 pressure ulcers (partial thickness loss of dermis presenting in a shallow open ulcer with a red pink wound bed): a. Left inner heel, 5 cm x 7 cm; b. Left outer heel reddened area 1 cm x 2 cm; c. Right ankle 1.5 cm x 1.5 cm. d. Right mid outer aspect of foot (blackened skin) 2 cm x 2 cm; e. Right outer aspect of foot towards toes reddened area 3 cm x 2 cm. f. Right inner aspect of heel 4 cm x 4.5 cm. The assessment findings were documented and reported to the responsible party, DON and physician. Pending a call back from the physician, the staff cleansed the areas with wound cleanser; pat dried the wounds and applied clean dry gauze with Kerlix wrap. All opened areas were assessed Stage 2. Further description in the nursing note described the wound beds with granulation tissue, without exudate and slight odor. The surrounding skin colors were white/gray pallor and wound edges were macerated (injury accompanied by soft, white, deteriorating skin around the site due to exposure to moisture for extended periods of time). Review of the nursing notes for Resident #1 on 7/10/16 revealed that the physician responded to the facility's notification at 6:00 p.m. and ordered the treatment protocol for Stage 3 (decubital care to bilateral legs. LVN H documented that she verbally notified the incoming nurse LVN C for the 7 p.m. to 7 a.m. on 7/10/16 nurse to follow up on care and input (transcribe) orders to the PCC, or computerized orders system. Review of nursing notes for Resident #1 for 7/12/16 revealed that the treatment orders were not transcribed. LVN K performed a second head to toe skin assessment and then transcribed the physician's orders from 7/10/16. Further review of assessments on 7/13/16 revealed a non-pressure assessment was conducted on the sacrum (tail bone) and documented finding shearing (friction causes shear) and excoriation (raw irritated lesion) to the sacrum and buttock site. The left and right hips were assessed with [REDACTED]. Review of nursing notes dated 7/19/15 revealed Resident #1 was hospitalized for [REDACTED]. The nursing note documented that the resident had facility acquired pressure sores to both feet and coccyx (tailbone area), which developed since the 6/18/16 admission. While hospitalized from [DATE] to 7/23/16, Resident #1 was also diagnosed with [REDACTED]. Review of the facility's weekly pressure ulcer log dated 7/26/16 revealed that in addition to the multiple pressure ulcers on both Resident #1's feet and hips, a Stage 2 pressure ulcer, 12.0 cm x 6 cm, was identified to the sacrum on 7/13/16. On 7/19/16, the facility received an order from the attending physician to transfer the resident to a hospital for evaluation and treatment due to multiple skin infections with [MEDICAL CONDITION] to upper and lower extremities, dementia and to rule [MEDICAL CONDITION] (blood infection). Review of the hospital's physician's orders dated 7/19/16 revealed that the resident's condition was guarded and the physician ordered intravenous fluids and 2 antibiotics [MEDICATION NAME] (broad spectrum antibiotic) 1 Gm every 12 hours be initiated and [MEDICATION NAME] (antibiotic) 3.375 Gm by IV every 6 hours. Review of the hospital's skin assessment and physician's discharge summary revealed the following: a. Right hand, 3rd finger, necrotic (dead) tissue 1 cm x 1 cm. b. Right hip, non-blanchable redness with broken skin surface, superficial 6 cm x 5 cm. c. Left hip, non-blanchable redness, superficial broken skin 6 cm x 7 cm. d. Left shin, non-blanchable redness, skin intact, 2 cm x 1.5 cm. e. Coccyx, broken skin extending to underlying tissue, necrotic tissue, 8 cm x 12 cm. f. Left, medial heel, 6 cm x 5 cm, broken skin, extending into lower tissue levels, necrotic edges. g. Left 5th toe, dark, skin intact. h. Right foot, lateral surface, 1 cm x 2 cm, 1.5.cm x 1.75 cm, 4 cm x 2.5 cm medial heel. Review of the hospital's H&P for Resident #1 dated 7/19/16 revealed documentation that the resident was significant for weakness, poor appetite and increasing lethargy. The physician's assessment of the resident's skin was: significant for pale, senile, atrophic skin with multiple ulcers on various parts of his extremities and some ulcers are stage II, some are stage I and some are progressing to Stage 3 probably. The physician also noted that the resident had increasing confusion and lethargy lately and was also showing extrapyramidal (EPS - signs and symptoms with increasing rigidity of all extremities and tremors). Review of a hospital physician's progress note dated 7/21/16 revealed that the patient is still not doing well and having stage 3 and 4 decubitus ulcer in the sacral area. The physician documented increased rigidity with tremors/signs of [MEDICAL CONDITION]; dementia progressing fast; [MEDICAL CONDITION]; and multiple decubital ulcers as source of infection. The physician also documented that he would discuss with the family or his power of attorney person of the poor prognosis and referral to Hospice care in view of his poor prognosis and reduced chances of recovery based upon his progressive dementia and multiple decubital ulcers. The physician's discharge orders on 7/23/16 included returning the resident to the nursing facility, discontinuing antipsychotic medications ([MEDICATION NAME] and [MEDICATION NAME]), a referral for hospice care, and continuation of wound care and included a new medication to control EPS, [MEDICATION NAME] 2 mg by mouth TID. Review of skin assessments performed by LVN H upon readmission on 7/23/16 were described as follows: a. Stage 2, sacrum with granulation tissue (pink or red with shiny moist granular appearance) with serosanquinous (containing blood, especially mixed with other fluids) and top portion of wound has eschar (dry, dark scab or falling away of dead skin). b. Stage 2, left heel, with slough (yellow or white tissue that adheres to the ulcer bed in strings, clumps or mucinous); serosanquinous drainage; scant exudate with black/brown surrounding skin color with macerated edges. c. Stage 1 (intact skin with non-blanchable redness), left hip; d. DTI, right side of outer foot; Stage 1, right side of outer foot; e. Stage 1, left outer heel, left outer pinky; f. Stage 1, right hand thumb discoloration, index finger discoloration and middle finger discoloration. g. Stage 2, right outer ankle with [MEDICATION NAME] tissue (new skin), bright red and scant serous exudate. h. Stage 1, right inner heel; i. Stage 1, right heel; j. Stage 1, right hip, skin intact, discoloration; Review of the July 2016 TAR for Resident #1 revealed that the resident was discharged from the hospital on [DATE] and treatment was begun 2 days later on 7/25/16. During initial observations within the facility on 8/2/16 at 10:25 a.m., Resident #1 was observed lying on his left side on an air mattress with a Duoderm (Foam dressings to protect against skin breakdown caused by excess moisture and shear force) to the right hip dated 7/31/16. An anchored indwelling urinary catheter was draining yellow clear urine He was clean and asleep and the left hand was tremulous. During an observation of wound care on 8/2/16 at 1:46 p.m., LVN K and CNA M performed wound care on the resident's multiple areas. The coccyx wound area was large and extended between the buttock approximately 9 cm long. There was a large area of slough (dead tissue) in the center of the wound and grayish skin surrounding the slough. The outer edges were pink and red. A reddish area approximately 3 cm in circumference was located on the edge of the left buttocks and the center was pink with red edges. A small area to the outer edge was black with extended scar tissue. The right buttocks had a small opening that was grayish and pink. During the wound care, the resident made no signs of discomfort or pain. Review of a witness statement from LVN G, ADON, dated 8/8/16 at 7:25 p.m. revealed that the LVN was in charge of the secure unit and hall 200. LVN G reported that after Resident #1 returned from a surgical incident for gall bladder removal on 6/23/16, the resident began to decline and was no longer ambulatory and became more quiet and withdrawn. LVN G reported that head to toe skin assessments were conducted on Wednesdays on the memory unit and that she had not been able to conduct any skin assessments for 2 to 3 weeks, because of the many hats she wore. Resident #1 was not assessed for 2 weeks. LVN G stated that she had depended on CNAs and nurses to report any skin breakdowns on any residents. LVN G stated that she took the word of the staff to assess and report findings. Review of a witness statement from LVN K, Charge Nurse, dated 8/8/16 at 4:50 p.m. revealed that she did not perform head-to-toe skin assessments unless she noted skin breakdown, or if the day was Wednesday, on which the assessments were scheduled. LVN K stated that she was not aware of what the facility's Stage 3 wound care protocol was and did not ask for clarification. Review of a witness statement from RN B, Weekend Supervisor, dated 8/8/16 at approximately 1:30 p.m. revealed that she never performed head to toe skin assessments, even when acting as charge nurse, because the facility had specific days scheduled for assessments. While writing the statement, RN B reported that she noted a lot of irritation and excoriation to the Resident #1's buttock and some of the pressure sores were unstageable. RN B stated that the resident was being turned and repositioned and that the resident had declined after returning from the hospital after the lap. chole. RN B stated that the physician had given an order on 7/10/16 for Resident #1 to follow the facility's Stage 3 wound care protocol, but the charge nurse, LVN H, and RN B did not know what the order meant. RN B reported that the physician was not contacted for clarification. On 7/10/16, RN B and 2 other staff nurses conducted a complete skin assessment of Resident #1, and noted that the buttocks was excoriated (a scratch or abrasion of the skin). Review of a witness statement from LVN C, MDS Coordinator, dated 8/3/16 at 2:55 p.m. revealed that she had worked the night shift (7 p.m. to 7 a.m.) on 7/9/16 and did not conduct a head to toe skin assessment on the morning of 7/10/16, because CNA A had reported finding a broken blister to one of Resident #1's feet during report to the on-coming day shift at 7:00 a.m LVN C stated that upon returning on 7/10/16 at 7:00 p.m., she was not aware that a physician's order for Resident #1 had not been transcribed, but was surprised when the day shift informed her of the multiple pressure ulcers. LVN C stated that CNA A had reported only 1 area of skin breakdown. LVN C reported while writing the statement that she had performed treatments to both feet during the night shift that included cleansing with normal saline and applying [MEDICATION NAME] cream and covering the feet with Kerlix gauze during the shift (unspecified), but did not document the treatment in the nurse progress notes and/or the TAR. During an interview on 8/2/16 at 11:48 a.m., CNA A reported that she didn't usually work in the secure unit, but when Resident #1 returned from his gall bladder surgery, she showered him and did not notice any skin breakdown, including the coccyx area. She stated that she usually did a more thorough examination of residents ' feet by taking their socks off, but did not take both socks off during the night shift of 7/9/16. During a second interview on 8/2/16 at 4:21 p.m., LVN C, MDS Coordinator, stated that she wasn't able to complete Resident #1's MDS to reflect pressure ulcers because she was waiting for the measurements from the nurses. LVN C stated that she thought the nurses were performing skin assessments as scheduled on all the residents. During an interview by phone on 8/2/16 at 5:30 p.m., the DON confirmed that weekly skin assessments (head to toe) had not been performed on Resident #1 and other residents on the secure unit and hall 200 for at least 2 weeks. The physician order given to LVN H on 7/10/16 had not been clarified and transcribed. On Monday, 7/11/16, the Weekend Supervisor acted as charge nurse for the secure unit, and Resident #1 was not provided wound care. On Tuesday, 7/12/16, LVN K was informed of the multiple areas of skin breakdown on Resident #1 and no physician orders were found in the facility's computerized system (PCC). Review of the facility's undated policy for Decubitus Ulcers for high risk residents revealed staff were to: provide good skin care, turn frequently, provide pressure-reducing mattress and conduct weekly head to toe skin assessments. For Stage 3 (full thickness loss. Subcutaneous fat may be visible but bone, tendons or muscle are not exposed) and 4 (full thickness tissue loss with exposed bone, tendon, or muscle. Slough (dead tissue) or eschar (dry, dark scab or falling away of dead skin) ulcers: cleanse the site with normal saline or wound cleanser and apply a clean dressing. These wounds are complicated and