Every finding on record at Avir at Richland Hills

Based on observations, interviews, and record review, the facility failed to adequately equip residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bedroom of 3 of (Resident #1, Resident #2 and Resident #3) 7 resident rooms reviewed for resident call systems. The facility failed to ensure the call light in the room and bathroom were operable for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of being unable to have a means of directly contacting caregivers which could place them at risk for injuries and unmet needs. Findings included: Record review of Resident #1's face sheet, dated 06/09/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: acute respiratory failure (a life-threatening medical emergency where the lungs cannot adequately supply oxygen to the blood or remove excess carbon dioxide), lack of coordination (a symptom of nervous system dysfunction characterized by clumsy, uncoordinated, or jerky movements), muscle weakness, malignant neoplasm (an abnormal mass of tissue that grows uncontrollably, invades nearby healthy tissues), type 2 diabetes mellitus (chronic metabolic disorder where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), encephalopathy (a broad, clinical term for any diffuse disease or damage that alters your brain's function or structure), hereditary optic atrophy (a group of genetic disorders that cause the degeneration of retinal ganglion cells and their axons, leading to progressive, permanent vision loss), chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), dry eye syndrome of bilateral lacrimal glands (a condition where the main tear glands above both eyes fail to produce enough of the watery (aqueous) layer of the tear film), pruritus (an uncomfortable, irritating sensation on the skin that creates an urge to scratch), Parkinson's disease (a progressive neurological disorder characterized by the death of dopamine-producing neurons in the brain ), chronic pain syndrome (a condition where persistent pain lasts beyond the expected healing time (typically 3 to 6 months and causes secondary physical and emotional symptoms), insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to get back to sleep), cataract in diseases (the clouding of the eye's natural lens), glaucoma (glaucoma), legal blindness, gastro-esophageal reflux disease (chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus) and acute kidney failure (sudden and rapid loss of your kidneys' ability to filter waste products, balance fluids, and regulate electrolytes). Record review of Resident #1's Quarterly MDS assessment, dated 04/30/26, reflected a BIMS score of 14, which indicated cognition intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed setup or clean-up assistance with eating, oral hygiene, showering/bathing self. Section GG-Functional Abilities also reflected Resident #1 was independent with toileting hygiene, upper/lower body dressing, putting on/taking off footwear, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer and toilet transfer. Record review of Resident #1's care plan, revised 07/10/23, reflected Resident #1 had an ADL self-care performance deficit related to blindness. Intervention included: encouraging the resident to use bell to call for assistance. Resident #1 also had a communication problem related to hearing/visual deficit. One of the interventions included was ensuring/providing a safe environment to include call light in reach, Resident #1's care plan also revealed he was at risks for falls related to vision/hearing problems. One of the interventions included reminding the resident to use call light when needed assistance and ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed. It further reflected the resident needed prompt response to all requests for assistance. Record review of Resident #2's face sheet, dated 06/09/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), drug induced subacute dyskinesia (a medication-induced movement disorder characterized by involuntary, repetitive muscle movements (chorea, tics, or spasms) that develop over a period of days to weeks), muscle weakness, unsteadiness on feet, myopathy (any disease that affects the skeletal muscles), chronic pain syndrome (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to get back to sleep), hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, circulating in the blood), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (like hallucinations or delusions) with a mood disorder (like depression or bipolar disorder), bipolar disorder (a lifelong mental health condition that causes extreme, cyclical shifts in mood, energy, and activity levels), major depressive disorder (a severe, recurring mood disorder characterized by pervasive sadness, loss of interest in activities, and low energy), extrapyramidal and movement disorder (drug-induced movement disorders that primarily affect muscle tone, posture, and involuntary movement), obstructive sleep apnea (a chronic disorder where the airway repeatedly collapses during sleep, blocking airflow and causing breathing to stop and start) and type 2 diabetes mellitus (chronic metabolic disorder where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Record review of Resident #2's Quarterly MDS assessment, dated 03/16/26, reflected a BIMS score of 15, which indicated cognition intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 needed setup or clean-up assistance with toileting hygiene. Resident#2 was independent with eating, oral hygiene, showering/bathing self. Section GG-Functional Abilities also reflected Resident #1 was independent with toileting hygiene, upper/lower body dressing, putting on/taking off footwear, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer, toilet transfer, walking 50 feet with two turns and walking 150 feet. Record review of Resident #2's care plan, revised 07/12/23, reflected Resident #2 had had an ADL self-care performance deficit related to impaired balance and gait with tremors. One of the inventions included encouraging the resident to use bell to call for assistance. Record review of Resident #3's face sheet, dated 06/09/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: cellulitis (a common, potentially serious bacterial infection of the skin and the deep underlying tissues beneath it), megaloblastic anemia (the bone marrow produces abnormally large, immature, and dysfunctional red blood cells), morbid obesity, hyperosmolality (a condition where bodily fluids—most commonly blood plasma—have an abnormally high concentration of solutes, such as sodium, glucose, or urea) and hypernatremia (an electrolyte imbalance defined as a serum sodium concentration greater than 145 mEq/L), hypokalemia (abnormally low levels of potassium in the blood, typically falling below 3.5 mmol/L), bipolar disorder (a lifelong mental health condition that causes extreme, cyclical shifts in mood, energy, and activity levels), depression (a common and serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities), major depressive disorder (a severe, recurring mood disorder characterized by pervasive sadness, loss of interest in activities, and low energy), extrapyramidal and movement disorder (drug-induced movement disorders that primarily affect muscle tone, posture, and involuntary movement), obstructive sleep apnea (a chronic disorder where the airway repeatedly collapses during sleep, blocking airflow and causing breathing to stop and start), polyneuropathy (simultaneous malfunction or damage of many peripheral nerves throughout the body), muscular dystrophy (a group of over 30 genetic disorders characterized by progressive muscle weakness and degeneration), toxic encephalopathy (a neurological disorder caused by brain damage or malfunction from exposure to external poisons (toxins) or internal metabolic imbalances), hemiplegia (paralysis that affects only one side of the body, caused by brain or spinal cord damage) and hemiparesis (weakness or partial loss of movement on one entire side of the body )following cerebral infarction (stroke) affecting right dominant side, pulmonary fibrosis (a lung disease in which tissue becomes damaged and scarred), acute and chronic respiratory failure (when the respiratory system cannot adequately transfer oxygen into the blood or remove carbon dioxide from it), gastro-esophageal reflux disease (chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus.), umbilical hernia (occurs when part of the intestine or abdominal fat pushes through a weak spot or hole in the abdominal muscles near the belly button), pain in left and right knee, plantar fascial fibromatosis (plantar fascial fibromatosis), acute osteomyelitis (a sudden, localized bone infection), acute kidney failure (sudden and rapid loss of your kidneys' ability to filter waste products, balance fluids, and regulate electrolytes), ataxia (a neurological sign referring to a lack of voluntary muscle coordination, resulting in clumsy, unsteady movements), slurred speech, hyperglycemia (when there is too much glucose in the bloodstream), personal history of pulmonary embolism (a sudden, life-threatening blockage in one of the pulmonary arteries in your lungs). Record review of Resident #3's admission MDS assessment, dated 06/04/26, reflected a BIMS score of 13, which indicated cognition intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 needed supervision or touching assistance with lower body dressing, putting on/taking off footwear, rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to stand, chair/bed-to-chair transfer, toilet transfer, car transfer, walking 50 feet with two turns and walking 150 feet. Section GG-Functional Abilities also reflected Resident #3 needed partial assistance with showering/bathing self and walking 50 feet with two turns, setup or clean-up assistance with personal hygiene and independent with oral hygiene and upper body dressing. Record review of Resident #3's care plan, revised 06/04/26, reflected Resident #3 had potential communication related to hearing deficit in right ear, slurred speech and history of CVA (stroke). One of the interventions included ensuring/providing a safe environment to include call light in reach. The care plan also revealed Resident #3 risked falls related to gait/balance problems. One of the interventions was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Resident #3 needed prompt response to all requests for assistance. During an observation with the DON on 06/11/26 at 10:35, revealed Resident #1, Resident #2 and Resident #3's call light in their rooms did not light up when the button was used. Resident #1, Resident # 2 and Resident #3's call light did not light up on the outside of the room when the DON pressed the button. The DON witnessed that when the call light was used it did not light up outside of the residents' rooms. Resident #1, Resident #2 and Resident #3 shared the same restroom and the call light in the restroom was observed not working. The DON stated although it did not light up on the system on the door, it should at the nurse's station on the centralized box. Upon further observation, the DON and Investigator went to the nurse's station, and the rooms did not show on the centralized work station box. The centralized call system box was observed inoperable. The DON stated he did not know what was going on with the system, but he would reach out to maintenance. During an interview on 06/11/26 at 11:20 AM, Resident #1 stated the call light in their room had not been working for approximately six or seven weeks. Resident #1 stated he had to holler, beat on the wall or his roommate went to get assistance. Resident #1 stated he did not know what was going on with the call light, but it did not light when he pressed the button. Resident #1 also stated his restroom call light was not working. Resident #1 stated the staff knew that it did not work. During an interview on 06/11/26 at 11:29 AM, Resident #2 stated his room and restroom call light had not worked for approximately one month. Resident #2 stated he walked to the nurse's station for assistance for him or his roommate. During an interview on 06/11/26 at 1:02 PM, the Maintenance Director stated he worked in the building Monday-Friday 7:00am-3:30pm and was on call on the weekends. He stated he was informed this morning that one of the call lights was stuck and when the reset button was pressed, it did not reset. He stated it caused a malfunction by shortening rooms [ROOM NUMBERS]. He stated it was either room [ROOM NUMBER] or 205 call light that was stuck with the light on. The Maintenance Director stated he was not aware of the call light not working in the room prior to 06/11/26. The Maintenance Director stated the facility may have minor issues such as pressing the button too hard would push it inside the unit itself, causing the light to set on not register the reset. The Maintenance Director stated the risk of the call light not working was staff not knowing the resident needed assistance. During an interview on 06/11/26 at 3:58 PM, Resident #3 stated he was admitted into the facility less than a week ago. Resident #3 stated his call light had not worked since he admitted . Resident #3 also stated the one day during the week he attempted to press his call light and found that it did not work. Resident #3 stated he had to wait for staff to pass or go to the nurse's station for assistance. Resident #3 stated he informed the staff and they stated that someone would come to fix it. During an interview on 06/11/2 a4:12 PM, the DON stated no one informed him that the call light was not working. He stated he found out today with State being in the building. The DON stated the risk of an inoperable call light was that the resident was unable to call if there was any injuries and staff not knowing the resident needed assistance. During an interview on 06/11/26 at 4:20 PM, the Administrator stated she was unaware that the call lights were not properly working on 06/11/26. The Administrator stated she found it on 06/11/26 while State was in the building. She stated the risks of the call light not properly functioning were the residents not being able to call for assistance. Record review if the facility's policy titled, Call System, Residents, revised 10/15/22, updated January 2025, reflected the following: Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wired or wireless. 3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remained functional. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. 5. The resident call system is routinely maintained and tested by the maintenance department. 6. Calls for assistance are answered timely.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #12 and Resident #13) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #12 and Resident #13's rooms were in a position that was accessible to the residents on 02/03/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #12 Record review of Resident #2's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with history of falling and fracture (broken bone) of the rib.Record review of Resident #12's Quarterly MDS Assessment (tool used to assess health status), dated 01/30/2026, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS (tool used to assess cognitive status) score of 00. The Staff Assessment for Mental Status denoted the resident was severely impaired in decisions regarding tasks of daily living. The Quarterly MDS Assessment indicated the resident needed assistance for transfer, bed mobility, toileting hygiene, shower, dressing, and personal hygiene.Record review of Resident #12's Comprehensive Care Plan, dated 01/30/2026, reflected the resident was at risk for falls and had a communication problem. One of the interventions for both focus was to be sure the resident's call light was within reach.During an observation and interview on 02/03/2026 at 9:23 AM, revealed Resident #12 was sitting in his wheelchair, awake. It was observed that the resident's call light was on top of his bed. It was also observed that the cord of the call light was between the resident and his roommate's bed frame. When asked where his call light was, the resident shook his head. During an observation and interview on 02/03/2026 at 9:35 AM, CNA C stated call lights should always be within reach of the residents because that was how they called the staff if they needed something. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She went inside Resident's #12's room and saw the call light was not on top of the resident's bed and the cord was between the two beds. She pulled the call light and put it where the resident could reach it. She said, maybe, the call light fell when she fixed the resident's bed. She said she should have made sure the call light was with the resident before leaving the resident's room. She said the call lights were for all residents, dependent or independent. She said dependent residents might be having a distress and would not be able to call the staff. She said she was responsible in making sure the call lights were within reach for the residents assigned to her.Resident #13 Record review of Resident #13's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with epilepsy (brain disorder caused by abnormal electrical signals in the brain), muscle weakness, lack of coordination, repeated falls, and difficulty in walking.Record review of Resident #13's Quarterly MDS Assessment, dated 01/28/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Staff Assessment for Mental Status denoted the resident was severely impaired in decisions regarding tasks of daily living. The Quarterly MDS Assessment indicated the resident needed assistance for transfer, bed mobility, toileting hygiene, shower, dressing, and personal hygiene.Record review of Resident #13's Comprehensive Care Plan, dated 01/12/2026, reflected the resident was at risk for falls and one of the interventions was to be sure that the call light was within reach.Observation and interview on 02/03/2026 at 9:53 AM revealed Resident #13 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked where her call light was, the resident just shrugged her shoulders.Observation and interview on 02/03/2026 at 9:56 AM, the DON stated call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. He said the residents might fall trying to get the call light or trying to do some activities that needed assistance. He said the nurses and the CNAs were responsible in making sure the call lights were within reach. He went inside Resident #13's room and saw the call light on the floor. He picked it up and put it where the resident could reach it. He then said the resident was sleeping and might not need the call light and the resident was alert and able to communicate well so he did not see the problem if her call light was on the floor. He said he would still do an in-service about call lights.In an interview on 02/03/2026 at 4:48 PM, the Administrator stated call lights should be within the reach of the residents at all times in case they need help. She said sometimes the residents would knock them down when they move so the staff should make sure the call lights were secured that even the residents moved, they would not fall. She said the call lights were for the dependent residents more than the independent residents because the independent residents could yell or go to the nurse's station. She said the call lights should be monitored throughout the day by the CNAs and the nurses. She said she would start an in-service after the interview.Policy for call lights within reach requested on 02/03/2026 at 12:32 PM via email to the Administrator and verbally requested on 02/03/2026 at 4:48 PM from the Administrator. the Administrator said they do not have a policy regarding the call light within reach.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for one (Resident #9) of ten residents and one (LVN A) of three LVNs reviewed for accident hazard. The facility failed to ensure Resident #9 did not have a can of Off insect spray on his bedside table on 02/03/2026. The facility failed to ensure LVN A did not leave a container of germicidal wipes (cleaning wipes designed to eliminate bacteria, viruses, and fungi) on top of her cart on 02/03/2026.These failures could prevent the residents from having an environment that was free from toxic chemicals. Findings included:Resident #9Record review of Resident #9's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old male who admitted on [DATE]. The resident was diagnosed with dementia (decline in cognitive function that interferes with daily life).Record review of Resident #9's Comprehensive MDS Assessment, dated 11/26/2025, reflected severe cognitive impairment with a BIMS score of 06. Section GG (Functional Abilities) indicated the resident was independent with mobility, eating, dressing himself, and toileting. He required assistance with showers and personal hygiene. Record review of Resident #9's Comprehensive Care Plan, dated 01/03/2026, reflected the resident had a communication problem related to cognitive deficit, developmental and intellectual impairment as evidenced by impaired ability to make himself understood or understanding others. An intervention was to Request clarification from the resident to ensure understanding. Turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate. Use simple, simple, brief, consistent words/cues.During an observation on 02/03/2026 at 10:29 AM, Resident #9 was not in his room. The bedside table was placed against the wall. There were several personal items on the bedside table. A can of insect repellant was also on the bedside table. During an interview on 02/03/2026 at 11:23 AM, the DON stated most residents on the hall were alert and oriented and bought things for themselves or family did. He stated all residents were assessed on admission and if a resident started to wander from room to room, they were moved to the memory care unit. The DON was shown a picture of the insect repellant on the bedside table and entered Resident #9's room with the surveyor. Resident #9 was not in his room. The insect repellant had been removed from the bedside table. When asked about the insect repellant, the DON stated the resident had the right to have a home like environment. During an interview on 02/03/2026 at 5:10 PM, the Administrator stated in the past staff had removed items the resident's family member brought to his room. When asked if the resident should have insect repellant in his room, she stated the facility paid a lot of money for pest control and the resident did not need insect repellant. She stated the facility did not have a policy related to the resident having it in his room. LVN AAn observation on 02/03/2026 at 11:47 AM revealed LVN A was about to change a resident's colostomy bag. She went inside the room and closed the door. It was observed that a container of germicidal wipes was on top of a cart when LVN A closed the door and left her cart unattended. When she was about to start, she realized that there was no gown inside the resident's room. She went out of the room and went to get a gown. She left the germicidal wipes unattended on top of the cart she was using as she returned to the room. During an observation and interview on 02/03/2026 at 11:59 AM, LVN A stated she should have secured the germicidal wipes before leaving the cart unattended because residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, skin, and perineal area (area between the legs). She said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She took the container of germicidal wipes and put it inside the cart.In an interview on 01/08/2026 at 12:09 PM, the DON stated that the containers of germicidal wipes should not be placed or left on top of the cart because they have chemicals that could cause adverse effects if consumed or had contact with the skin, eyes, and mouth. He said the container of germicidal wipes was closed but somebody could open it and pull some wipes with their bare hand. She said the wipes were handled with gloves on because they had chemicals on them to eliminate germs on surfaces. He said the containers should be inside the carts. He said he would start an in-service about not leaving any germicidal wipes on top of the carts for resident safety.In an interview on 02/03/2026 at 4:48 PM, the Administrator stated the germicidal wipes with purple tops were used to clean some items that were used from one resident to another. She said she was not aware of the harm it could cause and did not want to speculate.Policy for storage of germicidal/disinfectant wipes requested on requested on 02/03/2026 at 12:32 PM via email to the Administrator and verbally requested on 02/03/2026 at 4:48 PM from the Administrator. The Administrator said they do not have a policy regarding storage of germicidal/disinfectant wipes.Record review of Safety Data Sheet on 01/21/2026 reflected Safety Data Sheet (SDS) Medline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity - oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #4) of eight residents reviewed for respiratory care.The facility failed to ensure Resident #4's BiPAP (noninvasive ventilation that helps you breathe) face mask and oxygen tubing were stored in a bag when not in use on 02/03/2026. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include:Record review of Resident #4's face sheet, dated 02/03/2026, reflected a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE]. She had diagnoses which included mild persistent asthma (airway becomes narrow and makes it difficult to breathe) and respiratory disorder (affects how well the lungs work and the ability to breathe). Record review of Resident #4's Quarterly MDS Assessment, dated 12/02/2025, reflected intact cognition with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) reflected the use of oxygen therapy and a non-invasive mechanical ventilator.Record review of Resident #4's Comprehensive Care Plan, dated 11/26/2025, reflected the following:*resident required the use of BiPAP related to sleep apnea (interruptions in breathing during sleep). An intervention was to administer the BiPAP face mask at bedtime and as needed during naps. *resident was at risk of breathing difficulties/complications related to asthma with shortness of breath and allergies. An intervention was to administer oxygen at 2-3 liters via nasal cannula continuously. Record review of Resident #4's Physician's Orders, dated 05/10/2021, reflected to administer oxygen at 2-3 liters via nasal cannula continuously every shift. Record review of Resident #4's Physician's Orders, dated 07/13/2024, reflected noninvasive ventilation was to be administered via face mask at bedtime every night shift and as needed during naps for shortness of breath. During an observation and interview on 02/03/2026 at 10:01 AM, Resident #4 was sitting in her wheelchair in her room asleep. Resident #4 was receiving oxygen via the portable oxygen tank on the back of her wheelchair. The oxygen tubing, connected to her oxygen concentrator, was on the floor unbagged. The resident's BiPAP mask was on the nightstand unbagged. LVN A entered Resident #4's room and stated the BiPAP should have been in a bag. She stated the resident used it at night and removed the BiPAP mask herself. She stated the resident did not use the oxygen concentrator very often, but the oxygen tubing should have been in a bag. LVN A picked up the oxygen tubing from the floor and stated she was going to throw it aways and get new tubing. She stated it was important to keep the items covered in a bag for infection control. During an interview on 02/03/2026 at 11:23 AM, the DON stated the nurses were responsible for ensuring the respiratory items were stored in a bag when not in use. He stated it was to prevent infection. During an interview on 02/03/2026 at 11:29 AM, the ADON stated the respiratory items should have been bagged when not in use. She stated the resident removed the respiratory items. She stated the nursing staff must ensure the items were placed in a bag. She stated anyone who sees respiratory items unbagged should tell the nurse. She stated it was important to keep them from getting dirty and causing infection.During an interview on 02/03/2026 at 5:10 PM, the Administrator stated it was the nurse or aides responsibility to ensure the items were bagged. The Administrator stated she had contacted the regional office and they did not have a policy about storing respiratory items when not in use.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two (Residents #11 and Resident #14) of ten residents reviewed for medication storage. 1. The facility failed to ensure that Resident #11's pain relieving spray was not on top of the resident's drawer on 02/03/2026.2. The facility failed to ensure that Resident #14's pain reliving roll-on was not on top of the resident's overbed table on 02/023/2026.These failures could place the residents at risk of misuse of medications and possible adverse reactionsFindings included: 1. Record review of Resident #11's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic pain, gout (form of inflammatory arthritis [inflammation of the joints] commonly affecting the big toe), and depressive disorder (persistent feeling of sadness or loss of interest).Record review of Resident #11's Comprehensive MDS (tool used to assess health status) Assessment, dated 12/17/2025, reflected the resident had a severe impairment in cognition with a BIMS (tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident had chronic pain, gout, and depressive disorder, and would frequently experience pain at any time.Record review of Resident #11's Comprehensive Care Plan, dated 01/20/2026, reflected that the resident was on pain medication and one of the interventions was to administer analgesia. The resident had no care plan for self-administration of medications.Record review of Resident #11's Physician Order on 02/03/2026 reflected the resident did not have an order for pain relieving spray.Record review of Resident #11's Clinical Assessment Notes on 02/03/2026 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications.An observation on 02/03/2026 at 9:46 AM, revealed Resident #11 was not inside his room. It was observed that there was a container of a pain-relieving spray on top of the resident's drawer and was on plain view. The drawer was just few steps from the door, and the pain-relieving spray was visible from the hallway.In an interview on 02/03/2026 at 3:16 PM, Resident #11 stated he used the pain-relieving spray for sometimes pain to his back. He said he would always put it on top of his drawer. He said he was not sure if the nurses knew about it but it had always been inside his room.2. Record review of Resident #14's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other) and fracture of the right hip.Record review of Resident #14's Comprehensive MDS Assessment, dated 12/02/2025, reflected the resident was cognitively intact with a BIMS. The Comprehensive MDS Assessment indicated the resident osteoarthritis and fracture of the right hip and would frequently experience pain at any time.Record review of Resident #14's Comprehensive Care Plan, dated 01/20/2026, reflected that the resident was on pain medication and one of the interventions was to administer analgesia. The resident had no care plan for self-administration of medications.Record review of Resident #14's Physician Order on 02/03/2026 reflected the resident did not have an order for pain relieving spray.Record review of Resident #14's Clinical Assessment Notes on 02/03/2026 reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications.During an observation and interview on 02/03/2026 at 10:02 AM, revealed Resident #14 was in her bed, awake. It was observed that a pain reliving roll-on was on top of her overbed table that was at her bedside. The resident said she would sometimes use the pain reliever on her arthritic knees. She said the staff knew she had a pain reliever with her.During an observation and interview on 02/03/2026 at 10:38 AM, LVN B stated the pain reliever spray and roll-on should not be inside residents' rooms and should be inside the nurses' carts because the nurses were supposed to be the ones administering them. She said it was the first time she heard about the pain relivers inside Resident #11 and Resident #14's rooms. She said she did not notice them when she would check on the residents. She said the residents might use them more than the recommended and could result in skin redness or dryness. She said confused residents might consume them as well that could result to upset stomach and nausea. LVN C said she would go to the residents' rooms, talk to them, and would get the medications.In an interview on 01/08/2026 at 12:09 PM, the DON stated medications should not be stored inside the residents' rooms because residents might use them inappropriately that could result in adverse reactions. He said the pain relievers should be inside the carts and the staff should be administering them he said he would start an in-service about medication storage. He said he would start an in-service.In an interview on 02/02/2026 at 4:48 PM, the Administrator stated she was not aware of the harm of storing the pain reliever inside the residents' rooms could cause and did not want to speculate. Record review of the facility's policy, Self-Administration of Medications 2001 MED-PASS, lnc., revised February 2021, reflected Policy heading: Residents have the right to self-administer medications if the interdisciplinary team has determined that it 1s clinically appropriate and safe for the resident to do so . Policy Interpretation and implementation . 3. If it is deemed sate and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications.

Based on observation, interview and record review the facility failed to ensure the nurse call system was assessable for one (Resident #7) of twelve residents reviewed for resident call system.The facility failed to ensure the call light system in Resident #7's room was functioning on 02/03/2026.This failure could place the residents at risk of not being able to directly contact the staff to obtain assistance for activities of daily living or help in an event of an emergency.Findings include:Record review of Resident #7's face sheet, dated 02/03/2026, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with limitation of activities due to a disability. Record review of Resident #12's Quarterly MDS Assessment, dated 12/18/2025, reflected severely impaired cognition with a BIMS score of 5. Section GG (Functional Abilities) indicated Resident #7 required staff assistance for mobility and self-care needs. Record review of Resident #7's Comprehensive Care Plan, dated 12/29/2025, reflected the resident was at risk for falls related to impaired mobility/balance, hemiparesis (muscle weakness on one side of the body), and cognitive deficits. An intervention was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 02/03/2026 at 10: 32 AM, Resident #7 was lying in bed. The bedside table was placed next to his bed. A call bell was observed on the bedside table. Resident #7 stated staff did not always come when he rang the bell. He stated his call light did not work, and he was unsure how long it had not worked. Resident #7's call light was connected to the wall and placed at the foot of the bed. LVN A was in the hall and entered the room. She stated she was unaware Resident #7's call light did not work. She checked the resident's call light, and it did not light up in the hall outside his door. She stated it was important for him to be able to call staff when he needed something. She stated she would let maintenance know.During an observation and interview on 02/03/2026 at 10:41 AM, the Maintenance Director was observed outside Resident #7's room. The Maintenance Director stated no there was not a work order for the resident's call light. He stated the nurse had just told him the call light was not working. He checked the call light, left the resident's room, and returned with another corded call light. He replaced the resident's call light and it lit up in the hall when he pulled it. He stated it was important for the residents to have a call light to reach staff if they needed help. During an interview on 02/03/2026 at 10:43 AM, CNA D stated she was unsure when Resident #7's call light quit working. She stated when the call light broke, the resident was given a call bell. She stated when you hear the bell, you know to go to the resident's room. She stated the bell was loud. She stated it was important for the resident to reach staff if he needed something. She stated he might need water or something that he could not reach himself. During an interview on 02/03/2026 at 11:23 AM, the DON stated he was unaware Resident #7's call light did not work. He stated the resident was alert, oriented, verbal, and able to communicate his needs. He stated the call light was important for the resident's safety. During an interview on 02/03/2026 at 11:29 AM, the ADON stated it was important for the resident to have a call light so he could let staff know if he needed help with anything. During an interview on 02/03/20256 at 5:10 PM, the Administrator stated they knew there was a problem and Resident #7 had a bell in his room. She stated the Maintenance Director found another call light to put in his room. She stated it was important for the resident to have a call light to notify staff if he needed assistance. Record review of the facility's policy Call System, Residents, updated January 2025, reflected Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional.

Based on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for two of five residents (Resident #7 and Resident #25) reviewed for pre-admission screening and resident review (PASARR) assessments. 1. Resident #7's PASRR Level I indicated he did not have a diagnosis of mental illness despite having a diagnosis of mental illness and the facility failed to ensure Resident #7 received a PASRR Level II Screening. 2. Resident #25's PASRR Level I indicated he did not have a diagnosis of mental illness despite having a diagnosis of mental illness and the facility failed to ensure Resident #25received a PASRR Level II Screening. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.Findings included: 1. Record review of Resident #7's MDS assessment dated [DATE], reflected a [AGE] year-old male, , admitted to the facility on [DATE], with a BIMS score of 7 which indicated moderate cognitive impairment and diagnoses that included: Bipolar Disorder (mood swings between high also referred to as manic and low, depressive), Schizoaffective Disorder Bipolar Type ((a serious mental illness blending symptoms of schizophrenia - psychosis like hallucinations/delusions, with mood disorders like depression or bipolar mania involving extreme mood swings, disorganized thinking, and disrupted reality perception.), and Unspecified Dementia without behavioral disturbance (memory loss and thinking problems caused by another medical condition, like Parkinson's or Huntington's, rather than Alzheimer's itself). Record review of Resident #7's Care Plan dated 11/29/2025, reflected Resident 7 received anti-psychotic medications to treat symptoms of Schizophrenia. Record review of Resident 7's PASRR Level 1 Screening dated 06/01/2020 reflected the resident had evidence of a mental illness. Record Review of Resident 7's Consumer Choice of Reduced Services from Recommended Level of Care dated 01/11/2021 reflected the resident qualified for medication management and rehabilitative services through the local mental health authority. The form stated services were pending post-Covid. Record Review of Resident 7's PASRR Level 1 Screening dated 08/11/2023, completed by the facility, reflected the resident did not have any evidence or indicators of mental illness. During an interview on 12/04/2025 at 1:30 PM, the MDS Nurse reported she reviewed Resident 7's PASRR Level 1 Screenings. She reported she was unaware of why Resident 7 did not start PASRR services after Covid restrictions. She reported some services were paused during that time. She reported the resident had another PASRR Level 1 completed after Covid which reflected he was negative. The MDS Nurse agreed the PASRR Level 1 dated 08/11/2023 was inaccurate due to the form indicating no mental illness. She reported the Resident's last PASRR level 1 was completed by a hospital upon their admission. She reported she would check for accuracy on the forms upon a resident's admission by reviewing hospital records, any psychiatric notes, and diagnoses. She reported if a resident was PASRR positive and not accurately identified, they might not receive special services. During an interview on 12/05/2025 at 11:37 AM, the Administrator reported she would help the MDS Nurse with PASRR questions and problems as needed. She reported she would sit in on PASRR meetings with the local mental health authority. She reported Resident # 7 was not PASRR positive. The Administrator was not aware that his PASRR Level 1 was not accurate. She reported if a resident was PASRR positive and not accurately identified; she was not sure of the harm it could have on the resident and would not want to speculate. She reported that the facility provided all services that PASRR provided to residents like laundry, meals, socialization, and therapies. 2. Record review of Resident #25's quarterly MDS dated [DATE] reflected an [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses of Schizophrenia Disorder with Bipolar, Heart Disease, and Diabetes Type II. The MDS reflected he had a BIMS of 7 which indicated severe cognitive impairment. He required total assistance with toileting and showers and maximum assist with dressing. He used a wheelchair to ambulate. He was frequently incontinent of bladder and had an ostomy.Review of Resident #25's Comprehensive Care Plan dated 04/01/2023, revised on 03/25/2025 reflected Resident #25 had focus area to address the effects of schizoaffective disorder with a goal to remain at current level of cognitive function. Interventions included engaging in simple structured activities, and to monitor/report any changes in cognitive function to the Medical Doctor. Record Review of the most current PL 1 for Resident #25 was completed on 08/10/2023 and it was negative. In an interview on 12/5/2025 at 10:10 AM with the MDS nurse revealed she was not aware that Resident # 25 had a diagnosis of Schizophrenia and that a new PL 1 was needed to be completed, she stated she would do that immediately. Record Review of the facility's PASRR Policy dated 07/29/2025, reflected in part the following: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. Preadmission happens when a person is coming from the community (psychiatric hospital, home, group home, jail, assisted living, etc.). This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community with a PASRR Level 1 that indicates suspicion of IDD, and/or mental illness must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission. Negative indicates the person has a negative PL1 screening, and is not suspected of having an intellectual disability, developmental disability and/or mental illness. Level I Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission. Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. Compliance: Nursing homes must comply with all federal and state regulations regarding PASRR. Failure to do so can result in penalties or loss of funding. The facility follows HHS PASRR For Nursing Facility guidelines.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The Dietary Aide failed to wear a beard restraint while working in the kitchen. This failure could affect the residents who receive their meals from the facility's only kitchen by placing them at risk for food contamination. Observation on 12/03/2025 at 11:12 AM revealed the dietary aide was not wearing a beard restraint while working in the kitchen. Observation and interview on 12/04/2025 at 11:01 AM revealed the dietary aide was wearing a beard restraint, but it was underneath his chin and not covering his beard and mustache. The dietary aide stated he was wearing a beard restraint yesterday (12/03/25), but he must have forgotten to put it back at some point. The dietary aide stated today (12/04/25), he pulled the beard restraint down around his chin and forgot to put it back up. He stated the risk to the residents would be that hair could get into their food. In an interview on 12/05/2025 at 10:22 AM with the dietary manager revealed she expected all of her staff to wear hair restraints when they were in the kitchen. She stated the risk to residents would be they could possibly get hair in their food. In an interview on 12/05/2025 at 11:26 AM with the administrator revealed she expected the dietary staff to follow their policy regarding beard restraints. She stated the risk to the residents is they could shed into the food. Record review of the Healthcare Services Group, Inc. dated 05/2014, revised 1/2025 reflected, All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on observation, interview, and record review, the facility failed to ensure the resident call light system was maintained within reach for 2 of 5 residents (Resident #7, and Resident #28) reviewed for call light system access. The facility failed to maintain Resident #7 and #28's call light system in working order. The call light in their shared room had detached completely from the wall, rendering it unusable. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Findings included:Record review of Resident #7's MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE], with a BIMS score of 7 which indicated moderate cognitive impairment, with diagnoses that included: Bipolar Disorder (mood swings between high also referred to as manic and low, depressive), Schizoaffective Disorder Bipolar Type ((a serious mental illness blending symptoms of schizophrenia - psychosis like hallucinations/delusions, with mood disorders like depression or bipolar mania involving extreme mood swings, disorganized thinking, and disrupted reality perception.), and Unspecified Dementia without behavioral disturbance (memory loss and thinking problems caused by another medical condition, like Parkinson's or Huntington's, rather than Alzheimer's itself), Acute and Chronic Respiratory Failure (the body does not receive enough oxygen) and repeated falls. Record review of Resident #7's Comprehensive Care plan dated 02/23/2025 reflected resident #7 had a communication problem and cognitive deficits. The plan intervention included ensure/provide a safe environment: Call light in reach. The Care Plan also reflected resident #7 had an ADL Self Care Performance Deficit. The plan intervention included Encourage the resident to use bell to call for assistance. The plan reflected Resident #7 was a high risk for falls. The plan intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review of Resident #28 MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE]. The BIMS score portion of the MDS was not completed as it stated resident was never/rarely understood. Resident #28 had diagnoses that included: Cerebral infarction due to thrombosis of right posterior cerebral artery (a stroke due to a blood clot in the back right part of the brain) and Unspecified dementia (memory loss and thinking problems caused by another medical condition, like Parkinson's or Huntington's, rather than Alzheimer's itself). Record Review of Resident #28's Comprehensive Care plan dated 11/10/2025 reflected Resident #28 had a communication problem and cognitive deficits/dementia, post stroke with impaired ability to make self-understood and understanding others. The plan intervention included ensure/provide a safe environment: Call light in reach. The Care Plan also reflected Resident #28 had an ADL Self Care Performance Deficit. The plan intervention included Encourage the resident to use bell to call for assistance. The plan reflected Resident #28 was a fall risk due to muscle weakness and impaired mobility. The plan intervention included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on 12/03/2025 at 11:05 AM, Resident #7 was observed sitting in his room and appeared to be well-groomed and dressed appropriately for the weather conditions. He reported his call light had been broken for 4-5 months, and he would holler if he needed help. Resident #7 said he was not sure how the call light system came out of the wall. The call light box was observed to have been pulled out of the wall and dangling behind Resident #7's bed. The resident had not been given an alternative means to call for assistance if needed. During an interview and observation on 12/03/2025 at 11:15 AM, Resident #28 was observed lying in his bed. He was awake and alert. He appeared to be well-groomed. His body was covered by a blanket. His call light button was observed underneath his bed. Resident #28 said he did not know why it was there. He was unable to explain how he called the staff if he needed help. During an interview on 12/03/2025 at 1:10 PM, CNA A reported the call light system in Resident #7 and #28's room was broken. She reported she noticed it broken yesterday (12/02/2025) during her 6am-2pm shift. She stated she reported the broken call system to the DON yesterday after she saw it was broken. She reported she conducted rounds on each resident every 2 hours or more. She reported Residents #7 and #28 will yell or scream if they needed help. She reported the risk of a resident not having access to a call light was that the resident would not be able to call if they needed help. During an interview on 12/03/2025 at 1:16 PM, the Maintenance director reported he was on his way to fix the call light system in Resident #7 and #28's room. He stated he was just now made aware that it was broken. He stated a maintenance request was never submitted to him as he was just now learning it was broken. During an interview on 12/03/2025 at 1:21 PM, the DON reported the whole call light system came out of the wall in Resident #7 and #28's room. He stated the maintenance was fixing it now. He denied that a staff member told him it was broken yesterday, he said he just learned it was broken today. He reported it had only been broken since Tuesday. The DON reported Resident #7 was given a bell to ding if he needed help. During a follow up observation on 12/03/2025 at 1:30 PM, Resident #7 was observed in his room. A bell was observed on his bed side table. The resident stated he was given the bell about 15 minutes ago and had never used it before. During a follow up interview with the DON on 12/05/2025 at 11:25 AM, he reported the call light being broken was discovered on Tuesday. He stated it was reported to maintenance but not put in the maintenance log. He stated a CNA told him she reported it to the maintenance director on Tuesday. The DON stated he was not sure why it was not fixed on that same day it was reported. He stated the Department Heads were responsible for checking each room every morning to ensure the call light systems were working. He was unsure which department head was assigned to Resident #7 and #28's room. He was unable to describe the harm that could be placed on residents without access to a call light system. During an interview with the Administrator on 12/05/2025 at 11:47 AM, she reported she was made aware of the broken call system on Wednesday, 12/3/2025 by the maintenance director. She reported she was unaware of how long it had been broken. She reported the maintenance director was made aware that it was broken on 12/03/2025. She reported any maintenance request was put into their TELs System (the building maintenance and compliance tracking system used to schedule, document, and manage equipment in a facility) where the maintenance director is immediately notified of a request. She reported any staff member can put in the request. Record review of facility maintenance request log for the past (6 months) reflected there had not been any requests for services for Resident #7 or #28's call light system. Record review of the facility's Call System Policy dated January 2025 reflected in part: The resident's call system remains functional at all times.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 Resident of 3 (Resident#1), reviewed for infection control. The facility failed to ensure that CNA A performed hand hygiene before providing peri care. The facility failed to ensure that CNA A provided perineal care according to professional standards of practice when she cleaned a female resident (Resident#1) perineal area from back to front, rather than from front to back which is consistent with professional standards. This failure could cause residents the risk of urinary tract infections and compromise their health and safety. Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 07/08/25, reflected the resident was a [AGE] year-old female, who admitted on [DATE], had a BIMs score of 15 indicating she was cognitively intact. The resident had diagnoses which included arthritis, hypotension (low blood pressure), urinary tract infections, anxiety, and asthma.Record review of Resident #1's Comprehensive Care Plan, revised 08/11/2025 reflected the resident had bowel incontinence. Facility interventions included: Check resident every two hours and assist with toileting as needed, provide peri care after each incontinent episode, take resident to toilet PRN as requested.10/13/25 at 11:38am Incontinent care observation on Resident #1 by CNA A revealed Resident#1 had a bowel movement and her brief was wet. CNA A entered Resident #1's room and did not perform hand hygiene. CNA A donned clean gloves, unfastened Resident #1's brief, cleaned the resident from back to front. Removed dirty gloves, donned cleaned gloves, touched trash can and moved it closer then touched clean brief, applied brief on the resident and fastened the brief. CNA A then removed gloves and washed her hands.10/13/25 at 11:56 AM interview with CNA A revealed she knew that she was supposed to perform hand hygiene before and after peri care. She stated she forgot to perform hand hygiene before peri care. She stated the professional standard was to clean the resident from front to back, and there was no reason she cleaned the resident from back to front. She stated that the risk to the resident when cleaned from back to front was urinary tract infection. She stated that she had been in-serviced on infection control, hand hygiene and peri care. An interview on 10/13/25 at 1:41 PM with DON revealed that his expectation was that the staff should perform hand hygiene before and after care, or when the gloves were contaminated by touching surfaces such as trash cans. He also stated that when providing peri care the staff should clean the residents from front to back. He stated that the risk to a female resident being cleaned from back to front was the urinary tract infections. The risk of not performing hand hygiene was infection control. He stated that the staff had been in-serviced and had completed skills checkoffs on infection control and peri care. The facility policy titled Perineal Care Revised February 2018 reflected: The purpose of this procedure is to provide cleanliness and comfort to the resident to prevent infection and skin irritation and observe the residents' skin condition.Steps in the Procedure1. Beginning stepsa. Wash hands. Wear gloves and follow Standard Precaution if contact with blood or body fluid is likely.b. Gather needed supplies.If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag.Female:1. Follow below:Cleanse the perineal are with wipes going from front to back/clean to dirty.Separate the labia (clean to dirty)Use a new wipe with each stroke.Wipe one side, wipe the other side down the center and then once from hip bone to hip bone. The facility policy titled Infection Control and Prevention Program Revised October 2018 reflected:An infection prevention and control program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Policies and proceduresa. Policies and procedures are utilized as the standard of the infection prevention and control programb. Policies and procedures reflect the current prevention and control standards of practicec. The infection prevention and control committee, medical director, director of nursing services and other key clinical and administrative staff review the infection control policies at least annually. The review will include:1. Updating or supplementing policies and procedures as needed.2. Assessment of staff compliance with existing policies and regulations andAny trends or significant problems since the previous review

Based on observation and interview, the facility failed to provide a safe, comfortable, and homelike environment, for daily living for three (Resident#1 room, Resident#2 room and Resident# 3 room) of sixteen resident rooms reviewed for environmental concerns. The facility failed to maintain Resident#1, Resident#2 and Resident#3 room at temperatures levels ranging of 71 F to 81 F. This failure could put residents at potential risk associated with temperature extremes, like hypothermia or overheating.Findings included: Resident #1Record review of Resident #1's admission record dated [DATE] revealed, he was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE] with diagnoses, which included but were not limited to: Parkinson's disease without Dyskinesia (the condition where individuals experience the symptoms of Parkinson's but do not exhibit the involuntary movements often associated with long-term treatment, particularly with levodopa), without mention of fluctuations, chronic pain syndrome ( long-term condition characterized by persistent pain that lasts for months or years, significantly affecting daily life.), and legal blindness, as defined in USA. Record Review of Resident#1 MDS dated [DATE] revealed, he had a BIMS of 13 indicates cognitively intact. Resident #2Record review of Resident #2's admission record dated [DATE] revealed, he was a [AGE] year-old male, admitted on [DATE] with diagnoses, which included but were not limited to schizoaffective disorder (hallucinations and delusions, and mood disorder symptoms), unspecified, chronic pain syndrome ( long-term condition characterized by persistent pain that lasts for months or years, significantly affecting daily life.), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest.), recurrent, moderate and bipolar disorder (mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), current episode manic serve with psychotic features. Record Review of Resident#2's MDS dated [DATE] revealed, he had a BIMS of 12 indicates moderate cognitive impairment. Resident #3Record review of Resident #3's admission record dated [DATE] revealed, she was a [AGE] year-old female, admitted on [DATE] with diagnoses, which included but were not limited to Type 2 Diabetes Mellitus with Ketoacidosis without coma (characterized by high ketone levels and symptoms like excessive thirst and frequent urination), adjustment disorder with depressed mood, adjustment disorder with depressed mood (short-term symptoms that affect your thoughts, behaviors and emotions) and Personal history of Transient Ischemic Attack (TIA)- (a short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain), and cerebral infraction without residual deficits. Record Review of Resident#3's MDS dated [DATE] revealed, she had a BIMS of 13 indicates cognitively intact. Record review of maintenance logs dated, [DATE] to [DATE] reflected no documentation of room temperature checks or AC unit concerns. Observation of Initial Walk through of facility on [DATE] at 9:45 am revealed rm# 119, rm# 205, rm# 206, rm# 216, rm#223, rm# 229 had portable fans in rooms. Observed rm# 221 had window units in the room. Observed floor fan at the entrance of the facility and at the two nurse's station. Observation revealed playmates at both nursing station were full of ice. Interview and observation on [DATE] at 11:30 am with the MD revealed the facility had AC unit issues for the last 3 weeks. The MD stated he did not have an exact date. The MD and surveyor completed a walkthrough of the facility and checked the temperatures. The MD read the temperature for Resident#3 room at 86.3F. The MD read the temperature in Resident#1 room at 92 F on A side and 89 F for Resident#2 room on B side. Interview and observation on [DATE] at 12:00 pm, Resident #1 stated he was miserable, and his roommate was miserable. Observed both residents had portable fans facing them. Observed Resident#2 with no t-shirt on and sweating. Resident#2 stated he was hot. Resident#1 stated he was asked if he wanted to move rooms, and he told staff no. Resident#1 stated he did not want to be separated from Resident#2. Resident#1 stated he was not asked about a window unit. Interview on [DATE] at 1:56 pm, the AC/HT Technician stated he had to wait on the facility to get the curb order in. The AC/HT Technician stated he was due to return to the facility on Wednesday on [DATE] to complete the repairs. The AC/HT Technician stated it should take a full day to complete. Interviews on [DATE] between 2:00 pm to 3:00 pm, LVN A, LVN B, LVN C, CNA D, CNA E, CNA F, and CNA G stated residents on 200 hall south have complained of being hot and staff reported to the MD. The Staff reported the facility did get hot sometimes, but the floor fans help combat the heat. Staff stated Residents are offered more hydration throughout the day. Observation and interview on [DATE] at 3:30 pm with the MD revealed Resident#3 room temperature read 82.9. Observation revealed the facility added a window unit to Resident#3 room. The MD stated his digital thermometer was no longer working and needed to be charged. Observation on [DATE] at 5:00 pm the surveyor checked back with the MD to see if the digital thermometer would work and observed it was not turning on at that time. Interview on [DATE] at 5:30 pm with the Admin, the DON and the MD revealed the AC started going out two to three weeks ago and they did not have an exact date. The Admin stated estimate for repairs were completed and approved. The MD stated by the end of next week the repairs should be completed. The MD stated the curb was ordered and should be delivered by [DATE] or [DATE]. The MD stated AC/HT technician should be at the facility by [DATE] to complete repairs. The DON stated they offered to move Resident#1 and Resident#2 to another room, and they both declined. The Admin stated they offered to put in a window unit and Resident#1 declined. The DON stated residents are offered water throughout the day. Observation on [DATE] at 8:10 am, The surveyor and the MD did a walk through to check the room temperatures which revealed, Resident#3 room was in the safe temperature range of 71 F to 81 F. Observation of Resident#1 and Resident#2 room temperature read 82.5 F. Observed both Resident#1 and Resident#2 in the room sitting up in their beds. Interview on [DATE] at 8:45 am Resident#1 stated the room felt a lot better. Resident#2 stated he was ok. Review of AC/HT company invoice reflected, estimated date of [DATE] and expired on [DATE].Services reflected in part: Gas package unit change out 5 -ton, fresh air damper, [NAME] guards, and curb adapter. Review of website : https://www.hhs.texas.gov/provider-news/[DATE]/hhsc-reminds-nursing-facilities-importance-maintaining-hvac-equipment. Titled HHSC Reminds Nursing Facilities of the Importance of Maintaining HVAC Equipment dated [DATE] reflected, Nursing facilities initially licensed before Sept. 11, 2003, must have cooling systems that ensure the indoor air temperature is no warmer than 81 degrees in areas used by residents. Review of facility's policy titled Maintenance service, revised 12/2009, revealed in part the following: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times.2. Functions of maintenance personnel include but are not limited to: d. maintaining the heat/cooling system .in good working condition. Review of facility's policy titled Homelike Environment, revised 12/2009, revealed in part the following:2. The facility staff and management maximize, to the extent possible, the characteristics and personal needs and preference. H) comfortable and safe temperatures (71 F-81 F).

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for one (100 Hall) of two halls and two (room [ROOM NUMBER] and room [ROOM NUMBER]) of six rooms reviewed for decent living environment. 1. 100 Hall had a leak from the ceiling tile opening, with a trashcan and bucket in the middle of the hallway floor to catch the water. 2. room [ROOM NUMBER] had a socket hanging from the wall. 3. room [ROOM NUMBER] light switch in the bathroom was not fully covered. These failures could result in a resident's diminished quality of life due to an unsafe environment that is not homelike. Findings Included:In an observation and interview on 07/22/25 at 10:05 AM, reflected a half covered light switch in the bathroom of room [ROOM NUMBER]. The resident in room [ROOM NUMBER] stated the covering kept falling off the light switch. The resident in room [ROOM NUMBER] stated it did not cause issues, but her roommate could not see well, and it might have been a problem for her. The light switch covering was sitting in the bathroom. The Maintenance Director stated he covered the light switch the other day and one side of it must have come off. He stated he was not aware that part of the covering had fallen off. He stated the light switch needed to be covered for the safety of the resident, to prevent any possible harm. An observation of the 100 Hall on 07/22/25 at 12:29 PM, reflected missing tile on the ceiling with wires and pink insulation exposed. There was a pink wash basin in the ceiling, with a black, small trashcan and blue bucket, sitting on a towel on the floor, in the middle of the hallway, directly below the opening. There was no water present at the time of the observation. An observation and interview on 07/22/25 at 1:10 PM, reflected the wall socket in room [ROOM NUMBER] was hanging from the wall. The residents in room [ROOM NUMBER] stated the socket had been like that but was still working. Their Family Member was present and stated the wall socket had been like that a while, and the facility knew about it. In an interview on 07/22/25 at 1:56 PM, the Maintenance Director stated he did not do anything with the leak yet, because he was waiting on the facility's corporate office to approve a bid. He stated the roof was not sealed properly when the roof was repaired three years ago. The Maintenance Director stated the leak only happened when there was a downpour of rain. He stated the leak first happened about two months ago. The Maintenance Director stated the risk of the leak was possibly major damage to the roof. The Maintenance Director stated the wall socket was repaired in room [ROOM NUMBER]. He stated there was no risk since the socket was always in the wall unless the resident's bed was moved, which would sometimes pull the socket away from the wall.In an interview on 07/22/25 at 3:31 PM, The Administrator stated she addressed the concern with the leak with the facility's regional office, but they prioritize repairs in their own way. She stated the regional office asked why the bid was so high to repair the leak and more bids were requested. The Administrator stated the regional office now, was trying to determine if they will fix part of the roof or the entire roof. She stated the leak only occurred when it rained. The Administrator stated repairs have been completed quickly in the past if the Maintenance Director was aware of the issues. The Administrator stated the risk of repairs not happening in the facility was the resident's not having a decent environment.Record review of the facility's policy, dated, December 2009, and titled, Maintenance Service, reflected the following: Policy statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. Maintaining the building in good repair and free from hazards.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. The facility failed to ensure food on the steam table reached the appropriate temperature before plating food for resident consumption. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/08/24 beginning at 9:20 AM revealed: - 6 cucumbers with fuzzy white spots; - 3 cut tomatoes in a box open and exposed to air; - 1 onion with black spots; - 7 withered tomatoes; - 1 bag of shredded lettuce with brown lettuce leaves; - 1 bucket of pork chops thawing on the second shelf above eggs; - 1 box of bacon open and exposed to air; - individually wrapped sandwiches cut in half with no date; - pasta salad with no date; - 2 green bell peppers with black spots; - 4 withered green bell peppers; and - 1 bag of shredded cheese open and exposed to air. Observation of the facility's freezer on 09/08/24 beginning at 9:51 AM revealed: -1 box of cut green beans open and exposed to air; and - 1 box of green peas open and exposed to air. Observation of the facility's dry storage in the kitchen on 09/08/24 beginning at 10:12 AM revealed: -1 bag of macaroni noodles open and exposed to air. Observation of the facility's seasoning shelf on 09/08/24 beginning at 10:21 AM revealed: -1 container of onion powder open and exposed to air; and - 1 container of quick creamy wheat open and exposed to air. Observation of the facility's steam table on 09/10/24 beginning at 11:46 am revealed the pork loin reached 131 degrees Fahrenheit. The dietary staff plated approximately 20 plates of pork loin on two rolling carts. The carts were taken to the dining room to serve to residents. There were six residents served pork loin prior to Surveyor intervention. The Dietary Supervisor pulled and discarded all plates containing pork loin. The dietary staff reheated the pork loin to 150 degrees Fahrenheit. In an interview with the Dietary Supervisor on 09/10/24 at 3:30 PM revealed she completed walk throughs of the kitchen in the morning and evening. She stated she was responsible for ensuring dietary staff were storing food properly. She stated dietary staff were supposed to label and seal foods. She stated anything in the refrigerator after three days old was thrown away. She stated she ensured staff were aware of food temperatures by posting signs and having information in the temperature log books. She stated the pork loin at a temperature of 131 degrees Fahrenheit was not supposed to be served to residents. She stated the pork loin should have been pulled and warmed up to hold a temperature of 165 degrees Fahrenheit for 15 seconds. She stated improper food storage and undercooked pork loin could cause harm to residents such as contamination and food borne illnesses. Record review of the facility policy titled Food Storage: Dry Storage, dated February 2023 (revised), revealed All packaged and canned food items will be kept clean, dry, and properly sealed. Record review of the facility policy titled Food Storage: Cold Foods, dated February 2023 (revised), revealed All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Record review of the facility policy titled Food: Preparation, dated February 2023 (revised), revealed All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or state regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. Review of the Food and Drug Administration Food Code, dated 2022 reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one of thirteen resident (Resident # 74) reviewed for ADLs. The facility failed to provide Resident #74 with ADL care (incontinent care). This deficient practice could place residents who required extensive assistance with ADLs at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological wellbeing. Finding included: Record review of Resident #74's face sheet revealed she was [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included, dementia, essential hypertension, muscle wasting and atrophy, muscle weakness and need for assistance for personal care. Record review of Resident #74's significant change in status MDS dated [DATE] revealed her Brief Interview for Mental Status (BIMS) was a 6 out of 15 revealing cognitive impairment. Her ADL status revealed she needed limited assistance of one person for bed mobility, total dependence of one staff for toilet use. Resident #74 was always incontinent of bladder. Record review of Resident #74's care plan revised 05/02/24 reflected, Focus . (Resident #74) has bladder incontinence r/t cognitive deficit and impaired mobility. Goal, the resident will remain free from complications r/t incontinence such as UTIs through the review date. Intervention . Monitor for incontinence. Wash, rinse and dry the perineum. Monitor for incontinence and provide incontinent care or barrier cream as needed. Observation on 09/10/24 at 02:02 PM revealed Resident #74 was in bed, and the aide was providing care. The aide started providing care after positioning the resident. The resident was soiled with urine, also the linens were soiled with urine and the fitted sheet had a ring of urine around where the resident was lying. Initially the staff cleaned the resident and applied the clean brief, and when the surveyor was asked if the linens were wet that was when the aide stated the linens were wet and removed the linens and then the resident stated, I am soaking wet. No indication of skin breakdown. In an interview on 09/10/24 at 02:08 PM with CNA B she stated she had checked the resident early and the resident was dry, but she did not specify what time. In an Interview on 09/10/24 at 02:09 PM with Resident #74 she stated while the CNA B was in the room that she had not been changed since the night before. Resident #74 stated CNA B had assisted her with her breakfast, but CNA B did not check if she was wet. Then the resident stated the aide might have been busy taking care of other residents. After the resident stated she had not been changed since last night, then CNA B stated she was busy, and she was not able to change the resident throughout the shift. CNA B stated she was expected to check the resident routinely and provide incontinent care to prevent skin breakdown and making sure the resident was well groomed. In an interview on 09/10/24 at 02:32 PM with the DON he stated he expected CNA B to complete and assist the resident with her ADLs care. The DON stated he expected Resident #74 to be provided with incontinent care routinely to prevent skin breakdown and maintain resident's dignity. The DON stated he was responsible and the charge nurses to check and make sure the residents are changed and ADLs cares completed timely. Review of the facility policy revised March 2018, titled Activities of Daily Living (ADLs) Supporting, reflected, Residents will be provided with care, treatments, and services to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1(Resident #67) of 3 residents reviewed for pressure ulcers. The facility failed to prevent the development of a pressure ulcer for Resident #67. This failure placed residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain, and infection. Findings Include: Record review of Resident #67's face sheet dated 09/10/24 revealed, an [AGE] year-old female who admitted to the facility originally on 01/05/23 and readmitted on [DATE] with the following diagnoses which included; dementia, essential hypertension, protein calorie malnutrition and muscle weakness Record review of Resident #67's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADL's, total dependence with most functional abilities including shower/bathe self, upper body dressing, substantial/maximal assistance (helper does more than half the effort) assistance with personal hygiene (includes washing and drying hands). The resident was at risk for developing pressure ulcer/injury. Record review of Resident #67's care plan revised 03/21/24 revealed, Focus: [Resident #67] has potential for impairment to skin integrity/pressure ulcer development r/t impaired mobility requiring assist, nutritional deficits and incontinence of B/B.Goal, The resident will have no evidence of skin breakdown noted through the review date.Intervention, .Complete weekly skin assessment. Encourage good nutrition and hydration in order to promote healthier skin Review of the physician's order dated 09/10/24 for the month on September (2024) reflected, Clean area to L back of the ear, pat dry, apply skin prep daily. everyday shift for Maintain skin integrity, order date 09/09/24. Clean underneath left ear with normal saline pat dry and apply TAO for 5days . every day shift, order date 09/09/24. Assess bilateral back of the ears daily, ensure ear protectors are in place, document/report any skin breakdown as indicated every shift for Maintain skin integrity. Observation on 09/09/24 at 01:14 PM during wound care revealed Resident #67 was in bed. LVN D completed wound care on Resident #67's left heel, right heel, right buttock and behind the right knee. During care the resident reported pain but declined to take pain medication. The times when the resident was being positioned on the left side, she reported pain to her ear. Resident #67 was using oxygen via nasal cannula and the tubing was behind her ears. The Surveyor asked LVN D if she could assess the resident's ears and on assessment the resident was noted with a wound behind the left ear. There was some drainage and hair were attached on the drainage that had already dried. In an interview on 09/09/24 at 02:05 PM with LVN D, who was completing the wound care, she stated she had taken care of the resident last on Friday (09/06/24) and she did not assess the resident's ears because she did not think she had any wounds to her ear. LVN D stated today was when she noted the wound after the resident complained of ear pain. LVN D stated the resident was supposed to have ear protectors to prevent the skin breakdown, she noted the tubing pulling on the ears. LVN D stated the charge nurses were to assess the resident ears periodically (no specific time provided) for any skin breakdown due to the use of oxygen tubing. LVN D stated not being aware of the resident having a wound could result to the wound getting worse and getting infected. LVN D stated she would inform the resident's primary care provider of the new wound. In an interview on 09/09/24 at 02:43 PM with RN E, she stated she took care of Resident #67 last week, and she did not notice the open area behind the resident's ear, and she did not assess the resident's ears. RN E stated she completed wound care rounds with the wound care Dr, and there were no reports of the resident having any wounds to her ear. RN E stated the charge nurse were responsible to assess the resident's ears for any skin breakdown frequently. RN E stated wounds that were not addressed timely could lead to wound infection and wounds getting worse. Observation on 09/10/24 at 11:21 AM of an assessment with RN E revealed Resident #67 had an open area on the back of the left ear, no drainage, open to air, wound bed was red, and there were no signs or symptoms of infection. RN E stated the resident was assessed by the primary care provider on 09/09/24 and gave new orders for treatment for five days. The nurse stated the nurses were to assess the resident ear's daily and make sure the resident had the protective foam on the oxygen tubing to prevent any skin breakdown. In an interview on 09/10/24 at 02:05 PM with the DON he stated he was not aware Resident #67 had a wound to the left ear. The DON stated per the skin assessment completed on 09/02/24 the resident did not have any skin issues. The DON stated the nurses were responsible to monitor for the resident's skin breakdown and inform the resident's primary care provider and follow the orders. The nurses should assess the resident ears since she had oxygen tubing to make sure the resident was not having skin breakdown. The DON stated lack of wound care could lead to the wound getting worse and the wound getting worse. Review of the facility policy revised 10/2020, titled Wound care reflected, Purpose. This procedure provides guidelines for the care of wound care to promote healing. Facility did not have a policy regarding addressing new wounds.

Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal health care information for two of six (Resident #6 and Resident #65) residents reviewed for confidentiality of records. The facility failed to ensure LVN F locked and closed the laptop during a medication pass, which exposed Resident #6's personal information to include some of his medication orders. The facility failed to ensure LVN A locked the computer prior to leaving the Nurse's Station, which exposed Resident #65's personal information to include some of her diagnoses. This failure could affect residents by placing them at risk for loss of privacy and dignity. Findings included: Review of Resident #6's Face Sheet, dated 09/10/24, reflected he was an [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including dementia (a general term for a range of conditions that cause a decline in cognitive functioning, such as thinking, remembering, and reasoning), schizoaffective disorder/bipolar type (a mental health condition that combines schizophrenia and bipolar disorder - people with this condition experience both manic episodes and depressive episodes, along with psychotic symptoms like hallucinations and delusions), major depressive disorder (a mental health condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable), and type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't make enough insulin or doesn't use it properly, resulting in high blood sugar levels). Review of Resident #65's Face Sheet, dated 09/10/24, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable), type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't make enough insulin or doesn't use it properly, resulting in high blood sugar levels), and alcoholic cirrhosis of the liver with ascites (a condition that occurs when a person has a buildup of fluid in their abdomen due to cirrhosis of the liver, which is often caused by drinking too much alcohol). Observation on 09/08/24 at 9:12AM revealed the computer screen on LVN F's medication cart was unlocked and unsupervised for approximately 1-2 minutes while LVN F was down the hallway. Resident #6's personal information, including medication orders, was exposed to staff, residents, and visitors who were present on the hall. Observation on 09/08/24 at 9:14AM revealed the computer screen at the Nurse's Station in which LVN A was assigned was unlocked and unsupervised for approximately 1-2 minutes while LVN A was providing care in a resident's room. Resident #65's personal information, including some of her diagnoses, was exposed to staff, residents, and visitors who were present on the hall. During an interview with LVN F on 09/08/24 at 9:20AM, she stated she did not know why she left the computer screen unlocked and unsupervised. She stated she had been in-serviced on the importance of maintaining the privacy and confidentiality of residents, and the computer screen should have been locked prior to walking away from the medication cart. During an interview with LVN A on 09/08/24 at 9:26AM, she stated there was no good reason as to why she left the computer screen unlocked and unsupervised while providing care for another resident. She stated she had been in-serviced on the importance of maintaining the privacy and confidentiality of residents, and the computer screen should have been locked prior to leaving the Nurse's Station. During an interview with the DON on 09/10/24 at 1:55PM, he stated facility staff were expected to maintain the privacy and confidentiality of residents, which included ensuring their personal information was not left visible to other staff, residents, and visitors. He stated the risk of staff leaving their computers unlocked with resident information visible was that individuals who were not privy to those residents' information could have access to it. Review of the facility's Confidentiality of Information and Personal Privacy policy, dated 08/2024, reflected, .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

Based on observation, interview, and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 (Resident #19) of 2 Residents who were observed for transfers. LVN A failed to use the gait belt as needed due to the resident having unsteady gait while repositioning Resident #19 in the wheelchair. The deficient practices could affect residents who require assistive devices during transfers and could contribute to avoidable falls. The findings were: Review of Resident #19's face sheet, dated 09/10/24, revealed she was admitted to the facility on [DATE] with some of the diagnoses including history of falling, repeated falls, muscle waiting and atrophy and muscle weakness. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed her BIMS was 10 reflective of mild cognitive impairment; had a history of fall after admission and required maximum assistance from sitting to standing. Review of Resident #19's Care Plan, revised 2/26/24, revealed, Focus, (Resident 19) has HX of falls and remains at risk for falls r/t impaired mobility/balance, unsteady gait, . Goal, The resident will be free from falls through the review date. Observation on 09/08/24 at 02:15 PM revealed Resident #19 was in the wheelchair, family was in the room, and the family member stated the resident had said she was having pain in her back, and she was not sat well in the wheelchair. The resident's family member left the room and came back with LVN A. LVN A was observed lifting Resident #19 from the wheelchair by putting her arms below the resident's arm. The resident's family member assisted pulling the resident's pants in position, and then LVN A assisted Resident #19 to sit back in the wheelchair. In an interview on 09/08/24 at 02:37 PM with LVN A she stated, she was aware she did not use the gait belt because she was old school. LVN A stated per the facility policy she was supposed to use the gait belt, but she did not have one with her because normally she did not do transfers. LVN A stated gait the belt was required to transfer the resident to prevent falls or harming the resident because it could cause a fracture. In an interview on 09/10/24 at 02:34 PM with the DON, he stated per the facility policy, staff were required to use a gait belt while assisting the resident with a transfer. The DON stated the staff should have the gait belt with them and some of the gait belts were in the residents' rooms. The DON stated staff were supposed to use a gait belt to prevent harm through falls or causing any fracture on the residents. Review of the facility policy revised July 2017, titled Safe Lifting and Movement of Residents, reflected, In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1(Resident #74) of 8 residents reviewed for infection control in that; During a wound dressing change for Resident #74, LVN C did not sanitize her hands or change gloves in between removal of an old dressing and cleansing and application of a new dressing. The deficient practices could place residents at-risk for infection due to improper care practices. Findings Included: Record review of Resident #74's face sheet revealed she was [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included, dementia, essential hypertension, muscle wasting and atrophy, muscle weakness and need for assistance for personal care. Record review of Resident #74's significant change in status MDS dated [DATE] revealed her Brief Interview for Mental Status (BIMS) was a 6 out of 15 revealing cognitive impairment. Her ADL status revealed she needed limited assistance of one person for bed mobility, total dependence of one staff for toilet use. Resident #74 was always incontinent of bladder. Observation on 09/09/24 at 11:04 AM revealed LVN C providing surgical wound care to Resident #74. LVN C gowned and gloved and then took off the dressing from Resident #74's right toe and revealed all the right toes had been amputated and the resident had sutures on the wounds. LVN C cleaned the surgical area with normal saline and gauze, pat dried and then applied betadine and dry dressing and then wrapped with ace wrap. LVN C used the same gloves for the entire wound care and did not change gloves or complete hand hygiene. In an interview on 09/09/24 at 12:15 PM with LVN C she stated she forgot to change gloves and complete hand hygiene during the wound care. LVN C stated she was supposed to wash hands and change gloves and complete hand hygiene after cleaning the resident's wound to prevent the spread of infection. She stated she had received an in-service on infection control about 6months ago. In an interview on 09/10/14 at 01:34 PM with the DON he stated he was the infection preventionist. The DON stated the facility had in-serviced staff on hand washing and PPE on 08/28/24 with nursing staff and it was random. The DON stated he expected the staff to maintain infection control and complete hand hygiene during wound care. The DON stated he expected the staff to maintain infection control to prevent the spread of infection. Review of the facility policy revised October 2018 and titled Infection Prevention and Control Program reflected, .3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance improvement program.11. Prevention of infection 8. following established general and disease-specific guidelines such as those of the Center for Disease Control (CDC)

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of seven residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1 first eloped from the facility on 12/19/23. As a result of the elopement, she was placed on the secured unit at the facility. However, the facility continued to fail to provide adequate supervision and Resident #1 eloped from the facility for the second time on 05/04/24. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:19PM. The IJ template was provided to the facility on [DATE] at 4:45PM and signed by Administrator A. While the IJ was removed on 07/26/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for not being adequately supervised and the potential for serious injury and/or death. Findings included: Review of Resident #1's Face Sheet, dated 07/24/24, reflected she was a [AGE] year-old female who most recently admitted to the facility on [DATE]. Review of Resident #1's MDS Assessment, dated 06/07/24, reflected she was identified as having severe cognitive impairment. Resident #1 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (a mental disorder that can affect how someone feels, thinks, and behaves). Resident #1 was not identified as having any behaviors, including wandering behaviors, in the 7-day lookback period of the MDS Assessment being completed. Review of Resident #1's Care Plan, revised 05/04/24, reflected Resident #1 was at-risk for wandering and elopement due to being disoriented to place, having a history of attempting to leave the facility unattended, and having impaired safety awareness. Resident #1 was documented to have left the facility unattended on 12/19/23. Resident #1 was documented to have removed her WanderGuard (a device worn by at-risk residents which alarmed when said resident(s) approached an exterior door in order to alert staff) on 12/22/23 and refused to have it replaced; she was then placed on the secured unit. Resident #1 was documented to have left the facility unattended for a second time on 05/04/24. Goals for Resident #1 included maintaining the resident's safety. Interventions for this goal included Resident #1 being placed on the secured unit, providing reorientation to her surroundings and environment, providing her with clear and simple instructions, monitoring her for fatigue and weight loss, and providing structured activities. Review of the facility's Provider Investigation Report, dated 12/22/23, reflected on 12/19/23 at 5:53PM, Resident #1 pushed on the exterior egress door at the front of the building. The door released after 15 seconds, and Resident #1 walked next door to the retirement community and knocked on an apartment door. The individual who answered the door called the police department. Resident #1 was brought back to the facility at around 6:20PM without incident. She sustained no injuries as a result of the elopement. All appropriate parties were notified, including Resident #1's family and physician. The facility's investigation revealed the exterior egress door at the front of the building, as well as the magnetic door lock, were functioning properly. Cognitive screening indicated she was sustaining a natural progression of her diagnosis of Alzheimer's disease and unspecified dementia. Her care plan was reviewed and updated. She was moved to the secured unit after an attempt at utilizing a WanderGuard was unsuccessful. Facility staff were in-serviced on abuse/neglect and the facility's elopement policy. Review of the facility's Provider Investigation Report, dated 05/10/24, reflected on 05/04/24 at 12:30AM, Resident #1 pushed on the exterior egress door of the memory care unit. The door released [after 15 seconds], and Resident #1 exited the building. Facility staff responded to the door alarm and did not see any residents outside. A head count was conducted, and it was noted that Resident #1 was not in her room or the immediate vicinity. Facility staff began searching for Resident #1; the Director of Nursing was notified, and the police department was contacted for additional assistance. Police located Resident #1 on 05/10/24 at approximately 1:00AM and brought her back to the facility without incident. She sustained no injuries as a result of the elopement. All appropriate parties were notified, including Resident #1's family and physician. Her care plan was reviewed, her elopement assessment was updated, an a medication evaluation and adjustment was completed by her psychiatrist. Facility staff were in-serviced on abuse/neglect and the facility's elopement policy/quick response time. Observation of the exterior egress door of the front of the building (where Resident #1 eloped the first time) and the exterior egress door of the secured unit (where Resident #1 eloped the second time) on 07/25/24 at 10:05AM revealed both doors led out to the front of the building. There was a 2-way (4-lane) street located approximately 100 feet in front of these doors. Observation of Resident #1 on 07/24/24 at 9:53AM revealed she was lying in her bed, which was located on the secured unit at the facility. She was clean, well-groomed, and appropriately dressed. She was free from any odors. She displayed no obvious signs or symptoms of distress. There were no concerning marks or bruises noted on her person. There were no noted concerns regarding her appearance. During an attempted interview with Resident #1 on 07/24/24 at 9:53AM, it was noted that Resident #1 was pleasantly confused and was unable to participate in a reliable interview due to cognitive impairment. However, she reported that she had never left the facility by herself before, because that would be dangerous, and, as she stated, I'm not a dangerous person. During interviews with Administrator A on 07/24/24 at 10:35AM and 2:03PM, she stated when Resident #1 initially admitted to the facility, she resided with the general population in the unsecured area of the facility. Resident #1 had a history of confusion but had not been identified as an elopement risk. On 12/19/23, the facility hosted an activity in which a musical group performed for a holiday celebration. After the musical group left the facility, the front exterior door was confirmed to be adequately secured and all staff disbursed to their assigned workstations. Resident #1, who was noted to have thought one of the performers was her child, pushed on the front exterior egress door of the building. The alarm sounded and after the door unlocked (following the 15-second delay), she exited and eloped from the facility. Facility staff heard the alarm sound, identified Resident #1 as missing from the facility, and went to look for her. She was brought back by police approximately twenty minutes later, after she had walked to the retirement community next door. Resident #1 returned in good spirits and was pleasantly confused. The facility attempted to place and utilize a WanderGuard anklet on Resident #1, but she cut the WanderGuard anklet off. Because of this, Resident #1's family was agreeable to place her in the secured unit. Resident #1 had resided on the secured unit of the facility since that time. On 05/04/24 at approximately 12:30AM, Resident #1 eloped from the exterior egress door of the secured unit. There were two staff members assigned to the secured unit that shift, RN B and CNA C. Administrator A reported that RN B was documenting at the Nurse's Station directly outside of the secured unit (within the same area of the general population at the facility) due to having issues with the computer located in the secured unit. CNA C was conducting resident rounds. When Resident #1 eloped from the secured unit, she pushed on the handle of the exterior egress door, which sounded an alarm and subsequently opened after 15 seconds. RN B and CNA C reportedly heard the alarm sounding, but by the time they got to the door they did not see any residents who had left. A head count was conducted, and Resident #1 was identified as missing. Facility staff immediately began to search for her, and the police and administrative staff were notified. Resident #1 was found by the police and brought back to the facility approximately 20-25 minutes after she had eloped from the building. Administrator A stated she was not sure exactly where Resident #1 was located; the facility had requested the police report, but it was never received. Resident #1 sustained no injuries but was confused; she stated she believed her children were going to steal her money, so she was trying to go to the bank to withdraw money from her account. Administrator A said it was noted that Resident #1's family memebers had visited at the facility earlier on 05/05/24 and she became increasingly confused following their visit. Administrator A stated the facility's interventions included updating Resident #1's care plan and ensuring she received frequent monitoring, which she reported did not entail line-of-sight supervision but making sure staff always knew where she was located. The surveyor requested any documentation available for the frequent monitoring as described, but no such documentation was provided. Administrator A stated the facility's expectation was for a staff member to be physically present on the secured unit at all times. She stated the risk of a resident being able to elope from the facility included potential injury. During a telephone interview with CNA C (no longer employed by the facility) on 07/24/24 at 11:56AM, she stated she was assigned to care for Resident #1 when Resident #1 eloped from the secured unit on 05/04/24. CNA C stated in addition to being assigned to care for the residents on the secured unit that shift (approximately 15 residents), she was also assigned to care for several residents outside of the secured unit, within the area of the general population at the facility. She said this was common practice when she worked for the facility. CNA C stated when she arrived for her shift around 10:00PM on 05/04/24, she noted Resident #1 was asleep in her bed. That was the last time she saw Resident #1 prior to her elopement. She said when Resident #1 eloped from the secured unit, neither she nor the Charge Nurse assigned to work the secured unit (RN B) were physically present on the secured unit. CNA C said she was providing care for one of the residents outside of the secured unit and did not hear the exterior egress door alarm sound when Resident #1 pushed on the door and subsequently exited the facility. CNA C said she heard the alarm sounding when she exited the room of the resident whom she was providing care for, and following a head count, Resident #1 was identified as missing. All facility staff were notified and a search of the interior and exterior areas of the building were conducted. Police were also notified; they were the individuals who located Resident #1 and brought her back to the facility. Resident #1 did not sustain any injuries due to the elopement. CNA C stated she attempted to watch Resident #1 more closely following her elopement, but that no changes in staffing assignments were made. She said it continued to be common practice for the night shift staff who were assigned to work on the secured unit to also have residents to care for outside of the secured unit. CNA C said, I didn't really understand that [regarding the staffing], because people can get out. CNA C stated she had been made aware of Resident #1's previous elopement from the facility when she lived in the general population (12/19/23); that was the reasoning for Resident #1 being moved to the secured unit. During interviews with the Director of Nursing on 07/24/24 at 12:37PM and 1:40PM, he stated he was responsible for creating staffing assignments. He said on the 10:00PM-6:00AM shift, the secured unit was staffed with one Charge Nurse and one CNA. These staff members were also assigned to care for up to four residents outside of the secured unit, dependent upon the facility's census. He said the Charge Nurse and the CNA who were assigned to work on the secured unit as well as within the general population were responsible for making sure there was always a staff member present on the secured unit. He stated this was between the staff members to coordinate and ensure. The Director of Nursing stated the risk of a resident being able to elope from the facility was that anything can happen if they get outside. During a telephone interview with RN B on 07/24/24 at 2:40PM, she stated she was assigned to care for Resident #1 when Resident #1 eloped from the secured unit on 05/04/24. RN B stated in addition to being assigned to care for the residents on the secured unit that shift, she was also assigned to care for several residents outside of the secured unit, within the area of the general population at the facility. At the time Resident #1 eloped from the facility, RN B stated she was documenting on a computer, at a Nurse's Station directly outside of the secured unit. RN B stated the other staff member who was assigned to work with Resident #1 that night, CNA C, was providing care in another resident's room. RN B stated she heard the alarm sound when Resident #1 pushed the exterior egress door, but she thought the alarm was coming from a different location. She checked the other location and did not see anything suspicious, so she went inside of the secured unit to check that door. Again, she did not see anything suspicious and did not note any residents outside. A head count was conducted and Resident #1 was identified as missing. All facility staff were notified and a search of the interior and exterior areas of the building were conducted. Police were also notified; they were the individuals who located Resident #1 and brought her back to the facility. Resident #1 did not sustain any injuries due to the elopement. RN B stated it was noted that Resident #1 had become increasingly confused after her family had visited with her that day; staff were advised to keep a close eye on her following family visits; however, no specific instruction or documentation requirements were given for this type of monitoring. RN B stated the risk of a resident being able to elope from the facility was that there was a road nearby the exterior doors of the building. Review of the facility's Wandering and Elopements policy, dated 03/2019, reflected, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:19PM. The IJ template was provided to the facility on [DATE] at 4:45PM and signed by Administrator A. A Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 07/25/24 at 12:29PM and reflected the following: .Corrective Action: DON/Administrator has been re-educated on Change of Condition/Elopement/Wandering/Accidents/ Hazards/Supervision by Clinical Nurse Consultant, RN 7/24/24. Effective 7/24/24: Staff schedule will change on the secured unit from 2 staff to 3 staff; new staff pattern is 2 c.n.a.'s and 1 charge nurse, on the 10 pm - 6 am shift. Additional c.n.a. was added to the schedule for 7/24/24 for the secured unit on the 10 pm to 6 am shift. Director of nursing/designee is responsible for staffing schedule for all shifts, including the night shift. Verified per DON that he spoke to LVN charge nurse on the night shift 7/24/24 and there were a total of 3 staff; 2 c.n.a.'s and 1 charge nurse. Direct care staff were educated starting 7/24/24 about new staffing pattern and the expectation that either the c.n.a. or the charge nurse is to sit at the nurse desk at all times on the night shift to monitor the doors. Unlicensed staff will be obtained to sit at the desk should there be issue with direct care staff availability to ensure all doors on the secured unit are monitored during the night shift. Administrator/designee to verify new staff schedule and adherence to the plan is in place by daily review of schedule effective 7/24/24. Any areas of non-compliance will be immediately addressed by administrator/designee. Training: All staff to receive training 7/24/24 requiring responsibility of sitting at the desk at all times on the night shift. All staff to receive training 7/24/24 regarding effective communication between staff to ensure doors are secure. All staff to receive training 7/24/24 regarding change of condition and reporting appropriately/elopement/ wandering. Director of Nursing/designee to provide training to direct care staff 7/24/24. DON/designee to provide training to all direct care staff prior to their next scheduled shift to be completed by 7/25/24. Training started 7/24/24. All education to be completed by 7/25/24. Residents affected: All residents residing on the secured unit have the potential to be affected. Affected resident had elopement assessment completed by the charge nurse 5/4/24. Care plan was reviewed, changes made as indicated. Stat labs/ua ordered/care plans reviewed. Updated elopement risk assessment. Residents residing on the unit had elopement risk assessments completed by charge nurse. All residents who have been identified in the facility as an elopement risk has had a new assessment completed by their charge nurse according to the assessment schedule. Identified resident returned to facility; no injury noted upon return. RP and medical director notified. Systemic Changes: Staff pattern has been changed on the night shift from 2 direct care staff to 3 direct care staff effective 7/24/24. This will include 2 c.n.a's and 1 charge nurse. Staffing pattern will continue 7 days a week, ongoing. Unlicensed staff will be obtained to sit at the desk should there be issue with direct care staff availability to ensure all doors on the secured unit are monitored during the night shift. Administrator/designee to verify new staff schedule and adherence to the plan is in place by daily review of schedule and validation from Director of Nursing effective 7/24/24. DON/designee to review staffing schedule and report findings to the administrator/designee daily. Maintenance director to continue to provide test operations of doors, locks and alarms every week and document in TELS. All direct care staff to be educated prior to next scheduled shift. To be completed by 7/25/24. All direct care new hires will receive this training upon hire as part of their new employee orientation. Monitoring: DON/designee to monitor staffing daily effective 7/24/24; verification to be provided to Administrator/designee. DON to report any areas of non compliance to the Administrator/designee immediately. Any areas of non-compliance will be addressed immediately by the DON/Administrator. Administrator/designee to review daily staffing daily ongoing and report findings and any areas of non-compliance to the QAPI committee. Maintenance director/designee to provide the results of test operations of doors, locks and alarms to the monthly QAPI committee. Results/findings to be provided to the monthly QAPI committee going forward. QAPI committee meeting conducted 7/24/24. Medical director has been notified as of 7/24/24 . The facility's implementation of the Plan of Removal was verified through the following: Observation of the secured unit on 07/25/24 at 4:33AM (10:00PM-6:00AM, night shift) revealed three staff members were assigned to work the unit, including one staff member who was sitting at and monitoring the exterior egress door on the secured unit. During interviews with multiple staff members who represented all departments and all assigned shifts (CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, LVN O, LVN P, LVN Q, RN R, [NAME] S, Housekeeper T, and the Dietary Manager) between 07/25/24 at 4:35AM and 07/26/24 at 2:30PM, they each reported being in-serviced on topics including changes of condition, elopement/wandering prevention and response, accident hazards, resident supervision, and the facility's new staffing pattern and expectations for the secured units. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas, as well as how they would respond to resident changes of condition, residents who were wandering, missing residents, etc. These staff members appeared knowledgeable on the facility's policies and procedures. They each verbalized being aware that the facility had increased staffing on the secured unit during the night shift, and they all reported being aware of the expectation that a designated staff member was to sit at and monitor the exterior egress door. These interviews were conducted without incident or concern regarding the trainings provided. During interviews with Administrator A and the Director of Nursing on 07/25/24 between 12:15PM and 12:40PM, they reported being in-serviced on topics including changes of condition, elopement/wandering prevention and response, accident hazards, resident supervision, and the facility's new staffing pattern and expectations for the secured units. It was reported the Director of Nursing was to monitor staffing daily, and verification would be provided to Administrator A who would complete daily reviews. Any areas of non-compliance would also be reported to Administrator A, who would immediately address these areas. Administrator A and the Director of Nursing reported a QAPI meeting had been conducted on 07/24/24, and any results/findings related to facility staffing would continue to be discussed at monthly QAPI meetings. During an interview with the Maintenance Director on 07/26/24 at 12:25PM, he stated he had verified all exterior egress doors, magnetic locks, and alarms were in proper working order as of 07/24/24. He said he would continue to test these systems weekly and document the results, as well as notify Administrator A and the Director of Nursing of any issues. Review of in-service logs, dated 07/24/24, reflected facility staff members had been in-serviced on areas including changes of condition, elopement/wandering prevention and response, accident hazards, resident supervision, and the facility's new staffing pattern and expectations for the secured units. The Administrator was notified the IJ was removed on 07/26/24 at 1:04PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #2) of 5 residents reviewed for notification of changes. The facility failed to notify Resident #2's designated emergency contact [Family Member] when he developed altered mental status and sustained a head injury while nearly falling out of bed. This failure could place residents at risk of their responsible parties not being notified or involved in their plan of care. Findings included: Record review of Resident #2's Admission Record dated [DATE] revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Under Contacts, Resident #2 was listed as being his own responsible party and the name and phone number Resident #2's Family Member was included as his additional contact. Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed he had diagnoses including anemia (lack of enough red blood cells needed to carry oxygen throughout the body), orthostatic hypotension (low blood pressure that happens when sitting or lying down that can cause dizziness), cirrhosis (liver damage), anxiety, depression, and chronic obstructive pulmonary disease (lung disease that can make breathing difficult). He had clear speech, he was usually understood and could usually understand others. He had a BIMS score of 11 indicating he had moderately impaired cognition. The MDS reflected it was very important for him to have his family or close friend involved in discussions about his care and he required substantial/maximum assistance to transfer from his bed to a chair. The MDS reflected he was almost constantly in pain that frequently made it hard to sleep and he had sustained one fall since readmission with no injury. He was receiving hospice care while a resident. Record review of resident #2's Care Plans revealed an entry dated initiated [DATE] that reflected, [Resident #2] has had an actual fall r/t Unsteady gait [DATE]. Interventions/Tasks included checking range of motion and providing activities that promote exercise and strength building where possible. There were no facility care plans related to any other incidents or his hospice care. Record review of Resident #2's Physician's orders revealed an entry dated [DATE] which reflected, admitted to [hospice company name] Hospice diagnosis of [COPD] . Record review of Resident #2's Progress Notes reflected the following nursing entries for [DATE]: [DATE] 11:57 AM: Skin Only Evaluation. Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Signed by the DON. [DATE] 10:21 PM: Resident refused medications this shift. Signed by LVN V. [DATE] 7:51 AM LATE ENTRY Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Seems different than usual At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] - [DATE] 07:53 Position: Lying r/arm - Pulse: P 68 - [DATE] 07:54 Pulse Type: Irregular - new onset - RR: R 26 - [DATE] 07:54 - Temp: T 97.1 - [DATE] 07:55 Route: Tympanic - Weight: W 130.0 lb -[DATE] 09:36 Scale: Wheelchair - Pulse Oximetry: O2 81 % - [DATE] 07:55 Method: Oxygen via Nasal Cannula - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: K74.60 UNSPECIFIED CIRRHOSIS OF LIVER E44.0 MODERATE PROTEIN-CALORIE MALNUTRITION F32.A DEPRESSION, UNSPECIFIED D64.9 ANEMIA, UNSPECIFIED K59.00 CONSTIPATION, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED G89.4 CHRONIC PAIN SYNDROME M87.059 IDIOPATHIC ASEPTIC NECROSIS OF UNSPECIFIED FEMUR B18.2 CHRONIC VIRAL HEPATITIS C F51.05 INSOMNIA DUE TO OTHER MENTAL DISORDER Z79.891 LONG TERM (CURRENT) USE OF OPIATE ANALGESIC J18.9 PNEUMONIA, UNSPECIFIED ORGANISM R53.1 WEAKNESS R29.6 REPEATED FALLS J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED I95.89 OTHER HYPOTENSION Relevant medical history is: COPD Code Status: DNR Advance directives are: Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin [blood thinners]: No The result of last INR: Date: Resident/Patient is on anticoagulant [blood thinner] other than warfarin: No Resident/Patient is on: Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Behavioral Status Evaluation: - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: No changes observed - GU/Urine Status Evaluation: No changes observed - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? Yes - Neurological Status Evaluation: No changes observed Nursing observations, evaluation, and recommendations are: Generalized weakness, gasping for air, refused to eat or drink. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: [name of hospice] HOSPICE B. New Testing Orders: [blank] C. New Intervention Orders: [blank]-- Comments: [blank] Signed by LVN Q and the DON. [DATE] 4:27 PM: V/S assessed ,d+[DATE],68,16,97.8, 96% O2 @ 2 via n/c, resident not responding when called by his name, and unable to eat or drink. [name of hospice] hospice contacted spoke to [Hospice RN] on call and requested for RN to come back and reassess resident, [Hospice RN] said he will send a nurse. Signed by LVN V. [DATE] 7:42 PM: Writer called resident [Family Member] to update her, said she 5mins aware [sic]. write heard door alarm going off upon arriving noted [Family Member] pulled and held the door until the door opened. [Family Member] called writer to the room and stated what happened to [Resident #2's] right side of head you better call your administrator here or someone this is abuse and neglect because i'm on the phone with the corps [sic] and channel 5 will be here and state will be here too Administrator and DON made aware. Noted redness to resident right side of head, skin assessment performed and no other skin issues noted. Morphine and Xanax administered per [Family Member] request. Police arrived and took statement from writer, hospice contacted again for comfort kit to be delivered spoke to [Hospice nurse] again, said they don't use comfort kit anymore but the nurse is on the way and will place order for atropine [used to decrease mouth secretions and congestion] and other meds needed. Resident made comfortable in bed. [Hospice nurse] here. Administrator and DON arrived. Signed by LVN V. [DATE] 10:18 PM: 9:55 pm Administrator called wanting to talk to residents [Family Member]. Notified the [Family Member] that Admin would like to talk to her on the phone, she said NO I want her to come in the building message relayed to the Administrator. Signed by LVN O. [DATE] 11:00 PM: Skin Only Evaluation: Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Skin note: the skin is intact, small discoloration to the right side scalp noted Signed by RN B. [DATE] 11:19 PM: This resident [Family Member] called at 1515 [3:15 PM] stated Hospice called me .no one called me writer made [Family Member] aware that the change in condition was noted today and previous shift nurse notified hospice. [DATE] 11:45 PM: Resident's [Family Member] called the nurse requesting more pain medication that [Resident #2] seemed to be in much pain and anxiety. 0.25 ml of morphine [pain medication] and XANAX [anxiety medication] 2mg 1 tab administered sublingual and effective. Signed by RN B. [DATE] 2:00 AM: . complete skin assessment done, no skin issues noted except small discoloration on right side of scalp. resident repositioned every 2 hrs and incontinent care provided. Signed by RN B. [DATE] 10:12 AM: [hospice nurse] arrived and pronounced resident at 0916 [9:16 AM]. [funeral home] picked up resident remains at 1012am. Record review of Resident #2's hospice Visit Description Log revealed the following visits made by hospice staff to Resident #2 in [DATE]: [DATE]-Hospice Aide CC [DATE]-Hospice Aide CC [DATE]-Hospice Nurse DD [DATE]-Hospice Aide CC [DATE]-Hospice Aide CC Record review of Resident #2's hospice Physician Order documents revealed medication changes were made for pain control on [DATE] by Hospice Nurse EE, and [DATE] by Hospice Nurse DD and Hospice Nurse FF. No hospice nursing assessments or other visit information were located within Resident #2's electronic medical record. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident #2's Family Member had made an allegation of abuse stating Resident #2 had a bruise on his head. The report reflected the following Description of Injury: Upon charge nurse assessment, no bruise or bump noted on his head, Resident was in the active dying phase. The report reflected the following Provider Response: Charge nurse completed skin assessment and pain assessment. No noted bruising or pain noted. [Resident #2] was currently in the active dying phase and staff were making him comfortable. The Investigation Summary reflected: Based on the investigation; including staff interviews and resident safe surveys, no evidence of abuse can be founded . [Family Member] arrived at the facility after being notified of his decline .charge nurse reported the [Family Member] wanted to visit with the administrator about her concerns . nurse came back and stated the [Family Member] told her, No I won't talk to her on the phone. I expect her to show up at the facility to visit. Administrator and Director of Nursing went to facility She looked at me still yelling, look at these bruises! .I could see the director of nursing go up and look at what she was saying was a bruise. My director of nursing told her he did not see any bruising . Skin assessment and pain assessment completed. No signs of bruising noted . Skin assessments showed no bruising noted on his head An attached Skin Only Evaluation dated [DATE] at 11:00 PM reflected Resident #2's skin was warm and dry, skin color was within normal limits, and turgor (elasticity) was normal. Skin note reflected, the skin is intact, small discoloration to the right-side scalp noted. An attached SBAR Communication Form and Progress Note (used to document a change in condition) dated [DATE] reflected Resident #2's change in condition started on [DATE] and they were unable to determine whether it had gotten worse, better, or stayed the same. -The condition, symptom, or sign had not occurred before. -The resident evaluation reflected boxes checked for altered level of consciousness and needs more assistance with ADLs. -The Pain Evaluation section indicated he had worsening of chronic pain with an intensity of 7 [out of a ,d+[DATE] scale, 10 being the worst]. -Code status was DNR. -Appearance was described as Generalized weakness, gasping for air, refused to eat or drink. The Form reflected: Primary Care Clinician Notified: Yes. Date: [DATE] Time: 10:00 AM. Recommendations of Primary Clinicians (if any): [Hospice company name]. No nurses notes were included for additional information. Name of Family/Healthcare Agent Notified: [Family Member] Date: [DATE] Time: 1:00 PM The document was signed by the DON. Record review of photographs obtained from an outside source and identified as those taken of Resident #2 on [DATE] revealed there were two dark pink/purple round bruises approximately 1 cm in diameter on the top right side of his forehead close to his hairline. There was another bruise which was blue and pink and appeared to be raised situated between the two darker pink/purple areas. Another pink area with a scab was observed just inside his hairline on the top right side of his head. Record review of a Police Report, dated [DATE] and provided by the facility, revealed police were dispatched to the nursing facility on [DATE] at 9:04 PM. The report reflected the Police Officer had spoken with resident #2's Family Member who reported being upset that Resident #2 had two contusions and a laceration on his head that could not be explained by facility staff. The Police Officer made contact with LVN V who was unable to locate any documentation of the injuries. The report reflected, I took photographs of [Resident #2's] injuries that were uploaded through [NAME] Capture [police software]. There were no photographs included with the report. During an interview with Resident #2's Family Member on [DATE] at 10:41 AM, she stated she received a call from the hospice Social Worker at around 5:00 PM on [DATE] stating a hospice had been to visit Resident #2 and his death was imminent. She stated she called his hospice nurse who told her he had not been eating or drinking for three days and the nurse seemed surprised by the information. The Family Member stated the facility should have called the hospice nurse and should have called her as well because she was listed as his emergency contact. The Family Member stated she called the facility right afterward and the nurse told her she was just PRN, had not worked with him for a few days, and was not certain. The Family Member stated she told the nurse she wanted to speak with the ADON or DON and requested a call back. She stated she received a call back from the nurse who told her they did not need to call her because Resident #2 was his own Responsible Party. She stated the nurse confirmed her name and number were listed as his emergency contact. Family Member stated she began stroking Resident #2's head, felt some knots and noticed some bruises that appeared to be in different stages of healing and a hematoma that had a cut in it. She stated she was a nurse herself and was concerned he had been abused. She stated she asked the nurse about it who stated she was unaware, checked and could not find any documentation about it. She stated she again asked to speak with someone in administration. She stated she received no calls from any administrative staff and finally called 911 at around 9:00 PM. She stated the police arrived at about 9:22 PM, spoke with her and took pictures of Resident #2's injuries. Family Member stated, at around 9:46 PM, she stepped out of the room to make a phone call and notices two people in the hallway, a man had his arms crossed and was staring at her. She stated she did not notice and name badges on them and assumed they were there visiting someone else and went on with her call. She stated she returned and the two people entered Resident #2's room and stared at her. She asked them who they were, and they identified themselves as the Administrator and the DON. She stated when she asked them about the injuries on Resident #2's head, the man began aggressively poking on him, so she told him to stop and leave. She stated when she asked them if they were going to call and report the matter, the man laughed, shook his head and guided the Administrator away from the room. The Family Member cried and stated, had she known sooner that Resident #2 was nearing the end, she could have called other family to be there with them, but they lived several hours away. She stated she sat with him alone the rest of the night until he passed away. Family Member stated she was very upset that no one could account for his injuries, and no one had provided any further information since the incident. The Family Member stated she last saw Resident #2 a couple of weeks earlier, near the end of March and he was alert and doing very well. She stated she had not received any prior calls from the facility and only occasional calls from the hospice company, nothing that would have indicated his deterioration or explain his injuries. The local police department was called on [DATE] at 11:27 AM and a message was left for the responding officer. A request for police report was submitted. In an interview on [DATE] at 2:04 PM, LVN Q stated she had previously received in-service training related to abuse, neglect, and injuries of unknown origin. She stated any concerns or complaints related to abuse or neglect should be reported to the Administrator immediately. LVN Q stated, if bruises or injuries were noted, she would check the notes to see if a previous nurse had documented anything. She stated, if not, she should have assessed the resident, contacted the resident's physician, and noted any new orders, notify the family and notify the Administrator and DON. LVN Q stated the risk of failing of notify the emergency contact was it could upset the family very much if they didn't know, they need to know. She stated the family needed to know even if the resident was their own responsible party. When asked about Resident #2 and the events on [DATE], LVN Q stated that day he started to decline, she had called hospice and they arrived later after her shift. She could not recall who she had spoken with. She stated she did not call his family because there was no emergency contact listed. When shown Resident #2's Admission Record with the Family Member's phone number, she stated she thought hospice was going to call them. She stated, I accept I made mistakes; it was the first time I had anyone decline like that and I should have called [Family Member]. LVN Q stated she had assessed Resident #2 and did not recall any skin issues. She stated administration had called her later that evening and asked whether she had noticed any injuries and she told them no. She stated she never spoke with his family. During a telephone interview on [DATE] at 6:38 PM, the police officer who had responded to the call related to Resident #2, he stated he recalled speaking to Resident #2's Family Member. The police officer stated he recalled seeing a knot and some bruises on Resident #2's head. He stated he spoke with facility staff and he was unable to determine how the injuries were sustained. During an interview with ADON AA on [DATE] at 8:50 AM, she identified herself as the facility's wound treatment nurse and began working in the facility in February 2024. She stated the nursing staff reported any new skin findings to her. She stated her responsibilities included assessing all facility wounds, including bruises and skin tears. She stated, if the wound was new, she requested treatment orders and notified family members. ADON AA stated she had never been notified of any skin conditions for Resident #2 and he had never been on her service. In an interview on [DATE] at 9:04 AM, the DON stated the procedures for a change in condition for residents receiving hospice services were the charge nurse was to call the hospice providers because they handled the orders. He stated the hospice nurses would usually indicate if they were going to contact the resident's family members and, if not, the charge nurse was to contact them. He stated any changes in a resident's condition and calls made related to the residents were documented in the progress notes. In an interview on [DATE] at 10:50 AM, LVN BB stated she had been caring for two hospice residents. She stated any changes in the resident's condition were called to the hospice nurse and the resident's family. She stated it was important to call the family because she could not be certain if the hospice nurse contacted them, and it was important they were notified of any changes. On [DATE] at 12:11 PM, attempts to call Resident #2's hospice company were unsuccessful, and no voice mailbox was available. During an interview on [DATE] at 12:20 PM, CNA U stated she had been working at the facility for two years and had begun working as a Restorative Aide about a month ago. She stated she had cared for Resident #2 during his stay. She stated she had noticed he was declining during the last week he was there. She stated, I'm a reporter, always go to the nurse first, anything I find out of the ordinary or I haven't seen before. When asked about his skin care, CNA U stated the hospice aides typically performed bathing, but the facility aides did everything else. When asked about the week leading up to [DATE], CNA U stated she was pretty sure there was a wound on his head, and she was pretty sure he had hit his head. CNA U stated she had entered his room and found him leaning out of the bed. She stated the upper part of his body was leaning to the side out of the bed, his right hand was on the floor, and his left hand was holding onto his bedside table as if trying to keep himself from falling to the floor. She stated he had a dresser and an oxygen concentrator next to his bed. CNA U stated she asked him what he was trying to do, and he was confused. She stated she assisted him back onto the bed and noticed his head was bleeding. She stated she thought he had hit his head on his oxygen concentrator. She stated she went to get the nurse and was pretty sure it was LVN Q. CNA U was unable to recall on what day the incident occurred but thought it was one or two days before Resident #2 died . She stated the nurse came, checked his vital signs and cleaned his wound. She stated the incident occurred near the end of her shift and she went home. When asked if she had cared for him in the days after the incident, she replied, I might have but I don't remember. She stated she could not recall any other incidents involving Resident #2, but she could tell he was declining before the incident. She stated he had previously been able to tell them what he needed. CNA U stated she had previously had training about abuse and neglect and knew any incidents were to be reported to the Administrator and DON. She stated she did not report that incident because the nurse was caring for him and she assumed the nurse would have reported it. CNA U stated she did recall the DON later asking about Resident #2's skin and stated, I think I told him no though, I think I forgot. During another interview with LVN Q on [DATE] at 12:53 PM, when she was asked again about any skin issues with Resident #2, she replied, I checked, no issues. When asked whether she had received any reports that he had stopped eating, she stated she had only heard about his refusing to eat on [DATE] .I didn't see her [hospice nurse] before I left. LVN Q denied ever being told by CNA U that Resident #2 was found leaning out of bed with his head bleeding. She denied seeing any bruising or cuts on his head. LVN Q was shown the photos of Resident #2 obtained during the investigation. She stated, I did see the cut, I don't recall seeing the bruises. He was not hanging out of the bed, he was more to the side of the bed. We repositioned him. She pointed out the cut and stated, Yes, I saw that one, I cleaned it, it was a small cut. I told the hospice nurse that day, they came, and I reported the cut. She stated she did not report the injury to Resident #2's physician or his family member. She could not recall they day it occurred and stated, I called the hospice nurse and saw them the same day. She stated she thought it may have occurred the same day he had declined on [DATE]. When reminded she had already stated she never saw the hospice nurse on [DATE], she replied, Right. LVN Q stated she did not document the incident or injury anywhere and could not say why she did not. She stated she had only reported it verbally to the hospice nurse. She stated she had received training on abuse and neglect and should have reported the incident and completed an incident report. She stated she did not tell the DON about it when he had contacted her on the evening of [DATE] and asked her specifically about any injuries. She stated she forgot to tell him. LVN Q stated the risk for failing to report incidents and injuries was great injury and harm and apologized for her mistakes. During an interview on [DATE] at 1:16 PM, the DON was asked about the incident related to Resident #2 on [DATE]. He stated Resident #2 had been on hospice. The DON stated, on [DATE], Resident #2's nurse had notified hospice that he needed increased care and was told they would send someone out. He stated they did not arrive until later that evening, and he was not there when they arrived. The DON stated he had only come in later that evening because Resident #2's Family Member had complained of bruises, so he and the Administrator came to the facility. The DON stated he checked Resident #2 and there was nothing there other than typical color changes seen when someone was dying. The DON stated Resident #2's Family Member had not seen Resident #2 in years. He said he knew this because he had not seen her in the facility and their Social Worker had said the same. He stated they had attempted to contact the Family Member when After Resident #2 had returned from his last hospital trip and had elected to go onto hospice services. He stated Resident #2 had identified the Family Member as his emergency contact. He stated the nurses reported they had tried to reach the Family Member when Resident #2 had stopped eating but no one was picking up the phone. He stated he thought it was LVN Q or one of the other nurses who had given him that information. He stated he did not follow up on the calls because the hospice nurse was following up. The DON stated he was told the Family Member was irate, had called the police, and complained Resident #2 had an injury to his head and wanted to know what had happened. He stated the police were gone when he arrived. He stated he and the Administrator spoke with the nurse, went to Resident #2's room to speak with them and the hospice nurse was there. He stated the Family Member stepped out a short time later and he went in to assess Resident #2. The DON stated, I went in and assessed him, didn't see bruises or anything, just skin discoloration. He stated he called and spoke with LVN Q and CNA U to see whether they had seen anything and both [NAME] him no. He stated he spoke LVN V who was caring for him during the 2 PM to 10 PM shift. When asked whether he had seen the police report-the DON stated he had glanced at it. He did not recall seeing any photographs of Resident #2's injuries or the area on the report that indicated photographs were taken. The DON stated the Family Member told him there was something there, I didn't see anything, everyone I talked to said they didn't see anything. When the DON was shown the photos obtained during the investigation, he stated he did see the red spots. He stated he told the night shift nurse to complete a skin assessment. When asked about the blue raised area or the scabbed area, he stated he had not seen them during his assessment. He stated the room was dim and he did not look in the resident's hair. When asked why he did not document the red spots he had observed, the DON stated they had a nurse on the floor to do that. The facility's Provider Investigation Report was reviewed with the DON, and he was asked about the fact that he was identified as stating there were no signs of bruising noted. The DON stated he had attributed the areas he saw as skin changes due to the dying process and he did not believe they were bruises. The DON was informed of the information received during interviews with CNA U and LVN Q including their admission of noting Resident #2 had sustained an injury to his head and their failure to report the information. The DON stated he was previously unaware of the situation and repeated he had reached out to both of them to ask if they knew anything and was told no. The DON stated failure to report incidents and injuries placed the residents at risk of missed injuries and delayed treatment. He stated he expected his staff to follow their incident reporting protocol and report any incidents or injuries to himself and the Administrator. He was asked again to assist with locating the resident's hospice documentation. During an interview with Administrator A on [DATE] at 4:20 PM revealed the DON had spoken with her regarding the interview related to Resident #2. She stated she felt confident the staff interviews had been conducted during the investigation and staff surveys were conducted with other staff as well. She stated, on [DATE], she had received a call from the facility stating Resident #2's Family Member was upset. She stated she did not attempt to reach the Family Member on their phone because she did not have the number and had been told they wanted her to come to the facility. Administrator A stated she arrived at the facility and she stood near the doorway while the DON was speaking with the Family Member and she heard her say something about a gash and a bruise. Administrator A stated the Family Member was pointing toward Resident #2's head but she was unable to see anything from where she was standing. Administrator stated she asked the Family Member if they could tell her what was wrong, and she was told he had a bruise and a gash on his head. She stated she was unable to see it from where she was standing. Administrator A stated when she arrived the next morning, Resident #2 had died . She stated she looked at Resident #2 and did not see anything on the front of his forehead. She stated she was not a nurse, so she did not touch the resident. She stated she asked the DON, and he told her he had not seen anything. Administrator A was shown the photographs obtained during the investigation and she stated she did not see the injuries shown in the photographs when she observed Resident #2. She stated they could have been covered by his hair and she did not touch him. The DON joined the interview with Administrator A. The DON stated he spoke with LVN Q who insisted the injury to Resident #2's head occurred on [DATE] and that she had called the hospice company but had failed to document it and the hospice nurse arrived after she had gone home that day Administrator A stated the DON had shared with her already that the information they had received during their initial investigation was not what was learned this day. Administrator A stated if a resident was found with a head injury or any new injury, the nurse should notify the physician and family. She stated the nurse should then immediately notify herself and the DON so they could properly follow-up and investigate. Administrator A stated she expected the nurses to document and at least have a note documenting the assessment, the vital signs, a note detailing what happened. She stated notification of the physician and family should be noted as well and an incident report initiated. She stated she expected the nurse to treat any wounds and do whatever the situation entailed. She stated it could be many different scenarios. Administrator A stated there was always a risk of negative outcomes for residents sustaining injuries that were not reported. During an interview on [DATE] at 4:55 PM, Administrator A stated LVN Q had been suspended pending investigation. During an interview with the DON on [DATE] at 7:45 AM, he stated he was still unable to locate any additional hospice documentation for Resident #2. He stated he had been unable to reach anyone at the hospice company when he attempted on [DATE]. A copy of the hospice contact information was provided. In an interview on [DATE] at 8:42 AM, the DON was provided with the Hospice Representative's name and email address. He was asked to send an email request for all of Resident #2's hospice documentation, call logs and list of contact numbers for Resident #2's nurses and CNAs. The DON began drafting the email request as we spoke. He stated he would r [TRUNCATED]

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #247) of 32 residents reviewed for being treated with dignity. The facility failed to treat Resident #247 with dignity and promote enhancement of his quality of life when he was not provided with a bariatric bedside commode which resulted in the resident, who was continent of bowel and bladder, being placed in a brief from his admission to the facility on [DATE] until 04/11/18. Resident #1 suffered humiliation and embarrassment as a result. The Administrator failed to treat Resident #247 with respect and dignity when she had staff get the resident onto the standard bedside commode to demonstrate that he could utilize it. This failure placed all 96 residents at risk of not receiving appropriate medical equipment when needed, not having their right to a dignified existence maintained and a decline in their quality of life. Findings included: A review of a hospital Physical Therapy Initial Evaluation dated 03/27/18 revealed the resident was morbidly obese and was diagnosed with [REDACTED]. He had received debridement of the foot wound during hospitalization . He had pressure ulcers to his sacrum and buttocks and was in a great amount of pain with any shearing movement of his buttocks. His wheelchair was unable to fit through the bathroom door at home and he had been able to transfer with minimal assistance to a bedside commode (BSC) prior to admission. He had a history of [REDACTED]. A review of Resident #247's undated face sheet revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He was 73 inches tall and weighed 296lbs. A review of the resident's Baseline Care Plan, completed and signed by the DON on 04/07/18 revealed Resident #247 was alert and cognitively intact, the resident's functional goals was to Maintain current functional status, the resident was independent with locomotion, he required the assistance of one person with transfers and he required set-up for toileting. He was continent of both bowel and bladder. Other treatment/procedures: Beri (Bariatric)-bed with mattress, Beri-toilet to be delivered 04/04/18 approx. (approximately). A review of an Occupational Therapy Evaluation dated 04/05/18 revealed a short-term goal was Patient will safely perform toileting tasks using bedside commode with Set-up . A review of physician's telephone orders revealed an order dated 04/05/18 which reflected the resident was able to transfer with moderate assist with a walker, to wheelchair and to the bed to bedside commode upon arrival of equipment. Another telephone order dated 04/06/18 reflected to discontinue Foley catheter on 04/07/18 Bariatric bedside commode. An observation of Resident #247 on 04/09/18 at 1:49 p.m. revealed he was lying in a bariatric bed, he was wearing a brief. He stated at that time he was not able to bear weight on his right foot and he required a bariatric bedside commode (BSC). He stated he had a bariatric BSC at home which he used because his bariatric wheelchair did not fit into the bathroom. He stated staff had told him that a bariatric BSC was ordered on [DATE] and would be delivered on 04/05/18. He was then told it was ordered on [DATE] but it had still not arrived. He stated staff had put him in a brief because he was not able to use the regular-sized BSC and he found this to be both humiliating and embarrassing. An interview with the Maintenance Supervisor on 04/11/18 at 09:40 a.m. revealed he was responsible for ordering beds, mattresses and bedside commodes, along with other items. He stated he was notified Resident #247 required a bariatric bedside commode, on 04/05/18, although he could not remember who had told him this, and he ordered it that same day. He stated the Administrator was required to approve the order before it could be sent to the facility. He stated the Administrator was out of the facility on 04/05/18 and 04/06/18 but received notification of the order and was able to approve the order while out of the building. He stated he contacted his equipment representative on 04/10/18 and was told the order was shipped on 04/09/18 and should arrive on 04/11/18. He stated the facility had a bariatric bed already and he had not needed to order one for the resident. A review of a purchase order dated 04/05/18 at 2:11 p.m., revealed the Maintenance Supervisor had placed an order for [REDACTED]. He stated usually equipment was delivered within two days. An interview with the Administrator on 04/11/18 at 10:55 a.m. revealed the DON had reviewed Resident #247's hospital paperwork on 04/03/18 and had notified her the resident required a bariatric bed on 04/03/18 but she had not mentioned he also needed a bariatric BSC. She stated she was out of the building on 04/05/18 and 04/06/18. She revealed she received a text or email from the Maintenance Supervisor on 04/05/18 that the resident required a bariatric bedside commode but she had poor internet connection and waited until she was back in the building on 04/09/18 before approving the order. An interview on 04/11/18 at 12:15 p.m. with the DON revealed she had reviewed Resident #247's hospital paperwork on 04/03/18 to determine if the facility would be able to care for him. She determined the resident was appropriate for the facility and would require a bariatric bed and bariatric BSC, based on his height and weight. She stated she could not remember if she told anyone the resident would require the equipment. She stated the goal was to have all the equipment at the facility prior to the resident's admission. An interview on 04/12/18 at 12:30 p.m. with ADON A revealed equipment was ordered based on information received from the hospital prior to the resident's admission. He stated the DON had reviewed Resident #247's hospital paperwork and in the morning meeting on 04/05/18 it was discussed that the resident would require a bariatric bed and a bariatric BSC. He stated the goal was to have all equipment available for the resident upon admission to the facility. He stated based on Resident #247's height and weight he would expect the resident would require bariatric equipment, however, there was no policy in place to indicate when bariatric equipment was required. Observation on 04/11/18 at 1:45 p.m. at the Administrator's request of Resident #247 revealed the resident, along with two other staff, was in the room and the resident was sitting, fully dressed, on the regular-sized BSC. The resident stated the commode was too tight for him. Observation on 04/11/18 at 2:31 p.m. revealed Resident #247 was using the regular-sized bedside commode behind the privacy curtain. He stated staff had just left him in it so I have to use it. He stated he was unable to get out of the chair. He stated that earlier, staff told him he had to get onto the bedside commode to see if he would fit. An observation on 04/12/18 at 1:35 p.m. Resident #247 was sitting in a wheelchair with an over-the-bed table in front of him. The resident stated the bariatric BSC had arrived the evening of 04/11/18 but staff had placed it behind him and he had soiled himself while trying to get out of the wheelchair. Observation of the bariatric BSC which was placed directly behind the resident, the resident's walker was not within reach. A review of the Resident Census List dated 04/09/18 reflected a census of 96 residents.

Based on interview and record review, the facility failed to immediately consult with the resident ' s physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for one (Resident #1) of four residents reviewed for pressure ulcers and/or wounds. 1. The facility failed to consult with Resident #1's physician and/or NP when her pressure ulcer showed signs and symptoms of worsening. 2. The facility failed to consult with Resident #1's physician and/or NP to obtain new treatment orders when the wound care consult was not obtained. Resident #1's pressure ulcer worsened, resulting in osteo[DIAGNOSES REDACTED] (infection in the bone), increased pain and discomfort, and hospitalization . These failures placed the three residents, who had pressure ulcers, at risk for wound deterioration and the development of new pressure ulcers. The findings include: Resident #1 was a [AGE] year-old-female whose significant change MDS assessment, dated 09/27/16, reflected she was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. She was incontinent of bowel and bladder, was totally dependent on staff for all of activities of daily living, and transfers from one surface to another, and needed extensive assistance for bed mobility. She had no pressure ulcers present during this evaluation, but was at risk for developing pressure ulcers. Resident #1's care plan dated 06/01/16 reflected she was at risk for impaired skin integrity and they should notify the doctor of changes as needed. Resident #1's Nurses Note signed and dated by LVN A on 09/28/16 at 1:40 PM reflected a CNA had notified her that Resident #1's right heel was having some breakdown. The nurses note further reflected LVN A notified the wound nurse and was going to notify Hospice. Resident #1's Nurses Note signed and dated by LVN B on 09/29/16 at 8:49 PM reflected a pressure ulcer was noted to Resident #1's right exterior foot and the wound nurse was to follow up in the morning. Resident #1's Nurses Note signed and dated by the Wound Nurse on 09/30/16 at 5:12 PM reflected Resident #1 had an .unstageable wound, red darkened area with a scant amount of sanguineous (bloody) drainage to right heel. Wound is L (length) 2 CM X W (width) 1 CM, no depth, no foul odor, Pain to area upon touch. surrounding skin normal to ethnicity. The note also reflects the NP notified and gave new order for wound to be cleansed with normal saline, pat dry, place Santyl (a chemical debridement) and calcium alginate (Absorbent dressing) dressing on wound bed. Apply TAO (Triple Antibiotic Ointment) around surrounding skin everyday (sic), referred for consult with wound care doctor. Resident #1's Physician telephone order dated 09/30/16 reflected to clean right heel wound with NS, pat dry, apply Santyl to wound bed, apply TAO around wound and place calcium alginate on wound bed then cover with a dry dressing every day. Resident #1's second Physician telephone order dated 09/30/16 reflected an order for [REDACTED].>Resident #1's clinical record revealed no evidence of a consult from the wound doctor. Resident #1's Wound Assessment Report dated and signed by the Wound Nurse on 10/04/16, 10/13/16, and 10/21/16 reflected the unstageable wound on her right heel was L 5 CM by W 4 CM and with no depth. It also reflected a small amount of sanguineous drainage and the skin color to the affected limb was normal. Resident #1's Nurses Note signed and dated by the Wound Nurse on 10/21/16 at 5:16 PM reflected Right heel has an (sic) non blanchable (sic), localized darkened area covered with eschar (a hard crust or scab) and an irregular shaped L 4.0 X W 4.0. Tissue around wound whitish in color (indicates surrounding tissue is moist and beginning to break down) . It further reflected Wound consult recommended. Notified DON of resident change 09/28/16. DON pulled writer into office with Hospice Liason (sic) and stated no wound consult can be done. Hospice stated forms of aggressive treatment are not administered .NP notified . On 12/02/16 at 3:00 PM an attempt was made to contact the Wound Nurse, (Per the DON she no longer worked for the facility and had moved out of state) a message was left, but she never returned the call. An interview with the DON on 12/02/16 at 10:15 AM revealed when shown the wound nurse's note from 10/21/16 at 5:16 PM, the DON stated yes, that indicated the wound was getting worse. When asked why they had not gotten the treatment order changed on 10/21/16 when they had noted the wound on Resident #1's heel was getting worse, the DON stated she did not know if the Wound Nurse had called or not but she had not. Resident #1's clinical record revealed no evidence of a treatment order change. Resident #1's Nurses Note signed and dated by LVN B on 10/25/16 reflected Dressing changed to her right heel pressure wound, red blood drainage noted from area. Wound cleaned with NS, pat dry, Santyl applied and covered with calcium alginated (sic), then dry dressing applied. It further reflected LVN B called the Hospice to ask them to come in and assess the wound with the DON tomorrow and resident's physician was called and notified to follow up with the wound, as it requires more attention. During an interview with the DON on 11/22/16 at 1:15 PM she stated the wound on Resident #1's right heel had developed into a 4 cm by 4 cm area, the Wound Nurse dressed it on Friday, 10/21/16. She stated on Monday, 10/24/16, LVN B came and asked her to look at the wound. The DON stated the wound was 10 cm by 6 cm and soppy wound with lots of exudate (drainage) half covered with eschar. She stated she had placed a wet dressing on it and wrapped it. The DON stated Resident #1's Responsible Party was in the facility and was upset. The DON stated I told her the Hospice Nurse would not provide a wound doctor consult . The DON stated the Responsible Party rescinded hospice the next day and Resident #1 was sent to the hospital, and subsequently to another nursing facility. During an interview with the facility's Medical Director (MD) and Resident #1's physician on 11/22/16 at 3:49 PM he confirmed he was Resident #1's physician, had been aware of the breakdown on her heel, and stated she was being followed by the wound care physician. When informed the wound care consult had never taken place, he stated he had not been aware, and when asked if he should have been informed by the facility he stated, Absolutely, the facility should have let us (him and his NP) know. Me and my NP are there enough that we should have been told . During an interview with the NP on 12/02/16 at 3:05 PM she stated she had not been aware the wound care consult she had ordered for Resident #1 on 09/30/16 had not been carried out. She also stated she had not been personally informed and .if they had said something I could have changed the wound treatment. During an interview with ADON C on 11/22/16 at 4:30 PM she stated she would typically call the house physician if a wound consult was ordered by him but refused by hospice. The facility's policy and procedure Wound Care dated January 2002 reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Reporting .report other information in accordance with facility policy and professional standards of practice. The facility's policy and procedure Wound Expert Help undated reflected: If a pressure ulcer fails to show some evidence of progress towards healing within 2-4 weeks, the pressure ulcer .and the resident's overall condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated The physician's involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. Per the documentation of residents with pressure ulcers and or wounds provided by the DON on 12/02/16, three residents with pressure ulcers resided at the facility.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for pressure ulcers. 1. The facility failed to acquire a wound consult for Resident #1 as ordered by the NP on 09/30/16. 2. The facility failed to consult with Resident #1's physician and/or NP when her pressure ulcer showed signs and symptoms of worsening. 3. The facility failed to consult with Resident #1's physician and/or NP to obtain new orders when the wound consult doctor was not obtained. Resident #1's pressure ulcer worsened, resulting in osteo[DIAGNOSES REDACTED] (infection in the bone), increased pain and discomfort, and hospitalization . These failures placed the three residents, who had pressure ulcers and/or wounds, at risk for wound deterioration and the development of new pressure ulcers. The findings include: Resident #1 was a [AGE] year-old-female whose significant change MDS, dated [DATE], reflected she was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Her MDS further reflected she was incontinent of bowel and bladder, was totally dependent on staff for all of activities of daily living, and transfers from one surface to another, and needed extensive assistance for bed mobility. This document also reflected that while she had no pressure ulcers present during this evaluation, she was at risk for developing pressure ulcers. Resident #1's care plan dated 06/01/16 reflected she was at risk for impaired skin integrity and they should notify the doctor of changes as needed. Resident #1's Nurses Note signed and dated by LVN A on 09/28/16 at 1:40 PM reflected a CNA had notified her that Resident #1's right heel was having some breakdown. The nurses note further reflected LVN A notified the wound nurse and was going to notify Hospice. Resident #1's Nurses Note signed and dated by LVN B on 09/29/16 at 8:49 PM reflected a pressure area was noted to Resident #1's right exterior foot and the wound nurse was to follow up in the morning. Resident #1's Nurses Note signed and dated by the Wound Nurse on 09/30/16 at 5:12 PM reflected Resident #1 had an .unstageable wound, red darkened area with a scant amount of sanguineous drainage to right heel. Wound is L (length) 2 CM X W (width) 1 CM, no depth, no foul odor, Pain to area upon touch. surrounding skin normal to ethnicity. The note also reflects the NP notified and gave new order for wound to be cleansed with normal saline, pat dry, place Santyl (a chemical debridement) and calcium alginate (Absorbent dressing) dressing on wound bed. Apply TAO (Triple Antibiotic Ointment) around surrounding skin everyday (sic), referred for consult with wound care doctor. Resident #1's Physician telephone order dated 09/30/16 reflected to clean (R) heel wound with NS, pat dry, apply Santyl to wound bed, apply TAO around wound and place calcium alginate on wound bed then cover with a dry dressing every day. Resident #1's second Physician telephone order dated 09/30/16 reflected an order for [REDACTED].>Resident #1 ' s Clinical record revealed no evidence of a consult from the wound doctor. Resident #1's Wound Assessment Report dated and signed by the Wound Nurse on 10/04/16, 10/13/16, and 10/21/16 reflected the unstageable wound on her right heel was L 5 CM by W 4 CM and with no depth. It also reflected a small amount of sanguineous drainage and the skin color to the affected limb was normal. Resident #1's Nurses Note signed and dated by the Wound Nurse on 10/21/16 at 5:16 PM reflected Right heel has an (sic) non blanchable (sic), localized darkened area covered with eschar (a hard crust or scab) and an irregular shaped L 4.0 X W 4.0. Tissue around wound whitish in color (indicates surrounding tissue is moist and beginning to break down) . It further reflected Wound consult recommended. Notified DON of resident change 09/28/16. DON pulled writer into office with Hospice Liason (sic) and stated no wound consult can be done. Hospice stated forms of aggressive treatment are not administered .NP notified . On 12/02/16 at 3:00 PM an attempt was made to contact the Wound Nurse, (Per the DON she no longer worked for the facility and had moved out of state) a message was left, but she never returned the call. An interview with the DON on 12/02/16 at 10:15 AM revealed when shown the wound nurse's note from 10/21/16 at 5:16 PM, the DON stated yes, that indicated the wound was getting worse. When asked why they had not gotten the treatment order changed on 10/21/16 when they had noted the wound on Resident #1's heel was getting worse, the DON stated she did not know if the Wound Nurse had called or not but she had not. Resident #1's clinical record revealed no evidence of a treatment order change. Resident #1's Nurses Note signed and dated by LVN B on 10/25/16 reflected Dressing changed to her right heel pressure wound, red blood drainage noted from area. Wound cleaned with NS, pat dry, Santyl applied and covered with calcium alginated (sic), then dry dressing applied. It further reflected LVN B called the Hospice to ask them to come in and assess the wound with the DON tomorrow and resident's physician was called and notified to follow up with the wound, as it requires more attention. During an interview with the DON on 11/22/16 at 1:15 PM she stated the wound on Resident #1's right heel had developed into a 4 cm by 4 cm area, the Wound Nurse dressed it on Friday, 10/21/16. She stated on Monday, 10/24/16, LVN B came and asked her to look at the wound. The DON stated the wound was 10 cm by 6 cm and soppy wound with lots of exudate (drainage) half covered with eschar. She stated she had placed a wet dressing on it and wrapped it. The DON stated Resident #1's Responsible Party was in the facility and was upset. The DON stated I told her the Hospice Nurse would not provide a wound doctor consult . The DON stated the Responsible Party rescinded hospice the next day and Resident #1 was sent to the hospital, and subsequently to another nursing facility. During an interview with Resident #1's Hospice Company's Administrator on 11/22/16 at 4:00 PM he stated he was unaware Resident #1 had not had a wound care consultation. He stated the hospice company had never refused a wound care consultation, and the facility always treated the wounds except in cases requiring aggressive care that exceeded the scope of hospice practice. During an interview with the DON of Resident #1's Hospice Company on 11/22/16 at 4:40 PM she stated the hospice had never refused a wound care consult and was providing hospice services to two residents (Resident #2 and #3) residing in the facility who were receiving care from the wound care physician. She stated no one from our hospice has or would have told the facility Resident #1 could not have a wound care consult. During an interview with the facility's Medical Director (MD) and Resident #1's physician on 11/22/16 at 3:49 PM he confirmed he was Resident #1's physician, had been aware of the breakdown on her heel, and stated she was being followed by the wound care physician. When informed the wound care consult had never taken place, he stated he had not been aware, and when asked if he should have been informed by the facility he stated, Absolutely, the facility should have let us (him and his NP) know. Me and my NP are there enough that we should have been told . During an interview with the NP on 12/02/16 at 3:05 PM she stated she had not been aware the wound care consult she had ordered for Resident #1 on 09/30/16 had not been carried out. She also stated she had not been personally informed and .if they had said something I could have changed the wound treatment. During an interview with ADON C on 11/22/16 at 4:30 PM she stated she would typically call the house physician if a wound consult was ordered by him but refused by hospice. An interview with the DON on 12/02/16 at 10:15 AM when asked what Resident #1's hospice company had said to her regarding Resident #1's wound care consult she stated, They said they don't do that. When asked who they were she stated she did not remember who from the hospice company said it but she would try to find out. When asked if she was aware they had two other residents residing in the facility using the same hospice service who were receiving wound care from the wound care physician she stated she did know and did not know why they (hospice) would have refused the consult for Resident #1. The facility's policy and procedure Wound Care dated January 2002 reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Reporting .report other information in accordance with facility policy and professional standards of practice. The facility's policy and procedure Wound Expert Help undated reflected: If a pressure ulcer fails to show some evidence of progress towards healing within 2-4 weeks, the pressure ulcer .and the resident's overall condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated The physician's involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. The facility's policy and procedure Abuse and Neglect Policy undated reflected: Purpose: To prohibit abuse of residents from any source Definitions: Abuse - .This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It further reflected the definition of neglect was: Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness. Per the documentation of residents with pressure ulcers and or wounds provided by the DON on 12/01/16, three residents with pressure ulcers resided at the facility.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for pressure ulcers. 1. The facility failed to acquire a wound consult for Resident #1 as ordered by the NP on 09/30/16. 2. The facility failed to inform Resident #1's physician and/or NP when her PU showed signs and symptoms of worsening. 3. The facility failed to consult with Resident #1's physician and/or NP to obtain new orders when the wound consult doctor was not obtained. Resident #1's pressure ulcer to worsened, resulting in osteo[DIAGNOSES REDACTED] (infection in the bone), increased pain and discomfort, and hospitalization . These failures placed the three residents, who had pressure ulcers and/or wounds, at risk for wound deterioration and the development of new pressure ulcers. The findings include: The facility's policy and procedure Wound Care dated January 2002 reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Reporting .report other information in accordance with facility policy and professional standards of practice. The facility's policy and procedure Wound Expert Help undated reflected: If a pressure ulcer fails to show some evidence of progress towards healing within 2-4 weeks, the pressure ulcer .and the resident's overall condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated The physician's involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. The facility's policy and procedure Abuse and Neglect Policy undated reflected: Purpose: To prohibit abuse of residents from any source Definitions: Abuse - .This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It further reflected the definition of neglect was: Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness. Resident #1 was a [AGE] year-old-female whose significant change MDS, dated [DATE], reflected she was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Her MDS further reflected she was incontinent of bowel and bladder, was totally dependent on staff for all of activities of daily living, and transfers from one surface to another, and needed extensive assistance for bed mobility. This document also reflected that while she had no pressure ulcers present during this evaluation, she was at risk for developing pressure ulcers. Resident #1's care plan dated 06/01/16 reflected she was at risk for impaired skin integrity and they should notify the doctor of changes as needed. Resident #1's Nurses Note signed and dated by LVN A on 09/28/16 at 1:40 PM reflected a CNA had notified her that Resident #1's right heel was having some breakdown. The nurses note further reflected LVN A notified the wound nurse and was going to notify Hospice. Resident #1's Nurses Note signed and dated by LVN B on 09/29/16 at 8:49 PM reflected a pressure area was noted to Resident #1's right exterior foot and the wound nurse was to follow up in the morning. Resident #1's Nurses Note signed and dated by the Wound Nurse on 09/30/16 at 5:12 PM reflected Resident #1 had an .unstageable wound, red darkened area with a scant amount of sanguineous drainage to right heel. Wound is L (length) 2 CM X W (width) 1 CM, no depth, no foul odor, Pain to area upon touch. surrounding skin normal to ethnicity. The note also reflects the NP notified and gave new order for wound to be cleansed with normal saline, pat dry, place Santyl (a chemical debridement) and calcium alginate (Absorbent dressing) dressing on wound bed. Apply TAO (Triple Antibiotic Ointment) around surrounding skin everyday (sic), referred for consult with wound care doctor. Resident #1's Physician telephone order dated 09/30/16 reflected to clean (R) heel wound with NS, pat dry, apply Santyl to wound bed, apply TAO around wound and place calcium alginate on wound bed then cover with a dry dressing every day. Resident #1's second Physician telephone order dated 09/30/16 reflected an order for [REDACTED].>Resident #1 ' s Clinical record revealed no evidence of a consult from the wound doctor. Resident #1's Wound Assessment Report dated and signed by the Wound Nurse on 10/04/16, 10/13/16, and 10/21/16 reflected the unstageable wound on her right heel was L 5 CM by W 4 CM and with no depth. It also reflected a small amount of sanguineous drainage and the skin color to the affected limb was normal. Resident #1's Nurses Note signed and dated by the Wound Nurse on 10/21/16 at 5:16 PM reflected Right heel has an (sic) non blanchable (sic), localized darkened area covered with eschar (a hard crust or scab) and an irregular shaped L 4.0 X W 4.0. Tissue around wound whitish in color (indicates surrounding tissue is moist and beginning to break down) . It further reflected Wound consult recommended. Notified DON of resident change 09/28/16. DON pulled writer into office with Hospice Liason (sic) and stated no wound consult can be done. Hospice stated forms of aggressive treatment are not administered .NP notified . On 12/02/16 at 3:00 PM an attempt was made to contact the Wound Nurse, (Per the DON she no longer worked for the facility and had moved out of state) a message was left, but she never returned the call. An interview with the DON on 12/02/16 at 10:15 AM revealed when shown the wound nurse's note from 10/21/16 at 5:16 PM, the DON stated yes, that indicated the wound was getting worse. When asked why they had not gotten the treatment order changed on 10/21/16 when they had noted the wound on Resident #1's heel was getting worse, the DON stated she did not know if the Wound Nurse had called or not but she had not. Resident #1's clinical record revealed no evidence of a treatment order change. Resident #1's Nurses Note signed and dated by LVN B on 10/25/16 reflected Dressing changed to her right heel pressure wound, red blood drainage noted from area. Wound cleaned with NS, pat dry, Santyl applied and covered with calcium alginated (sic), then dry dressing applied. It further reflected LVN B called the Hospice to ask them to come in and assess the wound with the DON tomorrow and resident's physician was called and notified to follow up with the wound, as it requires more attention. During an interview with the DON on 11/22/16 at 1:15 PM she stated the wound on Resident #1's right heel had developed into a 4 cm by 4 cm area, the Wound Nurse dressed it on Friday, 10/21/16. She stated on Monday, 10/24/16, LVN B came and asked her to look at the wound. The DON stated the wound was 10 cm by 6 cm and soppy wound with lots of exudate (drainage) half covered with eschar. She stated she had placed a wet dressing on it and wrapped it. The DON stated Resident #1's Responsible Party was in the facility and was upset. The DON stated I told her the Hospice Nurse would not provide a wound doctor consult . The DON stated the Responsible Party rescinded hospice the next day and Resident #1 was sent to the hospital, and subsequently to another nursing facility. During an interview with Resident #1's Hospice Company's Administrator on 11/22/16 at 4:00 PM he stated he was unaware Resident #1 had not had a wound care consultation. He stated the hospice company had never refused a wound care consultation, and the facility always treated the wounds except in cases requiring aggressive care that exceeded the scope of hospice practice. During an interview with the DON of Resident #1's Hospice Company on 11/22/16 at 4:40 PM she stated the hospice had never refused a wound care consult and was providing hospice services to two residents (Resident #2 and #3) residing in the facility who were receiving care from the wound care physician. She stated no one from our hospice has or would have told the facility Resident #1 could not have a wound care consult. During an interview with the facility's Medical Director (MD) and Resident #1's physician on 11/22/16 at 3:49 PM he confirmed he was Resident #1's physician, had been aware of the breakdown on her heel, and stated she was being followed by the wound care physician. When informed the wound care consult had never taken place, he stated he had not been aware, and when asked if he should have been informed by the facility he stated, Absolutely, the facility should have let us (him and his NP) know. Me and my NP are there enough that we should have been told . During an interview with the NP on 12/02/16 at 3:05 PM she stated she had not been aware the wound care consult she had ordered for Resident #1 on 09/30/16 had not been carried out. She also stated she had not been personally informed and .if they had said something I could have changed the wound treatment. During an interview with ADON C on 11/22/16 at 4:30 PM she stated she would typically call the house physician if a wound consult was ordered by him but refused by hospice. An interview with the DON on 12/02/16 at 10:15 AM when asked what Resident #1's hospice company had said to her regarding Resident #1's wound care consult she stated, They said they don't do that. When asked who they were she stated she did not remember who from the hospice company said it but she would try to find out. When asked if she was aware they had two other residents residing in the facility using the same hospice service who were receiving wound care from the wound care physician she stated she did know and did not know why they (hospice) would have refused the consult for Resident #1. Per the documentation of residents with pressure ulcers and or wounds provided by the DON on 12/01/16, three residents with pressure ulcers resided at the facility.

Based on interview and record review, the facility failed to ensure that a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. 1. The facility failed to acquire a wound consult for Resident #1 as ordered by the NP on 09/30/16. 2. The facility failed to inform Resident #1's physician and/or NP when her pressure ulcer showed signs and symptoms of worsening. 3. The facility failed to consult with Resident #1's physician and/or NP to obtain new orders when the wound doctor consult was not obtained. Resident #1's pressure ulcer worsened, resulting in osteo[DIAGNOSES REDACTED] (infection in the bone), increased pain and discomfort, and hospitalization . These failures placed the three residents, who had pressure ulcers, at risk for wound deterioration and the development of new pressure ulcers. The findings include: Resident #1 was a [AGE] year-old-female whose significant change MDS assessment, dated 09/27/16, reflected she was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. She was incontinent of bowel and bladder, was totally dependent on staff for all of activities of daily living, and transfers from one surface to another, and needed extensive assistance for bed mobility. She had no pressure ulcers present during this evaluation, but was at risk for developing pressure ulcers. Resident #1's care plan dated 06/01/16 reflected she was at risk for impaired skin integrity and they should notify the doctor of changes as needed. Resident #1's Nurses Note signed and dated by LVN A on 09/28/16 at 1:40 PM reflected a CNA had notified her that Resident #1's right heel was having some breakdown. The nurses note further reflected LVN A notified the wound nurse and was going to notify Hospice. Resident #1's Nurses Note signed and dated by LVN B on 09/29/16 at 8:49 PM reflected a pressure ulcer was noted to Resident #1's right exterior foot and the wound nurse was to follow up in the morning. Resident #1's Nurses Note signed and dated by the Wound Nurse on 09/30/16 at 5:12 PM reflected Resident #1 had an .unstageable wound, red darkened area with a scant amount of sanguineous (bloody) drainage to right heel. Wound is L (length) 2 CM X W (width) 1 CM, no depth, no foul odor, Pain to area upon touch. surrounding skin normal to ethnicity. The note also reflects the NP notified and gave new order for wound to be cleansed with normal saline, pat dry, place Santyl (a chemical debridement) and calcium alginate (Absorbent dressing) dressing on wound bed. Apply TAO (Triple Antibiotic Ointment) around surrounding skin everyday (sic), referred for consult with wound care doctor. Resident #1's Physician telephone order dated 09/30/16 reflected to clean right heel wound with NS, pat dry, apply Santyl to wound bed, apply TAO around wound and place calcium alginate on wound bed then cover with a dry dressing every day. Resident #1's second Physician telephone order dated 09/30/16 reflected an order for [REDACTED].>Resident #1's clinical record revealed no evidence of a consult from the wound doctor. Resident #1's Wound Assessment Report dated and signed by the Wound Nurse on 10/04/16, 10/13/16, and 10/21/16 reflected the unstageable wound on her right heel was L 5 CM by W 4 CM and with no depth. It also reflected a small amount of sanguineous drainage and the skin color to the affected limb was normal. Resident #1's Nurses Note signed and dated by the Wound Nurse on 10/21/16 at 5:16 PM reflected Right heel has an (sic) non blanchable (sic), localized darkened area covered with eschar (a hard crust or scab) and an irregular shaped L 4.0 X W 4.0. Tissue around wound whitish in color (indicates surrounding tissue is moist and beginning to break down) . It further reflected Wound consult recommended. Notified DON of resident change 09/28/16. DON pulled writer into office with Hospice Liason (sic) and stated no wound consult can be done. Hospice stated forms of aggressive treatment are not administered .NP notified . On 12/02/16 at 3:00 PM an attempt was made to contact the Wound Nurse, (Per the DON she no longer worked for the facility and had moved out of state) a message was left, but she never returned the call. An interview with the DON on 12/02/16 at 10:15 AM revealed when shown the wound nurse's note from 10/21/16 at 5:16 PM, the DON stated yes, that indicated the wound was getting worse. When asked why they had not gotten the treatment order changed on 10/21/16 when they had noted the wound on Resident #1's heel was getting worse, the DON stated she did not know if the Wound Nurse had called or not but she had not. Resident #1's clinical record revealed no evidence of a treatment order change. Resident #1's Nurses Note signed and dated by LVN B on 10/25/16 reflected Dressing changed to her right heel pressure wound, red blood drainage noted from area. Wound cleaned with NS, pat dry, Santyl applied and covered with calcium alginated (sic), then dry dressing applied. It further reflected LVN B called the Hospice to ask them to come in and assess the wound with the DON tomorrow and resident's physician was called and notified to follow up with the wound, as it requires more attention. During an interview with the DON on 11/22/16 at 1:15 PM she stated the wound on Resident #1's right heel had developed into a 4 cm by 4 cm area, the Wound Nurse dressed it on Friday, 10/21/16. She stated on Monday, 10/24/16, LVN B came and asked her to look at the wound. The DON stated the wound was 10 cm by 6 cm and soppy wound with lots of exudate (drainage) half covered with eschar. She stated she had placed a wet dressing on it and wrapped it. The DON stated Resident #1's Responsible Party was in the facility and was upset. The DON stated I told her the Hospice Nurse would not provide a wound doctor consult . The DON stated the Responsible Party rescinded hospice the next day and Resident #1 was sent to the hospital, and subsequently to another nursing facility. During an interview with Resident #1's Hospice Company's Administrator on 11/22/16 at 4:00 PM he stated he was unaware Resident #1 had not had a wound care consultation. He stated the hospice company had never refused a wound care consultation, and the facility always treated the wounds except in cases requiring aggressive care that exceeded the scope of hospice practice. During an interview with the DON of Resident #1's Hospice Company on 11/22/16 at 4:40 PM she stated the hospice had never refused a wound care consult and was providing hospice services to two residents (Resident #2 and #3) residing in the facility who were receiving care from the wound care physician. She stated no one from our hospice has or would have told the facility Resident #1 could not have a wound care consult. During an interview with the facility's Medical Director (MD) and Resident #1's physician on 11/22/16 at 3:49 PM he confirmed he was Resident #1's physician, had been aware of the breakdown on her heel, and stated she was being followed by the wound care physician. When informed the wound care consult had never taken place, he stated he had not been aware, and when asked if he should have been informed by the facility he stated, Absolutely, the facility should have let us (him and his NP) know. Me and my NP are there enough that we should have been told . During an interview with the NP on 12/02/16 at 3:05 PM she stated she had not been aware the wound care consult she had ordered for Resident #1 on 09/30/16 had not been carried out. She also stated she had not been personally informed and .if they had said something I could have changed the wound treatment. During an interview with ADON C on 11/22/16 at 4:30 PM she stated she would typically call the house physician if a wound consult was ordered by him but refused by hospice. An interview with the DON on 12/02/16 at 10:15 AM when asked what Resident #1's hospice company had said to her regarding Resident #1's wound care consult she stated, They said they don't do that. When asked who they were she stated she did not remember who from the hospice company said it but she would try to find out. When asked if she was aware they had two other residents residing in the facility using the same hospice service who were receiving wound care from the wound care physician she stated she did know and did not know why they (hospice) would have refused the consult for Resident #1. The facility's policy and procedure Wound Care dated January 2002 reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Reporting .report other information in accordance with facility policy and professional standards of practice. The facility's policy and procedure Wound Expert Help undated reflected: If a pressure ulcer fails to show some evidence of progress towards healing within 2-4 weeks, the pressure ulcer .and the resident's overall condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated The physician's involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. Per the documentation of residents with pressure ulcers and or wounds provided by the DON on 12/02/16, three residents with pressure ulcers resided at the facility.

Based on observation, interview, and record review the facility failed to keep the resident environment as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for one (Resident 3) of five residents observed for adequate supervision. CNA B failed to supervise Resident #3 while the resident's bed was not in the lowest position and the resident fell . This failure resulted in Resident #3 sustaining a hematoma on top of her right eye, bluish bruising to her right cheek, and a skin tear to her left hand. This failure could affect the other resident, identified with falls, by placing the resident at risk for bruises, hematomas, skin tears and fractures. Findings included: Resident #3's Face Sheet (date illegible) reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] reflected Resident #3 was severely cognitively impaired, needed one person physical assist for bed mobility, and was totally dependent on staff for transfers. Review of the physician's orders [REDACTED]. Review of Resident #3's Comprehensive Care Plan dated 08/24/11 revealed, "Resident is at risk for falls R/T requiring assist with most ADLs." One of the approaches to prevent falls was to, "Anticipate needs, provide prompt assist." Another part of the care plan reflected Resident #3 resided in the Secure Unit and the goal was to provide "safety," and the approach was to "Keep environment free of possible hazards." Resident #3's Nurse's Notes documented on the SBAR (form for change in condition) dated 06/03/12 at 8:41 AM reflected the resident had a fall with a skin tear. The Notes also reflected the resident was confused. Further review of the Notes revealed, "Resident had a fall at her room. Hematoma on top of right eye and bruise bluish color at right cheek along with S/T of...left hand ...1. Skull x-ray 2. Orbital bone x-ray. 3. S/T tx per standing order ...." During the Initial Tour on 06/04/12 at 9:30 AM, Resident #3 was sitting in the dining room area at a table with other residents in the Secured Unit. The right side of her face was colored deep purple. The bruising was visible from her hairline on her forehead, through her right eye, right cheek, and down through the right side of her neck. LVN A stated she had fallen out of her bed "yesterday morning." She also stated she had sustained a skin tear to her right hand. Review of the Nurses' Notes dated 06/04/12 at 9:50 AM revealed a new order for stat orbital x-ray and a facial series; plus, Gentamycin two drops to be administered in Resident #3's right eye twice a day for seven days. The notes continued and at 4:07 PM of the same day, Resident #3 was noted to have "lips and mucus membrane bluish in color. O2 sats (saturation) at 67 % (normal is 98 to 100 percent). Administered PRN O2 via n/c at 2 liters per min.(minute.) One minute later, skin color normal to resident. SO2 at 95 %..., bed in low position. Call light within reach." In an interview with LVN A on 06/05/12 at 12:15 PM, she stated the facility had a fall prevention program in place and Resident #3 was a fall risk. LVN A said Resident #3 had non-skid shoes and her bed was kept in the low position, although her bed was not in the low position when she fell . LVN said Resident #3 would sit up in bed and would wiggle her feet to try to touch the floor. Her call light was within reach so she could get assistance when she wanted to get out of bed. When she was up in her wheelchair, a close eye was kept on her because she would move herself around. On the morning of 06/03/12 around 8:00 AM or 9:00 AM, Resident #3 fell out of bed. LVN A stated, "the CNA failed to lower her bed." She stated if Resident #3 could not reach the floor, she would continue to try to touch the floor. LVN A stated she saw the accident report "yesterday" because she was still doing neuro checks. A skull series had been done the previous day and she was waiting on the report. LVN A stated Resident #3 did have a history of falls, but this was the first fall she was aware of. Review of the Facial series dated 06/04/12 revealed, "No evidence of facial bone fracture." During the noon meal observation on 06/05/12 at 12:45 PM, Resident #3's right knee was more swollen than the left knee and both knees were slightly discolored with a dull grayish purple. LVN A was queried at this time as to the staff assessment of Resident #3's knees. LVN A said she was unaware of the resident's knees. Review of Nurses' Notes dated 06/05/12 at 2:25 PM, revealed the nurse had received a new order for a stat x-ray to both knees due to Resident #3's discolored knees. Review of the Nurses' Notes dated 06/05/12 at 3:50 PM, revealed, "Discoloration still noted to right side of face. Discoloration and swelling noted to bil (bilateral) knees. No S/S of pain noted at this time...." Review of the Provider Investigation Report dated 06/06/12 revealed the resident was sitting on the edge of the bed and fell to the floor when the nurse aide had turned her back to the resident. Resident #3 had sustained a hematoma to her right eye, a bruise to her right cheek, and a skin tear to her left hand. (The bilateral knees were not mentioned.) A skull series and an x-ray of the orbital bone were done. Neuro checks were done per protocol and the skin tear was treated. Physical and Speech Therapy was provided to Resident #3 to assist in her evaluation and treatment for [REDACTED]. Disciplinary action was given to the involved employees. Employee statements were attached. In an interview with CNA B on 06/06/12 at 12:05 PM she stated Resident #3's bed was in the high position at the time of her fall. She stated she was in the resident's bathroom washing her hands and Resident #3 was sitting on her bedside. She stated she had called for another nurse aide to assist her to transfer the resident from the bed to her wheelchair. Resident #3 fell while the CNA was washing her hands. In an interview with CNA C on 06/06/12 at 12:05 PM she stated Resident #3 was sitting on her bedside when she entered the room and the CNA was reaching for gloves when she turned around and saw the resident on the floor. Review of the Physical Therapy documentation dated 06/06/12 revealed the current referral was due to "a fall in her room, over the last weekend. Nursing report there is considerable risk of fall which warranted a PT evaluation and required fall prevention strategies recommendations." Review of the Physical Therapy notes dated 06/06/12 revealed the therapist's recommendations were as follows: "1. Resident to be provided a low bed, or the current one to be lowered to its minimum possible height. Therapist recommends electrical bed so that the height can be set to minimum when resident is in bed and the height is slightly raised, during transfers for safety during transfers. 2. A floor rubber mat to be placed on the left hand side of the bed to prevent any possible injuries from accidental falls. 3. A bed alarm to be placed under resident's mattress' outer layer, to alarm the nurses' station, of any instances where the resident is attempting to get up without CG (caregiver) assistance." Review of the facility's policy on Fall Assessment/Intervention Process dated January, 2011 revealed, "the facility must ensure that -(a) the resident environment remains as free from accident hazards as is possible; and (b) each resident receives adequate supervision and assistance devices to prevent accidents." The facility's CMS-802, Roster/Sample Matrix, provided by the DON on 06/04/12 at 11:50 a.m. reflected two residents with falls.