Every finding on record at Buena Vida Nursing and Rehab-San Antonio

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was not left unattended in the shower room during a shower on 07/14/26, which resulted in the resident falling and sustaining a hip fracture which required surgical repair. The noncompliance was identified as PNC. The noncompliance began on 07/14/26 and ended on 07/17/26. The facility corrected the noncompliance before the survey began on 07/22/26. This failure could place residents at risk of experiencing falls, serious injuries, harm or death as a result of a fall.The findings included: Record review of Resident #1's admission Record, dated 08/22/26, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: unspecified dementia (a decline in memory and thinking skills with the exact underlying cause not yet determined), repeated falls, and cognitive communication deficit (trouble with communication caused by problems with thinking skills like attention, memory, and problem-solving rather than a basic speech or language problem). Record review of Resident #1's Quarterly MDS Assessment, dated 06/18/26, revealed a BIMS score of 6 of 15, which indicated severe cognitive impairment. Further review revealed it was noted Resident #1 used a wheelchair for mobility, and required supervision or touching assistance during chair to bed or bed to chair transfers. Walking was not attempted during assessment due to safety concerns. Record review of Resident #1's Fall Risk Assessment, dated 06/09/26, revealed the resident had balance problems when standing and walking. His ambulation status was chair bound - requires assist with elimination. Resident #1 had taken 1-2 of medications in a list consisting of anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics. The score was 8 with the Category indicating: NA Record review of Resident #1's Fall Risk Assessment, dated 07/14/26, revealed the resident required the use of assistive devices (i.e. cane, wheelchair, walker, furniture), had taken 1-2 of medications in a list consisting of anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics. His ambulation status was chair bound - requires assist with elimination and his score was 9 with the Category indicating: NA Record review of Resident #1's care plan, with revision date of 02/02/26 and prior to the resident's fall on 07/14/26, revealed the resident required one staff member to assist with bathing; at risk for falls and history of falls; and at risk for elopement as evidenced by impaired safety awareness, Record review of the medical information system (a computerized quick reference to organize daily care needs) revealed Resident #1 required one person physical assist for showers prior to the fall on 07/14/26. Record review of Nurses Notes, dated 07/14/26 at 10:45 a.m. by LVN B, revealed the resident was found unattended in the shower room sitting on the floor in front of the shower chair. After an initial assessment by the Charge Nurse LVN B, The Nurses Notes stated Resident #1 was having localized pain to the right foot. He was noted with an abrasion to the right upper rib area. Resident #1 was asked to straighten out his legs he was able to move his leg with no pain at the time. He was assisted to a sitting position with no s/s of pain at the time. Staff and two other staff members assisted the resident off the floor into a wheelchair. Once the resident was sitting in the wheelchair he repositioned himself back in the chair then began to vocalize pain. Resident #1 was taken to his room and a further head to toe assessment was completed by the ADON and LVN B. According to the Nurses Note of 07/14/26, as the head to toe assessment was completed it was observed the right leg was shorter than the left. Following the assessment, the Nurse Practitioner was called and an order received to send him to the hospital for evaluation and treatment. Record review of Nurses Notes, dated 07/18/26 at 2:26 p.m. by LVN B, revealed the resident was readmitted back to the facility with an acute intertrochanteric fracture of the right femur (a type of hip break that happens on the upper part of the thigh bone [femur] between the greater and lesser trochanters [thigh bones]). The note stated Resident #1 attempted to get out of bed to go for a smoke break but unable at the time due to pain. He was medicated for pain one time with effective results. Record review of Nurses Notes dated 07/18/26 at 3:20 p.m. by LVN B, revealed the resident was found lying on the floor in front of the door in his room. He stated that he was trying to close his room door. The resident was assisted back to bed with the help of two staff members. NP was informed with new orders for and xray of the right hip. RP was called a message was left to call the facility. Record review of Nurses Notes dated 07/19/26 at 5:09 p.m. by LVN B, revealed Resident #1 was last noted sitting in his wheelchair wheeling himself around. Writer was later in the hall and heard someone yell out Help Me. Upon walking up the hall writer [sic] was noted lying on the floor on his back in front of his room door. When asked when happened the resident stated that he was trying to get in the bed. Record review of the facility's 3613-A Provider Investigation Report, dated 07/20/2026, revealed on 07/16/26 at approximately 3:51 p.m. the Administrator and DON contacted Resident #1's RP and were informed by the RP that the resident had a surgical repair to intertrochanteric fracture of the right femur. During an interview with the SW on 07/22/26 at 4:13 p.m., the SW stated the facility had a care plan meeting with the family to discuss Resident #1's insistence on getting up by himself without calling anyone and his impulsive behavior. SW stated the RP reported that Resident #1 was very hard headed but they did not know how to control his behavior. The SW stated she suggested to Resident #1's family they come and stay with him for extended periods of time or possibly get a sitter service and the resident's RP stated they would consider it. During an interview with CNA A on 07/22/26 at 4:28 p.m., CNA A stated she started PRN work and had finished doing her 3 days of orientation the day prior to Resident #1's fall on 07/14/26. CNA A stated she was not aware Resident #1 had a history of falls. CNA A stated she started the shower for Resident #1 and had washed his hair and upper body when she ran out of soap. CNA A stated, since the supply closet was near the shower room, she told Resident #1 she was going to get more soap and then she would return to finish the shower. CNA A stated she rinsed off the soap from Resident #1 and then went to the nurses' station to ask the ADON to get her more soap from the supply closet. CNA A stated as she was returning to the shower room, CNA A and the ADON heard a yell in the shower room. CNA A and the ADON along with the DON and charge nurse, found Resident #1 on the floor in front of the shower chair. CNA A stated Resident #1 told her that he had grabbed the safety bar in the shower and tried to stand up but his foot slipped and he fell. CNA A stated at first Resident #1 said he was okay, but the staff members carefully put him back in his wheelchair and took him to his bed. Resident #1 then said his hip hurt. CNA A stated she was given a one-to-one in-service about the incident, the importance of the [medical information system] to determine the care needs of each resident, and to never leave a resident unattended. CNA A said she was suspended for two of days. CNA A stated she did not think to use the call light in the shower or ask another staff member to get her the soap since the supply closet was, right around the corner, and she did not think it would take that long to get it. CNA A stated she knew residents should not be left alone during a shower, but she did not think it would take too long to obtain the soap she needed. During an interview with the ADON on 07/22/26 at 4:54 pm, the ADON stated she did not realize CNA A already had a resident in the shower when she was asked to get more soap or she, would have told her to immediately go back to the shower. The ADON stated when they were coming out of the supply room, they heard a yell so Resident #1's nurse, LVN B, the DON, CNA A and ADON went to the shower room and then assisted Resident #1 back into his chair and took him to his room. The ADON stated the NP was contacted and they were told to send Resident #1 to the ER for evaluation. The ADON stated they immediately began in-servicing everyone to make sure the medical information system was reviewed before starting care for residents. The ADON stated she in-serviced CNA A on making sure all supplies were available prior to shower, ANE, reviewing the [medical information system] and [electronic medical record]. The ADON stated nursing staff were told to ensure all supplies were available prior to starting care such as a shower and if something was needed during the shower to use the call light or just call out for assistance. The ADON stated they in-serviced non-nursing staff to make sure that if they, see something - say something, to ensure residents were maintained safe. The ADON also stated they in-serviced everyone on ANE. During an interview with the ADM and DON on 7/22/26 at 5:25 p.m., the DON stated she was near the shower when Resident #1 fell. The DON stated the ADON assessed the resident and then she assisted the other staff members to get him up. The DON stated Resident #1 told them he used the grab bar and tried to stand up but his foot slipped. The DON stated Resident #1 did self-transfer. During an observation and interview with Resident #1 on 07/23/26 at 9:06 a.m., Resident #1, who was in his room at the time, stated he was doing okay and, they are taking care of me. Resident #1 said, I fell in the shower. Resident #1 stated he could not remember why he stood up without help. Observation of the resident's room revealed the call light was next to Resident #1 on the bed and he stated he used it, sometimes. During a telephone interview with the NP on 07/23/26 at 2:44 p.m., the NP stated she could not say whether the hip fracture resulted from the fall or from the movement to put him back in his chair since she, was not there. The NP stated that bones were more fragile at Resident #1's age than at [AGE] years old. The NP stated she was not aware of any tests done at the hospital which might have indicated the cause of the fracture. During an interview with Resident #1's RP on 07/23/26 at 2:55 p.m., the resident's RP was interviewed about the incident and the subsequent care plan meeting. Resident #1's RP stated, I believe the facility is doing the best they can. They do call us for changes and we had a family meeting this week. We spent an hour discussing the issue. The resident's RP stated the family would not be able to provide 24-hour coverage and they were just trying to convince Resident #1 not to get up without assistance. Resident #1's RP stated the resident had always been independent and, hard headed, but now believed, it is a combination of his remembering and then not being able to do things for himself. During an interview with COTA and PTA on 07/24/26 at 1:00 p.m., the COTA and PTA stated Resident #1 was on the therapy caseload. The PTA stated they were, working on transfers, bed mobility, sitting on side of bed, working on gait prep but his problem is his cognition. He gets himself up and I've told him to wait for someone. The PTA stated they had given him a cushion and dycem (specialized non-slip mat that can be added to the seat of a wheelchair) for his wheelchair to raise him up to make it a little safer to stand up. During a telephone interview with the NP on 07/24/26 at 2:18 p.m., the NP stated their goal was for Resident #1's surgical site to heal . Record review of the facility's policy titled, Bath, Tub/Shower, undated, revealed: Procedure: . 1. The resident will receive assistance with bathing according to their resident centered plan of care. 2. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dressing or casts. 3. Explain procedure to resident. 11. Assist to stand in the shower, or sit on a stool or chair in the shower or tub, inform the resident of the use of the rails for support in getting in and out to prevent falls. 12. Remain with the resident if he is weak or assistance is needed in washing. 15. Place a call light within reach for resident to call for assistance; remain with the resident if weak and remove from bath or shower if complaining of weakness of faintness. 16. Limit the tub bath to less than 15 minutes and shower to less than 10 minutes depending on fatigue and weakness status . Record review of the facility's policy titled, Fall Policy, undated, revealed: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk,Procedure:On admission, the nurse will complete a fall risk assessment for each resident.If the resident is unable to assist in completion of the tool, or if medical records are available, the nurse may obtain the assistance of a family member or legal representative that is familiar with the resident's current functional status.Fall Risk Assessment:The Fall Risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history, and current functional status. Information may be obtained by reviewing current medical records, interview with resident/family, or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.The MDS completed on admission quarterly and upon significant change will also assess for fall risk.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.Interventions will be resident centered. In instances where fall risk measures do not prevent a fall, the residents will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized.The nurse will complete an event fall nurses note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator.The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required.Appropriate education will be provided to all staff members as needed on fall prevention. The facility took the following actions prior to surveyor's entrance to ensure residents were adequately supervised during showers:Record review revealed Resident #1's MD and RP were notified by telephone immediately of the fall on 07/14/26 at 10:15 a.m. Record review revealed Resident #1 was sent to the hospital via ambulance on 07/14/26 at 11:45 a.m. for evaluation and surgical treatment. Record reviews revealed on 07/14/26, 100% of facility staff were provided with in-service training on ANE, safe showering of residents (residents must not be left unattended), and use of the medical information system prior to caring for residents either in person or by telephone. Interviews with staff on the training received included: CNA A, LVN B, CNA C, CMA E, LVN F, DM, CNA G, and LVN H. Staff revealed in-service training was held on ANE on 07/14/26, use of the medical information system to determine the care needed and to never leave a resident unattended in the shower. Staff stated if something was needed, then they should either use the call light or open the door and call out to someone. Record review of the facility's investigation report revealed the Administrator monitored staff for 4 days after the incident for knowledge of in-service training and for compliance, a QAPI meeting was held to address Resident #1's fall on 07/14/26, and safe surveys of residents were completed for ANE. Record review of the facility's monitoring plan with dates ranging from 7/14/26 through 7/17/26, revealed the ADM would ask 10 nursing staff members per week, how to locate how much assistance is needed for a resident task and what they would do if the proper amount of staff is not present. Answers were recorded on the form. Record review of CNA A's personnel record indicated she was suspended pending the investigation and brought back to duty after a one to one in-service and counseling. Record review of CNA A's 1-on-1 In-Service Training Attendance Rosters, dated 07/15/26, revealed CNA A was trained on by the ADON:-In Service Training Topic: When staff is caring for a resident, you need to ensure that you look at the resident [medical information system] which is in [electronic medical record] under the POC [Plan of Care] documentation section. The [medical information system] will give you the resident care plan and inform you of the assist level the resident needs with ADLS (i.e., transferring, showering, etc.) If you have any questions or are unsure of how to locate or read the [medical information system], please get with ADON/DON or MDS. If you notice a resident [medical information system] is blank, YOU MUST notify ADON/DON immediately or this so it can be corrected.-In Service Training Topic: [Medical information system] needs adjustment. If the number of staff required for an ADL is not listed in the [medical information system] and/or needs to be revised (i.e., a resident original 1-person is now requiring 2 people to transfer) we will need to notify the charge nurse, ADON and/or DON to get this corrected immediately.:-In Service Training Topic: Staff CANNOT leave residents unattended in the shower room. All supplies are to be gathered prior to starting resident showers. If anything is needed employee is to call for assistance and not leave resident alone. Record review revealed the facility held a care plan meeting with Resident #1's RP and other family members on 07/20/26 to discuss interventions for ADL tasks, possible assistance from family members to sit with Resident #1 and the therapy Resident #1 would receive. Record review revealed Resident #1's care plan was updated to reflect the number of staff required for ADL tasks and revised on 07/15/26 to add that resident was resistive to care, has poor safety awareness, poor impulse control, and refuses to call for assistance related to dementia. Record review revealed Resident #1's care plan with a revision on 02/02/26 reflected a focus of [Resident #1] is risk for falls, History of Falls, Acute falls with Interventions that included 6/9/26 Fall Intervention: Encouraged resident to utilize call light for assistance; Anticipate and meet his needs; Resident #1 needs a safe environment with (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach); Resident #1 needs activities that minimize the potential for falls while providing diversion and distraction; Be sure his call light is within reach and encourage him to use it for assistance as needed; Educate him/family/caregivers about safety reminders and what to do if a fall occurs; Encourage him to participate in activities that promote exercise, physical activity for strengthening and improved mobility; Ensure that he is wearing appropriate footwear when ambulating or mobilizing in wheelchair; Keep furniture in locked position; Keep needed items, water, etc. in reach; PT evaluate and treat as ordered or PRN; review information of past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes; Staff x 1 to assist with transfers. Record review revealed the facility reported Resident #1's fall to HHSC per regulations. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance on 07/22/26.

Based on interview and record review, the facility failed to ensure residents were provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services, in that: The facility failed to ensure Resident #1 received his Ibuprofen 200 mg by mouth on 07/06/2026 at 8:00 a.m. and 4:00 p.m. for inflammation as ordered. This deficient practice and failure could place residents at risk for pain and collapse of daily life because of the pain. Findings included:Record review of Resident #1's face sheet, dated 07/08/2026, revealed the resident was a 72-years-old male and admitted to the facility on [DATE] with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain in right hip, and hepatitis-C (viral infection that causes liver swelling, called inflammation). Record review of Resident #1's admission MDS assessment, dated 04/20/2026, revealed the resident's BIMS score was 5 out of 15 indicated the resident had severe cognitive impairment and required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand, chair to bed, and toilet transfers. Record review of Resident #1's comprehensive care plan, dated 04/10/2026, revealed the resident had the care plan of The Resident is non-compliant with medication administration related to Agitation - For intervention, Allow the resident to choose the time of day for administering medications if appropriate. Record review of Resident #1's physician order, start dated 07/06/2026, revealed the resident had the order of Ibuprofen Tablet 200 milligram Give 1 tablet by mouth two times a day for inflammation for 7 Days. Record review of Resident #1's medication administration record from 07/01/2026 to 07/31/2026 revealed the resident did not receive his Ibuprofen on 07/06/2026 at 8:00 am and 4:00 pm because the medication was not available. Interview on 07/08/2026 at 10:50 p.m. with Resident #1 said he had a swollen right wrist, but no pain and received pain medications without any issue. Interview on 07/08/2026 at 12:00 p.m. with MA-A, she said she did not give Resident #1's Ibuprofen on 07/06/2026 at 8:00 am and 4:00 pm because the medication was not available. MA-A said, per the facility's policy, she documented it on the resident's medication administration record and notified the charge nurse. Interview on 07/08/2026 at 1:44 p.m. with LVN-B, she said she did not know Resident #1 did not receive his Ibuprofen on 07/06/2026 at 8:00 am and 4:00 pm because the medication was not available, and nobody reported it to the nurse. LVN-B said if somebody reported it to the nurse, she might call the ADON or DON, and they usually obtained the medications from the local pharmacy because this medication was over-the-counter. The nurse stated she performed a pain assessment because the resident had swollen wrist due to the inflammation to his right side, and the resident denied any pain on 07/06/2026. The LVN-B said she did not know which nurse MA-A reported, but it was incorrect because the resident did not receive his medication as ordered due to lack of communication, and the resident might have pain because of not receiving the pain medication as ordered. Interview on 07/08/2026 at 1:48 p.m. with the DON and ADON, [WHO] said on 07/06/2026, nobody report regarding Resident #1's Ibuprofen, and if somebody reported it, the DON or ADON would get the medication from local pharmacy immediately because it was over-the-counter. The DON said that due to lack of communication between the nurses and medication aides, the resident did not receive his pain medication, and he might have pain. The DON said the facility would start in-services for that. It was the facility failure.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy.The facility failed to ensure Resident #1's Nursing Assistant ADL Flow Sheets were accurately documented from 4/13/2026 to 5/12/2026.This failure could place residents at risk for an incomplete clinical picture and errors in care and treatment.The findings included: Record review of Resident #1's face sheet, dated 5/12/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), type 2 diabetes mellitus (body does not use insulin effectively), and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment, dated 4/1/2026, revealed a BIMS score of 07 which indicated severe cognitive impairment. His functional abilities were supervision or touching assistance with bathing and personal hygiene/toileting. Record review of Resident #1's undated ADL self-care performance deficit care plan revealed Bathing: requires staff x1 for assistance and Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care was listed with a frequency of Monday-Wednesday-Friday during the day shift. Record review of Resident #1's ADL completed bath activity for the last 30 days from 4/13/2026-5/12/2026 did not reveal the resident's scheduled bathing days. There were seven showers, baths, or sponge baths documented in the electronic medical record in the last 30 days from 4/13/2026-5/12/2026. There were no showers, baths, sponge baths, or refusals entered for seven scheduled M-W-F bath days in the electronic medical record. Days missing a record include, 4/15/2026, 4/17/2026, 4/22/2026, 4/24/2026, 4/29/2026, 5/4/2026, and 5/8/2026. During an interview on 5/12/2026 at 4:18 PM, CNA A stated baths were recorded in the POC and sheets. CNA A stated, [Resident #1] received a bed bath on 4/11/2026 and that she mis-marked it as a shower. CNA A stated she always offered Resident #1 a bath on his scheduled day but that he refuses if its during the smoke break. During an interview on 5/12/2026 at 4:18 PM, CNA B stated baths were recorded in the POC. CNA B stated, [Resident #1] received peri-warm wipe down [bed bath] on 4/11/2026 instead of a bath because he wanted to go to a smoke break. During an interview on 5/13/2026 at 12:01 PM, LVN C stated CNAs documented showers/baths in the POC and that missing records looked like the residents were being neglected. During an interview on 5/13/2026 at 12:15 PM, LVN D stated missing records, can cause issues if a resident states that did not have a shower but did receive one. Some residents with dementia could forget. During an interview on 5/13/2026 at 12:25 PM, the ADON stated staff were trained to record baths/showers in the POC. The ADON stated missing records, could be a resident refusal, not offered, or didn't document. During an interview on 5/13/2026 at 1:17 PM, the DON stated, staff were trained to fill out the [shower task] form, let the nurse know, and document in POC if showers/baths were given or refused. The DON stated she would be implementing a new shower sheet but that the POC was the official record. The DON said the impact of missing records was the residents electronic medical record was, inaccurate documentation. Things can be missed. Showers could possibly be missed. Record review of the facility's undated policy titled Documentation revealed: Goal1.The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.2.The facility will ensure that information is comprehensive and timely and properly signed.Procedure7.Document or check information on flow sheets each shift or as appropriate for the care or treatment being monitored.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 residents (Resident #2, Resident#3, and Resident #4) reviewed of 29 residents reviewed for pharmaceutical services. The facility failed to ensure that Resident #2's, Resident #3's, and Resident #4's narcotic sheets were labeled in way to account for all medications dispensed by pharmacy. This facility failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.The Findings Include: 1. Record review of Resident #2's admission Record, dated 03/04/2026, revealed resident was a [AGE] year-old male and admitted to facility on 06/25/2025 with diagnoses of Muscle Weakness (often sudden reduction in strength where muscles cannot exert expected force), Dementia (progress decline in cognitive function severe enough to interfere with daily life), Spinal Stenosis (narrowing of spinal canal, often caused by age-related degeneration, bone spurs, or herniated discs, which compress nerves and the spinal cord), and Lack of Coordination and Unsteadiness on Feet (clumsy, uncoordinated voluntary movements often caused by damage to cerebellum or nervous system and balance disorder). Record review of Resident #2's Care Plan, dated 10/17/2025, revealed resident had care planned 'adverse medication effect and behavior monitoring', impaired mobility, gait/balance problems, and potential for uncontrolled pain. Record review of Resident #2's MDS, dated [DATE], revealed BIMS score of 14, depressed mood, walker or wheelchair for mobility depending on lower extremities and pain, partial assistance to max assistance for ADL's, and fractures and trauma. Record review of Narcotic Book on Medication Cart for hallways 2200/2500 on 03/05/2026, revealed Resident #2's Narcotic sheet for APAP/Codeine Tab 300-30mg tab was not labeled in a way to account for all medications dispensed by pharmacy. Observation of LVN A on 03/05/2026 at 6:38 am, surveyor witnessed LVN A change the documentation on Narcotic Sheet from 'card 1 of 2' to 'card 2 of 2' to match the numbering on the blister pack of medication. Interview on 03/05/2026 at 6:38 am LVN A stated that the numbers on the Narcotic Sheet for Resident #2 for the accounting of blister packs did not match what was written on the blister pack. Surveyor asked how this could affect residents and LVN A stated that they would not be able to accurately keep track of narcotics or when to reorder as the numbers were wrong. Interview on 03/05/2026 at 11:24 am, DON stated that she was initiating a plan of correction to address the concerns with all of the narcotic sheets. DON stated facility needed to follow policy and she had only been employed for a month and a half and she was actively working to address issues. 2. Record review of Resident #3's admission Record, 03/04/2026, revealed resident was a [AGE] year-old female and admitted to facility 11/26/2025 with diagnoses of Muscle Weakness and Wasting (often sudden reduction in strength where muscles cannot exert expected force), Polyneuropathy (chronic condition characterized by damage to multiple peripheral nerves, causing widespread numbness, tingling, weakness, and burning pain, typically starting in the feet and hands), and Cognitive Communication Deficit (often characterized by brain injury or neurological disease, characterized by impaired communication due to underlying cognitive issues like memory, attention and executive function). Record review of Resident #3's Care Plan, dated 01/26/2026, revealed resident had fracture of hip, care planned 'adverse medication effect and behavior monitoring', and potential for uncontrolled pain. Record review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 07, mobility use of wheelchair, dependent to supervision assistance for ADL's, and indwelling catheter. Record review of Narcotic Book on Medication Cart for hallways 2200/2500 on 03/05/2026, revealed Resident #3's Narcotic Sheet for Tramadol HCL Tab 50mg was not labeled in a way to account for all medications dispensed by pharmacy. Interview on 03/05/2026 at 6:32 am LVN A stated that there was no labeling for Narcotic Sheet card count for Resident #3. The form had no documentation relating to this and LVN A stated that they would not be able to accurately keep track of narcotics or when to reorder as the numbers were wrong. Interview on 03/05/2026 at 11:24 am, DON stated that she was initiating a plan of correction to address the concerns with all of the narcotic sheets. DON stated facility needed to follow policy and she had only been employed for a month and a half and she was actively working to address issues. 3. Record review of Resident #4's admission Record, 03/04/2026, revealed resident was a [AGE] year-old male and admitted [DATE] with diagnoses of Cognitive Communication Deficit (often characterized by brain injury or neurological disease, characterized by impaired communication due to underlying cognitive issues like memory, attention and executive function), Pain, of Muscle Weakness and Wasting (often sudden reduction in strength where muscles cannot exert expected force), and Lack of Coordination and Unsteadiness on Feet (clumsy, uncoordinated voluntary movements often caused by damage to cerebellum or nervous system and balance disorder). Record review of Resident #4's Care Plan, dated 01/05/2026, revealed resident had hemiplegia/hemiparesis, ADL self-care deficit, limited physical mobility, and potential for uncontrolled pain. Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 01, mobility use of wheelchair, and dependent to moderate assistance for ADL's. Record review of Narcotic Book on Medication Cart for hallways 2200/2500 on 03/05/2026, revealed Resident #4's Narcotic Sheet for APAP/Codeine Tab 300-30mg was not labeled in a way to account for all medications dispensed by pharmacy. Interview on 03/05/2026 at 6:27 am LVN A stated that there was no labeling for Narcotic Sheet card count for Resident #4. The form had no documentation relating to this and LVN A stated that they would not be able to accurately keep track of narcotics or when to reorder as the numbers were wrong. Interview on 03/05/2026 at 11:24 am, DON stated that she was initiating a plan of correction to address the concerns with all of the narcotic sheets. DON stated facility needed to follow policy and she had only been employed for a month and a half and she was actively working to address issues.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards in that: The facility failed to ensure Resident #1's environment was free of hazards and Resident #1 was adequately monitored. On 2/4/2026 Resident #1 told CNA A she wanted to kill herself. Resident #1 was discovered harming herself by cutting her right wrist with a shaving razor on 2/5/2026. The noncompliance was identified as PNC. The IJ began on 2/4/2026 and ended on 2/8/2026. The facility had corrected the noncompliance before the survey began. This failure could result in residents experiencing suicidal ideations being at risk for harm, injuries, and death. The Findings:Record review of Resident #1's admission Record dated 2/5/2026 revealed she was admitted on [DATE] with diagnoses of mild cognitive impairment, depression, and anxiety disorder. Record review of Resident #1's admission MDS dated [DATE] revealed her BIMS was 8/15 (moderate cognitive impairment), she had no behaviors, she was ambulatory, she required partial/moderate assistance for personal hygiene (shaving), her active diagnoses was anxiety disorder and depression. Record review of Resident #1's consolidated orders for February 2026 revealed an order of Buspirone HCI oral tablet 10 mg give 1 tablet by mouth three times a day for anxiety and Sertraline HCI oral tablet 50 mg give 1 tablet by mouth one time a day for depression. Record review of Resident #1's MAR revealed she was administered Buspirone HCI oral tablet 10 mg give 1 tablet by mouth three times a day for anxiety and Sertraline HCI oral tablet 50 mg give 1 tablet by mouth one time a day for depression, as ordered. Record review of Resident #1's care plan dated 2/6/2026 revealed she required antidepressants, and anti-anxiety medications. Resident #1's care plan revealed Resident #1 wanted to end her life. Interventions included: notify physician, attempt to refocus Resident #1 to something positive when behavior occurs, SW/staff will counsel with Resident #1 and listen to her concerns, make referral to psychology consult, send emergency room for evaluation and treatment, treatment to left wrist per order. Suicidal Ideation, intervention was SW/staff will counsel with Resident #1 and listen to her concerns, staff will encourage Resident #1 to attend activities to help occupy their mind and time, staff will encourage friends/family to visit resident, staff will give medication as ordered, staff will monitor for effectiveness and side effects for medication. The care plan did not mention a history of suicidal ideation. Record review of Resident #1's mood assessment dated [DATE] revealed a score of 9, meaning minimal depression. Record review of Resident #1's SBAR dated 2/4/2026 at 3:48 PM revealed a mental status change. Suicidal ideation started on 2/5/2026, treatment was ordered and Resident #1 was sent to emergency room for treatment. The MD and family were notified on 2/5/2026 at 10:42 AM; signed by LVN B on 2/5/2026. Record review of Resident #1's transfer form dated 2/5/2026 at 10:57 AM revealed suicidal ideation. The resident expressed multiple times that she wanted to harm herself. The resident was noted with a superficial scrape on her left wrist. The resident sent out for evaluation of suicidal thoughts. The resident was placed on one-to-one care until ambulance service arrived for transport. The MD and family were notified on 2/5/2026 at 10:45 and 11:00 AM; signed by LVN B on 2/5/2026. Record review of self-reported incident filed by the ADM of the facility dated 2/6/2026 at 10:28 AM revealed the Brief summary of the report: on 2/5/2026 at approximately 10:30 am the ADM learned of Resident #1's intent to self-harm, as reported to the DON. LVN B stated she received report from CNA C the resident had voiced wanting to kill herself while in the dining room and decided not to have dinner and went to her room. LVN B immediately initiated monitoring one to one by assigning CNA A in the resident's room. LVN B, the AM-Charge Nurse, reported the incident to the NP and DON. The NP ordered the residents to be sent out to hospital for treatment and evaluation. The police/behavioral team came in to assess the incident and determined that residents did not meet criteria due to her denial of self-harm. LVN B reported to have secured a razor blade from the resident's room, as she had voiced wanting to shave her legs. LVN E, PM-Charge Nurse, reported Resident #1 informing the police that she was upset because she thought they were in a relationship, when she saw a male resident talking to other women. Resident #1 was seen ambulating and communicating with the male resident that may have caused her emotional imbalance. LVN E administered her night medications, routinely monitoring, and the resident slept well overnight. On 2/6/2026, LVN B and the ADON learned of the resident having a self-inflicting superficial abrasion to her left wrist while sitting in the dining room with other staff members and residents. Resident #1 was tearful because she did not want to get anyone in trouble, claiming the injury was only a scratch. When asked about the razor, she reported having hidden a razor in a drawer in her room and then moved it to the bag on her walker. LVN B notified the MD, and orders to discharge resident to hospital were received. Resident #1 was discharged to hospital for evaluation and treatment where she was admitted . Observation on 2/8/2026 at 8:30 AM with Resident #1, at the hospital behavioral unit, she revealed her left wrist, underside, had a superficial 1 inch scratch. Resident #1 stated she did scrap herself due to a broken heart and she knew that was wrong. Resident #1 stated she did not blame the facility. During an interview on 2/8/2026 at 8:30 AM Resident #1 stated she asked CNA A for a razor to shave her legs and received 2 shavers with no supervision. Resident #1 stated she was upset because a male resident had broken her heart. Resident #1 stated she did scrap herself due to a broken heart and she knew that was wrong. Resident #1 stated she did not blame the facility. During an interview on 2/8/2026 at 10:15 am LVN B started on 2/4/2026 at 5:30 PM, during dinner, CNA C reported to LVN B that Resident #1 did not want to be here (kill herself) anymore. LVN B had CNA A follow Resident #1 to her room and picked up a razor and brought it to LVN B. LVN B stated she called the DON, NP and ordered Resident #1 to the hospital due to suicidal ideation, then called 911. CNA A was with Resident #1 until the police came. LVN B stated the police had talked to Resident #1, and the police stated she did not meet qualifications to be sent out to emergency room-hospital. LVN B stated Resident #1 had told police she was upset because a male resident broke up with her and did not want to hurt herself. LVN B stated she had texted the DON about the police response and Resident #1 did not meet requirements. LVN B stated that when the ambulance was called the police arrived. This was protocol the police/behavior response team stated for SI. LVN B stated the next day, 2/5/2026 at 10 AM, Resident #1 was downstairs, with the ADON staying Resident #1 until the ambulance arrived at the facility. Resident #1 had a razor in her hand, and had a superficial scratch on her left wrist. LVN B stated she Buspirone HCI oral tablet 10 mg give 1 tablet by mouth three times a day for anxiety and Sertraline HCI oral tablet 50 mg give 1 tablet by mouth one time a day for depression took the razor form Resident #1, notified the NP, ordered Resident #1 to go to hospital for evaluation of suicidal ideation. LVN B stated she started the SBAR on 2/4/2026, then the police/behavioral team arrived and stated Resident #1 did not [NAME] the requirements. Then when Resident #1 cut herself on 2/5/2026, she completed the SBAR. During interview on 2/8/2026 at 3:50 PM with CNA C stated she wrote a statement for ADM. CNA C stated she was stayed with Resident #1 on 2/4/2026, when she had stated she did not want to kill herself, CNA C stated she went reported this to LVN B that was in the dining room. CNA C stated CNA A was stayed with Resident #1 while she reported this incident to LVN B. During an interview on 2/8/2026 at 3:55 PM CNA A stated she gave Resident #1 two shavers on 2/4/2026. Resident #1 stated she wanted the shavers to shave her legs and did not supervise her with the razors. CNA A stated on Wednesday (2/4/2026), around dinner, Resident #1 stated she wanted to kill herself and the aide reported that to LVN B. CNA A stated while in Resident #1's room she removed a razor from her room and was with her until the police arrived. CNA A stated she had forgotten that she gave Resident #1 two shavers. During interview on 2/9/2026 at 1:40 PM with CNA E stated the police were at the facility when she arrived for her shift at 6:00 PM. CNA E stated the police had stated Resident #1 was not a risk for SI. CNA E stated she monitored Resident #1 and she had slept and rested all night. Resident #1 was back to normal. CNA E stated the staff were supposed to stay with residents if they ask for a shaver, and staff dispose of it in sharps container, after use. CNA E stated residents are not supposed to have sharp objects. During interview on 2/9/2026 at 2:03 PM the ADON stated on 2/5/2026 soon after the morning meeting, at 10:35 AM, CNA D had brought him a razor from Resident #1 and stated she was going to kill herself. The ADON stated he stayed with Resident #1, until the ambulance came to transport her to hospital for suicidal ideation. The ADON stated the ADM and DON were also waiting and talking with Resident #1. ADON stated the staff were supposed to stay with residents if they ask for a shaver, and staff dispose of it in sharps container, after use. ADON stated residents are not supposed to have sharp objects. ADON stated no resident had attempted SI before at facility. ADON stated he was not aware of Resident #1's SI before 2/5/2026. Record review of policy revealed resident suicide threats must be taken seriously and immediately reported to the nurse supervisor/charge nurse. Immediately notify the physician, staff member must remain at 1:1 with the resident until the threat of immediate danger has changed. Record reviews of policy for razors revealed no razors to be given to residents, residents that can and choose to shave independently must be monitored, and staff will properly dispose of used razors. PNC IJ verification: During an interview on 2/9/2026 at 3:28 PM with the ADM stated she was with Resident #1 on 2/5/2026 in morning and talked with Resident #1. The ADM stated Resident #1 had 2 razor blades she was provided by CNA A. The ADM stated CNA A was suspended on 2/5/2026 pending an investigation. The ADM stated staff were in-serviced on abuse/neglect, razors, and suicidal ideation, dated 2/5/2026 to 2/8/2026. The facility took the following actions to ensure residents are adequately supervised to prevent suicide attempts: This was all verified by surveyors by observations, interviews and record review. Record review of Resident #1's comprehensive care plan was revised on 2/6/2026 to address the resident's statements and actions that she wanted to end her life. Resident #1 was placed on 1:1 on 2/5/2026 until EMS arrived. The MD and Resident #1's RP/family were notified. The SW met with Resident #1, she was referred to psychological services, a urine test was ordered, and she was sent to the emergency room for evaluation and treatment. The 1:1, psychological referral and urine test was verified for Resident #1's orders. The urine test was negative. The facility suspended CNA A on 2/5/2026 pending an investigation and submitted a self-report for the incident to HHSC. Record review was verified of CNA A suspension on time records and was disciplined. Record review the facility assessed the other residents in the facility for suicidal ideations and ensured all sharp objects were removed from resident rooms and bathrooms. Record review and interview with Interview with maintenance supervisor on 2/11/2026 at 12:48 PM the facility did conduct a sweep of the facility to ensure no razors or sharp objects to ensure resident safety. Interviews on 2/12/2026 between 11 AM and 6:00 PM with staff confirmed those who had not received the above education were not allowed to work until the in-services were provided. Record review of in-service for Abuse/Neglect and Exploitation was dated 2/5/2026 to 2/8/2026 revealed all staff were in-serviced. Record review of in-service for Razors was dated 2/5/2026 to 2/8/2026 revealed all direct care staff were in-serviced. Record review of in-service for Suicidal Ideation was dated 2/5/2026 to 2/8/2026 revealed all staff were in-serviced. Interviews with all staff on 2/12/2026 between 11 AM and 6:00 PM and 2/13/2026 at 8:00 AM to 4:00 PM revealed they had received training for Abuse/Neglect and Exploitation and Suicidal Ideation staff were able to state what they were trained on. Interviews with direct care staff on 2/12/2026 between 11:00 AM and 6:00 PM and 2/13/2026 at 8:00 AM to 4:00 PM revealed they had received training for razors, not to leave razors with the resident, supervise and throw away in sharps containers. Nursing staff were able to state what trained on. Record review the staff trained in-services on Abuse/Neglect and Exploitation to keep residents safe, notify ADM the ANE coordinator and monitor the residents. Suicidal Ideation to notify DON, ADM, MD, follow orders, keep resident safe, place on 1:1, make sure they don't hurt themselves. Razors were to be supervised by staff and dispose of them in the sharp's containers. During interviews on 2/8/2026 from 12:56 PM to 2/11/2026 at 3:38 PM with CNA G, CNA F, LVN H, CNA I, ADON, Wound nurse, LVN J, CNA D, LVN K, CNA C, Hsk L, CNA M, Hsk N, Activities O, MDS P, PT Q, SW U, ST R, OT S, Dietary T, Dietary Supervisor U, Laundry V, Hsk Supervisor W, Hsk X, CNA Y, Maintenance Supervisor CC, CNA Z, HR AA and OTA BB. During an interview on 2/12/2026 at 4:37 PM with the ADM and DON stated they had discussed incident with Resident #1 with QAPI and during Adhoc (staff meeting) meetings.

Based on observation, interview, and record review, the facility failed to ensure the resident receives adequate supervision to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 received adequate supervision and did not elope from the facility on 9/05/2025 at approximately 6:15 PM until he was returned to the facility by a visitor at 6:45 PM. The noncompliance was identified as PNC. The IJ began on 9/05/2025 at approximately 6:15 PM and ended on 9/06/2025 at 5:30 PM. The facility had corrected the noncompliance before the survey began. The failure could place residents at-risk of injury or death due to not being adequately supervised. Findings included: Record review of Resident #1's admission Record, dated 1/13/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progressive disorder that affects memory, reasoning, and other cognitive processes), adjustment disorder (emotional or behavioral reactions to stressful life events), alcohol abuse, and psychosis (a loss of contact with reality). Record review of Resident #1's quarterly MDS, submitted 12/3/2025, reflected a BIMS score of 06, which indicated severely impaired cognition. Section E0900 of the MDS reflected Resident #1 did not exhibit wandering behavior during the assessment period. Resident #1's prior MDS, submitted 9/1/2025, also reflected a BIMS score of 06, but indicated in section E0900 that Resident #1 exhibited wander behavior daily. Section GG0115 reflected no impairment of Resident #1's upper or lower limbs, and section GG0120 indicated Resident #1 did not require a mobility device for ambulation. Record review of Resident #1's Care Plan Report, undated/printed 1/13/2025, revealed the following: Resident wants to go across the street to visit his friend. Resident left facility without notifying staff to corner store [sic]. (Date initiated: 9/05/2025, revision on 9/08/2025)SW/Staff will remind resident of safety concerns (date initiated 9/08/2025, revision on 9/08/2025)Resident sent to [Psychiatric Facility] in [location] for review of medications due to his increased anxiety and agitation in relation to missing his friend placed at another facility (date initiated 9/08/2025, revision on 9/08/2025)Further record review of Resident #1's care plan report did not reveal care planning related to the ongoing risk of elopement. Record review of Resident #1's Elopement Risk Assessment- V 6 revealed the following:assessment dated [DATE], score of 24- elopement riskassessment dated [DATE], score of 19- elopement riskassessment dated [DATE], score of 17- elopement risk Record review of Resident's #1's progress notes revealed the following:Progress note dated 9/3/2025 11:37 AM by DON C: Resident expressed that he wanted to leave and go see his friend [ friend] who no longer resides here. Resident was informed that his friend is in [other city]. He stated that he wants to walk there. He was redirected and taken by social worker to call [friend].Progress note dated 9/3/2025 6:19 PM by DON C: Resident has given consent to move rooms in the secured unit. After spending some time in the unit. resident expressed that he does not want to be back there. He is his own responsible party. Nursing to observe for elopement or exit seeking behaviors.Progress note dated 9/03/2025 10:53 PM by RN B: Noted patient is anxious and agitated. Place patient under 15 minute monitoring during shift. At this time resident is at his bedroom sleeping. Will give report to night nurseProgress note dated 9/04/2025 6:23 PM by LVN A: Resident is pacing in front of the door to exit the building in the main lobby. He is intently focusing on the door sign that indicates how to open after 15 secs of pushing. He sat down in the chair when this nurse approached and said, I just want out. [Friend] is out there and I want to see her. This nurse asked if a call with her would be nice he said no he wanted to leave again. This nurse stayed with the resident in the front for 25 min. The resident went back to the 2nd floor and came down. ADON and Administrator notified of the behavior.Progress note dated 9/05/2025 4:37 AM by LVN A: Pacing up and down the hall and taking the elevator to go to first floor, continues to go from second to first floor. Interventions: Q15 minute monitoring, [sic]Progress note dated 9/05/2025 1:07 PM by DON C: On 8/29/2025, [Resident #1] was involved in a resident-to-resident altercation. Immediately afterward, he was placed on 1:1 monitoring until cleared by the psychiatrist. The resident continued to experience increased anxiety and expressed a desire to leave the facility to be with a former resident friend. On 9/2/25, he had a consultation with [Telehealth Company] and was advised to find ways to communicate with the former patient. The Activity Director contacted the other facility and arranged video calls between the resident and the former resident. The psychiatrist also increased Depakote dosage. Staff have monitored him for further agitation and anxiety, with ongoing signs of nervousness and a short temper with staff. During the IDT review with [NP], he recommended sending the patient to a higher level of care for medication adjustment. Patient referral sent to [inpatient psychiatric hospital] for review.Progress note dated 9/05/2025 6:45 PM by DON C: Called [inpatient psychiatric hospital] to find out if resident was accepted. Spoke to [hospital staff] and did a nurse to nurse report. He was accepted for admission. Pending transportationProgress note dated 9/05/2025 6:45 PM by DON C: LATE ENTRY [sic] Note text: Event-Elopement/Attempted . Door Exited: Front door / How long missing: approx 30 min / Where was the resident discovered: Resident was at the convenience store / Resident alert and oriented x 4 resident was aware that [sic] he should not have left without notifying the staff that he was leaving / Injuries: No / Cognition / Behavior at Time of Event: Oriented / no problem, / Resident returned to the facility on 9/5/2025 at approximately 6:40 pm after he had left the facility for approximately 30 minutes. Staff were not aware that resident had left the facility as resident did not properly sign himself out. Head to toe assessment was completed upon his return, resident did not have injuries and was not in any emotional or physical distress. Resident is A&O x4 and stated that he should not have left and not tell the staff that he was leaving / Initial Treatment/New Orders: n/a / Resident Statement: I know i [sic] know i [sic] wanted to see [friend] didn't think it was that far. I know i [sic] should have told yall i [sic] was going . / Interventions: 1 on 1 supervision, educated resident on the sign out processProgress note dated 9/05/2025 10:14 PM by RN B: Patient was high risk for elopement. Patient was place [sic] on every 15 minutes monitoring. During meal time [sic] nurse was checking the tray patient [sic] was still at the hallway. CNA asked patient if he will join the other residents in the dining room. [sic] while nurse is watching the dining room and feeding residents at the second floor. Resident went downstairs and managed to come out of the front door at the first floor. Administrator, DON, ADON where [sic] at the first floor at that time. ADON brought the patient back to the second floor. Received patient with drink on ]sic] his hand and asked how he got out. Patient stated i [sic]pushed the door because it did not close completely and i [sic] got out but i [sic] came back. Nurse assessed the patient, V/S are within normal limit [sic]. Also stated I been requesting to visit my friend but they always says NO [sic]. nurse [sic] offered patient to go to his room so he can rest and cool down. Nurse kept monitoring patient and offered water to drink. DON arranged for the patient to be transferred to [inpatient psychiatric hospital] for his behavior. Transportation arrived and nurse handed all the paper works [sic] to EMT including 2 t shirts, 2 pants and 2 under wears [sic]. Patient Transferred [sic] from bed to stretcher safely and wheeled to the ambulance a little after 10 pm [sic]. Reported to Night shift nurse. [sic]Further record review of Resident #1's progress notes reflected Resident #1 readmitted to the facility on [DATE]. No documentation regarding additional elopements, actual or attempted, was documented from 9/22/2025 through 1/13/2026. Record review of Resident #1's Kardex dated 1/15/2026 reflected the following: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. [Resident #1] will be monitor/record [sic] occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of the facility document titled Incidents By Incident Type date range 8/1/2025 to 1/13/2026 reflected one elopement or attempt incident on 9/05/2025 at 6:45 PM for Resident #1. There were no additional incidents in this category listed on the report. Record review of the facility document titled Self-Reporting Protocol/Ad Hoc QAPI- Missing Resident or Elopement dated 9/05/2025 revealed the facility began investigating Resident #1's elopement incident on 9/05/2025. This investigation included assessment of Resident #1 on 9/05/2025 and a review and update of the care plan for Resident #1, reassessments of all residents in the facility for elopement risks, and updated care plans for any resident who has been assessed to be a high risk for elopement. Additionally, the document reflected an in-service for facility staff was initiated on 9/05/2025 regarding elopement; resident rights, signage was placed at the front door to remind visitors to be mindful of residents attempting to exit the facility on 9/05/2025, and the security code for the door was changed on 9/05/2025. Record review of a written statement from RN B dated 9/05/2025 revealed RN B observed Resident #1 in the hallway of the second floor of the facility prior to dinner. RN B then assisted with the dinner service in the dining room and did not observe Resident #1 during the meal. RN B was providing care for other residents after dinner when the ADON brought Resident #1 to the second floor, at which time she performed an assessment and found no injuries. Resident #1 left the facility for the inpatient psychiatric hospital between 10:00 and 10:30 PM. Record review of the facility document titled 1:1 Observation Form dated 9/05/2025 reflected 1:1 observation was initiated for Resident #1 on 9/05/2025 at 6:40 PM and ended 9/05/2025 (no time documented). Record review of the facility document titled Coaching Form dated 9/05/2025 revealed RN B received verbal and written coaching/education for the documented situation of [Resident #1] was on 15 min [sic] checks related to aggressive behaviors. Nurse failed to monitor resident appropriately at dinner time. Record review of the facility document titled Monitoring for Door Locking/Alarm function Properly reflected the facility made daily checks of the front door from 9/05/2025 to 9/12/2025. Record review of the facility document titled Record of Departmental In Service [sic] and Meetings reflected the facility conducted elopement drills for staff on 9/08/2025 at 11:00 PM, 9/10/2025 at 8:00 AM, and 9/12/2025 at 3:30 (time of day not documented). Record review of the facility document titled Elopement Drill or Actual Elopement Guide revealed additional elopement drills were conducted on 11/10/2025 at 3:05 PM and 12/18/2025 at 5:15 AM. Record review of the facility document titled Missing Resident Elopement Monitoring revealed the facility performed observations of front door entry/exit on 9/08/2025, 9/09/2025, 9/10/2025, 9/11/2025, and 9/12/2025. The locking mechanism and alarm function were tested daily 9/05/2025 through 9/09/2025, and elopement drills were conducted as previously notated. Record review of the facility document titled Actual/Alleged Abuse Monitoring revealed two staff members were interviewed about abuse/neglect procedures on 9/08/2025 through 9/11/2025, and 5 total residents were interviewed about potential abuse/neglect from 9/05/2025 to 9/10/2025. Record review of facility document titled Task List Report dated 1/15/2026 revealed behavior monitoring assigned to all residents for staff documentation daily on every shift. Record review of the facility document titled In-Service Program Attendance Record reflected training for elopement prevention and elopement response was conducted on 9/05/2025. A staff roster attached to the document reflected all staff had received the in-service. In an observation on 1/13/2026 at 10:00 AM, signage was observed on the front door of the facility directing visitors to not allow residents to exit without first notifying staff. A receptionist was seated at a desk facing the front door of the facility. The desk had an unobstructed view of the front lobby. The front door was locked, and the pressure bar initiated an alarm when pushed. In an observation on 1/3/2026 at 4:00 PM, a gas station was observed directly across a two lane street from the facility, approximately 25 yards away. The facility and the gas station were observed to be on opposite sides of a four-way stop, and the traffic was minimal. Observed vehicles were traveling at low speeds, approximately 30 miles per hour. In an observation and interview on 1/14/2026 at 9:44 AM, Resident #1 was observed ambulating independently in the first-floor common area of the facility. Resident #1 could not recall the elopement incident, nor could he state what the facility procedure was for leaving the premises. Resident #1 stated if he wanted to leave the facility, he would walk out of the front door. He was unsure if he should tell staff prior to leaving. RN B did not respond to a request for interview left by voicemail on 1/14/2026 at 9:03 AM. In an interview with the RCN on 1/14/2026 at 9:50 AM, she said the Admin and DON employed by the facility at the time of Resident #1's elopement incident were no longer employees. She said Resident #1 eloped from the facility after a staff member failed to ensure the door was closed after entering the facility for the scheduled shift. She said Resident #1 was discovered by a former employee at the gas station who recognized Resident #1. The former employee notified the RCN of Resident #1's elopement, and she returned Resident #1 to the facility. She said Resident #1 should have been visualized by the staff every fifteen minutes, as ordered by the NP, but RN B failed to ensure the observations were conducted. She said RN B received written and verbal counseling for the incident. She said in response to the investigation, the facility also hired a receptionist to monitor the front lobby during the daytime hours, placed signage directing visitors and staff to not allow residents to exit, and performed multiple elopement drills. She said that in-services about elopements, including door entrance safety, were given to all staff members, and a new procedure for new employees was introduced to include elopement training. She reported no additional elopement attempts from any residents, and she said Resident #1's medications were adjusted while he was at the inpatient psychiatric facility, and he had not exhibited any negative behaviors since readmission. In an interview on 1/14/2026 at 2:13 PM, the Admin stated all staff received on-the-spot in-servicing regarding procedures and expectations of 1:1 observations at the time the staff member is assigned to service as the 1:1 observer. She said the facility policy was to maintain visual observation of the resident at all times during 1:1 observation, and a resident requiring 15 minute observations would be visualized every fifteen minutes to ensure location and safety. She said LVN A was on medical leave at the time of survey. In an interview on 1/15/2026 at 12:23 PM, the ADO said Resident #1 had been stable since readmission. She said all residents are monitored for wandering and elopement through assigned behavior monitoring by all clinical staff and the results are reviewed during the daily meeting. She said that all staff at the facility have been in-serviced about elopement procedures, including the risk of exit from the front door. The following staff interviews were conducted regarding elopement training:NA K was interviewed on 1/13/2026 at 12:50 PM. She said she had received training about abuse, neglect, and elopements from the facility and would report any issues to the nurse and administrator. NA L was interviewed on 1/13/2026 at 3:18 PM. She said she had received training from the facility about elopements and had participated in an elopement drill. NA M was interviewed on 1/13//2026 at 2:32 PM. She said she had received in-service training about elopements and frequent monitoring for residents who were at risk for elopements. NA N was interviewed on 1/14/2026 at 2:24 PM. She said she had received the elopement training from the facility and would notify her nurse to initiate the missing resident procedure if she could not locate a resident. NA O was interviewed on 1/15/2026 at 4:30 PM. She said she had received training about elopements from the facility, and she would notify the nurse if a resident was missing. NA D was interviewed on 1/16/2026 at 8:50 AM. She said she had received training about elopements from the facility, as well as abuse/neglect and 1:1 observations. RN E was interviewed on 1/13/2026 at 2:35 PM. He said he had received training from the facility about elopement procedures and the process for locating a missing resident. LVN F was interviewed on 1/13/2026 at 3:11 PM. She said she had participated in an elopement drill and had training about elopements. LVN G was interviewed on 1/14/2026 at 2:39 PM. She said she had participated in an elopement drill and had training about elopements. LVN H was interviewed on 1/15/2026 at 4:15 PM. She said she had training from the facility about 1:1s and elopements. LVN I was interviewed on 1/16/2026 at 8:40 AM. He said he had received training from the facility about elopements. Receptionist P was interviewed on 1/14/2026 at 8:15 AM. She said she had received training about elopements and making sure residents do not exit from the front door without notifying staff. The noncompliance was identified as PNC. The IJ began on 9/05/2025 at approximately 6:15 PM and ended on 9/06/2025 at 5:30 PM. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs for 4 of 11 residents (Residents #1, #2, #3, and #4) reviewed for comprehensive care planning. The facility failed to develop and implement comprehensive care planning for assessed elopement risks of Residents #1, #2, #3, and #4. This failure could lead to residents not receiving necessary care and decreased quality of life. Findings included: 1.Record review of Resident #1's admission Record, dated 1/13/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progressive disorder that affects memory, reasoning, and other cognitive processes), adjustment disorder (emotional or behavioral reactions to stressful life events), alcohol abuse, and psychosis (a loss of contact with reality). Record review of Resident #1's quarterly MDS, submitted 12/3/2025, reflected a BIMS score of 06, which indicated severely impaired cognition. Section E0900 of the MDS reflected Resident #1 did not exhibit wandering behavior during the assessment period. Record review of Resident #1's Care Plan Report, undated/printed 1/13/2025, revealed the following:Resident wants to go across the street to visit his friend. Resident left facility without notifying staff to corner store [sic]. (Date initiated: 9/05/2025, revision on 9/08/2025)SW/Staff will remind resident of safety concerns (date initiated 9/08/2025, revision on 9/08/2025)Resident sent to [Psychiatric Facility] in [location] for review of medications due to his increased anxiety and agitation in relation to missing his friend placed at another facility (date initiated 9/08/2025, revision on 9/08/2025)Further record review of Resident #1's care plan report did not reveal care planning related to the ongoing risk of elopement. Record review of Resident #1's Elopement Risk Assessment- V 6 revealed the following:assessment dated [DATE], score of 24- elopement riskassessment dated [DATE], score of 19- elopement riskassessment dated [DATE], score of 17- elopement riskNo additional Elopement Risk Assessments were documented between 9/22/2025 and survey entrance on 1/13/2026. Record review of the facility incident reported dated 1/13/2025 reflected Resident #1 eloped from the facility on 9/05/2025 at 6:45 PM. In an observation and interview on 1/14/2026 at 9:44 AM, Resident #1 was observed ambulating independently in the first-floor common area of the facility. Resident #1 could not recall the elopement incident, nor could he state what the facility procedure was for leaving the premises. Resident #1 stated if he wanted to leave the facility, he would walk out of the front door. He was unsure if he should tell staff prior to leaving. 2.Record review of Resident #2's admission Record, dated 1/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included psychotic disorder with delusions (a loss of contact with reality with firmly held false beliefs). Record review of Resident #2's annual MDS, submitted 12/16/2025, reflected a BIMS score of 06, which indicated severely impaired cognition. Section E0900 of the MDS reflected Resident #2 did not exhibit wandering behavior during the assessment period. Record review of Resident #2's Elopement Risk Assessment V 6 reflected the most recent assessment was dated 10/15/2025 and scored 12, which indicated elopement risk. Record review of Resident #2's Care Plan Report, undated/printed 1/15/2026, did not reveal care planning related to elopement risk. In an observation and interview on 1/15/2026 at 10:08 AM, Resident #2 was observed in the common area of the second floor, interacting with staff. While conversational, Resident #2 was unable to participate in the interview in a meaningful way due to her mental status. Resident #2 did not answer interview questions and only wanted to discuss her personal history. 3.Record review of Resident #3's admission Record, dated 1/15/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included herpesviral [sic] encephalitis (severe inflammation of the brain caused by a viral infection that can result in confusion and personality changes). Record review of Resident #3's admission MDS, submitted 11/04/2025, reflected a BIMS score of 15, which indicated intact cognition. Section E0900 of the MDS reflected Resident #3 did not exhibit wandering behavior during the assessment period. Record review of Resident #3's Elopement Risk Assessment V 6 reflected the most recent assessment was dated 10/28/2025 and scored 23, which indicated elopement risk. Record review of Resident #3's Care Plan Report, undated/printed 1/15/2026, did not reveal care planning related to elopement risk. In an interview and observation of Resident #3 on 1/14/2026 at 3:10 PM, Resident #3 was observed in an unoccupied wing on the first floor of the facility. Resident #3 was inspecting a handrail on the wall. No staff were present in the hallway. Resident #3 stated he has never attempted to leave the facility, and he then ended the interview to return to his room. 4.Record review of Resident #4's admission Record, dated 1/15/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia. Record review of Resident #4's annual MDS, submitted 10/03/2025, reflected a BIMS score of 01, which indicated severely impaired cognition. Section E0900 of the MDS reflected Resident #4 exhibited wandering behavior daily during the assessment period. Record review of Resident #4's Elopement Risk Assessment V 6 reflected the most recent assessment was dated 12/15/2025 and scored 21, which indicated elopement risk. Record review of Resident #4's Care Plan Report, undated/printed 1/15/2026, did not reveal care planning related to elopement risk. In an observation and attempted interview of Resident #4 on 1/15/2026 at 10:10 AM, Resident #4 was observed sleeping in his bed. Resident #4 awoke upon surveyor entry to the room but declined to participate in the interview. In an interview with the RCN on 1/14/2026 at 9:50 AM, she said the facility underwent a leadership change in October 2025, including the Admin, DON, and MDS/care plan nurse. She said care plans were being overseen by the current DON, but that she was new to the role and had not yet reviewed every care plan from the former administration. In an interview with the ADO on 1/15/2026 at 12:23 PM, she said she felt comfortable speaking about the care plan process for the facility as she was involved in the daily functions during the administration transition period. She said the facility utilizes Elopement Risk Assessments to alert the IDT of a resident's potential for elopement, and the IDT will then determine specific risks and interventions for each resident and discuss possible placement in a secured unit for safety. She was unaware the care plans for Residents #1-4 did not contain planning for elopement risks, and she said the care plans should contain what is discussed during IDT. Record review of the facility policy titled Comprehensive Care Planning, undated/printed 1/15/2026, revealed the following: When developing the comprehensive care plan, facility staff will, at a minimum, use the [MDS] to assess the resident's clinical condition, cognitive and functional status, and use of services there may be times when a resident risk, weakness or need is identified within the context of the MDS assessment but may not cause a CAA to trigger. The facility will address these areas and will document the assessment of these risks, weaknesses, or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area .

Based on observation, interview and record review the facility failed to protect the residents' right to be free from neglect for 1 of 8 residents (Resident #1) reviewed for neglect in that: 1. Resident #1 was not provided wound care daily to the left ankle or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. Resident #1 was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. 2. Resident #1 went for approximately one month without adequate treatment for wounds which led to infection and right BKA. 3. The facility failed to ensure Resident #1 was provided with wound care to a surgical wound on the resident's right leg. 4. The ADON failed to ensure wound care treatment orders were added to Resident #1's EMR. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect, worsening of existing wounds or the development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 1. Unstageable left lateral, (outer) ankle, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. 2. Unstageable right heel, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September WAR/TAR orders revealed orders, keep dressing clean, dry intact. Do not remove, do not get wet. Cover to shower, every shift for surgical wound and monitor right leg stump for signs and symptoms of infection every shift for surgical wound, with a start date of 08/19/2025. The WAR/TAR administration record for these orders was not initialed as completed on 09/07/2025 at 11 p.m. and 09/13/2025 on 3 p.m.- 11 p.m. Further review revealed there were no wound treatment orders for the left ankle. Record review of Resident #1's EMR revealed Resident #1 had a readmission initial skin assessment, dated 08/19/2025, that had yes checked for surgical incision. The assessment did not identify any other wounds and was not signed. Resident #1 had no additional weekly skin assessments or weekly pressure ulcer assessments through the end of August and during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Further review revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had a Stage IV pressure wound (a wound that has full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) of the left, lateral ankle and measured 3.5cm x 2.5 cm x 0.1 cm with a surface area of 8.75cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The goal of the treatment was healing evidenced by a 75% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Further review revealed Resident #1 had an (unstageable (due to necrosis) of the right heel (signing off-area has been amputated). The etiology revealed pressure and stage was unstageable necrosis. Record review of wound care physician assessment, dated 09/02/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3 cm x 2.5 cm x 0.5 cm with a surface area of 7.50 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 30 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 30 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 30 days. The goal of the treatment was healing evidenced by a 14.3% decrease in surface are within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/09/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.5 cm x 0.5 cm with a surface area of 8.75 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 23 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 23 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 23 days. The assessment revealed, Thorough review of history performed, including speaking with nursing staff for further information and Coordination of care and plan for this wound discussed with nursing staff for further information. Record review of Resident #1's Nurse Practitioner (NP) progress notes, dated 09/09/2025, revealed, surgical dressing orders reinforced; stump dressing remains clean/dry/intact without drainage. Record review of an outpatient clinic wound progress note, dated 09/15/2025, revealed, Veteran seen in clinic today with [physician name]. Veteran is at [facility name]. Wound dressings are soiled, and odor present to left foot dressing. The wound assessment revealed a stage IV pressure ulcer to the left lateral malleolus (bony prominence on the outer side of the ankle) measuring 4.0 cm x 4.5 cm x 0.5 cm. The assessment revealed a DTI pressure ulcer (deep tissue injury characterized by damage to tissue underneath intact skin) inferior (inside) to left lateral malleolus measuring 6.7 cm x 7.0 cm x 0.0 cm. The wound assessment identified the right BKA and revealed the wound bed sutures were in place and no drainage noted. Record review of wound care physician assessment, dated 09/16/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.9 cm x 0.5 cm with a surface area of 10.15 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 16 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 16 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 16 days. The goal of the treatment was healing evidenced by a 66.7% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. The assessment revealed, the patient's plan of care was discussed with patient assigned nurse. Record review of wound care physician assessment, dated 09/23/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 5.0 cm x 4.0 cm x 0.5 cm with a surface area of 20.00 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The assessment included an arterial wound (skin injury caused by poor blood circulation) of the left, distal (outer), lateral foot that was arterial and measured 1.5 cm x 1.7cm x 0 and described as a scab. Record review of Resident #1's podiatry progress note, dated 09/24/2025, revealed, patient presents to clinic in a stretcher for left lateral ankle decubitus ulcer (caused by prolonged pressure to an area). The note revealed the left lateral ankle pressure ulcer measured 2.5 cm x 3.0 cm on 09/04/2025 and measured 3.5 cm x 3.5 cm on 09/24/2025. The wound was described as necrotic (death of tissue) in the peri wound (tissue surrounding a wound), had purulent drainage (a skin of infection. Thick milky fluid that comes out of a wound) noted and revealed the fibula bone (long slender bone in the lower leg) was exposed. The assessment revealed a left lateral ankle pressure ulcer stage 4 and history of right BKA. The plan revealed purulent drainage, malodor (offensive odor), necrotic wound base (dead or dying cells and tissues within a wound that are no longer able to carry out their normal function), and exposed fibula notified to left lateral ankle wound. Due to this and high risk right BKA patient was advised to go to [hospital] ED for further workup. Patient was transported via [ambulance]. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, sutures in place from R BKA, central area with small area of chronic weeping wound (a type of wound that produces clear fluid, blood, or pus that seeps from the injured area), no cellulitis (bacterial infection of the skin and soft tissues causing swelling, redness and pain), no pain, or crepitus extending proximally (air inside body tissues that can cause popping or cracking sounds). Left ankle with 4 cm lateral wound with exposed lat al, appears to track to joint (tunneling of wounds underneath the skin). CT imaging of the LLE revealed, lateral malleolus soft tissue ulceration which extends to the bone. Osteomyelitis (infection in the bone) of the distal fibula. Septic tibiotalar joint (infection in the joint of the ankle) with associated osteomyelitis of the tibia and talus (small bone in the ankle). CT of RLE revealed, no evidence of active osteomyelitis at this time. No evidence of soft tissue gas. The disposition plan was to admit Resident #1 to the hospital for further management and stabilization with the diagnosis of osteomyelitis of the left ankle and stated a surgical intervention was scheduled for the following day. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility progress note, dated 09/25/2025 at 12:48 a.m. by RN G, revealed, received report that patient is out to a doctor's appointment. At this time, the patient still out. Reported to administrator. There were no other relevant progress notes related to Resident #1's wounds observed in the progress notes. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and also revealed for other skin findings, L ankle covered with dressing, L foot art. Wound. Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses were, osteomyelitis of left ankle status post (a patients condition after a specific procedure, treatment or event) left below knee amputation, completed 09/24/2025 and history of right below knee amputation status post right below knee amputation incision and drainage by orthopedic surgery. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to LBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Monitor surgical incision to RBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with the hospital case manager, 09/30/2025 at 3:08 p.m., the hospital case manager stated Resident #1 was sent to the hospital directly from a doctor's appointment on 09/24/2025 due to Resident #1 having an infection in his left leg wound and stated Resident #1 had to have a below the knee amputation. The hospital case manager stated an outpatient wound nurse would go to the facility to see Resident #1 approximately once a week. She stated the outpatient wound care nurse would have to perform wound care for Resident #1 because it was not getting done by the facility and observed Resident #1 with no treatment dressings to his left ankle. The hospital case manager stated the outpatient wound care nurse discussed her concerns with nurses providing care and with the ADON/LVN, but nothing was done about it. The hospital case manager expressed concern over Resident #1's lack of wound care that resulted in an amputation. During an interview with LVN T, 10/02/2025 at 9:50 a.m., LVN T stated Resident #1 had orders for wound care for his right amputated knee and stated she did not provide wound care to Resident #1's left foot in the month of September because he did not have any orders. LVN T stated she followed the physician orders for the right stump. LVN T was aware of the wound to the left foot because LVN T stated the wound had had black tissue (dead or dying tissue) but did not report it to anyone including the physician, because everyone already knew. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with LVN B, 10/02/2025 at 10:51 a.m., LVN B stated he was assigned to Resident #1 and had been assigned to work with Resident #1 on previous shifts. LVN B stated he was aware that Resident #1 had a right BKA and wounds to his left foot and did not recall Resident #1 having treatment orders for his left foot. LVN B stated the nurses were responsible for performing wound care and completing skin assessments if the wound care nurse was not available. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated he just returned from the hospital and said, they amputated my left foot so now I have no feet. Resident #1 stated his right foot was amputated about a month ago and stated the left foot was amputated because it was infected. Resident #1 stated the doctors at the hospital just told him his foot was infected, and he stated he was glad that the infection did not go up further into his body. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1 stated staff were checking his right stump when he returned from the hospital after the right BKA but stated he did not recall any staff members providing wound dressings to his left foot in the last month. During an interview with CNA F, 10/02/2025 at 1:13 p.m. CNA F stated she was aware that Resident #1 had wounds on his left foot and stated she was in his room a day or two before he went to the hospital on [DATE]. CNA F stated Resident #1's left foot had an odor, and she would have to open the window to let the stench out of the room. CNA F stated Resident #1 told her he could not feel his leg and Resident #1 told CNA F that he thought it was getting infected and stated, he could also smell it and asked me to open the window. CNA F stated she told LVN H that Resident #1's foot had an odor when CNA F would give him bed baths. CNA F stated she thought other CNAs reported the wound odor to the nurses as well but could not confirm. During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. ADON/LVN stated when she transitioned to ADON/LVN the charge nurses were responsible for wound treatments and the charges nurses would follow the physician orders for wound care. The ADON/LVN stated Resident #1 was being followed by a wound care physician and the wound care physician would write wound orders in the wound care physician's progress notes and the progress notes were uploaded into the resident EMR. The ADON/LVN stated that she was responsible for reviewing the wound care physician notes and entering new wound care orders into a resident's EMR. The ADON/LVN stated, it's me, I am responsible for all the systems, and we should have a DON, but we don't, so I missed it. The wound care physician comes on Tuesday, and I will look in the system the next day to see if she saw any patients. IF there are new orders I go in and update them, but she does not change the orders often, so I didn't verify them every single week. ADON/LVN stated Resident #1 did not have wound care orders in his administration record and charge nurses would not have known to do wound care if there were no wound care orders. The ADON/LVN stated she performed wound care for Resident #1's left ankle wound several days during the month of September but did not know what days and did not document the wound care. The ADON/LVN stated she followed the orders in the wound care physician progress notes to complete the treatments for Resident #1 and stated she should have reviewed Resident #1's treatment orders and added the wound orders into Resident #1's orders at that time. The ADON/LVN stated the nurses were responsible for completing weekly skin assessments. The ADON/LVN stated she was responsible for completing the pressure ulcer assessments and no pressure ulcer assessments were completed for Resident #1 during September. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated it was important for residents to have treatment orders for their wounds, so the wound did not worsen or get infected. The ADON/LVN stated Resident #1 did not have any weekly skin assessments or pressure ulcer assessments during the month of September and stated she was responsible for monitoring the UDAs to ensure they were completed weekly. During an interview with the RCN, 10/02/2025 at 4:05 p.m., the RCN stated she became aware of a concern regarding Resident #1's wound care the prior night, 10/01/2025, when the RCN was reviewing Resident #1's clinicals and found that Resident #1 did not have wound care orders for his left ankle prior to his hospitalization and amputation of the left BKA. The RCN stated the concern was identified as neglect and reported the incident to HHSC. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was aware that Resident #1 had an amputation of his right leg, a few weeks ago and LVN L stated she did not recall any wound care orders for him and there was really not anything documented in the computer for what to do about the stump. LVN L stated she observed the stump on several occasions and stated that every time she observed the stump it did not have a dressing on it. LVN L stated she was unaware of Resident #1 having any wounds on his left foot and did not recall any treatment orders for his left foot. LVN L stated LVN N told her last week that Resident #1's stump was red and warm and stated LVN N reported the stump concern to nursing management. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was notified by a CNA that Resident #1's stump did not have a dressing on it and LVN N reviewed Resident #1's orders and recalled an order for the stump to have a wound dressing and to be kept clean and dry and stated Resident #1 had no other treatment orders. LVN N stated she did not recall the wound being red or warm and did not recall reporting an issue with Resident #1's stump. During an interview with CNA Q, 10/03/2025 at 8:35 a.m., CNA Q stated she had worked at the facility for two months and CNA Q stated she would help get Resident #1 ready for doctor appointments and stated she did not observe any wound care bandages on Resident #1's left foot. During an interview with LVN H, 10/03/2025 at 8:49 a.m., LVN H stated she was not sure if Resident #1 had any wounds, did not perform any wound care for Resident #1 and stated she never observed any wound care orders for Resident #1. During an interview with the Nurse Practitioner, 10/03/2025 at 10:42 a.m., the Nurse Practitioner stated when a resident returns from the hospital with wounds and no wound care orders, the nursing staff should have reassessed and measured the wounds, and a nurse should have called to get wound care orders. The Nurse Practitioner stated Resident #1 should have had wound care treatments completed daily and stated the lack of wound care treatments daily could have led to a catastrophic event. With such a complicated medical history, yes, it is very possible for lack of wound care to have led to that and worse. The Nurse Practitioner stated the facility wound care had room for improvement. During an interview with the Wound Care Physician, 10/03/2025 at 12:11 p.m., the Wound Care Physician stated that any changes in treatment orders were documented in her progress notes and uploaded into a resident's EMR and stated she did not have access to view resident orders. The Wound Care Physician stated it was up to the facility as to who was responsible for adding the Wound Care Physician orders into a resident's administrative orders and stated in most facilities it was completed by the Wound Care Nurse or the ADON. The Wound Care Physician stated she had concerns about the wound care performed for Resident #1 because he would have wound dressings that were not dated and there was no way for the Wound Care Physician to know when the treatment was completed. The Wound Care Physician stated Resident #1 should have had daily wound care treatments and stated Resident #1's wound had declined prior to Resident #1 going to the hospital on [DATE]. The Wound Care Physician stated leaving a wound dressing in place too long for Resident #1 could lead to infection for someone like him who had multiple other comorbidities and is vascular compromised and that can lead to wound deterioration and risk of infection. The Wound Care Physician stated a lack of daily wound care could have contributed to Resident #1 being admitted to the hospital with sepsis, osteomyelitis, and an amputation. The Wound Care Physician stated she would do a wound dressing for Resident #1 when she assessed him but stated she would only see him weekly. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated resident skin assessment should be completed by the nursing staff on admission, readmission and weekly. The Administrator stated it was important to complete weekly skin assessments because, it tells us if there is skin breakdown, wounds, pressure, etc. and we can monitor to see if skin is changing and what the baseline of the patient is and what the integrity of the skin is and to make sure the skin is taken care of because if you don't, it can lead to infection, sepsis, etc. During an interview with the Administrator, 10/03/2025 at 4:31 p.m., the Administrator stated that the lack of wound care for Resident #1 was neglect because it was a failure of the facility to not inquire about Resident #1's wound care and treatments and stated, all around, the staff were not doing their due diligence to take care of the wound. During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. Record review of an undated facility policy titled, Documentation, revealed, Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). The procedure revealed, document completed assessments in a timely manner and per policy. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. Record review of facility wound treatment management policy, revised 05/05/2025, revealed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse and treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Record review of the facility's undated abuse and neglect policy revealed, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal F600 Problem: The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE OR

Based on observation, interview, and record review the facility failed to ensure residents with surgical wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 8 residents (Resident 1) reviewed for surgical wounds in that: Resident #1 did not have weekly skin assessments during the month of September 2025, did not receive care to the right surgical wound as ordered by the physician and was admitted to the hospital on [DATE] with an infection to Resident #1's right below the knee amputation. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing surgical wounds or development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 2. Unstageable right heel, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September 2025 WAR/TAR revealed orders, start date 08/19/2025, keep dressing clean, dry intact. Do not remove, do not get wet. Cover to shower, every shift for surgical wound and monitor right leg stump for signs and symptoms of infection every shift for surgical wound. The WAR/TAR administration record for these orders was not initialed as completed on 09/07/2025 at 11 p.m. and 09/13/2025 on 3 p.m.- 11 p.m. Record review of Resident #1's EMR revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had an (unstageable (due to necrosis) of the right heel (signing off-area has been amputated). The etiology revealed pressure and stage was unstageable necrosis. Record review of Resident #1's Nurse Practitioner (NP) progress notes, dated 09/09/2025, revealed, surgical dressing orders reinforced; stump dressing remains clean/dry/intact without drainage. Record review of an outpatient clinic wound assessment progress note, dated 09/15/2025, revealed, Resident #1 had a right BKA and the wound bed sutures were in place and no drainage noted. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, sutures in place from R BKA, central area with small area of chronic weeping wound (a type of wound that produces clear fluid, blood, or pus that seeps from the injured area), no cellulitis (bacterial infection of the skin and soft tissues causing swelling, redness and pain), no pain, or crepitus extending proximally (air inside body tissues that can cause popping or cracking sounds). CT of RLE revealed, no evidence of active osteomyelitis at this time. No evidence of soft tissue gas. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and revealed, Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses revealed, history of right below knee amputation status post right below knee amputation incision and drainage by orthopedic surgery. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to RBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025, Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated his right foot was amputated about a month ago. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1 stated staff were checking his right stump when he returned from the hospital after the right BKA During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. The ADON/LVN stated the charge nurses were responsible for completing weekly skin assessments and the ADON/LVN was responsible for completing the pressure ulcer assessments. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated Resident #1 did not have any weekly skin assessments or pressure ulcer assessments during the month of September and stated she was responsible for monitoring the UDAs to ensure they were completed weekly. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was aware that Resident #1 had an amputation of his right leg, a few weeks ago and LVN L stated she did not recall any wound care orders for him and there was really not anything documented in the computer for what to do about the stump. LVN L stated she observed the stump on several occasions and stated that every time she observed the stump it did not have a dressing on it. LVN L stated she was unaware of Resident #1 having any wounds on his left foot and did not recall any treatment orders for his left foot. LVN L stated LVN N told her last week that Resident #1's stump was red and warm and stated LVN N reported the stump concern to nursing management. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was notified by a CNA that Resident #1's stump did not have a dressing on it and LVN N reviewed Resident #1's orders and recalled an order for the stump to have a wound dressing and to be kept clean and dry and stated Resident #1 had no other treatment orders. LVN N stated she did not recall the wound being red or warm and did not recall reporting an issue with Resident #1's stump. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated resident skin assessment should be completed by the nursing staff on admission, readmission and weekly. The Administrator stated it was important to complete weekly skin assessments because, it tells us if there is skin breakdown, wounds, pressure, etc. and we can monitor to see if skin is changing and what the baseline of the patient is and what the integrity of the skin is and to make sure the skin is taken care of because if you don't, it can lead to infection, sepsis, etc. During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. Record review of an undated facility policy titled, Documentation, revealed, Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). The procedure revealed, document completed assessments in a timely manner and per policy. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal Problem: The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE ORDERS MATCH. THIS MONITORING WILL BE INIATED [sic] ON 10/7/25 AND INDEFINATELY [sic]. CNAs INSERVICED ON REPORTING ALL NEW SKIN ISSUES TO NURSE ASAP AND DOCUMENTING THE FINDING/ALERT IN THE KIOSK ON 10/4/25 BY REGIONAL COMPLIANCE NURSE. CNAs INSERVICED ON S/SX OF SKIN BREAKDOWN, COMMON PRESSURE AREAS, AND PREVENTION ON 10/4/25 BY REGIONAL COMPLIANCE NURSE NURSES WERE INSERVICED ON COMPLETING SKIN ASSESSMENTS ON ADMISSION/readmission AND WEEKLY THEREAFTER, PER THE SCHEDULE PROVIDED. MANAGERS INSERVICED TO REVIEW CLINICAL ALERTS IN DAILY STAND UP TO MONTIOR FOR NEW WOUNDS, CHANGES IN WOUND, AND DECLINING WOUNDS. The medical director [physician] was notified of the immediate jeopardy situation on 10/4/2025 at 1:25 pm. MonitoringThe DON / designee will view each wound weekly AND ENDURE [sic] CORRECT ORDER IS IN PLACEThe DON / designee will audit all skin assessments and Weekly ulcer assessments weekly to ensure all assessment match the resident's current condition weekly.DON/Designee will audit all skin assessments and ulcer assessments weekly to ensure all residents received an assessment.DON/Designee will review all admissions/readmissions within 24 hours of admission to ensure orders are transcribed correctly and appointments are scheduled.DON/Designee will review WAR for completion of ordered wound treatments DAILY IN STAND UPDON/Designee will assess all dressings to ensure date reflects current date 5 x week X 4 WEEKSRegional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks.The QA committee will review findings and makes changes as needed monthly.The Administrator/Designee will review during stand up meetings if there was any evidence of any potential Neglect and initiate investigation / Self Report to HHSCADO/Regional Compliance Nurse will monitor by participating in facility's weekly SOC meeting x 6 weeks and at least 1 x per month x 3 months or until compliance is met. Monitoring of the POR included the following: During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head to toe skin assessment for Resident #3 and #5. The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings. Record review of EMR UDA log revealed 63 resident names. The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed. Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present. Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN). Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with the training for reporting and identifying skin concerns, abuse and neglect and reporting grievances or concerns from outside care teams. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text. Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issues to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention. The in-service had 16 signatures. Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns. Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD. All [wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match. The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN. Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks. The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. DON/Designee will assess all dressings to ensure date reflects the current date of 5 x week. DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The QA committee will review the findings and make changes as needed monthly. Wound care monitoring will be reviewing in stand up and stand down. Wound care monitoring will be reviewed for holes/omissions daily in stand up and stand down. Admin personnel must ensure systems will have adequate coverage when position is vacated. The in-service was signed by the ADON/LVN, Administrator and Interim DON. Record review of a facility in-service tracking spreadsheet revealed 12 licensed nurses received in person training and 6 licensed nurses had not worked the floor and received a text message with the training for identifying, assessing, notification, skin assessments and treatments. Record review of the daily staffing schedules for 10/02/2025 - 10/05/2025 and 10/06/2025 6a-6p revealed that all licensed nurses had signed the in-service for licensed nurses. Record review of an in-service dated 10/2/2025, for licensed nurses, read Pressure ulcer prevention and treatment including providing treatment as ordered and initialing/dating dressings-see attached policy. Documentation and accurate assessment of pressure ulcers- see policy. Initiating wound orders per MDs and upon admission/readmission. If a CNA reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MDs of changes immediately. Notification of physician with change of condition immediately. The in-service was signed by 12 LVNs. Record review of an employee roster revealed 73 total employees. Record review of an in-service dated 10/02/2025 revealed the topic was abuse and neglect and revealed 40 employee signatures. Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation. The in-service revealed 62 signatures. During an interview with CNA R, 10/04/2025 at 9:43 a.m. CNA R stated she had received training on identifying wounds and reporting wounds to the charge nurse. During an interview with LVN P, 10/04/2025 at 11:56 a.m., LVN P stated she received training on wound care, following physician orders and abuse and neglect on 10/02/2025 and stated the training was provided by the RCN. During an interview with CNA U, 10/04/2025 at 12:13 p.m. CNA U stated she had received training on identifying wounds and abuse and neglect on 10/02/2025 and stated she would report any skin concerns to the charge nurse and report allegations of abuse to the Administrator. During an interview with the Administrator, 10/4/2025 at 3:30pm, the Administrator stated Admin/Personnel were identified as the Administrator, Interim DON, and ADON. The Administrator revealed the Medical Director was notified of the immediate jeopardy regarding neglect and wound care on 10/4/2025. The Administrator revealed monitoring forms were created to monitor the wound care processes and stated the DON/Designee will review wounds weekly to ensure the correct orders are in place, will audit skin assessments and weekly pressure ulcer assessments, review admission and readmissions within 24 hours of admission, review resident WAR/TAR weekly to ensure treatments are being completed and will observe resident wound dressing for accurate dates and validate that resident wounds have treatment orders in place. These findings will be documented on the monitoring forms and the findings will be brought to QA. The Administrator stated she received the training and education on expectations from the RCN on 10/4/25. During an interview with the Administrator, 10/05/2025 at 3:30 p.m., the Administrator stated staff in-servicing on abuse and neglect was initiated on 10/02/2025 and all staff that have worked since 10/02/25 have been educated on abuse and neglect. The Administrator stated staff were educated on types of abuse and neglect, who to report to, how soon to report and the importance of reporting complaints or concerns from visitors, vendors, etc. directly to the administrator. During interviews conducted on 10/05/2025 and 10/06/2025, included a total of 10 CNAs [CNA E, R, F, Q, LL, KK, X, LL, MM, NN] ( 5 - 6a-6p and 1 6p-6a) (2 6a-6p and 1 6p-6a who confirmed receipt of a text message with training on abuse and neglect [CNA LL, MM, NN]), 4 LVNs [LVN P, O, B, H] (2 6a-6p, 1 6p-6a, 1 PRN both shifts), 1 PRN 6p-6a RN [ RN J] who confirmed receipt for a text in-service on abuse and neglect, 1 RN [RN G] ( 6p-6a), 1 MDS/LVN, 1 BOM, 4 Dietary [Dietary Y, DD, EE, FF], 5 Housekeeping [Housekeeping Z, AA, BB, CC, JJ], 1 Maintenance Director, 2 Therapists [Therapy GG, HH], 1 Social Worker, 1 Activity Director, 1 Medical Records/Central Supply and 1 HR. Staff interviews revealed staff had received education on abuse and neglect and were able to provide examples of neglect Staff demonstrated understanding of reporting allegations of abuse and neglect directly to the administrator immediately and reporting any concerns or complaints to the Administrator immediately. During an interview with the Administrator, 10/04/2025 at 4:03 p.m., revealed the Administrator was educated by the ADO on 10/04/2025 on ensuring the DON/ADON reviewed new wound orders and validated the orders that were transcribed into PCC accurately by auditing an order listing report and the Administrator was to investigate and report to corporate and HHSC any incidents that may be considered abuse or neglect. During an interview with the RCN, 10/05/2025 at 9:45 a.m., the RCN revealed 100% resident skin rounds were completed on 10/02/2025 that included head to toe assessments of each resident. Skin assessments were completed with detailed findings and new orders were transcribed into [EMR]. The RCN revealed multiple in-services were initiated for CNAs, licensed nurses and administration/personnel and all staff currently working had been in-serviced by discipline. The RCN stated any staff that had not been in-serviced would be in-serviced prior to the start of their shift and the in-servicing was completed by the RCN and Administrator. The RCN stated CNAs were in-serviced on 10/04/2025 and ongoing on identifying skin breakdown, reporting skin issues to the nurse immediately and where to document new findings on the kiosk. The RCN stated licensed nurses were in-serviced on 10/02/2025 regarding pressure ulcer prevention and initialing and dating dressing, documentation and completing accurate assessments, initiating wound orders upon admission/readmission, immediately assessing and notifying the physician, documenting and obtaining treatment orders when notified or observing a new skin issue and notifying the physician immediately of changes in condition. The RCN stated all facility staff were in-serviced on abuse and neglect and reporting complaints directly to the Administrator. The Administrator/DON and ADON were educated on 10/04/2025 that the DON/Designee will round with the wound care physician weekly and will ensure orders are immediately entered into the EMR when the order is verbally given by the wound care physician and the progress notes will be printed 24 hours after the wound care physician visit to ensure the orders match in the EMR. The RCN revealed the Administrator, DON and ADON were educated on expectations monitoring of the plan of removal. The RCN stated monitoring forms were created to track the monitoring, and the DON/Designee was responsible for completing and documenting on the monitoring tool. Monitoring included viewing each wound weekly and making sure the correct orders were in place and round with the wound care physician weekly. Audit all skin and ulcer assessments weekly to make sure they match the resident's current condition and audit to make sure all residents have weekly skin assessments and ulcer assessments. Review admission/readmissions to ensure the orders are transcribed correctly and appointments were scheduled as needed. Review the administration record for the completion of ordered wound treatments from the previous day and ensure all dressing have the current date and are initialed. The monitoring forms will be reviewed, signed, and dated by the RCN weekly to validate it was being completed. The RCN and ADO will attend standard of care meetings weekly. Findings from the monitoring will be brought to QAPI monthly and reviewed for compliance and changes to the plan initiated as needed. During an interview with the ADO, 10/05/2025 at 10:50 a.m., revealed the ADO educated the Administrator on 10/04/2025 regarding checking orders daily in the morning meeting and ensuring the nursing managers were reviewing wound orders and validating the orders were transcribed into the EMR. During an interview with DON, 10/05/2025 at 11:48 a.m., revealed the DON received education and training from the RCN on 10/2/2025 and 10/4/2025 regarding expectations for rounding with the wound care physician weekly and validating daily in clinical review that resident treatment orders reflect the wound care physician progress notes, wound assessments are completed weekly and on admission and readmission, each resident has appropriate wound care orders, wound dressings are accurately dated and monitoring wound administration to ensure wound treatments are completed daily. The DON stated she would track the monitoring on a monitoring log and document her findings, and the findings would be brought to the monthly QAPI to review for compliance. During an interview with Medical Director, 10/5/2025 at 2:09pm, revealed the Medical Director and [physician] were notified of the immediate jeopardy for neglect and wound care by the Administrator on 10/04/2025 and the Medical Director reviewed the plan of removal, the protocols and steps being taken to ensure compliance. Record review of a monitoring document revealed, The DON/designee will view each wound weekly to ensure the correct order is in place. The document had 5 blocks with blanks for a date, resident name, and staff name. Record review of a monitoring document revealed, The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly. The document had 5 blocks with blanks for the date, weekly skin assessments correct YES/No, staff name. Record review of a monitoring document revealed, DON/Designee will review all admissions/readmissions within 24 hours of admission. The document had 5 blocks with blanks for date, resident name, admission complete YES/NO if no describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly. The document had 5 blocks for date, resident name, WAR/TAR completed YES/No If no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will assess all dressing to ensure date reflects current date. The document had 5 blocks for date, resident name, Dressing dated correctly YES/NO if no, describe on back of form and staff name. Record review of a monitoring document revealed, DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks. The document had 5 blocks for date, resident name, treatment orders in place YES/NO If no, describe on back of form and staff name. Record review of an ADHOC QAPI meeting, dated 10/2/2025 revealed signatures including the Administrator, Interim DON, and ADON. The Administrator was informed that the Immediate Jeopardy was removed on 10/06/2025 at 2:24 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 8 residents (Resident 1) reviewed for pressure ulcers in that: Resident #1 had a Stage IV pressure ulcer on his left ankle and did not have wound treatment orders in the month of September 2025. Resident #1 was admitted to the hospital on [DATE] with osteomyelitis and had a left below the knee amputation on 09/25/2025. An Immediate Jeopardy (IJ) was identified on 10/03/2025. The IJ template was provided to the facility on [DATE] at 4:53 p.m. While the IJ was removed on 10/06/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not IJ, due to the need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #1's, undated, face sheet revealed Resident #1 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus of lung (cancer of the lung or respiratory airway), quadriplegia (paralysis of a person's limbs), kidney disease (damage to kidney function), viral hepatitis c (a liver disease), cirrhosis of liver (scarring and damage to the liver) and encephalopathy (condition that caused brain dysfunction). Record review of Resident #1's quarterly MDS assessment, dated 08/19/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 had impairment on one side of his upper and lower extremity, used a wheelchair for mobility, required moderate assistance with bed mobility and was dependent on staff for transfers and personal hygiene. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers, had 1 Stage III pressure ulcer and 2 unstageable pressure ulcers. Record review of Resident #1's undated comprehensive care plan revealed a care plan, the resident has a pressure ulcer or potential for pressure ulcer development: 1. Unstageable left lateral, (outer) ankle, dated 08/05/2025 and revised 08/11/2025. The goal of the care plan was for Resident #1's pressure ulcer to show signs of healing and remain free from infection with a target date of 11/07/2025. Interventions revealed staff would administer treatments as ordered, monitor the effectiveness and replace loose or missing dressings PRN. The interventions also included for staff to assess/record/monitor wound healing at least weekly and measure length, width, and depth, document the status of the wound perimeter and wound bed and healing process. Staff were to report declines to the MD. Record review of Resident #1's September 2025 WAR/TAR revealed no wound care treatment orders for the left ankle. Record review of Resident #1's EMR revealed Resident #1 had no weekly skin assessments or weekly pressure ulcer assessments during the month of September until 09/25/2025, after Resident #1 was admitted to the hospital on [DATE]. Record review of wound care physician assessment, dated 08/26/2025, revealed Resident #1 had a Stage IV pressure wound (a wound that has full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) of the left, lateral ankle and measured 3.5cm x 2.5 cm x 0.1 cm with a surface area of 8.75cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The goal of the treatment was healing evidenced by a 75% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/02/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3 cm x 2.5 cm x 0.5 cm with a surface area of 7.50 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 30 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 30 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 30 days. The goal of the treatment was healing evidenced by a 14.3% decrease in surface are a within the wound bed in comparison to the previous wound care visit.Record review of wound care physician assessment, dated 09/09/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.5 cm x 0.5 cm with a surface area of 8.75 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 23 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 23 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 23 days. Record review of an outpatient clinic wound progress note, dated 09/15/2025, revealed, Veteran seen in clinic today with [physician name]. Veteran is at [facility name]. Wound dressings are soiled, and odor present to left foot dressing. The wound assessment revealed a stage IV pressure ulcer to the left lateral malleolus (bony prominence on the outer side of the ankle) measuring 4.0 cm x 4.5 cm x 0.5 cm. The assessment revealed a DTI pressure ulcer (deep tissue injury characterized by damage to tissue underneath intact skin) inferior (inside) to left lateral malleolus measuring 6.7 cm x 7.0 cm x 0.0 cm. Record review of wound care physician assessment, dated 09/16/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 3.5 cm x 2.9 cm x 0.5 cm with a surface area of 10.15 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 16 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 16 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 16 days. The goal of the treatment was healing evidenced by a 66.7% decrease in nonviable tissue within the wound bed in comparison to the previous wound care visit. Record review of wound care physician assessment, dated 09/23/2025, revealed Resident #1 had a Stage IV pressure wound of the left, lateral ankle and measured 5.0 cm x 4.0 cm x 0.5 cm with a surface area of 20.00 cm. The dressing treatment plan revealed, Leptospermum honey apply once daily and as needed: if saturated, soiled or dislodged. For 9 days; Alginate calcium apply once daily and as needed: if saturated, soiled or dislodged, for 9 days. Secondary Dressing - gauze island w/bdr apply once daily and as needed: if saturated, soiled or dislodged. For 9 days. The assessment included an arterial wound (skin injury caused by poor blood circulation) of the left, distal (outer) lateral foot that was arterial and measured 1.5 cm x 1.7cm x 0 and described as a scab. Record review of Resident #1's podiatry progress note, dated 09/24/2025, revealed, patient presents to clinic in a stretcher for left lateral ankle decubitus ulcer (caused by prolonged pressure to an area). The note revealed the left lateral ankle pressure ulcer measured 2.5 cm x 3.0 cm on 09/04/2025 and measured 3.5 cm x 3.5 cm on 09/24/2025. The wound was described as necrotic (death of tissue) in the peri wound (tissue surrounding a wound), had purulent drainage (a skin of infection. Thick milky fluid that comes out of a wound) noted and revealed the fibula bone (long slender bone in the lower leg) was exposed. The assessment revealed a left lateral ankle pressure ulcer stage 4 and history of right BKA. The plan revealed purulent drainage, malodor (offensive odor), necrotic wound base (dead or dying cells and tissues within a wound that are no longer able to carry out their normal function), and exposed fibula notified to left lateral ankle wound. Due to this and high risk right BKA patient was advised to go to [hospital] ED for further workup. Patient was transported via [ambulance]. Record review of Resident#1's emergency department hospital notes, dated 09/24/2025 revealed, Chief Complaint: patient presents from a nursing home with low blood pressure and possible wound infections. History of Present Illness (HPI): The patient was transported from a nursing home to a podiatry appointment where they were noted to have low blood pressure and significant ulcers. The ulcers include a deep ulcer on the left lateral malleolus open wound, as well as a recent BKA on the right, both appearing infected. The patient is found to be lethargic and poorly responsive, indicating altered mentation (occurs when illnesses, disorders and injuries affect brain function). Onset of symptoms is acute, with ulcers likely developing over time due to underlying conditions. Exam revealed, left ankle with 4 cm lateral wound with exposed lat al, appears to track to joint (tunneling of wounds underneath the skin). CT imaging of the LLE revealed, lateral malleolus soft tissue ulceration which extends to the bone. Osteomyelitis (infection in the bone) of the distal fibula. Septic tibiotalar joint (infection in the joint of the ankle) with associated osteomyelitis of the tibia and talus (small bone in the ankle). The disposition plan was to admit Resident #1 to the hospital for further management and stabilization with the diagnosis of osteomyelitis of the left ankle and stated a surgical intervention was scheduled for the following day. Record review of Resident #1's hospital ED critical care note, dated 09/24/2025, revealed, the patient meets the criteria for critical illness, with acute impairment of circulation, septic shock (life threatening immune system reaction to an infection) in the setting of osteomyelitis. Vital organ systems, and is at high risk of imminent, life threatening deterioration without urgent intervention and revealed, Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis and osteomyelitis, which required my direct attention, intervention and personal management. Record review of Resident #1's facility progress note, dated 09/25/2025 at 12:48 a.m. by RN G, revealed, received report that patient is out to a doctor's appointment. At this time, the patient still out. Reported to administrator. There were no other relevant progress notes related to Resident #1's wounds observed in the progress notes. Record review of Resident #1's facility weekly skin assessment, effective date 09/25/2025 at 12:00 p.m. and signed by LVN K 09/26/2025, revealed a question, Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete the Ulcer Assessment. The answer was coded yes and also revealed for other skin findings, L ankle covered with dressing, L foot art. Wound. Wound provider consult in place and Tx orders in place. Record review of Resident #1's facility progress note, dated 09/25/2025 at 3:26 p.m. by ADON/LVN revealed, Patient went out for a scheduled appointment and was admitted to [hospital] following appointment. Record review of Resident #1's hospital discharge notes, dated 10/01/2025, revealed Resident #1's principal discharge diagnoses were, osteomyelitis of left ankle status post (a patient's condition after a specific procedure, treatment or event) left below knee amputation, completed 09/24/2025. Equipment supplies listed for discharge included, two portable [company] incision management system. Record review of Resident #1's facility progress note, dated 10/01/2025 at 9:45 p.m. by LVN N, revealed, Resident has wound vacs (vacuum-assisted closure is a type of therapy that uses a device to decrease air pressure on a wound) to BLE, has bilateral below knee amputations. Record review of Resident #1's weekly skin assessment, dated 10/02/2025 at 1:55 p.m. by LVN N, revealed Resident had wound vacs to BLE related to bilateral below knee amputations and LVN N was unable to assess due to bandages and wound vacs. Record review of Resident #1's October 2025 administration orders revealed the following orders, Monitor surgical incision to LBKA, surgical wound vac in place and will be discontinued by surgeon. Wound vac not to be changed by nurses, contact [hospital] if wound vac malfunctions. Every shift for wound care dated 10/02/2025. Wound MD to evaluate resident dated 10/02/2025 and an ortho (orthopedic) follow up appointment scheduled for 10/7/2025 at 9:30 a.m. During an interview with the hospital case manager, 09/30/2025 at 3:08 p.m., the hospital case manager stated Resident #1 was sent to the hospital directly from a doctor's appointment on 09/24/2025 due to Resident #1 having an infection in his left leg wound and stated Resident #1 had to have a below the knee amputation. The hospital case manager stated an outpatient wound nurse would go to the facility to see Resident #1 approximately once a week. She stated the outpatient wound care nurse would have to perform wound care for Resident #1 because it was not getting done by the facility and observed Resident #1 with no treatment dressings to his left ankle. During an interview with the Interim DON, 10/1/2025 at 12:51 p.m. The Interim DON stated she started at the facility 3 days prior, and the previous DON had not worked in the facility for approximately 3 weeks. The Interim DON stated ADON/LVN was the prior wound care nurse and moved into the ADON/LVN position several weeks ago. During an interview with LVN C, 10/01/2025 at 2:03 p.m., LVN C said she was assigned to Resident #1's hall and stated she had not received training on completing wound care and stated the wound care nurse was responsible for wound care treatments and she thought the facility had a wound care physician but did not know who reported findings to the physician. LVN C stated if the wound care nurse was not in the facility, the charge nurses were responsible for completing wound care and LVN C said she would review a resident's administration orders in the EMR to determine what wound treatments are ordered. LVN C stated wound orders are located in a resident's EMR under the TAR or WAR section of the orders and the orders would detail the interventions to follow to provide wound care. LVN C stated if she were aware of a resident wound that did not have an order for treatment, she would have notified the wound care nurse or the ADON. LVN C stated she was not aware of any residents having wounds without orders and stated it was important for resident wounds to be treated, to prevent further breakdown of the skin and they could become septic. We want to stop infection. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated she knew when a resident had wounds because she would review a resident's physician orders and see if the resident had wound care treatment orders. LVN D stated the wound treatment nurse was responsible for wound treatments and if that person was not available, the charge nurses were responsible for wound care. LVN D stated she thought the ADON, or wound care nurse communicated directly with the wound care physician regarding resident wound progress and orders. LVN D stated resident wound care orders and treatments were listed in the EMR under the TAR/WAR for the residents and stated the ADON or DON were responsible for adding wound care orders to the TAR/WAR. LVN D stated it was important for residents to have wound care treatment orders if they had a wound, because if not, they could get an infection and get septic, and the wound will never heal if it does not get treated. LVN D stated the wound care nurse was responsible for doing weekly skin assessments when a resident had a wound. During an interview with LVN B, 10/02/2025 at 10:51 a.m., LVN B stated he would look at a resident's treatment orders in the EMR to see if a resident had a wound and what treatment orders were to be administered for the resident. LVN B stated nurses were responsible for completing weekly skin assessments and performing wound care if the wound care nurse was not available. LVN B stated he was assigned to Resident #1 and had been assigned to work with Resident #1 on previous shifts. LVN B stated Resident #1 had wounds on his left leg. LVN B stated he would complete wound treatments for Resident #1 based on the wound treatment orders in the EMR and stated he was unaware of what treatment orders were in place for Resident #1. During an interview with Resident #1, 10/02/2025 at 11:41 a.m., Resident #1 stated he just returned from the hospital and said, they amputated my left foot so now I have no feet. Resident #1 stated his right foot was amputated about a month ago and stated the left foot was amputated because it was infected. Resident #1 stated the doctors at the hospital just told him his foot was infected, and he stated he was glad that the infection did not go up further into his body. Resident #1 denied having pain and did not appear in psychosocial distress. Resident #1 was observed lying in bed with a wound vac connected to his R and L BKA. Dressings appeared clean and dry. Resident #1stated he did not recall any staff members providing wound dressings to his left foot in the last month. During an interview with CNA F, 10/02/2025 at 1:13 p.m. CNA F stated she was aware that Resident #1 had wounds on his left foot and stated she was in his room a day or two before he went to the hospital on [DATE]. CNA F stated Resident #1's left foot had an odor, and she would have to open the window to let the stench out of the room. CNA F stated Resident #1 told her he could not feel his leg and Resident #1 told CNA F that he thought it was getting infected and stated, he could also smell it and asked me to open the window. CNA F stated she told LVN H that Resident #1's foot had an odor when CNA F would give him bed baths. CNA F stated she would see a bandage on his left ankle at times but unable to recall dates or times. CNA F stated she thought other CNAs reported the wound odor to the nurses as well but could not confirm. During an interview with ADON/LVN, 10/02/2025 at 2:19 p.m., ADON/LVN stated she was hired as the wound care treatment nurse in July 2025 and transferred into the ADON/LVN position right before the facility had their recertification survey 08/27/2025. ADON/LVN stated when she transitioned to ADON/LVN the charge nurses were responsible for wound treatments and the charges nurses would follow the physician orders for wound care. The ADON/LVN stated Resident #1 was being followed by a wound care physician and the wound care physician would write wound orders in the wound care physician's progress notes and the progress notes were uploaded into the resident EMR. The ADON/LVN stated that she was responsible for reviewing the wound care physician notes and entering new wound care orders into a resident's EMR. The ADON/LVN stated, it's me, I am responsible for all the systems, and we should have a DON, but we don't, so I missed it. The wound care physician comes on Tuesday, and I will look in the system the next day to see if she saw any patients. IF there are new orders I go in and update them, but she does not change the orders often, so I didn't verify them every single week. ADON/LVN stated Resident #1 did not have wound care orders in his administration record and charge nurses would not have known to do wound care if there were no wound care orders. The ADON/LVN stated the charge nurses were responsible for completing weekly skin assessments and the ADON/LVN was responsible for completing the pressure ulcer assessments. The ADON/LVN stated she had received training on completing the pressure ulcer assessments and said the assessments were important to monitor the progress of wounds. The ADON/LVN stated it was important for residents to have treatment orders for their wounds, so the wound did not worsen or get infected. During an interview with LVN H, 10/02/2025 at 3:51 p.m., LVN H stated no one had reported Resident #1 having an odor to his left foot wound. During an interview with the RCN, 10/02/2025 4:05 p.m., the RCN stated she became aware of a concern regarding Resident #1's wound care the prior night, 10/01/2025, when the RCN was reviewing Resident #1's clinicals and found that Resident #1 did not have wound care orders for his left ankle prior to his hospitalization and amputation of the left BKA. The RCN stated the concern was identified as neglect and reported the incident to HHSC. During an interview with LVN L, 10/02/2025 at 6:16 p.m., LVN L stated she worked the night shift and was assigned to Resident #1's hall. LVN L stated she was unaware of Resident #1 having any wounds on his left foot, did not perform any wound care for Resident #1's left foot, and did not recall any treatment orders for his left foot. During an interview with LVN N, 10/02/2025 at 7:20 p.m., LVN N stated she was not aware of Resident #1 having any wounds on his left foot. LVN N stated she did not provide wound care for Resident #1's left foot and never observed anyone doing wound care for Resident #1's left foot. During an interview with CNA Q, 10/03/2025 at 8:35 a.m., CNA Q stated she had worked at the facility for two months and CNA Q stated she would help get Resident #1 ready for doctor appointments and stated she did not observe any wound care bandages on Resident #1's left foot. During an interview with LVN H, 10/02/2025 at 8:49 a.m., LVN H stated she did not perform any wound care for Resident #1 and stated she never observed any wound care orders for Resident #1. During an interview with the Nurse Practitioner, 10/03/2025 at 10:42 a.m., the Nurse Practitioner stated when a resident returns from the hospital with wounds and no wound care orders, the nursing staff should have reassessed and measured the wounds, and a nurse should have called to get wound care orders. The Nurse Practitioner stated Resident #1 should have had wound care treatments completed daily and stated the lack of wound care treatments daily could have led to a catastrophic event. With such a complicated medical history, yes, it is very possible for lack of wound care to have led to that and worse. The Nurse Practitioner stated the facility wound care had room for improvement. During an interview with the Wound Care Physician, 10/03/2025 at 12:11 p.m., the Wound Care Physician stated that any changes in treatment orders were documented in her progress notes and uploaded into a resident's EMR and stated she did not have access to view resident orders. The Wound Care Physician stated it was up to the facility as to who was responsible for adding the Wound Care Physician orders into a resident's administrative orders and stated in most facilities it was completed by the Wound Care Nurse or the ADON. The Wound Care Physician stated she had concerns about the wound care performed for Resident #1 because he would have wound dressings that were not dated and there was no way for the Wound Care Physician to know when the treatment was completed. The Wound Care Physician stated Resident #1 should have had daily wound care treatments and stated Resident #1's wound had declined prior to Resident #1 going to the hospital on [DATE]. The Wound Care Physician stated leaving a wound dressing in place too long for Resident #1 could lead to infection for someone like him who had multiple other comorbidities and is vascular compromised and that can lead to wound deterioration and risk of infection. The Wound Care Physician stated a lack of daily wound care could have contributed to Resident #1 being admitted to the hospital with sepsis, osteomyelitis, and an amputation. The Wound Care Physician stated she would do a wound dressing for Resident #1 when she assessed him but stated she would only see him weekly. During an interview with the Administrator, 10/03/2025 at 2:42 p.m., the Administrator stated the ADON/LVN was still responsible for doing wound care treatments 3 days out of the week and overseeing the wound care responsibilities after she transitioned to the ADON/LVN position. The Administrator stated it should have been communicated to the Wound Care Physician that Resident #1 did not have wound care orders to provide wound care and stated a resident who had a wound and no wound care orders could lead to an amputation of an extremity and cause infections and sepsis. Record review of facility wound treatment management policy, revised 05/05/2025, revealed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse and treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention, Assessment and Treatment, revealed, Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [EMR]. 2. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. This was determined to be an Immediate Jeopardy (IJ) on 10/03/2025 at 4:20 p.m. The Administrator and Interim DON were notified. The Administrator and the DON were provided with the IJ Template on 10/03/2025 at 4:53 p.m. The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 12:26 p.m.: Problem: The facility failed to ensure that a resident with pressure ulcers (Resident #1) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from development. Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses. All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced. All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR] AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE ORDERS MATCH. THIS MONITORING WILL BE INIATED [sic] ON 10/7/25 AND INDEFINATELY [sic]. CNAs INSERVICED ON REPORTING ALL NEW SKIN ISSUED [sic] TO NURSE ASAP AND DOCUMENTING THE FINDING/ALERT IN THE KIOSK ON 10/4/25 BY REGIONAL COMPLIANCE NURSE. CNAs INSERVICED ON S/SX OF SKIN BREAKDOWN, COMMON PRESSURE AREAS, AND PREVENTION ON 10/4/25 BY REGIONAL COMPLIANCE NURSE NURSES WERE INSERVICED ON COMPLETING SKIN ASSESSMENTS ON ADMISSION/readmission AND WEEKLY THEREAFTER, PER THE SCHEDULE PROVIDED. MANAGERS INSERVICED TO REVIEW CLINICAL ALERTS DAILY STAND UP TO MONTIOR FOR NEW WOUNDS, CHANGES IN WOUND, AND DECLINING WOUNDS. The medical director [name] was notified of the immediate jeopardy situation on 10/3/2025 at 5:26 pm. MonitoringThe DON / designee will view each wound weekly AND ENDURE [sic] CORRECT ORDER IS IN PLACEThe DON / designee will audit all skin assessments and Weekly ulcer assessments weekly to ensure all assessment match the resident's current condition weekly.DON/Designee will audit all skin assessments and ulcer assessments weekly to ensure all residents received an assessment.DON/Designee will review all admissions/readmissions within 24 hours of admission to ensure orders are transcribed correctly and appointments are scheduled.DON/Designee will review WAR for completion of ordered wound treatments DAILY IN STAND UPDON/Designee will assess all dressings to ensure date reflects current date 5 x week X 4 WEEKSRegional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks.The QA committee will review findings and make changes as needed monthly. Monitoring of the POR included the following: During an observation, 10/04/2025 at 11:45 a.m., Resident #1 was observed and had clean and dry bandages to the left and Right BKA, and wound vac was attached to both BKAs. During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head-to-toe skin assessment for Resident #3 and #5. The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings. Record review of EMR UDA log revealed 63 resident names. The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed. Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present. Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN). Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with training for reporting and identifying skin concerns. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text. Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issued to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention. The in-service had 16 signatures. Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns. Record review of an employee roster revealed 73 total employees. Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation. The in-service revealed 62 signatures. Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD. All [Wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match. The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN. Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks. The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident # 5, 6 and 8) reviewed for infection control in that: Resident #5 had a foley catheter and did not have a sign for Enhanced Barrier Precautions (EBP).Resident #6 had a foley catheter and was observed with her foley catheter tubing touching the floor under Resident #6's wheelchair.Resident #8 had a gastric tube and did not have a sign for Enhanced Barrier Precautions (EBP). This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: 11.Record review of Resident #5's undated face sheet revealed Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type 2 (high blood sugar levels), cerebral infarction (stroke) and hydronephrosis with renal and ureteral calculous obstruction (swelling of one or both kidneys causing a blockage or obstruction).Record review of Resident #5's MDS assessment, dated 08/12/2025, reflected Resident #5 had a BIMS score of 04, indicating severe cognitive impairment. Section GG- Functional Abilities revealed Resident #5 was dependent on staff for bed mobility, transfers, toileting hygiene, and bathing. Section H - Bladder and Bowel revealed Resident #5 had an indwelling catheter and was incontinent of bowel and bladderRecord review of Resident #5's comprehensive care plan revealed a care plan, dated 08/11/2025 and revised 09/11/2025, that read, [Resident] is on enhanced barrier precautions. An intervention revealed, posting at the residents room entrance indicating the resident is on enhanced barrier precautions.During an observation, 10/01/2025 at 1:17 p.m., Resident #5's room did not have any postings indicating Resident #5 was on enhanced barrier precautions. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated she was assigned to Resident #5 and stated Resident #5 was on EBP. LVN D stated residents on EBP should have had a sign outside of the door indicating the residents were on EBP and what PPE supplies were required to provide direct care. LVN D stated she had received training on EBP and stated it was important to identify residents on EBP to prevent the spread of infection.2. Record review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), cerebral infarction (stroke) and chronic kidney disease (loss of kidney function to filter waste from the blood). Record review of Resident #6's quarterly MDS assessment, dated 09/02/2025 revealed Resident #6 had short term and long-term memory deficits and Resident #6's cognitive decision making was severely impaired. Section GG - Functional Abilities revealed Resident #6 required supervision assistance with transferring from the bed to wheelchair and required maximum assistance with toileting hygiene. Section H - Bladder and Bowel revealed Resident #6 had an indwelling catheter and was incontinent of bowel and bladder.Record review of Resident #6's comprehensive care plan revealed a care plan dated 03/07/2025, catheter. The interventions revealed, check tubing for kinks and maintain the drainage bag off the floor.During an observation of Resident #6, 10/01/2025 at 1:45 p.m., Resident #6 was observed sitting at the nurse's station with a foley catheter bag underneath her wheelchair and the foley tubing was touching the floor underneath the wheelchair.During an interview with LVN C, 10/01/2025 at 2:03 p.m., LVN C stated a resident's foley catheter tubing should not touch the floor and the tubing should have been secured to prevent the spread of infection. LVN C stated all nursing staff were responsible for ensuring tubing was not loose or touching the floor and LVN C stated she had received training on infection control.3. Record review of Resident #8's undated face sheet revealed Resident #8 was a [AGE] year-old male who admitted to the facility in 07/11/2025 with diagnoses that included spastic quadriplegic cerebral palsy (a disorder that causes muscle stiffness in all four limbs), dysphagia (difficulty swallowing) and epilepsy (a disorder causing seizures).Record review of Resident #8's quarterly MDS assessment, dated 09/05/2025, revealed Resident #8 had a BIMS score of 00, indicating a severe cognitive impairment. Section GG - Functional Abilities revealed Resident #8 was dependent on staff for eating, transfers, and bed mobility. Section K - Swallowing/Nutritional Status revealed Resident #8 had a feeding tube. Record review of Resident #8's undated comprehensive care plan revealed a care plan, dated 07/11/2025 and revised 07/30/2025, [Resident] is on enhanced barrier precautions in relation to the gastric tube placement and the intervention, posting at the residents room entrance indicating the resident is on enhanced barrier precautions.During an observation, 10/01/2025 at 1:52 p.m., Resident #8's room had PPE supplies outside of the room door and no EBP sign posted to indicate that Resident #8 was on EBP.During an interview with LVN C, 10/01/2025 at 1:58 p.m., LVN C stated Resident #8 had a peg tube and stated Resident #8 had a PPE cart outside of his room because he had a peg tube. LVN C stated she was not sure if there was a EBP sign indicating Resident #8 was on EBP. LVN C stated she had training on EBP precautions not too long ago but it was not recent and stated she did not know who was responsible for posting the EBP signs. LVN C stated it was important to post the signs, I guess so we know what to put on.During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated EBP was to be used for a list of reasons and for anything that can be contagious when contacting the patient. The Administrator stated residents on EBP would have a PPE container outside of the resident room and would have a sign on the resident door indicating they were on EBP. The Administrator stated staff had received training on EBP and it was important for residents on EBP to be identified with a sign because We have residents with suppressed immune systems and if they were in contact with someone who has something that is contagious, they could get infected and put them at greater risk. The Administrator stated catheter tubing should not touch the floor Because there is debris on the floor and particles can get in the peri area and it is an infection control concern. Floors are unsanitary and stated staff had received training on keeping foley tubing off of the floor. Record review of a facility policy titled, Enhanced Barrier Precautions revealed, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. The policy revealed, Communication to Staff: The facility will utilize postings outside the room and [EMR] to communicate to staff is a resident requires EBP.

Based on observation, interview and record review the facility failed to ensure personal privacy for 1 of 8 residents (Resident #5) observed for foley catheters in that: Resident #5 was observed in bed with her foley bag attached to the side of the bed without a privacy cover, exposing her foley bag contents to the open bedroom door. This deficient practice could affect residents who have foley catheter bags and could result in loss of dignity and low self-esteem. The findings were: Record review of Resident #5's undated face sheet revealed Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type 2 (high blood sugar levels), cerebral infarction (stroke) and hydronephrosis with renal and ureteral calculous obstruction (swelling of one or both kidneys causing a blockage or obstruction). Record review of Resident #5's MDS assessment, dated 08/12/2025, reflected Resident #5 had a BIMS score of 04, indicating severe cognitive impairment. Section GG- Functional Abilities revealed Resident #5 was dependent on staff for bed mobility, transfers, hygiene, toileting hygiene and bathing. Section H - Bladder and Bowel revealed Resident #5 had an indwelling catheter and was incontinent of bowel and bladder. Record review of Resident #5's comprehensive care plan revealed a care plan, dated 09/11/2025, that read, [Resident] has indwelling foley catheter. Record review of Resident #5's October 2025 administration orders revealed an order, Ensure foley bag is in privacy bag while in bed or wheelchair every shift for foley care. During an observation, 10/01/2025 at 1:17 p.m., Resident #5 was observed lying in bed with a foley catheter bag attached to the side of the bed, facing the open door. The foley catheter bag did not have a privacy cover and the content of the bag was exposed. During an interview with Resident #5, 10/01/2025 at 1:18 p.m., Resident #5 stated staff would often place the foley catheter bag on the opposite side of the bed for privacy and Resident #5 stated she was not bothered if people can see her bag. During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated she was assigned to Resident #5 on 10/01/2025 and LVN D stated she observed Resident #5 without a foley privacy bag before lunch time. LVN D stated she looked for a privacy bag and could not locate one, so she notified the interim DON. LVN D stated the nurses were responsible for ensuring privacy bags were covering foley catheter bags and stated she had received training on privacy covers. LVN D stated it was important for privacy covers to be in place for the residents' privacy. During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated all foley catheter bags should have a privacy cover and some of the foley catheter bags have a shaded side so the bag can be turned to expose the shaded side for privacy. The Administrator stated nursing staff and anyone that identified a resident without a foley bag privacy cover would notify the charge nurse or nursing management and said facility staff had received training on privacy covers. The Administrator stated that privacy covers were important to provide dignity and respect for the rights of each resident. The Administrator stated the facility did not have a policy on privacy covers for foley bags and stated the facility follows the resident rights policy. Record review of a facility document titled, Resident Rights, the document revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview and record review, the facility failed to post the daily nursing staffing formation that included the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides and resident census in a prominent place readily accessible to residents, staff, and visitors for 61 residents in that: The facility failed to post the daily staff posting information on 10/01/2025 and 10/02/2025. This failure could place residents and visitors at risk of not being able to review the facility's daily staffing hours. The findings included: During an observation, 10/01/2025 at 8:28 a.m., a daily staffing poster was observed on top of the receptionist desk in a plastic display holder that was titled, Daily report of nursing staff directly responsible for resident care and was dated 09/10/2025. During an observation, 10/02/2025 at 12:02 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed. During an observation, 10/02/2025 at 4:00 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed. Record review of a facility staff schedule, dated 10/01/2025, revealed the facility had 5 licensed nurses, 2 MAs and 11 CNAs scheduled throughout the day. Record review of a facility staff schedule, dated 10/02/2025, revealed the facility had 5 licensed nurses, 2 MAs and 10 CNAs scheduled throughout the day. During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated the ADON was responsible for updating the daily staffing posters daily and the ADON had received a directive to complete the daily staffing form and post it daily at the reception desk. The Administrator said it was important to post the daily staffing posters because it gives families and visitors the ability to know how many staff are present for the patients and gives us a visual number of staff available and it is part of our regulatory requirements. The Administrator stated the facility did not have a policy on posting staffing information daily but followed the regulatory guidelines.

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 2 of 8 residents (Resident #3 and Resident #34) reviewed for infection control: 1. The facility failed to ensure staff wore proper PPE while performing wound care for Resident #3. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene between glove changes while performing incontinent care for Resident #34. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #3's admission record, dated 8/29/25, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included liver cell carcinoma (liver cancer), mid protein calorie malnutrition, malignant neoplasm (cancerous tumors) of bone and articular cartilage, and alcoholic cirrhosis of liver without ascites (condition resulting from long term heavy alcohol use, characterized by the scarring of liver tissue. Unlike other forms is does not usually cause fluid retention in the abdomen). Record review of Resident #3's quarterly MDS assessment, dated 8/4/25, revealed the resident cognition was severely impaired for daily decision-making skills, and section M revealed he had 1 stage 1 pressure injury, 1 stage 4 pressure injury, 4 unstageable pressure ulcers, and 2 deep tissue injuries. Record review of Resident #3's care plan, initiated 2/7/25 revealed the resident was on enhanced barrier precautions, with interventions to gloves and gown should be donned if any of the following activities occur . wound care. Record review of Resident #3's Physician Order, dated 8/29/25, revealed the following:- Stage IV (L) Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Stage IV Sacrum Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. -Unstageable R Ischium Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25.-Unstageable DTI left heel, Cleanse with wound cleanser/Normal saline pat dry WITH 4X4 gauze. Apply skin prep/betadine to area left open to air as, one time a day for Skin fragility or hair/nail weakness for 30 Days with a start date of 8/11/25 and end date of 9/10/25. -Unstageable DTI left lateral foot, cleanse with wound cleanser/normal saline, pat dry with 4X4 gauze apply skin prep/betadine daily/as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. -Unstageable DTI to right ankle cleanse with wound cleanser/normal saline, pat dry with 4x4 gauze apply skin prep/betadine daily or as needed to area leave open to air. One time a day for 30 Days, with a start date of 8/11/25, and an end date of 9/11/25. - Unstageable left hip Cleanse with normal saline wound cleanser, pat dry w/ 4X4 gauze. Apply medihoney and calcium alginate to wound bed, dress with gauze island with border dressing daily or as needed one time a day for 30 Days, with a start date of 8/11/25 and an end date of 9/11/25. During an observation on 8/29/25 at 11:19 a.m. the ADON prepare to provide wound care to Resident #3's wounds. The ADON cleansed the residents right foot wound with skin prep, removed her gloves, and stated she forgot a PPE gown and went outside the room to put one on. During an interview on 8/29/25 at 12:34 p.m. the ADON stated she needed a gown to provide wound care to resident #3 because he was on EBP and also to prevent her from getting any wound drainage on her. During an interview on 8/29/25 at 1:15 p.m., the DON stated staff should be wearing a gown while providing wound care to Resident #3 because he was on EBP. The DON stated the gown helped protect staff and resident from infection. 2. Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes(high blood sugar levels, insulin resistance, and a relative last of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania), generalized anxiety disorder, epilepsy (a brain condition that causes recurring seizures), insomnia, and disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thought process, speech, and behavior). Record Review of Resident #34's quarterly MDS assessment, dated 8/2/25, reflected Resident #34 had intact cognition for daily decision making and was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #34's care plan, initiated 6/11/25, revealed a care area for Resident #34 had bowel incontinence with an intervention to check resident every 2 hours and assist with toileting as needed. During an observation on 8/29/25 at 10:54 a.m. CNA F and CNA G provided incontinent care to Resident #34. Both aides removed their gloves during the care and put on new gloves. They did not perform hand hygiene after removing soiled/used gloves, and putting on new gloves. During a joint interview on 8/29/25 at 11:11 a.m. CNA F and CNA G stated they did not have any hand sanitizer on them when they started. They stated the resident was in pain so they wanted to be quick with the incontinent care. They stated they should have preformed hand hygiene between glove changes to prevent infection to the resident. During an interview on 8/29/25 at 1:07 p.m. the DON stated staff was expected to perform hand hygiene between glove changes to provide infection control. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 3/2024, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care.After removing gloves or aprons. Record review of the facility policy titled Enhanced Barrier Precautions, dated 4/1/24, stated Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following. Wounds.

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 4 of 6 residents (Resident #7, Resident #8, Resident #10, and Resident #35) who were reviewed for resident assessments. 1.The facility failed to document Resident #7's use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to accurately code Resident #8's hypoglycemic medication on the quarterly MDS assessment.3. The facility failed to document Resident #10's use of antiplatelet medication on the quarterly MDS assessment.4. The facility failed to accurately code Resident #35's diagnosis of bipolar disorder on the quarterly MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #7's admission sheet dated 10/16/2023 with an original date of 4/08/2020 documented a [AGE] year-old female resident with diagnoses including dementia, schizophrenia, diabetes mellitus, anxiety, hypertension (high blood pressure), bipolar disorder, depression, and hyperlipidemia (high cholesterol). Record review of Resident #7's MDS dated [DATE] documented a BIMS of 6 indicating severe cognitive impairment and recorded the use of antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications. Further review of Resident #7's MDS revealed the assessment did not include the use of anticonvulsants, despite the resident receiving Lamotrigine and Depakote. Record review of Resident #7's order summary documented active orders for the psychotropic medications: -Lamotrigine 100 mg give by mouth one time a day for anxiety, with a start date of 04/22/2024.-Depakote 500 mg give one tablet by mouth two times per day related to biploar disorder, with a start date of 04/21/2024.-Sertraline 100 mg give on e tablet by mouth one time a day related to major depressive disorder, with a start date of 08/26/2024. -Zyprexa 20 mg give one by mouth one time a day related to schizophrenia, with a start date of 04/21/2024. Record review of Resident #7's July 2025 MAR documented the resident had been receiving Lamotrigine, Sertraline, Zyprexa, and Depakote as prescribed. Further review of the July MAR documented that Lamotrigine was ordered as Lamotrigine 100mg, give 1 tablet by mouth one time a day for anxiety. Sertraline was ordered as Sertraline 100mg give 1 tablet by mouth one time a day.give with 25mg tab to equal 125mg daily. Zyprexa was ordered as Zyprexa 20mg give 1 tablet by mouth one time a day. Depakote was ordered as Depakote 500mg give 1 tablet by mouth two times a day. Record review of Resident # 7's care plan, revision dated on 04/07/2025, documented ANTIPSYCHOTIC MEDICATIONS: The resident requires the use of antipsychotic medications r/t long-standing mental illness, dx Schizophrenia -depakote -lamotrigine. The care plan listed Depakote and Lamotrigine in the antipsychotic medication section. The care plan did not include monitoring for anticonvulsant medications. 2. Record review of Resident #8's admission sheet dated 3/28/2023 with an original date of 9/13/2017 documented a [AGE] year-old male resident with diagnoses including schizoaffective disorder, diabetes mellitus, dementia, depression, anxiety, insomnia, hypertension, and cerebral infarction (stroke). Record review of Resident #8's MDS assessment dated [DATE] documented a BIMS score of 14 indicating intact cognition and recorded the use antipsychotic, diuretic, and hypoglycemic medications. Further review of Resident #8's MDS revealed the assessment inaccurately recorded a total of one day for the number of days that insulin injections were received during the last 7 days. Record review of Resident #8's order summary documented an active order for the hypoglycemic medication Trulicity (a glucagon-like peptide 1 [GLP-1] receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus). Further review of the order summary did not include an order for insulin. Record review of Resident #8's June 2025 MAR documented the resident had been receiving Trulicity as prescribed. Further review of the June MAR recorded Trulicity was ordered as Trulicity 3mg/0.5mL, Inject 3mg subcutaneously one time a day every 7 day(s) related to type 2 diabetes mellitus without complications. Record review of Resident #8's care plan documented a diagnosis of diabetes mellitus with interventions including Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. 3. Record review of Resident #10's admission sheet dated 8/13/2024 with an original date of 7/30/2024 documented a [AGE] year-old female resident with diagnoses including schizophrenia, diabetes mellitus, hyperlipidemia, depression, hypertension, and chronic obstructive pulmonary disease (a lung condition caused by damaged to the airways that limits air flow). Record review of Resident #10's MDS dated [DATE] documented a BIMS score of 13 indicating intact cognition and recorded the use of antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, opioid, and hypoglycemic medications. Further review of Resident #10's MDS revealed the assessment did not include the use of antiplatelet medications and inaccurately recorded the resident as receiving anticoagulant therapy. Record review of Resident #10's August 2025 MAR documented the resident had been receiving Aspirin as prescribed. Further review of the August MAR recorded Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day for heart health. Further review of the August MAR revealed Resident #10 did not have an order for an anticoagulant medication. Record review of Resident #10's care plan, dated 08/03/2024, documented The resident is on anticoagulant therapy. Further review of the care plan showed the assessment did not include monitoring for antiplatelet therapy. 4. Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's order summary documented active orders for the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability). Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as prescribed. Further review of the July 2025 MAR documented Risperdal was ordered as Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar, with a start date of 07/01/2025. Record review of Resident #35's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Further review of Resident #35's MDS revealed the assessment did not include a diagnosis of bipolar disorder. Record review of Resident #35's care plan, revised dated on 07/18/2025, documented Adverse medication effect and behavior monitoring but did not specify the type of medication class to monitor. Further review of the care plan revealed the diagnosis of bipolar disorder was not included on the diagnosis list. In an interview with the MDS Coordinator on 8/29/25 at 10:01 AM, the MDS Coordinator stated if the MDS was not coded correctly or has missing information, they could miss a side effect of a medication. The MDS Coordinator went on to state they would not know if behaviors were mania or altered mental status, and a resident could have issues if someone did not know specific side effects of a medication to look for if something was wrong. The MDS Coordinator stated it was important for the MDS to be accurate so the facility could know what was going on with the whole resident. In an interview with the DON on 8/29/25 at 1:23 PM, the DON stated her expectation for the MDS was that it be accurate, complete, and detail-oriented. The DON went on to state the MDS is the whole picture of a resident, it encompasses everything, and if medications and diagnoses were coded incorrectly, they needed to do some education with the staff. In an interview with the Regional Compliance Nurse on 8/26/25 at 12:58 PM, the Regional Compliance Nurse stated they did not have an MDS or assessment policy, and they followed the RAI manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 noted Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. and Code all high-risk drug class medications according to their pharmacological classification. and Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant.

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 of 5 carts (2300/2400 hall nurse cart, 2300/2400 hall medication aide cart, and the 2200/2500 hall medication aide cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life. The findings included: During an observation of the 2200/2500 hall medication aide cart on 8/28/2025 at 8:14 AM, a sample of controlled medications was inventoried for accuracy with Medication Aide B. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit during shift change revealed the log was missing a signature. During an interview with Medication Aide B on 8/28/2025 at 8:14 AM, Medication Aide B stated it was important to perform the card audit and to sign the reconciliation log in the presence of the staff member who was receiving or relinquishing the cart. Medication Aide B further stated she should always sign the reconciliation log, because if the log was not signed the next person responsible for the cart will not know if the count of controlled medications was correct. During an observation of the 2300/2400 hall medication aide cart on 8/28/2025 at 8:24 AM, a sample of controlled medications was inventoried for accuracy with Medication Aide C. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit during shift change revealed the log was missing a signature. During an interview with Medication Aide C on 8/28/2025 at 8:24 AM, Medication Aide C stated it was important to sign the reconciliation log to make sure the medication count was right. Medication Aide C further stated if the reconciliation log was not signed at shift change, it would not be known if the log was accurate, and the count of medication could be off. During an observation of the 2300/2400 hall nurse cart on 8/28/2025 at 8:40 AM a sample of controlled medications was inventoried for accuracy with LVN D. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit during shift change revealed the log was missing a signature. During an interview with LVN D on 8/28/2025 at 8:40 AM, LVN D stated if the reconciliation log was missing a signature, the medication count might be wrong, and the log should be verified during shift change. LVN D stated if she found the count of a controlled substance to be incorrect, she would bring it to the attention of the DON. During an interview with the DON on 8/29/25 at 1:23 PM, the DON stated her expectation for medication carts was that anytime a staff member hands off a cart to another employee, there needed to be two people to perform the controlled medication audit, and both parties should be looking at both the log and the blister packs while counting. The DON further stated it was important to never accept someone else's cart without inventorying the controlled medications together, because it cannot be known if there was a discrepancy without counting. Record review of the facility policy titled Controlled Medications-Administration dated 2025 noted At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record.

Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan after each assessment for 5 of 6 residents (Residents #1, #4, #7, #10, and #35) reviewed for care planning. 1. The facility failed to ensure Resident #1's care plan was accurate to reflect that he was not a smoker.2. The Facility failed to ensure Resident #4's care plan reflected he was on dialysis. 3. The facility failed to ensure Resident #7's care plan was accurate and updated to reflect the type of psychoactive medications prescribed for Resident #7 and the specific side effect monitoring of those medications. 4. The facility failed to ensure Resident #10's care plan was accurate and updated to reflect the type of blood thinning medication Resident #10 was prescribed.5. The facility failed to ensure Resident #35's care plan was accurate and updated to reflect Resident #35's psychiatric diagnoses and psychoactive specific medication monitoring. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #1's admission Record dated 08/28/2025, reflected a [AGE] year-old male admitted to the facility 07/09/2025. His diagnoses included other frontotemporal neurocognitive disorder (a group of neurodegenerative disorders associated with changes in the brain's frontal and temporal lobes which control functions related to personality, behavior, and language), pneumonia due to methicillin susceptible staphylococcus aureus (a bacterial infection of the lungs that can be treated with antibiotics), and schizophrenia (a mental health condition where people can experience a disconnection from reality, presenting with symptoms such as false beliefs and disorganized thinking). Record review of Resident #1's Smoking Assessment with an effective date of 07/28/2025 revealed he was unable to find the smoking areas, was unable to extinguish smoking materials or know how to dispose of ashes and was unable to smoke unattended. The assessment had a box checked indicating the evaluation has been explained to the family responsible party. There was no indication on the form, however, if the resident was a current smoker or had ever smoked. Record review of Resident #1's Care Plan, with date initiated 07/27/2025, indicated Resident Smokes with a goal of resident will be able to smoke without causing injury. Another entry on the same Care Plan with date initiated 08/13/2025 indicated Resident is a smoker with a goal of will smoke in designated areas without occurrence of injury over next 90 days. Record review of Progress Notes dated 07/09/2025 contained an admission Note that documented Resident Smokes: No. Observations of Resident #1 during the survey from 08/26/2025 through 08/29/2025, revealed resident sleeping or wandering in the secure unit with his arms crossed in front of him. Resident #1 was never observed in the smoking area with other residents. During an interview with LVN E on 08/29/2025 at 9:45 am, LVN E stated that Resident #1 was not a smoker and did not participate in many activities. During an interview with MDS Coordinator on 08/29/2025 at 10:01 am, MDS Coordinator stated she had only been employed in this facility for 2 months. The MDS stated, I review Care Plans and make sure the whole IDT team is in agreement with the needs of the residents. I am also part of the care conference team. In the first set of care plans, I go through the triggers and I do an assessment. I look at the resident as well as look at notes from the Treatment Nurse, weekly nurse assessment, etc. The MDS Coordinator stated that Resident #1 was not a smoker and this should not have been placed in the Care Plan. 2. Record review of Resident #4's admission record, dated 8/29/25 with an initial admission date of 12/13/2017 and readmission of 7/31/25 revealed an [AGE] year-old male resident with diagnoses that included end stage renal disease (the final stage of kidney failure), and type 2 diabetes mellitus (high blood sugar levels and insulin resistance) without complications. Record Review of Resident #4's quarterly MDS assessment, dated 7/31/25, reflected Resident #34 had severely impaired cognition for daily decision making and section O revealed he received dialysis while a resident. Record review of Resident #4's physician's order, dated 8/29/25, revealed Resident #4 received dialysis every Monday, Wednesday, and Friday, with a start date of 8/1/25, and no end date. Record review of Resident #4's care plan, dated 8/28/25, revealed he was at risk for malnutrition and to monitor and document meal intake and resident weights. There were no care areas for dialysis. During an interview on 8/28/25 at 11:39 a.m. the DON stated dialysis should be care planned for continuity of care and to ensure staff was monitoring the resident and dialysis site. During an interview on 8/28/25 at 11:51 a.m. the MDS Coordinator stated the resident was started on dialysis about 2 weeks prior. The MDS Coordinator stated she was responsible for updating the care plans and should have updated the residents care plan to include he was on dialysis. The MDS Coordinator stated the care plan needed to be updated for nursing staff and CNAs to see necessary interventions on their point of care system. 3. Record review of Resident #7's admission sheet dated 10/16/2023 with an original date of 4/08/2020 documented a [AGE] year-old female resident with diagnoses including dementia, schizophrenia, diabetes mellitus, anxiety, hypertension (high blood pressure), bipolar disorder, depression, and hyperlipidemia (high cholesterol). Record review of Resident #7's MDS dated [DATE] documented a BIMS score of 6 indicating severe cognitive impairment and documented the use of antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications. Record review of Resident #7's order summary documented active orders for the psychotropic medications Lamotrigine (an anticonvulsant indicated for the treatment of epilepsy and bipolar disorder), Sertraline (an antidepressant indicated for the treatment of depression, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder), Zyprexa (an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar disorder), and Depakote (an anticonvulsant indicated for the treatment of manic episodes associated with bipolar disorder, seizures, and migraine prophylaxis). Record review of Resident #7's July 2025 MAR documented the resident had been receiving Lamotrigine, Sertraline, Zyprexa, and Depakote as prescribed. Further review of the July MAR documented that Lamotrigine was ordered as Lamotrigine 100mg, give 1 tablet by mouth one time a day for anxiety. Sertraline was ordered as Sertraline 100mg give 1 tablet by mouth one time a day.give with 25mg tab to equal 125mg daily. Zyprexa was ordered as Zyprexa 20mg give 1 tablet by mouth one time a day. Depakote was ordered as Depakote 500mg give 1 tablet by mouth two times a day. Record review of Resident #7's care plan, revision dated on 04/07/2025, documented ANTIPSYCHOTIC MEDICATIONS: The resident requires the use of antipsychotic medications r/t long-standing mental illness, dx Schizophrenia -Depakote -lamotrigine. The care plan listed Depakote and Lamotrigine in the antipsychotic medication section, however both medications are in the anticonvulsant medication class. The care plan did not include the use of Zyprexa in the antipsychotic medication class. 4. Record review of Resident #10's admission sheet dated 8/13/2024 with an original date of 7/30/2024 documented a [AGE] year-old female resident with diagnoses including schizophrenia, diabetes mellitus, hyperlipidemia, depression, hypertension, and chronic obstructive pulmonary disease (a lung condition caused by damaged to the airways that limits air flow). Record review of Resident #10's MDS dated [DATE] documented a BIMS score of 13 indicating intact cognition and documented the use of antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, opioid, and hypoglycemic medications. Record review of Resident #10's August 2025 MAR documented the resident had been receiving Aspirin (an antiplatelet medication) as prescribed. Further review of the August MAR documented Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day for heart health. Record review of Resident #10's care plan, dated 08/03/2024, documented The resident is on anticoagulant therapy. Resident #10's active orders did not include any anticoagulant medications. Further review of the care plan showed the assessment did not include monitoring for antiplatelet therapy. 5. Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Record review of Resident #35's order summary documented active orders for the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability). Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as prescribed. Further review of the July 2025 MAR documented Risperdal was ordered as Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar, with a start date of 07/01/2025. Record review of Resident #35's care plan, revised dated on 07/18/2025, documented Adverse medication effect and behavior monitoring but did not specify the type of medication class to monitor. Further review of the care plan revealed the diagnosis of bipolar disorder was not included on the diagnosis list. During an interview with the DON on 8/29/25 at 1:23 PM, the DON stated it was important for the care plan to be accurate, because the care plan is the communication between staff regarding a resident's care and includes information necessary for the Kardex (a patient care summary tool often found in digital format). The DON stated her expectation is for care plans to be part of the morning meetings so they can be done quickly, and important things needed on the plan can be covered in the meetings. Review of the facility's policy titled Comprehensive Care Planning, undated, noted Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs and The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 (dry #1, #3, and #4) of 4 dryers reviewed for environment. The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. This failure could put residents at risk for an unsafe and unsanitary environment.Findings included: Observation on 8/28/25 at 4:19 p.m. of facility's laundry room revealed there were four (4) dryers that were in use at that time. Observation of the lint collector area beneath three (3) dryers revealed a layer of thick lint about 0.5 inch thick accumulated on the top of lint trap and on the bottom of the dryer. Record review of a document titled Dryer Cleaning, no date, showed a log that was filled out on 8/26/25 at 11:00 a.m., 1:00 p.m., and 3:00 p.m. Interview on 8/28/25 at 3:07 p.m. Laundry Aide H stated they should clean out the lint trap every 2 hours and document it in a log after she cleans it. Laundry Aide H stated she forgot to document on the log when she last cleaned the lint traps, and she thought she cleaned them about 4 times that day already. Laundry Aide H stated if she had not cleaned the lint traps regularly and documented when she had it could be a fire hazard. During an interview on 8/28/25 at 3:15 p.m. the Laundry Supervisor (LS) stated staff should be every 2 hours or after every cycle. The LS stated they vacuum the lint trap with a shop vac. The LS stated not cleaning the lint traps on the dryers could cause a fire. During an interview on 8/29/25 at 3:02 p.m. the Administrator stated staff should be completing the log but was unsure of how often they needed to clean the dryer lint traps. The Administrator stated the purpose of the log was to ensure staff was being accountable and cleaning the lint. The Administrator stated there was a risk of fire if they had not filled out the log or cleaned the lint traps as needed. Record review of a facility document titled Sign off sheet for Laundry Dryer, stated Dryer filters will be inspected and cleaned free of any lint every two hours; any damage must be reported to maintenance supervisor immediately. Laundry Employee to confirm and sign off that this has been completed every two hours.

Based on interview and record review, the facility failed to ensure residents have the right to be informed of and participate in their treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option they prefer for 1 of 6 residents (Resident #35) whose records were reviewed for informed consent. The facility failed to obtain signed consent prior to administering the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability) for Resident #35. This failure could place residents at risk of receiving medications without consent and without the option choose alternative treatment or decline treatment based on awareness of the risks and benefits of the medications.The findings included: Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition and documented the use of antipsychotic, antidepressant, and opioid medications. Record review of Resident #35's order summary included active orders for Risperdal 1mg, give 0.5 tablet by mouth one time a day for bipolar and Risperdal 1mg, give 1 tablet by mouth at bedtime for bipolar. Record review of Resident #35's July 2025 MAR documented the resident had been receiving Risperdal as ordered. Record review of Resident #35's medication consents included a Texas Health and Human Services Form 3713 Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment for the medication Risperdal with no resident or resident representative signature in Section II of the form. During an interview with the DON on 8/29/25 at 1:23 PM, the DON stated for new psychotropic medication orders, her expectation is for consents to be complete with doctor and resident signatures on the appropriate forms and be obtained within 24 to 48 hours for inclusion in the resident's medical record. The DON stated all consents should be signed by either the resident if they are their own responsible party, or by their designated representative if they are unable to sign themselves. The DON stated Resident #35's consent for Risperdal should have been signed by the resident or the responsible party so they would be informed of the medication's potential side effects, understand why they have been prescribed the medication, and decide if they want to take the medication. Record review of the facility policy titled Unnecessary Medications, with a revision date of 2/12/2025, documented Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a mediation. To demonstrate compliance, the resident's medical record must include documentation that the resident or resident representative was informed in advance.

Based on observations, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Laptop) of three medication cart computers reviewed for confidential medical records. The facility failed to ensure a laptop A was not left open with patient information on the screen. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included: Observation on 08/26/25 at 11:21 a.m. revealed laptop A was on top of a medication cart was left open in hallway displaying Resident #25's appointment information for a medical appointment with the date, time, and location for the appointment for anyone passing by to see. No staff was at the cart with laptop A and no staff returned to Laptop A before it timed out and turned off on its own. Interview on 8/29/25 at 1:05 p.m. the DON stated the laptop was used by all staff. The DON stated the computer should not be left on displaying patient information because it was a HIPPA violation and anyone could access patient health records. Record review of the facility's policy titled Resident Rights, revised 11/28/16, stated .Privacy and confidentiality- the resident has a right to personal privacy and confidentiality of his or her personal and medical records .

Based on observation, interview and record reviews the facility failed to ensure that acceptable parameters of nutritional status, such as usual body weight, were maintained for 3 of 9 residents (Residents #1 #2, and #3) reviewed for weight loss, in that; The facility did not follow up and ensure RD recommendations were put in place to address Residents #1's, #2's, and #3's significant weight loss. These deficient practices affected residents which required facility interventions to maintain their normal weight and resulted in a decline in significant weight loss and placed them at risk for a decline of health. The findings were: 1. Record review of Resident #1's face sheet, dated [DATE], revealed an admitted [DATE], with a readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1 Quarterly MDS, dated [DATE], revealed the resident had a severe cognitive impairment. Further review revealed Resident #1 required the physical assistance of one staff member for eating with limited assistance, and the resident was highly involved in the activity but staff may provide guided maneuvering of limbs. Record review of Resident #1's Care Plan, first initiated on [DATE] and last updated on [DATE], revealed the resident had a significant unplanned/unexpected weight loss with poor food intake with interventions which included: monitor and report any changes in the residents eating habits to the DON, place a red glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement and substitutes and percentage. Further review revealed, The resident has a diet order other than regular and is at risk for unplanned weight loss or gain, with interventions which included: Glucerna 90 ml twice daily for weight loss, RD assess per facility protocol, resident is on red glass program, serve diet and snacks as ordered with a sugar free house shake twice daily and a bedtime snack, low concentrated sweets diet, mechanically altered diet. Record review of a facility document titled, Weekly Weight and Red Glass List, [DATE]-[DATE] and dated [DATE], by an unknown author, revealed: Please encourage resident to eat and/or assist with meals if needed. Red glass must be placed on these resident's trays. Resident #1 weighed 127 lbs. with a 1 lb. weight loss for the week. Please note/document resident's eating habits (preferred snacks or food dislikes) percentage eaten (especially if decreased intake is noted, notify ADON and MD). Record review of a facility document titled, Weekly Weight and Red Glass List, [DATE]-[DATE], by an unknown author, revealed: The following residents have been placed on the red glass list due to 5% or more weight loss. Please encourage resident to eat and/or assist with meals if needed. Red glass must be placed on these resident's trays. Resident #1 weekly weight of 125 lbs. with a weekly 2 lbs. 5% weight loss. Please note/document resident's eating habits (preferred snacks or food dislikes) percentage eaten (especially if decreased intake is noted, notify ADON and MD). Record review of Resident #1's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed the resident had a weight loss of 13 lbs. in 1 month which equaled an 8.1% weight loss with intake decreasing since COVID-19 diagnosis. The dietitian recommendation included: HS snack QD due to diabetes mellitus type II. ADON A documented TO (telephone order) on the document and the physician had signed the document on [DATE]. Record review of Resident #1's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed Resident #1 had a weight loss of 44 lbs. in one year or a total body weight loss of 24.3% in one year. Dietitian recommendations included: offer glucerna 90 mg TID. The box indicating the physician was in agreement had been checked by ADON A with a handwritten note TO (telephone order). The physician had signed the document on [DATE]. Record review of Resident #1's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed Resident #1 had a weight loss of 11 lbs. or 7.7 % in one month. Continues in ideal body weight range, but rapid weight loss is concerning. Resident recently recovered from COVID with decline in PO intake Current diet low condensed sweetener, mechanical soft regular diet with fortified food TID, Glucerna 90 ml TID, snacks TID. The Dietitian recommendations included: 1. Liberalize diet to regular . 3. Consider appetite stimulant if PO intake does not return to baseline. ADON A had made a handwritten note which read, TO(telephone order). The physician signed the document on [DATE]. Record review of Resident #1's physician order dated [DATE] revealed No added salt and low sweetened food, mechanical soft diet. Fortified foods all meals. Record review of Resident #1's physician order history revealed: - Glucerna 90 ml two times a day started on [DATE] and discontinued [DATE] Record review of Resident #1's [DATE] MAR/TAR revealed: - Glucerna 90 ml BID (twice a day) for supplementation had been given [DATE] and [DATE] bid (instead of the ordered 3 times a day and one time on [DATE]. The supplement had been discontinued on [DATE]. There was no indication of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - Snack two times a day for weight loss at 10:00 a.m. and 8:00 p.m. - Snack at at bedtime for diabetic snack scheduled at 9:00 p.m. - No appetite stimulates had been ordered or given for the month of [DATE] Record review of Resident #1's Weekly Nursing Summary Mini Nutritional Assessments revealed: - [DATE]: unknown or no decrease in food intake, unknown weight loss in last 3 months signed by LVN B - [DATE]: unknown or no decrease in food intake, unknown weight loss in last 3 months signed by ADON A - [DATE]: unknown or no decrease in food intake, no weight loss in the last 3 months - [DATE]: unknown or no decrease in food intake, no weight loss in the last 3 months Record review of Resident #1's Weight Watchers assessments revealed: - [DATE] weekly weight loss of 5 lbs., physician not notified of any negative changes signed by ADON A. - [DATE] weekly weight loss of 1 lb., physician not notified of any negative changes signed by ADON A. - [DATE] weekly weight loss of 1 lbs., red glass initiated, provide verbal cuing at meals, provide physical hands-on assistance at meals, physician not notified of any negative change Record review of Resident #1's weights: - [DATE]: 186 lbs. - [DATE]: 182 lbs. - [DATE]: 182 lbs. - [DATE]: 174 lbs. - [DATE]: 160 lbs. - [DATE]: 166 lbs. - [DATE]: 165 lbs. - [DATE]: 166 lbs. - [DATE]: 161 lbs. - [DATE]: 148 lbs. - [DATE]: 143 lbs. - [DATE]: 132 lbs. - [DATE]: 131 lbs. - [DATE]: 128 lbs. - [DATE]: 127 lbs. During an observation of meal service on [DATE] at 1:15 p.m. staff was observed proving total feeding assistance to the resident who was eating without difficulty or complaint. Further observation revealed the resident was not interviewable due to cognitive status. During an interview on [DATE] at 6:24 p.m., CNA H stated Resident #1 was able to feed herself and did not require feeding assistance. CNA H declined to answer further interview questions. During an interview on [DATE] at 10:31 a.m., NP D stated she was aware of Resident #1's significant weight loss and stated it was somewhat expected to due her age. The NP stated the resident was supplemented with Med-Pass, but Resident #1 was very picky with her food. The NP stated Resident #1 had also been sick with COVID-19 and the resident's family stopped visiting due to COVID restrictions. The NP stated that many residents lose the will to live once their families stop visiting. The NP stated, Resident #1 was doing far better than a lot of residents that she had seen. The NP stated she followed all of the RD recommendations and could not remember a time when she did not follow a recommendation. The NP stated she received reports directly from the RD and/or the ADON picks up the phone and called her with recommendations. The NP stated she was not aware that all of the recommendations were not being followed. The NP stated due to COVID-1 pandemic she had not been into the nursing facility in person for several months and relied on staff to give her updates and concerns about resident condition. During an interview on [DATE] at 4:56 p.m. the Dietary Supervisor confirmed Resident #1 diet was restricted on salt and sweeteners per physician order given to her by nursing staff. The Dietary Supervisor stated she receives little slips of paper from nursing staff whenever she needs to change a diet for a resident. The Dietary Supervisor stated she relies on nursing staff to inform her of any changes to a resident's diet plan. During an interview on [DATE] at 5:56 p.m. RN K stated Resident #1 typically did not require feeding assistance and was able to eat independently, but since she came back from the hospital on [DATE] staff was now assisting the resident with meals. During further interview on [DATE] at 10:56 a.m. ADON A confirmed many of the Dietitian Recommendations were not signed by the resident's physician, including recommendations made in [DATE]. ADON A stated she had a stack of the recommendations ready and waiting to be signed but she missed the clinician's when they came into the facility. ADON A stated when she received a recommendation she would call the physician and get a telephone order and put it into the computer as a physician order that the physician can sign electronically. The ADON stated that a lot of the physicians were not allowed into the facility due to COVID due to a Corporate decision not to allow them in until [DATE]. ADON stated she was not trained on the facility policy or time frame for having the Dietitian Recommendations signed. ADON A confirmed she did not place a physician order into the computer for Resident #1 to liberalize her diet or for an appetite stimulant. ADON stated, I missed it. I didn't update it. I don't really remember. ADON A stated, she did have a conversation with the NP about the appetite stimulant but didn't document the conversation or the telephone order. ADON A further confirmed she did not put the order for Glucerna into the computer correctly. ADON A confirmed the order for Glucerna should be three times a day instead of two times a day and she was unsure why it was the Glucerna supplement was discontinued. During an interview on [DATE] at 12:30 p.m., the DON stated since Resident #1 is still losing weight, she will be started on an appetite stimulate today. The DON stated Resident #1 had been on the Weight Watchers program to monitor weight loss, we offer alternative meals, but I didn't get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing Resident #1's weight loss over the last year with this surveyor, the DON stated she reviews weight loss from week to week because that is how the program is run. I didn't see the significant weight loss. If I had seen it we would have had a discussion about an appetite stimulant sooner. I wanted to wait to see how she did without it. The DON confirmed she received the latest RD recommendation on [DATE]. The DON further stated staff is trained to monitor trays by checking food texture and consistency. Dietary was the first eyes to ensure the resident is getting ordered items, nursing staff verified the dietary items based on physician orders. If a resident tray was missing an ordered item, the staff should get the missing item for the resident. The DON stated, We had to trust dietary staff that they are putting the appropriate interventions in place. The DON stated she monitored staff by talking about orders during morning meetings and auditing the weight watchers program. The DON stated she last audited the program before [DATE]. The DON stated she reviews emails from the dietitian and confirms the dietary recommendations with the actual order in the computer. The DON stated, I have not audited (for orders) this month as she only audits orders every ,d+[DATE] months. The DON stated she had not seen errors by ADON A before and was unsure why they were occurring. The DON further confirmed RD recommendations should be signed by the physician within 5 days of receiving the recommendation. During an observation of lunch meal service on [DATE] at 1:39 p.m. Resident #1's lunch meal was missing the eggroll that was listed on the meal tray ticket. Further observation revealed CNA L was assisting Resident #1 with eating. During an interview on [DATE] at 1:39 p.m. CNA L confirmed the eggroll was not part of the meal tray as listed on the meal ticket. CNA L stated the Charge Nurses check trays for accuracy and CNA's will notify the nurses if they notice an item missing. CNA L confirmed she had not noticed the missing item and had not notified the nurse. 2. Record review of Resident #2's face sheet, dated [DATE], revealed an admission [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a severe cognitive impairment. Further review revealed Resident #2 required extensive assistance of one staff member for eating. Record review of Resident #2's Care Plan, first initialized on [DATE], revealed the resident had a significant unplanned weight loss over than past year with a current weight of 54 lbs. Interventions included: 2 cal/cc supplement with med pass, fortified pudding with meals. Further review revealed Resident #2 is on a regular, pureed texture diet with thin liquids and is at risk for unplanned weight loss, first initiated on [DATE] and last revised on [DATE], with interventions which included: monitor weight per facility protocol, pudding TID with meals, dietitian assess per facility protocol, serve diet and snacks as ordered. Record review of Resident #2's physician orders, dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's dietician recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed: Continues to lose weight. Current PO (by mouth) intake should meet needs as assessed, but weight loss is of concern. Record review of Resident #2's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed Resident #2 had a 6 lb. weight loss in the last 6 months and had lost 10.3% of her total body weight. The resident's weight was recorded as 52 lbs. The dietitian recommendations included: Add ice cream at lunch and dinner QD, 2 cal Health Shake BID, Med Pass 2.0 90 ml TID for 30 days. Consider increasing appetite stimulant dose to increase PO intake. Record review of Resident #2's Dietary Profile, dated [DATE] and signed by the Dietary Supervisor, revealed the resident was on a regular pureed diet with a frozen nutritional treat as supplement. Resident height obtained [DATE] was 49.2 inches and weight obtained [DATE] was 52 lbs. The profile indicated the resident had no weight loss within the last six months. Record review of Resident #2's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician dated [DATE] revealed: Resident #2 had a weight loss of 15 lbs. in the last year which resulted in a 22.7% lost of total body weight. The Dietitian recommendations included: 1. re-order Med Pass 2.0 after 30 day order is complete and keep if resident consistently consumes it as ordered. 2. Consider increasing appetite stimulant dose. ADON A checked the box indicating the physician agreed and wrote TO (telephone order, no date indicated. The document was not signed by the physician. Record review of Resident #2's Annual Nutritional Risk Assessment, dated [DATE], revealed the resident was on a regular pureed died with a weight loss history of 15 lbs or 22.7% in one year with a stable weight for the last 3 months. Ideal body weight was 89 lbs. Supplements include: 2 cal 90 ml BID (twice daily) and Med Pass 2.0 90 ml's TID, the resident required extensive or total assistance with eating and drinking. Weight stable for 3 months. Continues on appetite stimulant, unclear if resident still receives fortified foods at all meals. PO (by mouth) intake should promote weight gain. Consider increasing appetite stimulant dose to increase PO intake. Document signed by the Registered Dietitian. Record review of Resident #2's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed Resident #2 had a weight loss of 6 lbs. or 10.3% of total body weight in 6 months. Further review revealed, Current interventions and documented meal intake of greater than ,d+[DATE]% should promote weight gain. Recommendation included: Increase med pass 2.0 to 120 ml as tolerable. 2. Offer resident's preference of whole milk or chocolate milk BID and Resident #2 is on max PO interventions. Consider supplemental enteral nutrition if needs cannot be met through oral intake. ADON A had checked the box indicating the physician was in agreement and wrote, TO, (telephone order) on the document. ADON A had also checked off the first and third recommendation and wrote monitor for supplemental needs on the document. The physician had not signed the recommendation. Record review of Resident #2's MAR/TAR for [DATE] revealed: - 2 cal two times a day scheduled for 8:00 am and 4 p.m. was discontinued on [DATE]. There was no indication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - On [DATE] 2 cal was increased to 120 ml's TID for 30 days (not part of the dietitian recommendation) - Med-Pass plus 2.0 90 ml TID was discontinued on [DATE]. There was no indication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] 7.5 mg 1 tablet by mouth at bedtime for appetite stimulant with a start date of [DATE]. Record review of Resident #2's Weekly Nursing Assessment with Mini Nutritional Assessment revealed: - [DATE]: unknown or no decrease in food intake, weight loss between 2.2 and 6.6 lbs. signed by LVN C. - [DATE]: unknown or no decrease in food intake, weight loss between 2.2 and 6.6 lbs. signed by ADON A. Record review of Resident #2's Weekly Weight Watcher's Assessments revealed: - [DATE]: regular pureed diet requiring physical assistance for the entire meal, weight loss of 1 lbs with current weight 51 lbs., red glass initiated. None of the nutritional supplements were checked on the list, signed by ADON A. - [DATE]: regular pureed diet requiring physical assistance for the entire meal, weight loss of 1 lb. with a total weight of 52 lbs. signed by ADON A. - [DATE]: regular pureed diet requiring physical assistance for the entire meal, weight gain of 2 lbs. Record review of Resident #2's weight history revealed: - [DATE]: 65 lbs. - [DATE]: 64 lbs. - [DATE]: 62 lbs. - [DATE]: 61 lbs. - [DATE]: 60 lbs. - [DATE]: 59 lbs. - [DATE]: 58 lbs. - [DATE]: 56 lbs. - [DATE]: 52 lbs. - [DATE]: 52 lbs. - [DATE]: 53 lbs. - [DATE]: 51 lbs. - [DATE]: 54 lbs. Record review of Resident #2's lunch meal tray card, dated [DATE], revealed the resident meal did not included either whole white milk or chocolate milk. The resident's beverage was listed as iced tea. Record review of Resident #2's evening meal tray card, dated [DATE] revealed the residents meal did not include either whole white milk or chocolate milk. The resident's beverage was listed as choice of beverage. Observation on [DATE] at 6:07 p.m. for Resident #2's meal service revealed the resident did not receive a choice of milk or chocolate milk with her meal tray. The resident was served iced tea. Further observation of evening meal service revealed Resident #2 meal tray did not contain ice cream or pureed cookie as stated on the meal card. Further observation revealed Resident #2 was blind and kept her eyes closed most of the time. The resident was also very petite, with a proportionately small head, torso and extremities and short in stature. During an interview on [DATE] at 6:20 p.m. with CNA F confirmed Resident #2's meal tray did not contain ice cream or pureed cookie as stated on the meal tray ticket and had not been served milk. CNA F stated staff feeds Resident #2, but the resident will not eat anything unless she tasted a little of the food first. CNA F stated Resident #2 normally eats 25% of her meals, but mostly just the sweet foods. CNA F stated if a food item is missing then it is just missing and she will feed the resident what is on the tray and notify the nurse. Observation on [DATE] at 1:20 p.m. of lunch meal service for Resident #2 revealed the resident's meal tray was on the bedside table. The pureed meat and mashed potatoes were half consumed. The pureed green beans had not been touched and remained with a smooth surface as if no utensil had touched them. The pudding cup was empty. No tray card observed. Further observation revealed Resident #2 had bilateral hand and finger contractures. During an interview on [DATE] at 1:20 p.m. Resident #2 stated she was finished eating and stated she was fine. During an observation of lunch meal service on [DATE] at 1:10 p.m. staff was observed proving total feeding assistance to Resident #2. The resident was observed eating without difficulty or complaint. During an observation on [DATE] at 12:18 p.m. CNA I obtained a weight for Resident #2 at surveyor request. CNA I placed a clean sheet on a sling scale without zeroing the scale prior to placing Resident #1 on the sling. Resident #2 weighed 55 lbs. During an interview on [DATE] at 12: 25 p.m. CNA I started she is responsible for obtaining weekly weights on the residents. CNA I stated she normally placed a clean sheet on the sling scale prior to weighting Resident #1. CNA I stated Resident #1 is so tiny, I don't want her to slip through the hold in the sling. The sheet makes her more comfortable. CNA I stated she had weighed the resident a couple of days ago with a weight of 53 lbs but had forgotten to document the weight in the computer. Record review of Resident #2 evening meal ticket indicated the resident was to receive two ,d+[DATE] cup ice cream servings, 6 ounces of super cream (fortified) soup, and choice of beverage. During an observation of evening meal service on [DATE] at 5:49 p.m. Resident #2 did not super cream fortified soup as stated was on her meal ticket. Further observation revealed Resident #2 was served iced tea and was not served or offered her choice of milk as ordered by a physician. During an interview on [DATE] at 5:49 p.m. CNA J confirmed Resident #2 food tray was missing fortified soup, 1 of 2 ice creams and milk. CNA J stated the Charge Nurses are responsible for checking meal trays for accuracy. CNA J stated if a missing item is noticed it is the responsibility of the CNA to notify the Charge Nurse. During an interview on [DATE] at 5:56 p.m. RN K confirmed he verified Resident #2's food tray for accuracy prior to meal service. RN K stated he didn't notice the missing items and stated Resident #2 did have 1 of the 2 ice creams on the meal tray. RN K stated he thought dietary may have listed the ice cream on the ticket twice by mistake. During an interview on [DATE] at 6:14 p.m., the Dietary Supervisor confirmed Resident #2 should have two ice creams on the meal tray. The Dietary Supervisor stated the resident should get 1 dessert and today, that was ice cream. In addition, the resident had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:56 a.m. ADON A confirmed Resident #2 should be receiving fortified foods and confirmed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON A confirmed 2 cal was incorrectly placed in the computer as 90 ml's twice a day instead of 90 ml's three times a day as ordered. ADON A further confirmed on [DATE] 2 cal was discontinued and restarted at 120 ml's three times a day which was not part of the dietician recommendation. The ADON confirmed the dietitian recommendation for the resident to receive her choice of whole milk or chocolate twice a day was not placed into a physician order and not been put into place with dietary. ADON A further confirmed Resident #2's appetite stimulant had not been increased and there was no plan for enteral feedings. ADON A stated, I do not know what happened or why. The ADON stated she remembered a conversation with the NP who did not think those interventions were necessary. The ADON confirmed she did not make any documentation in the resident's medical record about the recommendations or her conversation with the NP about the recommendations. During an interview on [DATE] at 12:30 p.m., the DON confirmed Resident #2's low weight of 52 lbs. The DON further confirmed she had not discussed the recommendation for enteral feeding with the resident's physician or the resident's RP. The DON stated I am going to have a Care Plan meeting to discuss this recommendation. 3. Record review of Resident #3's face sheet, dated [DATE], revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS, dated [DATE], revealed the resident's cognitive status was not assessed. Further review revealed the resident required one staff person assistance with limited physical assistance where the resident was highly involved in the activity but staff provide guided maneuvering of limbs. Record review of Resident #3's Care Plan for significant unplanned/unexpected weight loss due to recent hospitalization first initiated on [DATE] revealed interventions which included: Monitor and report any changes in the resident; eating habits to the DON, place a red glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement and substitutes, provide verbal assistance and cues during meals. Record review of Resident #3's physician orders, dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a facility document titled, Weekly Weight and Red Glass List, [DATE]-[DATE] and dated [DATE], revealed: The following residents have been placed on the red glass list due to 5% or more weight loss. Please encourage resident to eat and/or assist with meals if needed. Red glass must be placed on these resident's trays. Resident #3 weighed 129 lbs. with a 2 lbs. weight loss for the week. Please note/document resident's eating habits (preferred snacks or food dislikes) percentage eaten (especially if decreased intake is noted, notify ADON and MD). Record review of a facility document titled, Weekly Weight and Red Glass List, [DATE]-[DATE], revealed: The following residents have been placed on the red glass list due to 5% or more weight loss. Please encourage resident to eat and/or assist with meals if needed. Red glass must be placed on these resident's trays. Resident #3 weekly weight of 128 lbs with a weekly 1 lb 5% weight loss. Please note/document resident's eating habits (preferred snacks or food dislikes) percentage eaten (especially if decreased intake is noted, notify ADON and MD). Record review of, Weights and Vitals Exceptions, dated [DATE]-26th, 2021 for Resident #3 revealed: - [DATE]: weight 136.0 lbs. 7.5% charge with a comparison weight of [DATE] of 151.0 labs for a 15 lbs. or 9.9% weight loss. - [DATE]: weight 132.0 labs 10% change for a loss of 19 lbs or 12.6%. - [DATE]: weight 131.0 lbs. 5% change with a comparison weight of [DATE] of 141 lbs. for a weight loss of 9 lbs. or 6.4% - [DATE]: weight 126.6 lbs 6% change with a comparison weight of [DATE] of 136 lbs. for a weight loss of 7 lbs. Record review of Resident #3's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed dietary recommendations which included: offer HS snack QD and fortified foods TID for 30 days. The box for attending physician agreement had been checked and ADON A placed a comment on the documents which stated TO (telephone order) [DATE]. The physician had not signed the document. ADON A had checked the box for physician agreement and had written a comment, TO, (telephone order) no date recorded. Record review of Resident 3's physician order, dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's dietitian recommendation titled, Communication Between the Dietitian and the Attending Physician, dated [DATE], revealed Resident #3 had a weight loss of 15 lbs or 9.9% total body weight loss in 2 months. The dietitian recommendations included: reduce pro-stat to 30 ml QD (daily) for 30 days, keep fortified meal program for 30 more days and offer ice cream at lunch and dinner for 30 days. ADON A checked the box indicating the physician agreed and wrote TO (telephone order) on the document. The physician had not signed the recommendation. Record review of Resident #3's MARS/TARS for [DATE] revealed: - Pro-stat (unknown dosage) two times a day related to unspecified protein calorie malnutrition with a start date of [DATE] - Snacks BID (two times a day) for weight loss Record review of Resident #3's Weight Watcher Assessments revealed: - [DATE]: Resident #3 had a 10 lb weight loss or 5% or greater within 30 days or less. Current weight 140 lbs. MD notified. No feeding assistance required. Red glass initiated, provide verbal cueing assistance at meals, signed by ADON A. - [DATE]: Resident #3 had a regular diet and required no feeding assistance, no problems identified with eating. Current weight 136 lbs with a 4 lbs. weight loss. Physician not notified of negative changes, signed by ADON A. - [DATE]: Resident #3 had a regular diet and required no feeding assistance, no problems identified with eating, current weight 136 lbs. Physician not notified of any negative changes, signed by ADON A. - [DATE]: Resident #3 had a regular diet and required no feeding assistance, no problems identified with eating, current weight 132 lbs. with a 4 lbs weight loss. Physician not notified of any negative changes, signed by ADON A. - [DATE]: Resident #3 had a regular diet and required no feeding assistance, no problems identified with eating, current weight 131 lbs., snacks BID, physician not notified of negative changes, signed by ADON A. - [DATE]: Resident #3 had a regular diet and required no feeding assistance, no problems identified with eating, current weight 129 lbs. with a 2 lbs. weight loss. Intervention added: provide physical hands-on assista [TRUNCATED]