Every finding on record at Cedar Hill Healthcare Center

Based on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records and failed to ensure each resident had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and resident groups for three of twelve residents (Residents #5, #11, and #80) reviewed for privacy and confidentiality. 1.The facility failed to ensure LVN J closed, locked, or minimized her laptop monitor before leaving her cart, thus exposing Resident #5's medical information, on 08/25/2026. 2.The facility failed to ensure RN D pulled the privacy curtain or closed the door while connecting Resident #11's IV on 08/26/2026. 3.The facility failed to ensure Resident #80's medical information was not exposed when MA B disposed of his empty medication container on 08/26/2026. These failures could place residents at risk of not having their personal privacy maintained while treatments were provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.Findings included: 1.Record review of Resident #5's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #5's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 06/30/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 03. The Comprehensive MDS Assessment indicated nonsurgical dressing and medications were being applied to the resident's skin. Record review of Resident #5's Comprehensive Care Plan, dated 08/18/2026, reflected the resident had a wound to her left lateral (towards the side) calf and one of the interventions was to document progress in wound healing. Record review of Resident #5's Physician Order, dated 08/25/2026, reflected CLEANSE LEFT CALF WITH NORMAL SALINE, PAT DRY, APPLY ANASEPT AND XEROFORM, COVER WITH DRY DRESSING. everyday shift. During an observation on 08/25/2026 at 1:11 p.m., LVN J was about to perform Resident #5's wound care and would be assisted by the ADON. LVN J and the ADON both went to the restroom to wash their hands. LVN J left the monitor of the laptop open with the resident's medical information exposed. The monitor displayed the resident's name, date of birth , name of physician, location in the facility, code status, allergies, vital signs, weight, pain level, the order for her wound care to left calf and abdomen. The cart, where the laptop was placed, was not totally blocking the resident's doorway and with a space where an individual could easily enter the resident's room. During an observation and interview on 08/25/2026 at 1:13 p.m., the ADON saw that the monitor was not locked and Resident #5's medical information was exposed. She locked the monitor and told LVN J that she needed to lock her computer everytime she would leave her cart unattended because other individuals, non-clinical staff, other residents, and visitors could enter the room and would see the resident's medical information. She said it could be a HIPAA (law protecting health information aimed to ensure confidentiality) violation if the medical information of the residents were exposed. During an interview on 08/25/2026 at 1:15 p.m., LVN J said she went inside Resident #5's restroom to wash her hands. She said somebody might enter the resident's room and would see the resident's information that was confidential. During an observation on 08/26/2026 at 8:01 a.m., LVN J was preparing medications when the ADON passed by. The ADON reminded LVN J to lock her computer before going inside the resident's room to administer the medications. 2.Record review of Resident #11's Face Sheet, dated 08/26/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #11's Comprehensive MDS Assessment, dated 08/19/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #11's Comprehensive Care Plan, dated 08/25/2026, reflected the resident is on IV medications for pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) and one of the interventions was to administer medications as ordered. Record review of Resident #11's Physician Order, dated 08/25/2026, reflected Ceftriaxone Sodium Solution Reconstituted 1 GM Use 1 gram intravenously (administering fluids or medications directly into a vein) every 12 hours for Pneumonia for 10 Days (Via Midline [a long and thin tube inserted into a large vein in the upper arm used for medication administration]). During an observation on 08/26/2026 at 8:45 a.m., RN D was about to connect Resident #11's IV medication via her midline. The resident was sitting in her wheelchair beside her bed and a midline with a single lumen was observed on her right upper arm. She washed her hands and put on a pair of gloves. She went inside the resident's room with the IV bag, IV infusion set, alcohol wipes, and pre-filled IV flush syringes, and placed them on the resident's overbed table. She reconstituted the IV medication and connected the IV infusion set to the IV bag. When she was about to prime the reconstituted IV medication, the medication would not flow to the tubing. She told the resident that she would get another IV bag. She did not close the door while preparing the resident's medication nor pull the privacy curtain beside the resident's door. During an observation on 08/26/2026 at 9:18 a.m., RN D went back to Resident #11's room with a new IV bag and infusion set. She reconstituted the medication, primed it, flushed the resident's midline, and connected the IV to the resident's midline. She did not close the resident's door nor pull the privacy curtain beside the resident's bed while she was connecting the resident's IV. The treatment could be seen from the hallway. During an interview on 08/26/2026 at 9:22 am, RN D said she forgot to pull the privacy curtain or close the door when she connected Resident #11's IV. She said the privacy curtain should have been pulled, or the door should have been pulled to provide privacy during treatment or care. She said the resident might get embarrassed that other people could see what their treatments were. She said it did not matter if the resident minded it or not, but the staff had the responsibility to provide privacy. During an interview on 08/26/2026 at 9:27 a.m., Resident #11 did not reply when asked if the staff were always closing her door when providing treatments. 3.Record review of Resident #80's Face Sheet, dated 08/26/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with constipation (problem with passing stool) and altered mental status (any change on a person's awareness, cognition, and behavior). Record review of Resident #80's Comprehensive MDS Assessment, dated 07/15/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had a cognitive loss. Record review of Resident #80's Comprehensive Care Plan, dated 08/12/2026, reflected the resident had impaired cognitive function and one of the interventions was to administer medications. Record review of Resident #80's Physician Order, dated 07/08/2026, reflected Milk of Magnesia Oral Suspension 1200 MG/15ML (Magnesium Hydroxide) Give 30 ml bymouth one time a day for constipation. During medication cart inspection on 08/26/2026 at 1:29 p.m., a plastic container of milk of magnesia was observed inside the trash bin of a medication cart. The sticker of the container was facing up, and the medical information of Resident #80 was exposed. The sticker had the resident's name, the name of the medication, its route, its dosage, and its frequency. The sticker also had the name of his pharmacy and the name of his physician. During an observation and interview on 08/26/2026 at 1:35 p.m., the ADON said empty medication containers could be thrown in the trash bin, but the staff should make sure that they erased any medical information on the containers. The staff could also strip the sticker before throwing the empty container to prevent HIPAA violation. She took the container from the trash bin and pulled the sticker from the empty container. She then reminded MA B to make sure that the empty containers did not have any medical information. During an interview on 08/26/2026 at 1:38 p.m., MA B said he did not know that he was not supposed to throw an empty container with the resident's information still intact. During an interview on 08/27/2026 at 8:42 a.m., the DON said the computer should be locked or minimized before leaving it unattended and the sticker on the empty medication container, with the resident's medical information, should have been peeled off before throwing it in the trash bin to prevent HIPAA violation. She said she just did an in-service regarding HIPAA but would do one again to re-educate the staff. She said she did not think closing the door during treatment was a privacy issue. She said she would check their policy. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said the door should be closed, or the privacy curtain should be pulled when staff were doing any treatment to provide privacy. She said the staff were responsible in securing the medical information because there might be people around that would see the confidential information. She said they would re-educate the staff about privacy and confidentiality of records. Record review of the facility's policy Confidentiality of Information and Personal Privacy 2001 MED-PASS, Inc. revised October 2017 reflected Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . Policy Interpretation and Implementation . 1.The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 2. The facility will strive to protect the resident's privacy regarding his or her . b. medical treatment.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three of twelve residents (Resident #5, #18 and Resident #54) reviewed for care plans. The facility failed to ensure Resident #5 had a care plan for her colostomy that was initiated on 06/23/2026. 2. The facility failed to ensure Resident #18 had a care plan for his C-tube that was initiated on 07/24/2026. 3. The facility failed to ensure Resident #54 had a care plan for her anti-psychotic medication, ordered on 07/18/2026. These failures could place the residents at risk of not receiving the necessary care and services. Findings include: Record review of Resident #5's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with a disease of the digestive system. Record review of Resident #5's Comprehensive MDS Assessment, dated 06/30/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had an ostomy (surgical procedure that creates an opening to the body). Record review of Resident #5's Comprehensive Care Plan, dated 07/02/2026, reflected the resident did not have a care plan for her colostomy (surgical procedure that creates an opening to the abdomen to allow feces to pass). Record review of Resident #5's Physician Order, dated 06/23/2026, reflected Observe for gas in ostomy pouch and release if indicated every shift. During an observation on 08/25/2026 at 1:11 p.m., Resident #5 was in her bed, awake. It was observed that the resident had a colostomy bag to her right lower quadrant. 2. Record review of Resident #18's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with perforation (a hole that develops through the wall of a body organ) of gallbladder in cholecystitis (inflammation of the gallbladder). Record review of Resident #18's Comprehensive MDS Assessment, dated 07/30/2026, reflected the resident had severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident had an ostomy to his gall bladder. Record review of Resident #18's Comprehensive Care Plan, dated 08/09/2026, reflected the resident did not have a care plan for his cholecystostomy (surgical procedure that creates an opening to the gallbladder) tube. Record review of Resident #18's Physician Order, dated 07/24/2026, reflected Monitor C-Tube (a small catheter placed into the gallbladder for drainage) drain at Right Upper Quadrant for S/S of infection. Notify MD/NP of any abnormal every shift. During an observation and interview on 08/26/2026 at 2:01 p.m., Resident #18 was in his bed, awake. He said he still had a tube on his abdomen. The resident then lifted his shirt and showed his c-tube. During an observation and interview on 08/27/2026 at 8:18 a.m., the MDS Nurse said care plans should be in place so that everybody taking care of the resident would be aware of how to manage the resident's conditions. She logged on to her computer, reviewed Resident #5's physician orders, and saw the resident had orders for her ostomy. She then checked Resident #5's care plan and saw Resident #5 did not have a care plan for her ostomy. She then checked Resident #18's physician orders and saw resident #18 had orders for his c-tube. She then checked Resident #18's care plan and saw he did not have a care plan for his c-tube. She said she must have missed it. She said she would make the care plans for Resident #5's colostomy and Resident #18's c-tube. She said she was not sure what the risk would be if the residents did not have care plans. She said she needed to ask about it. During an interview on 08/27/2026 at 8:42 a.m., the DON said the residents should have care plans to address any medical conditions the residents had. She logged onto her computer and opened Resident #5's care plan. She said Resident #5 did not have a care plan for the colostomy but had a care plan for enhanced barrier precaution that mentioned the Resident #5 was on enhanced barrier precaution due to colostomy. She said, maybe, the MDS Nurse thought that the care plan for the EBP was the care plan for the colostomy. She then checked Resident #18's care plan and saw the resident did not have a care plan for his c-tube. She said she did not know why it was missed. She said it was an oversight on her side because she was overseeing the work of the MDS Nurse. She said she would coordinate with the MDS Nurse to check on the care plans of the other residents. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said the expectation was that all the residents were care planned specific to their needs so the staff taking care of the residents could provide the care and services needed. She said care plans served as guidelines on how the residents should be cared for. She said she would coordinate with the MDS Nurse and the DON regarding the care plans of the residents. 3. Record review of Resident # 54's face sheet dated 08/26/2026 reflected that she was admitted on [DATE]. Her diagnosis included unspecified sequelae of cerebral infarction (a long-term medical condition, physical disabilities and neurological deficits that remain after a person suffered a stroke), unspecified dementia(clear signs of memory loss and cognitive decline), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities) and diabetes (a chronic condition where the body cannot turn food into energy leading to high levels of sugar). Review of Resident #54's admission MDS dated [DATE] reflected a BIMS of 10 indicating moderate cognitive impairment. Record review on 08/26/2026 of Resident #54's care plan reflected that the resident did not have a care plan to address the use of an anti-psychotic. Record review on 08/27/2026 of Resident #54's Physician Orders reflected Quetiapine Fumarate 25 mg, give one tablet by mouth at bedtime related to anxiety. In an interview on 08/27/2026 at 8:50 a.m., the MDS nurse stated there should be a care plan to address the use of the anti-psychotic medication, and it was her responsibility to add it to the care plan. She stated it was an oversight and that the medication triggered behavior monitoring. She stated the risk to the residents was that staff might not know how to take care of the residents. In an interview on 08/27/2026 at 1:44 p.m., the DON stated there should be a care plan to address the use of an anti-psychotic. She stated there was not a risk to the residents if it was not care planned. Record review of the policy Comprehensive Assessment and Care Delivery Process, dated March 2025 reflected, Define conditions and problems that are causing or could cause other problems .link the problems and diagnosis and identify care goals. Record review of the facility's policy Care Plans, Comprehensive Person-Centered 2001 MED-PASS, Inc. revised January 2025 reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure all food items in the kitchen were dated, discarded prior to their use-by date, and were properly sealed. The failures could place residents at risk for food contamination and food-borne illness. Findings Included: An observation on 08/25/2026 between 9:05 AM and 9:45 AM in the facility's kitchen revealed: Dry storage: One two gallon bag containing blueberry muffin mix with an open date of 08/22/26, no visible expiration date. One two gallon bag containing elbow pasta noodles with open date of 08/05/26, no visible expiration date. One 10lbs. bag containing bow tie noodles with no open date, and no visible expiration date. One two gallon bag containing pasta noodles with an open date of 08/06/26, no visible expiration date. One gallon bag containing [NAME] sauce with an open date 08/06/26, no visible expiration date. One gallon bag containing lemon pie filling mix with an open date of 08/17/26, no visible expiration date. One two gallon bag containing fruit loops cereal with an open date 07/25, no visible expiration date. One 10lbs. bag containing elbow pasta noodles with no open date and no visible expiration date. One gallon bag containing vanilla wafers with an open date of 07/21/26, with a use by date of 07/30/26, not properly sealed and exposed to air. One 16oz bottle of decorating liquid, with liquid around the bottle top not properly sealed and exposed to air contaminants. One 32oz bottle Egg Shade color with an open date of 02/25/25, with an expiration of date of 02/25/26. One two gallon bag containing coconut flakes with open date, 08/01/26 and no visible expiration date. Freezer #1 One plastic bag containing seasoned shredded potato tots, with no open date, and no visible expiration date. One gallon bag containing frozen dinner rolls with an open date of 08/24/26, no visible expiration date. One gallon bag containing cinnamon rolls with an open date of 08/24, no visible expiration date. During an interview on 08/27/26 at 2:05 PM DM stated the risk to residents if the policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated could cause food borne illness to residents Record review of the facility's policy food service revised 2014 revealed: Food Receiving and Storage Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twelve residents (Resident #7 and Resident #15) reviewed for infection control. 1.The facility failed to ensure CNA H and CNA I performed hand hygiene and changed their gloves as necessary during Resident #7's incontinent care on 08/25/2026. 2.The facility failed to ensure CNA F and CNA G performed hand hygiene and changed their gloves as necessary during Resident #15's incontinent care on 08/26/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1.Record review of Resident #7's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #7's Comprehensive MDS Assessment, dated 05/28/2026, reflected the resident had severe impairment in cognition with a BIMS score of 01. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #7's Comprehensive Care Plan, dated 06/01/2026, reflected that the resident had incontinence and one of the interventions was to clean peri-area with each incontinence episode. During an observation on 08/25/2026 at 9:23 a.m., revealed CNA H and CNA I were about to do Resident #7's incontinent care. They washed their hands and put on gloves. CNA H unfastened the resident's brief and tucked it between the resident's legs. CNA H changed her gloves but did not do hand hygiene before putting on a new pair of gloves. CNA I cleaned the resident's perineal area. CNA H rolled the resident to his side and cleaned the resident's bottom. After cleaning the resident's bottom, CNA H pulled the soiled brief and threw it the trash can. After throwing away the brief, CNA H went straight to the resident's overbed table where the new brief was placed. CNA H took the new brief and placed it under the resident's bottom. She did not change her gloves before touching the new brief. CNA I helped with fixing the brief. She did not change her gloves after cleaning the resident's perineal area. During an interview on 08/25/2026 at 9:32 a.m., CNA I said she should have changed her gloves after cleaning the resident's perineal area and before helping with fixing the new brief for infection control. During an interview on 08/25/2026 at 9:34 a.m., CNA H said she had a hand sanitizer in her pocket but forgot to use it when she changed her gloves. She said she was in a hurry that was why she went straight to the new brief after throwing away the soiled brief. She said her actions could cause infection. 2.Record review of Resident #15's Face Sheet, dated 08/26/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/12/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 06/10/2026, reflected that the resident had incontinence and one of the interventions was to clean peri-area with each incontinence episode. During an observation on 08/26/2026 at 8:56 a.m., revealed CNA F and CNA G were about to do Resident #15's incontinent care. They both entered the resident's room and put on gloves. Neither of them performed hand hygiene before putting on their gloves and before doing incontinent care. After putting on gloves, CNA F started to clean the resident's face. After cleaning the resident's face, she changed her gloves but did not do hand hygiene before putting on a new pair of gloves. After putting on gloves, CNA G removed the resident's brief and gave it to CNA F for her to throw away. CNA F changed her gloves but did not perform hand hygiene before putting on a new pair of gloves. CNA G also changed her gloves but also did not perform hand hygiene before putting on the new pair of gloves. CNA G pulled some wipes and cleaned the resident's perineal area. After cleaning the perineal area, CNA G rolled the resident to her side and cleaned the resident's bottom. After cleaning the resident's bottom, she took the resident's new brief and placed it under the resident's bottom. She did not change her gloves after cleaning the resident's bottom. CNA F, who did not perform hand hygiene from the last time she changed her gloves, also assisted in fixing the new brief. During an interview on 08/26/2026 at 9:14 a.m., CNA G said she was in a hurry, that was why she was not mindful of what she was doing wrong. She said hand hygiene should be done before the incontinent care and when she was changing her gloves for infection control. During an interview on 08/26/2026 at 9:14 a.m., CNA F said hand hygiene should been done before and after any care and when she was changing her gloves to prevent any infections. She said it should always be from dirty to clean and not the other way around. During an interview on 08/27/2026 at 8:42 a.m., the DON said hand hygiene should be done before, during, and after any care to prevent infection. She said the gloves should be changed after cleaning the resident's bottom and before touching the new brief to prevent cross contamination. She said she would do an in-service to re-educate the staff regarding infection control. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said the expectation was for the staff to be mindful not to cause any kind of infection. He said he was not a clinician and would let the DON take the lead on the issue of infection control. Record review of the facility's policy Handwashing/Hand Hygiene 2001 MED-PASS, Inc. revised December 22, 2023, reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub . b. Before and after direct contact with residents . g. Before handling clean or soiled dressings, gauze pads . h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves.

Based on observation, interview, and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort, and privacy for 4 of 55 rooms (Rooms #101A/101B, 103A/103B, 201A/201B, 226A /226B). This failure could affect residents by placing them at risk of residing in rooms without proper furnishings and privacy.Findings included: During an initial tour of the facility on 08/25/26 at 9:05 AM observations were made of Rooms #101 and #103, which also served as the surveyor teams office space during the facility's annual survey. The room had three round tables and 12 chairs. DON stated, the room was a dining room. Both rooms did not have any equipment to indicate there was a functional call light system. There were no tracks on the ceilings to provide for the installation of privacy curtains. During a follow up tour of the facility on 08/25/26 at 10:40 AM observations were made of room [ROOM NUMBER] which served as the SW and ADON's office. This space was filled with office furniture, filing cabinets, storage cabinets, books shelves. room [ROOM NUMBER] served as the Medical Records office and contained office furniture, filing cabinets, storage cabinets, supplies. Both rooms did not have any equipment to indicate there was a functional call light system. There were no tracks on the ceilings to provide for the installation of privacy curtains. Review of the facility's license located on the wall in the entranceway issued from State of Texas HHSC revealed, effective Date 04/01/2026, Capacity of 110 residents. Review of the Bed Classification Form 3740 dated 08/26/26, revealed the facility identified Hall 100; room [ROOM NUMBER]A / 101B, room [ROOM NUMBER]A / 103B as Title 18 Medicare-Only beds for both the A and B beds in each room. Hall 200; Rooms 201A / 201B, room [ROOM NUMBER]A / 226B as Title 18/19 Medicare/Medicaid (SNF/NF) beds in each room. Record review of the facility's daily census form for 08/25/26 listed rooms 101A Male, 101B Male, 103A Male, 103B Male. Record review of the facility's daily census form for 08/26/26 listed rooms 101A Male, 101B Male, 103A Male, 103B Male. Record review of the facility's daily census form for 08/27/26 listed rooms 101A Male, 101B Male, 103A Male, 103B Male. Record review of the facility's TULIP application for License Capacity Increase/Decrease Effective:2026-08-27, 3:29PM (Submitted)Proposed Licensed/Certified Beds Title 18 Medicare Only: 12Title 18/19 Medicare/Medicaid (dually certified): 92Total Bed Capacity: 104Change in Total Bed Capacity: -6 Record review of the facility's HHSC Form 3711, Request for Bed Changes and Bed Relocations signed and dated by the ADMIN on 08/27/2026 revealed Current Bed Configuration, Title 18 only Medicare (SNF) only beds (18), Rooms 101-106: Rooms 108-110: All 2 beds each. Title 18/19 Medicare/Medicaid (SNF/NF) Beds (92), Rooms 111-115: Rooms 119-131: Rooms 201-205: Rooms 207-225: Rooms 227-229: All 2 beds each. Proposed Bed Configuration, Title 18 only Medicare (SNF) only Beds (12) room [ROOM NUMBER]: room [ROOM NUMBER]-106: Rooms 108-109: All 2 beds each. Title 18/19 Medicare/Medicaid (SNF/NF) Beds (92) Rooms 110-115: Rooms 119-131: Rooms 201-205: Rooms 207-229: All 2 beds each. Record review of Texas HHSC Form 3614 LSC ROC - Visit Entrance date 03/31/2026; Exit Date 03/31/2026. Narrative: A Licensing Inspection for a 10-bed locked unit capacity increase to an existing 12 bed Men's Locked unit (South Hall 100) was conducted on 03/31/26. The capacity increase was not recommended and violations were cited.The facility is requesting an additional 10 beds in South Hall 100, includes room [ROOM NUMBER], 102, 104, 105, 106 and room [ROOM NUMBER] utilized as living space.The locked unit addition was not occupied. During an observation interview on 08/27/26 at 2:20 PM, MRC stated she has been here at this facility since 2021. MRC stated, it has been an office room since about 2022. The room was clearly marked Medical Records on the door and the door plate indicating it was a nonresident room. During an interview on 08/27/26 at 3:50 PM, SW stated she has been for 3 years 4 months. SW stated Well before me, it was an office for activities and MDS they were in there before for about 3- 4 months. During an interview on 08/27/26 at 4:00 PM ADON stated she has been ADON for 3 years. ADON stated started moving down there 3-4 months ago. ADON would not provide any further information pertaining to the location of her office. ADON refused to provide any other specific details regarding this matter. During an interview on 08/27/26 at 4:15 PM, MHD stated he has been employed here for about 9 months. MHD stated room#101 & room [ROOM NUMBER] have only recently been changed to non-resident rooms. It hasn't been more than 2-3 months, and the ladies was there before I got here. Rooms #226 and 201 were already an office. During an interview on 08/27/26 at 4:10 PM ADMIN stated she had been the administrator for about 4 years, and stated room [ROOM NUMBER]A / 226B and 201A / 201B were already declassified. ADMIN stated their corporate submitted the declassification requested dated 08/26/2026, but there was a data error or entry error which prevented the submission of it on the date. ADMIN stated she was unaware of the rooms not being declassified. ADMIN admitted that the dining room area with rooms 101 & 103 was a new thing but that they were currently working with LSC, and the matter had been addressed and added they were not getting a tag. ADMIN stated, Why was this not brought to her attention, it was not a concern of the survey team on day one, why is it now. ADMIN stated, after the LSC Exit conference, she felt they were in compliance with the Bed Classification. A policy request for facility's Maintenance Service was requested on 08/27/26 at 8:03 AM, via email to the ADMIN, but was not provided prior to exit. A policy request for the Bed Classification was requested on 08/27/26 at 4:17 PM from ADMIN, during the interview, but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 4 of 13 residents (Resident #28, Resident #56, Resident #36, and Resident #66) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking assessment on admission for Resident # 28, Resident #56 and Resident #36.The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly for Resident #66. This failure could place residents at risk of unsafe smoking and injury.Findings included:Record review of Resident # 28's face sheet dated 08/26/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis included COPD (a chronic lung disease that blocks airflow and makes breathing difficult), hypertension (high blood pressure), schizophrenia (a mental disorder that changes how a person thinks, feels and behaves, making it hard for them to tell what is real and what is not), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and emptiness).Record review of Resident # 28's Quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating moderate cognitive impairment. Resident #28 required set-up assistance with dressing, bathing and transferring. Record review of Resident #28's care plan dated 04/27/2026 reflected she was a current smoker and would maintain current level of safety. Record review of Resident # 28's electronic medical record revealed she did not have a safe smoking assessment completed since being admitted .During an observation on 08/26/2026 at 1:05 p.m., Resident #28 was outside smoking with staff.Record review of Resident #56's face sheet dated 08/26/2026 reflected a [AGE] year-old male who was admitted on [DATE]. His diagnosis included cerebral infarction (the death of brain cells caused by a blocked or narrowed blood vessel that stops blood and oxygen from reaching the brain), hypertension (high blood pressure), cognitive communication deficit and major depressive disorder, severe with psychotic features. Record review of Resident #56's Quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated moderate cognitive impairment. Resident #56 required moderate assistance with dressing and showers and supervision with toileting and transfers. Record review of Resident #56's care plan dated 02/10/2026 reflected he was a current smoker and would maintain current level of safety during smoking.Record review of Resident # 56's electronic medical record revealed he did not have a safe smoking assessment completed since being admitted . During an observation on 08/26/2026 at 1:05 p.m., Resident #56 was outside smoking with staff. Record review of Resident #36's face sheet dated 08/26/2026 reflected a [AGE] year-old female who was admitted on [DATE]. Her diagnosis included congestive heart failure (a chronic condition where the heart muscles cannot pump blood efficiently), dysphagia (a language disorder caused by brain damage), and unspecified dementia (noticeable memory loss and cognitive decline).Record review of Resident #36's Quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated moderate cognitive impairment. Resident # 36 required set up assistance with transfers, toileting, dressing and eating. Record review of Resident #36's care plan dated 05/15/2026 reflected she was a current smoker and would maintain current level of safety during smoking.Record review of Resident # 36's electronic medical record revealed she did not have a safe smoking assessment completed since being admitted .During an observation on 08/26/2026 at 1:05 p.m., Resident #36 was outside smoking with staff.Record review of Resident # 66's face sheet dated 08/26/2026 reflected a [AGE] year-old male who admitted on [DATE] and a re-admit date of 07/27/2026. His diagnosis included cerebral infarction affecting left non dominant side (the death of brain tissue caused by a blockage or narrowing of the blood vessel that stops blood and oxygen from reaching the brain), degenerative disease of the nervous system (a condition where cells in the brain and spinal cord gradually stop working), and seizures.Record review of Resident #66's Comprehensive MDS dated [DATE] reflected a BIMS score of 5 which indicated severe cognitive impairment. Resident #66 required set up assistance with eating and supervision with toileting, showers, dressing and transfers.Record review of Resident #66's care plan dated 04/09/2022, revised on 11/06/2025 reflected he required staff supervision and staff will complete a smoking assessment to ensure his safety.Record review of Resident #66's electronic medical record revealed his last smoking assessment was completed on 02/24/2026. During an observation on 08/26/2026 at 1:05 p.m., Resident #36 was outside smoking with staff.During an interview on 08/26/2026 at 1:34 p.m. the ADON stated any of the nurses could do the smoking assessments. She had the MDS nurse look in the electronic medical record and stated Resident #28, Resident #56 and Resident #36 did not have completed smoking assessments and Resident # 66 had not had one completed since February of 2026. She stated she expected them to be done on admission and quarterly. She stated there was no potential risk for the assessments not being completed. During an interview on 08/26/2026 at 3:47 p.m., the DON stated any nurse could do the smoking assessments, it should be done on admit and quarterly and the reason they were missed was because the residents were all new admits to the facility. She stated the risk to the residents was they could burn themselves or cause a fire. Record review of the Smoking policy dated March 8, 2023 revised revealed, The resident will be evaluated on admission if he or she is a smoker or non-smoker. Once a resident is determined to be a smoker, his/her ability to smoke with be evaluated upon admission, subsequent MDS and PRN.

Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for two of eight residents (Residents #5 and Resident #6) reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #5's Comprehensive MDS Assessment, dated 06/25/2026, accurately reflected the resident was using a hypoglycemic (medications used to lower the blood sugar) medication. 2.The facility failed to ensure Resident #6's Comprehensive MDS Assessment, dated 06/25/2026, accurately reflected the resident was using a hypoglycemic medication. These failures could place residents at risk of not receiving care and services needed to meet their needs, diminished function of health, and regression in their overall health.Findings included: 1.Record review of Resident #5's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (body has a higher sugar level). Record review of Resident #5's Comprehensive MDS Assessment, dated 06/30/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment did not indicated that the resident was using hypoglycemic medication. Record review of Resident #5's Comprehensive Care Plan, dated 07/02/2026, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #5's Physician Order, dated 06/22/2026, reflected INSULIN LISPRO 100 UNIT/ML PEN. Inject subcutaneously (administer under the skin) three times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE (loss of kidney function). 2.Record review of Resident #6's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #6's Comprehensive MDS Assessment, dated 06/25/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment did no indicated that the resident was using hypoglycemic medication. Record review of Resident #6's Comprehensive Care Plan, dated 07/02/2026, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #6's Physician Order, dated 05/19/2026, reflected Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 150 = 0 Follow Doctors hypoglycemic (low blood sugar) and facility's protocols; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12 contact doctor for hyperglycemic protocols, subcutaneously before meals and at bedtime for DM. During an observation and interview on 08/27/2026 at 8:18 a.m., the MDS Nurse said if the residents were being administered insulin or any hypoglycemic medications, their MDS should reflect that they were with hypoglycemic medications. She opened Resident #5 and Resident #6's profiles and saw that the residents were both receiving insulins. She then looked at the residents' MDS and saw the residents were not coded for hypoglycemic medications. She said she did not know how she missed it, and it was an oversight on her part. She started to click on the resident's MDS and modified it to reflect the resident was on hospice care. She said the residents should be assessed properly to accurately answer every section in the MDS. She said the MDS should reflect the whole picture of the resident to provide a plan of care. During an interview on 08/27/2026 at 8:42 a.m., the DON said she was not very familiar with the MDS of the residents. She said the MDS should reflect the conditions of the residents and could be the basis for what would be included in the residents' care plan. She said if the residents were receiving insulins, their MDS should reflect it. She said she would coordinate with the MDS Coordinators to audit the MDS of the residents. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said the MDS was the summary of the residents' clinical assessment and could be used to make and update the residents' care plan. She said she would coordinate with the DON and the MDS Coordinator to audit the MDS of the residents. Record review of the facility's policy Comprehensive Assessments and the Care Delivery Process 2001 MED-PASS, Inc. revised March 20, 2025, reflected Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans . Policy Interpretation and Implementation . Assessment and information . a. Assess the individual . (1) Gather relevant information . (2)Complete the Minimum Data Set . 3. Information analysis . e. Make decisions about care and treatment.

Based on observation, interview, and record review, the facility failed to ensure residents with wounds received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one of four residents (Resident #5) reviewed for quality of care. The facility failed to ensure LVN J did not clean Resident #5's wound with the gauze that was already used on 08/25/2026. This failure could place the residents with wounds at risk of infection.Findings included: Record review of Resident #5's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia and hemiparesis. Record review of Resident #5's Comprehensive MDS Assessment, dated 06/30/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated nonsurgical dressing and medications were being applied to the resident's skin. Record review of Resident #5's Comprehensive Care Plan, dated 08/18/2026, reflected the resident had a wound on her left lateral calf and one of the interventions was to document progress in wound healing. Record review of Resident #5's Physician Order, dated 08/25/2026, reflected CLEANSE LEFT CALF WITH NORMAL SALINE, PAT DRY, APPLY ANASEPT AND XEROFORM, COVER WITH DRY DRESSING. every day shift. During an observation on 08/25/2026 at 1:11 p.m., LVN J was about to do Resident # 5's wound care. She washed her hands, put on a gown, and a pair of gloves. She went inside the resident's room and brought with her a container of wound cleanser, gauzes, dressing, anasept ointment, and xeroform, and placed them on the resident's overbed table. She removed the old dressing, took off her gloves, sanitized her hands, and put on a new pair of gloves. She sprayed some wound cleanser to a couple of gauzes and started to clean the wound. She started cleaning the wound from inside to outside but used the same gauzes to clean the wound again. She took off her gloves, sanitized her hands, put on a pair of gloves, and proceeded with wound care. During an interview on 08/25/2026 at 1:26 p.m., LVN J said she knew she used the soiled gauze to clean Resident #5's wound. She said maybe she was just nervous and that was why she did not pay attention to using new gauzes to clean the wound the second time. She said the risk could be re-introducing microorganisms to the wound that she was cleaning. During an interview on 08/27/2026 at 8:42 a.m., the DON said the right way to clean the wound was one wipe, discard, one wipe, discard, to prevent worsening of the wound. She said she wound re-educate the staff about wound care and would also do a check-off. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said she was not a clinician, and she would let the DON take the lead about the wound care issue. Record review of the facility's policy Wound Care 2001 MED-PASS, Inc. revised November 2017 reflected Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for two of five residents (Resident #7 and Resident #15) reviewed for incontinent care. 1.The facility failed to ensure CNA I performed the right technique during Resident #7's incontinent care on 08/25/2026. 2.The facility failed to ensure CNA G performed the right technique during Resident #15's incontinent care on 08/26/2026. This failure could place the residents at risk of a urinary tract infection.Findings included: 1.Record review of Resident #7's Face Sheet, dated 08/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #7's Comprehensive MDS Assessment, dated 05/28/2026, reflected the resident had severe impairment in cognition with a BIMS score of 01. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent (unable to control) for bladder and bowel. Record review of Resident #7's Comprehensive Care Plan, dated 06/01/2026, reflected that the resident had incontinence and one of the interventions was to clean peri-area (area between the thighs) with each incontinence episode. During an observation on 08/25/2026 at 9:23 a.m., revealed CNA H and CNA I were about to do Resident #7's incontinent care. They both put on pairs of gloves and started with incontinent care. CNA H unfastened the resident's brief and tucked it between the resident's legs. CNA H pulled some wipes and cleaned the sides of the resident's perineal area (area between the legs). After cleaning the sides, she used the same wipes to clean the shaft of the penis from the base to the opening of the penis. She just did one stroke; she did clean the neck and the head of the penis. During an interview on 08/25/2026 at 9:32 a.m., CNA I said she should clean the penis downward to prevent any microorganism from entering the opening of the penis. She said she should not use the wipes used to clean the sides to also clean the head because the wipes were already dirty. She said the risk could be UTI (infection of any part of the urinary system). 2.Record review of Resident #15's Face Sheet, dated 08/26/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/12/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 06/10/2026, reflected that the resident had incontinence and one of the interventions was to clean peri-area with each incontinence episode. During an observation on 08/26/2026 at 8:56 a.m., revealed CNA F and CNA G were about to do Resident #15's incontinent care. CNA G unfastened the resident's brief and tucked it between the resident's legs. She removed her gloves and put on a new pair of gloves. She pulled some wipes and cleaned the resident's perineal area. After cleaning the perineal area, she rolled the resident to her side and cleaned the resident's bottom. She cleaned the resident's bottom from back to front. She did it twice. She then cleaned again the perineal area using the wipes she used to clean the resident's bottom. During an interview on 08/26/2026 at 9:14 a.m., CNA G said she was in a hurry, that was why she was not mindful of what she was doing wrong. She said cleaning the resident's bottom should be towards the back always and used wipes could not be used to clean the perineal area to help prevent UTI. During an interview on 08/27/2026 at 8:42 a.m., the DON said cleaning the penis should be towards the base of the shaft and not the other way around. She said the staff should slightly pull the skin of the shaft and clean the head of the penis in a circular motion. She said for female residents, the perineal area should always be cleaned from front to back and never use used wipes to clean the perineal area for patient safety. When asked what the risk could be, the DON replied, For resident safety. She said she would do an in-service and check-off about incontinent care to re-educate the staff. During an interview on 08/27/2026 at 9:50 a.m., the Administrator said she was not a clinician, and she would let the DON take the lead about the incontinent care issue. Record review of the facility's policy Diarrhea and Fecal Incontinence 2001 MED-PASS, Inc. revised September 2010 reflected Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing the resident's exposure to feces . Steps in the Procedure . 6 . Wipe away from the perineum.

Based on observation, record review and interview, the facility failed to provide adequate supervision for 1 (Resident#1) of 8 residents reviewed for supervision. The facility failed to ensure Resident #1 had adequate supervision on Saturday 07/19/25 for approximately 30 minutes. Resident#1 left out the front door and wheeled himself across 4 lanes (with two lanes that ran in the opposite direction) of traffic across the street to the gas station unsupervised. These failures could place residents' health and safety at risk. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/19/25 and ended on 07/31/25 the facility had corrected the non-compliance before the state's investigation began. Findings included: Record review of Resident#1's face sheet reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with unspecified Dementia ( diagnosis used when a person exhibits symptoms of dementia, but the specific type or cause cannot be determined), partial traumatic trans phalangeal amputation of right middle finger (traumatic injury that causes the partial loss of a finger at the level of the joint between the finger bone (phalanx) and the hand bone (metacarpal)), subsequent encounter, major depressive disorder, recurrent, Epileptic seizures related to external causes, not intractable without status Epilepticus (neurological events characterized by abnormal electrical activity in the brain), heart failure, unspecified, catatonic schizophrenia (brain doesn't manage muscle movement signals), mixed receptive-expressive language disorder (communication disorder), Rhabdomyolysis (Break down of muscle tissue), unspecified abnormalities of gait and mobility. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 06 which indicated severe cognitive impairment. Record review of Resident#1 care plan, undated reflected on 07/14/25 The resident has limited physical mobility r/t weakness and debility. Goals reflected, the resident will maintain current level of mobility Interventions reflected, the resident requires supervision to limited assistance by staff for locomotion using manual wheelchair. Support and assistance fluctuate r/t cognitive deficit, weakness. Record review of Resident#1's Elopement Risk Assessment, dated 06/18/25 reflected in part: 1. Mobility - propels, 2. Mental Stability- Alert oriented times 3 (patient is aware of their identity, location, and the current date), 4. History of elopement attempts - no attempts, 5. Behavior Modification- Behavior redirected.7. Diseases (Dementia, any type of mental illness)- non-present. 8. Summary of the elopement risk assessment- The resident is not at risk for elopement. Record review of Resident#1's progress notes dated, 07/16/25 to 08/15/25 reflected in part: Dated 07/16/25 reflected Per social worker resident been attempting to push the front door yesterday, at this time resident sitting at the front lobby at this time resident did not want to talk to this nurse .NP notified , Dated 07/17/25 Resident#1 test results reflected (Enterococcus faecalis (Gram-positive bacterium commonly found in the gastrointestinal tract): Positive, Pseudomonas aeruginosa (can cause infections in the blood, lungs, urinary tract, or other parts of the body after surgery.: Positive) and resistance to multiple antibiotics, Noted by RN C Dated 07/18/25 Resident#1's First dose of IV Vancomycin (glycopeptide antibiotic used primarily to treat serious bacterial infections, particularly those caused by Gram-positive bacteria) 1g administered via midline to the right upper arm for treatment of UTI . Noted by RN C Dated 07/19/25 reflected Approximately [1:00 pm] resident with others were taken out to the smoking zone. After the resident finished smoking, he was let inside by the CNA. The resident noted sitting across the nurse station for a few minutes, then wheeled himself on the hallway towards his room. Approximately [1:30 pm] the activity staff notified this nurse that the resident was outside in the front side of the building. This nurse rushed to the front of the building immediately and noted resident sitting on his wheelchair on the driveway with the maintenance Director standing behind him. Maintenance director stated that the resident was across the street. Resident Assisted back into the building. This nurse asked the resident where are you coming from? Resident replied, I don't know, I don't know, I don't know.shaking his head left to right Head to toe assessment completed no injuries noted, Vitals: BP126/60, P68, RR17 T97.7, o2 96% on room air. Resident denies pain at the moment and no s/s of distress noted. Administrator, [FNP] DON and Family notified.[FNP] gave new orders to house the resident in the secure unit. Resident transferred to the secure unit. Report given to the unit nurse . ADM and nurse followed up with resident regarding incident from earlier today. Resident was asked if he went across the street, resident smiled while shaking his head stated I went to the front because I'm a strong man. Resident stated he's fine and asked ADM not to worry .ADM called resident RP again to inform her of resident going outside of facility with no supervision. Resident RP stated, .please don't discharge him, just put him in the locked unit. ADM explained to her the physician has already ordered for him to be in the unit for his safety.Resident received to secure unit due to elopement risk. Resident continuously self-propelling up and down unit and sitting at exit doors waiting for people to enter or exit. Resident voices desire to leave. Redirected through this shift. Noted by Admin. Record review of incident report dated 07/19/25, completed by RN C reflected: Approximately [1:00 pm] resident with others were taken out to the smoking zone. After the resident finished smoking, he was let inside by the CNA. The resident noted sitting across the nurse station for a few minutes, then wheeled himself on the hallway towards his room. Approximately [1:30 pm] the activity staff notified this nurse that the resident was outside in the front side of the building. This nurse rushed to the front of the building immediately and noted resident sitting on his wheelchair on the driveway with the maintenance Director standing behind him. Maintenance director stated that the resident was across the street. Resident Assisted back into the building. This nurse asked the resident where are you coming from? Resident replied, I don't know, I don't know, I don't know.shaking his head left to right Head to toe assessment completed no injuries noted, Vitals: BP126/60, P68, RR17 T97.7, o2 96% on room air. Resident denies pain at the moment and no s/s of distress noted. Administrator, [FNP] DON and Family notified.[FNP] gave new orders to house the resident in the secure unit. Resident transferred to the secure unit. Report given to the unit nurse. ADM and nurse followed up with resident regarding incident from earlier today. Resident was asked if he went across the street, resident smiled while shaking his head stated I went to the front because I'm a strong man. Resident stated he's fine and asked ADM not to worry.ADM called resident RP again to inform her of resident going outside of facility with no supervision. Resident RP stated, .please don't discharge him, just put him in the locked unit. ADM explained to her the physician has already ordered for him to be in the unit for his safety . In an interview on 08/14/25 at 12:25 pm the AAD stated she took Resident#1 outside to smoke on smoke break, and she returned to do activities with the residents. The AAD stated Resident#1 was outside with CNA A on his smoke break. The AAD stated she was leaving the facility out the front door when the DOM let her know the Resident#1 was across street. The AAD let the nurse know who met the Resident#1 in the parking lot with the DOM. In an interview on 08/14/25 at 12:33 pm the DOM stated the DOM left the facility at approximately 1:30 pm and spotted Resident#1 across the street at the gas station. The DOM brought Resident#1 from across the street, and he refused to go back into the building. The nurse came out and assisted Resident#1 in the building. In an interview and observation on 08/14/25 at 12:45 pm the Admin stated CNA A was coming down 200 hall and heard the front door alarm going off. The admin stated the CNA A stated she looked out the front door and did not see anyone. The admin stated CNA A turned the alarm off and clocked out for lunch. The admin stated she did a one-on-one training with CNA A because she should not have turned the alarm off. The Admin stated the charge nurse should have been notified that the front door alarm went off and a head count should have been completed. The Admin stated she did not believe CNA A looked outside for anyone but since CNA A stated she did look that was way she did an education training with her instead of disciplinary action. The admin showed surveyor from the front door window where the gas station could. be viewed from across the street. Record review of the Admin's statement on 07/19/25 regarding Resident#1's elopement reflected, [Admin] and nurse followed up with resident regarding incident from earlier today. [Resident#1] was asked if he went across the street, Resident smiled while shaking his head, stated. Went to the front because [his] a strong man. Resident stated he's fine and as admin not to worry. Admin call resident RP again to inform her of residents going outside of facility with no supervision .the physician has already ordered for him to be in the unit for his safety. Resident RP was very relieved and thankful to facility.Record Review of the AAD's statement on 07/19/25 reflected, At 1:00 PM, [she] saw [Resident #1] in the front lobby and told him it was time to smoke. [she] then took [residents]to the smoking area around 1:00 PM and then [she] went to go do my activity. Resident was outside and smoking areas singing. Another resident smoking when [she] left him. Record review of CNA B's statement on 07/19/25 reflected. Supervised [ resident] on smoking at around 1:00 PM, smoke break and soon after residents smoke one cigarette. [she] helped residents to come back in because Resident #1 was getting very angry and agitated at the time. [Then took resident#1 to] the nursing stations and then went back out to finish the smoke break for the rest of [residents]. Record review of the DOM's statement on 07/19/25 reflected, leaving the facility about 1:30 PM and notice Resident #1 was across the street at the store. And then went across the street to the store and got out of my car to approach Resident #1.brought resident back to the facility and told nurse that i found resident across the street and I left the resident with the nurse. Record review of RN C's statement on 07/19/25 reflected,The same as the above incident report and his statement to the admin. Record review of CNA A's statement on 07/19/25 reflected, [CNA A] was coming down 200 hall to clock out for lunch upon coming to hall I heard alarm sound. [She] then [looked] out the door and window to see if anyone was leaving and saw no one then [she] reset the alarm. Record review of CNA B time sheet, dated 07/19/25 reflected, she clocked out at 1:19 pm.Record review of DOM time sheet dated 07/19/25 reflected, he clocked out at 1:07 pm.Record review of AAD time sheet dated 07/19/25 reflected, she clocked out at 1:35pm. Attempted to call RN C on 08/14/25 at 1:15pm and was not able to leave voicemail. Attempted to call RN C on 08/15/25 at 8:30 am and was not able to leave voicemail. Attempted to call CNA A on 08/15/25 at 8:35 am was not able to leave a voicemail. Attempted to call CNA B on 08/15/25 at 9:30 am was not able to leave a voicemail. Record review of facility policy, revised 04/24, titled Accidents and Supervision reflected in part: .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to decrease the risk of accidents.5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Record review of facility policy, revised 12/07, titled Elopements reflected in part: 4. If an employee discovers that a resident is missing from the facility, he/she shall:Determine if the resident is out on an authorized leave or pass.If the resident was not authorized to leave, initiate a search of the building(s) and premises.If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. emergency management, Rescue squad, etc.).Provide search teams with resident identification information; andInitiate an extensive search of the surrounding area.5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:Examine the resident for injuries.Contact the attending physician and report findings.Notify the resident's legal representative (sponsor)Notify search team that the resident has been located.Complete and file an incident report; andDocument relevant information in the resident's medical record. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/19/25 and ended on 07/31/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Resident#1 elopement risk assessment, dated 07/19/25 reflected in part: 1. Mobility - propels self/some assist 2. Mental Stability - Wanders aimlessly 4. History of elopement attempts - has had one plus attempts 5. Behavior Modifications - Behavior redirected.7. Diseases (Dementia, any type of mental illness)- one present 8. Summary of the elopement assessment - the resident is at risk for elopement.B-1, Elopement Interventions- Secured unit placement. Record review of Resident#1's order summary report, dated 08/15/25 reflected in part: on 07/21/25 the PA put in a verbal order for Resident#1 to be admitted to the secure unit for wandering/elopement. On 07/22/25 PA put in a verbal order that Resident#1 may be on one-on-one watch. Record review of a training sign in sheet, dated 07/21/25 reflected in part: elopement process, every hour rounding on every exit door, and elopement drill Training sign in sheet dated 07/19/25 - 07/22/25 and 07/31/25 reflected, elopement drill, facility elopement process and missing person. Record review of Resident#1's care plan, revised on 07/21/25 reflected Resident#1 was an elopement risk/[wanderer] as evidenced by disoriented to place and leaving the building. Resident#1's goal reflected safety will be maintained. Resident#1's interventions reflected Attempt to engage in pleasant, meaningful, purposeful enjoyable, activities, during episodes of constant wandering, by playing music or engage him with other activities. Observe for changes in gait/mobility/balance and notify the nurse of any changes. Observe for fatigue and weight loss, report observations to nurse. During an observation and interview on 08/14/25 at 10:30 am revealed, Resident#1 in the secure unit in his wheelchair and transferred himself to the bed. Resident#1 did not want to talk about the elopement. Resident#1 shook his head no and laid down. Observed doors in the secure units worked properly. Observed Resident#1 on Q15 throughout the day. In an interview and observation on 08/14/25 at 10:40 am LVN D stated the elopement happened over the weekend and when he returned to work Resident#1 was in the secure unit. LVN D stated before the elopement Resident#1 was on 200 hall and was on Q15 monitoring. LVN D stated he had not experienced an elopement while working in the facility. LVN D stated he had been trained on the elopement process and procedures. LVN D stated staff should do a head count when the alarm goes off, contact the admin, make an intercom announcement, search for the resident inside and around the facility. In an interview and observation on 08/14/25 at 12:45 pm the Admin stated The Admin added she completed in-services with regular staff on 07/31/25. The admin stated the ADON completed in- services with the PRN staff over the phone in 07/22/25. The Admin stand she completed elopement drills on 07/31/25, The admin stated they did monthly elopement drills. The Admin stated the facility completed upgrades to the alarm system that included blinking strobe lights and horn that could be heard throughout the facility. In an Interview on 08/14/25 between 1:15pm to 2:30 pm revealed staff were knowledgeable about the policy and procedures for elopement and drills. LVN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, RN L, CNA M, CNA N, LVN O, RN Q and CNA P stated they had been doing random drills for elopement. Staff stated when the alarm went off look outside, do head count, and let the charge nurse and admin know the alarm went off. The staff stated search the inside of the building then extend the search to the outside. The staff stated call code white for elopement over the intercom. RN L, RN F, RN Q and LVN O stated when the resident was found a head-to-toe assessment was to be completed and an incident report. During an observation on 08/14/25 at 4:15 pm revealed the Admin set the front door alarm off. The Admin lightly pushed the door and she stated that was the sound the door would make before the upgrade. The surveyor observed the sound was able to be heard in the front of the building but, was too low to be heard throughout the building. The surveyor heard the horn and flashing lights throughout the facility. Observed staff running to the front of the building. Observed exit doors throughout the building and no concerns noted at this time. In an interview on 08/15/25 at 9:35 am the PA stated the facility notified her on Saturday 07/19/25 that Resident#1 had eloped from the facility. The PA stated she gave the order for Resident#1 to be put on the secure unit. The PA stated Resident#1 was combative with staff and exit seeking. The PA stated at this time Resident#1 was appropriate for the secure unit. Record review of Tulip (A web- based system implemented for managing the licensure of long-term care facilities and agencies) reflected a self- report was submitted on 07/18/25. Record review of IC approved quote dated 08/04/25 reflected strobe white wall, amber lens and system sensor wall mini horn, white for installment for upgrades to alarm system.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility freezer on 06/30/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 6/30/25 at 9:48 AM in the facility freezer revealed frozen cinnamon rolls were left uncovered in an open brown box exposing them to frigid air. In an interview 07/01/25 12:44 PM with the Dietary Manager who stated that everyone including cooks, dietary aides and himself were responsible for covering, dating, and labeling all food items in the kitchen. He stated all foods should be appropriately covered and sealed. He stated he tossed away the cinnamon rolls that were left open inside the freezer. He added the risk to residents of improper food storage that included dating, labeling, and covering food items was possibility of food borne illness in residents and cross contamination of food. In an interview on 07/01/25 at 12:51 PM with [NAME] B who stated she was working in the facility for about 18 years. She stated that everyone in the kitchen including dietary aides, cooks, and managers were responsible for appropriate food storage. She stated all food items in the kitchen especially in the refrigerator and freezer should be tightly covered . She stated risk of not covering food appropriately can cause food borne illness in residents. In an interview on 07/01/25 at 12:56 PM with Dietary Aide C who revealed all food items in the kitchen should be covered appropriately and it was the responsibility of all kitchen staff. She added that the risk to residents of not appropriately covering food items was residents could get sick. Review of the facility's policy titled Food Storage revised June 1, 2019, reflected, . Policy: To ensure that all food served by the facility is. of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Review of the Food and Drug Administration Food Code, dated 2022, reflected, . Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 5 Residents (Resident#13, Resident#16, Resident#57, Resident#63, and Resident#87) of 20 residents reviewed for residents' call systems. The facility failed on 06/30/2025 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' toilets located inside the residents' rooms when the call lights were missing the pull strings, for:. Resident#13. Resident#16 . Resident#57. Resident#63 . Resident#87 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: -Observation on 06/30/25 at 10:48 AM residents' toilet call light pull string was missing for Resident#13 and Resident#16. - -Observation on 06/30/25 at 11:30 AM residents' toilet call light pull string was missing for Resident#57 and Resident#87. -Observation on 06/30/25 at 11:37 AM resident's toilet call light pull string was missing for Resident#63 Interview and observation on 07/02/25 at 12:38 PM the Maintenance/Housekeeping Director who stated he looked at the call light outlets and stated the string were missing. The Maintenance/Housekeeping Director stated he did not know about the missing call lights strings, and he would fix them right away. The Maintenance/Housekeeping Director stated the risk to a resident was the resident could fall, not get help, and could cause someone to be lying there for hours. Interview on 07/02/25 at 1:20 PM the DON who stated call light string supposed to be replaced if it was missing, and it was supposed to be within the reach of the resident. DON stated missing call light strings was a safety concerns. Interview on 07/02/25 at 2:33 PM the Administrator who stated the call light string should be within resident reach, so they could call for help when they need it. She stated missing strings for the bathroom call lights could be a safety issue. Review of the facility policy titled Call Lights: Accessibility and Timely response, revised 05/01/25 revealed The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance. 5.Staff will ensure the call light is within reach of resident and secured, as needed. Findings included: -Observation on 06/30/25 at 10:48 AM residents' toilet call light pull string was missing for Resident#13 and Resident#16. - -Observation on 06/30/25 at 11:30 AM residents' toilet call light pull string was missing for Resident#57 and Resident#87. -Observation on 06/30/25 at 11:37 AM resident's toilet call light pull string was missing for Resident#63 Interview and observation on 07/02/25 at 12:38 PM the Maintenance/Housekeeping Director who stated he looked at the call light outlets and stated the string were missing. The Maintenance/Housekeeping Director stated he did not know about the missing call lights strings, and he would fix them right away. The Maintenance/Housekeeping Director stated the risk to a resident was the resident could fall, not get help, and could cause someone to be lying there for hours. Interview on 07/02/25 at 1:20 PM the DON who stated call light string supposed to be replaced if it was missing, and it was supposed to be within the reach of the resident. DON stated missing call light strings was a safety concerns. Interview on 07/02/25 at 2:33 PM the Administrator who stated the call light string should be within resident reach, so they could call for help when they need it. She stated missing strings for the bathroom call lights could be a safety issue. Review of the facility policy titled Call Lights: Accessibility and Timely response, revised 05/01/25 revealed The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance. 5.Staff will ensure the call light is within reach of resident and secured, as needed.

Based on interview, observation and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 5 residents (Resident #31) reviewed for accuracy of assessments. The facility failed to accurately complete Resident #31's Quarterly Minimum Data Set assessment on 6/3/25 by not accounting for the falls on 4/18/25, 5/8/25, 5/16/25, 5/17/25, 5/21/25, 5/22/25 which occurred prior to her re-admittance to the facility on 6/2/25. This failure could place residents at risk of not having their needs met. Findings included: Record review of a face sheet dated 7/2/25 indicated Resident #31 was a [AGE] year-old female admitted to the facility on [DATE] with a re-admission on [DATE]. Resident #31 had the following diagnoses: metabolic encephalopathy (condition in which brain dysfunction occurs resulting in altered mental state, confusion and changes in behavior), and Extrapyramidal Movement Disorder (a disorder characterized by involuntary movements, muscle stiffness and tremors). Record review of Resident #31's comprehensive Minimum Data Set assessment dated [DATE] section A0310 reflected it was a quarterly assessment. In section J1800 regarding falls indicated, Resident #31 had no falls since admission/entry or reentry. Record review of Resident #31's Care Plan dated 6/2/25 reflected . I am at risk for falls r/t confusionDate Initiated: 11/16/2022Revision on: 11/16/2023 My fall risk will be minimized.Date Initiated: 11/16/2022Revision on: 12/13/2023Target Date: 05/25/2025 Become familiar with my daily routine and attempt to anticipate and meet my needsdaily.Date Initiated: 11/16/2022Revision on: 11/21/2022CG Encourage me to stay in common areas to promote more supervision.Date Initiated: 11/16/2022CMCG Encourage my participation in activities that will increase strength and mobility.Date Initiated: 11/16/2022CMResident had an actual fall on 5/17with no injuries, 5/21/25 abrasion to left knee and redness to forehead, 5/22/25 Date Initiated: 05/17/2025Revision on: 05/23/202 Ms. [NAME] will not have anymajor injuries from falls throughreview dateDate Initiated: 05/17/2025Target Date: 05/25/2025 Redirect Ms. [NAME] to chair when she wants to sit downDate Initiated: 05/17/2025CG sent to ER for evaluation.Date Initiated: 05/22/2025CN Therapy referral for strength and mobility/balance post fall and as needed per MDorder.Date Initiated: 05/17/2025PT. Record review of the facility Accident/Incident Logs reflected the following falls for Resident #31:- 4/18/25 witnessed fall- 5/8/25 unwitnessed fall- 5/16/25 unwitnessed fall- 5/17/25 unwitnessed fall- 5/20/25 unwitnessed fall- 5/22/25 witnessed fall- 6/28/25 witnessed fall- 6/30/25 unwitnessed fall In an interview with CNA F on 7/1/25 at 11:40pm who stated Resident #31was a fall risk and the interventions they had in place for her were close supervision, provide non-slip socks and follow behind her when she was up and walking. She stated resident was hospitalized recently and believed it was due to a fall she had. In an interview with LVN G on 7/1/25 at 11:59am who stated Resident #31 was a fall risk and should be checked on hourly to prevent falls. Resident #31's bed should always be in the lowest position. In an interview with RN H on 7/1/25 at 3:02pm who stated when Resident #31 came from the hospital she was a fall risk. Staff would ensure her bed was in the lowest position and make sure her call light was in reach. Observation of Resident #31 in bed on 7/2/25 at 12:07pm revealed resident was asleep with her bed in the lowest position. She had non-slip socks on, and the call light was within reach for her. In an interview with Minimum Data Set Coordinator on 7/2/25 at 11:23am revealed she had completed Resident #31's Quarterly Minimum Data Set Assessment on 6/3/25. She was responsible for accurately completing all sections of the Minimum Data Set assessment except for sections B, C, D, and E. She used the documentation from Certified Nurses Aids and nurses to complete the sections on the Minimum Data Set. She stated if a resident had a fall since the last Minimum Data Set she would mark the fall on section J. She reviewed Resident #31's Minimum Data Set, dated [DATE] and noted there were no falls marked for her. She stated Resident #31 was discharged from the facility on 5/22/25 and re-admitted on [DATE]. When she completed Resident #31's Minimum Data Set assessment on 6/3/25 she looked at what had changed from resident's last Minimum Data Set on 5/22/25 and updated it. The Minimum Data Set Nurse Coordinator noted resident had a fall on 5/22/25 which led to her hospitalization and therefore should have included that fall in her updated Minimum Data Set on 6/3/25. She stated she should have noted on the 6/3/25 Minimum Data Set Assessment any falls that resident had after 4/6/25. She stated she must have overlooked the information related to the residents falls when completing the Minimum Data Set assessment on 6/3/25. She stated she did not know if there would be a risk to the resident of not having an accurate Minimum Data Set since there were no injuries during her last fall. She did not think the failure put the resident at risk because the staff didn't refer to the Minimum Data Set to provide care for the resident. In an interview with the DON on 7/2/25 at 12:56pm revealed Resident #31 had been hospitalized for several weeks due to her declining health. She stated Resident #31 was a fall risk. She did not complete Minimum Data Set assessments, but the expectation would be the Minimum Data Set Nurse complete the Minimum Data Set assessments based on Certified Nurses Aid notes, observations and assessments for the resident. She stated falls should be noted in the MDS assessment. She was unable to state whether there was a risk to the resident of not having an accurate Minimum Data Set assessment. In an interview with the Administrator on 7/2/25 at 1:45pm revealed the Minimum Data Set nurse used information in the resident's medical record to complete an Minimum Data Set. She stated the Minimum Data Set Nurse should use the Certified Nurses Aid observations, notes and assessments to complete an Minimum Data Set accurately. Falls should be noted in the Minimum Data Set. The only risk to the resident of not having falls listed on their Minimum Data Set was if the issues had not been care planned, if the falls were care planned then it would just be an oversight. The Minimum Data Set assessment should be used to accurately complete the Comprehensive Care Plan. Record review of the facility's Minimum Data Set Completion Policy: Compliance with RAI Guidelines reflected .A. Compliance with RAI Guidelines: All MDS Coordinators must adhere to the CMS RAI User's Manual when completing MDS assessments. This includes Correctly coding each MDS item per RAI specifications .3. Documentation and Accountability: Each MDS assessment must reflect the resident's status as of the Assessment Reference Date (ARD) and be supported by clinical documentation in the medical record. MDS Coordinators are responsible for certifying the accuracy of the assessments they complete by signing and dating the assessment as required. Record review of CMS's RAI Version 3.0 Manual effective October 2024 reflected .J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Steps for Assessment 1. If this is the first assessment (A0310E = 1), review the medical record for the time period from the admission date to the ARD. 2. If this is not the first assessment (A0310E = 0), the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. 4. Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. 5. Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record. 6. Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment . Coding Instructions for J1900A, No Injury Code 0, none: if the resident had no injurious fall since the admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 2, two or more: if the resident had two or more non-injurious falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Coding Instructions for J1900B, Injury (Except Major) Code 0, none: if the resident had no injurious fall (except major) since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 1, one: if the resident had one injurious fall (except major) since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). CMS's RAI Version 3.0 Manual CH 3: MDS Items [J] October 2024 Page J-38 J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Code 2, two or more: if the resident had two or more injurious falls (except major) since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Coding Instructions for J1900C, Major Injury Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Code 2, two or more: if the resident had two or more major injurious falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Coding Tip If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to the Internet Quality Improvement and Evaluation System (iQIES), the assessment must be modified to update the level of injury that occurred with that fall.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident#8, and Resident#63) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #8's, and Resident#63's ADLs on the care plan revision dated 04/02/25. These deficient practices could place residents at risk of not receiving appropriate treatment and services. The findings included: Record review of Resident #8's Quarterly MDS assessment dated [DATE] reflected Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscles weakness (generalized). Resident #8 had a BIMS score of 09 which indicated Resident #8's cognition was moderately impaired. Further review reflected Resident #8 had a code of 4 (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 eating and oral hygiene, and code 1 (Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for C. Toileting hygiene. E. Shower/bathe self. F. Upper body dressing. G. Lower body dressing. H. Putting on/taking off footwear. I. Personal hygiene. Review of Resident #8's Comprehensive Care Plan, dated 04/02/25, revealed the care plan did not identify the resident's ADLs interventions. An observation and interview on 06/30/25 at 10:31 AM revealed Resident#8 was lying in bed. The nails on both hands were approximately 0.8 centimeter in length extending from the tip of her fingers. Resident #8 stated she did not like her long nails; she wanted them trimmed, and could not do it herself, and the staff did not want to trim them for her. Resident #8 uncovered her feet, and stated she wanted her toenails trimmed, and the staff did not want to trim them for her. Record review of Resident #63's admission MDS assessment dated [DATE] reflected Resident #63 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included spinal stenosis-cervical region, congestive heart failure, Morbid (Severe) obesity due to excess calories, and osteoarthritis of knee. Resident #63 had a BIMS score of 15 which indicated Resident #63's cognition was intact. Further review reflected Resident #63 had a code of 5 (Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) for eating and oral hygiene, and code 1 (Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for C. Toileting hygiene. E. Shower/bathe self. F. Upper body dressing. G. Lower body dressing. H. Putting on/taking off footwear. I. Personal hygiene. Review of Resident #64's Comprehensive Care Plan, dated 05/26/25, revealed the care plan did not identify the resident's ADLs interventions. An observation and interview on 06/30/25 at 11:37 AM revealed Resident#63 was up in wheelchair in her room. Resident#63 stated her understanding on admission was that she will get therapy to regain strength in her legs and hands, and she only got therapy for her hands, and have a better strength in her hands, and not on her legs. Interview on 07/02/25 at 11:15 AM OT Aide covering for the therapy department, she stated Resident#63 was admitted to facility on a long-term service and not skilled service. She stated the administration paid for the Resident to receivd five days of skilled services from 05/13/25 to 05/19/25. She stated the therapy department was only able to work on the Resident#63 upper extremities, and not on her lower extremities, because she was not able to come to the physical therapy room due to her refusal or the staff did not get her up in wheelchair. She stated the therapy department staff were able to get Resident#63 up out of wheelchair on Monday, Wednesday and Friday schedule, for lunch starting on 5/13/2025 to 5/19/2025 for the five days that were paid for by the facility. Follow up interview on 07/02/25 at 11:19 AM Resident#63 stated nobody talked to her about physical therapy in the morning. She stated the facility schedule her for showers MWF on the afternoon according to the position of her bed in the room (Bed B vs. Bed A). She stated, she asked to be accommodated for morning schedule shower and they refused. She stated the shower time was open all afternoon, and she never know the shower time exactly. Resident#63 stated it will be hard for her to be up in the wheelchair all day. She further stated on her shower schedule days, she got up in the wheelchair before lunch and go to bed after shower. Interview on 07/02/25 at 11: 25 AM with the Business Office Director, who stated Resident#63 was admitted to the facility with Medicaid insurance, and it only cover for her long-term care and not skilled services. She further stated, she explained the services to the Resident#63's family member over the phone, and the family want her to be in the facility for long-term service, because she was total care, and they could not take care of her at home. Interview on 07/02/25 at 11:43 AM the MDS coordinator stated as the MDS coordinator, she created the care plan and did the updates. The MDS coordinator stated do not know that the ADLs needed to be care planed, and the CNAs know the residents' needs since they are the ones reporting to her about those needs. When asked about the purpose of the care plan, she replied, the care plan was for the staff to know how to care for the residents. Interview on 07/02/25 at 1:20 PM the DON stated The MDS coordinator was responsible of updating the care plan and during IDT meeting every morning the staff go over the residents' needs. When asked about the risk to the residents if their ADLs had not been care planed, DON stated Resident#8 was care planed for; and she proceed to read Resident#8' care plan portion [Resident#8] prefer bed bath over Showers.; the DON stated that was enough to cover Resident#8's care plan for the ADLs intervention. Interview on 07/02/25 at 2:33 PM the Administrator stated, if the resident's care plan did not include the resident's ADLs, it could be just an oversight. She stated the facility staff do meeting every morning and discuss the intervention and ask the MDS coordinator to update the care plan. She further stated to complete the MDS assessment the MDS coordinator looked at the CNAs and nurses' notes. The Administrator stated the risk to the resident staff will not be able render his or her care. Record review of the facility ' s Comprehensive Person-Centered Care Planning policy, dated 08/01/24 reflected the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan foreach resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessmentPolicy Explanation and Compliance Guidelines: 1. The care planning will include an assessment of the resident's strengths and needs. 2. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preference, will also be addressed in the plan of care. 3. 3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. The resident's goals for admission, desired outcome, and preferences for future discharge. 4. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility forc. the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #8 and Resident #80) of 12 residents reviewed for ADLs. The facility failed on 06/30/2025 to ensure the following:1. Resident #8 had her fingernails trimmed.2. Resident #80 had fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included:1. Record review of Resident #8's Quarterly MDS assessment dated [DATE] reflected Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscles weakness (generalized). Resident #8 had a BIMS score of 09 which indicated Resident #8's cognition was moderately impaired. Resident #8 was dependent on the staff with personal hygiene. Review of Resident #8's Comprehensive Care Plan, dated 04/02/25, reflected the following: Problem: [Resident #8] has impaired cognitive r/t Dementia. Goal: [Resident #8] will be able to communicate basic needs on a daily basis through the review date. Intervention. Monitor/document/report.expressing self. Further review of care plan revealed Resident#8 had not been care planed for ADLS, and no documentation of her been resistive to care. An observation and interview on 06/30/25 at 10:31 AM with Resident#8 revealed she was lying in bed. The nails on both hands were approximately 0.8 centimeter in length extending from the tip of her fingers. Resident #8 stated she did not like her long nails; she wanted them trimmed, and could not do it herself, and the staff did not want to trim them for her. 2. Record Review of Resident#80's Quarterly MDS assessment dated [DATE] reflected Resident #80 was an [AGE] year-old male admitted to the facility with initial admission date of 02/24/2025. His relevant diagnoses included Heart failure (heart cannot pump adequate blood to meet body needs), Diabetes mellitus (high blood glucose), Cerebrovascular accident (disruption to blood flow to brain), Hyperlipidemia (high blood lipid levels), Renal insufficiency (kidney functioning at severely reduced capacity), Hypertension (high blood pressure). Resident #80's BIMS score was 8, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #80 was dependent on staff for all personal hygiene needs. Resident #80 was on hospice care. In an observation and interview on 6/30/25 at 12:08 PM with Resident #80 revealed Resident #80 had long, jagged fingernails. His fingernails on right hand were at least 0.75-1 inch in length extending from the tip of his fingers. The nails were discolored tan and had dark brown colored residue underside. Resident #80 stated he would like his fingernails trimmed and cleaned. He added he had asked the staff about trimming them some time ago, but he was not sure why it was not trimmed yet. In an interview on 06/30/25 at 12:23 PM with LVN D who stated she worked in the facility for last 2 years. She stated CNAs and Nurses were responsible for nail care. She added Resident #80 did not have any history of refusals and fingernails should be trimmed and cleaned. She added even if Residents were on hospice, nail care should be offered to all residents. She stated the risk of not cutting and cleaning nails was lapses in infection control and loss of quality of life. In an interview on 06/30/25 at 12:27 PM CNA E stated she had worked in the facility for last 10 months and was aware of Resident #80's care needs. She stated CNAs and LVNs were responsible for nail care. She added Resident #80 was on hospice and she had not recently offered nail care to the resident. She stated nail care should be done on shower days and as needed. She stated untrimmed , dirty nails could cause infection and injury. In an interview on 07/01/25 at 1:17 PM with the DON who she stated Resident#8 fingernail were long and needed to be trimmed. She added Resident#8 was alert and oriented X4 (person, place, time and event) and sometimes she could refuse. She added Resident#80 was on hospice and hospice aides take care of all ADLs for the resident. She also stated that Facility CNAs should be offering ADLs including nailcare for hospice residents on as needed basis and stated Resident #80 had long and dirty fingernails and should have been clipped and cleaned. DON stated her expectation was that nail care should be provided every shower day and as needed. She stated that both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had a diagnosis of diabetes. She stated Resident#8 was resistive to care. The DON stated residents who had long fingernails could scratch themself. Record Review of the facility policy titled Care of Fingernails/Toenails revised October 2010 reflected, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections 1. Nail care includes daily cleaning and regular trimming

Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #8) of 6 residents reviewed for foot care. The facility failed on 06/30/2025 and did not provide adequate foot care for Resident #8 who was also a diabetic and had a standing order for podiatric services. Resident #8's Toenails were chipped, thick, and long. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. Findings included: Record review of Resident #8's Quarterly MDS assessment dated [DATE] reflected Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscles weakness (generalized). Resident #8 had a BIMS score of 09/15 which indicated Resident #8's cognition was moderately impaired. Further review revealed Resident #8 was dependent for personal hygiene. Review of Resident #8's Comprehensive Care Plan, dated 04/02/25, reflected the following: Problem: [Resident #8] has impaired cognitive r/t Dementia. Goal: [Resident #8] will be able to communicate basic needs on a daily basis through the review date. Intervention. Monitor/document/report.expressing self. Further review of care plan revealed Resident#8 had not been care planed for ADLS, and no documentation of Resident#8 been resistive to care. Record review 07/01/25 at 10:00 AM revealed since Resident#8 was diabetic, she had a standing order dated (01/15/25) for podiatric referral. Review of the podiatric referral list for the residents in the facility Date Range: 01/01/25-06/30/25 printed on 06/30/25 revealed Resident#8 was not included on the list. An observation and interview on 06/30/25 at 10:31 AM revealed Resident#8 was lying in bed. Resident #8 uncovered her feet, and stated she wanted her toenails trimmed, and the staff did not want to trim them for her. She further stated the other day someone came in and did her roommate toenails, and when she asked the person to do hers, the person replied that she was not on the list. Interview on 07/01/25 at 12:10 PM the Social Worker) revealed someone had to let her know that the resident needed a referralShe stated the facility audited the referral list and starting from the current census everyone was put on podiatric referral list. She stated Resident#8 had never been referred for podiatric care. In an interview on 07/01/25 at 1:17 PM with the DON who stated Resident#8 was alert and oriented X4 and sometimes she could refuse or be resistant to care. She stated toenails care was a part of grooming, and it was the responsibility of the nurses during their weekly assessment to check. The DON stated the CNAs also were responsible to let the nurses know if the resident's toenail needed trimming. The DON stated the staff should report to the social worker the residents in need of podiatric referral. The DON stated she had to check with the SW if Resident#8 was included in the referral list for Podiatric care. The DON stated did not see how toenails not been trimmed could be a risk to the Resident, and added may be if the Resident got hurt and it became a problem. Follow up interview with the DON on 07/02/25 at 1:20 PM who stated Resident#8 podiatric referral went to the SW and now she was on the list. When asked about the Doctor order for toenails referral since December 2024, and never been referred for podiatric care, she replied it was the responsibility of Resident#8 to ask the staff and SW for her toenails care. The DON stated the standing order for toenail care were there to respond to resident's needs, and Resident#8 did not express her needs for toenail care, and it was the responsibility of the SW to follow the Doctor order, do the referral and maybe it was an oversight. In an interview on 07/02/25 at 2:30 PM with the Administrator, she stated Resident#8 knew her needs and did not ask for toenail care. When reminded of the Resident BIMS score of 09/15, and having dementia, she stated Resident#8 did not have dementia and she was self-responsible for her care, and needs. The Administrator stated the standing Doctor orders for podiatric referral was as needed to be utilized when the needs were there, and since Resident#8 did not express her needs for toenails care, the facility did not have to do the referral. The administrator refused to answer the question about the risk for untrimmed toenails to the residents and stated did not see how a resident could get hurt from untrimmed toenails. Review of the facility policy titled Skin integrity- foot care date implemented 09/10/2024, with the revised date 05/23/2025 revealed It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. Policy Explanation and Compliance Guidelines: 1. The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions.b. If necessary, the facility will assist the resident in making appointments with a qualified person and arranging for transportation to and from such appointments. iii. Referrals to podiatrists, will be made when appropriate.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #41) resident reviewed for infection control. The facility failed on 06/30/2025 when CNA A failed to change gloves and perform hand hygiene when she went from dirty to clean during incontinence care for Resident #41. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #41's quarterly MDS, dated [DATE], revealed that Resident #41 was a [AGE] year-old female admitted on [DATE], her diagnoses included type 2 diabetes mellitus, Cerebrovascular accident, and weakness. Resident #41 had a BIMS score of 09 which indicated Resident #41's cognition was moderately impaired. Further review revealed Resident #41 was always incontinent of bowel and bladder. Review of Resident #41's care plan, dated 4/28/25, revealed, Problem. The resident has an ADL self-careperformance deficit r/t Confusion. Goal. The resident will maintain current level of function through the review date. Intervention. TOILET USE: The resident requires assistance by (1) staff for toileting. In an observation on 06/30/25 at 10:30am, CNA A entered Resident #41's room to provide incontinent care for the Resident. CNA A performed hands hygiene upon entering the room, and put on clean gloves, from handful of gloves, she was carrying in her uniform pocket. CNA A uncovered Resident#41 and unfastened the brief. CNA A cleaned Resident#41 front area using two to three wipes at a time. Resident#41 had a pasty large bowel movement. CNA A gloves got soiled with feces, she cleaned them with wipes, and helped Resident#41 turn toward the wall. CNA A cleaned Resident#41 buttocks area using two to three wipes at time. CNA A put the dirty wipes in the brief, folded the brief, and dispose of it in a plastic bag at the foot of the bed. CNA A folded the under pad and push it under Resident#41. CNA A with the same gloves got the clean brief and put it on the Resident. CNA A helped the Resident#41 turn back, and to her left finished putting the brief on her and tapped it. CNA A Covered Resident#41, put the trash bag together, removed gloves, washed hands, and took the bag to the dirty linens room, and sanitized hands. In an interview on 06/30/ 25 at 10:45am, CNA A stated that she was supposed to change glove and perform hands hygiene when going from dirty to clean task during the residents' care. She stated was not supposed to carry the gloves in her pocket. She stated her pocket could be dirty. She stated the risk of not following proper hands hygiene, and gloves use was the spread of infection to staff and other residents. In an interview on 07/02/25 at 1:20 PM, the DON who stated the staff are not supposed to put the gloves in their pocket, and just grab what they needed at the time. DON stated the issue with putting the gloves in their pocket cross contamination. DON stated during the incontinent care, the staff was supposed to change gloves with hands hygiene going from dirty to clean task, and any time they take off the gloves. She stated the purpose of that was to prevent infection. She stated she usually provided hand hygiene in-services when a concern occurs with infection control. Review of facility's Perineal care policy, dated 05/01/25, revealed . 9. Remove Gloves and discard. Perform hand hygiene. 10.Re-apply new set of gloves. 11. Place appropriate incontinent product under resident. 13 Remove gloves and discard. Perform hand hygiene .

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of seven residents (Residents #2, #3, and #4) reviewed for accommodation of needs, in that: 1. The facility failed to ensure Resident #2's, and Resident #4's call lights were placed within their reach on 03/05/25. 2.The facility failed to ensure Resident #3's call light string was not obstructed by a mechanical lift sling which was placed on top of the call light string preventing Resident #3 to pull the string to activate the call light on 03/05/25. This failure could place residents at risk of injuries and unmet needs. Findings included: Resident #2 Review of Resident #2's Admission Record dated 03/05/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease (a progressive nervous system disorder, which affects the ability to move muscles), speech and language difficulty following stroke, pain in left knee and foot, chronic pain, type 2 diabetes (uncontrolled blood sugar), schizoaffective disorder (this is a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Resident #2 was her own responsible party. Record review of Resident #2's quarterly MDS dated [DATE], reflected a BIMS ( a standardized assessment to measure long and short-term memory) score of 4 out of 15, which suggested severe cognitive impairment. Continued review showed Resident #2 required partial/moderate assistance with staff doing less than half the effort for personal hygiene. Resident #2 was independent for toileting hygiene. Review of Resident #2's care plan dated 03/05/25 revealed Resident #2 had impaired visual function (difficulty seeing). The goal was for Resident #2 to have no indications of acute (immediate) eye problems. Her interventions were: Tell me where you have placed my items. Be consistent with location. Do not move my furniture or belongings unless requested and do not leave without telling me where things are located. Make sure that I have the call device (SPECIFY: pendant, pull cord, call light ) within easy reach before leaving the room. Further review of Resident #2's care plan revealed Resident #2 was at risk for falls related to unawareness of safety needs. Her goal was to be free of falls through the review date. Her interventions were to be sure that Resident #2's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed a prompt response to all requests for assistance. During an observation and interview with Resident #2 on 03/05/25 at 09:57 AM, a string attached to a call switch dangled near bed B. The string had no clip to attach it to Resident #2's bed/bedding. Resident #2 was walking from the bathroom with her walker to her bed. Resident #2 was in bed A. She sat on her bed and stated she did not feel good. She said, my stomach hurts can you please reach the call light over there for me (pointing near bed B). Resident #2 stated she always had to get out of bed to reach the call light because it was never within reach from her bed. She stated she did not have the strength to get up from her bed to walk near bed B to activate the call light. She stated she knew how to use the call light and had used it many times by pulling the string to activate it. She stated it was nonsense having to get out of her bed to reach the call light. Resident #3 Review of Resident #3's admission record, dated 03/05/25, revealed a [AGE] year-old female with an original admitted [DATE] and readmitted on [DATE]. Resident #3's diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (conditions that affect blood flow to the brain) affecting right dominant side. Review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Further review of the MDS revealed Resident #3 was dependent for bed mobility, transfers, toileting and personal hygiene. Review of Resident #3s careplan, dated 06/28/22, reflected she was resistive to care, including refusing to get out of bed for anything besides showers, and that she refused incontinence care. Her care plans dated 09/14/22 reflected she had chronic pain, and that she was a risk for falls related to gait/balance problems. A careplan dated 09/13/22 reflected Resident #3 had bladder incontinence. Review of Resident #3s careplan, dated 06/28/22, reflected she was resistive to care, including refusing to get out of bed for anything besides showers, and that she refused incontinence care. Her care plans dated 09/14/22 reflected she had chronic pain, and that she was a risk for falls related to gait/balance problems. A careplan dated 09/13/22 reflected Resident #3 had bladder incontinence. Observation on 03/05/25 at 9:58 AM, Resident #3's call light was within reach on the Resident's right side. Resident #3 attempted to pull the string and was not able to turn the light on. A mechanical lift sling was observed folded up on top of the string which was lying across the nightstand. Resident #3 stated she could not turn the light on. Resident #4 Review of Resident #4's admission record, dated 03/05/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia (cognitive decline), type 2 diabetes (uncontrolled blood sugar disorder), glaucoma (this is an eye disease that causes vision loss). Review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 10 out of 15, indicating Resident #4 had moderate cognitive impairment. Resident#4 could understand others and others could understand her. Further review of MDS revealed Resident #4 required extensive assistance with staff doing half the effort for toileting and bed mobility (turning left to right in bed and getting out of bed). Observation and interview with Resident #4 on 03/05/25 at 10:25 AM, revealed Resident #4's call light string was too far away from her bed, and she could not reach it. Resident #4 stated sometimes she had to holler (yell) out to the hallway to get a nurse or an aide to come and help her. She stated it was very inconvenient not having the call light within reach, which leads to her to not use it as often. She stated she would like for staff to check on her every 2 hours without having to wait for someone to pass by the room to call for help. In an interview with CNA C on 03/05/25 at 10:20 AM, she stated Resident #2 knew how to use the call light and had used it multiple times in the past. She stated she did not know who did not tie the call light string to Resident #2's overhead light string. CNA C stated it was hers and all nursing staffs' responsibility to make sure that the call lights were within reach for all residents. She stated the risk to the resident was not getting assistance when they needed it. She stated she would notify the nurses of Resident #2's stomach pain. In an interview with LVN D on 03/05/25 at 3:41 PM, it was revealed Resident #2 was one of the residents that used the call light for assistance on the unit. He stated he always made sure that he left her call light within reach by clipping it to her bedding or pillow when she was in her bed. He stated Resident #2 was independent, but she always called if she needed assistance. He stated Resident #2's call light string had a clip on it, but he did not know what happened to it. He stated it was hard on the unit to keep things intact because other residents removed items in other residents' rooms. He stated the risk of Resident #2 not having her call light with reach was delayed care. In an interview with the DON on 03/05/25 at 4:45 PM, she stated call lights in the unit were at times a safety hazard because a resident could wrap themselves and hurt themselves. She stated all residents in the secure units were independent and ambulatory and if they became bed bound and required a call light when in bed, then they are moved to another unit. She stated because the residents are constantly moving in the unit, they did not need a call light attached to their bed unless they were in bed. She stated the expectation was that if a resident was cognitive enough to use the call light while in bed then the expectation was that they should have a call light within reach. She stated all call lights should have a clip to help keep the call light in place by clipping it to the bedding or pillow. She stated the call light was important for safety. In an interview on 03/05/25 at 5:88 PM with the ADM she stated her expectation was for call lights to be reachable to the residents. If it was not within reach, the risk to the resident was they may not be able to get help as quickly as they would otherwise. She stated it was everyone's responsibility to answer call lights and when rounding to make sure that residents' call lights when in bed were within reach. Record Review of the facility policy tilted, Call lights: Accessibility and Timely Response revision date 05/01/24 reflected, in part , The purpose of this policy is to ensure the facility is adequately equipped with a call light to allow residents to call for assistance each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system Staff will ensure the call light is within reach of resident and secured, as needed .

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #1) resident reviewed for infection control. CNA A did not perform hand hygiene after providing incontinent care for Resident #1. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #1's face sheet, dated 3/5/2025, revealed that Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses of dementia, muscle wasting and atrophy (thinning of muscle mass), and convulsions (seizures). Review of Resident #1's care plan, dated 4/23/2024 , revealed that the goal for Resident #1 was to not have any signs and symptoms of infection through the target date of 3/21/2025. In an observation on 3/5/2025 at 10:30am, CNA A and CNA B entered Resident #1's room to provide incontinent care for the resident. Both staff performed hand hygiene upon entering the room, and put on gowns and gloves. CNA B assisted CNA A by turning Resident #1 to her side while CNA A wiped her bottom and changed her brief. After providing incontinent care to Resident #1, CNA B left the room to take the soiled linen to the linen room. CNA A was observed removing soiled gloves and discarded them in the trash but she did not perform hand hygiene after removing the gloves. She went in another resident's room to assist him because he was asking for a nurse. CNA A went down the hall to get the nurse to assist the resident. CNA A did not perform hand hygiene after providing incontinent care and in between resident's rooms. In an interview on 3/5/2025 at 10:45am, CNA A stated that she was trained to perform hand hygiene after providing incontinent care to a resident. She stated she got distracted with helping another resident and forgot to perform hand hygiene. She stated the risk of not practicing hand hygiene was the spread of infection to staff and other residents. In an interview on 3/5/2025 at 1:30pm, the DON stated that staff has to perform hand hygiene after providing care to residents, especially incontinent care when they have touched soiled linens and briefs. She stated the purpose of that is to prevent infection. She stated she usually provided hand hygiene in-services when a concern occurs with infection control. Review of facility's Hand hygiene policy, dated 6/13/2024, revealed that all staff should perform hand hygiene between resident contacts, before applying and after removing personal protective equipment (PPE), and before and after handling clean or soiled dressings, linens.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and exploitation for 1 of 3 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was protected from sexual abuse by Resident #2. Resident #2 was found in Resident #1's bed lying to top of Resident #1, both nude from the waist down and Resident #2 was observed to have his hand on Resident #1's vaginal area as he swayed his hips side to side. On 11/04/24 at 5:00 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/05/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of sexually inappropriate behaviors from other residents. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, anxiety disorder, depression, bipolar disorder, and psychotic disorder. Resident #1 had a BIMS score of 0 meaning her cognition was severely impaired. The MDS further reflected Resident #1 ambulated independently and she resided in the secure unit. Record review of Resident #1's care plan revised on 07/24/24 reflected she resided on the secure unit due to elopement history at prior placement and care planned for impaired safety awareness and wandering into other's rooms and to get in their bed. Interventions included distract from wandering and offering pleasant diversions or structured activities. The care plan further reflected Resident #1 had a communication problem and staff needed to anticipate the resident's needs. Record review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, schizophrenia, and suicidal ideations. Resident #2 had a BIMS score of 4, which indicated his cognition was severely impaired, he was usually understood by others and usually able to understand others. Per the MDS, Resident #2 ambulated independently and used a manual wheelchair for mobility. The MDS further reflected the resident had behavior problems related to paranoia, and was verbally and physically aggressive. Other behavior problems included taking clothes off down to brief in the hallway, shaking exit doors, becoming physical and verbal with staff, cursing and name calling. Interventions included to administer medications and analyze key times, places, circumstances, triggers, and what de-escalates behavior and document in the behavior tracking log. Record review of the facility's Provider Investigation Report dated 11/02/24 reflected during rounds Resident #2 was observed lying down with Resident #1 in her bed naked. Resident #1 was sent to the hospital for further evaluation and Resident #2 was put on one-on-one monitoring. Record review of the progress notes dated 11/02/24 documented by the Agency Nurse reflected the following: Rounds made on the hall this patient was noted lying naked on top of another patient in her room with his pants down. Her pants were also down and her brief was off and noted on the floor. This nurse immediately instructed patient to get up and exit room. Record review of Resident #2's progress notes dated 11/03/24 documented by LVN A reflected: 5:45am Remains on one-on-one till police took him away to their car Record review of the police report dated 11/03/24 reflected the following: .[Officer] then went to the offender's room and began to speak with him. The offender was hard of hearing and [Officer] had to type out messages for him to read to ask questions. When asked if he knew [Resident #1] he stated he did. When asked if he was in [Resident #1's] room, he stated he was. When asked why he was in [Resident #1's] room he advised because they were having sex. The offender advised he has had sex with her before and was invited into the room by the victim. He stated the victim never asked for sex today but invited him into the room, so he thought it was okay. [Resident #2] was ablet to tell [Officer] his name and birth date, what day of the week it was, and that he was currently in [City], showing that he was able to communicate and has his mental capacities. [Resident #2] was read his [NAME] Rights. When asked what the physical act of sex meant between him and [Resident #1] , [Resident #2] said my penis and her vagina. [Resident #2] said he did penetrate [Resident #2], did not wear a condom and did not ejaculate. [Resident #2] said he did not understand why he was being arrested because he did not hit [Resident #1] Observation on 11/04/24 at 10:28 AM revealed Resident #1 sitting in a chair in the common area of the locked unit. The locked unit was a long hall that was split up into two locked units, which were both co-ed with male and female residents. An attempt was made to interview Resident #1, but the resident did not respond nor did she make eye contact. The resident was asked simple basic yes/no questions, and the resident was not able to respond. A staff member, who was present, asked the resident if she wanted to color, and the resident did not make eye contact with the staff member. The resident was nodding her head to the music that was playing on the television. Resident #1 ambulated with no assistance and wandered through the secure unit hall. After wandering, she would sit back down in the chair in the common area. Interview with the Hospitality Aide on 11/04/24 at 10:30 AM revealed she worked with Resident #1 and #2 but was not working at the time of the incident. The Hospitality Aide said Resident #1 wandered through the halls and was totally dependent with care. Resident #1 was not able to communicate with others and at times may answer a simple yes/no question. The Hospitality Aide stated Resident #2 was independent with most all ADLs and was in his right mind meaning he could carry on conversations with others and make his own daily decisions. Interview on 11/04/24 at 11:28 PM with CNA B revealed Resident #1's dementia was very advanced. CNA B stated Resident #1 did not understand what was being said to her most of the time. When the resident was asked questions, she could not respond most of the time, and she mainly wandered the secure unit going in and out of other resident rooms looking for a bed to lie down on. CNA B said Resident #2 had some aggressive behaviors and could be very demanding but did not have any confusion CNA B stated Resident #2 was able to make all his needs known. Interview on 11/04/24 at 12:18 PM with CNA I revealed Resident #1 wandered the halls of the secure unit and at times would enter other resident rooms looking for a bed to lie on. The CNA said the resident was not able to hold or understand most conversations or commands. Resident #1 would at times say simple words like thank you and may or may not be able to answer yes/no questions. CNA I described Resident #2 as being more alert and oriented, independent with most all ADLs, and able to make his needs known. Resident #2 had moments where he displayed aggressive behaviors, mainly towards staff when things did not go his way or when he was not able to go outside and smoke. Interview on 11/04/24 at 12:27 PM with LVN C revealed she was working the night of the incident between Resident #1 and #2, on 11/02/24. LVN C said the Agency Nurse who was working the other side of the secure unit, told her that during her rounds, around 9:00 PM, she noticed Resident #2 was not in his bed, so they began to look in every room and bathroom on the unit because it was not normal for the resident to wander. LVN C said she when she opened the door to Resident #1's room she found Resident #2 lying on top of Resident #1, and both residents were nude. Resident #1's brief was on the floor and appeared to have been ripped off. Resident #1 was seen moving his hips side to side and because he was hard of hearing, they had to tap on him to get his attention. At that time, LVN C noted Resident #2's hand was in between Resident #1's vaginal area. Resident #2 then ran out of the room appearing embarrassed but with a smirk. At that time, Resident #1 was assessed and there was no redness, discharge, or trauma noted to her vaginal area. While in his room, Resident #2 was asked to pull down his pants to see if there was any evidence of semen to know if he had actually penetrated Resident #1, but none was found. Resident #2 told the staff Resident #1 had asked him to her room; however, due to her severely impaired cognition, LVN C said she did not see that being possible as Resident #1 was not able to communicate. LVN C said while the Agency Nurse was asking him questions, she did hear Resident #2 say everyone needs a little sex sometimes. LVN C further stated she was not aware of any previous history of sexually inappropriate behaviors. Interview on 11/04/24 at 11:57 AM with the Agency Nurse revealed she was making room rounds around 9:00 PM when she noticed Resident #2 was not in his room, so she alerted LVN C and the aides. They began to look for Resident #2. The Agency Nurse stated she was behind LVN C when she opened the door to Resident #1's room. Upon opening the door, they saw Resident #2 lying on top of Resident #1, and both residents were nude from the waist down. Resident #1's brief was on the floor. When they got Resident #2's attention, he quickly got off Resident #1 and left her room. They immediately assessed Resident #1. Resident #1 she did not appear to look fearful, and they did not see any redness or trauma on her vaginal area. After Resident #1 was assessed, the Agency Nurse went to talk to the Resident #2 in his room. She also called the Administrator to let her know about the incident and while the Administrator was asking questions, the Agency Nurse was writing the questions down because Resident #2 was hard of hearing. Resident #2 was asked if he had sex with Resident #1, and Resident #2 said yes. He was asked if Resident #1 was his girlfriend, and Resident #2 said no. Resident #2 was asked why he had done what he did, and he responded with sometimes a man needs sex. Resident #2 said Resident #1 had invited him to her room. Resident #1 was sent to the hospital for further evaluation and Resident #2 was put on one-on-one monitoring. The Agency Nurse stated she had not previously worked with Resident #2, but staff told her sexually inappropriate behaviors were not part of his history. Interview on 11/04/24 at 12:53 PM with CNA D revealed she was alerted by the Agency Nurse that Resident #2 was not in his room during her rounds, so they began to check every room and bathroom. When opened the doot to Resident #1's room, they saw Resident #2 lying on top of Resident #1. CNA D stated both residents were nude from the waist down, and Resident #1's brief was on the floor. She stated Resident #2 was seen moving his hips side to side, while he was on top of Resident #1, and his left hand was on her vaginal area. Resident #2 was hard of hearing, so they had to tap on him to get his attention and he immediately left the room. The nurse assessed Resident #1, and the resident did not look frightened. When Resident #1's vaginal area was checked, there was no redness or trauma noted. CNA D said she had worked with Resident #2, and she was not aware of the resident having a history of sexually inappropriate behaviors. Interview on 11/05/24 at 1:58 PM with LVN E revealed he worked the night of the incident, 11/02/24, and he got report from the Agency Nurse about what had occurred between Resident #1 and #2. Resident #2 was on one-on-one monitoring. LVN E said he asked Resident #2 what happened, and all the resident said was that Resident #1 had invited him to her room. LVN E said he had worked with both residents, and he did not believe Resident #1 was capable of making such a statement due to her severely impaired cognition. While working with Resident #2, he had never known the resident to have sexually inappropriate behaviors. LVN E said the police arrived during his shift, and they went to see Resident #1. After they left her room, they went to speak with Resident #2. LVN E stated he was not present during their interaction, but he was able to hear the resident tell the police he had been invited by Resident #2 to her room. He asked them if he had done anything wrong, and he was later taken by the police. Interview on 11/04/24 at 4:32 PM with the Social Worker revealed Resident #1 wandered the hall of the secure unit. She stated the resident was not able to answer yes or no questions due to her dementia. The Social Worker described Resident #2 as aggressive when it was time to smoke. She stated Resident #2 had a history of suicidal ideations, but she was not aware of Resident #2 having a history of sexually inappropriate behaviors. She further stated she had read about the incident between Resident #1 and #2 on 11/03/24, and she was asked to conduct safe surveys with the other residents on the secure unit today (11/04/24) as part of the investigation. The Social Worker said there were no other concerns identified during the safe surveys with the residents. Interview on 11/04/24 at 9:00 AM with the Administrator revealed she got a call from the Agency Nurse to let her know that during rounds they had found Resident #2 lying on top of Resident #1 and both residents were nude from the waist down. Resident #1 was assessed by the nursing staff and was sent to the hospital for further evaluation. She stated Resident #2 was put on one-on-one monitoring. The Administrator said she asked Resident #2 if he had sex with Resident #1, and Resident #2 responded, I think so. The Administrator asked him if Resident #1 had invited him to her room, and Resident #2 said yes she did. She stated Resident #2 told her he did not think he had done anything wrong. The staff were told to send Resident #1 to the hospital for further evaluation, and Resident #2 was later arrested by the police. The Administrator said Resident #1 was not alert and oriented, could not hold a conversation, and was always having to be redirected as she wandered in the secure unit. The Administrator stated Resident #2 did not have a history of having sexually inappropriate behaviors. The Administrator further stated Resident #2 had been placed in the locked unit because he had attempted to leave the facility in the past. Interview on 11/04/24 at 9:35 AM with the Hospital Sexual Assault Nurse Examiner revealed she had attempted to do a SANE exam on Resident #1 on 11/03/24 while the resident was at the hospital. She said the resident was responding to her name but was not making any sense. She stated Resident #1 had a sitter because she was trying to get out of bed. She said she was not able to do a swab or see if there was any trauma to her vaginal area because Resident #1 was not cooperative. Record review of the facility's Abuse, Neglect, and Misappropriation of Property policy, dated 2022, reflected: Subject: Prohibiting and preventing of Abuse, Neglect, Exploitation, and Misappropriation of Property .The Health Care Center will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect, exploitation, and misappropriation of resident property. .Protection 1. All residents will be immediately protected from harm This was determined to be an IJ on 11/04/24 at 3:41 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 11/04/24 at 5:00 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/05/24 at 11:03 AM and reflected the following: Plan of Removal: F600- Free from Abuse and Neglect Deficient practice: 1.The facility failed to ensure a resident had the right to be free from abuse when resident #1 sexually abused Resident #2. Procedures to address Deficient Practice: 1.) [Agency Nurse] Immediately separated the residents at around 9pm on 11/2/2024. 2.) [Agency Nurse] immediately completed head to toe assessment on identified female resident. 11/2/2024 3.) [Agency Nurse] was ordered by [Physician] to send identified female resident to the hospital for further evaluation. 11/2/24 4.) [Administrator] instructed Agency Nurse to place male resident that was observed in female residents' bed on 1:1 until alternate placement is found. 5.) Physicians and families were notified on 11/2/2024 by the (Administrator). 6.) City police department was notified by [Hospital] and male resident was arrested and taken to jail on 11/3/2024. 7.) All female residents that reside on the secure unit had a head-to-toe assessment completed by [LVN C]. No injuries or signs or symptoms of trauma observed. 11/2/24 8.) Directed re-in-service initiated on 11/2/2024, by the Administrator, with secured unit staff present at time of incident, on Abuse Prohibition Policy and Procedure. 9.) Safe Surveys were conducted by the [Social Service Director] on 11/4/2024. Actions to decrease risk of Occurrence/Re-Occurrence: 1.) Directed re-in-service, by the Administrator and Director of Nursing, with all staff, on Abuse Prohibition Policy and Procedure with emphasis on sexual abuse to be completed by 11/4/2024. 2.) Pre and post test will be completed for redemonstration of training by all staff prior to working assigned shift. Starting 11/5/24 3.) Administrator will be responsible for ensuring all staff are educated and complete a pre-and -post test to show understanding of the training. 4.) Administrator and Director of Nursing will complete random testing with staff weekly for four weeks and monthly for 3 months . 5.) All new hires will be educated by Director of Nursing, Administrator, on Facility's policy on Abuse and neglect. 6.) [Behavioral Health Services] will complete Comprehensive training for staff on recognizing signs of abuse, appropriate response protocols, reporting procedures, and de-escalation techniques by 11/5/2024. 7.) [Behavioral Health Services] /[Administrator] to complete Specific training for staff working with residents with cognitive impairments regarding potential triggers for aggressive behavior by 11/5/2024. 8.) Regular refreshers on abuse prevention policies and procedures to be completed during facility monthly employee meeting. 9.) Facility will separate the female resident from the male resident to avoid further interaction 11/5/2024. Resident Assessment and Monitoring: 10.) The charge nurses will weekly, quarterly, and as needed assess residents for potential risk factors, for abusive behavior, including cognitive decline, behavioral changes, and medical conditions and notify the physician of any changes. 11.) [MDS Nurse] to complete Individualized care plans for residents at risk, including strategies to manage potential aggressive behavior. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #1's and other female resident's clinical records revealed the resident had been assessed by nursing after the incident. Interviews on 11/05/24 from 11:03 AM to 3:47 PM with staff from various shifts to include the Social Worker, HR, BOM, Receptionist, Activity Assistant, Hospitality Aide, Restorative Aide, Activity Director, MDS Nurse, LVN A, CNA B, LVN C, CNA D, LVN E, CNA F, CNA G, [NAME] H, CNA I, Housekeeping J, [NAME] K, RN L, Laundry Aide M, CNA N, Housekeeping O, CNA P, CNA Q, OTA, OT, CNA R, CNA S, CNA T, RN U, RN V, LVN W, CNA X, CNA Y, CNA Z, CNA AA, and Housekeeping BB. All staff were able to identify: - the the different types of abuse; - definition of sexual abuse; - what to do if they observed two residents having sexual contact; - consensual and non-consensual sexual contact; and - what to do when residents wandered and entered other residents' rooms. Observation on 11/05/24 at 3:20 PM revealed the secure unit was split in two, separated by a secure door that required a code to open. The units were split into a male unit and a female unit. The Corporate Administrator and Corporate RN were informed the Immediate Jeopardy was removed on 11/05/24 at 4:03 PM. On 11/04/24 at 5:00 PM, an IJ was identified. While the IJ was removed on 11/05/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record reviews the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1of 10 residents (Resident #1) review for bed rails in that: The facility failed to assess Resident #1 for risk of entrapment from bed rails and contact Resident #1's representative to obtain informed consent. Resident #1 lodged his left arm on 05/24/22 into the 1/4 sized bed rail, causing him to sustain a fracture to his left elbow. On 06/03/22 at 3:30 pm an an Immediate Jeopardy was identified. While the IJ was removed on 06/05/22 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and/or fatal injury. Findings included: Record review on 06/02/22 of Resident #1's clinical record revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted after an emergency stay on 05/24/22 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS dated [DATE] revealed his BIMS score was a 99 indicating severe cognitive impairment. He required extensive assistance by 2 or more people for bed mobility and transfers. The MDS section that addressed the use of bed rails was left blank and indicated the bed rails were not in use. Record review of Resident #1's care plan dated 04/26/22 revealed Resident #1 was at risk for falls related to limited mobility and muscle weakness. Resident #1's care plan revealed there was no care plan for the assist/grab bars (bed rails). The care plan also reflected Resident #1 required staff assistance of one staff member with most ADLs. Care plan reflected 05/24/22 fall with elbow fracture. Revision on 05/26/22. The only intervention approach dated 05/26/22 was to have the bed in the lowest position while the resident was in bed. Resident #1 already had planned interventions dated 03/06/22 for the use of a bolstered mattress and mat at the bedside due to a past fall. Record review on 06/02/22 of Resident #1's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails) and no signatures of the family giving consent for the use of the side rails, nor was there a signature of staff completing a form. Record review of the facility's self-report investigation dated 05/25/22 involving a fall Resident #1 sustained on 05/24/22, revealed the resident suffered a fracture of his left elbow after he had a fall. The Administrator documented an assessment of the fall, Resident had a fall from his bed while bed was in lowest position with air mattress in range and sustained an elbow fracture from getting his left arm jammed between side halo railing (a series of ¼ grab bars) on his bed for assistance. The self report's provider response revealed what the interventions were, first Resident #1's vitals were assessed, a pain assessment was completed and the resident complained of pain to the left side of his arm. Resident #1 was given pain medication and his arm was assessed for how far he could stretch it out. Then the family and doctor were notified, and a new order was given by the physician for an x-ray of the left elbow. Resident was educated to use his call light for assistance when he needed to get out of bed. A fall mat was in place near the bed, and the bed was positioned in the lowest position. Resident #1's facility report regarding the provider's action taken post-investigation revealed the xray taken on 05/24/22 confirmed Resident #1 had a left elbow fracture, and the physician was notified and Resident #1 was sent out to the emergency department for further evaluation. The report further states that Resident #1 returned to the facility on [DATE] wearing a sling on the left arm and was to follow up with an orthopedic surgeon. The actions that were noted was to continue with pain management, and an update on the care plan would be made. Another note was added that the nursing staff were educated on abuse and neglect and fall precautions. No other preventions were added to prevent the incident of bed rail accidents from happening again were discussed. Record review of Resident #1's nurse's note written by LVN A on 06/02/22 at 12:25 p.m. revealed the following: Resident heard yelling, entered room and found resident on the floor mat with left arm jammed between side halo railing. Resident AAOx3 (awake, alert, and oriented to person, place, or time), able to move all extremities, verbalized pain on the left elbow and knee. Doctor was notified, new order: 2View Xray for left knee and elbow. RP (Representative) notified and verbalized understanding. Observation on 06/02/22 at 10:45 a.m. of Resident #1 revealed he was in bed, on an air type of scoop mattress, it had foam borders along both sides of the bed and the bed was placed in the lowest position. A fall mat was positioned near the bed and two ¼ raised side rails were at the head of the bed. During an interview on 06/02/22 at 10:45 a.m. with Resident #1 revealed that he was slightly confused, he could not speak clearly when asked about the fall, his speech was garbled and hard to understand. Resident #1 could not explain the sling he was wearing on the left side of his arm, his answer was hard to understand, he seemed happy and there were no signs of pain. During an interview with LVN A on 06/02/22 at 12:06 p.m., she said she came to work at 7:00 a.m. and went around and checked on each resident, as was her normal routine. LVN A said when she checked on Resident #1, he was in bed, he was on a scoop mattress (fall prevention mattress), the bed was in the lowest position and his fall mat was in place and she left the room to chart at the nurse's desk. LVN A said, Resident #1 began screaming while she was down the hall and when she got to his room she saw he was on the floor with his back to the bed and his left arm was caught on the bed railing. She said she lifted his arm out from between the mattress and the railing and Resident #1 said it was painful. LVN A said the railing was up on both sides of the bed. LVN A said she went out into the hall and got CNA B to help and they both lifted him up onto the bed. LVN A said the incident was communicated to the DON and she was told to call the physician after her assessment. LVN A said that all the bed in the facility have always had bed rails, all different types and sized, but she said Resident #1 always went around the rails and scooted himself off the bed onto the floor mat, and that she never saw him grab on to the bed rails for assistance. LVN A said that she understood there was a probability for entrapment and injury with the use of any size bed rail, and there was the need for a consent due to the risks, and that an order had to be given by a doctor before the bedrails were applied to any residents bed. During an interview with CNA B on 06/02/22 at 12:30 p.m., she said Resident #1 had side rails up which LVN A told her they were used for positioning. CNA B said she did not know what size the side rails were but Resident #1 did not use the side rails at all. During an interview and observation, in an unoccupied room with the Maintenance Director 06/2/22 at 4:36 p.m. the, Maintenance Director said he was responsible for the installation and maintenance of the beds, including the bedrails. When asked how often he inspecteds the bedrails, he said every month, but explained that he was not keeping records of how many residents had rails in the facility because he was not told do so by administration. When asked to describe what was done when he inspects the beds and the tightness of the bedrails, he demonstrated in the unoccupied room, his routine. He said he visually looks at the bedrails. When asked how he can visually determine how tight the bedrail is to the bed frame, he said he looks at the bolt to see if it is coming out. He said he does not physically grab the bedrail and shake it side to side from the bed. He said he will see if it is loose going towards the up and down position, but not side to side, the maintenance director said he was not sure of the position of the bed rails where they should be up or down, and said he thought that was left up to the nursing staff to decide. On 06/03/22 at 4:47 p.m., the DON and ADM were asked to come into the unoccupied room with the Maintenance Director. When the ADM, DON and the Maintenance Director were shown how much movement there was when a person moved the bedrail, they did not think the amount of movement was significant enough to entrap a person's limb. The DON said she was more concerned with the risk of skin tears the mattress could cause than a resident's arm becoming entrapped between the mattress and the bedrail. The ADM said he thought the facility was following the manufacturer's recommendations and specifications for low beds with assistive devices. The ADM said they couldn't have done anything different to prevent what happened to Resident #1. During an interview on 06/03/22 at 9:20 a.m. the Maintenance Director said maintenance to the current rooms with bed rails was being performed by him on a monthly basis and it was performed on a monthly basis for all rooms that had any type of bed rails. He said he was not keeping a log of the types of rails, room numbers, or maintenance findings because he was not instructed to do so by the Administrator ever since he began working for the facility which was six years ago. He was asked if he was aware of the maintenance policies and procedures for bed frames, mattresses and bed rails, and he denied ever reading the material or instructed to review the policies. The Maintenance Director said that should be part of his visual inspection on a monthly basis. Interview on 06/03/22 at 11:00 a.m. with the Administrator and the DON, they said the Maintenance Director was in charge for the maintenance of the side rails and the beds. They said it was up to physical therapist to determine and assess the residents for the need for side rails. The Administrator said she would provide the physical therapy assessment for the use of bed rails for Resident #1. The Administrator and the DON said there was no need for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ bed assistive devices because they were not considered bed rails, they said that a full bed rail was the one that was considered the type that needed to be planed and needed a physician order, therefore Resident #1 did not have any on record. The administrator said that low beds usually come with assistive grab rails, and since they are ¼ size, they do not possess a risk for injury for a resident since the resident is not able to get their limbs caught up in the openings of the rail, she said that Resident #1 was an unfortunate accident, but that she did not believe that the railing caused the fracture, saying he had weak bone structure. The DON admitted never speaking to Resident #1's wife who is the residents representative, she said the wife is an elderly woman that does not participate in her husbands plan of care meetings and therefore the DON never approached her for consents for the assistive devices, and she reiterated that she thought there was no need for consent or doctors order for ¼ sized bed rail, stating that they were not considered full bed rails. Interview on 06/03/22 at 2:30 p.m. with the PT Director, she said physical therapy only assesses the overall functional ability of the residents and not for the use of bed rails, and right now Resident #1 is in a sling for his left elbow fracture, and they had to pick him back up after the fall. She said during a care plan meeting on 5/26/22, the resident was discussed due to a fall and his left arm fracture, and said the rails were not brought up by anyone of the persons present at the care plan meeting. The PT Director said she was not aware that the resident's arm got caught in the railing. She said currently Resident #1 is helped to mobilize in the bed, to log roll around and out of bed, PT Director said the rails are to be care planned by nursing, and it is up to nursing to ask for the orders for bed side rails and whether the rails are to be put up or down. The PT Director said if there is a request by nursing to assesses a resident for bed rails, it is usually communicated in a request form, and their department will comply and assess, but she said there was never a request to assess Resident #1 for bed rail use. She said Geri chairs, bed rails and seat belts can be considered restraints if the resident cannot either remove them or put the rails down. She said Resident #1 used to get up, out of bed, and may have used the bed rails for assistance when he first got to the facility in the beginning of the year 2022, but since his health has declined and his cognitive ability as well and he no longer can grasp the rails. During an interview on 06/03/22 at 3:30 p.m. he DON was asked how she implemented the use of bed rails and who was responsible for monitoring the residents with bed rails/assistive devices and she said the nurses check every two hours and added that she goes up and down the hall checking on all residents, and said, but the gentleman still swings his legs out off the bed because he thinks he can walk as he once did. The DON said the benefits of having the assistive devices along with the scoop type mattress can keep Resident # 1 safe and from rolling out of bed. The DON was asked who evaluates and assesses a resident to determine the ongoing need for bed rails, and she said that she, the Administrator and the therapy manager were in charge of the assessments, and she said that Resident #1 could grab on to the rails to help staff roll over when they were providing him with incontinent care. The DON said the physical therapy department kept the assessments. The DON said the need for side rails is recorded in the resident's care plan after discussion with the interdisciplinary team which included physical and occupational therapists, social services, and nursing, if a resident is assessed for bed rails they let the primary care giver about the necessity. The DON was asked if there had to be an existing physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON there were no risks to residents due to use with a small type of assistive device. The DON was asked if she knew what type of bed rail was applied on Resident #1's bed, she said it was a ¼ assistive device, and then she was asked if she thought Resident #1 could get his arm entangled between the bed and the assistive device and said, I do not believe that his arm was fractured from the rail, that is not the description from the incident that I received from [LVN A]. Record review of the facilities incident report dated 05/24/22, the report revealed Resident #1 had a fall in his room, and the person reporting was LVN A, she gave a description of the incident stating that she heard yelling coming from Resident #1's room and when she entered she found him sitting next to the bed on the floor mat with left arm caught on the railing. She pulled out the left arm from between the rail and mattress and wrote that Resident #1 was alert and oriented, and could move all of his extremities, but that the resident complained of pain to left elbow. LVN A notified the doctor and she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Incident report states Resident #1 said I was trying to get up and go the bathroom, and LVN A wrote, Resident does not ambulate. Record review of the facility's Bed Rails and Side Rails, Installation and Use policy and procedure, with a revision date of 6/22/18 reflected the following: Policy: The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident. Procedures: 2. The resident will be evaluated for the risk of entrapment prior to installation. 4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party and consent will be obtained prior to the installation of bed rails/side rails. 6. Facility will install and maintain bed rails/side rails per the manufacturer's recommendations and specifications for the duration of use. 7. Qualified staff will assess the patient/resident for continued use of bed rails/side rails at a minimum of quarterly, annually and with significant change. PATIENT SAFETY Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessments by the patient's health care team will help to determine how best to keep the patient safe. Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. Consider the following: reduce the gaps between the mattress and side rails. On 06/03/22 at 2:13 p.m. The Administrator and DON were notified, and Immediate Threat was identified and a Plan of Removal was requested. The facility Administrator was notified on 06/05/22 at 1:00 p.m. the Plan of Removal was accepted. An Immediate Jeopardy Plan of Removal dated 06/03/22 stated the facility Director of Nursing (DON) initiated an assessment for Resident #1 to be evaluated for the need of bed rails/repositioning bar on 06/03/22 at 3:30 p.m. The DON with the help of Evaluation Physical Therapist C completed the assessment on for Resident #1 on 06/03/22 at 5:30 p.m., and a recommendation for the use of solid mobility bar was made and immediately provided to the resident. The assessment indicated Resident #1 required the assistive device for turning and repositioning to promote his independence, the family representative was notified on 06/03/22. The DON and Regional MDS nurse identified other residents with ¼ size rails that had no orders or care plans and rectified the deficient practice by making changes in their medical records adding a full assessment for the need of side rails, getting physician orders, consents and updating care plan charts. All family have been contacted on 06/3/2022 for consent and resident responsible for themselves signed consents. Facility completed all consents on 06/3/2022. Resident's consent is in residents' chart and IJ binder in administrator's office. The facility will follow the policy for rails that requires the implementation of other interventions prior to utilizing ¼ bed rails as an intervention. The Maintenance Director will apply ¼ rails only after the approval by the Administrator or DON after all policy protocols have been followed such as first trying other interventions prior to the use of bed rails. All residents and new admissions will continue to be evaluated by the DON and Evaluation Physical Therapist C, current residents on a monthly basis and new resident upon admission. The resident assessments for bed rail use will be kept in the resident's charts and in the Immediate Jeopardy binder in administrator's office. The DON educated nursing staff on the use for bed rails on 6/3/2022 at 9.15am with topics of inputting orders for ¼ side rail, bed rails assessment/evaluation, consent, and safety monitoring. The Maintenance Director will complete weekly safety rounds to ensure maintenance of beds. The DON will conduct ongoing training monthly for the next 30 days, as of now facility has one nurse left to train and will be done on 6/4/2022.Nurses are responsible for completing bed rail assessment upon admission, quarterly, annually and with changes in condition and responsible for getting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/03/22 approximately at 1:30 p.m. 30 staff were in-service by the Administrator and DON, on getting orders for bed rails, obtaining consents for the use of bed rail, risks of utilizing rails, reporting maintenance issues with bed rails, bed rail assessment/assist bar evaluation upon admission, readmission, quarterly, annually change in conditions as well as falls and remaining staff will be in serviced prior to their shift and to be completed by 6/5/2022 for all staff. Licensed nurses are responsible for getting orders for bed rails, obtaining consents for the use of bed rail, bed rail assessment/assist bar evaluation upon admission, readmission, quarterly, annually change in conditions as well as falls and all staff are responsible for risks of utilizing rails, reporting maintenance issues with bed rails On 06/03/22 and 06/04/22 Pre and posttest were used by the Administrator and DON for redemonstration training for all the facility staff members. The Administrator will be responsible to ensure all staff are educated and complete a pre and posttest to show understanding of the training, and the Administrator and the DON will complete random testing with staff weekly for four weeks and then after for 3 months. Charge nurses will complete every shift observation for proper use of rails and document it and notify maintenance of any malfunction. All new hires will be educated by DON and Administrator on Facility's policy on bed rails usage. Maintenance Director completed a walkthrough of facility on 06/02/22 and 06/03/22 for bed rail safety and non was identified with errors. Maintenance director and administrator will complete the daily safety rounds as well as assigned department heads and report to morning clinical meeting. Monitoring of the Plan of Removal: During interviews with medication Aid's (MA) (E, F, G, H), Certified Nursing Assistants(CNA)'s ( ), Licensed Vocational Nurses (LVN) (I, J, K, L, M, O, P, Q, R) and Registered Nurses (S,T, U) on 06/03/22 said they had received a pre and post test on the use of bed rails, they explained the test had questions on the size and type of bedrails, the need for a physician order, and that a resident had to be assessed for the use of bedrails before the rails could be adjusted to the bed. The staff said that there were serious risks for the resident when their bed had side rails and gave examples of possible fractures, chocking hazard, and their limbs getting caught up in the rails and causing cuts. Interview on 06/03/22 at 8:45 a.m. with LVN A, said the in-service for the rails was about the different sizes, the probability for entrapment, they need for a consent and an order before the resident's bed is applied the rails. An assessment of the resident and the need for the rails must be included in their chart. Interview on 06/03/22 at 9:00 a.m., LVN J, said fall risk precautions consist of fall mats, low beds, and reorienting a resident back in the bed, sometimes there is the use of a scoop mattress to keep a resident from rolling out of bed. The use of side rails requires a physician order, and they should not be raised unless there is an order to raise them. she said a consent must be obtained prior to the use of bed rails. Interview on 06/03/22 at 9:10 a.m. with LVN K, she said the use of Bed rails was the title of the test that she was given by the DON, LVN K said to make sure there is a consent, call the representative if the resident is not competent to make the decision, and get an order from the physician. There is the need to assess the resident for the need for bed rails and the assessment sheet is going to be used for admission and the assessment on bed rails is being overseen by Director of maintenance who has a book, In the front office, we can see which resident is on bed rails. Interview on 06/03/22 at 9:20 a.m. with CMA G, she said the staff was In serviced on bed rails and the need for consents and an order by a physician, she was told not not raise them and to check with the nurse on whether it should be down or up. She said the bed rails can used for the resident to grab on to, and the risk of having the rails, can cause a fracture, and choke, and death. She said the Assessment for the use of a bed rail is done by nursing and they communicate the need for rail to other staff members. Interview on 06/03/22 at 9:35 a.m. with LVN L, she said the post test was about the use of bedrails, and maintenance has to notified to fix the rail if there is a loose one. Assessment are to be done on all new admissions to assess and check for orders for rails, the assessment sheets are placed in the admission packet, it is scanned by medical records after it is filled out, the requirement is find out if the resident requires the rails, an assessment for bed rails, if they will have the bed rail, get a physician order, consent from Resident or responsible party. The risk for having bedrails, she said they can cause injury, fractures, can be considered as a restraint, can cause death, cuts and bruising. Interview on 06/03/22 at 9:45 a.m. with CNA W, she said the DON educated her on the use of bed rails, the in service went over the types and sizes, and that mainly the facility would be using ¼ size rails. She was told that only Nursing does an assessment on whether a resident can have a bed rail and if it is supposed to be raised. The risks that were discussed with the use of bed rails included, entrapment of a limb and the possibility of fractures, also a person can choke and death. She said if the rails need some type of repair, contact maintenance, and she learned that there needs to be a consent and a doctor's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 06/03/22 at 10:00 a.m. with CNA X, she said the post test was about bed rails and the different types of rail, also there must be a consent and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment for the rails is done by DON and the risks are the limbs can caught up in the rails, fractures, bruising and death. She added If there is something wrong with it, reported to the maintenance person, so they can fix it. Interview on 06/03/22 at 11:15 am with RN U, she said the in service education was about bed rails and the policy for the use of them. She said they have to have a physician order, a consent, and liability of the use of bedrail can cause bruising, skin tears, fractures, choking and death. She said the nurses assess the resident for the need of the bed rails, monthly, quarterly, yearly and upon new admission. Record review of the facilities Bed Rail/Assist Bar Evaluation, the document revealed areas that need to be checked off when assessing a resident for the use of bed rails, they include interventions prior to the use of bed rail use, types of interventions such as low bed and frequent monitoring and then the summary of findings such as the resident's cognitive status, representative notification and type of recommended bed rail. The Bed Rail Evaluation document also served as a guide for the nurse who is assessing the resident for the use of bed rails to check for cognitive deficits, if there are intellectual deficiencies, there is an area in the summary findings within the assessment tool that requests a date of when the residents representatives were alerted to the need for bed rails and well as an area that needs to be filled when the nurse contacted the physician for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/03/22 at 3:30 pm an an Immediate Jeopardy was identified. While the IJ was removed on 06/05/22 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for all residents in the facility excpet those on the COVID-19 isolation unit reviewed for infection control. The facility failed to have an effective protocol in place to ensure facility and agency staff were tested for COVID-19 as required by the county's positivity rate and screened upon entry and did not work while displaying signs and symptoms of COVID-19. An Immediate Jeopardy (IJ) was identified on 10/20/20. The facility was provided with the IJ template on 10/20/20. While the IJ was lowered on 10/27/20, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that was not immediate jeopardy and a scope of widespread because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place residents at risk for exposure to COVID-19 virus which could result in serious illness, hospitalization and/or death. Findings included: An interview with the ADM on 10/20/20 at 1:19 PM revealed he had 11 residents currently on isolation that were positive for COVID-19, but new testing results had come in that brought the new total of residents who were COVID-19 positive to 18. He also stated there were currently five staff members were has tested positive for COVID-19. An interview on 10/20/20 at 12:12 PM with SC revealed the DON, ADON and RN B were responsible for collecting COVID-19 PCR swab specimens at the facility for staff and residents. She said the lab company then picked up the swabs and completed the COVID-19 test offsite. SC said the facility had to use an agency to staff many of their positions since a number of facility staff had recently tested positive for COVID-19. She said the agency staff worked the previous weekend on 10/17/20-10/18/20 and were working the floor presently. For agency staff, SC said the facility had recently resumed using the agency and she did not know if the facility was responsible to complete a COVID-19 test on them or if the agency was supposed to test them. Interview with the RVPO on 10/20/20 at 12:30 PM revealed he was also the interim ADM for the facility. He stated the last time facility staff were PCR tested for COVID-19 was Friday, 10/16/20. He said presently, there were 17 residents who were positive with COVID-19 and two or three staff from Friday's test, but facility staff were going to be tested later in the day for their twice a week COVID testing (as required by the county's positivity rate) and the numbers may increase. He stated of the staff who had tested positive, three of them were CNAs who worked the overnight shift, one of them was the overnight LVN and one of them was the housekeeping supervisor (HK). The RVPO also said that with the exception of two residents, all the newest staff and residents positive for COVID-19 came from Hall A. He said for screen of staff the facility used a log for staff to sign in, have their temperature taken and then complete a separate written screening form. The RVPO also said the agency staff who were working at the facility were tested for COVID-19 only if they were working in the facility on testing days and outside of that, he did not know if they got tested by their agency. He said the agency was trying to send the same agency staff to the facility to try and keep them dedicated. Review of the facility's testing log and lab conducted PCR COVID-19 test, provided by the ADM, revealed on 10/13/20 there was no data documented for CNA A and HS. According to the log, CNA A and HS were tested on [DATE] and were positive for COVID. Review of CNA A's punch time detail reflected she worked 10/09/20-10/12/20 and 10/15/20, 10/16, 10/17 and 10/18. Review of HS's punch time detail reflected he worked 10/11/20 through 10/18/20. An interview with RN A on 10/20/20 at 2:17 PM revealed she was normally a charge nurse but was standing in to assist since the DON and ADON were both out. She said the facility tested staff every Tuesday and Friday; residents were tested every Monday and Thursday. RN A was asked to locate the COVID-19 PCR tests dated Tuesday 10/13/20 for CNA A and HS since they had both tested positive from the test conducted on Friday 10/16/20. She said she would look for them. RN B said that sometimes if staff were out sick or on leave, they would not be tested on the testing days and would not show up on the facility testing log. She said the DON was in charge of filling out the facility spreadsheet for COVID-19 testing. RN A said if staff could not come in to be tested on the designated testing day, they had until the next morning/afternoon to be tested . She said she would continue testing the next day if needed until about 2:00 PM. If staff still did not come in, then the staffing coordinator (SC) was notified by the DON not to schedule that staff member until a COVID-19 test was completed. She said for the agency staff, when the SC called the temp agency, she would ask them when the last COVID-19 test date was and what the result was for the staff coming and verified it verbally. RN A said the SC did not obtain a copy of the COVID-19 tests for agency staff. She said the agency was responsible for conducting the testing of their staff but did not know what the frequency was. Further interview with RN A on 10/20/20 at 3:21 PM revealed she could not locate the COVID-19 tests for CNA A and HS for Tuesday 10/13/20 and didn't see their names on the facility's interval testing log, so she could not verify they were tested . Interview with the ADM on 10/20/20 at 3:26 PM revealed he did not know that CNA A and the HS were not tested on Tuesday, 10/13/20. He said he just found out. The ADM said what was supposed to happen was the SC should have been notified and the two staff should have been taken off the schedule until they had a negative test. He said he was not sure why that did not happen. An interview with CNA C on 10/20/20 at 4:05 PM revealed she was from a staffing agency and not a facility employee and she was working from 2 PM-10 PM on Hall A. She said she had worked only one day prior at the facility on Sunday 10/18/20 from 6:00 AM-6:00 PM on Hall A. She stated that because today was a facility testing day, she would get tested during her shift. She said she was not tested Sunday when she began working at the facility. She said her staffing agency did not require her to be tested for COVID-19 and she had not tested before elsewhere. An interview with CNA A via telephone occurred on 10/20/20 at 4:12 PM and she said she usually worked overnight shifts on Hall A. She said her last shift was Saturday night into Sunday morning (10/18/20). She was notified by HR on Sunday (10/18/20) that she was positive for COVID-19. She said she normally had been tested by the facility twice a week. She said last week, she was not feeling good. She worked Thursday (10/15/20) overnight shift and saw that some of the residents on Hall A were gone and she figured they must have tested positive for COVID-19. CNA A said she had worked with several residents earlier in the week, one in particular who was having excessive diarrhea and had been in and out of his room all night. There was a second resident who she was working closely with that evening as well. Both of those residents ended up testing positive for COVID. By Friday morning on 10/16/20 when she was getting ready to leave, she said did not feel good. She got her regular Friday test per policy. She said when she left the facility after her shift, she told the SC that she would not be able to come into work that evening to work the overnight Friday shift. She said she went home Friday and was sick. Her chest was hurting and she was running a temperature of 104 degrees. She said the fever subsided by Saturday but she still felt real sick. She said her body was aching but she went into work anyway for her overnight shift. She said she did not want to leave the facility short-staffed and she felt bad because she had already called in for one shift. CNA A said the charge nurse Saturday night knew she did not feel good because she asked her if she was okay. She said the overnight nurse was LVN E. CNA A said she did not complete the facility required COVID screening when she arrived to work that Saturday overnight shift. She stated she was trying to make sure she could work before she got on the floor and needed to check her temperature but the thermometer was not at the front where staff were screened. She said she went to the nurses' station and LVN E had the thermometer. Her temperature was 97.8. She said she did not get complete any COVID-19 screening questions and LVN E did not ask her about them. CNA A said she took a PCR test Monday, 10/12/20, and the overnight nurse, LVN D, did the swab specimen but she never found out her results. She said if she had known she was positive, she would not have come to work. She said she worked the overnight shifts on Monday, Thursday, Saturday and Sunday that week. An interview with LVN E on 10/20/20 at 5:12 PM revealed that she admitted she did not verify that CNA A completed the COVID screening questions when she arrived for her shift Saturday night. She said she was the charge nurse for the overnight shift Saturday and was in charge of screening staff coming in. She said she told CNA A to take her temperature and write it down. LVN E said she was usually at the front door when the shift started to screen staff because the door was locked and they could not come in unless she screened them and let them in. She said Saturday night, CNA A was late and not there at 10 PM so she thought maybe another staff on the floor let her in the front door. LVN E again said the charge nurse was the only one who did temperatures and screenings for COVID and staff could not enter until it was done but CNA A was late so she had to move on and tend to residents on the floor. Review of the facility COVID-19 screening for staff for Saturday, 10/17/20 reflected that CNA A did not sign in or assess herself for symptoms of COVID-19, nor was her temperature documented. An interview with the SC on 10/20/20 at 4:27 PM revealed that no one had informed her that CNA A did not show for her test on Tuesday, 10/13/20. She said she was doing 3-4 transports that day so it was very busy. She said normally the DON would let her know if a staff did not show up for COVID-19 testing and then she would then call them to come in and test. She said with the HS, she did not have any authority to remove him from the schedule because he was contracted and she only did nursing staff schedules. The SC said she was the person responsible for calling the staffing agency to get shifts covered and she did not ask the agency about the agency staff's COVID status before they came to the facility. She stated she did not obtain agency verification in writing or through documentation that agency staff had been tested and were negative. An interview with RN B on 10/20/20 at 4:30 PM revealed she did the facility PCR testing on 10/13/20 with the DON and they kept a log of who came into test. She said the overnight staff are supposed to stay after their shift the next morning and she and/or the DON will complete their tests around 6:15 AM before they go home. She said the overnight staff know this protocol. She said if she were not present to be tested , they were not supposed to work any further shifts until the test was completed and the SC would be notified. RN B said, I can see the error in (CNA A) not testing Tuesday and possibly spreading COVID to other staff and residents. Regarding agency staff, RN B said she the facility did have rapid tests but they were reserved only for emergency use when a resident was showing signs and symptoms of COVID-19. She said there were not enough to routinely test agency staff. An interview with the HS on 10/20/20 at 4:34 PM via telephone revealed he worked every day last week, Monday through Sunday (10/12/20 through 10/18/20) and did not take a day off. He said he was currently feeling fine but had been notified the day prior, Monday 10/19/20 that he had tested positive for COVID-19. There was some confusion with HS and the facility management on when he completed the PCR test. HS said the DON swabbed him on Tuesday 10/13/20 and he did not test again that week but continued to work on the floor every day until Sunday. He felt his positive result was from the Tuesday test. However, facility staff could not locate the 10/13/20 test. HS said he never tested on Friday because he was busy in the laundry department when they called staff to come get tested , however, the facility produced a lab result test collected Friday showing he was tested positive. (It is unknown when the actual swab was obtained and placed for lab pickup) HS said he did not know how he caught [MEDICAL CONDITION] and was currently asymptomatic. The ADM, CRN, LVN E and RN B were informed on 10/20/20 at 5:07 PM of the concerns related to the facility's testing of staff, concerns that CNA A and the HS being COVID positive and missing the previous COVID test and still being allowed to work even when one was sick and did not screen out, and agency staff working without verifying they were COVID negative. An interview with the DON on 10/20/20 at 5:21 PM via telephone revealed she did not think CNA A tested on Tuesday 10/13/20 because of come issue with her finger being injured, so she got tested the following Friday. The DON said, Usually, if someone doesn't test, I will tell (SC), we call the staff and then if they don't come in, they cannot come to work until it's done. She said in response to agency staff not being tested or verified as having been tested by the agency, We will need to look at the testing issue because we only test them if they are here on testing days. Review of the facility's staffing schedule for Monday 10/12/20 through Friday 10/17/20 reflected agency staff cotnracted with the facility were working on all halls of the facility. Review of the facility's policy titled, COVID, Prevention and Control dated 03/02/20, reflected, This facility follows current CDC guidelines and recommendations for the prevention and control of COVID-19 .Healthcare Workers Monitoring: 1. The Infection Preventionist and/or designees will monitor any ill healthcare personnel Staff who develop a fever and respiratory symptoms will be: (screened out) a, Instructed not to report to work, or if at work, to stop resident care activities, don a facemask, and promptly notify their supervisor and the Infection Preventionist and/or designees before leaving work; b. Excluded from work until at least 72 hours after they no longer have a fever (without the use of fever-reducing medications such as [MEDICATION NAME]) .2. Staff will self-assess for symptoms of febrile respiratory illness including temperature monitoring and indicate on the screening tool; a. The nurse will review any positive screening toll and determine if the person is safe to enter the facility., b. Facility staff will be screened each shift prior to reporting to their assigned hall using the screening tool .5. Statewide ordered testing: The facility supports and recommends all staff should be tested . A. Overview: You are required to test 1 x month, 1xwek, or 2 x week depending on your county % positive. This is mandatory for all SNFs. Everyone is to test including therapy and HCSG(TX). Th only people excluded from testing=anyone who has tested positive in the last 90 days, unless they are now symptomatic; B. Facility Action .3. 2 x Week-Test on Tuesday and Friday. An Immediate Jeopardy (IJ) was identified on 10/20/20 at 6:10 PM in the area of Infection Control. The IJ template was provided to the Administrator on 10/20/20 at 6:35 PM. The Plan of Removal was accepted on 10/22/20 at 8:12 AM and reflected: (Facility) IJ given on 10/20/2020 in the area of Infection Control due to 2 staff members not being tested for COVID-19 as required by the county's positivity rate. Also, due to a staff member displaying signs/symptoms of COVID-19 and was allowed to work and not screened. Deficient Practice 1. Facility did not have a tracking mechanism to ensure all employees were tested twice a week or not allowed to return to work. 2. Facility did not ensure screening process was completed. Procedures to address deficient practice 1. All staff will be in-serviced by (RN B) and (LVN Q) on twice a week testing requirement and that failure to test will result in being taken off the schedule until testing occurs. PTO is the only exception. Start Date 10/20/20-Complete Date 10/21/20 2. All staff will be in-serviced by (RN B) and (LVN Q) that staff must self-assess symptoms of COVID-19 at home and report any symptoms to their supervisor before coming to work. Staff supervisor will report Signs/Symptoms of COVID to DON or designee and HR. (HR) will document Signs/Symptoms and ability to return to work per the DON/designee's direction for Start Date 10/20/20-Complete Date 10/21/20. 3. All staff will be in-serviced by (RN B) and (LVN Q) that they must complete screening form and have it reviewed by front office staff or charge nurse for approval prior to beginning their shift. Failure to comply with screening process will result in disciplinary action up to termination. Start Date 10/20/20-Complete Date 10/21/20. 4. All new hires will be educated upon hire on the COVID policy and they will complete competency tests to ensure comprehension of the 3 in-services above. 5. DON or Designee will utilize a staff list while conducting testing to track all staff who were tested . Any staff members not tested will be contacted by DON or designee and taken off the schedule until a COVID test and screening form are conducted. This tracking list will be given to HR and Staffing Coordinator by 5pm on each testing day to ensure staff who did not test do not work subsequent shifts until testing and screening occurs. 6. DON or Designee will require all agency staff to present a COVID negative test result within the last 7 days via hard copy, picture, or email so the results can be placed in the weekly COVID testing folder then HR will log the result on a tracking spreadsheet. If the agency employee does not have a negative COVID test result within the last 7 days then the DON or trained nursing designee will conduct a rapid COVID test on the agency employee when they arrive for shift. If there is not a trained nurse to conduct the rapid COVID test, the agency employee will not be permitted to work the shift and will be asked to leave the building. All rapid test results will be documented and maintained by the DON or designee on a tracking spreadsheet. 7. Plan will be reviewed weekly for 1 month then monthly for the next 5 months during QAPI. Monitoring of the plan of removal included: Interviews were conducted from 10/22/20 through 10/27/20 with facility and agency staff on all shifts (ADM, RN B, SC, DM, Cook F, AA, CNA G, HR, CNA G, CNA H, LVN I, RA J, RA K, LVN L, CNA M, NA N, RN O and CNA P). Staff interviewed confirmed they received in-service training and were able to demonstrate competency in how to recognize signs and symptoms of COVID-19, how COVID-19 virus spreads, staff COVID-19 screening protocols upon start of shift and notifying the facility when they are having symptoms of COVID-19. Staff confirmed they continued to monitor for COVID-19 symptoms via respiratory assessments and vitals checks and logged them on a monitoring sheet that was reviewed by nursing management every day. Interviews with facility management and corporate staff from 10/22/20 and 10/27/20 revealed they implemented the use of the rapid [MEDICATION NAME] COVID-19 tests and completed them in-house for the time being to get a quicker [DIAGNOSES REDACTED]. Observations between 10/22/20 and 10/27/20 revealed agency staff were also observed to be rapid tested prior to the start of their shift and the scheduler was aware of the protocol for removing them from the schedule if they were not able to be tested or tested positive during the rapid test. An Immediate Jeopardy (IJ) was identified on 10/20/20. The facility was provided with the IJ template on 10/20/20. While the IJ was lowered on 10/27/20, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that was not immediate jeopardy and a scope of widespread because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to immediately consult a resident's physician when the resident experienced a significant change of condition for one (Resident #1) of four residents reviewed for a change of condition. LVN A failed to consult Resident #1's physician when the resident had a change of condition on [DATE] at 12:00a.m. when Resident #1 had black, tarry emesis on her mouth, face and pillow at 12:00 a.m. The physician was not consulted until 5:30 a.m. An immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy, and a scope pattern of pattern because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. Resident #1 was admitted to the hospital on [DATE] and later died at the hospital. This failure could affect the 39 residents that lived on Hall 200 including the three residents with feeding tubes by placing the residents at risk of not receiving appropriate treatment in a timely manner that could result in increased and unrelieved pain, inaccurate over-all assessments, a lack of medical intervention and/or death. Findings included: Review of Resident #1's Face Sheet revealed she was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. The Nurse's Notes on [DATE] revealed Resident #1 vomited approximately 200 cc (centimeters). There was no description of the emesis. The notes indicated the nurse phoned the physician and no new orders were given. The nurse wrote cont. (continue) to monitor. On [DATE], nothing was documented in the Nurse's Notes. There were no concerns noted. On [DATE] at 12:00 AM, LVN A documented, Resident noted with Episode of N & V (Nausea and Vomiting) @___? (Emesis of approximately 20 cc, and noted black & tarry in color). Abdomen noted not distended @ this time. B/S (Bowel Sounds) noted X 4 quadrants. Hypoactive Sounds noted. VS (Vital Signs): noted: BP (Blood Pressure) ,[DATE], (pulse) 72, (respirations) 19, (temperature) 97.8. SaO2 (Blood Oxygen Saturation) @ 95% R.A. (on Room Air). There was no documentation the physician, DON, or family was notified at that time. Nurses ' Notes on [DATE] at 2:00 AM and 4:00 AM by LVN A reflected the resident was sleeping, the tube feeding was infusing, and there were no episodes of nausea or vomiting. Nurses' Note on [DATE] at 5:30 AM by LVN A reflected, During Routine Rounds, Nursing Aide notified this SN (Supervising Nurse) that Resident was noted with episode of N & V. Upon Further Assessment, Resident was noted with Black Tarry Emesis in large Amount, Abdomen of Resident was noted Distended and hard to touch. Hypoactive bowel sounds noted X 4 quadrants. Resident noted very lethargic. Unable to Follow commands. VS: ,[DATE], 77, 98.1, 20. SaO2 noted @ 92% R.A. Tube-Feeding Discontinued @ this time. M.D Notified of Residents Change in Condition. N/O (New Order) Transfer Resident to the ER for Evaluation d/t (due to) Change in Condition. DON Notified, R/P (Responsible Party) notified. Posted time 5:55 AM, Paramedics in Facility @ this time to Transfer Resident to the ER of (local hospital). During an interview with LVN Aon [DATE] at 4:30 PM, she stated during report on [DATE], the 2:00 PM to 10:00 PM shift nurse told her Resident #1 vomited two days ago([DATE]) and the doctor said to continue to monitor. When asked if the type of emesis Resident #1 had during the first incident of vomiting on [DATE] had been reported to her, LVN A stated, No. When asked if Resident #1 had ever had a black tarry emesis or stool prior to [DATE], LVN A stated, No. LVN A was asked why she did not notify the physician at 12:00 AM and she replied, I did not see it as a change in condition since she had vomited two days ago, her vital signs remained her normal, and her level of consciousness did not change. I still do not see it as a change in condition at that time. The Assistant Director of Nurses was interviewed on [DATE] at 5:00 PM. She was asked when she thought Resident #1 had a change in condition. She stated it occurred at 12:00 AM. When asked if she would have notified the physician at that time, she nodded her as if to indicate yes. At 5:20 PM on [DATE], the Director of Nurses was interviewed. When asked at what time she believed Resident #1 had a change in condition, she replied, 12:00 AM. She (LVN A) should have called the doctor then, but I don't think in this case it made a difference in the resident's outcome. When asked what she thought defined the change of condition at 12:00 AM, the DON stated, Because she had black tarry emesis. The tube feeding should have been discontinued, then the doctor notified, and the resident sent to the hospital, and the family notified. I was notified at 5:30 AM by ___ (LVN A). An interview on [DATE] at 5:09 p.m. with the DON revealed she had begun an in-service with all her licensed staff concerning assessments and care of feeding tubes on [DATE]. The DON said she had completed this in-service within a 24 hour period. The DON said that LVN A was included in this in-service. The in-service training did not include change of condition. An interview on [DATE] at 7:15 p.m. with the Medical Director revealed he understood the immediacy of the situation, because of the length of time the nurse went without notifying one of the physicians. The Medical Director said even though the resident had several co-morbidities, the Physician on call should have been notified much sooner. It is the Physician's decision to decide the action that should have been taken, based on the assessment of the nurse, but we have to be informed. The facility needed to realize they should have in-serviced the staff concerning assessment and notification of the physician right away. The Medical Director stated the resident died , during hospital stay. Review of facility policy titled Acute Condition Changes-Clinical Protocol, dated [DATE], revealed: .Assessment and Recognition .5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician . .6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less) On [DATE] at 5:15 p.m. the Administrator and the DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated [DATE] was accepted on [DATE] at 9:25 a.m. and the reflected the following: .All licensed nurses will be in-serviced on facility ' s policy regarding Change in a Resident ' s Condition or Status prior to starting their next assigned shift by the DON and ADON. All licensed nurses will be in-serviced starting [DATE]th, 2016; and will be completed by the end of Sunday [DATE]th, 2016; any nurse unable to attend in-service by this date will be removed from schedule until in-service has been completed. ADON will monitor new hires to ensure that licensed nurses will receive training in the Change in a resident's condition or status policy. An interview on [DATE] at 8:32 p.m. with the DON revealed she had audited all the clinical records concerning the residents who had feeding tubes. The DON said she wanted to determine if there had been any other undetermined changes in conditions, with these residents. When asked concerning the incident with Resident #1 the DON said she could not believe when LVN A called her, that the nurse had not called the physician or the DON. The DON said on [DATE], the date of the incident, she told LVN A if Resident #1 was not gone from the facility already, she (LVN A) better call 911 right now. An interview on [DATE] at 9:52 p.m. with LVN A revealed she had learned a lot from this incident. LVN A said she had been called in early and in-serviced prior to taking her shift. LVN A said she would always use her nursing judgment and she would never have anything happen again. LVN A said she went into the room of Resident #1 at 12:00 a.m., the resident had a small amount of dried coffee ground emesis on her face and pillow. LVN A said she assessed the resident and had continued to monitor. The LVN said she did not contact the physician. At 5: 00 a.m. the resident vomited a large amount of coffee ground emesis, I called the DON. The DON told me to call 911. To verify the facility implemented their Plan of Removal the following interviews were obtained. Interviews were conducted with LVN A, ADON, MDS B, RN C, LVN D, RN E, RN F, LVN G, [DATE] 9:29 p.m. through 10:14 p.m. with LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, on [DATE] 9:00 a.m. through 10:30 a.m. and with MDS S, LVN T LVN U, and LVN V on [DATE] 8:26 a.m. through 8:35 a.m. They stated they had been in-serviced concerning assessment and change of condition with all residents in the facility, the in-service included: assessment of the resident, contact the physician, to follow physician orders, reassess the resident and contact the physician for further orders, if the resident's condition continued to change. On [DATE] at 9:45 a.m. the Administrator was informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern. Review of the Resident Census and Conditions of Residents (CMS Form 672) dated [DATE] revealed three residents at the facility received tube feedings. Review of Resident roster dated [DATE] revealed 39 residents were on Hall 200, including the three residents with feeding tubes.

Based on observation, interview, and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #1) of eight residents reviewed for abuse and neglect. LVN A and the Rehabilitation Director failed to report an allegation of physical abuse to the Administrator for (Resident #1). As a result, the alleged perpetrator, CNA O, continued to provide care to other residents in the facility on 08/23/16. An IJ existed on 08/23/16. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could have affected the 42 residents in hallway 100 CNA O was responsible for by exposing them to a risk for abuse or neglect. Findings included: Resident #1 ' s face sheet, reviewed 09/16/16, identified the resident as being a [AGE] year-old male admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Resident #1 ' s MDS assessment, dated 08/18/16, revealed the resident was moderately cognitively impaired. He had physical and verbal behaviors directed towards others four to six days out of the seven day look-back period. He was totally dependent on staff for transfers, bed mobility, locomotion, and toilet use. An interview with LVN A on 09/16/16 at 9:55 PM revealed on 08/23/16 around 10:30 AM she heard a commotion and CNA O yelling, stupid . She walked towards the room of Resident #1 and was standing by the door looking inside the room when she saw CNA O hit the resident with an inflatable heel boot on his upper left arm. The resident was lying on the bed with his legs facing towards the door and saw him kicking CNA O. LVN A asked CNA O why she was hitting the resident, but she looked down and said, he kicked me . LVN A said she informed LVN B, the charge nurse, as she passed by the room, but all LVN B said was, Oh that ' s why he has been to three nursing facilities, and walked off. LVN A performed a skin assessment and noted no injuries or bruising. LVN A finished providing care and took Resident#1 to therapy because resident wanted to speak with the Rehabilitation Director. LVN A indicated the Social Worker (SW) was standing near the therapy room when she informed the Rehabilitation Director the resident had been physically abused. The resident was asked why he was crying and he stated, the lady hit me with the boot. LVN A saw the SW speaking with the ADON and stated she assumed the SW informed the ADON of the incident. The following morning she found out the Administrator had not been contacted because LVN A asked him if the incident had been reported, but he had no knowledge. LVN A said CNA O was working the 6:00 AM to 2:00 PM shift and continued providing care to residents the day the incident ocurred 08/23/16. CNA O did not provide care to residents the following day when she reported to work. LVN A stated she received an in-service training pertaining to abuse and neglect and the proper reporting procedure. She said the protocol to report abuse and neglect was to report the incident to the Administrator who was the abuse coordinator. Interview with LVN B on 09/16/16 at 11:30 AM revealed she was the charge nurse on the day the alleged incident occurred. LVN B said she was called over by CNA O who told her Resident #1 had kicked her, and the CNA wanted her to tell the resident to calm down. LVN B went in the room and saw LVN A providing care to the resident. LVN B told the resident the staff members where there to help him, and that he should not kick them. She stated the resident apologized and said, Sorry ma ' am . She said she conducted a pain assessment for Resident #1 since he also may have gotten hurt when he kicked CNA O, but he denied having any pain. LVN B wrote an incident report about the behaviors the resident was having, notified the family, and the doctor. She asked CNA O if she was alright or if she wanted to go to the hospital, but she said she was fine. LVN B said LVN A never reported to her an allegation of abuse or neglect. The day after the incident LVN B was approached by the DON who asked her if CNA O had been abusive towards Resident #1. LVN B was surprised and said she was not aware of any incidents of abuse. LVN B then proceeded to do a full skin assessment of Resident #1 where she noted no bruises or skin discoloration. LVN B described CNA O as a person that went above and beyond her job duties to help residents, and LVN B never received any complaints from the residents about CNA O. LVN B received an in-service training pertaining to abuse and neglect and the proper reporting procedure. She said the protocol for reporting abuse or neglect was to notify the Administrator and ensure the staff member was removed off the floor and suspended pending the facility investigation. Interview with the ADON at 11:50 AM on 09/16/16 revealed she was called into the Administrators ' office the day after the alleged incident occurred and was asked by the Administrator why she had not called him to report an incident of abuse that LVN A had reported to her. The ADON said LVN A never reported an incident of abuse. The Administrator then asked for her to write a statement. According to the ADON, CNA O completed her shift on the day of the alleged incident. The following day, CNA O reported to work but she did not provide care to any of the residents becasue she was immediately called in to the office of the administrator. The ADON said she conducted rounds on 08/23/16 and saw Resident #1 during her morning rounds. She later saw him around 12:00 PM sitting up in his wheelchair in his room. The resident did not alert the ADON to any unusual behaviors. The ADON stated there had been no previous incidents where CNA O had been physical or verbally abusive to other residents. The ADON stated she received an in-service training pertaining to abuse and neglect and the proper reporting procedure. She identified the procedure as immediately notifying the Administrator, and ensuring the staff member was suspended until the facility investigation was complete. Interview with the Rehabilitation Director at 12:11 PM on 09/16/16 revealed LVN A wheeled Resident #1 into the therapy room and said she had seen CNA O hitting the resident with a shoe, not an orthopedic boot. The Rehabilitative Director said LVN A was unsure whether she should report the incident because the Administrator was not there. LVN A said she would wait until the next day when the Administrator was back in to report it. The Rehabilitation Director said he instructed LVN A to report it immediately to the DON. LVN A replied she would. The Rehabilitation Director stated the SW was there when LVN A reported to him what happened. The Rehabilitation Director stated the resident reported no pain and he noted no injuries. The Rehabilitation Director stated he received an in-service training pertaining to abuse and neglect and the proper reporting procedure. He said the protocol for reporting abuse was to report the incident to his immediate supervisor, who was the Administrator, and was also required to report to his boss. Interview with the SW on 09/16/16 at 1:10 PM revealed she had no knowledge of the alleged incident of physical abuse until the following day. The SW reported she was present in the therapy room when LVN A brought the resident in, but she never heard LVN A say Resident #1 had been physical abused. The SW indicated she had no additional information about the incident. She identified the protocol of reporting abuse or neglect was to immediately notify the Administrator who was the abuse coordinator. Interview with the DON at 3:20 PM on 09/16/16 revealed she became aware of the incident the day after it occurred. The Administrator came in her office and told her LVN A witnessed CNA O physically abuse Resident #1. The DON said LVN A arrived at the facility around 6:00 AM and did not mention anything concerning abuse/neglect during the stand-up meeting which happened at around 9:00 AM. The DON began the investigation process by interviewing LVN A, who informed her she had seen CNA O hit Resident #1 with a boot. LVN A said she instructed CNA O to leave the room and took Resident #1 to therapy. The DON asked her why it was not reported immediately, and LVN A replied, I thought they would have told you . The DON did not ask her if she told anyone else about the incident and said LVN A and all staff were required to report to the Administrator who was the abuse coordinator. The DON stated she and the Administrator were at a meeting and were out for the day, but staff members knew they could be reached by phone. The DON attempted an interview with Resident #1, but he could not remember what happened and all he said was, If she hit me what are you going to do? . The DON said CNA O was removed from her duties pending the investigation and was terminated the day following the incident. The DON said the protocol for reporting abuse and/or neglect was to notify the Administrator or the corporate office if he could not be reached. She further added the alleged perpetrator was to be removed from resident care pending the facility investigation. Interview with the Administrator at 4:35 PM on 09/16/16 revealed LVN A did not report the alleged incident of abuse until the following day when he happened to stop by LVN A ' s office. LVN A reported she witnessed CNA O hit Resident #1 and she asked the CNA to leave the room while she finished providing resident care. She then wheeled Resident #1 to the therapy room. The Administrator reported he reviewed the video recordings and saw CNA O and LVN A wheeling the resident out of the room at the same time. The Administrator said LVN A had been an employee with the facility for a long time and knew she was required to report any allegation of abuse or neglect to him immediately. LVN A reported the SW, the ADON, and LVN B were aware of the incident. The Administrator interviewed these staff members, but none of their stories matched. He believed no one was speaking up because they were afraid and did not want to get in trouble. The Administrator interviewed CNA O who denied the allegations made against her, but because the incident was witnessed by one staff member, he confirmed the allegation of abuse against CNA O. A telephone interview with CNA O at 4:55 PM on 09/16/16 revealed she was informed by a housekeeping worker that Resident #1 had a bowel movement. CNA O stated she immediately went to the resident ' s room to provide incontinence care. CNA O said the resident was known to have very aggressive behaviors, and that particular day he was having a bad day because as soon as she went inside the room he called her a b**ch . CNA O said the resident has had this type of behavior in the past and she knew how to manage the resident by talking to him in a nice and calm manner. However when she got close to the resident, he began kicking her. CNA O reached over for his orthopedic boots to get them out of the way and prevent them from getting soiled with feces, but the resident kicked her. This was when she told the resident to stop it on various occasions. This was also when LVN A came into the room. CNA O reported to LVN A the resident had kicked her in the stomach area. CNA O said her English skills were limited and understood LVN A wanted her to report to someone else what happened. CNA O reported the incident to LVN B who asked her if she wanted to go to the hospital, but CNA O declined. CNA O reported she finished a double shift that day. The following day 08/24/16 when she reported to work at 2:00 PM the administrator called her in immediately to get a statement about what had occurred. CNA O said she never hit the resident and said she felt devastated because she was accused of something she never did. Record review of CNA O time sheet, dated 08/23/16, revealed she worked a double shift from 6:09 AM to 10:00 PM the day the alleged incident occurred. On 08/24/16 CNA O clocked in at 2:02 PM and clocked out at 03:17 PM. There are no records of additional clock ins after 08/24/16 for CNA O. Interview with the ADON at 11:50 AM on 09/16/16 revealed CNA O completed her shift on the day of the alleged incident. The following day, CNA O reported to work but she did not provide care to any of the residents. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation on 08/23/16. The facility took the following action to correct the non-compliance on 08/25/16: An in-service was conducted on 08/25/16 regarding the immediate reporting of an allegation of abuse to the Administrator, abuse and neglect investigation protocol, and safety of residents by removing the alleged perpetrator from patient care. Signature sheets reflected 63 of the 78 employees had received the training. Review of employee disciplinary actions revealed LVN A received a verbal warning and suspension pending investigation for failure to notify alleged abused in a timely manner, and was counseled to call the abuse coordinator. The ADON and the SW received a written warning for failure to report abuse and were counseled to call the abuse coordinator. CNA O received a termination notice effective 08/26/16. Disciplinary action notices were signed by the Administrator and the HRD. Interview with 7 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) was conducted on 09/16/16 between the hours 5:00 PM and 8:30 PM. Residents interviewed were all knowledgeable in the process of reporting an allegation of abuse and or neglect, they felt safe, and reported no incidents of abuse or neglect. On 09/16/16 between the times of 3:00 PM and 8:00 Interviews were conducted with the following staff regarding reporting of an allegation of abuse to the Administrator and safety of residents by removing the alleged perpetrator from patient care. Administration: The Administrator, DON, ADON, LVN A (MDS Coordinator), Rehabilitation Director, Social Worker, and the Human Resources Director First Shift 6:00 AM to 2:00 PM: LVN B, CNA E (works as needed 6 AM to 2 PM and 2 PM to 10 PM), CNA F (works 6 AM to 2 PM and 2 PM to 10 PM) Second Shift 2:00 PM to 10:00 PM: CNA C, CNA E (works as needed 6 AM to 2 PM and 2 PM to 10 PM), CNA F (works 6 AM to 2 PM and 2 PM to 10 PM), CNA G, LVN H, RN L, and LVN N Night Shift 10:00 PM to 6:00 AM: LVN I and CNA J Weekends: MA D (7AM to 7PM) and LVN K (6AM to 10PM) The facility roster provided by the DON reflected 42 residents in hallway 100.

Based on observation, interview and record review, the facility failed to implement its policy and procedures which prohibits neglect for one (Resident #1) of five residents reviewed for neglect. Resident #1 was ambulatory prior to her fall on 11/06/14. Resident went to the hospital and was discharged back to the facility the same day. The facility failed to follow doctor's orders as a result Resident #1 is no longer ambulatory. Resident #1 received a referral to see an Orthopedic Specialist from an ER physician on 11/06/14 and as of 03/24/15 the facility had not gotten an appointment for Resident #1. This failure could affect all 96 residents who may require consultation with outside specialist. Findings included: Review of Resident #1 clinical record revealed resident was admitted on [DATE]. The admitting [DIAGNOSES REDACTED].#1 secondary [DIAGNOSES REDACTED]. According to the (MDS Assessment) dated 09/26/2014 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Revealed Resident #1 was not walking and required assistance with everything. According to the (MDS Assessment) dated 03/27/15 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Resident required assistance with everything. Review of Resident #1 latest care plan dated 12/31/14 did not reveal any interventions for a broken ankle. Review of Resident #1 nurses notes revealed Resident #1 fell on [DATE]. X-rays were taken on 11/06/14 and revealed resident had a fractured right ankle. Resident was sent to local hospital on [DATE] at 9:35 PM due to the fractured ankle. Resident #1 was discharged the same day and sent back to the facility. Review of hospital discharge documentation dated 11/06/14 revealed resident was not treated at the hospital. Resident #1 was discharged back to the facility with orders to see an orthopedic specialist. Review of Resident #1 clinical record on 03/24/15 revealed there was no documentation to show the referral was ever faxed to the county hospital. There was no documentation to show the SW followed up with any doctors. Interview with the Social Worker, on 03/24/15 at 1:45 PM revealed when a resident needs to see a doctor other than the facility doctor she gets a communication form from nursing. The SW stated she then goes through her data base to see what doctor took residents payer source. She makes the appointment and contacts the responsible party. She stated after the appointment is made the appointment is given to the nurse. The SW stated it is her responsibility to make the referrals. She stated there is no follow-up from the nurse to see if the appointment was made. She stated referrals are discussed in the morning meetings but not sure what happened in the instance with Resident #1. Re-interview with SW on 03/24/15 at 4:10 PM revealed Resident #1 was scheduled to see the doctor on 04/02/15 at 11:30 AM. When the SW was asked how resident can see this doctor now when he does not accept residents payer source she replied the facility will be paying for it. The SW was asked why didn't the facility pay for the doctor visit four months ago she replied she does not know why the facility did not cover it prior. The SW was asked who approved the payment for resident to see the doctor she replied she assumed corporate. SW was asked how corporate found out the SW stated she did not know the ADON informed her that the facility would pay for the appointment. Nurse ' s notes and Social Services notes indicated the doctor Resident #1 was referred to did not accept her payment source. Social Services notes indicated the facility called another orthopedic clinic and they did not accept Resident #1 payer source either. Subsequently a referral was made to the county hospital on [DATE] and again on 11/24/14 according to the Social Worker. Review of Social Services documentation on 03/24/15 revealed the SW faxed the referral to the county hospital but never ensured it was a successful transmission. There were two Fax Transmission Verification reports one dated 11/11/14 and one dated 11/24/14 and both results revealed busy/no response indicating county hospital never received the referral. The SW could not produce a Fax Transmission Verification Report indicating the fax was received by the county hospital. Subsequently Resident #1 had not seen an orthopedic specialist as of 03/24/15. Interview with LVN A, Charge Nurse for the secured unit on 03/24/15 at 2:25 PM revealed he has worked on the secured unit for one year. He stated when he first started working on the unit Resident #1 was ambulating with a walker. Resident #1 stopped walking later part of last year as a result of a fall. He stated each time Resident #1 fell she was referred to therapy. He stated when Resident #1 fell back in November 2014 resident was sent to the hospital and was sent back with a brace and not to do anything until they got the consult. LVN A stated due to residents insurance no doctor would see her so they checked with the county hospital and put resident on a waiting list. He stated the brace was up to resident's knee. He stated he thought the fracture has healed because the swelling has gone down. He stated the resident's ankle was swollen as big as his head. He stated the resident has been in bed as a result of the injury but they get her up so she is not completely bed ridden. He stated when a resident is on the waiting list at the county hospital follow up calls are made to see where the resident is on the list. LVN A stated it is the SW responsibility to follow up on all referrals. Record review of the nurses notes and Social Services notes on 03/24/15 revealed there was no documentation that any follow up calls were made. Interview with the ADON on 03/24/15 at 4:31 PM revealed when there was an order/referral a communication sheet was filled out, one copy goes to the SW, one copy goes to nursing management, and the other copy goes in the chart. She stated the SW makes the follow-up calls. She stated the referrals are usually discussed in the morning management meeting. The ADON was asked if they discussed Resident #1 referral for four months in the morning meetings and she replied she was not saying that. She stated they talk about the referrals and the SW follows up. The ADON stated she ordered an x-ray stat, she conducted a pain evaluation, did an in-service with the nurses to see if they could get a better system going forward, and went to therapy to see when the last time resident had been seen. When the ADON was asked what made her do all that today she replied the PA brought it to her attention that Resident #1 had not seen by an Orthopedic Specialist. The PA told her she had received a call over the weekend. The ADON was asked if the resident was ambulatory prior to the fall and she said yes. Review of Resident #1 x-ray results date 03/24/15 revealed the right tibia and fibula show no fracture, lytic lesion, blastic lesion, or dislocation. No foreign body is noted. Suggestion of old healed [MEDICAL CONDITION] fibula Interview on 03/31/15 at 1:05 PM with the PA revealed she started at the facility on January 2015 and was told Resident #1 had a fractured right ankle and was scheduled to see an orthopedic physician. Interview with the DON on 03/24/15 at 6:40 PM revealed Resident #1 returned from the hospital with an orthopedic referral. The DON stated the SW told her the doctor Resident #1 was referred to did not accept residents payer source so the next step was a referral to the county hospital. The DON stated the SW told her the paperwork was faxed and she never followed up with the SW again. The DON stated the facility was paying for Resident #1 to go see the orthopedic doctor. She stated the facility had paid for residents in the past to see a doctor when they had difficulty finding a doctor that accepts resident payer source. The DON was asked why it took the facility four months to pay for an orthopedic consult. The DON replied because it was not brought up again until the PA brought it to the ADON's attention today. Interview with CNA #1 on 03/24/15 at 10:25 AM revealed Resident #1 was walking at times prior to her fall. Resident was able to transfer to her wheelchair. Resident #1 was supposed to have standby assist but now resident is total assist. Observation of Resident #1 on 04/03/15 at 12:00 PM revealed resident was in the dining room sitting in her wheelchair. Resident had on her heel protector. Interview with Resident #1 on 04/03/15 at 2:46 PM revealed she was fully dressed lying in bed. Resident was only oriented to self and was not a reliable source of information. Review of Resident #1 clinical record on 04/03/15 revealed resident had an appointment to see the orthopedic specialist on 04/06/15. Observation of Resident #1 on 04/03/15 at 2:46 PM revealed Resident #1 had on a foam heel boot that covered only her heel and ankle. Review of in-services dated 03/24/15 revealed the nursing staff were in-serviced on how to complete appointments and review orders for completion of resident appointments. Review of Resident Census and Conditions of Residents dated 04/03/15 revealed there were 96 residents in the facility.

Based on observation, interview and record review, the facility failed to implement its written policy and procedures which prohibits neglect for one (Resident #1) of five residents reviewed for neglect. Resident #1 was ambulatory prior to her fall on 11/06/14. Resident went to the hospital and was discharged back to the facility the same day. The facility failed to follow doctor's orders as a result Resident #1 is no longer ambulatory. Resident #1 received a referral to see an Orthopedic Specialist from an ER physician on 11/06/14 and as of 03/24/15 the facility had not gotten an appointment for Resident #1. This failure could affect all 96 residents who may require consultation with outside specialist. Findings included: Review of the abuse prohibition policy dated 2001 and revised April 2010 revealed the facility had all seven aspects of the policy. Record review of the facilities investigations revealed a thorough investigation and was reported timely to DADS. Review of Resident #1 clinical record revealed resident was admitted on [DATE]. The admitting [DIAGNOSES REDACTED].#1 secondary [DIAGNOSES REDACTED]. According to the (MDS Assessment) dated 09/26/2014 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Revealed Resident #1 was not walking and required assistance with everything. According to the (MDS Assessment) dated 03/27/15 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Resident required assistance with everything. Review of Resident #1 latest care plan dated 12/31/14 did not reveal any interventions for a broken ankle. Review of Resident #1 nurses notes revealed Resident #1 fell on [DATE]. X-rays were taken on 11/06/14 and revealed resident had a fractured right ankle. Resident was sent to local hospital on [DATE] at 9:35 PM due to the fractured ankle. Resident #1 was discharged the same day and sent back to the facility. Review of hospital discharge documentation dated 11/06/14 revealed resident was not treated at the hospital. Resident #1 was discharged back to the facility with orders to see an orthopedic specialist. Review of Resident #1 clinical record on 03/24/15 revealed there was no documentation to show the referral was ever faxed to the county hospital. There was no thorough documentation to show the SW followed up with any doctors. Interview with the Social Worker, on 03/24/15 at 1:45 PM revealed when a resident needs to see a doctor other than the facility doctor she gets a communication form from nursing. The SW stated she then goes through her data base to see what doctor took residents payer source. She makes the appointment and contacts the responsible party. She stated after the appointment is made the appointment is given to the nurse. The SW stated it is her responsibility to make the referrals. She stated there is no follow-up from the nurse to see if the appointment was made. She stated referrals are discussed in the morning meetings but not sure what happened in the instance with Resident #1. Re-interview with SW on 03/24/15 at 4:10 PM revealed Resident #1 was scheduled to see the doctor on 04/02/15 at 11:30 AM. When the SW was asked how resident can see this doctor now when he does not accept residents payer source she replied the facility will be paying for it. The SW was asked why didn't the facility pay for the doctor visit four months ago she replied she does not know why the facility did not cover it prior. The SW was asked who approved the payment for resident to see the doctor she replied she assumed corporate. SW was asked how corporate found out the SW stated she did not know the ADON informed her that the facility would pay for the appointment. Nurse ' s notes and Social Services notes indicated the doctor Resident #1 was referred to did not accept her payment source. Social Services notes indicated the facility called another orthopedic clinic and they did not accept Resident #1 payer source either. Subsequently a referral was made to the county hospital on [DATE] and again on 11/24/14 according to the Social Worker. Review of Social Services documentation on 03/24/15 revealed the SW faxed the referral to the county hospital but never ensured it was a successful transmission. There were two Fax Transmission Verification reports one dated 11/11/14 and one dated 11/24/14 and both results revealed busy/no response indicating county hospital never received the referral. The SW could not produce a Fax Transmission Verification Report indicating the fax was received by the county hospital. Subsequently Resident #1 had not seen an orthopedic specialist as of 03/24/15. Interview with LVN A, Charge Nurse for the secured unit on 03/24/15 at 2:25 PM revealed he has worked on the secured unit for one year. He stated when he first started working on the unit Resident #1 was ambulating with a walker. Resident #1 stopped walking later part of last year as a result of a fall. He stated each time Resident #1 fell she was referred to therapy. He stated when Resident #1 fell back in November 2014 resident was sent to the hospital and was sent back with a brace and not to do anything until they got the consult. LVN A stated due to residents insurance no doctor would see her so they checked with the county hospital and put resident on a waiting list. He stated the brace was up to resident's knee. He stated he thought the fracture has healed because the swelling has gone down. He stated the resident's ankle was swollen as big as his head. He stated the resident has been in bed as a result of the injury but they get her up so she is not completely bed ridden. He stated when a resident is on the waiting list at the county hospital follow up calls are made to see where the resident is on the list. LVN A stated it is the SW responsibility to follow up on all referrals. Record review of the nurses notes and Social Services notes on 03/24/15 revealed there was no documentation that any follow up calls were made. Interview with the ADON on 03/24/15 at 4:31 PM revealed when there is an order/referral a communication sheet was filled out, one copy goes to the SW, one copy goes to nursing management, and the other copy goes in the chart. She stated the SW makes the follow-up calls. She stated the referrals are usually discussed in the morning management meeting. The ADON was asked if they discussed Resident #1 referral for four months in the morning meetings and she replied she was not saying that. She stated they talk about the referrals and the SW follows up. The ADON stated she ordered an x-ray stat, she conducted a pain evaluation, did an in-service with the nurses to see if they could get a better system going forward, and went to therapy to see when the last time resident had been seen. When the ADON was asked what made her do all that today she replied the PA brought it to her attention that Resident #1 had not seen by an Orthopedic Specialist. The PA told her she had received a call over the weekend. The ADON was asked if the resident was ambulatory prior to the fall and she said yes. Review of Resident #1 x-ray results date 03/24/15 revealed the right tibia and fibula show no fracture, lytic lesion, blastic lesion, or dislocation. No foreign body is noted. Suggestion of old healed [MEDICAL CONDITION] fibula Interview on 03/31/15 at 1:05 PM with the PA revealed she started at the facility on January 2015 and was told Resident #1 had a fractured right ankle and was scheduled to see an orthopedic physician. Interview with the DON on 03/24/15 at 6:40 PM revealed Resident #1 returned from the hospital with an orthopedic referral. The DON stated the SW told her the doctor Resident #1 was referred to did not accept residents payer source so the next step was a referral to the county hospital. The DON stated the SW told her the paperwork was faxed and she never followed up with the SW again. The DON stated the facility was paying for Resident #1 to go see the orthopedic doctor. She stated the facility had paid for residents in the past to see a doctor when they had difficulty finding a doctor that accepts resident payer source. The DON was asked why it took the facility four months to pay for an orthopedic consult. The DON replied because it was not brought up again until the PA brought it to the ADON's attention today. Interview with CNA #1 on 03/24/15 at 10:25 AM revealed Resident #1 was walking at times prior to her fall. Resident was able to transfer to her wheelchair. Resident #1 was supposed to have standby assist but now resident is total assist. Observation of Resident #1 on 04/03/15 at 12:00 PM revealed resident was in the dining room sitting in her wheelchair. Resident had on her heel protector. Interview with Resident #1 on 04/03/15 at 2:46 PM revealed she was fully dressed lying in bed. Resident was only oriented to self and was not a reliable source of information. Review of Resident #1 clinical record on 04/03/15 revealed resident had an appointment to see the orthopedic specialist on 04/06/15. Observation of Resident #1 on 04/03/15 at 2:46 PM revealed Resident #1 had on a foam heel boot that covered only her heel and ankle. Review of in-services dated 03/24/15 revealed the nursing staff were in-serviced on how to complete appointments and review orders for completion of resident appointments. Review of Resident Census and Conditions of Residents dated 04/03/15 revealed there were 96 residents in the facility.

Based on observation, interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of for one resident (Resident #1) of five residents reviewed for referrals requiring services outside the facility. Resident #1 was ambulatory prior to her fall on 11/06/14. Due to the fall Resident #1 went to the hospital and was discharged back to the facility the same day with an orthopedic referral. The facility failed to follow doctor's orders as a result Resident #1 is no longer ambulatory. Resident #1 received a referral to see an Orthopedic Specialist from an ER physician on 11/06/14 and as of 03/24/15 the facility had not gotten an appointment for Resident #1. This failure could affect all 96 residents who may require consultation with outside specialist. Findings included: Review of the abuse prohibition policy dated 2001 and revised April 2010 revealed the facility had all seven aspects of the policy. Record review of the facilities investigations revealed a thorough investigation and was reported timely to DADS. Review of Resident #1 clinical record revealed resident was admitted on [DATE]. The admitting [DIAGNOSES REDACTED].#1 secondary [DIAGNOSES REDACTED]. According to the (MDS Assessment) dated 09/26/2014 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Revealed Resident #1 was not walking and required assistance with everything. According to the (MDS Assessment) dated 03/27/15 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Resident required assistance with everything. Review of Resident #1 latest care plan dated 12/31/14 did not reveal any interventions for a broken ankle. Review of Resident #1 nurses notes revealed Resident #1 fell on [DATE]. X-rays were taken on 11/06/14 and revealed resident had a fractured right ankle. Resident was sent to local hospital on [DATE] at 9:35 PM due to the fractured ankle. Resident #1 was discharged the same day and sent back to the facility. Review of hospital discharge documentation dated 11/06/14 revealed resident was not treated at the hospital. Resident #1 was discharged back to the facility with orders to see an orthopedic specialist. Review of Resident #1 clinical record on 03/24/15 revealed there was no documentation to show the referral was ever faxed to the county hospital. There was no thorough documentation to show the SW followed up with any doctors. Interview with the Social Worker, on 03/24/15 at 1:45 PM revealed when a resident needs to see a doctor other than the facility doctor she gets a communication form from nursing. The SW stated she then goes through her data base to see what doctor took residents payer source. She makes the appointment and contacts the responsible party. She stated after the appointment is made the appointment is given to the nurse. The SW stated it is her responsibility to make the referrals. She stated there is no follow-up from the nurse to see if the appointment was made. She stated referrals are discussed in the morning meetings but not sure what happened in the instance with Resident #1. Re-interview with SW on 03/24/15 at 4:10 PM revealed Resident #1 was scheduled to see the doctor on 04/02/15 at 11:30 AM. When the SW was asked how resident can see this doctor now when he does not accept residents payer source she replied the facility will be paying for it. The SW was asked why didn't the facility pay for the doctor visit four months ago she replied she does not know why the facility did not cover it prior. The SW was asked who approved the payment for resident to see the doctor she replied she assumed corporate. SW was asked how corporate found out the SW stated she did not know the ADON informed her that the facility would pay for the appointment. Nurse ' s notes and Social Services notes indicated the doctor Resident #1 was referred to did not accept her payment source. Social Services notes indicated the facility called another orthopedic clinic and they did not accept Resident #1 payer source either. Subsequently a referral was made to the county hospital on [DATE] and again on 11/24/14 according to the Social Worker. Review of Social Services documentation on 03/24/15 revealed the SW faxed the referral to the county hospital but never ensured it was a successful transmission. There were two Fax Transmission Verification reports one dated 11/11/14 and one dated 11/24/14 and both results revealed busy/no response indicating county hospital never received the referral. The SW could not produce a Fax Transmission Verification Report indicating the fax was received by the county hospital. Subsequently Resident #1 had not seen an orthopedic specialist as of 03/24/15. Interview with LVN A, Charge Nurse for the secured unit on 03/24/15 at 2:25 PM revealed he has worked on the secured unit for one year. He stated when he first started working on the unit Resident #1 was ambulating with a walker. Resident #1 stopped walking later part of last year as a result of a fall. He stated each time Resident #1 fell she was referred to therapy. He stated when Resident #1 fell back in November 2014 resident was sent to the hospital and was sent back with a brace and not to do anything until they got the consult. LVN A stated due to residents insurance no doctor would see her so they checked with the county hospital and put resident on a waiting list. He stated the brace was up to resident's knee. He stated he thought the fracture has healed because the swelling has gone down. He stated the resident's ankle was swollen as big as his head. He stated the resident has been in bed as a result of the injury but they get her up so she is not completely bed ridden. He stated when a resident is on the waiting list at the county hospital follow up calls are made to see where the resident is on the list. LVN A stated it is the SW responsibility to follow up on all referrals. Record review of the nurses notes and Social Services notes on 03/24/15 revealed there was no documentation that any follow up calls were made. Interview with the ADON on 03/24/15 at 4:31 PM revealed when there is an order/referral a communication sheet was filled out, one copy goes to the SW, one copy goes to nursing management, and the other copy goes in the chart. She stated the SW makes the follow-up calls. She stated the referrals are usually discussed in the morning management meeting. The ADON was asked if they discussed Resident #1 referral for four months in the morning meetings and she replied she was not saying that. She stated they talk about the referrals and the SW follows up. The ADON stated she ordered an x-ray stat, she conducted a pain evaluation, did an in-service with the nurses to see if they could get a better system going forward, and went to therapy to see when the last time resident had been seen. When the ADON was asked what made her do all that today she replied the PA brought it to her attention that Resident #1 had not seen by an Orthopedic Specialist. The PA told her she had received a call over the weekend. The ADON was asked if the resident was ambulatory prior to the fall and she said yes. Review of Resident #1 x-ray results date 03/24/15 revealed the right tibia and fibula show no fracture, lytic lesion, blastic lesion, or dislocation. No foreign body is noted. Suggestion of old healed fracture of the distal fibula Interview on 03/31/15 at 1:05 PM with the PA revealed she started at the facility on January 2015 and was told Resident #1 had a fractured right ankle and was scheduled to see an orthopedic physician. Interview with the DON on 03/24/15 at 6:40 PM revealed Resident #1 returned from the hospital with an orthopedic referral. The DON stated the SW told her the doctor Resident #1 was referred to did not accept residents payer source so the next step was a referral to the county hospital. The DON stated the SW told her the paperwork was faxed and she never followed up with the SW again. The DON stated the facility was paying for Resident #1 to go see the orthopedic doctor. She stated the facility had paid for residents in the past to see a doctor when they had difficulty finding a doctor that accepts resident payer source. The DON was asked why it took the facility four months to pay for an orthopedic consult. The DON replied because it was not brought up again until the PA brought it to the ADON's attention today. Interview with CNA #1 on 03/24/15 at 10:25 AM revealed Resident #1 was walking at times prior to her fall. Resident was able to transfer to her wheelchair. Resident #1 was supposed to have standby assist but now resident is total assist. Observation of Resident #1 on 04/03/15 at 12:00 PM revealed resident was in the dining room sitting in her wheelchair. Resident had on her heel protector. Interview with Resident #1 on 04/03/15 at 2:46 PM revealed she was fully dressed lying in bed. Resident was only oriented to self and was not a reliable source of information. Review of Resident #1 clinical record on 04/03/15 revealed resident had an appointment to see the orthopedic specialist on 04/06/15. Observation of Resident #1 on 04/03/15 at 2:46 PM revealed Resident #1 had on a foam heel boot that covered only her heel and ankle. Review of in-services dated 03/24/15 revealed the nursing staff were in-serviced on how to complete appointments and review orders for completion of resident appointments. Review of Resident Census and Conditions of Residents dated 04/03/15 revealed there were 96 residents in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #1). Resident #1 was ambulatory prior to her fall on 11/06/14. Resident #1 went to the hospital and was discharged back to the facility the same day with an orthopedic referral. The facility failed to follow doctor's orders as a result Resident #1 is no longer ambulatory. Resident #1 received a referral to see an Orthopedic Specialist from an ER physician on 11/06/14 and as of 03/24/15 the facility had not gotten an appointment for Resident #1. This failure could affect all 96 residents who may require consultation with an outside specialist. Findings included: Review of Resident #1 clinical record revealed resident was admitted on [DATE]. The admitting [DIAGNOSES REDACTED].#1 secondary [DIAGNOSES REDACTED]. According to the (MDS Assessment) dated 09/26/2014 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Revealed Resident #1 was not walking and required assistance with everything. According to the (MDS Assessment) dated 03/27/15 Resident #1 [AGE] years old admitted to the facility on [DATE]. Resident Assessment and care screening reflected resident was severely cognitively impaired. Resident required assistance with everything. Review of Resident #1 latest care plan dated 12/31/14 did not reveal any interventions for a broken ankle. Review of Resident #1 nurses notes revealed Resident #1 fell on [DATE]. X-rays were taken on 11/06/14 and revealed resident had a fractured right ankle. Resident was sent to local hospital on [DATE] at 9:35 PM due to the fractured ankle. Resident #1 was discharged the same day and sent back to the facility. Review of hospital discharge documentation dated 11/06/14 revealed resident was not treated at the hospital. Resident #1 was discharged back to the facility with orders to see an orthopedic specialist. Review of Resident #1 clinical record on 03/24/15 revealed there was no documentation to show the referral was ever faxed to the county hospital. There was no thorough documentation to show the SW followed up with any doctors. Interview with the Social Worker, on 03/24/15 at 1:45 PM revealed when a resident needs to see a doctor other than the facility doctor she gets a communication form from nursing. The SW stated she then goes through her data base to see what doctor took residents payer source. She makes the appointment and contacts the responsible party. She stated after the appointment is made the appointment is given to the nurse. The SW stated it is her responsibility to make the referrals. She stated there is no follow-up from the nurse to see if the appointment was made. She stated referrals are discussed in the morning meetings but not sure what happened in the instance with Resident #1. Re-interview with SW on 03/24/15 at 4:10 PM revealed Resident #1 was scheduled to see the doctor on 04/02/15 at 11:30 AM. When the SW was asked how resident can see this doctor now when he does not accept residents payer source she replied the facility will be paying for it. The SW was asked why didn't the facility pay for the doctor visit four months ago she replied she does not know why the facility did not cover it prior. The SW was asked who approved the payment for resident to see the doctor she replied she assumed corporate. SW was asked how corporate found out the SW stated she did not know the ADON informed her that the facility would pay for the appointment. Nurse ' s notes and Social Services notes indicated the doctor Resident #1 was referred to did not accept her payment source. Social Services notes indicated the facility called another orthopedic clinic and they did not accept Resident #1 payer source either. Subsequently a referral was made to the county hospital on [DATE] and again on 11/24/14 according to the Social Worker. Review of Social Services documentation on 03/24/15 revealed the SW faxed the referral to the county hospital but never ensured it was a successful transmission. There were two Fax Transmission Verification reports one dated 11/11/14 and one dated 11/24/14 and both results revealed busy/no response indicating county hospital never received the referral. The SW could not produce a Fax Transmission Verification Report indicating the fax was received by the county hospital. Subsequently Resident #1 had not seen an orthopedic specialist as of 03/24/15. Interview with LVN A, Charge Nurse for the secured unit on 03/24/15 at 2:25 PM revealed he has worked on the secured unit for one year. He stated when he first started working on the unit Resident #1 was ambulating with a walker. Resident #1 stopped walking later part of last year as a result of a fall. He stated each time Resident #1 fell she was referred to therapy. He stated when Resident #1 fell back in November 2014 resident was sent to the hospital and was sent back with a brace and not to do anything until they got the consult. LVN A stated due to residents insurance no doctor would see her so they checked with the county hospital and put resident on a waiting list. He stated the brace was up to resident's knee. He stated he thought the fracture has healed because the swelling has gone down. He stated the resident's ankle was swollen as big as his head. He stated the resident has been in bed as a result of the injury but they get her up so she is not completely bed ridden. He stated when a resident is on the waiting list at the county hospital follow up calls are made to see where the resident is on the list. LVN A stated it is the SW responsibility to follow up on all referrals. Record review of the nurses notes and Social Services notes on 03/24/15 revealed there was no documentation that any follow up calls were made. Interview with the ADON on 03/24/15 at 4:31 PM revealed when there is an order/referral a communication sheet was filled out, one copy goes to the SW, one copy goes to nursing management, and the other copy goes in the chart. She stated the SW makes the follow-up calls. She stated the referrals are usually discussed in the morning management meeting. The ADON was asked if they discussed Resident #1 referral for four months in the morning meetings and she replied she was not saying that. She stated they talk about the referrals and the SW follows up. The ADON stated she ordered an x-ray stat, she conducted a pain evaluation, did an in-service with the nurses to see if they could get a better system going forward, and went to therapy to see when the last time resident had been seen. When the ADON was asked what made her do all that today she replied the PA brought it to her attention that Resident #1 had not seen by an Orthopedic Specialist. The PA told her she had received a call over the weekend. The ADON was asked if the resident was ambulatory prior to the fall and she said yes. Review of Resident #1 x-ray results date 03/24/15 revealed the right tibia and fibula show no fracture, lytic lesion, blastic lesion, or dislocation. No foreign body is noted. Suggestion of old healed [MEDICAL CONDITION] fibula Interview on 03/31/15 at 1:05 PM with the PA revealed she started at the facility on January 2015 and was told Resident #1 had a fractured right ankle and was scheduled to see an orthopedic physician. Interview with the DON on 03/24/15 at 6:40 PM revealed Resident #1 returned from the hospital with an orthopedic referral. The DON stated the SW told her the doctor Resident #1 was referred to did not accept residents payer source so the next step was a referral to the county hospital. The DON stated the SW told her the paperwork was faxed and she never followed up with the SW again. The DON stated the facility was paying for Resident #1 to go see the orthopedic doctor. She stated the facility had paid for residents in the past to see a doctor when they had difficulty finding a doctor that accepts resident payer source. The DON was asked why it took the facility four months to pay for an orthopedic consult. The DON replied because it was not brought up again until the PA brought it to the ADON's attention today. Interview with CNA #1 on 03/24/15 at 10:25 AM revealed Resident #1 was walking at times prior to her fall. Resident was able to transfer to her wheelchair. Resident #1 was supposed to have standby assist but now resident is total assist. Observation of Resident #1 on 04/03/15 at 12:00 PM revealed resident was in the dining room sitting in her wheelchair. Resident had on her heel protector. Interview with Resident #1 on 04/03/15 at 2:46 PM revealed she was fully dressed lying in bed. Resident was only oriented to self and was not a reliable source of information. Review of Resident #1 clinical record on 04/03/15 revealed resident had an appointment to see the orthopedic specialist on 04/06/15. Observation of Resident #1 on 04/03/15 at 2:46 PM revealed Resident #1 had on a foam heel boot that covered only her heel and ankle. Review of in-services dated 03/24/15 revealed the nursing staff were in-serviced on how to complete appointments and review orders for completion of resident appointments. Review of Resident Census and Conditions of Residents dated 04/03/15 revealed there were 96 residents in the facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure Residents #2 and #13, who entered the facility without pressure sores did not develop pressure sores and Resident #11, who had pressures sores received necessary treatment and services to promoted healing, prevent infection and prevent new sores from developing. These failures were evident for three (Resident #2, #11 and #13) of five residents reviewed for pressure sores. (1) On 08/27/11, Resident #11 was admitted with a Stage II pressure sore on the coccyx and an unstageable pressure sore on the right great toe. On 09/06/11, the resident had a new Stage I pressure sore on the left ankle and a new Stage II pressure sore on the left knee. The left ankle was assessed again on 09/16/11 and on 09/19/11, the pressure sore had progressed to a Stage II. The left knee was reassessed on 09/16/11 and the pressure sore had increased in size. On 09/08/11, a new Stage II pressure sore was identified on the resident's left hip. There was no further assessment until surveyor request on 09/23/11. Treatment orders for the pressure sores on the coccyx, left ankle, left knee and left hip were all the same. There had been no evaluation or revision of the treatment since 09/06/11. On 09/23/11, the pressure sore on the left ankle was unstageable due to slough covering the wound bed. (2) On 06/21/11, Resident #13 was identified with a Stage III pressure sore on the coccyx, on 06/21/11. From 07/05/11 until 08/25/11, there was no evidence of assessments of the pressure sore until the Wound Consultant assessed the pressure sore on 08/25/11. A weekly nursing summary dated 09/21/11 reflected the pressure sore had healed. Following surveyor inquiry on 09/22/11, Resident #13 was identified with a "reopened" Stage II pressure sore, which had not been identified by the facility. (3) On 07/27/11 Resident #2 was identified with a facility-acquired Stage III pressure ulcer. There was no onset date and there were no other assessments of the resident's pressure ulcer in July 2011, prior to or following 07/27/11. By 08/25/11, the resident had been identified with four "healing" Stage III pressure ulcers, all facility-acquired. Treatment orders were from 08/25/11 and as of 09/22/11, there had been no change in treatment orders. These failures affected Residents #2, #11 and #13 by failing to ensure they received weekly, accurate assessments with updates to their physicians and ensure appropriate treatments were provided to promote healing of their pressure sores, prevent the recurrence of previous pressure sores and new pressure sores from developing, resulting in discomfort, pain, the potential for infection and social isolation. These failures could affect the 44 residents identified as receiving preventive skin care and placed them at risk for developing pressure sores with the potential for delayed healing of pressure sores, development of infection, and a decline in overall health and well-being. Findings included: 1) Review of Resident #11's initial MDS assessment dated [DATE] revealed the resident's cognitive skills for daily decision-making were severely impaired. The assessment further reflected the resident was totally dependent on staff for all activities of daily living. Further review of the MDS revealed Resident #11 was at risk for developing pressure sores and had one Stage I pressure sore and two Stage II pressure sores. Review of Resident #11's nurse's notes dated from 08/27/11 through 09/15/11 revealed the following: On 08/27/11 at 4:00 p.m., the resident was admitted to the facility with a Stage II pressure sore on the coccyx area, which measured 2 cm in length by 2 cm in width. Resident #11's right great toe was noted with black eschar (hard, dead tissue). According to the note the treatment orders for the pressure sore on the coccyx consisted of applying a [MEDICATION NAME] dressing every three days and [MEDICATION NAME] ointment to the great toe two times a day. On 09/06/11 at 11:00 a.m., Resident #11 was noted with a Stage I pressure sore on the left ankle which measured 2 cm in length by 2 cm in width and a Stage II pressure sore on the left knee measuring 3 cm in length by 2.5 cm in width. The orders for the new pressure sores were to treat them with a [MEDICATION NAME] dressing every three days and as needed. On 09/08/11 a Stage II pressure sore was noted on Resident #11's left hip, which measured 1.5 cm in length by 1.0 cm in length and 1.0 cm in depth. Physician orders [REDACTED]. Review of Resident #11's treatment records for September 2011 revealed the resident had a pressure sore on the left ankle, the left knee and the left hip. The left hip pressure sore was identified as a Stage II pressure sore. There was no identification of the other two pressure sores on the treatment sheet. According to the treatment sheet,;;l Resident #11 was receiving treatments to the pressure sores every three days of cleansing with normal saline and applying a [MEDICATION NAME] dressing. Resident #11's skin was observed with LVN A on 09/23/11 at 1:45 p.m. During this time LVN A stated the resident's coccyx pressure sore had healed. When queried about when the pressure sore had healed, she stated she was not sure. The resident was observed with the following four pressure sores: (1) A Stage II pressure sore on the left hip had pink edges and granulating tissue in the center. The pressure sores measured 1 cm in length and 0.5 cm in width with no significant depth. (2) A Stage II pressure sore on the left outer leg below the left knee. LVN A stated this area was (incorrectly) identified as the left knee on the treatment sheets and weekly skin assessments. The pressure sore presented as an abrasion with a pink/gray-colored wound bed. Measurements were 2 cm in length by 2 cm in width with no depth. (3) A pressure sore on the left ankle was covered with a large amount of gray-colored slough with pink/red edges. LVN A identified the area as a Stage II pressure sore. However, the pressure sore was unstageable due to the amount of slough covering the wound bed. Measurements were 2 cm in length by 1.5 cm in width and no significant depth. (4) The left great toe was covered with black eschar and was unstageable. During this time, LVN A was queried about the [MEDICATION NAME] dressing change every three days being an appropriate treatment for [REDACTED]. She stated the treatment "might" need to be changed. LVN A was unable to recall if the physician had observed/assessed Resident #11's pressure sores. LVN A stated she would notify the physician today (09/23/11) regarding the condition of Resident #11's left ankle pressure sore. According to the National Pressure Ulcer Advisory Panel's revised pressure sore stages (2007), an unstageable pressure sore is defined as having full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 09/23/11 at 3:30 p.m., the DON provided pressure sore/skin assessments for Resident #11. An evaluation flow sheet dated 09/08/11 reflected measurements of Resident #11's left hip pressure sore were the same as those documented in the 09/08/11 nurse's notes. The evaluation reflected the pressure sore had no odor or drainage. There were no other assessments of the left hip pressure sore in September 2011. A weekly skin assessment sheet for Resident #11's left knee pressure sore reflected entries made on 09/06/11 and 09/16/11. On 09/06/11, the pressure sore measured 3.0 cm in length by 2.5 cm in width and had a scant amount of red drainage. The wound bed was described as red. On 09/16/11, the size of the pressure sore had increased and measured 3 cm in length by 3 cm in width. There was no other documentation on the sheet related to the condition of the pressure sore. A weekly skin assessment sheet for Resident #11's left ankle reflected entries were made on 09/06/11, 09/16/11 and 09/19/11. On 09/06/11 and 09/16/11, the pressure sore was a Stage I, measured 2 cm in length by 2 cm in width and was dark in the center and surrounded by red/white tissue. The entry made on 09/19/11 reflected the pressure sore had progressed to a Stage II without any change in the size. The pressure sore was an open area, which was white-colored in the center and surrounded by red-colored tissue. A weekly skin assessment sheet for Resident #11's pressure sore on the left great toe reflected on 09/02/11 and 09/09/11 the status of the resident's toe was "eschar." There was no other description of the great toe (not skin color, tissue type or condition of surrounding tissue) and no other assessments of the pressure sore in September 2011. LVN A was queried on 09/23/11 at 2:10 p.m. about the lack of completed weekly skin/pressure sore assessments for Resident #11. She stated, "I try for every week if nothing is going on." Review of Resident #11's care plan dated 09/07/11 revealed pressure sores were addressed. Interventions included assessing the resident's pressure sores and paying attention to the size, color, drainage, swelling and tenderness. The care plan further reflected the pressure sores should be measured weekly. 2) Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident's most current admitted was 10/15/10. Cognitive skills for daily decision-making were severely impaired and the resident was totally dependent on staff for all activities of daily living. The MDS reflected the resident was at risk for developing pressure sores and had one Stage III pressure sore. Weekly skin assessment sheets for Resident #13 were reviewed and revealed the following: The assessment sheet dated 06/21/11 reflected Resident #13's coccyx pressure sore was a Stage III. The pressure sore was described as having 90% yellow slough and 10% pink tissue. Measurements were 3.5 cm in length, 1.5 cm in width with a 0.5 cm depth. Resident #13's weekly skin assessment sheet dated one day later on 06/22/11 reflected the Stage III coccyx pressure sore still had 90% yellow slough and 10% pink tissue. Measurements were 3.0 cm in length, 1.5 cm in width and the depth was not able to be determined. Resident #13's assessment sheets dated from 06/30/11 through 08/17/11 reflected only what treatment should be provided. The area for documenting measurements, exudate, color and a description of the wound bed of the pressure sore was blank. Resident #13's nurse's note dated 07/04/11 and timed 11:40 a.m. reflected the coccyx pressure sore wound bed was "getting deeper," and drainage and slough were present. The note did not include the amount of drainage/slough or the type and color of the drainage. There was also no assessment, which included measurements or a stage of the pressure sore. There were no other descriptions/assessments of Resident #13's pressure sore until 08/25/11 when the wound consultant assessed the resident's pressure sore. A wound care/skin integrity evaluation dated 08/25/11 reflected the resident had been evaluated by the Wound Consultant. The evaluation reflected Resident #13 had a coccyx pressure sore described as a healing Stage III pressure sore. Measurements were 1.4 cm in length by 0.3 cm in width and depth. According to the evaluation the pressure sore had serous drainage and was acquired in the facility. Resident #13's physician's telephone order dated 08/25/11 reflected the treatment was to cleanse the pressure sore with normal saline or wound cleanser, apply collagen to the wound bed and cover with a boarded foam dressing. Resident #13's weekly nursing summary dated 09/21/11 reflected the pressure sore on the coccyx had healed. The treatment sheet dated 09/20/11 reflected the last day of treatment to the pressure sore on the coccyx was 09/14/11. Observation of Resident 13's coccyx on 09/22/11 at 5:20 p.m. with the DON and the facility's only ADON revealed an undated foam dressing was present. The dressing was dirty and brown-colored. After the DON removed the dressing, a dark-colored, waxy substance was noted in a gray and white open area on the resident's coccyx. The DON first stated the substance was possibly an old collagen dressing. On 09/22/11 at approximately 5:30 p.m., the open area on Resident #13's coccyx was confirmed by the DON and ADON to be a Stage II pressure sore. Review of Resident #13's entire clinical record revealed nurse's notes were dated from 02/11/11 through 09/21/11. Review of all of the nurse's notes revealed there were no documented assessments of the resident's pressure sore/skin. Following surveyor intervention, on 09/22/11 at 6:10 p.m. the DON provided a new assessment of Resident #13's pressure sore, which was dated 09/22/11. The assessment reflected the pressure sore was a Stage II, which was waxy, white-colored and slough was present. The measurements were 1.6 cm in length by 1.4 cm in width with less than a 0.1 cm depth. Orders had been received from the physician to cleanse the pressure sores with normal saline or wound cleanser, apply collagen and cover with a foam dressing. During this time, the DON stated Resident #13's pressure sore had "reopened." The DON stated she did not know when the pressure sores had reopened and had no explanation about why there was an old dressing in place on 09/22/11 at 5:20 p.m. The DON confirmed she had not been aware of the pressure sore. An interview was conducted with LVN A on 09/23/11 at 10:30 a.m. about Resident #13's coccyx pressure sore. The nurse stated the resident's pressure sore was healed. She further stated she was not aware of any orders, treatment or assessment performed by the DON on 09/22/11. 3) Review of Resident #2's quarterly MDS assessment dated [DATE] revealed the most current admitted was 12/13/10. Cognitive skills for daily decision-making were severely impaired and the resident was totally dependent on staff for all activities of daily living. The MDS reflected Resident #2 received nutrition orally and via a [MEDICAL CONDITION] feeding tube. The MDS further reflected the resident was at risk for developing pressure sores but did not have any pressure sores. A wound consultant progress note dated 07/27/11 reflected Resident #2 was assessed with [REDACTED]. The note further reflected the pressure sore was assessed with [REDACTED]. The pressure sore measured 9.5 cm in length, 13.0 cm in width and 0.3 cm in depth. According to the note Resident #2 was observed wearing a brief and lying on top of a blanket on a "Roho mattress" (therapeutic pressure relief mattress) in urine-soaked bedding. A physician's telephone order dated 07/27/11 reflected orders for wound care to the resident's pressure sore with [MEDICATION NAME] (a topical sulfonamide/silver antibacterial) and Calcium Alginate (a wound dressing used to manage exudates in partial to full-thickness wounds) two times a day and as needed. The orders further reflected the [MEDICATION NAME] should be discontinued once the slough (a layer or mass of dead tissue separated from surrounding living tissue) had been removed. Review of Resident #2's entire clinical record revealed there was no documentation related to when the pressure sore developed or any other assessment of the resident's wound/skin during the month of July 2011, prior to the wound consultant's note on 07/27/11. Weekly skin assessment sheets dated 07/06/11 and 07/13/11 reflected [MEDICATION NAME] ointment (multipurpose moisture barrier) was being applied to Resident #2's coccyx as a preventative measure. The area on the assessment sheet for documenting a description of the skin was blank. Nurse's notes dated 08/23/11 and timed 1:30 p.m. reflected Resident #2 had drainage from "wound area." The drainage was described as thick with a foul odor. The Physician Assistant was notified and an order was received to add the [MEDICATION NAME] back to the treatment regime. A wound care/skin integrity evaluation for Resident #2 dated 08/25/11 reflected the following: (1) A healing Stage III pressure sore on the right ischium (the lower and back part of the hip bone) which measured 3.0 cm in length, 2.5 cm in width and less than 0.2 cm in depth. The onset date was 08/16/11. (2) A healing Stage III pressure sore on the right lower back which measured 0.5 cm in length, 1.0 cm in width and less than 0.2 cm in depth. The onset date was 08/16/11. (3) A healing Stage III pressure sore on the coccyx which measured 1.5 cm in length, 2.0 cm in width. There was 100 % yellow slough and the depth was not able to be determined. The onset date was 04/01/10. (4) A Stage III healing pressure sore on the left buttock which measured 0.5 cm in length, 1.0 cm in width and less than 0.2 cm in depth. The onset date was 09/15/11. According to the evaluation, all the pressure sores had serous drainage and were facility-acquired. On 08/25/11, the wound consultant changed the treatment orders initiated on 07/27/11 (four weeks later). A physician's telephone order dated 08/25/11 reflected the pressure sores were to be cleansed with normal saline or wound cleanser, apply collagen (a type of wound dressing made with a form of collagen to aid in the body's healing process) and cover with a [MEDICATION NAME] dressing (provides a moist wound-healing environment, while protecting from contamination) three times a week. The new treatment for [REDACTED]. The next weekly skin assessment sheet was dated 08/25/11. The only information related to the resident's skin was the treatment ordered on [DATE]. The area on the assessment sheet for documenting a description of the pressure sore was blank. There was no assessment or any documentation in the nurse's notes in August 2011 related to the condition of Resident #2's skin and/or pressure sores prior to 08/23/11. The DON was queried on 09/20/11 at 1:05 p.m. about the lack of assessments of Resident #2's skin and/or pressure sores. The DON stated evening shift nurses were responsible for performing weekly skin assessments for residents residing in the B beds and day shift nurses performed the weekly skin assessments for residents in A beds. Resident #2 resided in a B bed. The DON further stated the evening shift nurse, LVN I, had been disciplined in the past for not performing her assigned skin assessments. During an interview with LVN I on 09/20/11 at 2:45 p.m., she stated she had not done the skin and/or pressure ulcer assessments for Resident #2 because LVN A told her the pressure ulcer was healed on Friday 09/16/11. When queried about skin and/or pressure sores assessments prior to 09/16/11, LVN I stated she had not done any of the skin and/or pressure sores assessments for Resident #2. She further stated she only documented the treatments on the assessment sheets. Additionally, LVN I stated she had intended to ask LVN A what the resident's pressure sores looked like but had forgotten. During an interview with LVN A on 09/21/11 at 7:50 a.m., she stated she never told LVN I Resident #2's pressure sores had healed. She stated she (LVN A) still provided daily wound care for the resident. Observation of Resident #2's pressure sores on 09/21/11 at 10:05 a.m. revealed there were two pressure sores covered with [MEDICATION NAME] dressings. LVN A removed the dressings and obtained measurements of the pressure sores. The pressure sore located on the resident's coccyx measured 2.5 cm in length by 1.5 cm in width and 0.5 cm in depth. The pressure sore presented as a hole with pink and white surrounding tissue. A Stage II pressure sore located on the resident's right lower buttock (ischium) measured 6 cm in length by 4 cm in width with no significant depth. The edges of the pressure sore were pink and the center was brown. Weekly skin assessments dated 09/02/11 and 09/09/11 reflected Resident #2's coccyx pressure sore measured 1.5 cm in length by 2.0 cm in width. According to the assessments the pressure sore contained serous drainage (body fluids typically pale yellow and transparent) and no depth was able to be determined. The weekly skin assessments dated 09/02/11 and 09/09/11 further reflected the pressure sore on the right ischium measured 3.0 cm in length and 2.0 cm in width and less than 0.2 cm in depth. According to the assessments, the pressure sore contained serous drainage. Nurse's notes dated 09/05/11 and timed 10:00 a.m. reflected Resident #2's coccyx/sacral pressure sore was pink and appeared to be healing. Further review of the resident's clinical record on 09/22/11 revealed there were no other description/assessment of the resident's skin/pressure sores during September 2011. The last nurse's note in the clinical record was dated 09/17/11. Review of Resident #2's clinical record included physician orders. There had been no change in the resident's treatment for [REDACTED]. On 09/22/11 at 3:00 p.m. the DON stated she was unable to locate any additional pressure sore/skin assessments for Resident #2. She stated, "That's all I could find." 4) An interview with the DON on 09/23/11 at 3:30 p.m. revealed there were no other assessments available for Resident #2, #11 or #13. The facility's policy and procedure related to pressure sore and skin assessments was requested from the DON on 09/20/11. On 09/20/11 at 3:05 p.m., the DON provided an undated quarter-page document entitled "Pressure Ulcer Prevention and Care-General" and identified it as the facility's current policy/procedure. The DON stated there was no other policy/procedure available. The policy section reflected: It is the policy of this facility that residents shall receive appropriate assessment and management for pressure ulcer prevention and care. The procedure section reflected: 1. Residents shall be assessed for skin integrity upon admission. 2. Appropriate measures for pressure ulcer prevention and care will be implemented with the resident's care plan. 3. Additional resident assessments and interventions will be provided according to the Skin Care Management System. The Skin Care Management System was requested from the DON on 09/23/11 at 1:15 p.m. On 09/23/11 at 1:45 p.m., the DON provided the facility's Skin Integrity Management Program dated January 2007 and identified it as current and available to nursing staff. The purpose of the SIMP (Skin Integrity Management Program) included: 1. Providing a system of assessment, evaluation and monitoring of resident's skin integrity. 2. Identifying risk factors specific to individual residents who needed prevention. 3. Implementing measures aimed at preventing the development of pressure ulcers and possibly other skin integrity problems. 4. Managing the treatment of [REDACTED]. To reduce the prevalence of pressure ulcers. According to the SIMP, pressure ulcers would be measured and a description of the wound with associated pain assessment would be documented at least weekly on the "Wound Care Measurement and Assessment Form." Licensed Nurses should document dimensions, treatment modalities, positioning devices, preventative measures for pressure ulcers, and response to treatment, in the nursing progress notes. The Charge nurse would complete a weekly skin assessment on each resident and document findings on the weekly Skin Condition Report form. The DON would view all pressure ulcers weekly. The SIMP reflected, when eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided. The wound should be identified as a necrotic area. The SIMP further reflected treatment protocols for pressure ulcers included notifying the physician if no improvement was apparent within 14 days of initiating a treatment. 5) The form CMS-672 (Resident Census and Conditions of Residents) signed by the MDS Coordinator on 09/20/11 reflected there were three residents in the facility with pressure sores and 44 residents, who were receiving preventive skin care.