Every finding on record at Cypress Creek Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II residents reviewed for 1 of 8 residents (Resident #10) reviewed for resident assessment.The facility failed to ensure Resident #10's PASRR Level I screening reflected his mental illness diagnosis. This failure could place residents at risk of not receiving specialized services for their mental illness.Findings included:Record review of Resident #10's admission Record dated 7/2/26 revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included major depressive disorder, recurrent severe without psychotic features (11/5/25), major depressive disorder, single episode mild (6/16/25), post-traumatic stress disorder (3/15/25), and anxiety.Record review of Resident #10's quarterly MDS assessment, dated 4/18/26 revealed a BIMS score of 14 out of 15 which indicated intact cognition. Record review of Resident #10's care plan dated 1/23/26 indicated he used antidepressant medication related to depression. He also had ineffective coping related to history of trauma, depression, and PTSD related to witnessing the death of his family member.Record review of Resident #10's PASRR Level I screening dated 3/14/25 indicated there was no evidence or an indicator that the resident had a mental illness. Resident #10 did not have a primary diagnosis of dementia.In an interview on 6/30/26 at 12:12 p.m. Resident #10 said he was on physical therapy but did not want to speak with any other therapists.In an interview on 7/2/26 at 11:09 a.m. the MDS Specialist said she was standing in for the facility's MDS nurse while she was on leave. She said Resident #10 had a PL 1 submitted on 3/14/25 which indicated negative eligibility. She said Resident #10 did have diagnoses of major depressive disorder and PTSD which would trigger a positive PL 1 for mental illness. She said a form 1012 (the Mental Illness/Dementia Resident Review, which assists nursing facilities (NFs) in evaluating whether a resident with a negative PASRR Level I (PL1) Screening requires additional assessment for mental illness (MI) or has a primary dementia diagnosis) should have been completed, but was not, so she completed one yesterday (7/1/26). She said she just completed a form 1012 and needed to resubmit a PL 1. She said if a PL 1 originally reflected negative but was supportive of a positive MI diagnosis, facility staff should reach out to the entity (unknown) to update to reflect positive. She said Resident #10 did not have a diagnosis of dementia. She said Resident #10's negative PL 1 should have been caught/addressed when the PTSD diagnosis was added on 3/15/25 and when the major depressive disorder diagnosis was added on 6/16/25. She said Admissions staff input the results of the PL 1 and the MDS nurse screened to ensure no diagnoses triggered a positive PL 1. She said the nursing IDT and Social Worker were responsible to ensure new diagnoses were reviewed. She siad the purpose of the PASRR screening was to see if the resident qualified for PASRR, behavioral, and psychosocial services. She said Resident #10 had not had any PASRR evaluations. She said there was no risk to Resident #10 because he currently saw psych services in the facility. She said the MDS nurse was ultimately responsible to ensure the accuracy of PASRR screenings.In an interview on 7/2/26 at 2:36 p.m. the Administrator said she was informed that a diagnosis for Resident #10 was put in last year and was unaware that they needed to submit another PASRR screening. She said if a diagnosis is added, the Social Worker and MDS nurse needed to ensure it was caught. She said the Social Worker was not in the building. She said there was no risk to Resident #10 because the facility was providing the same psych services. Record review of the facility's Resident Assessment - Coordination with PASARR Program policy revised 10/2023 read in part, . This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified andevaluated through PASARR.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry areas (Laundry Room) reviewed for infection control. The facility failed to ensure the Housekeeping Manager handled clean linen in a sanitary manner on 7/2/26.The failure could lead to cross contamination or infection.Findings included:In an observation and interview on 7/2/26 at 11:59 a.m. the Surveyor and Housekeeping Supervisor entered the clean linen side of the laundry room. Upon entering the clean side, the Housekeeping Supervisor did not wash his hands. He opened the lid of the broken trashcan so this Surveyor could throw away a paper towel. While the Housekeeping Supervisor showed the dryer lint trap to the Surveyor, the door to the dryer opened slightly and a clean towel fell on the ground. The Housekeeping Supervisor picked the towel up from the floor with his bare hands and tossed it back into the dryer that was filled with clean linens. The Housekeeping Supervisor said he did not wash his hands upon entering the laundry room and said he touched the trash can. He said he should handle clean linen with gloves. He said he picked the towel up and placed it back in the dryer but should not have due to cross contamination. He said the incident probably occurred because he was focused on showing the lint trap to the Surveyor. He said he conducted infection control training for his employees.In an interview on 7/2/26 at 12:21 p.m. the Corporate QA RN said when handling clean linen staff should wash their hands due to not wanting to get anything dirty. She said if clean linen hit the floor it would need to be rewashed, because it was now dirty. She said it was not good practice to throw the towel back into the dryer with clean linen. She said laundry staff were trained on infection by nursing and the online computer training.In an interview on 7/2/26 at 2:39 p.m. the Administrator said she expected dirty items to never come to the clean side without being laundered first. She said staff should follow company policies for linen and infection control and hand hygiene should be followed per CDC recommendation.Record review of the facility's Laundry policy revised on 1/2026 revealed in part, .The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. 2. The facility's laundry area will provide hand washing facilities and products as well as PPE.Record review of the Hand Hygiene in-service dated 6/11/26 presented by the Infection Preventionist revealed in part, .Proper hand hygiene is the most effective way to prevent the spread of infection and protect our resident, coworkers, and ourselves. Wash your hands with soap and warm running water for at least 20 seconds, making sure to clean all surfaces of your hands, including between fingers, thumbs, and wrists. Dry hands thoroughly with a clean paper towel and use the towel to turn off the faucet. Hand hygiene must be performed before and after resident contact, before clean procedures, after removing gloves, and after contact with body fluids or contaminated surfaces. Remember: Gloves do not replace handwashing. The Housekeeping Supervisor name was on the in-service.Record review of the facility's Infection Prevention and Control Program revised 3/2026 revealed in part, .This facility has established and maintains 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 as per accepted national standards and guidelines. 4. Standard precautions.c. hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. B. clean linen shall be separated from soiled linen at all times.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 3 of 16 resident rooms (rm 401, RM [ROOM NUMBER], and RM [ROOM NUMBER]) reviewed for pest control.1.The facility failed to ensure occupied resident room [ROOM NUMBER] was free of small black ants. 2.The facility failed to ensure occupied resident room [ROOM NUMBER] was free of flies.3.The facility failed to ensure occupied resident room [ROOM NUMBER] was free of small black ants and winged insects. This failure could place residents at risk of having pests in their rooms and a decreased quality of life.Findings included: Observation and interview on 6/30/26 at 10:50 a.m. of occupied resident room [ROOM NUMBER] revealed there were 11 ant-like insects with wings crawling on the bathroom wall and ceiling near the bathroom light. CNA H observed the insects and said they looked like termites. She said she never saw them before. Two small black ants were also observed crawling in the bathroom sink. In an interview on 6/30/26 at 10:55 a.m. the Plant Operations Director said the facility did not have termites to his knowledge and would call pest control to come to the facility. In an interview on 6/30/26 at 11:00 a.m. Resident #1 and Resident #3 who resided in room [ROOM NUMBER] said they used the restroom today and had not seen any bugs.In an observation on 6/30/26 at 10:59 a.m. of occupied room [ROOM NUMBER] with the Maintenance Director revealed there were 5 small black ants crawling in the bathroom sink. In an observation on 6/30/26 at 1:25 p.m. in room [ROOM NUMBER] revealed there were flies flying around Resident #2, with one fly landing on the resident. Resident #2 waved the fly off and asked the Surveyor if she brought them in. In an interview on 7/2/26 at 2:30 p.m. the Administrator said she expected the facility to provide a homelike environment that was free of pests. She said the facility had a good effective system in place and pest control made routine visits. She said there might be a sighting of insects here or there, and the Maintenance Director was good about getting pest control to the facility during an off cycle. She said the facility did their best to conceal pest and did not believe there was an infestation.Record review of the facility's service request log dated April 2026 - June 2026 revealed the following pertinent pest sightings:4/4/26 - black ants4/13/26 - ants restroom sink (310)4/25/26 - sugar ants bedside drawer (room [ROOM NUMBER])4/30/26 - bugs ( like ants with wings) room [ROOM NUMBER] by overhead light5/1/26 - ants beside drawer (room [ROOM NUMBER])5/5/26 - bugs5/15/(26) - bugs in bathroom sink5/20/26 - sugar ants in drawer (400 hall)6/25/(26) - black ants in the mini fridge6/30/26 - sugar ants, ants with wings in room [ROOM NUMBER] bathroom6/30/26 - sugar ants in room [ROOM NUMBER] restroom sinkRecord review of the facility's Pest Control Program revised 1/2026 read in part, . It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats).

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (CR #1) reviewed for pharmacy services.The facility failed to check CR #1's Vancomycin trough level according to MD orders after every 4th dose every 7 day for 2 weeks. The facility failed to ensure CR #1 did not receive IV Vancomycin after the 4th dose on 12/05/2026 at 7:00 am, without a trough level being obtained on 12/05/2026 at 7 p.m.,12/06/2025 at 7:00 am and 7:00pm, and 12/07/2026 at 7:00 am and 7:00 pm.This failure could cause Vancomycin toxicity, acute kidney injury, and hospitalization. Findings included:Record review of CR #1's admission record dated 4/30/26 revealed an [AGE] year-old female who admitted on [DATE]. She was discharged to an acute care hospital on 4/8/26. Her diagnosis included dementia, urinary tract infection, chronic kidney disease, acute kidney failure, and hypertension (high blood pressure). Record review of CR #1's discharge - return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making was moderately impaired. She was dependent on staff for ADL care and required supervision or touching assistance for eating.Record review of CR #1's Order Summary Report revealed orders for: Vancomycin Intravenous solution use 1 gram every 12 hours for UTI for 14 days, order date 12/3/25.Vanco trough at 6 a.m. after 4th dose every 7 days for Vancomycin monitoring for 2 weeks, order date 12/3/25.Record review of CR #1's Medication Administration Record for December 2025 revealed the 1st dose of Vancomycin 1 gm was administered on 12/3/25 at 7:00 p.m., the 2nd dose on 12/4/25 at 7:00 a.m., 3rd dose on 12/4/25 at 7:00 p.m., and the 4th dose on 12/5/26 at 7:00 a.m. Vancomycin continued to be administered on 12/5/26 at 7:00 p.m., 12/6/25 at 7:00 a.m., 12/6/25 at 7:00 p.m., 12/7/25 at 7:00 a.m., and 12/7/25 at 7:00 p.m. The MAR did not indicate that a Vancomycin trough was collected after the 4th dose.Record review of CR #1's nursing note dated 12/3/25 at 6:55 p.m. by LVN T read in part, .Initial dose of ABT given as ordered. Resident tolerated well. No s/s of inflammation at IV site. No acute distress noted at this time. Plan of care continue.Record review of CR #1's nursing note dated 12/4/25 at 12:08 p.m. by LVN W read in part, .Resident continues on IV Vancomycin through Left Upper Arm Midline for UTI with NARN. Dressing intact. Midline flushing well.Record review of CR #1's nursing note dated 12/4/25 at 11:41 p.m. by LVN A read in part, .Vancomycin IV Q 12 HRS DX: UTI in progress with no adverse effects noted.Record review of CR #1's nursing note dated 12/5/25 at 4:58 p.m. by RN K read in part, .Continues on IV Vancomycin ABT for UTI, medicated per orders.Record review of CR #1's nursing note dated 12/6/25 at 7:23 p.m. (created date: 12/7/25 at 8:59 p.m.) by LVN T read in part, . LATE ENTRY. Resident continue Vancomycin in left arm for UTI. No infiltration noted. Resident tolerated the medication well. No signs of pain or discomfort noted. Temp 97.5, order for Vanco trough being clarified.Record review of CR #1's nursing note dated 12/7/25 at 3:31 a.m. by LVN O read in part, .Resident received a dose of Vancomycin on this shift for UTI. No infiltration noted. Resident tolerated the medication well.Record review of CR #1's nursing note dated 12/7/25 at 10:32 a.m. by RN S read in part, .Reviewed labs for last Vanc level. None obtained. Has received > 4 doses of antibiotic. Called lab for stat trough before next dose. At 9:15 (a.m.) Doctor notified. stated to give dose now and monitor level when received. Lab contacted again will come this afternoon around 4 to draw trough. Subsequent orders entered.Record review of CR #1's nursing note dated 12/7/25 at 5:01 p.m. by LVN B read in part, .Resident continued on IV Vancomycin for UTI, no adverse reactions noted. Resident alert and responsive. Spoke with on-call this am concerning trough level. Lab notified to do trough level stat today. Lab called stated lab was done around 1537 today. Lab stated results should be ready in an hour or so.Record review of CR #1's nursing note dated 12/7/25 at 11:20 p.m. by LVN S read in part, .Vancomycin trough critical reported to on call physician . Critical Vancomycin trough 33.7. Ordered to hold next two doses of Vancomycin.Record review of CR #1's laboratory results dated [DATE] revealed Vancomycin trough was collected on 12/7/25 at 3:37 p.m. The result was a critical high level of 33.7 ug/mL with a reference range of 10.0 - 20.0. The results were called into the facility on [DATE] at 11:13 p.m.In an interview on 4/30/26 at 1:59 p.m. CR #1's MD said the Vancomycin trough was normally drawn before every 4th dose, approximately 30 minutes to 1 hour before the medication was due. She said she would advise staff to obtain the initial trough prior to administering the next dose because the trough was needed to provide guidance. She said without knowing the initial trough the nursing staff could not continue to give the medication. She did not recall having a conversation with nursing staff about clarifying the trough order. She said the critical trough level of 33.7 needed to be addressed and Vancomycin could have an effect on the kidneys, but said it was only at that level for a short time. She said the Vancomycin was filtered through the kidneys and the level decreased and there was no long-term effect. She said CR #1 had mild chronic kidney dysfunction and her kidney concerns were more related to her diabetes and age. In an observation and interview on 4/30/26 at 2:39 p.m. LVN T said Vancomycin trough levels were usually done according to the MD order. She said CR #1's MD order for the Vancomycin trough was not clear and she reported it to RN S and probably reached out to the NP. She said she was unsure what was wrong with the order. She said a trough level was pending but could not remember. She said she questioned where the trough was and was unsure if she hung the IV. LVN T pulled up CR #1's Medication Administration Record for December 2025 which showed a check mark for administration of the Vancomycin with LVN T's initials on 12/6/25 for the 7:00 a.m. dose.In an interview on 4/30/26 at 3:48 p.m., previous employee RN S said she vaguely remembered the incident and was unsure how she found out the trough was not collected. In an interview on 4/30/26 at 3:55 p.m., previous employee LVN O said staff were supposed to know the Vancomycin trough level before administering another dose. She said the level should be known prior to because it had to be in a certain therapeutic range. She said there was not a time when she gave Vancomycin without knowing the trough. In an interview on 4/30/26 at 4:22 p.m., previous employee LVN O said she did not recall administering Vancomycin. This Surveyor asked what the check mark on the medication administration record meant. LVN O said anyone could have set her up by putting her initials on the MAR.In an interview on 4/30/26 at 4:31 p.m. the DON said nursing staff should know that a Vancomycin trough was needed after the 3rd day. She said a nurse (unknown) put CR #1's Vancomycin trough order to start on 12/7/25 (instead of starting it after the 4th dose). She said Vancomycin troughs were collected on 12/7/25, 12/9/25, 12/11/25 and 12/13/25 and did not see any troughs collected for CR #1 prior to 12/7/25. She said some Vancomycin doses were given to CR #1 before the trough was known. She said if the trough was not taken according to MD order, staff should communicate with the MD because if not, there was a risk for toxicity. She said there were no concerns brought up to her at the time regarding missing the trough and said she did not remember doing any in-services about it. She stated she expected nursing staff to follow the MD order.Record review of the facility's Medication Administration policy revised 1/2026 read in part, .Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Record review of the facility's Intravenous Therapy revised 1/2026 read in part, .The facility will adhere to accepted standards of practice regarding infusion practices. Procedures: .Review and verify practitioner's orders for infusion solution or medication, dose, frequency and route of administration.

Based on observation, interview, and record review the facility failed to ensure the resident has the right to secure and confidential personal and medical records for 1 of 5 residents (Resident #17) reviewed for privacy.The facility failed to protect resident information from unauthorized access when resident medical records were left open, unsecured and visible to others.This failure could result in exposure to sensitive information that could cause embarrassment or emotional distress to a resident.Findings included:Record review of Resident #17's undated face sheet revealed she was a [AGE] year-old female with an initial admission date of 10/06/2022 and most recent admission on [DATE]. Resident #17 has diagnoses of cerebral palsy, major depressive disorder, mood disorder due to known physiological condition, and intellectual disabilities.Record review of Resident #17's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15. Resident #17's BIMS demonstrated normal memory and recall abilities for an intact cognitive status.Record review of Resident #17's Care Plan dated 09/23/2025 revealed residents have a risk for cognitive impairment due to diagnosis of mild intellectual disorders. The interventions in place are to monitor, document, report any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, and mental status.In an observation on 01/30/2026 at 7:18am on 100 hall, Resident #17's electronic medical record was left open and unattended on the medication cart. Resident #17's electronic medical record displayed room location, date of birth , allergies, code status, and medications.In an interview on 01/30/2026 at 7:20am on 100 hall, RT P came out Resident #17's room with an inhaler in hand. RT P stated she left the medical records unattended because she was trying to quickly administer medication to Resident #17 and did not realize the records were left open. RT P stated the risk of leaving medical records open is that anyone could look at the documents.In an interview on 01/30/2026 at 8:14am with DON stated medical records should not be open while walking away from the cart and they should be locked. The risk of medical records being left open is wandering eyes can view the residents' information and it was a HIPAA violation.In an interview on 01/30/2026 at 9:51am, the ADMN stated the confidentiality of resident's medical records have built in time out and the staff can minimize the screen to lock, before walking away. The ADMN stated the In -services on resident confidentiality of medical records are done quarterly or yearly. The risk of a resident's information being exposed can be shared with another party or potentially observed by an unattended party.Record Review of Resident Rights policy revised 01/2025 reflects.Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.The resident has a right to secure and confidential personal and medical records.The resident has the right to refuse the release of personal and medical records except as provided at S483.70(i)(2) or other applicable federal or state laws.

Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #37).The facility failed to revise the residents' care plan after a documented change in condition for redness to right eye which had worsened.This failure could result in avoidable complications, decline, or injury.Findings included:Record review of Resident #37's undated face sheet revealed a [AGE] year-old male with an initial admission of 04/07/2023 and most recent admission on [DATE]. Resident #37 has diagnoses of dry eye syndrome, cerebral infraction, dementia, congestive heart failure, dizziness and giddiness, and chronic chough.Record review of Resident #37's MDS assessment dated [DATE] revealed a BIMS of 13. Resident #17's vision revealed the resident see fine detail, such as regular print in newspapers/books.Record review of Resident #37's undated Medication Administration Record revealed Azithromycin Ophthalmic Solution 1%, Instill 1 drop in right eye two times a day for Eye irritation for 5 days with an order date of 01/27/2026.Record review of Resident #37's Care Plan did not indicate a change in conditions regarding the residents' eye.Record review of Resident #37's Change in Condition progress note dated 01/27/2026 by MD S. The change in condition stated Resident #37 had redness to the right eye with a small amount of drainage. An updated order was put into place for Azithromycin 1% eye drops in one drop right eye, twice a day for 5 days.In an interview on 01/29/2026 at 12:13pm the DON stated when a resident has a change in condition and she was present, she will access the resident and update the care plan, with the change. The DON stated care plans are updated by meeting with IDT and updated by the DON, ADON, MDS Nurse, and/or Unit Manager when a new risk has been identified and new interventions are updated daily. For Resident #37, the care plan was not updated timely, and she does take accountable. The risk of care plans not being revised based on a change in condition could be staff not using appropriate modalities.In an interview on 01/29/2026 at 1:09pm the ADMN stated they have a meeting every morning with IDT and discuss when it's deemed appropriate the care plan was updated. Care plans are to be revised as soon as possible. For a new change in condition, SBARS are completed, and the staff will communicate shift to shift when something is new with a resident. Once the care plan was updated, it is filtered in Kardex for all staff to review changes before providing care. For Resident #37, the order was received on 01/27/2026 and the expectation was the care plan to be updated after the SBAR was completed and not days on out. The risk of a care plan not being revised was lack of communication with staff and the residents, which could result in the residents having issues with an adverse effect.In an interview on 01/29/2026 at 3:25pm with LVN V, MDS Specialist stated she will assist with day-to-day MDS, Care Plans, and documentation. LVN V stated revisions to care plans are updated immediately as the change has been confirmed or within 24 hours. The risk of care plans not being revised was the residents not receiving proper care relating to their condition and change.In an interview on 01/29/2026 at 3:32pm with ADON stated changes in conditions are discussed during morning meetings. The IDT meetings assist with updating and educating staff on new changes or diagnosis for each resident of concern. The risk of the care plans not being revised is something missing, which could cause a decline in the residents.Record Review of Care Plan Revisions policy revised 01/2025 reflects.The purpose of this procedure is to provide a consistent process for reviewing and revising the care planfor those residents experiencing a status change.1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiencesa status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change:a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, thephysician, and the resident representative, if applicable.b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition andcollaborate on intervention options.c. The team meeting discussion will be documented in the nursing progress notes.d. The care plan will be updated with the new or modified interventions.f. Care plans will be modified as needed by the MDS Coordinator or other designated staffmember.g. The Unit Manager or other designated staff member will communicate care plan interventionsto all staff involved in the resident's care.

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 of 8 (Respiratory Therapist Cart on 100 hall and Nurse Cart on 300 hall) medication carts reviewed for storage of medications.The facility failed to ensure RT P on the 100 hall and LVN T on the 300 hall lock medication carts before walking away and providing care to residents.This failure could place all residents at risk oof unauthorized access to prescription and over-the-counter medications, including controlled substances.Findings included:An observation of RT cart on the 100 hall on 01/30/2026 at 7:18am was revealed to be unlocked.In an interview on 01/30/2026 at 7:20am RT P stated she was assisting a resident with their medications and forgot to lock the cart. The risk of the medication cart being unlocked was that anyone could come and take the medications.An observation of Nurse cart on the 300 hall on 01/30/2026 at 7:24am was revealed to be unlocked.In an interview on 01/30/2026 at 7:25am LVN T stated she heard a resident yelling for help and went to assist which is why the cart was not locked. The risk of the medication cart being left unlocked was that a resident could possibly get into the cart and take the medication.In an interview on 01/30/2026 at 8:14am the DON stated the expectation for the medication cart was to be locked before walking away. The risk for medication carts being unlocked was medication being taken out and used for alternative purposes.In an interview on 01/30/2026 at 9:51am the ADMN stated for safety and security they do purposeful rounding throughout the day to double check medication carts locked when staff walk away. Her role was to make sure all systems are completed within local, state, compliance and if it is a deficient practice discovered, they will need to form a plan to become compliant. The risk of medication carts being unlocked is medication error and potential harm to residents.Record Review of Medication Storage policy revised 05/2023 reflects.It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.1. General Guidelines:a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts,cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.b. Only authorized personnel will have access to the keys to locked compartments.c. During a medication pass, medications must be under the direct observation of the personadministering medications or locked in the medication storage area/cart.

Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. CNA A was physically abusive to Resident #1 on 1/28/2025 when he slapped her on the left cheek with an open hand and pointed at her twice aggressively. The noncompliance was identified as past noncompliance (PNC). The IJ (immediate jeopardy) began on 1/28/2025 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. Resident #2 was physically abusive to Resident #1 on 4/21/2025 when she punched her in the arm with a closed fist three times. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 4/21/25 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish caused by fear. The findings included: Resident #1 Record review of Resident #1's undated admission Record revealed she admitted to the facility on [DATE] with diagnoses of colon cancer, hemiplegia (partial paralysis on one side of body), vascular dementia and adjustment disorder with depressed mood. She was [AGE] years of age. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 3, indicating severe cognitive impairment. She was dependent on staff for activities of daily living, including oral hygiene, toileting, bathing, and required substantial/maximum assistance for transfers. Record review of Resident #1's Care Plan Report, undated, revealed the following focuses, goals and interventions: - Focus: (Resident #1) had impaired cognitive function and impaired thought processes. Initiated on 12/6/24. Goal: The resident would maintain at current level of cognitive function through the review date. Target date 3/16/25. Interventions: Administer medications as ordered, ask yes/no questions to determine resident's needs, communicate with the resident regarding resident's capabilities and needs, and identify yourself at each interaction, face the resident when speaking and make eye contact. - Focus: (Resident #1) had unwanted behaviors related to yelling, combative with staff, refuses care, medications and meals and transfers independently without assistance. Initiated on 12/6/24. Goal: The resident would have fewer episodes of behavior by review date. Target date 3/16/25. Interventions: Caregivers to provide opportunity for positive interaction and attention, explain all procedures to the resident before starting, give 1:1 assistance (individualized attention provided by one person to the resident) to try and calm resident down, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, remove from situation and take to alternate location as needed and re-direct resident when combative, explaining this is inappropriate behavior. Record review of Resident #1's Incident/Accident Investigation Worksheet dated 1/29/2025 at 8:45am revealed an incident of abuse occurred. There were no witnesses listed. The pain assessment revealed she complained of a headache, Tylenol (a medication for pain management) was offered but refused. The conclusion/root cause was described as possible physical abuse .recommendations/interventions: Ask (family member) to check camera footage. Record review of an Abuse-Investigation Statement dated 1/29/25 revealed CNA A made the statement: (Resident #1) called asking to be changed around 9:00pm, after letter her know that I was in the middle of my round & that I would be assisting her afterward, (Resident #1) continued to call out. When I changed her/provided pericare, she asked for Tylenol & for the lights to be turned off. Approximately 5 min later (Resident #1) called out again, but she was not making any sense. In a continuance of the statement, CNA A reported that he entered Resident #1's room and asked what was wrong. I placed my hand down near her head on her bed, due to her bed being so low to the ground. (Resident #1) began to start jostling & throwing her head around. She hit her head against my hand. After that she shouted that I hit her & I moved my hand away & walked out of the room . Record review of a provider investigation report dated 2/5/2025 described an allegation of abuse in that CNA A hit Resident #1. A video from the incident shows a timestamp of 1/28/25 at 9:48pm and revealed CNA A hit Resident #1 on her left cheek. The police were notified, and CNA A was terminated on 1/30/25. The resident was assessed with no new injuries noted. An assessment was completed, and Resident #1 complained that her head hurt from the fall. The resident had a fall on 1/26/25 that resulted in a contusion (a bruise) to her right eye/cheek area. The provider investigation report was signed by the Former Administrator. The allegation of abuse was confirmed. Surveyor attempted interviews with Resident #1 on 5/13/25 at 11:11am and 5/14/2025 at 10:50 am with no success as she refused to be interviewed. Observation of the video footage sent by the Administrator to the surveyor by email on 5/14/2025 at 11:29am revealed the following: CNA A approached Resident #1 pointing at her face and talking, then hit her on her left cheek with his open right hand, then pointed at her face again, aggressively. After the slap, Resident #1 was yelling and pointing at CNA A. Conversation can be heard in the video, but it was difficult to determine what was said. In an interview on 5/14/25 at 1:48pm with CNA A, he said he recalled the incident with Resident #1. He said it was near the end of his shift, and she was the last person he cared for before charting and going home. He said Resident #1 never used her call light and she called out when she needed to be changed. He said he walked out, then walked back in and asked, I just changed you, are you sure you need to be changed. He said he then hit Resident #1 on the side of the face. When asked to describe how he hit her, he said he smacked her on the side of her cheek. He said she was screaming and irate. He said he slapped her to get her attention, but said it was not malicious. He said what he did to Resident #1 was physical abuse. In an interview on 5/13/2025 at 11:22pm, LVN C stated she was working the night of the incident between CNA A and Resident #1. She said CNA B reported to her that CNA A hit Resident #1. She said she approached the nurse who was caring for Resident #1 and shared with her what CNA B said. She said she noticed that the LVN was on her phone making notifications. She said she did not follow-up afterwards. She said she could not remember the other LVN's name. In an interview with CNA B on 5/14/2025 at 11:34am, she said she was at the facility at the time of the incident. She said CNA A approached her and told her that Resident #1 said he hit her. She looked into Resident #1's room and Resident #1 said, he hit me, he hit me! She said she was terrified, scared, yelling, crying, and asking for help. She said she and CNA A went to the break room to find Resident #1's nurse, then reported what happened. She said she stayed with CNA A until he went home. In a telephone interview on 5/15/25 at 9:15am, LVN D said she was assigned to Resident #1 when there was an allegation of abuse. She said she was on a lunch break, and LVN C came in and told her about the abuse allegation between CNA A and Resident #1. She said she assessed Resident #1, but did not see that she was fearful or upset. She said the incident occured at the end of CNA A's shift, and he completed charting, then went home. She said he did not care for other residents. In an interview on 5/14/25 at 1:28pm, MD A stated she was not aware that Resident #1 was distressed after the abuse incident. She stated residents who are abused could be fearful of caregivers and hesitant to receive care. In an interview on 5/14/25 at 3:20pm, The DON said she was aware of the incident regarding CNA A and Resident #1. She said the administrator watched video footage of CNA A slapping Resident #1 in the face. She said they suspended him the day after the incident and he was terminated after the investigation. She said they completed an assessment of Resident #1, notified police, ombudsman, HHSC, completed safety surveys with residents, took statements and in-serviced on abuse and neglect policies and procedures. She said CNA A worked from 2:30pm-10:30pm that evening, and the incident occured at 9:45pm. She said after the incident occured and notifications were made, it was time for him to go home. Resident #1 and Resident #2 Record review of Resident #2's admission Record (undated) revealed she admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, diabetes, major depressive disorder with psychotic symptoms, cerebral aneurysm (a bulge in a blood vessel in the brain), adjustment disorder and history of transient ischemic attack (temporary blockage of blood flow to the brain). She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 3, indicating she had severe cognitive impairment. She did not exhibit behavior symptoms during the review period. She used a wheelchair and required supervision to wheel 50 feet with two turns. Record review of Resident #2's care plan report (undated) revealed the following focuses, goals and interventions: - Focus: Resident #2 was a risk for delirium and reports of hallucinations. Initiated on 6/6/23. Goal: Cause of delirium will be resolved through the next review. Target date: 5/23/25. Interventions: Approach in calm manner, assess vital signs, medications, document changes noted. - Focus: Resident #2 had impaired cognitive function and impaired thought processes related to dementia. Initiated on 5/13/22. Goal: Resident will maintain current level of cognitive function through review dated. The resident would be able to communicate basic needs on a daily basis through the review date. Target date: 5/23/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Cue, reorient and supervise as needed. Monitor as needed for changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. - Focus: Resident #2 had unwanted behaviors related to delusions and hallucinations. Initiated on 9/5/24 and revised on 4/23/25. Goal: Behavior episodes would be reduced to less than daily until the next review. Target date: 5/23/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Give 1:1 assistance to try to calm resident down as needed. Record review of Resident #2's progress note dated 4/21/25 at 7:00pm revealed Resident #2 was at the nurse's station with another resident, and the other resident was mumbling to herself. At 6:30pm, Resident #2 struck the other resident with a closed fist three times. Record review of Resident #1's progress note dated 4/21/25 at 7:10pm revealed Resident #1 was involved in a physical altercation with a resident at the nurse's station. Resident sustained 3 hits to the (L) arm from the other individual. The resident attempted to retaliate, however made no physical contact. No visible injuries noted upon assessment . Record review of Resident #2's Incident/Accident Investigation Worksheet dated 4/21/25 at 6:30pm revealed Resident #2 reported that another resident was talking to her in a different language, and she asked her to stop. Resident #2 said whenthe other resident refused, she said she tried to get away from her, but did not hit her. LVN E was listed as a witness. LVN E reported seeing Resident #2 strike another resident with a closed fist three times. Further review of the worksheet revealed Resident #2 was separated from the other resident, was placed on 1:1 supervision, MD ordered a urinalysis and ammonia levels, and notifications were made to psychiatric nurse practitioner, DON, Administrator, and resident's responsible party. Record review of Resident #1's Incident/Accident Investigation Worksheet dated 4/21/25 revealed on 4/21/25 at 6:45pm, Resident #1 received verbal aggression. The incident was witnessed by LVN E who saw that Resident #1 was hit by another resident. In the section for What did the resident say happened, it stated, I don't know .I don't argue. There were no injuries or recent medical changes reported. Recommendations/Interventions included the following: Resident redirected and monitored closely for any changes in behavior or physical condition .safety precautions reinforced to prevent further occurrences. Record review of Resident #1's Behavioral Health Progress Note dated 4/22/25 revealed Resident #1 had a short attention span and had neurological symptoms such as cognitive deficits and memory problems. The progress note revealed she was being assessed after an altercation with another resident. No distress was noted during the assessment. Record review of Resident #2's Med Management Clinical Note dated 4/21/25 revealed the Psychological Services NP assessed the resident after she attempted to strike another resident. It was determined that the behavior was not repeated, and the behavioral disturbance was likely related to elevated Ammonia levels. In an interview on 5/13/2025 at 3:39pm, the Social Worker stated on the day that Resident #2 hit Resident #1, Resident #2 stole her phone. She said a family member called her phone and she heard it ring near Resident #2. She said after she retrieved her phone, she left Resident #2 near the nurse's station because she said she wanted to stay out in the halls. She said moments later she heard a commotion and found out that Resident #2 hit Resident #1. She said the nurse witnessed the interaction. She said that Resident #2 had occasional agitation, but not physical aggression. She said both incidents were outside of her baseline. She said the facility determined she had a urinary tract infection. In an observation and attempted interview on 5/13/2025 at 10:12pm, Resident #2 was in bed watching television. She was unable to answer surveyor's questions. When asked a question, she would talk about her past and her family. In an interview on 5/15/25 at 1:50pm, the DON said she was notified of the incident between Resident #2 and Resident #1 by phone. She said she believed they were too close together and Resident #2 hit Resident #1 in the arm. She said neither resident remembered the incident. She said the behavior was outside of Resident #2's baseline, and stated she was not aggressive. She said it was determined that she had a urinary tract infection at the time. She said Resident #2 as placed on 1:1 supervision until a staff member of the psychology services company visited and determined she was not a threat to others. In an interview on 5/15/25 at 4:02pm, LVN E said she witnessed the incident between Resident #1 and Resident #2. She said she had just retrieved Resident #2 from the 300 hall when she let her stay near the nurse's station. She said Resident #1 was yelling and saying something, then Resident #2 started talking back and hit Resident #1 three times in the arm with a closed fist. She said it was outside of Resident #2's baseline to hit someone. She said she had not experienced a situation like this before. She said to prevent something like this from occurring, staff need to stay vigilant, be aware of changes of condition and keep lines of communication open. In an interview on 5/15/25 at 4:10pm, the Administrator said Resident #2 struck Resident #1 in the arm a few times. She said in response to the altercation, the facility separated the residents, placed Resident #2 on 1:1 supervision, completed assessments of both residents, asked psychological services to assess both residents, completed an ad hoc QAPI IDT meeting, completed in-services with staff on abuse and behaviors, contacted the police department. She said she trained staff on how to monitor for aggressive behaviors and take appropriate actions before it leads to abuse. She said even with Resident #2's cognitive impairment, it was a willful act at the time of the incident according to the Appendix PP (The State Operations Manual provided by CMS that provides guidance to surveyors for Long Term Care Facilities). The facility took the following action to correct the non-compliance between 1/28/2025 and 4/23/2025: Record review of the Provider Investigation Report dated 2/5/25 revealed facility staff completed a skin, pain and psychological assessment for Resident #1 on 1/29/25. CNA A was suspended on 1/29/25 pending an investigation and terminated on 1/30/25. The police were notified and the facility changed their external access codes. Record review of multiple Resident Interviews dated 1/29/25 revealed facility staff interviewed residents .to determine their awareness of their rights and their experience at the facility. Some residents reported they wre unaware of their reports or knowledge on how to report abuse. They were educated during the interview. All residents reported no knowledge or evidence of abuse. Record review of a facility list of residents titled, 300's Hall Skin Sweep, 1/29/25 revealed skin assessments were completed for residents who resided on the 300 hall. Record review of a facility list of residents titled, 2/3/25 Skin Sweep revealed skin assessments were completed for residents who resided on the 100 hall. The findings indicated that no new or suspicious skin issues were observed. Record review of an email from the Former Administrator dated 1/31/25 revealed the Former Administrator notified the Long-Term Care Ombudsman of the allegation of abuse. Record review of a Resident Council Minutes dated 2/3/25 revealed the Former Administrator discussed the following topics with the residents in attendance: resident rights, identifying the abuse coordinator (Former Administrator) and how to report problems. Record review of In-Services dated 1/29/25-2/3/25 revealed all staff were educated on abuse and neglect identification and abuse and neglect policies and procedures. Staff completed an abuse quiz after completion of the in-service. It was noted that after completion of the quiz, the answers were reviewed with the group and corrections were made following the discussion. Record review of Resident #1's care plan (updated) revealed it was updated on 3/13/25 to reflect that she was physically aggressive toward staff related to poor impulse control and agitation. Interventions included analyzing circumstances, triggers of behavior, assess and address for contributing sensory deficits, assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, give the resident as many choices as possible about care and activities, when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff were to walk away calmly and approach later. Record review of the Provider Investigation Report dated 4/28/25 revealed the allegation of resident-to-resident abuse between Resident #2 and Resident #1 was confirmed. Resident #1 was assessed after the incident on 4/21/25 at 6:30pm by LVN E. The police were notified. Record review of an attachment to the Provider Investigation Report that included a detailed summary of the facility's response (undated) revealed Resident #2 was placed on 1:1 supervision pending a psychology evaluation. The physician ordered labs that indicated Resident #2 had elevated ammonia levels, which could have contributed to Resident #2's behaviors. The psychologist cleared the resident to remove 1;1 supervision. Record review of Behavioral Health Progress Note dated 4/22/25 revealed Resident #1 was assessed by a nurse practitioner. The nurse practitioner noted she was not in distress and did not sustain any injuries. Record review of Inservice Attendance Records dated 4/22/25 revealed staff were educated regarding caring for residents with aggressive behaviors, resident rights and abuse, neglect and exploitation. Record review of Resident #2's care plan revealed it was revised on 4/22/25 to include additional interventions for aggressive behaviors, including administer medications as ordered, analyze times of day, place and circumstances to determine what de-escalates behavior, assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, give positive feedback, give the resident as many choices as possible, place resident on one-to-one monitoring following aggressive behaviors until resident can be assessed by the physician. Observations between 5/13/25 and 5/15/25 revealed interactions between residents were pleasant, with no signs of abuse. Interviews with facility staff between 5/13/25 and 5/15/25, including CNA B, LVN A, LVN B, Unit Manager A, LVN C, LVN E, CNA K, CNA E, CNA S, CNA T and CNA L revealed they were aware of the types of abuse and what to do if they were aware of abuse in the facility. They reported how they would monitor and care for residents with behaviors that may lead to abusive actions. Interviews with facility staff on 5/29/25, including LVN S, Social Worker, CNA B, CNA R, LVN I and CNA O revealed they could state how to intervene when Resident #1 had behaviors that was consistent with her care plan. Observations between 5/13/25 and 5/15/25 revealed interactions between staff and residents were pleasant, with no signs of abuse. Interviews with 15 residents between 5/13/25 and 5/15/25 revealed no reports of abuse. Record review of the facility's Abuse, Neglect and Exploitation policy revised on 1/8/2023 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing writing policies and procedures that prohibit and prevent abuse, neglect .'physical abuse' includes, but is not limited to hitting, slapping, punching, biting and kicking . The facility administrator is the Abuse Prevention Coordinator in the facility and is responsible for reporting allegations or suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state law .the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves . identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of training and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms

Based on observation, interview and record view the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #3, #1) reviewed for abuse and neglect. The facility failed to report a significant injury of unknown origin to HHSC when Resident #3 was found to have scattered bruising of different colors and a fractured arm. The facility failed to report a significant injury of unknown origin to the Former Administrator, who was the abuse coordinator, when Resident #3 was found to have scattered bruising of different colors and a fractured arm. The facility staff failed to immediately report an allegation of abuse to the administrator, who was the abuse coordinator, when CNA A slapped Resident #1 on her left cheek. The facility failed to report an allegation of abuse to HHSC within 2 hours when CNA A slapped Resident #1 on her left cheek. The incident was reported 15 hours after the incident occurred. These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life. Findings included: Resident #3 Record review of Resident #3's admission Record (updated) revealed she was admitted to the facility on [DATE] with diagnoses of dementia, diabetes, osteoarthritis of left knee and other disorders of bone density and structure. She was [AGE] years of age. Record review of Resident #3's Care Plan Report, undated, revealed the following focuses, goals and interventions: - Focus: (Resident #3) had impaired cognitive function and impaired thought processes. Initiated on 5/8/23. Goal: The resident would maintain at current level of cognitive function through the review date. Target date 10/16/24. Interventions: Administer medications as ordered, ask yes/no questions to determine resident's needs, keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. - Focus: (Resident #3) required assistance to perform functional abilities in self-care and mobility. Initiated on 4/30/24. Goal: The resident would maintain their highest practical usual functional ability status in self-care and mobility by next review date. Target date: 10/16/24. Interventions: provide the following self-care assistance- shower/bathe: substantial; upper body dressing: partial; lower body dressing: substantial; transfers: substantial to partial. - Focus: (Resident #3) was at risk for falls. Initiated on 5/8/23. Goal: The resident would not sustain serious injury through the review date. Target date: 10/16/24. Interventions: Anticipate needs, provide prompt assistance with ADLs. Coordinate with appropriate staff to ensure a safe environment. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 0, indicating severe cognitive impairment. She required partial/moderate assistance with bathing and dressing and required supervision for transfers. Record review of Resident #3's Incident/Accident Investigation Worksheet dated 9/27/24 revealed at 9:00pm, Resident #3 had an un-witnessed fall when she was found on the floor in front of the bathroom door. The worksheet was signed by LVN A. Record review of Resident #3's Progress Notes dated 9/28/24, 9/29/24, 9/30/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24 and 10/9/24, revealed resident was observed with no pain and no injuries were reported. Record review of Resident #3's Skin Observation Tool signed by LVN B on 10/2/24 revealed the resident had no skin issues. Record review of Resident #3's SBAR Progress Note dated 10/10/24 at 6:15pm revealed Resident #3 was noted to have scattered yellow, red and purple discoloration to upper right arm. The nurse noted it started on 10/10/24. Moving her arm made the condition worse. The nurse noted, .notified by (CNA A) of scattered yellow, red and purple discoloration to resident's right upper arm that was reported two weeks ago. Nurse manager on duty notified . Record review of Resident #3's Skin Observation Tool signed by ADON A on 10/14/24 revealed a skin assessment was completed on 10/10/24 that showed a scattered yellow, red and purple discoloration to upper right arm. Record review of Resident #3's Final X-ray Report dated 10/11/24 revealed an x-ray result of the right shoulder, elbow and wrist. Findings of the x-ray determined there was an age-indeterminate, obliquely oriented (meaning positioned at a slant or diagonal angle) mildly comminuted (reduced to minute particles or fragments), mildly displaced fracture of surgical neck of humerus (an area of the upper arm). There was a handwritten note on the document that stated, Noted 10/12/24. MD aware. (New order) transfer to (local hospital). Record review of Resident #3's Hospital Patient Visit Information report dated 10/12/24 revealed she was seen for humeral head fracture, acute pain due to trauma and blunt trauma. There was a new order for Gabapentin, a medication for neuropathic pain. Record review of Resident #3's Emergency Provider Report dated 10/12/24 from a local hospital revealed she was seen in the emergency room for concerns about a right upper extremity fracture. Patient has bruising on her right upper extremity for an unknown amount of time and is complaining about pain. The facility is unsure about potential fall. Patient cannot contribute interview because of dementia . Stated complaint: Right shoulder pain since Thursday .CAT Scan .impression . there is significant angulation (meaning the formation of angles) and displacement between the head and shaft fragments. There is also a displaced greater tuberosity fragment (a break in the bony bump on the outside of the upper arm bone). The humeral head is inferiorly subluxed (meaning partially dislocated where the bones in the joint are making contact)/dislocated . In an observation and attempted interview on 5/13/2025, Resident #3 was lying in bed, resting. An attempted interview revealed that she could not answer any type of questions. She spoke with random words strung together in phrases. In a telephone interview on 5/13/2025 at 5:42pm, LVN A said he worked the night in September 2024 when Resident #3 fell. He said he was doing rounds and tried to open Resident #3's door but noticed some resistance. He said he observed Resident #3 sitting on the floor next to the door, in the corner of the door frame. He said he completed a head-to-toe assessment and neurochecks (a physical evaluation completed after a head or neck injury to determine the functioning of the nervous system). He said he asked her to move her extremities and her movement was normal. He stated she had no complaints of pain. In a telephone interview on 5/13/2025 at 6:26pm, LVN T said she remembered when Resident #3 experienced a fall in September 2024. She said she cared for her a few times after the incident, and she did not notice any pain, range of motion issues, or bruising. She said she completed a skin assessment sometime between the fall and the day a bruise was found on her arm. She said she gave Resident #3 a shower, and again stated there was no pain, skin issues or range of motion issues. She said when she heard the bruise was identified, and the CNA reported it was two weeks old, she said that it was definitely incorrect. She said she believed she returned to work on a Friday and saw the bruise. She said the discoloration started right at her shoulder, above her elbow on the back side of her arm and coming over the top part of her arm. She said it was red, burgundy, yellow and green. She said most of the bruise was red/burgundy and the older yellow/green spots were small. She said starting on a Friday, Resident #3 retracted her arm and held it with her other hand to protect it. She said based on her observation, there was no way the injury was 2 weeks old, and it did not seem right. She said she reported her concerns to ADON A. In an interview on 5/13/2025 at 11:22pm, LVN C stated she was working the night Resident #3's bruises were discovered. She said CNA A told her that Resident #3 had a little bruise and it should be going away. She said when she heard that, they both observed the bruise on her arm. She said she observed a large bruise that was on her outer and inner arm, that was purple, red, and green in color. She said some of the bruises were healing. She could not say if they were fresh bruises. She said CNA A asked her to stay and help him change her, because she had become more agitated since the injury occurred. They changed her, then she completed the SBAR assessment and made notifications to the doctor and family member about the injury. She said CNA A told her the injury occurred a few weeks ago, and he reported it someone, but could not remember who. She said CNA A reported the injury occurred when she got stuck in her bed rails. She said in hindsight, there were two items in CNA A's story that were confusing: he reported it was a small bruise, but it was a large bruise that did not appear to be fading; he reported that he notified someone of the injury a few weeks ago but could not remember who he told. She said the next day, she was asked about the injury from upper management, because Resident #3 did not have bed rails. She said she did not think to report the injury to the abuse coordinator, who was the Former Administrator. In an interview on 5/13/2025 at 10:11am, Resident #3's RP said she was unsure how Resident #3 broke her arm. She said she first learned of the injury on a Wednesday. She said when she saw the bruise, it looked like streaks that were red at first. She said she was not aware if the injury was investigated. She said no one witnessed what happened. In an interview on 5/13/2025 at 12:15pm, ADON A stated when Resident #3 fell in September 2024, LVN C did not document any outward injuries. She said when she saw Resident #3 after the fall, she did not notice anything at that time. She said she ambulated with a wheelchair and could propel herself using her feet. She said on 10/10/2024, they discovered the bruising. She said it was a faded bruise that was different colors. She said it was possible for her to have a fall on 9/27/2024 and not show any injuries until 10/10/2024. When asked why she did not report pain prior to 10/12/2024 according to the nurse progress notes, she said it was because they started to manipulate her arm in the hospital and at her orthopedic appointment. She said the DON and Former Administrator investigated the injury. She said no one reported any concerns to her about Resident #3's injury. In a telephone interview on 5/14/25 at 1:28pm, MD A, when asked about Resident #3's broken arm and bruising, she said, I don't think they could conclude what occurred. In a follow-up telephone interview on 5/14/25 at 4:31pm, MD A said there could have been a number of reasons why Resident #3's injury was not identified after the fall for about two weeks. She gave a few examples, including Resident #3's poor cognition and possible high-pain tolerance. When asked if it could have occurred any other way, she said it was hard to say, and was hypothetical. In a telephone interview on 5/14/25 at 1:48pm, CNA A said he was at the facility the night Resident #3 fell in September 2024. He said she fell on her way to the bathroom, and she was confused. He said he thinks the bruising that was on her arm was a result of hitting the door frame. He said when they put her back in bed, there was a little redness on her arm. He said it kept getting worse. He said it was on the top of her elbow covering a 3-4 inch space, on the back and front arm near the bicep area. He said that was all he could remember about Resident #3's fall and injury. In an interview on 5/14/25 at 3:20pm, the DON stated it was her understanding that Resident #3 broke her arm when she fell in September 2024. She said when Resident #3 fell, a resident across the hall saw her fall by the restroom door trying to transfer herself. When asked about LVN A's statement that he felt resistance while trying to open the door, she said that it would not make sense, because then the other resident could not have seen the fall. During the interview, the DON reviewed the records showing the bruising was evident about two weeks after the fall, and the skin assessment on 10/2/25 showed no skin issues. She said Resident #3 did not have another fall before the bruising was visible. When asked if there could be another explanation for the bruising and fracture to her arm, she said her family takes her out occasionally, and she could have bumped her arm on something while ambulating. She said she did not think it could have been a result of abuse. When asked why it was not reported to HHSC, she stated the Administrator would make the determination to report. She further stated that if the cause of an injury was known, then it would not be reported to HHSC. In an interview on 5/14/25 at 4:45pm, the Administrator stated Resident #3's injury identified in October 2024 should have been reported. She said, you report now and investigate after. Resident #1 Record review of Resident #1's undated admission Record revealed she admitted to the facility on [DATE] with diagnoses of colon cancer, hemiplegia (partial paralysis on one side of body), vascular dementia and adjustment disorder with depressed mood. She was [AGE] years of age. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 3, indicating severe cognitive impairment. She was dependent on staff for activities of daily living, including oral hygiene, toileting, bathing, and required substantial/maximum assistance for transfers. Record review of Resident #1's Care Plan Report, undated, revealed the following focuses, goals and interventions: - Focus: (Resident #1) had impaired cognitive function and impaired thought processes. Initiated on 12/6/24. Goal: The resident will maintain at current level of cognitive function through the review date. Target date 3/16/25. Interventions: Administer medications as ordered, ask yes/no questions to determine resident's needs, communicate with the resident regarding resident's capabilities and needs, and identify yourself at each interaction, face the resident when speaking and make eye contact. - Focus: (Resident #1) had unwanted behaviors related to yelling, combative with staff, refuses care, medications and meals and transfers independently without assistance. Initiated on 12/6/24. Goal: The resident will have fewer episodes of behavior by review date. Target date 3/16/25. Interventions: Caregivers to provide opportunity for positive interaction and attention, explain all procedures to the resident before starting, give 1:1 (individualized attention provided by one person to the resident) assistance to try and calm resident down, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, remove from situation and take to alternate location as needed and re-direct resident when combative, explaining this is inappropriate behavior. Record review of Resident #1's Incident/Accident Investigation Worksheet dated 1/29/2025 at 8:45am revealed an incident of abuse occurred. There were no witnesses listed. The pain assessment revealed she complained of a headache, Tylenol (a medication for pain management) was offered but refused. The conclusion/root cause was described as possible physical abuse .recommendations/interventions: Ask (family member) to check camera footage. Record review of an Abuse-Investigation Statement dated 1/29/25 revealed CNA A made the statement: (Resident #1) called asking to be changed around 9:00pm, after letter her know that I was in the middle of my round & that I would be assisting her afterward, (Resident #1) continued to call out. When I changed her/provided pericare, she asked for Tylenol & for the lights to be turned off. Approximately 5 min later (Resident #1) called out again, but she was not making any sense. In a continuance of the statement, CNA A reported that he entered Resident #1's room and asked what was wrong. I placed my hand down near her head on her bed, due to her bed being so low to the ground. (Resident #1) began to start jostling & throwing her head around. She hit her head against my hand. After that she shouted that I hit her & I moved my hand away & walked out of the room . Record review of a provider investigation report dated 2/5/2025 described an allegation of abuse in that CNA A hit Resident #1. A video from the incident shows a timestamp of 1/28/25 at 9:48pm and revealed CNA A hit Resident #1 on her left cheek. The police were notified, and CNA A was terminated on 1/30/25. The resident was assessed with no new injuries noted. An assessment was completed, and Resident #1 complained that her head hurt from the fall. The resident had a fall on 1/26/25 that resulted in a contusion (a bruise) to her right eye/cheek area. The provider investigation report was signed by the Former Administrator. The allegation of abuse was confirmed. Surveyor attempted interviews with Resident #1 on 5/13/25 at 11:11am and 5/14/2025 at 10:50 am with no success as she refused to be interviewed. In an interview with CNA B on 5/14/2025 at 11:34am, she said she was at the facility at the time of the incident. She said CNA A approached her and told her that Resident #1 said he hit her. She looked into Resident #1's room and Resident #1 said, he hit me, he hit me! She said she was terrified, scared, yelling, crying, and asking for help. She said she and CNA A went to the break room to find Resident #1's nurse, then reported what happened. She said LVN C told LVN D to call the administrator rather than send a text message. In an interview on 5/13/2025 at 11:22pm, LVN C stated she was working the night of the incident between CNA A and Resident #1. She said on the night of the incident, CNA B reported to her that CNA A hit Resident #1. She said she approached the nurse who was caring for Resident #1 and shared with her what CNA B said. Then she noticed that the LVN was on her phone making notifications. She said she did not follow-up afterwards. She said she could not remember the other LVN's name. In a telephone interview on 5/15/25 at 9:15am, LVN D said she was assigned to Resident #1 when there was an allegation of abuse. She said she was on a lunch break, and LVN C came in and told her about the abuse allegation between CNA A and Resident #1. She said she assessed Resident #1, then tried to call the Former Administrator and the Former ADON. She said they did not pick up, so she texted them. She said during orientation, she remembered that they told her a text was an appropriate method of communication. In an interview on 5/14/25 at 3:20pm, The DON said she expected staff to contact the Administrator or the DON by phone when there was an allegation of abuse. She said staff should try to call until someone answered the phone. She said the abuse incident between CNA A and Resident #1 should have been reported to HHSC within 2 hours. She said the Administrator became aware of the allegation at about 7:10am the morning of 1/29/25, and the incident was not reported to HHSC until 12:45pm on 1/29/25, which was more than a 2-hour time difference. In a telephone interview on 5/15/25 at 10:23am, the Former Administrator, when asked about the notification she received from nursing staff about an allegation of abuse involving CNA A and Resident #1, she said it was super delayed. She said she received a text early in the morning the day after the incident occurred, but it did not have any context. She said she visited with Resident #1 who could not remember the incident, then called Resident #1's family member to ask her to view the camera footage. She said once Resident #1's family member confirmed that CNA A hit Resident #1, she called the police and HHSC. Record review of a Quality Assurance and Performance Improvement Committee Monthly Meeting Minutes dated 1/30/25 revealed the facility department heads met to discuss communication failure on allegation of abuse on 1/28/25. Facility made aware of allegation of abuse in untimely fashion. Nurse failed to call Admin or any other management to notify of abuse allegation . Record review of the facility's Abuse, Neglect and Exploitation policy revised on 1/8/2023 read in part, .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown origin source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility . Immediately is defined as: within two hours of an allegation involving abuse or result of serious bodily injury .

Based on observation, interview, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities which involved 2 of 6 residents (Residents #22 and #68) and 2 of 6 staff (MA V and LVN B) reviewed for medication administration. MA V crushed and administered Klor Con ER (an extended-release medication used to prevent or treat low blood levels of potassium) to Resident #22 on 5/14/25. Extended-Release formulations should not be crushed. LVN B administered the wrong Multivitamin to Resident #68 on 5/14/25 according to Physician orders. These failures could place residents at risk of incomplete therapeutic outcomes, increased side effects, or decline in health. Findings included: 1. Record review of Resident #22's face sheet dated 5/15/25 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), atrial fibrillation (irregular heart rhythm), hypokalemia (low potassium), and hypertension (high blood pressure). Record review of Resident #22's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #22's care plan revealed the resident had nutritional or potential nutritional problem related to dysphagia (difficulty swallowing), therapeutic diet, obesity, and hypokalemia. Interventions were to administer medications as ordered, date initiated 6/25/24. Record review of Resident #22's Physician orders for May 2025 revealed orders for: Potassium Chloride ER give 1 tablet by mouth in the morning for supplement related to hypokalemia. Dissolve with small amount of water or juice then mix with pudding, order date 3/14/25. Crush medications prior to administration and mix with a palatable substance, order date 3/14/25. In an observation on 5/14/25 at 8:47 a.m., MA V prepared Resident #22's medication for administration. She retrieved Klor-Con ER 20 mEq from the medication cart. MA V crushed the Klor-Con ER along with the other medications, mixed it with pudding and administered it to Resident #22. In an interview on 5/14/25 at 8:57 a.m., MA V said she crushed the potassium chloride but could not crush any enteric coated medication or potassium chloride. She then said Potassium chloride could be crushed. She said there was a list of medications that could not be crushed in a binder for reference. MA V retrieved the list and said Potassium chloride was listed on the sheet and could not be crushed. She said Potassium Chloride ER was long acting and it would not be the same if it were crushed. In an interview on 5/15/25 at 10:47 a.m. the DON said Potassium Chloride ER should be dissolved in water and not crushed because it would get into the system faster which could affect the heart rhythm and muscle function. She said if the order did not correlate, staff should stop and notify the nurse and MD for a medication change. Record review of Meds That Should Not Be Crushed dated 4/2025 and provided by the facility revealed Potassium Chloride Klor-Con tablet was listed due to modified-release. 2. Record review of Resident #68's face sheet dated 5/15/25 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included cerebral infarction, nutritional deficiency, and gastrostomy status (presence of an artificial opening to the stomach). Record review of Resident #68's discharge-return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She required assistance from staff with ADL care. Record review of Resident #68's care plan revealed she had a nutritional problem or potential nutritional problem. Interventions were to administer medications as ordered, date initiated 2/5/24. Record review of Resident #68's Physician orders for May 2025 revealed an order for Multivitamin tablet give 1 tablet enterally one time a day related to nutritional deficiency, order date 4/13/25. In an observation on 5/14/25 at 9:04 a.m., LVN B prepared Resident #68's medication for administration via g-tube. She prepared multivitamin with minerals (instead of without minerals), along with eight additional medications and administered them to Resident #68. In an interview on 5/14/25 at 9:35 a.m. LVN B said the medication listed on the eMAR was Multivitamin (without minerals), but she would clarify the order with the MD. In an observation and interview on 5/14/25 at 9:42 a.m. of the medication room revealed Multivitamin (without minerals) was available. LVN B said the multivitamin without minerals might not be crushable but she would clarify Resident #68's order with the MD. In an interview on 5/15/25 at 10:47 a.m. the DON said she expected nursing staff to follow the MD order. She said Multivitamin and Multivitamin with minerals were two different medications. She said the MD would specify if the order should contain minerals depending on different factors like lab work. She said staff should look at each individual medication one at a time to ensure the bottle, blister pack, and dosage are correct. She said the Consultant Pharmacist came once a month and walked with nursing staff to ensure they were administering medications appropriately. She said medication administration skills were checked annually and on hire. In an interview on 5/15/25 at 12:58 p.m. the Administrator said nursing staff should follow the physician orders and the 7 rights of medication administration. Record review of the facility's Medication Administration policy reviewed/revised 1/2025 read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation .17. Administer medication as ordered in accordance with manufacturer specifications .c. Crush medications as ordered. Do not crush medications with do not crush instructions.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #68) reviewed for infection control. -LVN B did not wear appropriate PPE when administering medication via peg-tube (PEG tubes allow you to receive nutrition through your stomach) to Resident #68 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 5/14/25. This failure could place residents at risk of infection. Findings included: Record review of Resident #68's face sheet dated 5/15/25 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included cerebral infarction, nutritional deficiency, and gastrostomy status (presence of an artificial opening to the stomach). Record review of Resident #68's discharge-return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She had a feeding tube and required assistance from staff with ADL care. Record review of Resident #68's Physician orders for May 2025 revealed an order for Multivitamin tablet give 1 tablet enterally one time a day related to nutritional deficiency, order date 4/13/25. Record review of Resident #68's care plan revealed she required enhanced barrier precautions to reduce risk of MDRO transmission. She was at risk for infection due to current use of indwelling device, g-tube. Interventions were to maintain EBP - staff to use gown and gloves during high contact care activities, date initiated 4/17/24. In an observation on 5/14/25 at 9:04 a.m. there was an orange sign on Resident #68's door that read, STOP Enhanced Barrier Precautions, everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and gown for the following high contact resident care activities . device care or use . feeding tube .' There was PPE in a cart in front of the door. LVN B prepared Resident #68's medication for administration via g-tube. She donned (put on) gloves but did not don a gown. She entered Resident #68's room and administered the medication to her via g-tube. In an interview on 5/14/25 at 9:34 a.m. LVN B said she wore gloves but forgot to put on the gown when she administered Resident #68's medication via g-tube. She said the sign on the doorway notified staff that the resident was on enhanced barrier precautions due to an open orifice such as a g-tube, wound or IV. She said the purpose of wearing a gown when caring for residents with g-tubes was to prevent any type of fluid exchange. In an interview on 5/15/25 at 10:57 a.m. the DON said residents on enhanced barrier precautions were immune compromised. She said enhanced barrier precautions policies and protocol were for staff to have on a gown and gloves during personal high contact activities such as medication administration through g-tube, wound care, dressing changes, and showers. She said there could be a risk of giving the resident an infection if the proper PPE was not worn. She said the orange sign on the doorway indicated for staff to wear gown and gloves. In an interview on 5/15/25 at 12:58 p.m. the Administrator said she expected staff to adhere to the CDC guidance and wear appropriate precautions which included a gown and gloves. Record review of the facility's Enhanced Barrier Precautions policy reviewed/revised April 2024 read in part, . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . 4. High-contact resident care activities include a. Dressing, b. Bathing, c. Transferring d. Providing hygiene e. Changing briefs or assisting with toileting, f. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, g. Wound care . Record review of the facility's Infection Prevention and Control Program reviewed/revised 1/2024 read in part, .This facility has established and maintains 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 as per accepted national standards and guidelines .

Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 13 residents (Resident #1) reviewed for abuse. CNA A was verbally abusive to Resident #1 on 04/23/2024 after he used a racial slur (derogatory terms or phrases used to insult, demean, or dehumanize individuals or groups based on their race or ethnicity). This failure placed residents at risk of experiencing anger, depression, and anxiety during staff encounters. Findings included: Record review of Resident #1's face sheet dated 05/08/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with psychotic disturbance (a state where an individual experiences a significant loss of contact with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior), anxiety (excessive worry about future events or fear of present or past events), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), history of urinary tract infection (an infection that affects any part of urinary system), insomnia due to other mental disorder (a significant lack of sleep related to mental disorders), essential hypertension (a chronic condition of persistently high blood pressure with no identifiable cause), cerebral infarction (an ischemic stroke which occurs when blood flow to the brain is blocked), and history of transient ischemic attack (a brief stroke-like attack that despite resolving within minutes to hours, still requires immediate medical attention). Record review of Resident #1's annual MDS dated [DATE] revealed he had a BIMS score of 14 (cognitively intact); Resident #1 did not exhibit symptoms related to hallucinations, delusions, physical or verbal symptoms directed towards others, or rejection of care; Resident #1 was independently ambulatory; Resident #1 was independent with eating, toilet hygiene, dressing, personal hygiene and required supervision or touching assistance with shoers/baths; Resident #1 was occasionally incontinent of bladder and always continent of bowel; and Resident #1 was not prescribed antipsychotic, antianxiety, or antidepressant drugs. Record review of Resident #1's care plan revised 03/17/2025 revealed the following care areas: * [Resident #1] has impaired cognitive function and impaired thought processes related to dementia, short/long-term memory issues, and impaired decision making. Goal included: The resident's needs will be met, and dignity will be maintained. Interventions included: Ask yes/no questions in order to determine the resident's needs. Cue, reorient, and supervise as needed. Engage the resident in simple, structured activities that avoid overly demanding tasks. Keep the resident's routine consistent and try to provide consistent care givers as much as possible on order to decrease confusion. Present just one thought, idea, question, or command at a time. * [Resident #1] has communication problems, at times does not understand English (Spanish speaking) and is slightly hard of hearing. Goal included: The resident will be able to make basic needs known on a daily basis. Interventions included: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. * [Resident #1] is resistive to care related to: refuses showers at times, refuses medications at times. Goal included: [Resident #1] will be encouraged to cooperate with care. Interventions included: Allow [Resident #1] to make decisions about treatment regime to provide sense of control. Educate resident/family/caregivers of the possible outcomes of not complying with treatment or care. Give clear explanation of all care activities prior to and as they occur during each contact. If the resident resists with ADLs, reassure resident, leave, and return 5-10 minutes later and try again. Provide resident with opportunities for choice during care provision. * [Resident #1] has unwanted behaviors. Resident reported to have sexually and aggressive behaviors. Goal included: Behavior episodes will be reduced to less than daily. Interventions included: Give 1:1 assistance to try and calm the resident down, as needed. * [Resident #1] has a camera in room that may or may not have sound per family request. Goal included: Family and resident choice to have a camera in the room will be respected. Interventions included: Do not be intimidated by the camera. Continue to provide good care as you always do. Do not judge the family or resident for their action. Provide dignity and respect to all we care for. Voice all concerns to the appropriate staff member such as the DON or Administrator. Record review of Resident #1's nursing progress notes for April 2024 revealed: * On 04/23/2024 at 7:15 a.m. the Former DON wrote, SBAR - Situation . Resident having some inappropriate behaviors and using vulgar slurs toward staff on this shift. This started on 04/23/2024 . RN thinks the problem may be resident appears to have some agitation with staff that could be related to his dementia or possible UTI . Upon re-entering the hallway, this nurse witnessed resident's family member and staff conversing loudly. This nurse and the housekeeping supervisor escorted family member into resident's room to deescalate the situation . * On 04/24/2024 at 6:26 p.m., LVN B wrote, Resident returned to the facility with family . Family noted taking resident to the hospital on [DATE], stating, 'His back was hurting him, and he was flushed, they said he had a UTI.' Writer received paperwork from the hospital visit. Cephalexin (an antibiotic) 500MG 1 capsule PO q6 hours x 9 days for UTI . Record review of the facility's, Provider Investigation Report dated 04/26/2024 revealed the investigation was signed and dated by the Former Administrator on 04/26/2024. The document read in part, . Date Reported to HHSC: 04/23/2024 . Incident Date: 04/23/2024. Time: approximately 7:30 a.m. Witnesses: Reviewed camera footage. Family member showed [Former] DON footage. Description of the Allegation: Verbal aggression toward resident. Injury/Adverse effect: No. Description of Assessment: Head to toe assessment completed, no injuries noted, no emotional distress noted . Investigation Summary: Family member notified facility [Former] DON that [CNA A] was verbally aggressive with resident. Facility ensured CNA and resident remained separated. Police notified of incident by family member, found no offense that they could act upon and stated that it needed to be handled internally between facility/family. When facility management approached CNA for interview/statement, she refused and left the facility, self-terminating. CNAs reported to nurse that resident was being verbally aggressive on multiple occasions that day and that he was calling them racial slurs. Family member allowed [Former] DON to review camera footage, and [Former] DON determined that [CNA A] was confrontational and verbally aggressive. Family member and [Former] DON agreed that no physical harm occurred, and the resident was not showing signs of emotional distress, but the CNA response was inappropriate. Upon investigation and a review of Provider Letter 19-17, this incident does not rise to the criterion of abuse as there was no resulting physical or emotional harm or pain to this resident. Facility has elected that this allegation is unfounded. Facility determined CNA response was inappropriate and she is no longer in the facility as she self-terminated prior to facility full executing the investigation. Provider Action Taken Post-Investigation: In-serviced staff on resident's rights. In-serviced staff on abuse and neglect prohibition and reporting. Life Satisfaction surveys completed with residents on same hall as [Resident #1], no issues or concerns reported. Further review of the document revealed all staff were in-serviced on, Customer service/Dementia Residents/Behaviors - 04/23/2024, and Resident's Rights - 04/23/2024, Abuse/Neglect/Exploitation - 04/23/2024 and residents on the 200 hall were interviewed regarding abuse. Record review of, [Resident #1] Incident Statement, completed by the Former DON on 04/23/2024 revealed: * 8:15 a.m., arrived to facility, officers and family in front of the facility. Officers stated after review of video, no chargeable offense and left family member with information on reporting incident internally. * Family member showed [Former] DON the video recorded approximately 6:45 a.m., aid in room standing by head of bed, shaking finger at resident, when aid exited room, she is heard stating 'Stay in the dark.' And she proceeds to turn out the lights in the resident's room. Aid returns to room and is heard telling resident, 'Better get up and go to the dining room cause I ain't bringing you breakfast (this was not observed or heard on the video provided).' Aid also heard telling resident she was going to take away his refrigerator . * CNA immediately removed from assignment and assisted to HR office to get written and verbal statement, aid refused to write a statement or give details of events. When explained she would be placed on suspension pending investigation, aid stated she was done and escorted out of facility . * Resident returned from pass with family member, no acute distress or signs of anxiety, emotional distress noted. Will continue observation/monitoring x 72 hours for any changes in condition . Record review of CNA A's personnel record revealed she was hired by the facility on 12/27/2023 and terminated on 04/23/2024. A criminal background check and Nurse Aide Registry search were completed on 12/21/2023. CNA A signed an Abuse/Neglect Policy and Procedure Competency Tool on 12/27/2023. CNA A was most recently in-serviced on Abuse, Neglect, and Exploitation and Safeguarding Resident Rights in Nursing Facilities on 03/04/2024. Observation and interview with Resident #1 on 05/08/2025 at 10:40 a.m. revealed he was alert, oriented, and laying in his bed. There was a camera on the wall facing Resident #1's bed. Resident #1 stated he lived in the facility about two years and the staff treated him well. He said one lady who worked at the facility was mean to him before when she tried to fight with him. He said the lady was a little crazy when he called her a nigger. He said nothing happened before the incident and the lady talked too strong to him. He said it did not feel good when she talked to him that way, but it did not make him sad or angry. He said he did not feel good about the incident, but he could not recall what the lady said, and he did not think what she said was abusive. He said before the incident, the lady had worked with him a lot and she was ok with him before that. He said the lady did not work at the facility anymore. Observation of a video taken inside of Resident #1's room dated 04/23/2024 and time stamped 6:56:38 a.m. revealed the camera faced Resident #1's bed. At the start of the video, CNA A and CNA C were standing a distance away from Resident #1 (he was sitting on the bed) while he waved his right hand in the air and repeated, Get out of here! Both staff walked closer towards Resident #1 and CNA A pointed her finger within approximately one foot of Resident #1's face and said, What you think you is? Resident #1 continued to repeat, Get out of here! CNA C stood towards the foot of Resident #1's bed. CNA A stood within approximately three feet on the side of Resident #1's bed and said, You know you almost my color? CNA C said to CNA A, Let's go. Resident #1 continued to say, Get out of here! CNA A (speaking to CNA C, who had already walked closer towards the door) said, We ought to take that ice box (refrigerator) right back out there on that hall. CNA A pointed towards an area below the camera's view (presumably where Resident #1's refrigerator was). CNA A walked closer towards Resident #1, within approximately two feet and said, Your mama a nigger! CNA A repeated the statement and Resident #1 called her a monkey. As both staff walked towards the door, CNA A said, You heard him say monkey, right? CNA A turned the lights off in Resident #1's room and said, Stay in the dark! Before CNA A closed the door all the way, Resident #1 said expletive words (curse words). In a telephone interview with Resident #1's family member on 05/08/2025 at 9:40 a.m., she stated on 04/23/2024, as she was on her way to work, she was alerted by a notification from the motion-operated camera in Resident #1's room that there was a commotion going on. She said the facility's staff woke Resident #1 up early that morning and he was already in a bad mood. She said Resident #1 asked the staff to leave him alone and leave the room several times, but they bullied and made fun of him. She said Resident #1 got angry and called the staff the n word. She said one of the staff (CNA A) got in Resident #1's face like she was about to hit him. She said she went to the facility and was not going to leave until the staff (CNA A) was fired. She said she told the staff (CNA A) that was the first and last time she would treat Resident #1 like that. She said she called the police but since the staff never hit Resident #1, the police said they could only make a report. She said she told Resident #1 he said something ugly to the staff, but they (facility staff) should be trained and used to being called names. In an interview with the Administrator and the DON on 05/08/2025 at 1:15 p.m., after reviewing the video, the DON stated CNA A's behavior was very inappropriate. The Administrator stated CNA A was manipulative and verbally abusive because of how she spoke to Resident #1 and walked up to him, pointing in his face. The DON stated she wondered what Resident #1 said and what happened in the few seconds before the start of the video. The Administrator stated CNA A and CNA C no longer worked at the facility, but she provided CNA C's name and phone number. The DON stated verbal abuse could result in the resident withdrawing socially and agitation during staff interactions. An attempt was made to contact CNA A by phone on 05/08/2025 at 1:36 p.m. A voicemail message was left, but the call was never returned. In a telephone interview with CNA C on 05/08/2025 at 1:38 p.m., she stated she stopped working at the facility in December 2024. She stated around 04/23/2024, Resident #1 was temporarily moved to the hall she normally worked because he had some issues with his roommate on his regular hall. She said on 04/23/2024, before breakfast, she and CNA A went into Resident #1's room to wake him and let him know breakfast was coming. She said Resident #1 was instantly aggravated and said, Get out, I don't want any niggers in here. She said they tried to calm Resident #1 down. She said she did not pay attention to what CNA A and Resident #1 were saying to each other because she was making sure Resident #1 did not get up and hit them. She said things happened so fast and Resident #1 had a history of hitting staff. She said she recalled Resident #1 saying get out, no niggers, and she turned around and said that was fine to [Resident #1]. She said nobody cursed Resident #1 out. She said she told the Former DON that she did not recall CNA A saying anything to Resident #1 that was threatening or disrespectful. She said the Former DON told her CNA A did say some threatening and disrespectful things. She said either before or after breakfast that day, Resident #1's family member arrived at the facility with a lot of other family members. She said Resident #1's family members said things happened that actually did not happen, and the family member said they should be used to being called niggers. She said after that incident, she did not work with Resident #1, but he was fine. An attempt was made to contact the Former DON by phone on 05/08/2025 at 2:00 p.m. A voicemail message was left, but the call was never returned. In a telephone interview with Resident #1's NP on 05/08/2025 at 2:28 p.m., he stated he recalled being contacted in 2024 about a confrontation Resident #1 had with staff. He said he could not recall the exact date, but Resident #1 was agitated, so he ordered labs and found Resident #1 had a UTI. He said he visited Resident #1 the next week and he did not verbalize any concerns. He said Resident #1 was forgetful and did not have any negative outcomes. He said no harm was done because of the incident. In a telephone interview with the Former Administrator on 05/09/2025 at 11:11 a.m., she stated her husband was in the hospital when the incident happened between Resident #1 and CNA occurred in 2024, so the Former DON handled the investigation. She stated she never saw the video of the incident, but Resident #1's family said the aide was too aggressive when he called her the n word. She said the family member told the staff they were an n word, and they should be used to that. She said all the information she received was second-hand because she was not there at that time. She said there were two staff in Resident #1's room, but she recalled one of them, CNA A, walked out and quit the day of the incident. In an interview with the Housekeeping Supervisor on 05/09/2025 at 12:27 p.m., he stated he did not see the incident between Resident #1 and the facility staff on 04/23/2024. He said he was outside that day and heard Resident #1's family member going crazy, yelling, and screaming. He said he tried to calm the family member down. He said the family member showed him the video of the staff inside Resident #1's room, but he could not recall what was said in the video. In an interview with the Administrator and RN D on 05/09/2025 at 2:15 p.m., after reviewing the video of the incident between Resident #1 and CNA A, RN D stated what CNA A did was abusive. RN D said all the facility's staff had been trained to handle aggressive residents. The Administrator stated if the incident occurred while she was the administrator, she would have removed/suspended the staff pending the investigation, assessed the resident, conducted life satisfaction rounds with all residents on the hall, completed a thorough investigation, asked all witnesses to write statements, in-serviced all staff, and initiated disciplinary action against all staff involved. Record review of the facility's policy, titled, Resident Rights revised 01/2025 revealed, . 1. Exercise of rights . a. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights . 4. Respect and dignity. The resident has the right to be treated with respect and dignity . 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part . 8. Safe environment. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . Record review of the facility's policy, titled, Abuse, Neglect, and Exploitation revised on 01/08/2023 revealed, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Definitions: . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 'Verbal Abuse' means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . 'Mental Abuse' includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident . Record review of the facility's policy, titled, Conduct and Behavior revised 02/2023 revealed, Policy: All employees must adhere to accepted professional standards. This includes displaying business conduct and behavior and exhibiting a high degree of integrity at all times. 1. Conduct that interferes with the safe operation of the facility, brings discredit to the company, residents, or staff, or that is offensive to a resident, family member, visitor, or employee, will not be tolerated and can be grounds for disciplinary action. 2. Examples of conduct and behavior that are considered inappropriate and are prohibited by this company include, but are not limited to, the following: a. Violation of the Resident Abuse or Neglect and/or Residents' Rights policies . d. Failure to treat all residents, visitors, and fellow employees with kindness, respect, and dignity; . h. Using profanity, abusive, or suggestive language or gestures or any other unprofessional behavior; . n. Fighting, threats, intimidation, or argumentative behavior .

Based on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six of 9 residents (Resident #31, #66, #90, #37, #72 and #11) reviewed for pressure sores. -The facility failed to ensure Resident #31 received wound care treatment for 38 days, did not evaluate, and obtain orders for wound care upon admission when the resident was noted to have an open wound to the buttocks. The right heel had a pressure ulcer that was not identified for further preventative treatment by the discharging hospital, and deteriated after admission - this wound was unavoidable per Wound Care MD. -The facility failed to ensure Residents #66's re-opened sacrum ulcer, #90's stage 4 ulcer to the foot, #37's stage 3 (full thickness tissue loss, open area) sacrum ulcer, #72's DTI (pressure ulcer as a [NAME] area with intack skin) to the left heel, and #11's DTI to the left heel were assessed, monitored, and treated. An Immediate Jeopardy (IJ) situation was identified on 03/01/2024 at 3:00 PM. While the IJ was removed on 03/06/2024 at 3:25 PM, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a delay in treatment, pain, a decline in health, hospitalization or a significant decline in health. Findings include: Resident #31 Record review of Resident #31's face sheet, dated 2/29/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hypertension (elevated blood pressure), malnutrition (condition that results from lack of sufficient nutrients in the body), dementia (group of symptoms that affects memory, thinking and interferes with daily life), thyroid disease (a medical condition that keeps the thyroid from making the right amount of hormones), need for assistance with personal care, sepsis (infection of the blood stream), obesity (condition characterized by abnormal or excessive fat accumulation) due to excess calories, Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), chronic kidney disease stage 3 (condition characterized by a gradual loss of kidney function) and osteoarthritis (long term degenerative joint condition). Record review of Resident #31's admission MDS, dated [DATE], with an ARD of 1/24/2024, reflected a BIMS score of 5, which indicated significant cognitive impairment. She had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Resident #31 required assistance or was totally dependent on staff for all ADL's except eating. She was always incontinent of bowel and bladder. Section M of the MDS revealed she had no pressure injuries but was at risk of developing pressure injuries. She utilized a pressure reducing device for her bed and received application of ointments and/or medications other than to feet. Resident #31 was administered anticoagulant, antiplatelet, and hypoglycemic medications during the assessment period. She received OT, PT and ST services. Record review of Resident #31's care plan, dated 1/29/2024, reflected a focus on her ADL self-care deficit with interventions which included OT, PT, and ST services as ordered, use of task segmentation, assistance with PODUS boots to both lower extremities, and assistance with all ADL's except eating. The note related to the PODUS (soft boot to relieve heel pressure) boots to BLE as tolerated for elevating the heels, was added on 2/29/2024. A focus on her incontinence with interventions which included assisting with dressing and hygiene during the toileting process, frequent checking for incontinence care and perineal care, use of a barrier cream and weekly skin check with showers and PRN. The resident was at risk for skin breakdown r/t decreased mobility, incontinent care and diabetes. The interventions included assist with turning and repositioning during rounds as needed and notify MD for ulcers that are deteriorating as needed. A focus on Resident #31's unstageable pressure injury (severe damage of the heel) of the right heel with interventions which included a dietary consultation, monitoring for signs of infection, use of a nutritional supplement, treatment and wound care per physician's orders, and turning and repositioning every two hours. The focus on Resident #31's heel injury was dated 2/28/2024. A focus on her type 2 diabetes mellitus with interventions which included medication administration and monitoring for skin changes. Focus: The resident was at risk for pain and discomfort r/t generalized discomfort, diabetes and osteoarthritis. The interventions included administer pain medication as ordered. The focus did not include pain associated with pressure ulcers. Focus: The resident was diabetic and at risk for pressure/venous/stasis ulcers. The interventions included monitor skin for changes-redness, circulatory problems, breakdown and report to MD/RP. Focus: the resident had impaired immunity r/t recent osteomyelitis, history of COVID-19, sepsis and flu. The interventions included the resident was at risk for infection and keep environment clean. Further review of the care plan did not include resident refusal of care or refusal of repositioning. Record review of Resident #31 2023 TAR revealed an order for weekly skin assessments every Saturday day shift. The skin assessments were completed on 2/3/2024, 2/10/2024, 2/17/2024, and 2/24/2024. Resident #31 received an order related to an unstageable DTI of the right heel, and the heel was to be cleansed with normal saline, patted dry, have betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. The order was written on 2/26/2024 An order for Resident #31 had an unstageable DTI of the right heel to be cleansed with saline, patted dry, betadine applied, and covered with an antibacterial pad and a Kerlix gauze roll written on 2/29/2024. Record review of resident #31's nurses notes dated 1/17/2024 at 7:23 PM, written by LVN EE, reflected the resident had an open wound to the right buttocks region, the size pencil eraser and an opening to the right heel. The note read in part .MD was notified with orders verified. Record review of Resident #31's baseline care plan, dated 01/18/2024, indicated the resident had no wounds. Record review of Resident #31's skin observation tool, dated 1/25/2024, written by LVN C, indicated the skin was intact and no new issues noted. Record review of Resident #31's skin observation tool, dated 2/14/2024, written by LVN HH, indicated there were no new skin issues noted. Record review of Resident #31's skin observation tool, dated 2/21/2024, written by LVN HH, indicated the skin was intact and no new skin issues were noted. Record review of Resident #31's skin observation tool, dated 2/26/2024, written by the TN indicated the right heel had unstageable DTI measuring 8cm x 7cm and the RP and MD were aware of the current treatment plan. Record review of Resident #31's notes revealed a clinically unavoidable skin condition pressure ulcer to the right heel, dated 2/28/2024, and signed by TN, and the physician. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/26/2024, related to an unstageable DTI of the right heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/29/2024, related to an unstageable DTI of the left heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll Record review of Resident #31's initial wound evaluation and management summary reflected the resident was seen by the WCD on 3/1/2024. The resident had arterial wounds of the right and left heel. Interview on 2/28/2024 at 9:10 AM, the TN said she was first notified of Resident #31's right heel wound on 2/26/2024 and that was when wound care treatment began. During wound care observation and interview on 2/29/2024 at 11:00 AM, Resident #31 had soft boots to both feet and both feet were propped with pillows. The TN removed the boots. The right heel had a dressing wrapped with gauze. The TN removed the dressing. The heel had thick, dark, black, dry scab, approximately 2-3 inches in length covering the entire right heel. When the betadine-soaked dressing was removed there was a foul odor. There was no drainage noted. The surrounding skin was pink with large patches of dry flaky skin. The TN completed wound care to the right heel. The resident winced during wound care. The TN re-applied the soft boots and did not inspect the left heel until the State Surveyor questioned the discoloration to the outer edge of the left heel. The left heel had thick dry flaky skin and large dark purple areas. The skin to the left heel was intact. Resident #31 said she did not like to be turned d/t fear of falling and the staff would turn her slightly as much as she could tolerate then she stayed in the same position on her back most of the time. The TN said the left heel was clear on 2/26/24 and on 2/28/24. The TN stated Resident #31 was up in the wheelchair yesterday (2/28/2024) which could contribute to the discoloration. The TN said the pressure ulcer would have happened d/t not repositioning and offloading the feet. The TN said she would notify the MD to get a doppler study (non-invasive test to measure blood flow). The TN said the wound could develop rapidly for diabetic residents' d/t poor blood flow. Observation on 3/4/2024 at 10:57 AM revealed Resident #31 was admitted to a local hospital and was receiving care. Interview on 2/29/2024 at 12:15 PM, LVN HH said she only recently learned of Resident #31's wounds and when she did the skin assessment on 2/21/2024 there were no skin wounds. LVN HH assumed the wounds to Resident #31 were not new and the treatment nurse was taking care of it. Attempted interview on 2/29/2024 at 12:35 PM with Resident #31's RP was unsuccessful. No call back was received by the end of the Survey. Interview on 03/01/2024 at 9:53 AM, CNA L said she was aware Resident #31 would be receiving wound care on 2/29/2024 so she left her in bed and the resident had skin irritation to the buttocks d/t runny stools. CNA L said she applied skin barrier to the redness on the buttocks but there were no open wounds. CNA L said she rounded on Resident #31 by 10:30 AM on 2/29/24 and the resident was sitting up in bed on her bottom, she then changed her brief and left her sitting up in bed with a wedge under the left arm. CNA said after lunch she changed her brief and sat her back up on her bottom in bed. CNA L said the reason for repositioning was to prevent bedsores and stiffness would be a risk to the resident. CNA L said the resident refused repositioning off her back. Interview on 03/01/2024 at 12:35 PM, the WCD said this was the first time he had been to the facility to see any of the residents. The WCD said eschar (a collection of dry, dead tissue within a wound, commonly seen with pressure ulcers) could develop in 24 hours depending on the resident's status. The WCD said it first began as an open wound, then drainage occurred, then slough (yellow tissue) and scarred over just like a regular cut would scab over. The WCD said Resident #31's whole foot was in jeopardy and it might be an arterial injury d/t her pain and was more of a circulatory type of wound. The WCD said failure to reposition the resident may not have contributed to the wound development. The WCD said she may need to go to the ER and he would be speaking with the NP. The WCD said it would be hard to say how fast the wound could get worse and once an arterial wound clotted it could be rapid. The WCD said the left foot was also in jeopardy. Interview on 03/01/24 at 2:30 PM, LVN C said he may have assessed Resident #31's skin when she first admitted but could not recall what the skin looked like. LVN C said he worked regularly on the 100 Hall and Resident #31 lived in the 200 Hall. LVN C said when he performed skin assessments, he would first ask the CNAs on shower days if a resident had any changes to the skin. He said he would follow up after the shower and conduct a head-to-toe assessment. He said he looked at the back of the head, back of the body, stomach, under female breasts, groin, legs, checked toes and heels. LVN C said it was important to catch skin changes early, unfortunately changes could be missed and when that happened the facility would be proactive and address appropriately. LVN C said it was good to have extra eyes on any changes and communication was important. In a telephone interview on 03/05/24 at 1:00 PM, LVN EE saidshe was the admitting nurse and did not notify the MD of Resident #31's open wound to the buttocks and open wound to the right heel. LVN EE said normally she would make a note of it and report to Tx nurse, but it was on the 24-hour report. LVN EE said she thought the wound care nurse would see the 24-hour report and would follow up with all new Admissions and their wounds. LVN EE said she communicated the report to the oncoming shift but could not remember who the report was given to. LVN EE said she probably should have verified her observations of the wounds with another nurse d/t she cannot stage wounds. Interview on 3/4/2024 at 11:09 AM the Hospital RN P said Resident #31 was admitted to the hospital for a pressure injury of the right heel skin. Hospital RN P stated Resident #31 received wound care, had blood labs drawn, was receiving electrolyte replacement therapy and the nephrology department was consulted d/t the resident's low potassium levels. Hospital RN P said the podiatry department reported the resident would need surgical care of the pressure wound. Hospital RN P said the pressure wound to the right heel was unstageable as it was covered with necrotic (dead) tissue. Hospital RN P said Resident #31 had a small sacral pressure wound as well. Hospital RN P said the heel wound could have occurred quickly if it was due to arterial injury, but in her opinion the injury was likely present for between one and two months if there was no arterial injury. Hospital RN P said Resident #31's heel wound did not have any infection which would lead to an amputation, but lab results were still pending. Hospital RN P said if the labs indicated a serious infection it could lead to an amputation of the foot. Interview on 03/05/2024 at 1:23 PM, the TN said the 24-hour report was not too familiar with it and was not something she reviewed daily. The TN said new admits were discussed with her during daily nurse meetings and when stop and watch tools (an early warning communication tool) were used for change in condition. The TN said if she was in the building, she would do the skin assessments for the new admits and if the skin assessments were already completed, she would trust the nurse would tell her if there were any areas of concern. The TN ssaid during evening admits the charge nurse would do the skin assessments. The TN said on 2/26/2024 the Agency Nurse notified her of Resident #31's right heel, she did not remember the name of the nurse. The TN stated the resident's left heel was pink and soft and she conducted a focused assessment on the heels only. The TN said no one notified her of any skin issues to the sacral or buttocks. The TN stated, had she been notified upon Resident #31's admission of the skin issues to the right heel she would have assessed it, notified the MD and RP then put a treatment plan in place. The TN said if there were skin issues the nursing staff should have made her aware. The TN said ultimately, she was responsible to address the wounds. Interview on 03/05/2024 at 3:00 PM, the DON said she was not the DON when Resident #31 was admitted on [DATE] and therefore was not aware of the wounds if they were on the 24-hour report. The DON said the 24-hour report would be reviewed during morning meetings and admissions, readmissions and discharges would be reviewed. The DON said she began as acting DON on 01/18/2024 and was in and out of the building periodically. The DON said when a wound was identified she expected the nurse would call the doctor, document, notify the treatment nurse and the RP. The DON expected it would be written on the 24-hour report and reviewed by the treatment nurse. The DON said she probably did attend the morning meeting but did not recall hearing about Resident #31's wounds. The DON said the expectation would be to address the wounds at the time of the meeting and if the nurse was unsure of the presentation of the skin that another nurse would be consulted. Interview on 03/06/2024 at 11:10 AM, the MD said she was notified of Resident #31's wounds to the heels by TN on 2/26/2024 and not before that date. Record review of Resident #31's hospital clinical records reflected she was admitted on [DATE] and the chief complaint was for wound check at the request of the physician for concern about venous ulcers to bilateral heels. The clinical records included pressure injury limited to skin breakdown on the left lower buttocks and on the right lower buttocks and based on clinical presentation Resident #31 was at risk for PAD (peripheral artery disease), pressure wounds, osteomyelitis (infection of the bone,) and nutritional deficits. The clinical records read in part: .External Record Review .inpatient record from another hospital admission on 01/20/2024. It appears the patient was discharged with pressure wound to right heel. It appears this has worsened and become bilateral since discharge to rehabilitation facility . The Emergency Department Clinical Summary indicated the final diagnoses was: pressure injury of skin of right heel, pressure injury of skin of left heel, skin ulcer of buttock. The pressure injury to the dorsal right of the foot was purple, with moderate serous drainage, blistered and the patient stated both of my feet are bothering me the patient was complaining of pain to both feet and there was blood filled blister present on the left heel. Resident #66 Record review of Resident #66's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms such as breathlessness and cough), bipolar disorder (a mental condition, with extreme mood swings), osteochondropathies of the left ankle and foot (disease of the bone and cartilage), HTN (elevated blood pressures), osteoarthritis, depression, cachexia (unintentional weight loss) and contractures to both hands. Record review of Resident #66's annual MDS, dated [DATE], reflected a BIMS score of 14 out of 15, which indicated intact cognition. She was dependent on staff for toileting, bathing, lower body dressing. She required substantial assistance with upper body dressing and personal hygiene. She required partial assistance from staff when rolling side to side in bed, sitting to lying and lying to sitting on side of bed. She required substantial assistance from staff when sitting to standing and transfers. She was always incontinent of bowel and bladder. She had progressive neurologic conditions. She was at risk of pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. She required pressure reducing device for the bed and applications of ointments/medications other than to feet. She was administered high-risk drug classes: antipsychotic, antidepressant and anticoagulant during the assessment period. She was receiving physical therapy. Record review of Resident #66's, undated, care plan reflected: Focus - Resident #66 had ADL self-care performance deficit, dated 02/21/2024. Interventions included: the resident was bedfast all or most of the time; the resident required skin inspections, observe for redness, open areas, cuts, bruises and report changes to the Nurse, dated 12/08/2022. Focus - Resident #66 was resistive to care, revision date 2/15/2024. Interventions included: if resident resists, leave and return 5-10 minutes later and try again, dated initiated 07/06/2023. Focus - Resident #66 at risk for skin breakdown d/t decreased mobility, incontinence and malnutrition. Interventions included: assist resident with turning and repositioning during rounds and as needed. Weekly skin assessment, notify MD for ulcers that were deteriorating as needed. Focus - Resident #66 had skin impairment (damage/pressure ulcers) and at risk for further skin breakdown, date initiated 03/01/2024 (after Survey entrance). Interventions included: assess skin and record findings in clinical records, notify MD and RP, perform treatments per order, notify MD/RP if no improvement. Record review of Resident #66's active orders, as of 2/28/2024, reflected an order for weekly skin assessment, complete head to toe. Start date 6/30/2023. An order for Zinc Oxide, external paste 25%, apply to sacrum topically every shift for redness. Start date 06/23/2023. Record review of Resident #66's skin assessment, dated 2/29/2024, by TN, reflected an open pink area to the sacrum and white on the inside, wound measurements were 0.7cm x 0.4cm x 0.1cm. The resident was complaining of pain, denied having anything for pain, repositioned on her side for offloading. Record review of Resident #66's active physician orders, as of 03/01/2024, reflected an order, dated 2/29/2024, to cleanse the sacrum wound bed with NS, pat dry and apply alginate calcium and cover with foam dressing. Record review of Resident #66's weekly skin assessments, dated 12/29/23, reflected the previous wound to sacrum was healed and skin barrier cream was applied. Skin assessment, dated 1/5/24, 1/12/24, 1/19/24, 1/26/24, 2/2/24, reflected intact skin. Skin assessment, dated 2/14/24, reflected healed sacrum wound. Skin assessment, dated 2/21/24, reflected redness to sacrum was present. Skin assessment, dated 2/23/24, noted redness to the sacrum and treatment was in place. Observation and interview on 2/27/2024 at 10:05 AM revealed Resident #66 was in bed lying on her back with the HOB elevated. She stated she preferred to stay in her room. Observation on 2/28/2024 at 3:15 PM revealed Resident #66 was in bed lying on her back with the HOB elevated. Observation and interview on 2/28/2024 at 3:30 PM revealed Resident #66 was in bed sitting up with the HOB elevated. She stated she did not want to get up today. Observation on 2/28/2024 at 4:04 PM revealed Resident #66 was lying in bed on her back. Observation on 03/01/2024 at 8:42 AM revealed Resident #66 was lying on her right side propped with a pillow with the HOB slightly elevated. Observation and interview on 2/29/2024 at 1:45 PM during skin assessment rounds with the TN revealed Resident #66 was lying in bed on her back with the HOB elevated, there were no pillows under her back. Resident #66 had a small open area on the sacrum. There was no redness or drainage noted. The TN cleansed the area and applied Alginate and a dry dressing. Resident #66 stated she was not turned throughout the day then she said sometimes they did turn her onto her sides. The TN stated this was the first time she saw the sacral wound and it was open. The TN stated it was time to in-service the CNAs on reporting skin changes. The TN stated the nursing staff should have reported this to her. The TN left the room, returned, and stated she spoke with CNA L. The TN stated CNA L told her she was aware of the sacral wound and did not report it to TN d/t she was putting zinc ointment on it. Interview on 2/29/2024 at 2:20 PM, CNA L said Resident #66 had the spot on her bottom for a while, since last week maybe. CNA L saidshe would apply cream from the zinc packets to the area. When asked who gave her the zinc packets and whether she applied it to the open wound, CNA L stated she put it on the open wound to heal the wound. When asked why she did not report the wound to the nurse, she stated the resident would tell her to just put the cream on it. Interview on 2/29/2024 at 4:07 PM, the DON said Resident #66 would refuse to turn. When asked why a CNA would apply cream onto an open wound, the DON stated that was the best they knew, and they were instructed to check for redness and to use skin barrier cream. The DON said she did not know why CNA L did not notify the nurse. The DON said if the cream was not appropriate for the wound, then it would not heal or help the open area depending on the state and nature of the resident. The DON said CNAs were responsible to notify the charge nurse as soon as possible when they noticed skin changes and the opportunities for CNAs to assess skin were: during peri care, bathing or showering three times per week and during dressing and undressing the residents. The DON said the skin changes could be communicated by verbal means or the use of stop and watch forms. The DON expected the CNAs to report open areas and obvious changes that may not have been on the resident the day before. The DON said skin changes should be reported because they could get bad or worse and open wounds could get infected, deeper or worse. She said the charge nurse, unit manager and treatment nurses continued to communicate well and she conducted staff in-services regarding notifying the treatment nurse no matter what the issue may be. The DON said she did not know why there was a wound to Resident #66's toe and did not know if the CNA would have recognized it as an issue to report. The DON said the admitting nurse was responsible for the skin assessments upon admit and the next day the treatment nurse would be responsible as well. The DON said she expected the nurse conducting the skin assessment to make sure it was complete and some nurses were not so good with making immediate decisions. She said the skin assessment should be a head-to-toe evaluation and more detailed if needed to better identify any skin issues. She said the unit managers and ADON were responsible to ensure the skin assessments were complete and accurate. The DON said skin issues would be communicated during morning meetings or during one-on-one nurse reporting. The DON said if skin issues were identified a day before then it would be brought to the IDT meetings for discussion, the MD and wound care physician would be notified. She said it would also be discussed during care plan meetings, QAPI meetings along with weekly weight meetings. The DON said she would want to make sure the facility had what was needed to heal the skin issues. Interview on 03/01/2024 at 8:59 AM, LVN S said she expected CNAs to reposition residents every 2 hours to prevent sores and to apply barrier cream during incontinent care. LVN S said it was the CNAs and nurses responsibility to do skin assessments and CNAs had the opportunity to see skin during showers/baths and brief changes. LVN S said she expects the CNAs to notify the nurse of any skin changes. Interview on 3/01/2024 at 9:53AM, CNA L said Resident #66 stays in bed by her choice, and sometimes she would scream. CNA L said she changed the resident's position about 3 times during her shift and said she did this for Resident #66 yesterday (2/29/2024). CNA L said she left Resident #66 sitting up in bed at the resident's request. CNA L said when the red spot on Resident #66's sacrum started to look open about one week ago, she reported it to evening CNA F. CNA L said she thought CNA F reported it to the nurse, but she did not. CNA L said she now realized she reported it to the wrong person. Observation and interview on 03/01/2024 at 11:44 AM, with the TN and the WCD, revealed Resident #66 had a PU to her coccyx. There was a lot of redness surrounding the open area, but there was only a small open area. Per the WCD, it was a stage 3 PU (full thickness, open wound) to her coccyx that was 1cm x0.5cm x0.1cm and due to it having some drainage he was going to treat it with collagen and alginate. He said she had a PU there before and it re-opened. Interview on 03/01/2024 at 12:35 PM, the WCD said the zinc cream would not have damaged Resident #66's wound but it would not have helped it either. The WCD said not repositioning and not turning the resident could cause pressure ulcers to the sacrum. Interview on 03/03/2024 at 9:38 AM, LVN U saidshe started orientation on 2/27/2024 and was assigned to residents which included Resident #66. LVN U said she was still getting familiar with the residents and did not know all the details about Resident #66's wound. LVN U said the areas on the body that were more susceptible to pressure injures included the heels and buttocks. LVN U said residents who were at higher risk of developing pressure injuries were residents who were immobile and any time a resident had a history of wounds. LVN U said closed wounds could be treated and if not identified then the risk to the residents would be worsening of wounds. LVN U said, in general, wound prevention would include off loading and repositioning. LVN U said all nursing staff were responsible to help prevent pressure injuries. LVN U said she received in-services which included wound care, repositioning, reporting and neglect on 03/02/2024 and in-services were ongoing for her since 2/27/2024. LVN U said she was responsible to ensure the aides repositioned the residents and notified the nurses about any changes to the resident. LVN U said the aides could use barrier creams and the nurses were responsible to administer treatments as ordered by the physician. LVN U said communication took place typically during morning clinicals, reports and walking rounds with the night nurse. Interview on 03/03/2024 at 11:45 AM, CNA V said Resident #66 did not have skin issues or wounds weeks ago. CNA V said the CNAs were responsible to report skin changes to the nurse as they were the ones who would see the skin especially during bathing. CNA V said some people just had different work ethics and all aides went to the same CNA school. CNA V said some aides just didn't do what they were supposed to do. Interview on 03/03/2024 at 10:20 AM, CNA W, was assigned to Resident #66 and stated the resident had a dressing over the sacrum today. CNA W said not reporting wounds to the nurse or the treatment nurse was probably d/t nursing not paying attention. CNA W said wounds could occur from not turning, or repositioning, from not getting up out of bed or not using pillows for propping. Interview on 03/03/2024 at 2:42 PM, CNA F said she did work with Resident #66 sometime last week but did not remember the exact date. CNA F stated Resident #66 had the red area to the sacrum from the time she was first admitted . CNA F said sometime during the week of 2/19/2024 to 2/23/2024, she noticed a small area on the sacrum that was not too open and reported it to an Agency Nurse. CNA F said she did not remember the Agency Nurse's name. CNA F said she recalled talking to CNA L about different things but could not recall if they discussed the sacral wound. Resident #90 Record review of Resident #90's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection, dementia (group of symptoms that affects memory, thinking and interferes with daily life) diabetes (a long-lasting health condition that affects how your body turns fo [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 2 of 9 residents (Residents #26 and #202) reviewed for quality of care. 1. The facility failed to recognize and assess, Resident #26's scabbed skin injury to the left foot, prior to Surveyor identification on 02/29/2024, resulting in a delay in treatment. 2. The facility failed to identify, evaluate and treat Resident #202's rash upon admission resulting in a delay in treatment. These failures could place residents at risk of pain, worsening of skin issues, delay in treatment, decline in health and hospitalization . Findings include: 1. Record review of Resident #26's face sheet, dated 02/29/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included diabetes (a long-lasting health condition that affects how your body turns food into energy), morbid obesity (a chronic disease in which a person has a body mass index of 40 or higher or 35 or higher and is experiencing obesity-related health conditions. Body mass index is a screening tool that measures the ratio of height to weight), hypertension (elevated blood pressure), cognitive decline (a reduction in one or more cognitive abilities such as memory, awareness, judgment and mental acuity) and chronic pain (persistent pain lasting for more than 3 months). Record review of Resident #26's annual MDS, dated [DATE], reflected a BIMS score of 7 out of 15, which indicated severe cognitive impairment. She had no impairment to both upper and lower extremities. She used a wheelchair for mobility. She was dependent on staff for toileting, bathing, lower body dressing and putting on/taking off footwear. She required substantial assistance with upper body dressing, personal hygiene, and rolling side to side in bed. She was always incontinent of bowel and bladder. She was at risk of developing pressure ulcers/injuries. She had no unhealed pressure ulcers and no venous or arterial ulcers. She used a pressure reducing device for the bed and applications of ointments/medications other than to the feet. She was administered anticoagulants and antiplatelets during the assessment period. She was receiving OT. Record review of Resident #26's February 2024 MAR/TAR reflected the resident was monitored for edema every shift and monitored for abnormal bruising and/or bleeding from the nose, gums, blood in urine or stool every shift. Further review reflected a treatment order for a dried scab area to the left fifth toe, did not begin until it was ordered on date 2/29/2024. Record review of Resident #26's, undated, care plan reflected the Focus - Resident #26 had ADL self-care performance deficit r/t limited mobility. Interventions included: the resident required skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Focus - Resident #26 was at risk for pressure ulcers as evidenced by impaired mobility, desire to stay supine, repositions self onto back, declines to be turned/repositioned. Interventions included: educate resident on the importance of repositioning, incontinent care every 2 hours and as needed and weekly skin assessments. Focus - Resident #26 was at risk for pressure/venous/stasis ulcers r/t diabetes. Interventions included: encourage activity attendance, monitor skin for changes - redness, circulatory problems, breakdown and report to MD/RP. Focus - Resident #26 had impairment to skin and at risk for further skin breakdown. Interventions included: assess skin and record findings, notify MD and RP of any skin concerns. Record review of Resident #26's Physician notes, dated 12/04/2023, reflected no suspicious lesions to the skin. Record review of Resident #26's skin assessments reflected on 2/02/2024 the skin was intact. On 02/07/2024 she had open skin areas to the right thigh (rear), left thigh (rear, left gluteal fold) and right gluteal fold. On 02/16/2024 and on 02/23/2024 the skin was intact. Record review of Resident #26's skin assessment dated [DATE] and written by TN reflected that Resident #26 had excoriation between the legs of the groin, left fifth toe had a dried scab area measuring 1.4cm x 1cm and skin prep (a protective film) was applied. She had purple/blue bruising to the right side of the abdomen and yellow/blue bruising to the right lower arm. The resident was to be assessed by WCD. The MD and RP were made aware. Record review of Resident #26's current physician orders, as of 03/01/2024, reflected an order for zinc oxide ointment for the groin and sacrum every shift and an order for weekly skin assessments with a start date of 01/05/2024. Further review reflected an order for the dried scab area to the left fifth toe: cleanse with normal saline, pat dry and apply skin prep then leave open to air, order dated 02/29/2024. Observation on 02/28/2024 at 3:15 PM revealed Resident #26 was asleep in bed lying on her back with the HOB raised. Observation and interview on 02/29/2024 at 2:07 PM revealed Resident #26 was lying asleep on her back. She was easily awoken. There was a dark thick, dry wound to the fifth toe on the left foot. The area was not open, and it measured approximately 1/2 inch in diameter. The resident denied pain and denied knowing about the area on the toe. The TN stated she was aware of the resident's excoriation to the perineal area (the triangle area between the legs), but was not aware of the area on the toe. The TN stated the CNAs and nurses should have notified her so she could assess, call the MD and begin treatment. The TN stated she would notify the MD and the wound care doctor would assess tomorrow (3/01/24). Observation on 03/01/2024 at 8:42 AM revealed Resident #26 was lying on her back asleep with the HOB elevated and on an air mattress. Interview on 02/29/2024 at 2:20 PM, CNA L stated she had an in-service about one month ago on skin care. CNA L stated she had not seen Resident #26's foot and did not know there was a wound. CNA L stated she would report it to the nurse if she found it. She stated the risk of not reporting skin issues was the wound could get worse. Interview on 02/29/2024 at 4:07 PM, the DON stated CNAs were responsible to notify the charge nurse as soon as possible when they noticed skin changes and the opportunities for CNAs to assess skin were: during peri care, bathing or showering three times per week and during dressing and undressing the residents. The DON stated the skin changes could be communicated by verbal means or the use of stop and watch forms. The DON expected the CNAs to report open areas and obvious changes that may not have been on the resident the day before. The DON stated skin changes should be reported because they could get bad or worse and open wounds could get infected, deeper or worse. She stated the charge nurse, unit manager and treatment nurses continued to communicate well and she conducted staff in-services regarding notifying the treatment nurse no matter what the issue may be. The DON stated she did not know why there was a wound to Resident #26's toe and did not know if the CNA would have even recognized it as an issue to report. The DON stated the admitting nurse was responsible for the skin assessments upon admit and the next day the treatment nurse would be responsible as well. The DON said she expected the nurse conducting the skin assessment to make sure it was complete and some nurses were not so good with making immediate decisions. She stated all skin assessments conducted should be a head-to-toe evaluation and more detailed if needed to better identify any skin issues She stated the unit managers and ADON were responsible to ensure the skin assessments were complete and accurate. The DON stated skin issues would be communicated during morning meetings or during one-on-one nurse reporting. The DON stated if skin issues were identified a day before then it would be brought to IDT meetings for discussion, the MD and wound care physician would be notified. She said it would also be discussed during care plan meetings, QAPI meetings along with weekly weight meetings. The DON stated she would want to make sure the facility had what was needed to heal the skin issues. Interview on 03/01/24 at 9:53 AM, CNA L stated Resident #26 refused to get out of bed when she offered. CNA L stated the resident could reposition herself from side to side and could move around on her own. CNA L stated Resident #26 likes to sleep a lot and was more awake later in the day. Interview on 03/01/2024 at 12:35 PM, the WCD stated Resident #26's left toe looked more like a trauma, maybe hit it on something and she did not have much feeling in the area. The WCD stated she was very large all over and would have difficulty getting through the door, she was already in a large bed. In an interview on 03/03/2024 at 9:38 AM, LVN U stated she started orientation on 2/27/2024 and was assigned to Resident #26. LVN U stated she was still getting familiar with the residents, and was not aware of Resident #26's wound. LVN U stated the areas on the body that were more susceptible to pressure injures included the heels and buttocks. LVN U stated residents who were at higher risk of developing pressure injuries were residents who were immobile and any resident who had a history of wounds. LVN U stated closed wounds could be treated and if not identified then the risk to the residents would be worsening of wounds. LVN U stated wound prevention would include off loading and repositioning. LVN U stated all nursing staff were responsible to help prevent pressure injuries. LVN U stated she received in-services which included wound care, repositioning, reporting and neglect on 03/02/2024 and in-services were ongoing for her since 2/27/2024. LVN U stated she was responsible to ensure the aides repositioned the residents and notified the nurses about any changes to the resident. LVN U stated communication took place typically during morning clinicals, reports and walking rounds with the night nurse. Interview on 03/03/2024 at 10:10 AM, Resident #26 stated her little toe bothered her some, it tingled and she was not aware that she had a sore on her toe. Resident #26 stated she did not know how it got there. Interview on 03/03/2024 at 11:45 AM, CNA V stated she worked with Resident #26 on 03/02/2024 and was not aware of any wounds. CNA V stated the CNAs were responsible to report skin changes to the nurse as they were the ones who would see the skin especially during bathing. CNA V stated some people had different work ethics and all aides went to the same CNA school. CNA V stated some aides didn't do what they were supposed to do. She was taught to report any skin issues right away. She stated residents more prone to skin issues were those who stayed in bed all the time, those who did not turn every two hours, independently. She said the areas more susceptible to pressure injuries would be the sacrum, under the breasts and the heels. She said the risks for the residents if they developed pressure injuries and they were not identified early would be they could get worse and become full blown wounds. She said she had training on skin assessments two weeks ago. She said she took care of the residents with passion and rounds two to three times a day, depending on their needs. In an interview on 03/03/2024 at 10:20 AM revealed CNA W, was assigned to Resident #26 and was unaware of the area on the left toe. CNA W stated not reporting wounds to the nurse or the treatment nurse was probably d/t nursing not paying attention. CNA W stated wounds could occur from not turning, or repositioning, from not getting up out of bed or not using pillows for propping. CNA W said she had training on skin assessments and was taught to check the skin and if she saw something new, she would report it to the nurse and if the nurse did not take care of it she would tell the ADON or the DON. She stated she looked at residents' skin during brief changes, dressing, undressing and taking socks off. 2. Record review of Resident #202's face sheet, dated 3/5/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #202 had diagnoses which included COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), viral pneumonia (infection of the air sacs in one or both the lungs caused by a virus), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), immunodeficiency (inability to produce antibodies to fight infection) due to drugs, respiratory failure (condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly), COPD (Chronic Obstructive Pulmonary Disease, common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), myasthenia gravis (neuromuscular disorder that leads to weakness of skeletal muscles), muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), dementia (group of symptoms that affects memory, thinking and interferes with daily life), insomnia (trouble falling and/or staying asleep), chronic pain syndrome (persistent or intermittent pain that last for more than 3 months), and traumatic brain injury (injury to the brain caused by an external force such as a violent blow to the head, resulting in loss of consciousness, memory loss, dizziness, and confusion, and in some cases leading to long-term health effects, including motor and sensory problems, cognitive and behavioral dysfunction, and dementia). Record review of Resident #202's admission MDS, dated [DATE], with an ARD of 3/1/2024, reflected a BIMS score of 8, which indicated significant cognitive impairment. He had no impairment of either of his upper or lower extremities, and he used a wheelchair for mobility. Resident #202 required assistance, or was totally dependent on staff, with toileting, bathing, dressing, and personal hygiene. He was at risk of pressure injury, but he did not have any current pressure injuries. Record review of Resident #202's baseline care plan, dated 2/23/2024, reflected he was admitted for short-term care. He was expected to discharge home or to the community with a family member or caregiver. He did not have any wounds or pressure ulcers. He was to receive care per the physician's orders for treatment, be monitored for medication effectiveness and side effects and complications from his illness, have any changes of condition reported to his PCP and RP, medication administration, oxygen therapy and diabetic care. He was scheduled to received OT and PT services. A focus on Resident #202's self-care deficit with interventions which included assistance with his ADL's. A focus on his actual fall on 2/26/2024 with interventions which included ensure his cell phone and call light were placed within reach, reporting any changes of condition, and reviewing to determine the cause of the fall. A focus on Resident #202's risk for skin breakdown with interventions which included repositioning during rounds and as needed, pain medication administration, use of a pressure reducing mattress, provision of incontinence care during rounds and as needed, and an RD consult and weekly skin assessments. Record review of Resident #202's care plan, dated 3/4/2024, reflected a focus on his dementia with interventions which included medication administration, cuing and reorienting, provision of a consistent routine, monitoring and reporting any changes of condition, task segmentation and a possible medication review. Record review of Resident #202's Braden Scale for Predicting Pressure Sore Risk form, dated 2/23/2024, reflected he was at moderate risk of development of pressure sores. Record review of Resident #202's Braden Scale for Predicting Pressure Sore Risk form, dated 3/1/2024, reflected he was at moderate risk of development of pressure sores. Record review of Resident #202's nurse's note, dated 2/23/2024, reflected he was admitted to the facility after discharge from a local hospital. His skin was warm, dry, and intact. Resident #202 complained of redness and tenderness of his scrotum. Record review of Resident #202's Skin Observation Tool form, dated 2/23/2024, reflected he had no open areas, no wounds, and had an IV wound on his right hand. He also had bruising on both hands from previous blood draws or IV placements. Record review of Resident #202's Skin Observation Tool form, dated 2/29/2024, reflected he had discolorations on his abdomen and healing areas on both knees. He had no open skin areas and had no active bleeding. Record review of Resident #202's physicians note, dated 3/1/2024, signed by his NP, reflected he had no skin breakdown observed. Record review of Resident #202's Skin Observation Tool form, dated 3/1/2024, reflected he had a red rash to the groin. He had no open areas of skin. Resident #202 was assessed by the WCD on 3/1/2024. The WCD recommended Nystatin cream be applied every day, instructed the CNA to apply barrier cream until the Nystatin cream arrived, and the RP and PCP were made aware of the concern. Record review of Resident #202's SBAR note, dated 3/1/2024, reflected the SBAR was related to a rash in his groin area. The rash began on 3/1/2024. Applying cream to the area provided Resident #202 with relief. The rash was identified by the TN when the WCD was on rounds on 3/1/2024. The WCD recommended Nystatin cream be applied to the groin area once daily, and barrier cream would be sufficient until the Nystatin cream arrived from the pharmacy. Resident #202's RP and PCP were informed of the concern and verbalized their understanding. Record review of Resident #202's February 2024 MAR/TAR reflected there was no treatment documented for the rash to the periarea and groin. Record review of Resident #202's administration note, dated 3/5/2024, reflected Nystatin External Cream was ordered. Cream was ordered for candida (yeast infection) rash, was to be used for ten days, and applied to the groin and perineal area. Record review of Resident #202's medication report, dated 3/5/2024, reflected a prescription ordered on 3/4/2024 for Nystatin External Cream 10,000 units/gm applied topically to the groin area once daily for ten days related to canidadis rash. Record review of Resident #202's March 2023 MAR, printed on 3/5/2024, reflected a prescription for Nystatin External Cream 10,000 units/gm applied topically to his groin area once daily for ten days related to canidadis rash. The prescription was ordered on 3/4/2024 at 2:12 PM. There was no documentation on the MAR that the medication was ever applied. Observation on 2/27/2024 at 10:55 AM of Resident #202 was sleeping on his back, the head of his bed was slightly elevated. Observation and interview on 3/5/2024 at 12:00 PM revealed Resident #202 lying on his back and receiving care. Resident #202 had redness to his groin, the shaft of his penis, scrotum and it extended to his perineal area, rectal area and buttocks. CNA DD reported she completed perineal care immediately prior to the observation. The Corporate RN entered the room with Nystatin cream and applied it to Resident #202's affected areas. Resident #202 winced as if in pain when the medication was administered. Resident #202 had healed wounds on his buttocks. The RP stated the old wounds to the buttocks were not too deep and they took 6 months to heal. RP stated the buttocks area was not red upon admission but were now red in color with excoriated areas. Resident #202 had large purple areas to the left and right buttocks with intact skin. The RP stated the purple areas would get darker if he sits on the area for long periods. Interview on 3/4/2024 at 2:20 PM with the TN, she said she put the order in for Resident #202's Nystatin on 3/4/2024 because she had other orders to put in on Friday, 3/1/2024. The TN said staff were applying barrier cream to Resident #202's rash until the nystatin came in. She said the cream would not come in from the pharmacy if the order was not put in the system. She said the facility had over-the-counter Nystatin but facility staff would not know to apply it if the order was not put into the system. Interview on 3/5/2024 with Resident #202's family member, she said Resident #202 had redness on his scrotum since 2/23/2024. Resident #202's family member said she had been at the facility since 8:15 AM that day and the staff had not provided Resident #202 with any incontinence care. Resident #202's family member said she did not know if he was incontinent at that time, but no one had come to check on him. Resident #202's family member said the staff brought him medication, but no one had checked for his incontinence. Resident #202's family member said the redness near Resident #202's scrotum had extended to his rectum. Resident #202's family member said the staff put a barrier cream on the area, but the medication the physician ordered had not come in yet. Resident #202's family member said when the WCD was present he said Resident #202 had a yeast infection from the antibiotics he received. Resident #202's family member said she expected the medications to be delivered to the facility either Saturday 3/2/2024 or Sunday 3/3/2024. Resident #202's family member said when the medication did not arrive during the weekend, she expected the medication to be delivered on 3/4/2024. Resident #202's family member said she wanted Resident #202 to receive the medication to alleviate his pain and distress. Resident #202's family member said Resident #202 reported the pain at an eight on a scale of one to ten. Interview on 3/5/2024 at 12:00 PM with Resident #202's family member, she said the wounds on Resident #202's buttocks were not deep, located on both buttocks and had taken six months to heal. Resident #202's family member said Resident #202 currently had redness, excoriation, and large purple areas on both buttocks. Resident #202's family member said if Resident #202 sat on his buttocks for extended periods of time, the areas darkened. Resident #202's family member said no one repositioned Resident #202 that morning. Resident #202's family member said she was at the facility from approximately 8:00 AM to 4:00 PM daily, and during that time she had not observed Resident #202 be repositioned. Resident #202's family member said the facility informed her of the importance of repositioning for Resident #202. Resident #202's family member said Resident #202 was most comfortable on his back. Interview on 3/5/2024 at 1:23 PM with the TN, she said she could not recall who informed her of Resident #202's redness in the brief area. The TN said she recalled becoming aware of the redness on 3/1/2024 when she was completing rounds with the WCD . The TN said she forgot to put in the order for Resident #202's order for Nystatin cream because she had many other duties when the physician created the orders. The TN said the order was prescribed by the WCD on 3/1/2024 at approximately 3:30 PM. The TN said she obtained Resident #202's Nystatin cream from the facility's electronic medication dispensation system. The TN said she did not know the electronic medication dispensation system had Nystatin cream stocked. The TN said she provided Nystatin powder to Resident #202's red areas on 3/4/2024. The TN said she had not put in Resident #202's Nystatin order on 3/1/2024 at any time. The TN said she typically did not treat rashes, but the floor nurses did. The TN said she would check a rash if requested, and that was what occurred on 3/1/2024 with Resident #202. Interview on 3/5/2024 at 3:23 PM, the DON said she did not know when Resident #202's Nystatin was ordered and did not know why the order was not put in the system by the nurse. She said the pharmacy would not be alerted about the need for the medication until the order was put into the system. She said she was notified on Friday 3/1/2024 when the WCD was in the building that the resident had redness with possible yeast but did not know what the treatment plan was. In a telephone Interview on 03/06/2024 at 2:37PM, CNA DD stated Resident #202's skin on 03/06/2024 at 7:15AM looked the same as it did at 03/06/2024 at 12:00PM when the Corporate RN applied the Nystatin cream. CNA DD stated the resident's skin was pinkish/red with purple blotches on the brief area and that 033/06/2024 was the first time she had worked with Resident #202. CNA DD stated she did not notify the nurse about the condition of Resident #202's skin and thought someone already knew about it because there was clear cream on the skin. CNA DD stated if there was no cream on the skin then she would have notified her nurse. In an interview on 03/07/2024 at 1:55 PM, the Administrator stated it was the responsibility of the nurses and CNAs to check resident skin and for the CNA to report changes to the charge nurse. The Administrator stated, now it had been included that the DON would be notified as well. The Administrator stated it appears someone may not have seen the wounds prior to 2/29/2024 when they were identified and that it was not for lack of checking. The Administrator stated maybe when the skin was checked, the wound/skin issues were easier to identify. The Administrator stated the staff were working as hard as they could. She stated her expectations were the residents be repositioned every 2 hours. Record review of the facility's policy and procedure for Notification of Changes, dated 05/2023, read in part: .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions or b. Clinical complications . Record review of the facility's policy and procedure for Skin Assessment, dated 11/2023, read in part: .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure .h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers and lesions .5. considerations for a bariatric resident .c. Thoroughly inspect each surface of a skin fold .7. Documentation of skin assessment: .b. Document observations .c. document type of wound .d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) Record review of the facility's policy and procedure for Wound Treatment Management, dated 11/2023, read in part: .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound Record review of the facility's policy and procedure for Pressure Ulcer/Skin Injury Management and Prevention, dated 01/08/2023, read in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Policy Explanation and Compliance Guidelines .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .7. Assessment of Pressure Injury Risk .e. Nursing assistants will inspect skin during bath or pericare and will report any concerns to the resident's nurse immediately after the task .9. Monitoring: a. The treatment nurse, unit manager, or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. b. the attending physician will be notified of: i. the presence of a new pressure injury upon identification.

47722 Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 (Resident #53, Resident #8, and Resident #42) out of 20 residents reviewed for incontinent care. -CNA M failed to change Resident #53's brief for over 5 hours. -CNA J failed to change Resident #8's brief for over 8 hours. -CNA N failed to change Resident #42's brief for over 5 hours. These failures could place residents at risk for dignity issues, skin breakdown, infection, and hospitalization . Findings include: Resident #53 Record review of Resident #53's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia/hemiparesis (paralysis and weakness on one side) following cerebral infarction (stroke) affecting right dominant side, unspecified dementia, cerebral infarction (stroke), aphasia (trouble speaking), history of falling, schizophrenia (people interpret reality abnormally), and bipolar (unusual shifts in mood, ranging from extreme highs to lows). Record review of Resident #53's care plan dated 1/23/24, revealed a Focus: Resident has an ADL self-care performance deficit r/t activity intolerance, confusion, dementia, fatigue, hemiplegia (paralysis on one side), impaired balance, limited mobility, limited ROM, musculoskeletal impairment (Initiated: 2/21/23, Revised on: 2/21/23). Goal: The resident will maintain current level of function through the review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Personal Hygiene- The resident requires total to extensive assistance by 1 staff with personal hygiene and oral care (Initiated: 2/21/23, Revised: 2/21/23). Toilet Use- The resident is totally dependent on 1 staff for toilet use (Initiated: 2/21/23, Revised: 2/21/23). Focus: Resident is at risk for skin breakdown r/t decreased mobility, incontinence, poor PO intake (Initiated: 2/21/23, Revised: 2/21/23). Goal: Will show granulation (new skin) and reduction in size through review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Pressure injury will be free from signs and symptoms of infection (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Will remain free of pressure injury(s) through the next review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Assist resident with turning and repositioning during rounds and as needed (Initiated: 2/21/23). Provide/offer incontinent care during rounds and as needed (Initiated: 2/21/23). Focus: Resident #53 is totally incontinent of B/B requires assistance r/t self-care deficit (Initiated: 2/21/23, Revised: 2/21/23). Goal: Reduce the risk for skin breakdown through the next review (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Promote dignity by keeping resident clean, dry and free from odor every shift through the next review (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Assist with dressing and hygiene during the toileting process. Be sure resident is kept clean, dry, every shift. Monitor for any skin breakdown-Report immediately. Use incontinent products, skin barrier, every shift and as needed. Weekly skin check. Record review of Resident #53's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 5 out of 15, which indicated severely impaired cognition. The resident had impairment on one side of her upper and lower extremities and used a wheelchair. According to the MDS the resident was substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. She was totally dependent with toileting hygiene, shower/bathes, lower body dressing, and putting on/taking off footwear. The MDS revealed Resident #53 was substantial/maximal assistant with rolling left and right, sit to lying, and lying to sitting on side of bed. She was dependent with chair/bed to chair transfer, and tub/shower transfers. Resident #53 was always incontinent of bowel and bladder and was not on a toileting program. The MDS indicated the resident was at risk of developing pressure ulcers/injuries but did not have any that were unhealed at that time. Record review of Resident #53's medical record revealed a form for B&B-Bladder Documentation for the past 30 days. On 2/29/24 at 7:21am it was documented that Resident #53 was incontinent of urine by CNA M. In an observation on 2/29/24 at 8:52am Resident #53 was sitting up in her wheelchair in her room. The room smelled strongly of urine. In an interview with CNA M on 2/29/24 at 10:07am, she said she worked with Resident #53. She said she arrived at the facility at 6:30am and started making rounds. She then started changing everyone, performing showers, and getting everyone up for breakfast. Then she said she checked/changed residents again. She said she would then give more showers, took a break at 10am, checked again, went to lunch, and more rounds. She said since Resident #53 was in a wheelchair she had to get her into a Hoyer lift with a teammate and put her into bed to check/change her and then put her back into the wheelchair with the Hoyer lift. She said she had not changed Resident #53 yet that morning because she had not gotten to her yet and the last time she was changed was whenever the night shift changed her. In an interview with CNA M on 2/29/24 at 2:25pm, she said she did not change Resident #53 until around 11:45am. In an interview on 3/5/24 at 11:53am with CNA KK, she said she last changed Resident #53 at 10:00am and was about to go and change her again. Resident #8 Record Review of Resident #8's undated face sheet, revealed a [AGE] year-old woman admitted on [DATE] with diagnoses of cerebral infarction (stroke), type 2 diabetes mellitus (condition results from insufficient production of insulin causing high blood sugar), morbid obesity (health condition resulting from an abnormally high body mass), immunodeficiency (immune system's ability to fight infections and cancer is compromised) due to drug use, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), pseudobulbar effect (nervous system disorder that causes inappropriate involuntary laughing and crying), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), hypertension (high blood pressure), and heart failure. Record review of Resident #8's annual MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. The MDS documented she had impairments to both upper and lower extremities, and she utilized a wheelchair for mobility. Per the MDS, Resident #8 required maximum assistance or was totally dependent on staff for all ADL's. The MDS revealed she was always incontinent of bladder and bowel, and she was not on a toileting program. The MDS documented she did not receive any OT, PT, and/or ST services. Record review of Resident #8's care plan dated 12/21/2024 revealed a Focus: Resident #8 has an ADL self-care performance deficit r/t activity intolerance, fatigue, hemiplegia (paralysis on one side), limited mobility, stroke (Initiated: 12/20/21, Revised: 12/20/21). Goal: The resident will maintain current level of function through the review date (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Interventions: The resident is totally dependent on (2-5) staff to provide bath/shower. The resident requires total assistance by (2-5) staff to turn and reposition in bed as necessary. The resident requires extensive to total assistance by (1-2) staff with personal hygiene and oral care. The resident is totally dependent on (1-3) staff for toilet use. Focus: The resident is totally incontinent of B/B requires assistance r/t self-care deficit (Initiated: 12/20/21, Revised: 12/20/21). Goal: Reduce the risk for skin breakdown through the next review (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Promote dignity by keeping resident clean, dry & free from odor every shift through the next review (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Interventions: Assist with dressing and hygiene during the toileting process. Be sure the resident is kept clean, dry every shift. Check with resident during rounds and as needed, assist to toilet, and as needed. Give incontinent care during rounds and as needed. Give peri care (washing the genitals and anal area) with facility protocol/policy. Record review of Resident #8's medical record revealed a B&B-Bladder Documentation for the past 30 days. On 2/29/24 at 5:55am it was documented that Resident #8 was incontinent of urine. Record review of Resident #8's progress notes revealed a nurse's note from 2/29/24 at 1:31pm from LVN OO that read, Resident stated that she had not been rounded on during the entire shift. Record review of Resident #8's progress notes revealed a nurse's note from 2/29/24 at 8:37pm from the DON that said resident stated, ' .They always come and change me at 3:00am .' Interview and observation on 2/27/2024 at 9:44am with Resident #8, she said the staff did not change her incontinence briefs during the night shift until 3:00am and they did not change her when they first came on shift. She said the staff arrived between 10:30pm and 11:00pm. Resident #8 said the staff did not change her until 3:00am every night. Interview and observation on 2/29/2024 at 12:59pm with Resident #8, she said the staff did not want to change her during the evening shift from 2:00pm to 10:00pm. Resident #8 said she had not been changed at all on 2/29/24. Interview on 2/29/24 at 1:06pm with LVN C, he was not aware that Resident #8 was not changed yet during the shift. Interview on 2/29/2024 at 2:14pm with LVN C, he said he had spoken with CNA J and CNA K about Resident #8 not receiving incontinence care that day. LVN C said he determined Resident #8 had not received incontinence care during the day shift that day. LVN C said the CNA's reported they were busy and did not have time to provide Resident #8 with incontinence care. LVN C said he assisted the CNA's with providing incontinence care and that that was her first incontinence care performed on 2/29/24 during the 6:30am to 2:30pm shift. Interview on 2/29/24 at 2:41pm with CNA J, she said she checked Resident #8 at 6:45am that day and she was dry. CNA J said she assumed the 10:30pm to 6:30am shift had changed her at shift change. CNA J said she checked Resident #8 again after breakfast and she was dry. She said then CNA K also checked on the resident during the day. Interview on 2/29/24 at 2:53pm with CNA K, she said she provided Resident #8 incontinence care on 2/29/2024 at approximately 1:50pm. She said she had not provided Resident #8 incontinence care at any other time on 2/29/2024. CNA K said she never checked Resident #8's incontinence brief to determine if it was soiled on 2/29/2024 because she was not the resident's CNA. She said the Resident #8 was not assigned to her and was assigned to CNA J. CNA K said she checked in on Resident #8 during the day on 2/29/2024, but she never checked her incontinence brief to determine if it was soiled. Interview on 3/1/2024 at 3:51pm with Resident #8, she said she was doing well that day. She said on 2/29/2024 when the facility staff did not provide her with incontinence care during the day, she felt neglected and bad. Resident #8 said she felt that because it took more than one person to assist her with incontinence care, the staff ran away from her call lights. She said when she did not receive incontinence care timely in the past, she felt neglected and sad. Resident #8 said she wished the staff would treat her the way they would like to be treated if they were in her position. Resident #42 Record review of Resident #42's undated face sheet revealed she was [AGE] years old, admitted on [DATE] with an original admitted [DATE]. She had diagnoses of dementia, traumatic subarachnoid hemorrhage (bleeding in the brain), chronic respiratory failure, HTN (high blood pressure), and abnormalities of gait and mobility. Record review of Resident #42's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. This MDS did not mention her ADLs. She was always incontinent of bowel and bladder and was not on a toileting program. The MDS revealed Resident #42 was dependent with toileting hygiene, shower/baths, lower body dressing, and putting on/taking off footwear. She was substantial/maximal assistance with oral hygiene, upper body dressing, and personal hygiene. Resident #42 was at risk of pressure ulcers/injuries but did not have any at the time. She had a pressure reducing device for bed and applications of ointments/medications other than to feet. Record review of Resident #42's care plan dated 1/24/23, revealed a Focus: Resident has an ADL self-care performance deficit r/t dementia, weakness, and deconditioning (Initiated: 5/28/21, Revised: 5/28/21). Goal: She will be clean, dry and well groomed (Initiated: 5/28/21, Revised: 1/24/24, Target: 4/23/24). Interventions: The resident is bedfast all or most of the time. The resident requires extensive assistance of 1 for personal hygiene. The resident requires total assist of 1-2 for toilet use. Focus: Resident has total incontinence of B/B requires assistance r/t self-care deficit. Goals: Promote dignity by keeping resident clean, dry & free from odor every shift through the next review (Initiated: 6/11/21, Revised: 1/24/24, Target: 4/23/24). Reduce the risk for skin breakdown through the next review (Initiated: 6/11/21, Revised: 1/24/24, Target: 4/23/24). Interventions: Assist with dressing & Hygiene during the toileting process. Be sure resident is kept clean dry, every shift. Monitor for any skin breakdown-Report to MD. Provide incontinent/peri care (washing the genitals and anal area) as needed; use incontinence products, apply skin barrier every shift and as needed. Weekly skin check with showers and prn. Focus: Resident is at risk for Decubitus Ulcer/Pressure Ulcer r/t Incontinence decreased mobility (Initiated: 9/25/20, Revised: 5/28/21). Goals: The resident will have intact skin, free of redness, blisters or discoloration by/through review date (Initiated: 9/25/20, Revised: 1/24/24, Target: 4/23/24). Skin will remain clean, dry and intact without evidence of breakdown through the next review (Initiated: 9/25/20, Revised: 1/24/24, Target: 4/23/24). Interventions: If Incontinent, give Incontinent care Q2 hours and as needed. Weekly skin assessment, notify MD for Ulcers that are deteriorating, as needed. In an observation on 2/28/24 at 9:29am Resident #42 was laying on her back in bed while CNA W and CNA J put her in a Hoyer lift to weigh her. The resident's diaper was observed to be soaked with urine and the CNAs did not change her and only weighed her and left the room. In an observation on 2/29/24 at 8:45am, Resident #42 was asleep on her side in bed. She smelled strongly of urine. Interview on 2/29/24 at 9:06am, CNA N said she took care of resident #42. She said she got to work at 6am and started to get everyone up, out of bed, and showered. Then she took them to breakfast and helped feed them. After that she said she would start changing residents around 8am. She said she had not changed Resident #42 yet and she still needed to get another resident up and showered, so it would be a little while before she could change her. Interview on 2/29/24 at 2:04pm with CNA N, she said she did not change Resident #42 until about 11am and she was not changed before that, since whenever the night shift had changed her. In an interview on 3/5/24 at 11:50am with CNA JJ, she said she last changed Resident #42 at about 11:30am and before that she changed her at about 8:50am-9:00am. Interview with the ADON on 2/29/24 at 9:00am, she said the CNAs rounded on the residents at least every 2hrs or more often if necessary and changed the residents at that time if they needed it. Interview with the DON on 2/29/24 at 1:55pm, she said her expectations were that the staff changed the residents when they got to the facility and every 2hrs and PRN. She said however, that the staff had a tough schedule. Interview with the DON on 3/4/24 at 10:00am, she said she ensured the CNAs were changing residents by performing Angel rounds. She said Angel rounds were when department heads were responsible for a hall, and they went through and checked the residents and spoke with them to ensure they were being taken care of and changed. She also said it was up to the nurses to ensure the aides were changing the residents. Interview with the DON on 3/4/24 at 10:30am, she said the facility was staffed well enough to keep residents clean and dry, unless they had a high number of call ins. She said incontinent care should be done every 2hrs and as needed. She said consequences of not providing timely care could appear neglectful and could have negative consequences to the resident. She also said nurses were in-serviced on going into the resident's rooms during shift change and asking the resident's how they were, checking for odors and changing them if they needed it. Interview with the Wound Care Nurse on 3/4/24 at 12:00pm, she said turning/repositioning and incontinence care every 2hrs and PRN, was a part of pressure injury management. Interview with LVN II on 3/4/24 at 1:01pm, she said residents needed to be turned/repositioned every 2hrs and incontinent care needed to be done every 2hrs as well. Interview with the Administrator on 3/7/24 at 2:15pm she said she expected staff to change residents every 2-3hrs and as needed. She was not sure why they were not being changed like they were supposed to be. She did not think any staff left the residents soiled intentionally. Record review of the facility's policy and procedure for Activities of Daily Living (ADLs) (revised 2/2023) read in part: .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; .3. Toileting .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Record review of the facility's policy and procedure for Perineal Care (revised 1/2024) read in part: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown . Record review of the facility's Job Description for Certified Nursing Assistant (revised 1/1/18) read in part: Certified Nursing Assistant's (CNA) perform routine tasks and care in accordance with established policies and procedures under the supervision of nursing to assure that the highest degree of quality resident care can be maintained at all times .Essential Job Functions: Provides and promotes resident's rights during resident care .Perform satisfactorily nursing care and activities of daily living (bathing, transfers, walking, bed mobility, eating, brace/splint care, bowel & bladder, toileting, vital signs, etc.) in a very caring and safe manner . Record review of the facility's Job Description for Charge Nurse (Registered Nurse/Licensed Vocational Nurse) (revised 1/1/18) read in part: The Charge Nurse is responsible for staff assignments and providing the overall supervision of resident care activities. Responsible for performing a variety of duties to provide quality nursing care to resident and to coordinate total nursing care for residents; implementing specific procedures and programs; participating with the Director of Nursing and the Assistant Director of Nursing in establishing specific goals; determining work procedures and expediting work flow; insuring compliance with all operating policies and procedures and Texas Department of Aging and Disability Services regulations and Federal Health Care Administration and Centers for Medicare and Medicaid Services .Essential Job Functions: .Assume the authority, responsibility and accountability for directing assigned unit/staff .

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 2 residents (Residents #8 and #352) reviewed for pharmacy services. The facility failed to ensure LVN A administered Oxycodone-Acetaminophen (a controlled medication used to treat moderate to severe pain) and Lorazepam (a controlled medication that treats anxiety) to Resident #8 in accordance with physician's orders. The facility failed to ensure MA A administered Oxycodone-Acetaminophen to Resident #8 in accordance with physician's orders. The facility failed to ensure LVN I destroyed two of Resident #8's Oxycodone-Acetaminophen tablets and one of Resident #352's Oxycodone tablets with a witness according to facility policy. These failures could place residents at risk of medication error and drug diversion. Findings included: Resident #8 Record review of Resident #8's face sheet dated 2/27/24 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side following a stroke), chronic pain, generalized anxiety order, and major depressive disorder. Record review of Resident #8's annual MDS assessment, dated 12/11/23, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. She was dependent on staff for ADL care. Record review of Resident #8's care plan dated 12/19/23 revealed she used an anti-anxiety medication related to anxiety disorder and pseudobulbar affect (emotional incontinence). The interventions were to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness. She was at risk for pain and discomfort. Interventions were to administer pain medications as ordered. Record review of Resident #8's Physician Orders for February 2024 revealed orders for: Lorazepam 0.5 mg give 1 tablet by mouth two times a day related to generalized anxiety, order date 12/20/23 and Percocet 5-325 mg (Oxycodone-Acetaminophen) give 1 tablet by mouth every 8 hours for pain, order date 4/11/23. There were no active prn (as needed) orders for Lorazepam or Oxycodone-Acetaminophen. Record review of Resident #8's Controlled Substance Disposition Record for Lorazepam dated 2/17/24 revealed directions to take 1 tablet by mouth twice daily. LVN A administered one Lorazepam tablet to Resident #8 on 2/20/24 at 3 a.m. Lorazepam was also administered by MA B on 2/20/24 at 7 a.m. and MA A on 2/20/24 at 7 p.m. for a total of three Lorazepam pills in one day. Record review of Resident #8's Medication Administration Record for February 2024 revealed Lorazepam 0.5 mg was scheduled twice a day (one in the morning and one at bedtime). There were no active prn orders for Lorazepam on 2/20/24. Lorazepam was signed off as administered on 2/20/24 for the morning administration by MA B and one tablet for the bedtime administration by MA A. There was no documentation to show LVN A administered Lorazepam to Resident #8 on 2/20/24 at 3 a.m. Record review of Resident #8's Controlled Substance Disposition Record for Oxycodone-Acetaminophen 5-325 mg dated 1/29/24 revealed directions to take 1 tablet by mouth three times per day. LVN A administered one Oxycodone-Acetaminophen tablet to Resident #8 on 2/20/24 at 3 a.m. MA B administered one tablet on 2/20/24 at 7 a.m., MA A administered one tablet on 2/20/24 at 3 p.m. and 7 p.m. and LVN I administered one tablet on 2/20/24 at 11 p.m. for a total of five Oxycodone-Acetaminophen tablets in one day. Further review of the record revealed that LVN I wasted one Oxycodone-Acetaminophen tablet on 2/23/24 at 11 p.m. and one tablet on 2/26/24 at 11 p.m. LVN I signed the record and wrote wasted but there were no additional signatures on those dates to indicate the waste was witnessed. Record review of Resident #8's Medication Administration Record for February 2024 revealed Oxycodone-Acetaminophen 5-325 mg was scheduled three times a day (7:00 a.m., 3:00 p.m., and 11:00 p.m.). There were no active prn orders for Oxycodone-Acetaminophen on 2/20/24. Oxycodone-Acetaminophen was documented as administered on 2/20/24 at 7:00 a.m. by MA B, one tablet on 2/20/24 at 3:00 p.m. by MA A, and one tablet on 2/20/24 at 11 p.m. by LVN I. There was no documentation to show LVN A administered Oxycodone-Acetaminophen to Resident #8 on 2/20/24 at 3 a.m. or that MA A administered one tablet on 2/20/24 at 7 p.m. In a telephone interview on 2/29/24 at 10:45 p.m. LVN I said on 2/23/24 and 2/26/24 Resident #8 dropped her Percocet (Oxycodone-Acetaminophen) pills. She said she (LVN I) put the pills in the pill buster (a Drug Buster uses activated charcoal to quickly neutralize the active ingredients in pills, liquids, controlled substances and transdermal patches) to waste them. She said another nurse did not witness the waste because she got busy and was passing medications. She said she should have stopped right then and there to get another nurse to witness her waste the medication. She said the purpose of a witness was to know the nurse did not take or do something else with the medication. She said after the waste, both nurses signed the controlled count sheet. She said she documented wasted only on the controlled record for 2/29/24 and there were no other nurse signatures for that administration. In an interview on 2/29/24 at 3:14 p.m. the DON said when nursing staff administered a narcotic medication, they should go in the MAR and narcotic/controlled record and document the medication was given. In an attempted interview on 3/1/24 at 11:39 a.m. with LVN A, she was unable to be reached. A voicemail was left requesting a call back. In a telephone interview on 3/1/24 at 12:16 p.m. MA A said she made a medication error when she administered Percocet to Resident #8 on 2/20/24 at 7 p.m. She said Resident #8 always called the nurse for a prn pain pill. She said she was unable to document the administration on the MAR because it was not highlighted and did not show up as ready to give. She said she did not realize she made a medication error until today. She said when preparing medication for administration she checked the MAR, order, dose, blister pack and directions. She said the resident could get sick or overdose if she received too much medication. In an observation on 3/1/24 at 1:08 pm of Resident #8 revealed she was lying in bed asleep. Interview on 3/1/24 at 1:30 p.m. with the DON she said MA A did not notify her of a medication error on the day of the incident (2/20/24). She said staff should verify the 5 rights when administering medications which include the right resident, medication, route, time, and documentation. She said staff should refer to the MAR prior to administering the medication. She said if the medication was not in the MAR, they did do not give it. Interview on 3/1/24 at 1:50 p.m. the Administrator said she expected nursing staff to read and following the physician orders. Resident #352 Record review of Resident #352's face sheet dated 3/1/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included fracture of shaft of humerus right arm (a long bone in the arm that runs from the shoulder to the elbow), and fracture of right femur (thigh bone). Record review of Resident #352's 5-day MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She required assistance of staff with ADL care. Record review of Resident #352's care plan dated 2/28/24 revealed she was at risk for pain and discomfort related to generalized discomfort, fracture to right femur and shoulder, muscle spasms. Interventions were to administer pain medications as ordered. Record review of Resident #352's Physician Orders revealed an order for Oxycodone 5 mg give 1.5 tablets by mouth every 6 hours for pain, order date 2/21/24. Record review of Resident #352's Controlled Substance Disposition Record for Oxycodone dated 2/24/24 revealed on 2/29/24 at 1 a.m. LVN I wasted 1.5 Oxycodone tablets and documented that the resident dropped the pill. There were no additional nurse signatures to indicate the waste was witnessed. In an observation and interview on 2/29/24 at 4:59 p.m. of Resident #352 revealed she was lying in bed. She said the facility provided her with pain medication and said she never dropped any of her pills. She said staff would give her the pill and she would put it in her mouth or staff would administer the pill to her with a spoon. In a telephone interview on 2/29/24 at 10:45 p.m. with LVN I, she said Resident #352 had a bad arm and dropped her Oxycodone tablet on the floor in the middle of the night on 2/29/24. She said she placed the pill in the pill buster and forgot to get a coworker to sign. She said she should have stopped to get another nurse to sign with her but did not stop because she was finishing her rounds. She said she was embarrassed she made the mistake and was doing the best she could. She said she signed on the narcotic sheet and wrote LVN after her signature. She said no other nurse signed the controlled record. Interview on 3/1/24 at 1:30 p.m. with the DON, she said two nurses, or a nurse and medication aide were needed to destroy a narcotic with the drug buster. She said both staff would witness the destruction and sign on the narcotic/controlled sheet. She said if that process was not followed the medication could be pocketed, swallowed, or given to someone else. She said the controlled medications process needed to be controlled and complete from beginning to end. Interview on 3/1/24 at 1:50 p.m. the Administrator said the policy, procedure, and expectation was to waste a controlled medication with a coworker. She said the procedure ensured proper handling reporting, and protected the resident, staff, and facility. Record review of the facility's Controlled Substance Administration & Accountability policy dated 5/2023 reflected in part, .It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: Controlled substances that are destroyed are appropriately documented . 4.Obtaining/Removing/Destroying Medications . d. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record . Record review of the facility's Medication Administration policy, revised 2/2023, reflected in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .Policy Explanation and Compliance Guidelines . 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Sign MAR after administered . 21. Facility to follow liberalized medication times unless other instructed by the physicians' orders .

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 5% based on 2 errors out of 34 opportunities, which involved 2 of 6 residents (Residents #57 and #11) reviewed for medication errors. - MA B administered Carvedilol (a medication used to treat high blood pressure and heart failure) to Resident #57 when it should have been held according to the parameters indicated in the physician's orders. - LVN BB administered insulin to Resident #11 during a meal instead of before a meal as indicated in the physician's orders. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Resident #57 Record review of Resident #57's face sheet dated 2/29/24 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included hypertension (high blood pressure), dementia, diabetes, and cerebral infarction (stroke). Record review of Resident #57's annual MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated no cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #57's care plan dated 1/29/24 revealed she had hypertension. Interventions were to give anti-hypertensive medications as ordered. Record review of Resident #57's order summary report for February 2024 revealed an order for Carvedilol 12.5 mg give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure less than 110 or Heart Rate less than 60 bpm, order date 7/26/23. Record review of Resident #57's medication aide administration record for February 2024 revealed Carvedilol 12.5 mg was documented as administered on 2/28/24 for the morning dose by MA B. Her blood pressure was 121/69 and heart rate was 53. In an observation on 2/28/24 at 8:50 a.m. with MA B revealed she entered Resident #57's and took her blood pressure which was 121/69 and the heart rate was 53. MA B prepared Resident #57's morning medication which included Carvedilol 12.5 mg - 1 tablet, Klor con 20 mEq, Polyethylene Glycol 3350 17 gm, Senna 8.6 mg 2 tablets, Chewable aspirin 81 mg 1 tablet, Clopidogrel 75 mg 1 tablet, Amlodipine 5 mg, Fluoxetine 20 mg - 1 tablet, Gabapentin 100 mg - 1 tablet, Lisinopril 40 mg - 1 tablet, Metformin 500 mg - 1 tablet, Furosemide 20 mg - 2 tablets, and Refresh Plus Carboxymethylcellulose 0.5% eyes drops. She entered the room and administered the medications to Resident #57. Interview on 2/28/24 at 9:05 a.m. with MA B, she said Resident #57's order for Carvedilol had instructions to hold the medication if the heart rate was less than 60. She said Resident #57's heart rate was 53. She said she never saw the heart rate parameter and thought it only applied to Metoprolol. She said the MD put the parameter in, but she did not know why. She said when administering medications, she checked the vital signs and verified that the blood pressure was within the specified parameters. Interview on 2/29/24 at 2:57 p.m. the DON said Resident #57's Carvedilol should have been held because it was a beta blocker and would slow down the heart rate. She said the instructions for when to hold the medication were on the physician orders and the MAR. She said MA B might have been focused on holding the medication if the systolic blood pressure was less than 110. Resident #11 Record review of Resident #11's face sheet dated 2/29/24 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included type 2 diabetes, chronic kidney disease, and Alzheimer's disease. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #11's order summary report for February 2024 revealed an order for Insulin Lispro inject as per sliding scale . subcutaneously before meals for diabetes, order date 1/18/24. Record review of Resident #11's Medication Administration Record for February 2024 revealed Insulin Lispro subcutaneously before meals was scheduled for 7:30 a.m. In an observation on 2/28/24 at 7:57 a.m. of Resident #11 revealed she was sitting up in bed with approximately 75% of her breakfast eaten. Resident #11 was eating her breakfast sausage and oatmeal. LVN BB took Resident #11's blood sugar which was 190 mg/dL. She prepared and administered 8 units of Humalog Kwik pen to Resident #11. Interview on 2/28/24 at 8:10 a.m. with LVN BB, she said she was supposed to catch the resident before meals because the blood sugar may be high, and the insulin would bring it down. She said after a meal the blood sugar would be elevated. She said she had a window of time to administer the insulin between 7:30 am and 8:30 am. She said administering the insulin at mealtime was sufficient and the resident had not finished eating. Interview on 2/29/24 at 3:04 p.m. with the DON she said short acting, mealtime insulin should be given before meals because they needed to know what the blood sugar was before eating. She said it was very hectic the morning of 2/28/24 and she did not know what happened. She said there were questions on when the insulin should be administered but it would be something the facility would discuss with Quality Monitoring. Interview on 3/1/24 at 1:50 p.m. the Administrator said she expected nursing staff to read and following the physician's orders. Record review of the facility's Medication Administration policy revised 2/2023 read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician . Policy Explanation and Compliance Guidelines . b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans. LVN A failed to follow physician's orders when she administered blood pressure medication (Metoprolol Tartrate) to Resident #1, who was totally dependent on staff for all ADL's and could not communicate, via gastrostomy tube before checking his blood pressure. This failure placed residents at risk of not receiving care and treatment to meet the resident's physical, mental, and psychosocial needs. Findings include: Record review of Resident #1's face sheet dated 06/30/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with severe dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), diabetes mellitus (a group of diseases that result in too much sugar in the blood), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), cardiac arrest (a sudden sometimes temporary cessation of function of the heart), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), tachycardia (a rapid heartbeat that may be regular or irregular, but is out of proportion to age and level of exertion or activity), chronic diastolic congestive heart failure (a stiff left heart ventricle), aphasia (loss of ability to understand or express speech caused by brain damage) following cerebral infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain), functional quadriplegia (paralysis of all four limbs), colostomy status (an opening into the colon from the outside of the body), essential hypertension (abnormally high blood pressure that is not the result of a medical condition), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), dysphagia (difficulty swallowing), and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of Resident #1's MDS dated [DATE] revealed he did not speak, and no BIMS was conducted; he had a severe cognitive impairment; he required total physical assistance from at least two staff for all ADL's; he was bed bound; he was always incontinent of bladder; he had a colostomy; he had a feeding tube (gastrostomy); and he had pressure ulcers. Record review of Resident #1's care plan revised 06/07/2023 revealed the following: * Resident #1 had impaired cognitive function and impaired thought processes. Goals included: The resident will maintain current level of cognitive function. The resident's needs will be met, and dignity will be maintained. Interventions included: Administer medications as ordered. * Resident #1 has a camera in room that may or may not have sound per family request. Goals included: Family and Resident choice to have a camera in the room will be respected. Interventions included: Do not be intimidated by the camera. Continue to provide good care as you always do. * Resident #1 has altered cardiovascular status due to hypertension, history of cardiac arrest, tachycardia, CAD (coronary artery disease is the most common type of heart disease), NSTEMI (partial blockage of one of the coronary arteries, causing reduced blood flow of oxygen-rich blood to the heart muscle), DVT (a blood clot that develops within a deep vein in the body), HLD (high levels of lipids in the blood), and cardiomegaly (enlarged heart). Goals included: The resident will be free from complications of cardiac problems. Interventions included: Monitor vital signs as ordered. Notify doctor of significant abnormalities. Monitor/document as needed any signs and symptoms of CAD. * Resident #1 has a history of CVA (also known as stroke. When blood flow to a part of your brain is stopped). Goals included: Minimize the risk of complications for CVA. Interventions included: Give medications per doctor orders - monitor labs and report to doctor. * Resident #1 had a cerebral vascular accident (CVA/stroke), functional quadriplegia, and Parkinson's. Goals included: The resident will be free from signs and symptoms of complications of CVA. Interventions included: Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Monitor vital signs as ordered. Notify doctor of significant abnormalities. Observation of Resident #1 on 06/30/2023 at 10:45 a.m. revealed he was asleep in bed on an air mattress. He did not open his eyes or respond in any way to verbal stimulus. Record review of Resident #1's physician's orders for June 2023 revealed the following: * Metoprolol Tartrate Tablet 25 MG via G-Tube every morning (12.5) and at bedtime (12.5). Hold if SBP is less than 110, DBP is less than 60, Pulse is less than 55 BPM related to Essential (primary) Hypertension (when you have abnormally high blood pressure that is not the result of a medical condition). Record review of Resident #1's MAR for June 29, 2023, revealed the following: * Metoprolol Tartrate Tablet 25 MG. Give 12.5 mg via G-Tube every morning and at bedtime. Hold if SBP is less than 110, DBP is less than 60, Pulse is less than 55 BPM related to Essential (primary) Hypertension. 8:00 a.m. BP: 135/60. The entry box was checked and initialed by LVN A, which indicated LVN A administered the medication. Record review of an email Resident #1's family member sent to the ADON and DON on 06/29/2023 at 10:12 a.m. revealed, Subject: Agency Nurse . The nurse this morning just went in the room to give Resident #1's medications and then took his vitals afterwards! We are getting tired of having to police the agency nurses. Resident #1's well being is at stake. Why would a nurse give medicine before taking vitals? This is dangerous and has to stop!! Please talk to her and all of the other agency nurses who either do not know what they are doing or perhaps just do not care! In an interview with the DON on 06/30/2023 at 9:50 a.m., she stated Resident #1 could not communicate, he was bed bound, he had a G-tube, and he required repositioning every two hours. The DON said Resident #1's family member called and said she saw the agency nurse (LVN A) who cared for Resident #1 on 06/29/2023 on camera when she gave him the blood pressure pill before taking his blood pressure. The DON said Resident #1's family member told her she (LVN A) went back and took Resident #1's blood pressure after she gave him the medicine. The DON said she had to look at Resident #1's MAR to see if he had parameters (orders to hold blood pressure medicine if the blood pressure was over or under a given number). The DON said she previously did an in-service in April 2023 (04/07/2023) because staff previously failed to check Resident #1's vitals prior to administering his medication. She said she would do another in-service for all nurses to ensure they checked blood pressure before administering blood pressure medication. She also stated LVN A would be placed on the do not use list and would not be allowed to return to the facility. In a follow up interview with the DON on 06/30/2023 at 1:00 p.m., she stated Resident #1 did have parameters, so every time nurses give blood pressure medication, they have to take his (Resident #1's) blood pressure first. The DON said the problem usually occurred when they had agency nurses in the evenings. She said she would post signs in Resident #1's room to remind nurses to check his blood pressure prior to administering medication. She said she had to figure out where to post the sign, but she should not have to do that (post signs to remind nurses to check blood pressure before administering medication) for nurses. In an interview with the ADON on 06/30/2023 at 3:36 p.m., she stated she just called Resident #1's family member approximately 10 minutes prior to let her know she (the ADON) had just placed a sign in Resident #1's room to make sure nurses (only nurses administered medications) checked blood pressure prior to administering blood pressure medication. The ADON said there was a camera in Resident #1's room, so any time his family questioned something was because they saw it on the camera. The ADON said Resident #1's family member previously expressed concern regarding nurses administering his blood pressure medication before checking his blood pressure. The ADON said Resident #1 had orders to check blood pressure prior to administering medication, but if any resident had blood pressure medication, nurses needed to check before giving the medication to make sure the residents' blood pressure did not go too low. In a telephone interview with LVN A on 06/30/2023 at 3:56 p.m., she stated she was an agency nurse who worked at the facility on 06/29/2023 from 6:00 a.m. until 2:00 p.m. LVN A said she gave Resident #1 his blood pressure medication before checking his vitals on 06/29/2023. She said she knew that was not the correct way to administer the blood pressure medication, but she had to handle a 911 emergency fall across the hall from Resident #1. She said she should always check a resident's blood pressure before administering blood pressure medication. LVN A said she was a little behind with Resident #1's medication and she was told his family watched on his camera. She said she did take Resident #1's blood pressure after administering the medication and it was within the ordered parameters. LVN A said she was overwhelmed with various incidents and that hall was new to her. She said she tried to accommodate all families and resident needs and she knew not to do that again. LVN A said she paused and realized after she gave Resident #1 the medication, and said to herself, she should have taken his blood pressure prior to giving the medication. LVN A said it would not happen again and she realized Resident #1's blood pressure could have dropped too low if it was already low. She said she made sure she checked after she realized her mistake. She said there was no negative outcome with Resident #1. Unsuccessful attempts were made to contact Resident #1's family member on 06/30/2023 at 9:15 a.m. and 7:58 p.m. Voice mail messages and text messages were left but were not returned. Record review of Education/Training Attendance Record dated 04/07/2023 revealed, Training Title: Importance of Vital Signs Prior to Administration of Blood Pressure Medication. 1. Taking vital signs before medication administration is very important. 2. Safety: Vital signs, such as blood pressure, heart rate, respiratory rate, and temperature, can indicate potential health problems or changes in a patient's condition that could affect the safety of medication administration. For example, if a patient's blood pressure is too low, administering certain medications could cause a dangerous drop in blood pressure . 5. Taking vital signs before medication administration is a critical step in ensuring patient safety, monitoring response to treatment, and maintaining accurate documentation . Record review of facility policy, Medication Administration revised February 2023 revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vitals outside the physician's prescribed parameters .

Based on observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary and comfortable environment to help prevent the transmission of infection for 2 of 11 residents (Resident #1, Resident #2) reviewed for infection control in that: -LVN A did not wash her hands after taking Resident #1's blood sugar. -LVN A did not sanitize the glucometer machine after taking Resident #1 blood sugar. -CNA B took disposable wipes from Resident #2 room to another resident room after providing incontinent care for Resident #2. -CNB B did not wash her hands after providing incontinent care for Resident #2. These failures could place residents at risk for infections with the potential for complications and hospitalization . Findings included: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; dementia (condition that impact memory, thinking, and social skills), respiratory failure, morbid obesity, hypertension (high blood pressure), hemiplegia (severe or complete loss of strength) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can effect the arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and diabetes mellitus (elevated blood sugar). Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Record review of Resident #1's Care Plan revised 04/28/2023 revealed that resident was being care planned for diabetes mellitus with intervention that included to monitor blood glucose per order-report abnormal to MD Record review of Resident #1's Physician orders included the following: Accuchecks (blood glucose measuring system) before meals and at bedtime dated 11/27/21. Observation on 05/04/2023 at 4:25pm of blood sugar check for Resident #1 by LVN A. LVN A took the residents blood sugar that that was 145. When LVN A finished taking the resident blood sugar, she removed her gloves and left the resident room without washing her hands. LVN A returned to her medication cart placing the glucometer machine inside of the medication cart without sanitizing the device. Interview on 04/05/2023 at 5:10pm the DON said when the nurse used the glucometer to test a resident blood sugar, the nurse should be sanitizing the machine after each use for infection control purposes. The DON said she would speak with LVN A regarding not sanitizing the glucometer machine after use and infection control prevention. Interview on 05/04/2023 at 5:15pm LVN A said the reason handwashing and sanitizing of resident care equipment should be done prior to and after resident care was to prevent the spread of germs. Resident #2 Record review of Resident #2's face sheet revealed an [AGE] year-old male admitted to the NF on 01/21/2021 with diagnoses that included the following: type 2 diabetes mellitus, chronic obstructive pulmonary disease (group of lung diseases that block airflow making it difficult to breathe), hypertension, heart failure, spinal stenosis (narrowing of the spine), and Parkinson's disease (nerve cell damage in the brain that effects movement in the body). Record review of Resident #2's MDS dated [DATE] revealed that resident BIMS score was 15 indicating that resident cognition was intact. Observation on 05/09/2023 at 12:40pm revealed CNA B provided incontinent care for Resident #2 who was incontinent of urine. When CNA B left out of Resident #2's room she did not wash or sanitize her hands. CNA B proceeded to carry out of Resident #2's room a pack of disposable wipes to room [ROOM NUMBER]. CNA B placed the pack of disposable wipes inside of a drawer. Interview on 05/09/2023 at 1:05pm CNA B said the reason she took the wipes out of Resident #2's room was because some rooms did not have wipes in them. CNA B said and she sometimes had to search for wipes to provide care for the residents. Observation on 05/09/2023 at 1:10pm of the supply room with CNA B revealed 3 large boxes of disposable wipes inside of the supply room. Interview on 05/09/2023 at 1:10pm CNA B said she should have not taken disposable wipes from one resident room to another because of infection control. CNA B said the importance of hand washing was to prevent the spread of germs. Interview on 05/09/2023 at 1:20pm the DON said staff were supposed to wash their hands before and after resident care. In a Ffurther interview with the DON said staff were not to take patient care supplies from one room to another to prevent cross contamination. Record review of the NF policy on Glucometer Disinfection revised October 2022 revealed in part: .The purpose of this procedure is to provide guidelines for disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents and employees . Record review of the NF policy on Standard Precautions Infection Control Protocol dated October 2022 revealed in part: .Hand hygiene after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing PPE, between resident contacts .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 5 residents (Resident #1, Resident #2, and Resident # 3) reviewed for ADLs. -The facility failed to ensure Resident #1 was provided personal grooming (dry skin) by facility staff. -The facility failed to ensure Resident #2 was provided with timely incontinent care by facility staff. -The facility failed to ensure Resident #3 was provided with timely incontinent care and personal grooming (dry skin) by facility staff. These failures could place residents at risk for discomfort, skin breakdown, and urinary tract infections. Findings include: Resident #1 Record review of Resident #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should) macular degeneration (an eye disease that can blur your central vision) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #1's Annual MDS Assessment, dated 03/13/23, revealed the BIMS score was 15 out of 15 which indicated intact cognition. Further review of the MDS revealed he required extensive to total care with one to two staff assistance with all ADL. The resident was always incontinent of bowel and bladder. Record review of Resident #1's care plan, initiated 05/25/21and revised on 03/27/2023, revealed the following: Resident #1 has ADL self-care performance deficit related to CVA deficits, and recent decline in health status. GOAL: the resident would be clean, dry, and well groomed. Intervention: the resident requires extensive assistance with 1 staff assist. Interview on 05/01/23 at 11:23 a.m., Resident #1 said the staff applied lotion on his body when they felt like it, and he could not see his legs and feet and had not refused the aides from applying cream on him. Observation and Interview on 05/01/23 at 11:47 a.m., the DON and CNA A revealed Resident # 1's thighs had about 25 % dry skin, the lower legs had 50% dry skin, and both feet were covered with patches of dry skin. Resident #1 asked CNA A to massage his feet with lotion, and while she rubbed the resident's feet, the skin was flaking off. Interview on 05/02/23 at 12:09 p.m., CNA A said she gave Resident #1 a bed bath on Sunday, 04/30/23, and applied lotion on his skin . She said when a resident was not applied cream, the resident skin could become dry. She said when the resident asked her to massage his feet with lotion, and when she did, the skin was flaking off. She said she had not signed any in-service on preventing resident skin from drying. She said the resident had dry skin from his feet to his thigh. CNA A said dry skin could cause skin breakdown. Interview on 05/02/23 at 1:46 p.m. LVN C said if Resident #1 was not applied lotion or cream after a shower and as needed, it could cause dry skin, which could start to crack and break down. She said Resident#1 had not complained about his dry skin, and the nurses did the weekly skin assessment. She also said the aides had not complained the resident refused lotion being applied on him during grooming. Interview on 05/02/23 at 4:07 p.m., the DON said the staff should put moisturizer cream on Resident # 1 on shower day because the soap dries the resident skin and as needed during grooming. She said if the Resident was not moisturized, it had the potential for skin breakdown. Resident # 2 Record review of Resident #2's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should) hemiplegia (a condition cause by brain injury, that resulted in a varying degree of weakness, stiffness and lack of control in one side of the body) and hypertension(blood is pumping with more force than normal through arteries). Record review of Resident #2's Quarterly MDS Assessment, dated 04/21/23, revealed the BIMS score was 07 out of 15, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive to total care with one to two staff assistance with all ADL (activity of daily living). The resident was always incontinent of bowel and bladder. Record review of Resident #2's care plan, initiated 09/13/2022 and revised on 04/25/2023, revealed the following: Resident #2 was incontinent of bowel and bladder and the goal was to reduce the risk for skin breakdown and promote dignity by keeping the resident clean, dry, and free from odor every shift. Interventions: be sure the resident was kept clean and dry each shift, give incontinent care as needed. Observation and Interview on 05/02/23 at 8:30 a.m., Resident #2 reported that he had not received incontinent care recently and was unsure of how long it had been since he was last changed. Interview on 05/02/23 at 8:35 a.m., CNA A said that she had yet to change Resident #2's brief since starting work that morning. She explained that it was the responsibility of the night aides to change the resident's brief, and she planned to change it after breakfast. Interview on 05/2/23 at 8:40 a.m. with the DON and CNA A, DON said the night aides were making rounds by 6:00 a.m. when she came to work this morning, and when this surveyor asked her if the night aide changed Resident #2, she said she was not sure. CNA A said she came to work at 6:25 a.m., and the night aide was walking out of the door when she came, and she did not give any report. Observation and Interview on 05/2/23 at 8:45 a.m. of Resident #2's incontinent care provided by CNA A revealed Resident #2's incontinent brief was saturated from front to back. The wet indicator was all mashed, the inside was light brown, and it had streaks of bowel movement stains, and the draw sheets had bowel movement stains. CNA A said the brief was heavy and looked like it had not been changed for more than two hours. Interview on 05/02/23 at 10:38 a.m., the Corporate Nurse said CNA B should make rounds and provide incontinent care every two to three hours for Resident #2. She said the resident could have skin breakdown if the resident was not changed timely. During an interview on 05/02/23 at 12:16 p.m. CNA A said she came to work at 6:32 a.m. and was Resident #2's aide. She said she did not change the resident and was waiting to change him after breakfast because breakfast started at 7:30 a.m. She said if Resident #2 was left with a wet incontinent brief, Resident # 2 would have skin breakdown or infection. She said she had in-service on incontinent care, and the aides make rounds every two hours to change the resident. She said the brief was heavy and saturated from front to back. She also said the brief had stained with bowel movements, which meant he was not clean properly when he had bowel movements. In addition, the draw sheet was stained with bowel movement. Interview on 05/02/23 at 4:10 p.m., the DON said CNA A was supposed to round every two hours and provide care as indicated for Resident #2. She said the resident could have skin breakdown if left in a wet incontinent brief. She said the DON, Nurse managers, and the charge nurse monitored the aides and made sure the aides provided care to the residents. The DON said CNA A had skills check for incontinent care. Resident # 3 Record review of Resident #3's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should) hemiplegia (a condition cause by brain injury, that resulted in a varying degree of weakness, stiffness and lack of control in one side of the body) and hypertension(blood is pumping with more force than normal through arteries). Record review of Resident #3's Quarterly MDS Assessment, dated 03/17/23, revealed the BIMS score was 15 out of 15, which indicated intact cognition. Further review of the MDS revealed she was depended on staff, required two or more staff assistance with all ADL (activity of daily living) with exception of eating which required one staff. The resident was always incontinent of bowel and bladder. Record review of Resident #3's care plan, initiated 12/20/21 and revised on 03/20/23, revealed the following: the resident had self-care performance related to activity intolerance, fatigue, hemiplegia, stroke, and mobility. Interventions: bathing/showering; the resident was totally dependent on (2 -5) staff to provide bath/shower. Personal hygiene: the resident required extensive to total assistance by (2 - 5) staff. skin inspection: the resident requires skin inspection, observed for redness, open areas, scratches, cuts, bruises and report to the nurse. Further review of the care plan revealed she was totally incontinent of bowel and bladder related to self-care deficit. Goal: goal was to reduce the risk for skin breakdown and promote dignity by keeping the resident clean, dry, and free from odor every shift. Interventions: be sure the resident was kept clean and dry each shift, give incontinent care as needed. Observation and Interview on 05/02/23 at 8:55 a.m., Resident #3 said she was wet and was changed at 3:00 a.m. Observation of the resident's feet revealed they had dried patches of skin. She said the aides do not apply lotion on her daily. She said she was given a bed bath yesterday, and they applied the cream on her body, and she was unsure if they applied lotion on her feet. She said she did not want her feet to dry but could not see or feel them. She also said she does not want any wounds on her feet from dry skin because it would not heal because she had bad circulation in her feet. Observation and Interview on 05/02/23 at 9:24 a.m. revealed Resident #3's incontinent brief was saturated from front to back, and the wet indicator faded. CNA B said Resident #3's incontinent brief was saturated, and it looked like she had not been changed for more than four hours. She also stated Resident # 3's feet had dry patches of skin, and the resident needed lotion to be applied on her feet. Interview on 05/02/23 at 10:31 a.m., the Corporate Nurse said CNA B should have applied lotion on Resident #3 during shower days and as needed during grooming. She said this would help prevent the resident's skin from drying out. When asked about the adverse outcomes of not applying lotion, the Corporate Nurse asked the surveyor to provide an answer because she knew this surveyor wanted to document it. Interview on 05/02/23 at 12:52 p.m., CNA B said this was her first day because she was an agency aide. She said Resident #3's feet had dry skin patches, and she needed to apply lotion on her feet to prevent skin breakdown. CNA B said Resident #3's incontinent brief had not been changed for a long time and looked and felt drenched. She said it was saturated from front to back. She said Resident #3 would have a wound, rash, and infection if the resident was left in a wet incontinent brief. She said her agency trained her in incontinent care and skin care. She said she came to work around 8:30 a.m. Record review of the facility in service on importance of incontinent care dated 04/17/23 revealed CNA A name was not on the signature that attended the in service. Record review of CNA A's skills checklist for perineal revealed she met the skills, and it was signed on 11/19/22. Record review of the facility policy on skin integrity dated 02/23 read in part . it is the policy of this facility to ensure residents receive proper treatment and care . Record review of the facility's incontinence dated 01/23 read in part . all residents that ae incontinent will receive appropriate treatment and services .

Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of three residents (Resident #9 and Resident #8) reviewed for quality of care. The facility failed to properly identify change in condition for Resident # 9 and Resident #8 who were totally dependent on the staff and prevent facility acquired skin wound. Resident #9 developed a wound on the sacrum while Resident # 8 wound on right buttocks due to moisture associated skin damage. This failure could place residents at risk for a delay of care or treatment, pain, and suffering. Findings include: Resident #9 Record review of resident #9's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, dementia (impair ability to remember things or make decisions that interferes with doing everyday activities), hypertension (persistently raised pressure), heart failure (heart does not pump enough blood for the body use), and Diabetes Meletus (cannot make enough or cannot use insulin as well as it should). Record review of resident #9's annual MDS assessment dated [DATE] revealed on section C1000 revealed resident had severely impaired cognitive decision making. Further review revealed Resident #6 was total dependent on two staff with all ADL care, resident was incontinent of bowel and frequently incontinent bladder and had a colostomy. Record review of Resident #9's care plan revision on 07/13/22/ revealed the resident was total incontinent of bladder and had colostomy and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift. Give incontinent during rounds and as needed, give peri care with facility protocol/policy, and use incontinent products, skin barrier, every shift and as needed. Record review of Resident #9's order summary report for October 2022 read order date: 09/06/22 reads: cleanse sacral moisture associated skin disease (open area just above the buttocks because the area was wet) with normal saline. Pat dry. apply collagen powder and calcium alginate to wound bed. Skin prep to peri wound and cover with dry dressing, daily for wound care. Record review of the wound doctor visit on 09/06/22 revealed site 2 non - pressure sacrum full thickness measured 5.0x3.0 cm Peri wound radius: maceration(soaked), exudate (drainage from wound): moderate serous(watery fluid from wound), slough(dead skin cell in a wound): 30%, granulation tissue(healing tissue on a wound): 70% Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, group 2 mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed, skin prep to peri wound and cover with gauze island dressing. Record review of the wound doctor visit on 09/20/22 revealed site 2 non - pressure sacrum full thickness measured 4.0x3.0.8 cm. Peri wound radius: exudate: moderate serous, slough: 20%, granulation tissue: 80% Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, group 2 mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed, skin prep to peri wound and cover with gauze island dressing. Record review of the wound doctor visit on 09/27/22 revealed site 2 non - pressure sacrum full thickness measured 3.9x3.5 cm. Peri wound radius: maceration, exudate: moderate serous, slough: 80%, granulation tissue: 20% Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, group 2 mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed, skin prep to peri wound and cover with gauze island dressing. Record review of the wound doctor visit on 10/04/22 revealed site 2 non - pressure sacrum full thickness measured 3.6x3.02 cm. Peri wound radius: maceration, exudate: moderate serous, slough: 30%, granulation tissue: 70% Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, group 2 mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed, skin prep to peri wound and cover with gauze island dressing. Record review of the wound doctor visit on 10/11/22 revealed site 2 non - pressure sacrum full thickness measured 3.2x3.1 cm. Peri wound radius: maceration, exudate: moderate serous, peri wound maceration, thick adherent devitalized necrotic tissue:10%, slough: 10%, granulation tissue: 80% Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, group 2 mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed, skin prep to peri wound and cover with gauze island dressing. Interview on 10/06/22 at 2:30 p.m., the DON said she said Resident #9 developed MASD (moisture-associated skin damage) on 09/0/22. She said MASD occurred when a resident was not kept clean and dry. She stated the resident was dependent on staff for care. She said if a resident was left wet for an extended period, the area could become macerated. She also said when a resident was dragged on the bed, it could open the site because the area was already compromised. She said it was a preventable injury if care was provided timely, but the wound care doctor sees the resident every week. The resident is being turned every 2 hours, and incontinent was offered timely. Observation on 10/11/22 at 4:45 p.m., Resident # 9 was lying on his back with a wedge under his right shoulder. The resident's incontinent brief was wet with urine. Interview on 10/11/22 at 4:48 p.m., CNA F said she was Resident #9 aide, and he was lying on his left side because the wedge was under his right shoulder. She confirmed the Resident's back was on the mattress and that she was trained to turn the Resident to the side. She said she did not know if pressure was relieved from the wound site because the bottom was on the bed. She said she would not change the Resident's incontinent brief because the Resident was on scheduled turn time. She said she changed the Resident at 12:00 a.m. and 2:00 a.m. CNA F stated the subsequent change would be at 6:00 a.m. even though his incontinent brief was wet, and he had a wound. She said it was the family that passed the turning schedule times on the wall in the resident's room. Interview on 10/11/22 at 7:39 a.m. the DON said she was unsure if the Resident # 9 was on scheduled turning time and would check and get back to the surveyor. She stated the resident buttock should be off the mattress to relieve pressure on the wound, which was on the sacrum. She said if a resident wet, the resident should be changed regardless of if the resident was on turning schedule. She said she could not remember if she discussed the turning and repositioning schedule with Resident # 9's responsible party. Observation on 10/11/22 at 8:32 a.m. with the wound care doctor revealed Resident #9 wound on the sacrum was shallow (not deep) and had about 20% slough and it measured 3.2 x3.1x0.1 cm and the wound doctor debrided (removed damaged tissue) the wound. Interview on 10/11/22 at 9:23 a.m., the wound care doctor said Resident #9's wound was on a pressure site, and he would not classify it as pressure because the first time he saw Resident #9, the macerated area was from moisture and the wound was shallow. He said the macerated site might not open if the area was kept dry and not dragged, which could cause shearing (opening or tearing the skin). If the area is not taken care of, it opens up and must be treated until it is healed. He said if the Resident were kept clean and dry, the area would not have gotten macerated. He stated he recommended for the facility follow its protocol for wound care. Resident #8 Record review of Resident #8's Face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses were, cerebral infraction (necrotic tissue in the brain due to lack of oxygen), dementia (impair ability to remember things or make decisions that interferes with doing everyday activities), hypertension (persistently raised pressure), and hemiplegia (cause by brain injury that results in a varying degree of weakness or stiffness on one side of the body). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS of 09 indicating moderately impaired cognition. Further review revealed Resident #8 needed extensive to dependent assist with ADL care with one to two staff assistance resident was incontinent of bowel and had a foley in the bladder. It also revealed the resident did not have any pressure upon admission. Record review of Resident #8's care plan revision on 07/26/22 revealed the resident was total incontinent of bowel and foley in the bladder and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift. Give peri care with facility protocol/policy and monitor skin breakdown and report immediately. Record review of Resident #8's skin assessment upon admission on 07/18/22 revealed resident skin was clean and intact. Record review of Resident #8 skin assessment on 08/01/22 revealed the sacrum had developed deep tissue injury (area beneath the skin indicating damage by bruising/discoloration). Record review of Resident #8's order summary report dated October 2022 read: Foley catheter type 16 French 30ml (milliliter). Diagnosis urinary retention, date 08/05/2022. Record review of the facility non - pressure dated 09/27/22 (MASD) moisture associated skin disease, assessment revealed Resident #8 developed MASD on 09/06/22 on the buttocks. Record review of Resident# 8's Braden scale dated 08/01/22 revealed score of 15 which meant the resident was at risk for skin break down. Record review of Resident #8 wound doctor visit on 09/06/22 revealed site 2 non - pressure wound buttock full thickness measured 3.5x3.0 cm. Plan of care reviewed and addressed: off- load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8's wound doctor visit on 09/20/22 revealed site 2 non - pressure wound buttock full thickness measured 3.5x3.0 cm. Plan of care reviewed and addressed: off- load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8's wound doctor visit on 09/27/22 revealed site 2 non - pressure wound buttock full thickness measured 2.4x2.0 cm. Plan of care reviewed and addressed: off- load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8's wound doctor visit on 10/04/22 revealed site 2 non - pressure wound buttock full thickness measured 2.2x2.0 cm. Plan of care reviewed and addressed: off- load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8's wound doctor visit on 10/11/22 revealed site 2 non - pressure wound buttock full thickness measured 2.2x0.8cm. Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Interview on 10/06/22 at 2:30 p.m., the DON said Resident #8 developed MASD on 09/06/22, but Resident #8 was on hospice. She said MASD occurred when a resident was not kept clean and dry. She said Resident #8 was dependent on staff for care. She said if a resident was left wet for an extended period, the area could become macerated and open. Interview on 10/11/22 at 9:23 a.m. wound care doctor said Resident #8's MOSD MASD was on the right buttocks. He said the same scenario from Resident #8 applied to Resident #8. He said he recommended that the facility follow its wound care protocol(turning and repositioning and supplements) . Interview on 10/12/22 at 3:49 p.m., CNA G said today was her first time working with Resident #8 and she only knew she had two dressings on her buttocks. She said she turned and repositioned Resident #8 today but could not remember when she turned her last in this shift. She said residents with wounds are turned and moved every two hours and changed residents every two hours to prevent skin breakdown, and if the resident is left wet for a long time, the skin will break down. Interview on 10/12/22 at 4:02 p.m. LVN E said she does not do wound care, because the facility had a wound care nurse, but she does PRN wound care when the dressing gets soiled from bowel movement and the wound care nurse was not in the facility. She said if a resident especially does that, depending on the staff, like Resident #8 would have skin breakdown when she was not changed and kept clean because she could not do it for herself, the area would open. Interview on 10/13/22 at 10:54 a.m., the DON and Administrator said if a resident is not changed and cleaned frequently, it would cause MASD because the resident depended on the staff. The DON said the facility has no policy on quality of care or any other wound that was not a pressure ulcer.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 5 of 8 residents (Resident #8, Resident #11, Resident #6, Resident #5, and Resident #10) reviewed for incontinent care in that: -CNA G and LVN E did not completely clean Resident #8 during incontinent care revealed Resident # 8's peri area, upper thigh and her rectum area was red, and the resident said it hurt and she cried. -CNA B did not completely clean Resident #11 during incontinent care revealed the peri area was red and the resident stated it hurt. -CNA E did not completely clean Resident #6 during incontinent care. -CNA D and LVN B did not completely clean Resident #5 during incontinent care. -CNA F did not completely clean Resident #10 during incontinent care. These failures could affect residents who were incontinent and place them at risk for urinary tract infections, discomfort, skin breakdown, and a decreased quality of life. Findings include: Resident #8 Record review of Resident #8's Face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses were, cerebral infraction (necrotic tissue in the brain due to lack of oxygen), dementia (impair ability to remember things or make decisions that interferes with doing everyday activities), hypertension (persistently raised pressure), and hemiplegia (cause by brain injury that results in a varying degree of weakness or stiffness on one side of the body). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS of 09 indicating moderately impaired cognition. Further review revealed Resident #8 needed extensive to dependent assist with ADL care with one to two staff assistance resident was incontinent of bowel and had a foley in the bladder. It also revealed the resident did not have any pressure ulcer upon admission. Record review of Resident #8's care plan revision on 07/26/22 revealed the resident was total incontinent of bowel and foley in the bladder and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift. Give peri care with facility protocol/policy and monitor skin breakdown and report immediately. Record review of Resident #8's skin assessment upon admission on 07/18/22 revealed resident skin was clean and intact. Record review of the facility non - pressure dated 07/29/22 (MASD) moisture associated skin disease, assessment revealed Resident #8 developed MASD on 09/06/22. Record review of Resident #8's skin assessment on 08/01/22 revealed the sacrum had developed deep tissue injury. Record review of Resident #8's Braden scale dated 08/01/22 revealed score of 15 which meant the resident was at risk for skin break down. Record review of Resident #8's order summary report dated October 2022 read: Foley catheter type 16 French 30 ml (milliliter). Diagnosis urinary retention, date 08/05/2022. Record review of Resident #8's order summary report dated October 2022 read: Morphine Sulfate (Concentrate)solution 20 ml, give 1 ml by mouth every 2 hours as needed for pain or shortness of breath related to other chronic pain, dated 08/09/22. Record review of Resident #8's order summary report dated October 2022 read: Norco tablet 5 - 325 mg (Hydrocodone - acetaminophen) give 1 tablet by mouth three times a day related to other chronic pain, dated 08/09/22. Record review of Resident #8's wound doctor visit on 09/06/22 revealed site 2 non - pressure wound buttock full thickness measured 3.5x3.0 cm. Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8's wound doctor visit on 09/20/22 revealed site 2 non - pressure wound buttock full thickness measured 3.5x3.0 cm. Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8 wound doctor visit on 09/27/22 revealed site 2 non - pressure wound buttock full thickness measured 2.4x2.0 cm. Plan of care reviewed and addressed: off- -load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8 wound doctor visit on 10/04/22 revealed site 2 non - pressure wound buttock full thickness measured 2.2x2.0 cm. Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Record review of Resident #8 wound doctor visit on 10/11/22 revealed site 2 non - pressure wound buttock full thickness measured 2.2x0.8 cm. Plan of care reviewed and addressed: off - load wound: reposition per facility protocol: turn side to side, and front to back in bed every 1 to 2 hours, low air loss mattress. Dressing: antifungal to peri wound, alginate calcium on wound bed and cover with gauze island dressing. Observation on 10/12/22 at 3:25 p.m. revealed CNA G and LVN E provided incontinent care for Resident # 8. CNA G donned (putting on gloves) her gloves and did not wash her hand, took off Resident #8's dirty brief, and provided care for the Resident without separating her legs or labia. CNA G put her hand between her legs and wiped the Resident. She cleaned the Resident with one wipe multiple times and took wipes from the container with the dirty gloves that had a bowel movement , and the Resident was crying and said it hurt . She used the same gloves throughout the care. When she was about to apply, a clean incontinent brief surveyor intervened. Then she separated the resident legs with the assistance of the charge nurse it revealed that the peri area to the inner upper thigh was very red. There was bowel movement on the wipes when she wiped Resident's peri area three times. She turned the Resident to her side, and the Resident had another bowel movement. She took off her gloves without washing her hands. She went into the Resident drawer and brought another brief and wipe packet because the previous one was almost empty. She took another glove from her uniform pocket and donned it without washing her hands. She separated the resident buttocks, and her anus was very red, and the Resident kept saying it hurt, and she cried throughout the care. Interview on 10/12/22 at 3:49 p.m., CNA G said today was her first day working with Resident #8. When she saw the redness, she said she told her nurse, and LVN E gave her barrier cream (skin protection) and she applied it on the resident. She said the resident was saying that it hurt, and she was crying. She said she used one glove throughout the care. CNA G said she took off her gloves but did not wash her hands and went into the resident drawer and took another brief and wipe packet. She took gloves from her uniform pocket and donned it an continued to provide care for the resident and used the same gloves to take wipes from both packets. She said she should have wiped the resident more than once with wipes. She said she contaminated the wipe container and may have transferred her germs to the resident. She said she should have separated the resident's legs and labia and cleaned the resident well the first time. She said if Resident #8 was not properly cleaned, the resident may get an infection or skin breakdown, just like the red area on the resident. She said she was in - serviced on hand washing and infection control, and she also has skills - check off, including incontinent care. Interview on 10/12/22 at 5:00 p.m., the DON said she was unaware the Resident had redness in her peri area, which was the first time she heard about it. She looked through her computer and said sometime in September 2022, Resident #8 had redness, and hospice said they would bring cream that would be applied to the Resident. She said she did not know where the cream was, but they would look for it. The DON stated Resident #8 could develop redness if proper and timely incontinent care was not provided. She said the way the nurse described the red area showed it did not just happen. She said the nurse should make rounds and check on residents and the nurse managers also makes random rounds to check on the residents. Interview on 10/13/22 at 11:33 a.m., the DON said Resident #8 was admitted to hospice on 08/25/22. The DON said she had not seen the area as of today. The DON said if a resident was not provided incontinent care timely and adequately, it could cause the Resident to have redness that would be painful. She also said she could not find the cream from hospice, but they applied the facility incontinent brief, and they now have an order for nystatin powder (medicated powder) and it would be applied as soon as it delivered. Interview on 10/13/22 at 11:55 a.m., Unit Manager A said the nurse told her yesterday about the red area on Resident #8. LVN E called hospice after incontinent care was provided to Resident #8, which the surveyor observed, and got an order for nystatin, which would be applied three times a day. She said if a resident was left wet for an extended period of time and care was not appropriately provided during incontinent care, that could cause a skin breakdown. The discomfort from the skin breakdown could cause a resident to cry during incontinence care. She said the aides should separate Resident #8 labia when providing care to make sure the resident was cleaned well. She said gloves should not be carried in staff uniform pockets or used on the resident. CNA G should have washed her hand before donning her gloves and changed gloves when going from dirty to clean. She said there were a lot of infection control issues, and she could transfer her germs to the resident when she used the gloves from her uniform pocket. Resident #11 Record review of Resident #11's Face sheet revealed an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses were, hypertension (persistently raised pressure), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), lack of coordination and osteoporosis (when bone mineral density and bone mass decreases). Record review of Resident #11's significant change MDS assessment dated [DATE] revealed a BIMS of 05 indicating severely impaired cognition. Further review revealed Resident #11 needed limited to extensive assist with ADL care with one staff assistance resident was incontinent of bowel and frequently incontinent bladder. Record review of Resident #11's care plan revision on 05/22/22 revealed the resident was total frequently incontinent of bowel and bladder and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift, monitor for skin break down and report to the doctor. Observation on 10/11/22 at 5:55 a.m. Revealed CNA B donned gloves she took from her uniform pocket without washing or sanitizing her hand and started to provide incontinent care to Resident #11. The resident's incontinent brief was wet but not saturated. During the incontinent care, CNA B did not separate the resident's labia or buttocks and used the same gloves throughout the care. When she was about to apply a clean brief, the surveyor intervened. She then separated both areas and wiped each area three times. There was a yellow color substance from the labia area, while there was bowel movement from the anal area. She used the same gloves throughout the care and pulled wipes from the container. Resident # 11 peri area had redness and was not blanchable (the area stayed red) when the aide pushed on it. The resident said it hurt when the aide was producing care. Interview on 10/11/22 at 6:05 a.m. CNA B said she applied barrier cream on Resident #11 when she provided care to her earlier. She said she had been off for some days, and it was not this red before she was off. She said if Resident # 11 was not provided care and cleaned very well, applied barrier cream, the resident may have a skin breakdown, and redness is a sign of skin breakdown. CNA B said she forgot to separate the labia and buttocks and clean the resident thoroughly because she did wipe out a yellow substance when she separated the labia. CNA B said when she separated the resident buttocks and cleaned the anus there was bowel movement. She said should had separated the labia and buttocks and cleaned out very well to prevent Resident #11 from getting UTI. She said she was not supposed to use gloves in her pocket to care for the resident because of infection control. She could transfer her germs to the resident, and the resident could become sick. She said she should have washed her hands before she started incontinent care and changed her gloves when going from one area of the body to another and going from dirty to clean . Interview on 10/11/22 at 7:31 a.m., DON said she was unaware Resident #11 had any redness in the peri area. She said they must prepare the incontinent supplies in a bag and set up a clean field with wipes, gloves, and hand sanitizer. They can use the sanitizer up to three times before they wash their hands. She said gloves are changed when going from one body area to another and applying clean briefs. She stated the aide should separate Resident #11 labia and buttocks and clean them properly to prevent infection and skin breakdown. The DON also said the aide should apply barrier cream with every incontinent care. Resident #6 Record review of Resident #6's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, cerebral infraction (necrotic tissue in the brain due to lack of oxygen), atherosclerotic heart disease (thicken or [NAME] of the arteries caused by a buildup up plaque), hypertension (persistently raised pressure), and hemiplegia (cause by brain injury that results in a varying degree of weakness or stiffness on one side of the body). Record review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 indicating intact cognition. Further review revealed Resident #6 needed extensive assist with ADL care with two staff assistance resident was incontinent of bowel and frequently incontinent bladder. Record review of Resident #6's care plan revision on10/05/22 revealed the resident was total incontinent of bowel and bladder and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift. Give incontinent care every two hours and as needed. Observation on 10/05/22 at 5:40 p.m. revealed that CNA E and CNA C provided incontinent care to Resident # 6; the incontinent brief was saturated. Resident # 6 had a bowel movement as soon as CNA E opened the brief. She changed her gloves more than three times, but she did not wash or sanitize her hands. She did not separate the resident buttocks when she wiped the resident. When the surveyor intervened, she was about to apply a clean brief on the resident. She then separated the buttocks, and she wiped the resident four times, and there was bowel movement on the wipes, and it was clean on the fifth wipe. Interview on 10/05/22 at 6:13 p.m. CNA E said she changed her glove about 5 to 6 times but did not wash or sanitize her hand. She said she forgot to separate the resident buttocks and his legs and made sure there was no bowel movement. CNA E said when she was about to apply a clean brief because she had finished cleaning the resident and the surveyor intervened, she had to clean the anal area four times and in between his legs, and there were bowel movements. She said she did not completely clean Resident #6, and he could get an infection or skin breakdown. She said she received skills - check-off, and incontinent care was included. Interview on 10/06/22 at 9:37 a.m., the Administrator said the facility's expectation for incontinent care was to apply proper sanitation and clean all the areas of the body thoroughly. She said if Resident #6 was not cleaned well, it could cause infection and skin irritation or breakdown. She said the staff should sanitize her hand or wash her hand each time she changed gloves during care to prevent cross-contamination. Interview on 10/06/22 at 2:22 p.m., the DON said She said during incontinent care, the aide should sanitize hands up to three times and then wash their hands on the fourth glove change. She said Resident #6 could get UTI (urinary tract infection), mainly skin breakdown, if the staff did not clean the resident thoroughly. She stated the aide should have separated Resident #6 buttocks to see the rectum area and ensured it was cleaned. She said the charge nurse monitors the aides, and the unit manager and DON make rounds and check on the residents. Resident #5 Record review of Resident #5's Face sheet revealed a 45year-old female was admitted to the facility on [DATE]. Her diagnoses were, cerebral palsy (abnormal brain development or damage to the developing brain), peripheral vascular disease (narrowing, blockage, or spasms in a blood vessel), morbid obesity (excess of body fat greater than 40 percent of body mass index), and intellectual disabilities (limits to a person's ability to learn at an expected level and function in a daily life). Record review of Resident #5's admission MDS revealed it was not done because it was not due, and she was a new admission. Record review of Resident #5's baseline care plan dated 10/06/22 revealed resident was extensive/dependent assist with for ADL care required one to two staff assistances. Observation on 10/11/22 at 3:56 a.m. revealed Resident #5's incontinent care was provided by CNA D, and LVN B came and assisted CNA B later. Resident #5's, incontinent brief, was saturated with urine; her gown and draw sheet were also wet. When CNA B started to give incontinent care to the resident, it was revealed that CNA D did not wash her hand. She used the same gloves throughout the care. She pulled wipes from the container with her dirty gloves and wiped the resident multiple times with one wipe. She did not separate the labia or the buttocks when she cleaned the resident. When the surveyor intervened, she was about to apply a clean brief on the resident. She then separated the labia and wiped three times, and each time she wiped out bowel movements. She wiped out bowel movements when she separated the buttocks and wiped the rectum. Finally, she changed the wet draw sheet but did not wipe the damp mattress and placed another draw sheet and applied a clean incontinent brief on the resident. Interview on 10/11/22 at 4:18 a.m., CNA D said Resident # 5 did not have a bowel movement when she changed her; maybe whoever cleaned her before she took over the shift did not wash her well. CNA D said she should have separated the labia then she would have cleaned the bowel movement when she changed her earlier. She said she should separate the buttocks and clean the rectum. She said she should not have wiped the resident more than once with one wipe. CNA D said it was cross-contamination when she did not change her gloves during care and also used the gloves to pull wipes from the container. CNA D also said she did not disinfect the mattress before the resident laid back on the bed, and those were infection control issues because it was cross-contamination. She said if Resident # 5's vagina was not cleaned well, she would develop UTI or skin breakdown. Interview on 10/11/22 at 5:08 a.m., LVN B said that when he came to assist CNA D with incontinent care, she had wiped Resident #5 perineal area, and he helped her turn the resident to her side. She wiped the back area, and he did not realize she did not separate the resident buttocks until the surveyor intervened when she was about to apply the clean incontinent brief. When she separated the resident perineal and buttocks and cleaned these areas, there were bowel movements. He said if Resident # 5 were not cleaned completely over time, the resident would develop infection and skin breakdown. LVN B stated CNA D should have disinfected the bed before she placed a clean draw sheet to prevent cross-contamination. He said he was not sure if she changed her gloves during care. He said gloves should be changed when going from dirt to clean. Interview on 10/11/22 at 7:36 a.m., the DON said the same issues with above residents that were not provided appropriate care could cause the same negative outcome since the aides did not follow infection control measures such as: washing hands before the start of care, in between care and changing gloves, separating the labia and buttocks, and clean Resident # 5 completely to prevent skin breakdown and infection. Resident # 10 Record review of Resident #10's Face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, hypertension (persistently raised pressure), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Parkinson's disease (brain disorder that cause unintended or uncontrollable movements) and neurocognitive disorder with Lewy bodies (decreased mental function due to medical disease.) Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed in section C the resident had severely impaired cognitive decision marking. Further review revealed Resident #10 needed total assist with ADL care with one to two staff assistance resident was incontinent of bowel and bladder. Record review of Resident #10's care plan revision on 07/28/22 revealed the resident was total incontinent of bowel and bladder and had an ADL self - care deficit. Intervention: be sure resident is kept clean and dry every shift. Observation on 10/11/22 at 5:25 a.m. revealed CNA F provided incontinent care to Resident #10, and her incontinent brief was not saturated. CNA F donned gloves without washing her hand, used the same glove throughout the incontinent care, and pulled wipes from the container with the same gloves. She did not separate the labia or buttocks during incontinent care. She was about to apply clean brief when the surveyor intervened. Then she separated both areas and wiped each area twice, and there were bowel movements on the wipes. Interview on 10/11/22 at 5:39 a.m., CNA F said she forgot to separate Resident #10 labia and buttocks during care. She stated she provided care with the same glove and pulled wipes from the container. CNA F said she contaminated the wipe container and should have changed her glove when she finished cleaning the resident, sanitized her, and donned another glove to prevent cross-contamination. She said she wiped out bowel movements from both areas, and if Resident #10 was not cleaned properly, she could get an infection, redness, and skin breakdown. CNA F said she had skills - check off and in-service on infection control which included hand washing. Interview on 10/11/22 at 11:58 p.m., the ADON said the aides should separate Resident #10's labia and buttocks should be cleaned until there was no bowel movement on the wipe. ADON said if Resident #10 was not cleaned thoroughly, it could cause redness, infection, and skin breakdown. ADON said the aides must set up a clean field with the supply laid out, that was what she taught the aides during training, and gloves are changed as needed at least three times. She said the aide should sanitize in between glove changes. They are not supposed to go back to the wipe container with the dirty gloves because they contaminate the wipes. ADON said the charge nurse monitors the aides, and nursing managers monitor the nurse by making random rounds and checking PCC (point click care) for compliance. Record review of the facility policy on perennial care dated 2001 MED - PASS, Inc. (Revised December 2011) read in part . the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe residence skin . Steps in the procedure. #9b1 . Separate Labia and wash away . #9e. Wash the rectal area thoroughly . Record review of the facility policy on hand washing dated 2001 MED - PASS, Inc. (Revised August 2015) read in part . the facility considers hand hygiene the primary means to prevent the spread of infection . policy interpretation and implementation . #7b before and after direct contact with residents . #7h before moving from a contaminated body side to a clean body side during resident care . #9 the use of gloves does not replace hand washing . Record review of the facility policy on infection control dated 2001 MED - PASS, Inc. (Revised August 2007) read in part . the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infection . Record review of the facility hand hygiene competency validation. Revealed CNA F received training on 06/08/22 and CNA proficiency skills for peri - area on 06/08/22. Record review of the facility hand hygiene competency validation. Revealed CNA B received training on 08/16/22 and CNA proficiency skills for peri - area on 09/10/22. Record review of the facility hand hygiene competency validation. Revealed CNA C received training on 09/06/22 and CNA proficiency skills for peri - area on 09/04/22. Record review of the facility hand hygiene competency validation. Revealed CNA E received training on 09/13/22 and CNA proficiency skills for peri - area on 09/13/22.

Based on record review, interview, and review of the facility's abuse policy, the facility failed to ensure two of six residents (Resident R2 and R4) reviewed for abuse, out of a total sample of 26 residents, were protected from abuse by conducting a thorough investigation of the resident's allegation of abuse with named perpetrators. The facility's failure to thoroughly investigate any/all allegations of abuse, and failure to suspend the alleged perpetrators during abuse investigations placed all of the residents in the facility at an increased risk of continued abuse pending the outcome of an investigation. Findings included: Resident R2 Record review of Electronic medical record (EMR) review revealed on 11/01/20 at 9:15 PM, the ADON documented in R2's progress notes, located in the Progress Notes tab of the EMR, Patient stated that CNA while giving care to her was rough. She stated that CNA grabbed and squeezed her neck, grabbed her left arm and legs. She asked CNA do you want to kill me. She reported [sic] to her daughter and daughter called facility and laid the complaint. Patient repeated same statement before nurse. Head to toe assessment completed. No fresh scratch or bruising or marks of hand noted on the neck or arms and legs. However, patient c/o [complaint of] neck and left shoulder pain at 3/10 (pain scale 1-10 with 10 being intolerable pain). Nurse reassured her for her safety and removed CNA from the floor. There was no evidence that this allegation was reported to the Administrator at the time of the allegation; or that facility staff investigated this allegation to determine the root cause of the allegation and which certified nursing assistant (CNAs) were involved. Additionally, the facility failed to suspend the alleged perpetrators pending the outcome of the investigation to protect this resident and the other residents in the facility at the time the allegation was made. An attempt was made to contact R2's daughter by phone. No return call was received prior to exiting the survey. Interview with the Administrator on 07/21/21 at 5:30 PM, revealed that on 11/01/20 (time unknown) R2's daughter called him to notify him that R2 felt as though staff had been rough with her. The Administrator could not provide any documentation of this interview with R2's daughter. Review of a written statement dated 11/02/20, indicated that the Administrator interviewed R2 who stated that yesterday the helper came into my room and spilled water over my blanket and tried to unplug my phone from the wall, when I asked her for her name, she just stared at me and did not say a word. I do not want to be here I do want to go home. Interview with the Administrator on 07/21/21 at 5:30 PM, revealed that based on the interview with R2, he did not believe the resident was abused, so he did not conduct an investigation, or report it to the police, and did not report the allegation to the State Survey Agency per federal regulations. The Administrator was shown R2's nurse's note dated 11/01/21 at 9:30 PM written by the ADON. The Administrator stated that he was not aware that the ADON had documented alleged abuse in R2's progress notes. In an interview with the ADON on 07/22/21 at 11:15 AM, he stated that the expectation is, when an allegation of abuse is made first is to separate the two parties, in this case the resident and staff. Then call the DON and Administrator. When asked why he did not suspend the staff, the ADON stated he did not think he had that authority that he was just a floor nurse. Interview with the DON on 07/22/21 at 11:17 AM, stated the ADON can send staff home if necessary and that is addressed in the facility's abuse policy. Follow up interview with ADON on 07/22/21 at 12:11 PM revealed that he called the former DON and Administrator at the time he documented the abuse allegation in R2's progress note. The ADON was unaware what steps they took after he notified them or if there was an investigation. Resident R4 Review of R4's undated Face Sheet found in the electronic Medical Record (EMR) revealed R4 was originally admitted on [DATE] and re-admitted [DATE] with diagnoses including Type II diabetes mellitus with diabetic [CONDITION(S)] and [CONDITION(S)]. Review of R4's EMR revealed that on 06/09/21 (time unknown) the facility's Medical Director interviewed R4 who explained that she felt a CNA was rough with her last night during incontinence care. The Medical Director checked her for injuries and referred the matter to the Interdisciplinary Team (IDT). This message was reported to the administrator on 06/18/21 via email, 10 days after the alleged event. Interview with the facility's Administrator on 7/21/21 at 5:30 PM, stated that he checked the security cameras and found that an X-Ray technician had been in R4's room at or around the time the resident states a CNA handled her roughly. The Administrator did not indicate (or have documentation that supported) how he narrowed the time of the alleged abuse to coincide with the time the X Ray technician visited. The facility requested a statement from the technician which was provided to the facility via email on 6/11/21 (three days after the alleged event). The X-Ray technician indicated in the statement that she went into R4's room, informed her that she was going to do an X-Ray and said R4 did not respond. She stated I placed the board behind her back to perform the X-Ray and I lifted her shoulders to get the board behind her back. I took the X-Ray and told her I was done and would leave when I clean the equipment. Record review of the report made to the State Survey Agency on 06/18/21 indicated that a review of the facility's surveillance camera footage revealed that on the evening of 06/08/21, three staff members (the facility did not identify these staff member) went inside R4's room during the 3:00 PM to 11:00 PM shift. The report indicated The resident was inconsistent on her account of what happened. The resident mentioned to the attending physician she had hit her head somewhere but not sure when. She also gave different accounts to the police. An attempt was made to contact the responding officer by phone, but the officer was not on duty and no return call was received prior to survey exit. The facility did not provide the documented police report as requested. The facility interviewed five residents, two residents on 6/12/21 (four days after the alleged event) and three other residents with no dates on the documents. The facility interviews centered around the notion of how residents should report abuse and asking them do you feel safe? There were no negative resident responses based on these interviews. There is no evidence the facility interviewed the three staff observed on the video surveillance camera to enter R4's room. The alleged perpetrators continued to work without suspension pending the outcome of the investigation. Interview with the Administrator on 7/21/21 at 5:30 PM as to why the three CNAs were not suspended or interviewed, the Administrator stated that was because R4's story changed from the police to the medical director to staff interview. The X-Ray technician provided a statement that she was in the room at the time this event may have occurred and did not notice any negative interactions with R4 so we didn't consider it abuse. Record review of the facility policy entitled Abuse Prohibition Policy and Procedure, dated 2018, indicates on p.7 under INVESTIGATION, that all allegations resident abuse, neglect, exploitation, misappropriation of resident property and or injuries of unknown source shall be promptly reported to state and local agencies and thoroughly investigated by the facility management. The document continues by stating any alleged violation involving abuse, neglect or exploitation of a resident will be reported to the facility administrator IMMEDIATELY. The administrator will notify local police department and retrieve the appropriate paperwork from the investigating officer. The policy further indicates that any alleged staff member would be suspended pending the outcome of the abuse investigation.

Based on interview and record review the facility failed to ensure residents were free from abuse and neglect for 5 (Residents #1, CR#2, Resident#3, CR#4, Resident #5) of 12 residents reviewed for abuse and neglect as evidence by: Resident #1 was found sexually abusing CR#2 in her bedroom. CNA B left CR#2 alone with Resident #1 alone while he was sexually abusing CR#2. Resident #1 was found in Resident #3's bedroom after an incident of sexual abuse with CR#2. Resident #3's covers was pulled back and one side of her brief was unsnapped. LVN A failed to document an assessment after the incident between Resident #1, CR#2 and Resident #3. Resident #1 was overheard asking CR#4 to touch him on his private area. LVN D failed to report an incident of sexual inappropriate behavior to the Administrator between Resident #1 and CR#4. Resident #1 was found touching Resident #5's breast in the hallway. LVN F failed to complete an assessment after the incident between Resident #1 and Resident #5. The facility failed to address Resident #1's inappropriate behaviors/touching toward female residents. The facility failed to investigate incidents of inappropriate sexual behaviors. An Immediate Jeopardy was identified on 07/07/21 at 12:48 PM. While the Immediate Jeopardy was removed on 07/11/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. This failure could place vulnerable residents at risk for abuse causing harm and a diminished quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's significant change MDS dated [DATE] revealed Resident #1 had a BIMS of 10 which meant he had moderate cognitive impairment. Record review of the care plan dated 06/29/21 revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was verbally aggressive with staff and physically aggressive with staff. Staff were to administer medication as ordered and monitor/document for side effects and effectiveness. Staff were to anticipate and meet the resident's needs, caregivers are to provide opportunity for positive interaction and attention. Staff are to stop and talk with him/her as passing by, encourage to attend social activities of preference. Staff are to minimize potential for resident's disruptive behaviors by offering tasks which divert attention such as offering TV time in day area, monitor behavior episodes and attempted to determine underlying cause. Staff are to consider location, time of day, persons involved and situations. Document behavior and potential causes. Staff are to provide psych consult per MD order. Record review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 had a score of 2. Resident #1 was not at risk for elopement/wandering. Record review of Resident #1's clinical record revealed no nurse progress note of assessment, incident report or S-BAR documented for the incident with CR#2 and Resident #3 on 07/03/21 by LVN A when reviewed by surveyor on 07/04/21. Record review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Chief Complaint: Falls, Sexual aggression . History of Present Illness: . Patient is very impulsive. Not currently on therapy. Nurse requested evaluation due to patient sexual aggression towards another resident, states that patient is an appropriate session resident on yesterday on her shift in her breast area, states that resident is always asking about this particular resident. Nurse on duty today reports that no sexual aggression noted, states that she is only heard information on 2 occasions about patient touching another resident Assessment & Plan .Sexual inappropriateness/sexual breast - new problem - no adjustments of current medication, and possible treatment. Patient referred to psych services for evaluation or follow-up .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per NP. Observation and interview on 07/04/21 at 2:22 PM, revealed Resident #1 was sitting in wheel chair with staff monitoring him. Resident #1 was dressed, groomed, no visible signs of injury. Resident #1 stated he hurt all over, resident confused, resident could not recall the incident with CR#2. CR#2 Record review of CR#2's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#2's MDS dated [DATE] revealed she had a BIMS of 00 which meant she had severe cognitive impairment. Record review of the CR#2's nurse notes dated 7/3/2021 revealed .Received notice from resident's . requesting to call Methodist Willowbrook to provide type of tube feeding diet and rate. Spoke with .RN at the observation unit where resident is currently at and provided them with the diet. Resident receives [MEDICATION(S)] 2.0 250ml 4X a day. called and updated . Per DON Record review of CR#2's nurse progress notes revealed .7/5/2021 10:18 Nurse's Note Text: cna stated she found male resident in this resident room performing sexual behaviors. she then stated she tried removing resident and he became combative. she came in room next door where I was giving care to another resident at the time to inform me of what was taking place and stated she needed my help. I asked her to get the other nurse to come help her as I was giving care to another resident. once I was done giving care the cna and nurse had removed the male patient and had him sitting in day room on couch where he continued inappropriate behaviors by masturbating. once I left resident room I went back to this room to assess her. upon returning to the nurses station I asked the male resident to pick his pants up and stated that it wasn't nice and he could get in trouble. he stated he don't give a damn call the police and tried to swing at me. I immediately stepped back. I then proceeded to follow protocol by calling the DON, administrator, the physician, and family. I started the incident report but was unable to complete it appropriately. The cna came get the male resident to change his briefs. After changing his briefs she stated she rolled him back to the front. I went down hall to round on everyone to make sure everyone was safe. I heard someone talking loud; I then entered room and found him in another resident room. I turned the light on and found resident sitting in his wheelchair at the foot of the resident bed. Her cover was pulled back and one side of her briefs was un attached. I immediately removed the resident by bringing him to the nurse station to find out how did he get back down the hall. which the cna stated she bought him to his room to be changed then back to the front. I went back to assess the resident and make sure she was ok and safe. She stated that she think she is ok. I then asked her did she have any visitors tonight; did anyone come in her room. She then stated not that she know of. I went back to nurses station to follow protocol. upon arrival the administrator had arrived as we was waiting on police arrival. I called three different police station to have someone sent . On my first two attempts the dispatcher transfer me to a recording; that ask you to press this number for his and press this number for that. On my second attempt I called back and was redirected to the same answering service. Third attempt I stated to dispatcher that they kept sending me to a voicemail. she told me it was a voice recording not a voicemail. I then told her that i just need to speak to someone to have someone sent to facility. Third attempt was successful. upon waiting for authorities, the administrator started helping me follow protocol by calling family while I call physician . Per LVN A Record review of Resident CR#2's clinical record revealed no nurse progress note of assessment, incident report or S-BAR documented on 07/03/21 by LVN A when reviewed by surveyor on 07/04/21. Resident #3 Record review of Resident #3's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 8 which meant she had moderate cognitive impairment. Observation and interview on 07/04/21 at 5:02 PM, revealed Resident #3 was sitting in wheel chair drinking fluids, resident was in a pleasant mood, dressed, groomed, resident had left foot bandaged dated 7/3/21. Resident stated she did not recall a man coming into her room during the night. Record review of Resident #3's progress notes revealed no documentation of an assessment or incident report noted on 07/03/21 by LVN A when reviewed on 07/04/21. In an interview on 07/04/21 at 1:45 PM, LVN E stated the facility was waiting on the psych hospital to pick Resident #1. Resident #1 is currently on one to one supervision. CR#2 was not at the facility she went to the hospital and had not returned. In an interview on 07/04/21 at 2:54 AM, Emergency Medical Services (EMS) Personnel stated CR#2 had severe dementia and a stroke in the past she may not have known what happened. CR#2 rested the entire transport, her vital signs were stable. His partner overheard the Administrator say one of the nurses had completed a physical exam, inspected CR#2's vagina, and that she had no trauma. He was not sure of any injuries. EMS got the call around 6:00 AM and arrived around 6:10 AM. It was reported by law enforcement to him that at 2:10 AM in morning one of aides was monitoring patients. The aide found Resident #1 actively sexual assaulting CR#2. The nurse aide told him to stop but Resident #1 kept going. The aide went to get one of the nurses, 10 minutes later the nurse came into room and got Resident #1 to stop. The facility called the police around 5:00 AM. The officer stated he got the call around 5:30 AM. The officer then started his investigation. At 6:00 AM the officer requested EMS to come out. EMS arrived at 6:10 AM, received a report from the officer, talked with power of attorney and check CR#2's vitals. CR#2 was not in any distress. She did not seem to know what happened. In an interview on 07/04/21 at 2:27 PM, CNA B stated on 07/03/21 at 2:15 AM she went into the room of CR#2 to check and change. The door was closed, she went to opened door, Resident #1 was sitting on CR#2's bed, with his pants off. CNA B tried to get Resident #1 off CR#2's bed. Resident #1 was trying to fight her, she went into panic mode. CNA B had not seen anything like that happened before. Resident #1 refused to get off her. Resident #1 had his right hand was inside CR#2's vagina, Resident #1 had his left hand was on his penis masturbating. CNA B then went to call for help. CNA B found LVN A but she was next door with a patient. She got LVN C who came back to help. It took two minutes to get LVN B to come in and help get the Resident #1 off CR#2. When she returned Resident #1 was standing over CR#2's bed. CNA B and LVN C got Resident #1 away from CR#2. She took Resident #1 out of the room and he was taken to the nurse's station that night where he continued to masturbate by himself for two hours in the television room. Resident #1 just moved to her hallway two weeks ago, she was not sure if he had any other incidents like this before. The police got to the facility around 4:30 AM or 4:40 AM. CR#2 did not have any injuries, she had some blood on her sheets. She was not sure where the blood came from. The police took the sheets with them. In an interview on 07/04/21 at 4:00 PM, LVN A stated she was performing catheter care when CNA B came into the room and said she needed to speak with LVN A, CNA B asked LVN A to step out of room. When LVN A came on the other side of door, CNA B told her what was going on between Resident #1 and CR#2. LVN A was in room [ROOM NUMBER] and CR#2's was in room [ROOM NUMBER]. LVN A did not want to leave her patient alone so she told CNA B to get LVN C. LVN A reported she had gloves and cream on her hands. LVN A was not sure what time the CNA B came into the room. Resident #1 was sitting in the day room after she finished with her resident's catheter care. Resident #1 was upset and combative he masturbated in the day room. LVN A constantly attempted to redirect him. Resident #1 was yelling and telling staff they were wrong for taking him off of CR#2. Later, CNA B changed Resident #1 because he was soaked. Sometime after Resident #1 was changed LVN A heard some fussing on the 100 hallway. Resident #1 was in Resident #3's room. She was yelling trying to get him out of her room. LVN A turned on the lights and told Resident #1 he could not be in Resident #3's room. Resident #1 was still in his wheelchair. Resident #3 did not have any injuries. This was around 4:00 AM, before the police got to the facility. The police asked why it took two hours for them to be called. She explained that she had to follow the facility protocol and notify the DON, Administrator, Physician, and family first. She called the Administrator around 2:40 AM. The facility only had 2 nurses and 4 aides on duty that night, it is hard to try and watch Resident #1. The facility used to have 3 nurses and 5 aides but cut it down for some reason. It was a lot going on that night and she started medication pass late. Resident #1 used to be on the 400 hallway before he moved to the 100 hallway. He was moved because he attempted to touch another resident on the 400 hallway she was not sure which resident she had been out for two weeks when that incident occurred. LVN A did an assessment on CR#2, she went to the computer to see how to do the Incident Report, she had only been at the facility for two months. LVN A did not know she was supposed to complete the incident report. She was told to write a statement there was no incident report in the computer to fill out. She did not do an S-BAR, the Administrator and DON just wanted her to write a brief statement. Resident #1 and CR#2 did not have any injuries. CR#2 was sent to the hospital for further assessment. Resident #1 was just very angry that night. The police officer asked why CNA B left the residents alone but Resident #1 was combative and trying to fight CNA B so CNA B went to get help. In an interview on 07/04/21 at 3:56 PM, CNA B stated Resident #1 was in the nurse station by television room around 1:15 PM when she last saw him. She started marking rounds at 1:15 AM and she was not sure when he left from that area. In an interview on 07/04/21 at 4:57 PM, CNA B stated there were two nurses on duty and 4 nurse aides on duty. Resident #1 went into Resident #3's room between 4:45 AM and 5:15 AM. She was starting her last rounds, she had just changed him, and took him back to the front. He must have gone into her room at the time she started her rounds. CNA B did not see Resident #1 leave from the television area. In an interview on 07/11/21 at 7:32 AM, the Administrator stated Resident #1 lifted Resident #3's sheet back but did not touch her from what he was told by a family member that viewed the video footage in the room. CR#4 Record review of CR#4's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#4's MDS dated [DATE] revealed CR#4's had a BIMS of 4 which meant she had severe cognitive impairment. Record review of CR#4's Elopement Risk assessment dated [DATE] revealed CR#4 had a score of 2. CR#4 was not at risk for elopement/wandering. Record review of CR#4's progress notes revealed no documentation of an incident report or nurse progress note between her and Resident #1. In an interview on 07/04/21 at 5:15 PM, LVN D stated Resident #1 was moved because he had frequent falls, the facility wanted to move him closer to the nurse station. Resident #1 would go into other resident rooms, when she would tried to redirect him, he would curse at LVN D. Resident #1 did have an incident with CR#4, she was a wander and went to his room. She overheard Resident #1 tell CR#4 about a month ago I like when my women touch me down here on this side of my body. CR#4 was confused and did not understand, she just laughed. LVN D separated the residents and did not tell anyone. She did not think much of it until about two weeks later when the Social Worker told her to keep an eye on Resident #1. In an interview on 07/04/21 at 5:25 PM the Social Worker stated Resident #1 was moved from the 400 hallway for a change of location. Resident #1 wandered at times so the facility tried to make him safe. The Social Worker reported she was not aware of any sexually appropriate behaviors by Resident #1. Resident #1 would tell residents they were pretty sometimes but that was it. Resident #1 was up at night, sometimes in the evening he would come out into dining room and day room and watch television and move around. She was not sure if Resident #1 was seen by psych. Resident #1 should have been receiving psych services for medication management. In an interview on 07/04/21 at 5:46 PM, LVN E stated CR#4 would wander into other residents' rooms. CR#4 would also go into her roommate's drawers also. LVN E stated he was not aware of Resident #1 was sexual inappropriate with staff member or other residents. Sometimes Resident #1 went to the 400 hallway and take his old roommates belongings. Resident #1 would take the stuff back to his room on the 100 hallway. Any inappropriate sexual behavior needed to be care planned and reported to the Administrator and DON. If there is any injury or assault the physician will be notified. The nurses will complete an S-Bar, Incident Report, and document in the nurse progress notes. In an interview on 07/04/21 at 6:19 PM, LVN D stated if a resident was being sexually assaulting staff should intervene, contact the physician, family, DON, and Administrator. The document would document a nurse notes, complete a S-BAR, incident report, and send the resident out to the hospital if needed. In an interview on 07/04/21 at 6:48 PM, the DON stated the Administrator started an incident investigation after the incident between Resident #1 and CR#2. If a staff member walked in on an incident of sexual abuse the nurse should separate the residents. The staff should make sure they stay with the residents and call out for help. That is not the norm to leave a resident to be abused. The staff should have stayed and screamed for help if needed until someone came to help. The moment she got wind of what happened she started in-servicing staff on what should happen. The nurse would contact the DON and Administrator, call physician or NP of what they found. The nurse would document the assessment in a progress note, change of condition/S-BAR and complete an incident report. The S-BAR is the same as the change of condition. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not aware of Resident #1 touching of another resident on the 400 hallway. Resident #1 did tell a resident she was beautiful, so they had to move him to the 100 hallway. She was not aware of the incident with CR#4. The incident between Resident #1 and CR#4 should have been reported the Administrator or DON immediately. The DON spoke with the family yesterday to try and have the watch Resident #1 until the facility could find placement. The facility contacted 3 different psych hospitals. Currently a staff was assigned to Resident #1 at times. The staff completed 15-minute documentation on Resident #1. She was not able to elaborate about the staffing levels she just started at the facility, will need to speak with corporate or the Administrator. In an interview on 07/04/21 at 7:15 PM, the Administrator stated he was not aware of any inappropriate sexual behaviors with Resident #1. Resident #1 was a night owl. He had a history opening other resident's drawers and going in their rooms. Resident #1 had compulsive behaviors. About two or three weeks ago he was fixated on a female resident but had not crossed the line. That was why they moved Resident #1 from the 400 hallway to the 100 hallway. The Administrator was not aware of the incident with CR#4. The staff was supposed to notify the Administrator. He had in-serviced staff on reporting change of behavior to the Administrator and DON. The Administrator attempted to interview Resident #1 after the incident but he had no clue of what happened. The facility is maintaining him one to one right now until they get Resident #1 into the behavior hospital for further assessment. The Administrator advised the family that the facility may not be able to readmit Resident #1 unless the hospital can adjust meds and stabilize him. Resident #1 slept most of day and was up most of the night. Staff should intervene during incidents of abuse. Removing the resident from situation was the facilities expectation. The wellbeing and safety of resident came first. The staff then assessed the resident and should notify the Administrator immediately. The staffing pattern was 4 nurses on 1st and 2nd shift, and 2 nurses on the 3rd shift. The facility had 8 nurse aides on 1st shift and 2nd shift, and 4 aides on 3rd shift. On weekends they have non-licensed staff to help. The facility had been hiring staff, giving bonuses consistently but sometimes staff accept the position and don't come. There were 2 nurses and 4 aides on duty the night of the incident. The budget is given to them by corporate and they set the staffing schedule based on the national averages for nursing patterns. Staffing depends on the needs of the residents and how much care each resident needed. In interview on 07/06/21 at 11:34 PM, LVN C stated CNA B came and got her when she was at the desk charting around 2:15 AM. Resident #1 was in CR#2's room. When she went to CR#2's room Resident #1 was standing up next to CR#2's bed. He had his hand in her brief, and his clothes were off. LVN C and CNA B got Resident #1 away from CR#2 and placed him at the front desk. LVN A started making contacts and was advised by the Administrator to contact the police. There were 2 nurse and 4 nurse aides on duty that night. Later that night LVN A found Resident #1 another resident's room after the incident with CR#2. She was not sure why the staff left Resident #1 without supervision. CNA B had just cleaned him up. Today they had 2 nurses and 4 aides on duty. The staff told management that they did not have enough staff on the 3rd shift. In an interview on 07/08/21 at 1:20 PM, the Administrator stated Resident#1 was moved due to his fixation with CR#4. Resident #5 Record review revealed Resident #5 was an [AGE] year old female that was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's MDS dated [DATE] revealed she did not have a BIMS score. Observation on 07/09/21 at 3:19 PM, revealed Resident #5 was lying in bed, resident was dressed, groomed, no visible signs of injury. Resident #5 did not respond to questioning. In an interview on 07/09/21 at 2:27 PM, the MDS Coordinator stated she updated Resident #1's care plan with history of inappropriate sexual behavior when she read the note by the NP in June of 2021. She was not sure if administration met regarding the incident between Resident #1 and Resident #5. In an interview on 07/09/21 at 2:54 PM the NP stated she was informed by LVN F that Resident #1 touched a resident inappropriately. She was not sure which resident was touched by Resident #1. The resident was a female on the 400 hallway at the time. She did refer Resident #1 to psych. She discussed the plan with LVN F. She did not inform administration. She was not aware of the incident between CR#2 and Resident #1 she just found out from the Surveyor. She did not know Resident #1 was discharged . In an interview on 07/09/21 at 3:11 PM, LVN F stated she was informed by the Activity Assistant that Resident #3 touched Resident #5 on her breasts. She informed the NP of the incident during her visit. She did not tell administration, but she believed that the Activity Assistant wrote a statement and gave to the Administrator. She was not sure of the instructions from the NP after her assessment. The NP may have told her plan to another nurse. In an interview on 07/09/21 at 3:24 PM, the Activity Assistant stated she stepped out the activity room when she witnessed Resident #1 with is hands on Resident #5's breasts fondling her. Both residents were in wheelchairs. She pulled the residents apart. She reported the incident to LVN F. She reported this to her boss the Activity Director. The Activity Director had her write a statement to give to the Administrator. In an interview on 07/09/21 at 3:36 PM, LVN F stated she did not complete an assessment on Resident #5 because her clothes were still on at the time. In an interview on 07/09/21 at 4:17 PM, the Administrator stated the NP was at the facility on 06/17/21 when she completed the progress note for Resident #1's falls and sexual aggression. The NP was told this information by LVN F. He was not aware of the incident between Resident #1 and Resident #5. The facility interdisciplinary team met weekly to discuss incidents and complete follow ups. In an interview on 07/09/21 at 4:19 PM, the DON stated it was the nurse's responsibility to follow up on any information or new orders given by the NP. In an interview on 07/11/21 at 6:42 AM00:00 the Activity Director stated it was reported to her that the Activity Assistant witnessed Resident #1 touch Resident #5 inappropriately. She told the Activity Assistant to write a statement. After the statement was finished, she gave the statement to the Administrator. The Administrator was in his office at the time with another person. In an interview on 07/11/21 at 9:10 AM, the DON stated the nurse manager or DON were responsible to make sure the nurses completed incident reports and S-BAR notes. If she was notified, then the issue would be discussed during the morning meeting. Record review of the Facility Abuse Prohibition Policy and Procedure dated 2018 revealed .Component IV: Identification .The facility will use reasonable efforts to develop systems to identify events, occurrences, patterns and trends that constitute or may be a precursor to abuse, neglect or exploitation to help minimize the threat or occurrence of abuse .Our facility will not condone any form of abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Abuse Coordinator and/or to the Director of Nursing Services immediately .Component V: Investigation .All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported .Component VI: Protection Our facility will protect resident from harm, reprisal, discrimination or coercion during investigations of abuse allegations. During the abuse investigations, residents will be protected from harm by the following measures: .If the alleged abuse involves another resident, the accused resident's representatives and Attending Physician will be informed of the alleged abuse incident and that there may be restrictions on the accused resident's ability to visit other resident rooms unattended. If necessary, the accused resident's family members may be required to help meet this requirement . Record review of the facility policy Change in a Resident's Condition or Status dated 05/2017 revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident medical/mental condition or status . The Administrator was notified on 07/07/21 at 12:48 PM an IJ situation had been identified due to the above failures, the the IJ template was provided to him via email at 1:05 PM. PLAN OF REMOVAL F600 Name of Facility: CYPRESS CREEK REHABILITATION CENTER Date: July 9, 2021 Immediate action: 1. Resident #1 and CR #2 were immediately assessed from head-to-toe by Charge Nurse with no negative findings on 7/3/2021. CR#2 was transferred to a local hospital on 7/3/2021. SW sent paperwork for Resident #1 on 7/3/2021 to be sent to local hospitals for behavior evaluation. 2. Resident #1 was placed under supervision of the Administrator from 5:00AM until 10:00AM once family arrived on 7/3/2021. 3. Adhoc QAPI Committee meeting was held on 7/7/2021 with the Interdisciplinary Team (IDT) including the Medical Director in attendance to review and discuss items identified by surveyor regarding Immediate Jeopardy F600 and Immediate Threat F689. 4. The facility notified local law enforcement of the allegation and received case# 2107- Deputy Unit# 45N23 responded on 7/3/2021. 5. CR#2 hospice company was notified on 7/8/2021 by the Administrator. 6. The Administrator and DON were re-educated 1:1

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent sexual inappropriate incidents for 5 (Resident #1, CR#2, Resident #3, CR#4, Resident #5) of 12 residents reviewed for sexual inappropriate behavior as evidence by: Resident #1 was found sexually abusing CR#2 in her bedroom. Resident #1 was found in Resident #3's bedroom after an incident of sexual abuse with CR#2, he had pulled her covers back and one side of her brief was unsnapped. Resident #1 was overheard asking CR#4 to touch him on his private area. Resident #1 was found touching Resident #5's breast in the hallway. An Immediate Jeopardy was identified on 07/07/21 at 12:48 PM. While the Immediate Jeopardy was removed on 07/11/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. This failure could affect vulnerable residents placing them at risk for sexual abuse, injury and/or a diminished quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a diagnoses of [CONDITION(S)], dementia, type 2 diabetes, Alzheimer's disease, [CONDITION(S)] heart disease, hypertension, [CONDITION(S)], [CONDITION(S)], ischemic attack, traumatic hemorrhage of cerebrum, major depressive disorder, muscle wasting atrophy, abnormalities of gait, muscle weakness, cognitive communication deficit, [CONDITION(S)], arthropathies, presence of aortocoronary, abnormal weight loss, chronic kidney disease, [CONDITION(S)], [CONDITION(S)], tinea corporis, adjustment disorder with mixed anxiety and depressed mood, seizures, gastro-[CONDITION(S)] reflux, [CONDITION(S)], [CONDITION(S)], and history of falling. Record review of Resident #1's significant change MDS dated [DATE] revealed Resident #1 had a BIMS of 10 which meant he had moderate cognitive impairment. Record review of Resident #1's care plan dated 06/29/21 revealed Resident #1 had a history of sexual inappropriate behaviors. Resident #1 is often up at night and goes through cabinets/drawers/baskets/ other residents belongings often collecting items in his room. Resident #1 was verbally aggressive with staff and physically aggressive with staff. Staff were to administer medication as ordered and monitor/document for side effects and effectiveness. Staff were to anticipate and meet the resident's needs, caregivers are to provide opportunity for positive interaction and attention. Staff are to stop and talk with him/her as passing by, encourage to attend social activities of preference. Staff are to minimize potential for resident's disruptive behaviors by offering tasks which divert attention such as offering TV time in day area, monitor behavior episodes and attempted to determine underlying cause. Staff are to consider location, time of day, persons involved and situations. Document behavior and potential causes. Staff are to provide psych consult per MD order. Record review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 had a score of 2. Resident #1 was not at risk for elopement/wandering. Record review of Resident #1's clinical record revealed no nurse progress note of assessment, incident report or S-BAR documented for the incident with CR#2 and Resident #3 on 07/03/21 by LVN A when reviewed by surveyor on 07/04/21. Record review of Resident #1's physician progress note dated 06/17/21 revealed .Chief Complaint: Falls, Sexual aggression . History of Present Illness: . Patient is very impulsive. Not currently on therapy. Nurse requested evaluation due to patient sexual aggression towards another resident, states that patient is an appropriate session resident on yesterday on her shift in her breast area, states that resident is always asking about this particular resident. Nurse on duty today reports that no sexual aggression noted, states that she is only heard information on 2 occasions about patient touching another resident Assessment & Plan .Sexual inappropriateness/sexual breast - new problem - no adjustments of current medication, and possible treatment. Patient referred to psych services for evaluation or follow-up Diagnosis Inappropriate sexual behavior . Per NP. Observation and interview on 07/04/21 at 2:22 PM, revealed Resident #1 was sitting in wheelchair with staff monitoring him. Resident #1 was dressed, groomed, no visible signs of injury. Resident #1 stated he hurt all over, resident confused, resident could not recall the incident with CR#2. CR#2 Record review of CR#2's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnoses of dementia, [CONDITION(S)], history of ischemic attack, [CONDITION(S)], dysphagia, [CONDITION(S)] heart disease, chronic [CONDITION(S)], hypertension, pneumonia, contracture of left knee and ankle, candidiasis, cough, adjustment disorder, [CONDITION(S)], dry eye syndrome, dry eye syndrome, gastro-[CONDITION(S)] reflux, constipation, depressive episodes, and [CONDITION(S)]. Record review of CR#2's MDS dated [DATE] revealed she had a BIMS of 00 which meant she had severe cognitive impairment. Record review of the CR#2's nurse notes dated 7/3/2021 revealed .Received notice from resident's . requesting to call Methodist Willowbrook to provide type of tube feeding diet and rate. Spoke with .RN at the observation unit where resident is currently at and provided them with the diet. Resident receives [MEDICATION(S)] 2.0 250ml 4X a day. called and updated . Per DON Record review of CR#2's nurse progress notes revealed .7/5/2021 10:18 Nurse's Note Text: cna stated she found male resident in this resident room performing sexual behaviors. she then stated she tried removing resident and he became combative. she came in room next door where I was giving care to another resident at the time to inform me of what was taking place and stated she needed my help. I asked her to get the other nurse to come help her as I was giving care to another resident. once I was done giving care the cna and nurse had removed the male patient and had him sitting in day room on couch where he continued inappropriate behaviors by masturbating. once I left resident room I went back to this room to assess her. upon returning to the nurses station I asked the male resident to pick his pants up and stated that it wasn't nice and he could get in trouble. he stated he don't give a damn call the police and tried to swing at me. I immediately stepped back. I then proceeded to follow protocol by calling the DON, administrator, the physician, and family. I started the incident report but was unable to complete it appropriately. The cna came get the male resident to change his briefs. After changing his briefs she stated she rolled him back to the front. I went down hall to round on everyone to make sure everyone was safe. I heard someone talking loud; I then entered room and found him in another resident room. I turned the light on and found resident sitting in his wheelchair at the foot of the resident bed. Her cover was pulled back and one side of her briefs was un attached. I immediately removed the resident by bringing him to the nurse station to find out how did he get back down the hall. which the cna stated she bought him to his room to be changed then back to the front. I went back to assess the resident and make sure she was ok and safe. She stated that she think she is ok. I then asked her did she have any visitors tonight; did anyone come in her room. She then stated not that she know of. I went back to nurses station to follow protocol. upon arrival the administrator had arrived as we was waiting on police arrival. I called three different police station to have someone sent . On my first two attempts the dispatcher transfer me to a recording; that ask you to press this number for this and press this number for that. On my second attempt I called back and was redirected to the same answering service. Third attempt I stated to dispatcher that they kept sending me to a voicemail. she told me it was a voice recording not a voicemail. I then told her that i just need to speak to someone to have someone sent to facility. Third attempt was successful. upon waiting for authorities, the administrator started helping me follow protocol by calling family while I call physician . Per LVN A Record review of Resident CR#2's clinical record revealed no nurse progress note of assessment, incident report or S-BAR documented on 07/03/21 by LVN A when reviewed by surveyor on 07/04/21. Resident #3 Record review of Resident #3's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a diagnoses of dementia, transient cerebral ischemic attack, diastolic heart failure, chronic kidney disease, major depressive disorder, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] disorder, pressure ulcer left heal, hypertension, [CONDITION(S)], [CONDITION(S)], mood disorder, gastro-[CONDITION(S)] reflux, and constipation. Record review of Resident #3's MDS dated [DATE] revealed she had a BIMS of 8 which meant she had moderate cognitive impairment. Observation and interview on 07/04/21 at 5:02 PM, revealed Resident #3 was sitting in wheel chair drinking fluids, resident was in a pleasant mood, dressed, groomed, resident had left foot bandaged dated 7/3/21. Resident stated she did not recall a man coming into her room during the night. Record review of Resident #3's progress notes revealed no documentation of an assessment or incident report noted on 07/03/21 by LVN A when reviewed on 07/04/21. In an interview on 07/04/21 at 1:45 PM, LVN E stated the facility was waiting on the psych hospital to pick up Resident #1. Resident #1 is currently on one to one supervision. CR#2 was not at the facility she went to the hospital and had not returned. In an interview on 07/04/21 at 2:54 AM, Emergency Medical Services (EMS) Personnel stated CR#2 had severe dementia and a stroke in the past she may not have known what happened. CR#2 rested the entire transport, her vital signs were stable. His partner overheard the Administrator say one of the nurses had completed a physical exam, inspected CR#2's vagina, and that she had no trauma. He was not sure of any injuries. EMS got the call around 6:00 AM and arrived around 6:10 AM. It was reported by law enforcement to him that at 2:10 AM in morning one of aides was monitoring patients. The aide found Resident #1 actively sexual assaulting CR#2. The nurse aide told him to stop but Resident #1 kept going. The aide went to get one of the nurses, 10 minutes later the nurse came into room and got Resident #1 to stop. The facility called the police around 5:00 AM. The officer stated he got the call around 5:30 AM. The officer then started his investigation. At 6:00 AM the officer requested EMS to come out. EMS arrived at 6:10 AM, received a report from the officer, talked with power of attorney and check CR#2's vitals. CR#2 was not in any distress. She did not seem to know what happened. In an interview on 07/04/21 at 2:27 PM, CNA B stated on 07/03/21 at 2:15 AM she went into the room of CR#2 to check and change. The door was closed, she went to opened door, Resident #1 was sitting on CR#2's bed, with his pants off. CNA B tried to get Resident #1 off CR#2's bed. Resident #1 was trying to fight her, she went into panic mode. CNA B had not seen anything like that happened before. Resident #1 refused to get off her. Resident #1 had his right hand was inside CR#2's vagina, Resident #1 had his left hand was on his penis masturbating. CNA B then went to call for help. CNA B found LVN A but she was next door with a patient. She got LVN C who came back to help. It took two minutes to get LVN B to come in and help get the Resident #1 off CR#2. When she returned Resident #1 was standing over CR#2's bed. CNA B and LVN C got Resident #1 away from CR#2. She took Resident #1 out of the room and he was taken to the nurse's station that night where he continued to masturbate by himself for two hours in the television room. Resident #1 just moved to her hallway two weeks ago, she was not sure if he had any other incidents like this before. The police got to the facility around 4:30 AM or 4:40 AM. CR#2 did not have any injuries, she had some blood on her sheets. She was not sure where the blood came from. The police took the sheets with them. In an interview on 07/04/21 at 4:00 PM, LVN A stated she was performing catheter care when CNA B came into the room and said she needed to speak with LVN A, CNA B asked LVN A to step out of room. When LVN A came on the other side of door, CNA B told her what was going on between Resident #1 and CR#2. LVN A was in room #114 and CR#2's was in room #116. LVN A did not want to leave her patient alone so she told CNA B to get LVN C. LVN A reported she had gloves and cream on her hands. LVN A was not sure what time the CNA B came into the room. Resident #1 was sitting in the day room after she finished with her resident's catheter care. Resident #1 was upset and combative he masturbated in the day room. LVN A constantly attempted to redirect him. Resident #1 was yelling and telling staff they were wrong for taking him off of CR#2. Later, CNA B changed Resident #1 because he was soaked. Sometime after Resident #1 was changed LVN A heard some fussing on the 100 hallway. Resident #1 was in Resident #3's room. She was yelling trying to get him out of her room. LVN A turned on the lights and told Resident #1 he could not be in Resident #3's room. Resident #1 was still in his wheelchair. Resident #3 did not have any injuries. This was around 4:00 AM, before the police got to the facility. The police asked why it took two hours for them to be called. She explained that she had to follow the facility protocol and notify the DON, Administrator, Physician, and family first. She called the Administrator around 2:40 AM. The facility only had 2 nurses and 4 aides on duty that night, it is hard to try and watch Resident #1. The facility used to have 3 nurses and 5 aides but cut it down for some reason. It was a lot going on that night and she started medication pass late. Resident #1 used to be on the 400 hallway before he moved to the 100 hallway. He was moved because he attempted to touch another resident on the 400 hallway she was not sure which resident she had been out for two weeks when that incident occurred. LVN A did an assessment on CR#2, she went to the computer to see how to do the Incident Report, she had only been at the facility for two months. LVN A did not know she was supposed to complete the incident report. She was told to write a statement there was no incident report in the computer to fill out. She did not do an S-BAR, the Administrator and DON just wanted her to write a brief statement. Resident #1 and CR#2 did not have any injuries. CR#2 was sent to the hospital for further assessment. Resident #1 was just very angry that night. The police officer asked why CNA B left the residents alone but Resident #1 was combative and trying to fight CNA B so CNA B went to get help. In an interview on 07/04/21 at 3:56 PM, CNA B stated Resident #1 was in the nurse station by the television room around 1:15 PM when she last saw him. She started marking rounds at 1:15 AM and she was not sure when he left from that area. In an interview on 07/04/21 at 4:57 PM, CNA B stated there were two nurses on duty and 4 nurse aides on duty. Resident #1 went into Resident #3's room between 4:45 AM and 5:15 AM. She was starting her last rounds, she had just changed him, and took him back to the front. He must have gone into her room at the time she started her rounds. CNA B did not see Resident #1 leave from the television area. In an interview on 07/11/21 at 7:32 AM, the Administrator stated Resident #1 lifted Resident #3's sheet back but did not touch her from what he was told by a family member that viewed the video footage in the room. CR#4 Record review of CR#4's face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnoses of [CONDITION(S)], resistance to multiple antimicrobial drugs, mild protein-calorie malnutrition, hypertension, dementia, [CONDITION(S)], [CONDITION(S)] polyneuropathies, muscle weakness, abnormalities of gait, dysphagia, urinary tract infection, hypomagnesia, [CONDITION(S)], [CONDITION(S)], depressive episodes, gastro-[CONDITION(S)] reflux, low back pain, chronic kidney disease, nausea, and history of ischemic attack. Record review of an MDS dated [DATE] revealed CR#4 had a BIMS of 4 which meant she had severe cognitive impairment. Record review of an Elopement Risk assessment dated [DATE] revealed CR#4 had a score of 2. CR#4 was not at risk for elopement/wandering. Record review of CR#4's progress notes revealed no documentation of an incident report or nurse progress note between her and Resident #1. In an interview on 07/04/21 at 5:15 PM, LVN D stated Resident #1 was moved because he had frequent falls, the facility wanted to move him closer to the nurse station. Resident #1 would go into other resident rooms, when she would try to redirect him, he would curse at LVN D. Resident #1 did have an incident with CR#4, she was a wanderer and went to his room. She overheard Resident #1 tell CR#4 about a month ago I like when my women touch me down here on this side of my body. CR#4 was confused and did not understand, she just laughed. LVN D separated the residents and did not tell anyone. She did not think much of it until about two weeks later when the Social Worker told her to keep an eye on Resident #1. In an interview on 07/04/21 at 5:25 PM, the Social Worker stated Resident #1 was moved from the 400 hallway for a change of location. Resident #1 wandered at times so the facility tried to make him safe. The Social Worker reported she was not aware of any sexually appropriate behaviors by Resident #1. Resident #1 would tell residents they were pretty sometimes but that was it. Resident #1 was up at night, sometimes in the evening he would come out into dining room and day room and watch television and move around. She was not sure if Resident #1 was seen by psych. Resident #1 should have been receiving psych services for medication management. In an interview on 07/04/21 at 5:46 PM, LVN E stated CR#4 would wander into other residents' rooms. CR#4 would also go into her roommate's drawers also. LVN E stated he was not aware of Resident #1 being sexual inappropriate with staff members or other residents. Sometimes Resident #1 went to the 400 hallway and take his old roommates belongings. Resident #1 would take the stuff back to his room on the 100 hallway. Any inappropriate sexual behavior needed to be care planned and reported to the Administrator and DON. If there is any injury or assault the physician will be notified. The nurses will complete an S-Bar, Incident Report, and document in the nurse progress notes. In an interview on 07/04/21 at 6:19 PM, LVN D stated if a resident was being sexually assaulted staff should intervene, contact the physician, family, DON, and Administrator. They would document a nurse notes, complete a S-BAR, incident report, and send the resident out to the hospital if needed. In an interview on 07/04/21 at 6:48 PM, the DON stated the Administrator started an incident investigation after the incident between Resident #1 and CR#2. If a staff member walked in on an incident of sexual abuse the nurse should separate the residents. The staff should make sure they stay with the residents and call out for help. That is not the norm to leave a resident to be abused. The staff should have stayed and screamed for help if needed until someone came to help. The moment she got wind of what happened she started in-servicing staff on what should happen. The nurse would contact the DON and Administrator, call physician or NP of what they found. The nurse would document the assessment in a progress note, change of condition/S-BAR and complete an incident report. The S-BAR is the same as the change of condition. Resident #1 had a history of inappropriate sexual behavior and it was documented. She was not aware of Resident #1 touching of another resident on the 400 hallway. Resident #1 did tell a resident she was beautiful, so they had to move him to the 100 hallway. She was not aware of the incident with CR#4. The incident between Resident #1 and CR#4 should have been reported to the Administrator or DON immediately. The DON spoke with the family yesterday to try and have them watch Resident #1 until the facility could find placement. The facility contacted 3 different psych hospitals. Currently a staff was assigned to Resident #1 at times. The staff completed 15-minute documentation on Resident #1. She was not able to elaborate about the staffing levels she just started at the facility, will need to speak with corporate or the Administrator. In an interview on 07/04/21 at 7:15 PM, the Administrator stated he was not aware of any inappropriate sexual behaviors with Resident #1. Resident #1 was a night owl. He had a history opening other resident's drawers and going in their rooms. Resident #1 had compulsive behaviors. About two or three weeks ago he was fixated on a female resident but had not crossed the line. That was why they moved Resident #1 from the 400 hallway to the 100 hallway. The Administrator was not aware of the incident with CR#4. The staff was supposed to notify the Administrator. He had in-serviced staff on reporting change of behavior to the Administrator and DON. The Administrator attempted to interview Resident #1 after the incident but he had no clue of what happened. The facility is maintaining him one to one right now until they get Resident #1 into the behavior hospital for further assessment. The Administrator advised the family that the facility may not be able to readmit Resident #1 unless the hospital can adjust meds and stabilize him. Resident #1 slept most of day and was up most of the night. Staff should intervene during incidents of abuse. Removing the resident from situation was the facilities expectation. The wellbeing and safety of resident came first. The staff then assessed the resident and should notify the Administrator immediately. The staffing pattern was 4 nurses on 1st and 2nd shift, and 2 nurses on the 3rd shift. The facility had 8 nurse aides on 1st shift and 2nd shift, and 4 aides on 3rd shift. On weekends they have non-licensed staff to help. The facility had been hiring staff, giving bonuses consistently but sometimes staff accept the position and don't come. There were 2 nurses and 4 aides on duty the night of the incident. The budget is given to them by corporate and they set the staffing schedule based on the national averages for nursing patterns. Staffing depends on the needs of the residents and how much care each resident needed. In interview on 07/06/21 at 11:34 PM, LVN C stated CNA B came and got her when she was at the desk charting around 2:15 AM. Resident #1 was in CR#2's room. When she went to CR#2's room Resident #1 was standing up next to CR#2's bed. He had his hand in her brief, and his clothes were off. LVN C and CNA B got Resident #1 away from CR#2 and placed him at the front desk. LVN A started making contacts and was advised by the Administrator to contact the police. There were 2 nurse and 4 nurse aides on duty that night. Later that night LVN A found Resident #1 in another resident's room after the incident with CR#2. She was not sure why the staff left Resident #1 without supervision. CNA B had just cleaned him up. Today they had 2 nurses and 4 aides on duty. The staff told management that they did not have enough staff on the 3rd shift. In an interview on 07/08/21 at 1:20 PM, the Administrator stated Resident#1 was moved due to his fixation with CR#4. Resident #5 Record review revealed Resident #5 was an [AGE] year old female that was admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease, dementia, [CONDITION(S)], chronic lymphocytic [CONDITION(S)], major depressive disorder, dysphagia, abnormal weight loss, [CONDITION(S)], anxiety, [CONDITION(S)], [CONDITION(S)], vitamin B12 deficiency, [CONDITION(S)], gastro-[CONDITION(S)] reflux, incontinence, and history of falling. Record review of Resident #5's MDS dated [DATE] revealed she did not have a BIMS. Observation on 07/09/21 at 3:19 PM, revealed Resident #5 was lying in bed, resident was dressed, groomed, no visible signs of injury. Resident #5 did not respond to questioning. In an interview on 07/09/21 at 2:27 PM, the MDS Coordinator stated she updated Resident #1's care plan with history of inappropriate sexual behavior when she read the note by the NP in June of 2021. She was not sure if administration met regarding the incident between Resident #1 and Resident #5. In an interview on 07/09/21 at 2:54 PM, the NP stated she was informed by LVN F that Resident #1 touched a resident inappropriately. She was not sure which resident was touched by Resident #1. The resident was a female on the 400 hallway at the time. She did refer Resident #1 to psych. She discussed the plan with LVN F. She did not inform administration. She was not aware of the incident between CR#2 and Resident #1 she just found out from the Surveyor. She did not know Resident #1 was discharged . In an interview on 07/09/21 at 3:11 PM, LVN F stated she was informed by the Activity Assistant that Resident #3 touched Resident #5 on her breasts. She informed the NP of the incident during her visit. She did not tell administration, but she believed that the Activity Assistant wrote a statement and gave to the Administrator. She was not sure of the instructions from the NP after her assessment. The NP may have told her plan to another nurse. In an interview on 07/09/21 at 3:24 PM, the Activity Assistant stated she stepped out the activity room when she witnessed Resident #1 with his hands on Resident #5's breasts fondling her. Both residents were in wheelchairs. She pulled the residents apart. She reported the incident to LVN F. She reported this to her boss the Activity Director. The Activity Director had her write a statement to give to the Administrator. In an interview on 07/09/21 at 3:36 PM, LVN F stated she did not complete an assessment on Resident #5 because her clothes were still on at the time. In an interview on 07/09/21 at 4:17 PM, the Administrator stated the NP was at the facility on 06/17/21 when she completed the progress note for Resident #1's falls and sexual aggression. The NP was told this information by LVN F. He was not aware of the incident between Resident #1 and Resident #5. The facility interdisciplinary team met weekly to discuss incidents and complete follow ups. In an interview on 07/09/21 at 4:19 PM, the DON stated it was the nurse's responsibility to follow up on any information or new orders given by the NP. In an interview on 07/11/21 at 6:42 AM00:00 the Activity Director stated it was reported to her that the Activity Assistant witnessed Resident #1 touch Resident #5 inappropriately. She told the Activity Assistant to write a statement. After the statement was finished, she gave the statement to the Administrator. The Administrator was in his office at the time with another person. Record review of the facility sign-in sheet dated 07/02/21 revealed the facility had 2 LVN's on duty and 4 nurse aides on duty for the 11PM - 7AM shift. Record review of the facility Daily Nurse Staffing Information sheet dated 07/02/21 revealed the facility staffing totals were 2 LVN's and 4 CNA's for a census of 101. Observation on 07/06/21 at 11:37 PM revealed there were 2 nurses and 4 nurse aides on duty. Record review of the facility sign-in sheet dated 07/06/21 revealed the facility had 2 LVN's on duty and 4 nurse aides on duty for the 11PM-7AM shift. Record review of the facility Daily Nurse Staffing Information sheet dated 07/06/21 revealed the facility staffing totals were 2 LVN's and 4 CNA's for a census of 104. Record review of the facility policy Safety and Supervision revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individualized residents .3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices Systems Approach to Safety .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition . The administrator was notified on 7/7/21 at 12:48 PM an IJ had been identified due to the above failures, the IJ template was provided to the administrator via email at 1:05 PM. The plan of removal was accepted on 07/11/21 at 8:07 AM and included: PLAN OF REMOVAL F689 Name of Facility: CYPRESS CREEK REHABILITATION CENTER Date: July 9, 2021 Immediate action: 1. Resident #1 and CR #2 were immediately assessed from head-to-toe by Charge Nurse with no negative findings on 7/3/2021. CR#2 was transferred to a local hospital on 7/3/2021. SW [Social Worker] sent paperwork for Resident #1 on 7/3/2021 to be sent to local hospitals for behavior evaluation. 2. Resident #1 was placed under supervision of the Administrator from 5:00AM until 10:00AM once family arrived on 7/3/2021. 3. Adhoc QAPI Committee meeting was held on 7/7/2021 with the Interdisciplinary Team (IDT) including the Medical Director in attendance to review and discuss items identified by surveyor regarding Immediate Jeopardy F600 and Immediate Threat F689. 4. The facility notified local law enforcement of the allegation and received case# 2107- Deputy Unit# 45N23 responded on 7/3/2021. 5. CR#2 hospice company was notified on 7/8/2021 by the Administrator. 6. The Administrator and DON were re-educated 1:1 by the RVP and RNC on Safety and Supervision of residents and Abuse, Neglect and Exploitation on 7/6/2021. Staff were immediately re-educated on Abuse, Neglect, Exploitation, and Incident Reporting and Intervention beginning 7/3/2021 and continues as ongoing education. The training presented by the DON on 7/3/2021 included as Subject: You must intervene immediately to ensure the well-being and safety and supervision of the resident as follows: (1) Remove the threat immediately and call for help, do not leave potential victim unattended. (2) Assess the resident(s) and keep the alleged perpetrator under one-to one monitoring. (3) Report the event to the appropriate agencies, i.e. Local authorities, 911 for emergency according to policy. (4) Consult and notify immediately the attending physician, Administrator (Abuse Coordinator), DON and resident(s) RP of incident. (5) Complete the SBAR and Incident Report. Training will be completed on 7/9/2021. Ongoing training will continue as needed as continued education delegated by Administrator and DON. 7. The Regional Nurse Consultant immediately had [TRUNCATED]