Every finding on record at Deerbrook Skilled Nursing and Rehab Center

Based on observation, interview and record review the facility failed to ensure the residents' environment remained free of accident hazards, and each resident received adequate supervision to prevent accidents for 1 (CR #1) of 10 residents reviewed for accidents and supervision.The facility failed to ensure CR #1, who was wearing a wander guard for safety, did not leave the facility unsupervised on 8/10/26 around 8:30 p.m. CR #1 was found by the police down the street in a church parking lot approximately 15 minutes later.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 8/10/26 and ended on 8/11/26. The facility corrected the non-compliance before the investigation began on 8/18/26.This failure could place residents at risk of elopement and injury.Findings included: Record review of CR #1's admission record dated 8/18/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury) without loss of consciousness, pedestrian on foot injured in collision with car, pick-up truck or van in nontraffic accident, unsteadiness on feet, fracture of one rib, laceration of diaphragm (partial tear or cut in the diaphragm muscle), fracture of fourth lumbar vertebra, fracture of sacrum, fracture of left pubis, and fracture of other parts of pelvis. He was discharged to his previous group home on 8/12/26.Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He wandered for 1 to 3 days. He needed assistance from staff with ADLs.Record review of CR #1's care plan revealed he was at risk for Wandering / Elopement Identified, date initiated 8/10/26.Record review of CR #1's undated hospital Summary Report revealed, .XXX[AGE] year-old male who sustained high-energy multi-system trauma as a pedestrian struck by a vehicle (admitted [DATE]). He is medically complex, cognitively impaired at baseline per group home report and demonstrates acute cognitive-linguistic dysfunction post-injury, limited ability to follow commands consistently, oxygen desaturation with activity, and left lower extremity non-weight-bearing restrictions.Behavioral & Cognitive Status: Patient has pre-existing severe TBI history per group home and chronic cognitive impairment reported by POA. During this admission he demonstrated moderate to severe cognitive-linguistic dysfunction [when brain damage or developmental differences disrupt the connection between thinking and language].with lethargy/somnolence at times, echolalia [the repetition of words or phrases spoken by someone else], impaired orientation and memory, and limited reliable participation in therapy early in the course. Delirium precautions are in place. Cognitive deficits appear to be both chronic baseline (reported by group home) and acutely worsened post-trauma.Record review of CR #1's Admit/Readmit Screener dated 8/7/26 at 8:59 p.m. revealed he was alert and oriented to situation.Record review of CR #1's admission Elopement Risk assessment dated [DATE] revealed the resident was cognitively impaired with poor decision-making skills and was not at risk for elopement/wandering at this time.Record review of CR #1's MD orders revealed an order for Wander Guard: Check for proper placement every shift. Wander guard to the left lower extremity, order date: 8/10/26 at 6:52 p.m.Record review of CR #1's behavior note dated 8/10/26 at 6:56 p.m. by LVN J revealed, .Resident was observed by a CNA trying to leave out of the side door on 300 hall leading out to the laundry room. Resident was redirected and taken to his room. NP.was notified and given orders to put resident on a wander guard. Family member. also notified about resident. This writer was informed by (RP) that resident is an escapee. Wander guard applied to the resident lower left extremity.Record review of CR #1's progress note dated 8/10/26 at 8:03 p.m. by LVN J revealed, .Resident is alert and able to make his needs known. Resident admitting diagnosis is Encounter for other orthopedic aftercare.Resident uses a manual wheelchair as an assistance device and is independent.Resident was observed trying to leave out of one of the side doors to the facility. NP and family was notified and a wander guard was placed on the resident's lower left extremity.Record review of CR #1's Elopement Risk assessment dated [DATE] by LVN J revealed, .the resident was cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented). He had a history of elopement while at home and wandered aimlessly or non-goal-directed (i.e confused, moves without purpose, may enter others' rooms and explores others' belongings). CR #1 was at risk for elopement/wandering. He was observed trying to leave out of the 300 hall side door leading out to the laundry. Appropriate interventions were initiated, MD and RP were notified.Record review of CR #1's progress note dated 8/10/26 at 8:45 p.m. by LVN J revealed, .Received a call from a (city) Police officer stating that resident was down the street in a church parking lot. Resident informed officer that he came from the (nursing facility name) down the street. This writer immediately left the building in search of the resident. DON was immediately notified about the resident's elopement. Resident was located on (intersection name) in a church parking lot in his wheelchair. When this writer got out of her car, resident stated, Oh! You came to get me?. When writer asked the resident where he was going resident stated, I was going to one of the buildings next door to find a phone to call my friend, to come and pick him up. I want to go home and get away from that place. This writer assisted the resident into the backseat and buckled him in the seatbelt. Upon arrival back to the facility, resident assisted out of the car, into his wheelchair, and back into the building. Resident was moved to the room at the beginning of the hallway and one on one observation initiated. This writer performed a head-to-toe assessment on the resident. Resident skin is warm, dry, and intact. Resident has no visible injuries at this time. Resident able to move upper and lower extremities without any complications. Resident denies any pain at this time. NP.notified of the residents elopement.POA (name) was then notified. When this writer informed her that resident had left the facility and was down the street in his wheelchair, she started laughing. She then stated, That sounds like him. He will slip away in a heartbeat. That's how he ended up at (local) hospital and in the facility. He slipped away from the group home here in (city), got hit by a car, and was life flighted. He has to be monitored closely because he will disappear in the blink of an eye. POA talked with resident and informed him that she will be at the facility in the morning to visit him.Record review of the facility's undated detailed investigation summary for CR #1 revealed in part, . date of incident: 8/10/26. Incident type: elopement/missing resident. Upon Return to the Facility - Immediate Assessment: The resident was safely returned to the facility. A licensed nurse immediately completed a comprehensive head-to-toe assessment. No new injuries or skin concerns were identified. The resident's skin was warm, dry, and intact. He was able to move his upper and lower extremities without difficulty and denied pain. Pre-existing areas of scarring and discoloration were noted to have been present upon admission. The NP and POA were notified. The resident was moved to a room near the beginning of the hallway, and documented one-to-one supervision was immediately initiated. Resident Interview and Reconstruction of Events: As part of the investigation, the RVP interviewed the resident to determine how he exited the facility despite the exit alarm and Wander Guard intervention. The resident was able to provide a detailed account of his actions. He stated that he had learned this trick a long time ago. According to the resident, he intentionally held the exit door until the alarm alerted and then proceeded through the door while walking behind his wheelchair. Once outside the building, the resident reported that he approached the exterior gate, lifted the gate handle, exited through the gate, and then closed the gate behind him. He subsequently traveled down the street to a nearby church for the purpose of locating a telephone/contacting someone to pick him up. The resident was also able to show the nurse the door he reported using to exit the facility. Throughout the interview, the resident consistently expressed that he did not want to remain in a nursing facility and wanted to return to his previous residence in (city). His statements and expressed wishes were communicated to the interdisciplinary team for follow-up and discharge planning. The resident's ability to describe his destination, reason for leaving, method of exiting the building, manipulation of the exterior gate, and plan to contact someone to pick him up supports that his departure was purposeful and self-directed rather than aimless wandering. A 100% audit of facility exit doors was conducted following the incident. All exit doors were confirmed to be secure and functioning appropriately. The Wander Guard binder was reviewed and updated to ensure documentation was current. Staff were immediately re-educated regarding: Abuse and neglect prevention, Residents' rights, Elopement prevention and response, Emergency exit-door reset procedures. Investigation Findings: Based upon the information obtained during the investigation, the resident's departure appears to have been intentional, purposeful, and self-directed. The resident was able to explain how he exited the facility and exterior gate, where he was going, and why he wanted to leave. He consistently expressed a desire to return to the community rather than remain in the nursing facility.However, the investigation identified an important area requiring continued evaluation. At 6:56 PM, approximately two hours before the resident was discovered outside the facility, he had demonstrated exit-seeking behavior when he attempted to leave through another facility door. Staff redirected him, notified the NP and POA, obtained an order for a Wander Guard, and applied the device. Therefore, the investigation must continue to evaluate whether the interventions implemented following the initial exit-seeking episode were sufficient and whether all required supervision, monitoring, care-plan interventions, and elopement-prevention procedures were appropriately implemented and followed .In an interview on 8/18/26 at 1:09 p.m. CR #1's POA said he was very confused. While in her care he would go places and police would bring him back home because he said he was lost. The POA said she informed the facility that CR #1 was a runaway king and needed to be watched but did not know who she informed. The reason CR #1 was at the facility was because he got hit by a car and broke 7 ribs. While at the hospital he also tried to escape. The facility informed her that they found him down the road in his wheelchair. CR #1 told her he tried to go down to someone's house because he did not want to be at the facility. He did not have any injuries and kept leaving because he could not smoke and was looking for cigarette butts. She said he was not safe to be away from the facility because he did not know where he was. In an interview on 8/18/26 at 2:54 p.m. LVN J said on 8/10/26 around 6 p.m. a CNA was outside and saw CR #1 try to leave the building. LVN J notified the DON and NP and received an order for a wander guard for safety which was placed on the resident. She also informed the CNAs to keep an eye on him. She said that was her first time working with CR #1 and did not find out anything about him until she notified his POA of the incident and the POA said he was an escapee. Between 8:00 p.m. - 8:30 p.m. she saw the resident go in his room. Around 8:45 p.m. another LVN received a phone call from the local police department and said CR #1 was down the street and he (CR #1) said he came from the facility. LVN J searched for the resident and found him in the church parking lot and the road was a busy road. CR #1 told her he was going to a building next door to call a friend because he did not want to be at the facility anymore and wanted to go home. She said the resident was not hurt and noted the wander guard was in place. LVN J said no alarms went off at the building and CR #1 told her he went out of the back door on the 200 hall near the therapy room. She said it was storming earlier that day (8/10/26), the lights flickered off and she was unsure if the exit doors were reset. She said CR #1 did not sign out and did not say he was leaving the building. After the elopement the facility ensured all residents were accounted for in the building, initiated 1:1 observation for CR #1, and conducted in-services on elopement and abuse/neglect.In an interview on 8/18/26 at 3:22 p.m. LVN G said when he worked with CR #1 around admission, he was confused but did not have any elopement behaviors. After the elopement CR #1 went on one-to-one supervision. In an interview on 8/18/26 at 3:29 p.m. the DON said on an unknown date CR #1 tried to go out the side door, she contacted the MD and family, put a wander guard on him and informed staff to keep an eye on him. She verified the wander guard was functioning properly. Between 8:30-8:50 p.m. (on the same day) LVN J said she received a phone call that CR #1 was not in the building. An unknown person found him down the street in a church parking lot and stayed there until facility staff arrived. LVN J brought CR #1 back to the facility and he was placed on 1:1 supervision, assessed, and in-services were conducted with the staff. She said she was unable to answer if the alarms went off when he went out of the building and no one could attest that the door alarm sounded. She said the alarm would warn staff that something was not normal. If the door made any beeps staff should go to the door and verify that a resident did not get out. She said CR #1 had a wander guard in place because he tried to leave the facility previously and leaving would not have been safe because he was from another city. She said it was not safe for him to be out of the building by himself, he had a previous accident where he got hit as a pedestrian and was at risk of being hit again. The DON said CR #1 eloped, but she discussed with facility leadership and said CR #1's BIMS score was 13 and he knew what he was doing. She said CR #1 was discharged back to his group home the next day.In an interview on 8/18/26 at 4:41 p.m., the RVP said the door alarm was working at the time CR #1 eloped, but believed a staff silenced the alarm, did not reset (relock) it and did not see if anyone left the building. She said no one owned up to it. After the incident the facility conducted an audit of the wander guard binder and ensured all residents were in the facility. Education was initiated with staff on elopement and restarting the maglock. She said the door alarms were checked the night of the incident and the next day with no issues. All wander guards were checked for functioning on 8/11/26.In an interview on 8/19/26 at 9:29 a.m., the RVP said CR #1 was alert and cognitive. She spoke with CR #1 about the elopement, and he told her the address that he wanted to go to and that he was looking for a phone to call his friend to pick him up. CR #1 then started talking about an incident that occurred with his family member. She said the wander guard was placed on him earlier that day as a safety measure but said facility staff should have talked with CR #1 more to see what he was trying to do. She said staff did not follow protocol and should have gotten up to see if any resident left the building when the alarm sounded. In an interview on 8/19/26 at 11:08 a.m. LVN Y said CR #1 was alert and oriented x 2 (alert and oriented to two aspects, such as person and place) with slight confusion but did not exhibit exit seeking behavior. He said he would not be safe out of the building on his own for safety reasons. LVN Y said he received tons of in-services on door alarms, checking the surrounding area for a resident, and resetting the door. He tested wander guards daily.In an interview on 8/19/26 at 11:34 a.m. the DON said she reviewed CR #1's admission clinicals and was not aware he was an elopement risk. She said after his elopement the facility completed an assessment on all residents with wander guards which verified placement and an elopement risk was completed. CR #1 was also assessed that night for elopement risk. She said every resident was assessed for elopement risk upon admission, quarterly and as needed. She said if a resident was missing staff will immediately call a code white and search for the missing patient in all the rooms, review the leave of absence binder, check the parameter of the building and notify the police department.In an interview on 8/19/26 at 3:31 p.m. LVN J said on the day of the elopement (8/10/26) she could not recall any abnormalities of the alarms. If a door alarm went off staff would go to the panel to identify which door alarmed and go to the door to see if a patient went out of the building. To reset the alarm, you put in the code, hit the reset button and recheck the panel to ensure all doors have reset. She said every 2 hours nurses had to document that the residents were present/monitored. After CR #1's elopement they ensured everyone was accounted for. She said there was a purple book at the nursing station that identified elopement risk residents. In an interview on 8/19/26 at 3:53 p.m. CNA B said CR #1 was a slippery one, you would see him but turn your back and he would be gone. Staff had to constantly watch him. She worked the day he left the facility; she did not remember the exact date but said she checked CR #1 during rounds, and the next moment another aide brought him back into the building. She notified LVN J who put a wander guard on him. After placement of the wander guard CR #1 roamed around and everything was good. When she started her next round, she passed by the resident in the hallway. The next thing she heard was, check your residents, check your residents. She said one of the nurses received a call that a resident was down the street and LVN J went to get him (CR #1). She said CR #1 told her he left through the back door. CNA B said she did not hear an alarm go off. She said she was trained on door alarms and elopement. Training on the door alarms including: the door would alarm and staff respond to the alarm and check the surrounding area for a resident. To reset the alarm, press the button behind the nursing station and it would lock and reset the doors. In an interview on 8/19/26 at 4:22 p.m. LVN N said she worked on the day of CR #1's elopement and did not hear an alarm sound. She said the police called the facility and said there was a patient in a hospital gown going down the street and asked if the facility had anyone missing. A code white was called and all staff looked for CR #1. The police later pulled up to the facility and said they saw him by the church. She said the nurse went down to the church and found him. After the elopement they had in-serves on door alarms. She said if the alarm goes off, staff should check each hall, ensure residents are accounted for, check to see if anyone left out of the building, put the code in and reset the door alarms.In an observation on 8/19/26 at 6:20 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the two-way street at moderate speed. The posted speed limit was 45 mph. There was a construction site next door to the facility.The noncompliance was identified as Past Non-Compliance. The IJ began on 8/10/26 and ended on 8/11/26. The Administrator was notified and provided with the IJ template on 8/19/26 at 2:52 p.m. The facility took the following action to correct the non-compliance on 8/11/26:Record review of the facility's undated detailed investigation summary for CR #1 revealed in part, . date of incident: 8/10/26. Immediate Corrective and Protective Measures Immediate comprehensive nursing assessment completed, with no new injury identified. NP and POA notified of the incident. Documented one-to-one supervision initiated. 100% audit of facility exit doors completed; doors were confirmed secure and functioning appropriately. Wander Guard binder reviewed and updated. Staff statements obtained and resident safe surveys completed. Staff re-educated regarding abuse and neglect prevention, residents' rights, elopement prevention and response, and emergency exit-door reset procedures. Interdisciplinary discharge planning initiated/continued in response to the resident's expressed desire to return to the community.Record review of the facility in-service Alarm Systems dated 8/11/26 conducted by DON revealed in part, .to reset all facility exit doors step 1: Go to panel on wall next to fire panel. Step 2: press green exit button at nurse's station, then press green rest button. Once you have completed steps 1 & 2, all doors should be locked, all lights that indicated an open door should no longer be flashing. If any of the lights indicating an open door are still flashing, press exit button at nurse's station again and repeat steps 1 & 2 . There were 60 signatures. Record review of the facility in-service Abuse & Neglect & Elopement Resident rights dated 8/10/26 conducted by DON revealed in part, .Administrator is Abuse Coordinator, when a resident is missing a code white is called, All CNAs check their hallways to ensure all residents are present, notify DON, Administrator on missing resident. There were 18 signatures. Record review of the facility Exit door & elopement safety audit dated 8/10/26 completed by the ADON revealed in part, .Purpose: facility-wide inspection of exit doors and elopement-prevention systems. Audit summary: On August 10, 2026 (ADON) independently conducted a facility-wide physical inspection of the identified exit doors to evaluate exit security and the functioning of applicable elopement-prevention measures. Each listed exit was physically checked to verify that the door was secured, closed and latched appropriately, and that the applicable exit alarm/alert system was functioning at the time of the inspection. All eight identified exit locations were checked. No concerns were identified during the inspection. Any concerns identified with an exit door, locking mechanism, alarm, or other elopement-prevention system are to be immediately reported to facility leadership for corrective action. Record review of the facility Exit door & elopement safety audit dated 8/11/26 revealed in part, .Purpose: facility-wide inspection of exit doors and elopement-prevention systems following resident exit-seeking/self-directed departure. Eight doors were checked, they were all secured, alarm checked, door closed/latches properly, and no concerns were identified. Audit summary: On August 11, 2026 (RVP and ADON) conducted a facility-wide physical inspection of the identified exit doors as part of the facility's immediate response and elopement-prevention review. Each listed exit was physically checked to verify that the door was secured, closed and latched appropriately, and that the applicable exit alarm/alert system was functioning at the time of the inspection. All eight identified exit locations were checked. No concerns were identified during the inspection. Any future identified concerns with an exit door, locking mechanism, alarm, or other elopement-prevention system will be immediately reported to facility leadership and addressed in accordance with facility policy. Record review of the facility elopement policy revised December 2008 revealed in part, .Staff shall investigate and report all cases of missing residents.In an observation and interview on 8/19/26 at 10:38 a.m. of all facility exit doors accompanied by the Maintenance Director, all exit doors were locked with exception of the front door which remained unlocked during the daytime. The front door was armed with a wander guard system that sounded once approached with a wander guard. The remaining exit doors were locked and the alarm beeped when the handle was touched. After pressing on the door handle for a short while, the door alarm sounded and the door unlocked. After the alarm sounded, the alarm was silenced, and the door was reset and locked from the nurse's station. The Maintenance Director said he checked all door alarms weekly with no issues noted. He said once an alarm sounded, staff should check the exit door to see if a resident went out of the door. Once the door is opened it must be reset to lock it.Interviews were conducted on 8/18/26 and 8/19/26 with the following staff across all shifts regarding training received: RVP, DON, LVN J, LVN Y, LVN N, LVN C, LVN D, CNA B, CNA K, CNA H, CNA S, CNA F, CNA N, Staffing Coordinator, and Maintenance Director. All staff interviewed verbalized adequate understanding of the elopement policy, responding to a door alarm, resetting and locking the doors, and wander guard system.

Based on interview, and record review 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 resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 1 of 10 residents (CR #1) reviewed for abuse and neglect reporting.The facility failed to report to HHSC when CR #1 eloped from the facility on 8/10/26.This failure to report could place the residents at risk for neglect. Findings included:Record review of CR #1's admission record dated 8/18/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included traumatic subdural hemorrhage (a type of bleeding near your brain that can happen after a head injury) without loss of consciousness, pedestrian on foot injured in collision with car, pick-up truck or van in nontraffic accident, unsteadiness on feet, fracture of one rib, laceration of diaphragm (partial tear or cut in the diaphragm muscle), fracture of fourth lumbar vertebra, fracture of sacrum, fracture of left pubis, and fracture of other parts of pelvis. He was discharged to his previous group home on 8/12/26.Record review of CR #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He wandered for 1 to 3 days. He needed assistance from staff with ADLs.Record review of CR #1's care plan revealed he was at risk for Wandering / Elopement Identified, date initiated 8/10/26.Record review of CR #1's MD orders revealed an order for Wander Guard: Check for proper placement every shift. Wander guard to the left lower extremity, order date: 8/10/26 at 6:52 p.m.Record review of CR #1's progress note dated 8/10/26 at 8:45 p.m. by LVN J revealed, .Received a call from a (city) Police officer stating that resident was down the street in a church parking lot. Resident informed officer that he came from the (nursing facility name) down the street. This writer immediately left the building in search of the resident. DON was immediately notified about the resident's elopement. Resident was located on (intersection name) in a church parking lot in his wheelchair. When this writer got out of her car, resident stated, Oh! You came to get me?. When writer asked the resident where he was going resident stated, I was going to one of the buildings next door to find a phone to call my friend, to come and pick him up. I want to go home and get away from that place. This writer assisted the resident into the backseat and buckled him in the seatbelt. Upon arrival back to the facility, resident assisted out of the car, into his wheelchair, and back into the building. Resident was moved to the room at the beginning of the hallway and one on one observation initiated. This writer performed a head-to-toe assessment on the resident. Resident skin is warm, dry, and intact. Resident has no visible injuries at this time. Resident able to move upper and lower extremities without any complications. Resident denies any pain at this time. NP.notified of the residents elopement.POA (name) was then notified. When this writer informed her that resident had left the facility and was down the street in his wheelchair, she started laughing. She then stated, That sounds like him. He will slip away in a heartbeat. That's how he ended up at (local) hospital and in the facility. He slipped away from the group home here in (city), got hit by a car, and was life flighted. He has to be monitored closely because he will disappear in the blink of an eye. POA talked with resident and informed him that she will be at the facility in the morning to visit him.Record review of the facility's undated detailed investigation summary for CR #1 revealed in part, . date of incident: 8/10/26. Incident type: elopement/missing resident. Upon Return to the Facility - Immediate Assessment: The resident was safely returned to the facility. A licensed nurse immediately completed a comprehensive head-to-toe assessment. No new injuries or skin concerns were identified. The resident's skin was warm, dry, and intact. He was able to move his upper and lower extremities without difficulty and denied pain. Pre-existing areas of scarring and discoloration were noted to have been present upon admission. The NP and POA were notified. The resident was moved to a room near the beginning of the hallway, and documented one-to-one supervision was immediately initiated. Resident Interview and Reconstruction of Events: As part of the investigation, the RVP interviewed the resident to determine how he exited the facility despite the exit alarm and Wander Guard intervention. The resident was able to provide a detailed account of his actions. He stated that he had learned this trick a long time ago. According to the resident, he intentionally held the exit door until the alarm alerted and then proceeded through the door while walking behind his wheelchair. Once outside the building, the resident reported that he approached the exterior gate, lifted the gate handle, exited through the gate, and then closed the gate behind him. He subsequently traveled down the street to a nearby church for the purpose of locating a telephone/contacting someone to pick him up. The resident was also able to show the nurse the door he reported using to exit the facility. Throughout the interview, the resident consistently expressed that he did not want to remain in a nursing facility and wanted to return to his previous residence in (city). His statements and expressed wishes were communicated to the interdisciplinary team for follow-up and discharge planning. The resident's ability to describe his destination, reason for leaving, method of exiting the building, manipulation of the exterior gate, and plan to contact someone to pick him up supports that his departure was purposeful and self-directed rather than aimless wandering. A 100% audit of facility exit doors was conducted following the incident. All exit doors were confirmed to be secure and functioning appropriately. The Wander Guard binder was reviewed and updated to ensure documentation was current. Staff were immediately re-educated regarding: Abuse and neglect prevention, Residents' rights, Elopement prevention and response, Emergency exit-door reset procedures. Investigation Findings: Based upon the information obtained during the investigation, the resident's departure appears to have been intentional, purposeful, and self-directed. The resident was able to explain how he exited the facility and exterior gate, where he was going, and why he wanted to leave. He consistently expressed a desire to return to the community rather than remain in the nursing facility.However, the investigation identified an important area requiring continued evaluation. At 6:56 PM, approximately two hours before the resident was discovered outside the facility, he had demonstrated exit-seeking behavior when he attempted to leave through another facility door. Staff redirected him, notified the NP and POA, obtained an order for a Wander Guard, and applied the device. Therefore, the investigation must continue to evaluate whether the interventions implemented following the initial exit-seeking episode were sufficient and whether all required supervision, monitoring, care-plan interventions, and elopement-prevention procedures were appropriately implemented and followed. Immediate Corrective and Protective Measures Immediate comprehensive nursing assessment completed, with no new injury identified. NP and POA notified of the incident. Documented one-to-one supervision initiated. 100% audit of facility exit doors completed; doors were confirmed secure and functioning appropriately. Wander Guard binder reviewed and updated. Staff statements obtained and resident safe surveys completed. Staff re-educated regarding abuse and neglect prevention, residents' rights, elopement prevention and response, and emergency exit-door reset procedures. Interdisciplinary discharge planning initiated/continued in response to the resident's expressed desire to return to the community .Record review of the Texas Unified Licensure Information Portal revealed there was no incident report regarding CR #1's elopement on 8/10/26 indicating the facility did not submit a self-report. In an interview on 8/18/26 at 1:09 p.m. CR #1's POA said he was very confused. While in her care he would go places and police would bring him back home because he said he was lost. POA said she informed the facility that CR #1 was a runaway king and needed to be watched but did not know who she informed. The reason CR #1 was at the facility was because he got hit by a car and broke 7 ribs. While at the hospital he also tried to escape. The facility informed her that they found him down the road in his wheelchair. CR #1 told her he tried to go down to someone's house because he did not want to be at the facility. He did not have any injuries and kept leaving because he could not smoke and was looking for cigarette butts. She said he was not safe to be away from the facility because he did not know where he was. In an interview on 8/18/26 at 2:54 p.m. LVN J said on 8/10/26 around 6 p.m. a CNA was outside and saw CR #1 try to leave the building. LVN J notified the DON and NP and received an order for a wander guard for safety which was placed on the resident. She also informed the CNAs to keep an eye on him. She said that was her first time working with CR #1 and did not find out anything about him until she notified his POA of the incident and the POA said he was an escapee. Between 8:00 p.m. - 8:30 p.m. she saw the resident go in his room. Around 8:45 p.m. another LVN received a phone call from the local police department and said CR #1 was down the street and he (CR #1) said he came from the facility. LVN J searched for the resident and found him in the church parking lot and the road was a busy road. CR #1 told her he was going to a building next door to call a friend because he did not want to be at the facility anymore and wanted to go home. She said the resident was not hurt and noted the wander guard was in place. LVN J said no alarms went off at the building and CR #1 told her he went out of the back door on the 200 hall near the therapy room. She said it was storming earlier that day (8/10/26), the lights flickered off and she was unsure if the exit doors were reset. She said CR #1 did not sign out and did not say he was leaving the building. After the elopement the facility ensured all residents were accounted for in the building, initiated 1:1 observation for CR #1, and conducted in-services on elopement and abuse/neglect.In an interview on 8/18/26 at 3:29 p.m. DON said on an unknown date CR #1 tried to go out the side door, she contacted the MD and family, put a wander guard on him and informed staff to keep an eye on him. She verified the wander guard was functioning properly. Between 8:30-8:50 p.m. (on the same day) LVN J said she received a phone call that CR #1 was not in the building. An unknown person found him down the street in a church parking lot and stayed there until facility staff arrived. LVN J brought CR #1 back to the facility and he was placed on 1:1 supervision, assessed, and in-services were conducted with the staff. She said she was unable to answer if the alarms went off when he went out of the building and no one could attest that the door alarm sounded. She said CR #1 had a wander guard in place because he tried to leave the facility previously and leaving would not have been safe because he was from another city. She said it was not safe for him to be out of the building by himself, he had a previous accident where he got hit as a pedestrian and was at risk of being hit again. DON said CR #1 eloped but she discussed the incident with facility leadership and determined CR #1's BIMS score was 13, and he knew what he was doing. In an interview on 8/19/26 at 9:29 a.m. RVP said CR #1 was alert and cognitive. She spoke with CR #1 about the elopement, and he told her the address that he wanted to go to and that he was looking for a phone to call his friend to pick him up. CR #1 then started talking about an incident that occurred with his family member. She said the wander guard was placed on him earlier that day as a safety measure but said facility staff should have talked with CR #1 more to see what he was trying to do. She said staff did not follow protocol and should have gotten up to see if any resident left the building when the alarm sounded. She said the incident did not fall into a reportable category. In an interview on 8/19/26 at 5:04 p.m. RVP said CR #1 was a missing resident, he did not sign out of the facility, and that was why the facility conducted an investigation. She said a missing resident should be reported within 24 hours to HHS per regulation. She said the facility used the reporting provider letter along with the facility elopement policy but ultimately did everything according to the facility policy only. When she reviewed the facility elopement policy, she determined the resident was able to say where he was going, it was self-driven, and he knew the address he wanted to go to. She said the DON or herself were responsible for reporting the incident to HHS. She said because there was a thorough investigation completed by the facility she did not see where there was risk to the resident. In an interview on 8/19/26 at 5:17 p.m. the DON said RVP should have reported it because reporting falls under the Administrator. She said CR #1's incident could have been a reportable due to the elopement, but it was a thin line because they did everything they should have. She said HHS sends guidance on what was reportable and the Administrator made the final decision. She said CR #1 did not sign out and would not have remembered to sign out of the facility. He went out of the side door, was on a mission and wanted to do what he wanted to do. Record review of Long-Term Care Regulation Provider Letter dated 8/29/24 provided by the facility read in part, '.2.1 Incidents that a NF must report to HHSC. A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect. a missing resident.2.4 Reportable Incidents and Timeframes. Do Report: an incident that does not result in serious bodily injury but that involves any of the following: . a missing resident. when to report:. immediately, but not later than 24 hours after the incidents occurs or is suspected . Missing resident: example of a missing resident: A resident is not in his room when staff wake residents up in the morning and the bed appears not to have been slept in. Staff search the facility and cannot find the resident.

Based on observation, 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 1 of 6 residents (Resident CR# 1) reviewed for pressure ulcers.1. The facility failed to identify and provide wound treatment from 3/13/26 to 3/25/26 for CR #1 who experienced a decrease in skin integrity to the left hip that resulted in a stage 4 pressure wound, stage 3 pressure wound to the right sacrum, unstageable wound to the scrotum and an unstageable DTI of the right heel that were all identified on 3/25/26 by the wound care doctor. 2. The facility failed to complete a comprehensive skin assessment or initiate timely treatment orders for several significant pressure injuries for CR#1. Treatment orders were not obtained for multiple wounds until 03/25/26, approximately 12 days after admission. Additional wounds were not addressed until 04/15/26.3. The facility failed to turn/reposition Resident #13 every 2 hours as stated in the care plan, on 5/13 from 8:00 am-1:30 pm. This noncompliance was identified as non-immediate jeopardy.An Immediate Jeopardy (IJ) situation was identified on 05/14/2026. While the IJ was removed on 05/16/26, 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.These failures could place residents at risk of wound deterioration, infection and hospitalization.Findings included:Record review of CR#1's face sheet, dated 04/28/26, revealed a [AGE] year-old who was first admitted to the facility on [DATE]. CR #1 had diagnoses which included sepsis (blood infection), muscle wasting, anemia (deficiency of healthy red blood cells), malnutrition (lack of proper nutrition), Dementia (a decline in cognitive function), legal blindness, heart disease, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), partial intestinal obstruction, acute kidney failure, traumatic hemorrhage (bleeding) of brain.Record review of CR#1's admission MDS resident assessment, dated 03/17/26, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. CR#1 had impairment to both sides of the upper extremities. CR #1 was dependent on staff assistance for all ADLs. CR#1 had one unstageable deep tissue injury that was present upon admission and was receiving nutrition interventions to manage skin problems as well as pressure ulcer/injury care. Record review of CR #1's hospital records, dated 3/12/26, revealed a wound first assessed on 3/11/26 and present on original admission: pressure injury to the right posterior hip and a wound first assessed on 3/12/26: pressure injury to the left lateral foot, present on original admission. The CT of the abdomen and pelvis revealed a possible soft tissue abscess over the left lower pelvis or bursitis. CR #1 was receiving Zosyn 3.375g IV every 8 hours starting 03/12/26 for sepsis secondary to suspected skin/soft tissue abscess infection.Record review of CR #1's completed, discontinued, on hold orders with the date range: 02/28/26 to 04/30/26 revealed orders for:Zosyn 3-0.375gm/50ml IV every 6 hours for ischial (bony prominence of the lower pelvis) abscess until 3/24/26.Left lateral foot/DTI: skin prep to area three times a week daily and PRN, order date was 03/16/26. Further review revealed there were no additional treatment orders from 3/13/26 to 3/25/26 for the other wounds until orders were written on 03/25/26 for the following:Right medial heel DTI: apply betadine once daily and PRN, order date was 3/25/26. Left hip/stage 4 wound: apply Daikin's, skin prep to peri wound (the skin immediately surrounding a wound) daily and PRN, order date was 03/25/26.Right sacrum/stage 3 wound: cleanse area with wound cleanser, pat dry, apply leptospermum honey, calcium alginate, skin prep peri wound, daily and PRN, order date was 3/25/26. Scrotum/unstageable necrotic wound: cleanse area with wound cleanser, pat dry, apply calcium alginate/silver, apply abd pad, skin prep peri wound, daily and PRN, order date was 3/25/26. Low air loss mattress to promote wound healing every shift, order date was 3/25/26. Left ischium/stage 4 wound: cleanse area with wound cleanser, pat dry, apply Santyl, calcium alginate, skin prep peri wound, daily and PRN, order date was 4/15/26. Right distal lateral hip wound: cleanse area with wound cleanser, pat dry, apply xeroform, skin prep peri wound, daily and PRN, order date was 4/15/26. Record review of CR #1's March 2026 MAR/TAR revealed three times a week treatment for left lateral foot DTI were documented as started on 3/18/26. Further review revealed documented daily treatments for the right medial heel DTI, left hip stage 4 wound, right sacrum/stage 3 wound, and unstageable scrotum wound were started on 3/26/26. Record review of CR #1's last care plan review completed on 03/23/26 revealed: Focus - CR #1 had a DTI to left lateral foot with potential for further pressure injury development r/t decreased mobility and incontinence, date initiated was 03/18/26. Interventions included - administer medications as ordered, administer treatments as ordered. Focus - CR #1 has infection of the Ischial (lower pelvis bone) Abscess, dated initiated was 03/14/26. Interventions included - give antibiotics as ordered. Focus - CR #1 has the potential to for pressure ulcer development r/t decreased mobility, date initiated was 03/15/26. Interventions included - check for incontinence during rounds, keep skin clean and dry. Further review of the resident centered care plan did not include interventions for the DTI to the right hip, DTI to the right heel, stage 4 pressure injury to the right sacrum and unstageable wound to the scrotum.Record review of Resident CR#1's admission Braden Scale for Predicting Pressure Ulcer Risk, written by LVN A and dated 03/13/26, was scored 12. The resident's category was high risk for the development of pressure ulcers.Record review of the facility's admission progress note dated 03/13/26 and written by LVN A revealed CR#1 was noted to have a DTI to the right hip and left outer foot.Record review of CR #1's Initial Wound Evaluation and Management Summary by the Wound Care NP dated 03/16/26 read in part: .Site 1 - unstageable DTI of the left lateral foot. duration >5days, noted to be present upon admission per staff.Wound size (L x W x D): 1.5cm x 1cm x not measurable cm.Skin: intact with purple/maroon discoloration.Record review of CR #1's weekly skin review: effective, date 03/20/26 and signed by LVN B (a wound care nurse), revealed a DTI to the right hip and left lateral outer foot. Further review revealed no details such as wound type, stage of the wound or measurements.Record review of CR #1's Wound Care Physician note, dated 03/25/26, read in part: .Site 1 - unstageable DTI of the left lateral foot.wound size (L x W x D): 2.7cm x 2.3cm x not measurable cm. Site 2 - unstageable DTI of the right, medial heel, duration >8 days noted to be present upon admission per staff.Wound size (L x W x D): 2.9cm x 2.9cm x not measurable cm. This visit's measurements are noted by the clinician to be exactly the same as the previous visit.Site 3 - stage 4 pressure wound of the left hip.duration >7 days noted to be present upon admission per staff, wound size (L x W x D): 5.8cm x 9.5cm x 0.2 cm.Site 5 - stage 3 pressure wound of the right sacrum. wound size (L x W x D): 2.7cm x 1cm x 0.2 cm. duration >7 days noted to be present upon admission per staff.Site 6 - unstageable (due to necrosis) scrotum. duration >7 days noted to be present upon admission per staff. Wound size (L x W x D): 7cm x 6.5cm x not measurable cm.Record review of CR #1's weekly skin review: effective date 03/27/26 and signed by LVN C revealed redness location to the groin, and sacrum. Wound assessment: wound type was pressure, DTI to the lateral left foot. Measurements: 2.7cm(length), 2.3cm(width) and depth was N/A. Wound #2: wound type was pressure, DTI to the right medial heel. Measurements: 2.9cm(length), 2.9cm(width), depth was N/A. Wound #3: Wound type was pressure, stage 4. Measurements: 5.8(length), 9.5(width), depth(0.2cm). Wound #4: wound type as pressure, stage 3 to the sacrum. Measurements: 2.7cm(length), 1cm(width), 0.2cm(depth). Wound #5: wound type was pressure to the groin. Measurements: 7cm(length), 6.5cm(width), depth N/A. The RP and Primary Care Physician were notified on 03/27/26.Record review of the progress notes, dated 04/24/26 and written by LVN I, revealed CR#1 was discharged to the emergency room via 911 due to congestion in both lungs, abnormal vital signs and blood in the urine.In an interview on 4/29/26 at 2:30 PM, LVN C, who was the primary wound care nurse and who worked Monday to Friday, stated there were wound care nurses who worked on the weekends and expected the weekend nurses to complete nursing treatment tasks. LVN C stated she was off work when CR #1 admitted on Friday (3/13/26) and the weekend wound nurse should have completed a full skin assessment the following day on Saturday (3/14/26) and it was not done. LVN C stated the nurse working on 3/14/26 was LVN B. LVN C stated it was facility policy to do a full skin assessment soon after admission, within the next 36 to 72 hours, was what she was taught to do and that was the purpose of having a treatment nurse daily. LVN C stated when she did a full skin assessment on 3/27/26, she measured all the wounds. LVN C stated she should not have followed the previous skin assessment because it was not a full assessment and did not realize this until recently. LVN C stated she assumed the full skin assessment had already been done. LVN C stated the purpose of full skin assessments were to capture whatever the hospital overlooked or missed. LVN C stated not doing the initial full skin assessment soon after admission affected the residents because nursing needed to catch skin issues so they could be treated right away, resolved and then move on. LVN C stated CR #1 was in terrible condition when he admitted and was already on antibiotics for sepsis (from the hospital) due to the wounds. LVN C stated she could tell CR #1's wounds were present upon admission when she conducted the full skin assessment on 3/27/26 because of how terrible the wounds were and the severity of the condition of the wounds. Moving forward LVN C stated she would do a facility wide skin audit to ensure residents received correct treatments and correct documentation was in resident records.In an interview on 4/29/26 at 3:30 PM, the DON expected the admitting nurse to conduct the initial head-to-toe assessment, describe what they see and write a progress note then alert the wound care nurse about the new admit. The DON stated the admitting nurse does only the initial assessment but not the measurements of the wounds. The DON stated it was important to assess the wounds right away because they are an easy portal for infection and nurses need to know what needs to be done so we can implement a plan to attempt to heal the wounds. The wound assessments should be done as early as possible as it could affect the resident as to the reason why the resident was admitted in the first place and to jump start the process of healing. The DON stated LVN B on Saturday 3/14/26 should have completed the full skin assessment. The DON stated the initial full skin assessment for CR #1 was not done as early as expected and it should have been caught but it was missed. The DON stated moving forward the facility had already started conducting nursing staff inservices on skin assessments and documentations for new admissions. In an interview on 5/14/26 at 1:20PM, LVN A stated CR#1 was admitted later in the day on 3/13/26. LVN A stated CR#1 admitted with a hip wound and wound to the right heel but could not recall which hip. LVN A stated she reported the wounds to the wound care nurse the next day on 3/14/26 but could not recall the name of the wound care nurse. LVN A stated she expected the weekend wound care nurse lay eyes on newly admitted residents and get orders for wounds. LVN A stated she spoke with the on-call doctor to verify orders but did not discuss wounds. In an interview on 4/30/26 at 12:30 PM, the wound care physician stated he could have missed seeing all of CR#1's wounds initially. The wound care physician stated there were times when CR#1 would not allow him to look at all his wounds and that could have been one of the times. The wound care physician stated CR#1 had multiple wounds, and when more developed there were no more places to offload without the opposite side not healing well. The wound care physician stated CR#1 had multiple comorbidities plus contractures and was declining. In an interview on 4/30/26 at 1:16 PM, CNA E stated she worked with CR#1 and recalled he had bandages one on his bottom and one on the side of the leg for wounds.In an interview on 4/30/26 at 1:26 PM, CNA F stated she was familiar with CR#1 because she worked closely with wound care and only worked with LVN C. CNA F stated when LVN C returned to work after being ill, she recalls CR#1 had wounds to the right hip, left hip, left ischium, right foot and left heel. CNA F stated CR#1 did not always have the podus boots (a medical brace used to protect the ankle and foot) on his feet and after wound care, LVN C would ensure the boots were placed back on CR#1 CNA F stated his boots would be on the floor by the bed and did not know why they were not on his feet. In an interview on 04/30/26 at 1:50 PM, the MDS Nurse stated she was familiar with CR #1 and was aware of his wounds by looking through his chart. The MDS Nurse stated the purpose of the care plan was to give an overall view of what was going on with the resident which included active diagnoses and resident risks so staff would know how to care for the resident. The MDS Nurse stated the wound care nurse was responsible for updating the pressure ulcer care plans as it was part of the assignment. The MDS Nurse stated as changes happened to the resident the care plan should be updated as well. In an interview on 4/30/26 at 1:35 PM, LVN G stated she was familiar with CR#1 and was aware he had several wounds and had an air mattress d/t the wounds. LVN G never conducted a head to toe assessment for CR#1 as it was not needed at the time she took care of him. LVN G stated the wound care nurses conducted the skin assessments. In a telephone interview on 4/30/26 at 2:10 PM, the PCP stated CR #1 was admitted from the hospital for infected wounds from the group home. The PCP stated the facility notified her of all the wounds and he had a DTI to the left foot, left hip, wounds to the sacrum and heels. The PCP stated the Wound Care Physician and wound care nurse regularly gave updates on the status of the wounds.In a telephone interview on 5/14/26 at 2:10PM, LVN B stated she worked every other weekend and was the treatment nurse on the weekend of 3/14/26 and 3/15/26. LVN B stated LVN A would put wound orders in and if there were no orders then there was no need for wound care. LVN B stated she did not recall doing a comprehensive skin assessment for CR#1 and cannot recall when she saw CR#1 for the first time. LVN B stated if CR#1 admitted on a Friday evening then she would have been responsible for the full skin assessment the next day. LVN B stated she would have asked the charge nurse on Saturday 3/14/26, if there were any new admissions, or seen a note left on the cart, or seen a note in the communication book for wound care nurses or seen a wound care order. LVN B stated she never received any notifications that CR#1 needed a skin assessment on 3/14/26 or 3/15/26. LVN B stated she would have remembered him because his wounds were bad and that he admitted with multiple wounds as far as she knew. LVN B stated if there were no wound care orders for a new admission then it was because of poor communication. LVN B stated she did not identify any new wounds, that all the wounds were already there when she started working with him. LVN B stated she remembered he had a wound to the left hip, both ankles, both feet and a sacral wound. LVN B stated it was important to do skin assessments early on to help prevent sepsis. LVN B stated had she been made aware of CR#1 on Saturday 3/14/26 she would have completed a new skin assessment immediately and would not have waited. LVN B stated if there were any concerns she would have notified the wound care physician right away.In an interview on 5/14/26 at 3:50PM, LVN C stated, as the primary wound care nurse, if she was out sick then one of the weekend nurses would have been asked to come in to do the wound care for the facility. LVN C states she was not at the facility between 32/13/26 and 3/22/26 but returned on 3/23/26 and did not know how CR#1's wounds were addressed in her absence. LVN C stated whoever was in the position to do wounds should have followed up on getting orders for CR#1. LVN C stated the sooner the full skin assessment was done then wounds could get treatment. LVN C stated by checking the records, LVN B clicked on the full skin assessment in the electronic health record on 3/20/26 and conducted a weekly skin assessment which was not the comprehensive assessment. LVN C added when CR#1 was resistant to wound care, she would return later and was always able to complete the daily wound care. In an interview on 5/14/26 at 4:32PM, CNA H stated she did work with CR#1 and changed his briefs but did not recall seeing any wounds, skin breakdown or wound dressings.Resident #13 Record review of Resident #13's admission MDS assessment, dated 03/09/2026, revealed a [AGE] year old female, admitted on [DATE], with a BIMS of 13, indicating intact cognition, and diagnoses included multiple fractures of the spine (broken vertebrae in the neck and back secondary to being struck by a vehicle while on foot), neurogenic bladder (lack of bladder control secondary to nerve damage), hypertension (high blood pressure), peripheral vascular disease (condition in which narrowed arteries reduce blood flow to the arms or legs), thyroid disorder (conditions that disrupt the normal function of the thyroid gland, affecting hormone production and metabolism), diabetes mellitus, hyperlipidemia (high cholesterol), and depression. The assessment indicated she had one unhealed unstageable pressure ulcer.During an observation on 05/13/26 at 8:21 a.m. Resident #13 was lying in bed supine with no pillow or wedge behind her/under her back or sides. Continued hourly observations at 9:11 am, 10:35 am, 11:35 am, 12:35 pm, & 1:30 pm found Resident #1 lying on her back in the same position unmoved. Resident #13 was not turned and/or repositioned during the hours of 8:21 am-1:30 pm. During an interview on 05/13/26 at 9:11 am, Resident #13 stated she had not been turned all morning. She said the last time she had been turned was 3 days prior. She stated no one had attempted to turn her or even asked her all day. She mentioned she had recently healed from a wound on her sacrum (record review showed it was an unstageable pressure ulcer). She stated she was uncomfortable. She wanted to be turned & would not have refused. She said she did have pain when being turned. Resident said she was not able to turn herself because a car hit her and broke her back.During an interview with Resident #13 on 05/13/26 at 10:35 am, she stated she had not been turned and had not seen any staff.During an interview with Resident #13 on 05/13/26 at 11:35 am, she stated she had a staff member come in the room to take her blood sugar and give her medications, but no one turned her.During an interview with Resident #13 on 05/13/26 at 12:35 pm, she stated she had not seen any staff and had not been turned. During an interview with Resident #13 on 05/13/26 at 1:30 pm, she stated she had not been turned. She said CNA A just asked how she was and to refill her water and left the room.During an interview on 05/13/26 at 1:32 pm, CNA A stated that she had a list of which residents needed to be turned and how often. CNA A stated there were a couple of residents who refused all day to be turned. She stated Resident #13 does not like to be turned because it hurts her back. She said Resident #13 had even refused in the past. When told that Resident #13 had not been turned all day, she reiterated that Resident #13 does not like to be turned because it hurts her back and she stated Resident #13 had not asked to be turned. She stated the risks of a resident not being turned were skin breakdown & pain. She said that when a resident refused to be turned/repositioned she should notify a nurse because they chart refusals. She said she had not told a nurse Resident #13 refused. During an interview on 05/13/26 at 1:40 pm, Nurse A stated he was unaware of Resident #13 not being turned & that he was not told by CNA A that Resident #13 did not want to turn. He said that it was a CNA's responsibility, but it was the nurse's responsibility to ensure it was being done. He said that the risks were skin breakdown, pressure ulcers, rashes, discomfort, & pain. He said when a resident refused, nurses were to speak with the resident to find out why, encourage the resident, reeducate them on risks, chart the refusal, and notify the family and physician. During an interview on 05/13/26 at 3:33 pm, the DON stated that the CNAs knew who to reposition & when because it is in their tasks on electronic medical record. She said they can also know by looking at their residents to see if they look uncomfortable or have extra pillows. She stated if they were unsure they can always ask their nurse. She said staff were trained on repositioning/turning with check offs which were just completed last month (April 2026) & her goal was to have check offs done quarterly. She said that if a patient refused, her expectation was for a CNA to let a nurse know. The nurse should then go check with the resident to find out why. The nurse should encourage the resident to allow themselves to be turned/repositioned & reeducate them on the risks of not doing so. If they still refuse, the nurse should chart the refusal, contact the family, the physician, & care plan the refusals. She said her expectation is that all residents should be turned unless there is a contraindication. She said that the risks of not turning a resident are skin breakdown & pressure ulcers.Noncompliance with Resident #13 was found to be non-immediate jeopardy.Record review of the facility's policy for Wound Care, revised on December 2011, read in part: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure.Documentation: The following information should be recorded in the resident's medical record: 1. The date the wound care was given. 2. The initials of the individual performing the wound care. 3. Any change in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the treatment and the reason(s) why. 6. The signature and title of the person recording the data. Reporting.2. Report other information in accordance with facility policy and professional standards of practice.Record review of the facility policy for Change in a Resident's Condition or Status, revised on December 2016, read in part: .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.1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an).b. discovery of injuries of an unknown source.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.This was determined to be an Immediate Jeopardy (IJ) on 05/14/2026 at 7:45 PM. The Administrator was provide with the IJ template on 05/14/2026 at 7:45 PM.The following Plan of Removal submitted by the facility was accepted on 5/14/26 at 11:43AM:Immediate action:G.CR#1 was discharged to the hospital on 4/24/2026.H.On 4/29/2026 Medical Director reviewed and approved the RCA and ADHOC facility implemented.I.On 4/29/2026 the Nurse Managers completed a facility-wide skin assessment audit for all current residents to identify undocumented wounds, untreated wounds, missing physician orders, and missing care plans. No concerns were identified.J.On April 29, 2026, the DON, ADON, Unit Manager, Weekend Treatment Nurse, and Treatment Nurse received a disciplinary action regarding failure to follow wound care policy.K.The Clinical Services Director reviewed facility policy on 4/29/2026 regarding the wound care policy and no revisions were deemed necessary. L. DON re-educated the nursing staff on pressure injury prevention and documentation on 4/29/2026.M.The DON/designee re-educated the CNAs on the Stop and Watch early warning tool on 4/29/2026.N.The Medical Director was notified of the IJ for F 686 at 8:30 pm on 5/14/2026. Facility's Plan to ensure compliance quickly On 5/14/2026 the Corporate Clinical Services Director reeducated the DON, Nurse Managers, and Treatment Nurse on reviewing the 24-Hour report daily, admission checklist on all admissions, and the wound care policy. All new admissions will receive a complete head-to-toe skin assessment upon admission by the admitting licensed nurse. Any identified skin alteration will require immediate physician notification, treatment orders, and documentation. To ensure compliance moving forward, the DON, Unit Managers, and Wound Care Nurse will oversee and monitor the admission skin assessment process. The DON, Unit Managers, CSD, and RVP will oversee and monitor compliance through daily review of the Skin Management System audit tool, including admission skin assessments, wound documentation, physician notifications, treatment orders, and care plans to ensure timely identification, treatment, and follow-through of all skin integrity concerns. Any identified concerns or deficiencies will be addressed immediately through corrective action, re-education, and ongoing follow-up monitoring to ensure sustained compliance. The wound care nurse will complete a comprehensive skin assessment within 24 hours of admission. Any identified skin alteration will require immediate physician notification, treatment orders, documentation, and care plan initiation. Licensed nursing staff (full-time, part-time, and PRN) were re-educated regarding skin assessments, physician notification, treatment initiation, documentation, and care planning requirements, completed on 5/14/2026 by the Nurse Managers. Newly hired nurses will be in-serviced by the Director of Nursing or designee on the Wound Care Policy. No licensed nursing staff will be allowed to work without receiving the in-service Wound Care Policy. CNAs (full-time, part-time, and PRN) were re-educated on the Stop and Watch early warning tool, completed on 5/14/2026 by the Nurse Managers/designee. Newly hired CNAs will be in-serviced by the Director of Nursing or designee on the Stop and Watch early warning tool. No CNAS will be allowed to work without receiving the in-service. A daily skin management system audit form was implemented on 4/29/2026 and will be reviewed in the morning meeting to ensure orders, assessments, and care plans are initiated. The DON/designee will complete the daily skin management system audit form daily x 8 weeks. Quality AssuranceAn impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/14/2026 with the Medical Director. The Medical Director has reviewed and agrees with this plan.Monitoring of the POR included the following:Interview on 5/14/26 3:50PM, LVN C who worked day shift, was the primary wound care nurse said she reviewed the residents who were being seen by the wound care physician and completed an audit of the wound care physician's evaluations and resident care plans.Interview on 5/14/26 at 4:30PM, CNA E who worked day shift, stated wound care interventions included air mattress, turning every 2 hours, repositioning by use of wedges or pillows and keeping resident's skin clean and dry. CNA E stated she was trained to identify skin breakdown, to use the stop and watch forms and to notify the nurse. CNA E stated the risk of not implementing interventions would be further skin breakdown, infection and wound not healing.Observation on 5/16/26 at 1:25 PM, of wound care for Resident #45, RN T performed hand hygiene and put on appropriate PPE. Resident #45 was alert, oriented and lying on her right side on an air mattress. RN T removed the old dressing, the wound was large with a pink center, and the surrounding skin was appropriate skin color for the resident. Resident #45 denied pain. RN T cleansed the area with wound cleanser, dried area with gauze, applied the collagen sheet, calcium alginate, skin prep to the surrounding skin and applied the new border dressing. No issues were noted with the procedure or with infection control. RN T provided wound care as per physician orders. Interview on 05/16/26 at 2:10PM, CNA J stated she worked 2pm to 10pm shift and had recently received numerous in-services. CNA J stated that any time there is a change in skin or anything that is different on the resident, any open areas, scraps no matter what size she would report to her floor nurse and would always write a notification in duplicate and give to the nurse. CNA J stated she would document in PCC as well and the message would be seen by the Administrator but would always verbally notify her nurse first. CNA J stated the skin on the resident's bottom can be affected if not turned every 2 hours. CNA J stated turning every 1-2 hours would be most important to help prevent skin injuries and if a resident did have a wound and had been sitting up she would put the resident to bed after meals. CNA J stated prevention included thorough incontinent care because a wound can worsen quickly. CNA J stated she would get information about a resident's mobility assistance from the binder at the nurse station, from the Kardex, or from a verbal report from the nurse. CNA J stated for a newly admitted resident she would pay more attention to the skin on the buttocks and the feet.Interview on 05/16/26 at 2:36PM, LVN K worked 2 PM to 10 PM, stated she recently had an in-service regarding pressure ulcers and skin assessments. LVN K stated she was a certified wound care nurse but this was not her role at the facility. LVN K stated regarding new admissions she would ensure the resident was in bed, collect the paperwork, completed the head to toe skin assessment, check medications and then call the doctor. LVN K stated if a resident admits with wounds she would uncover the wound if the wound had a dressing then make her assessment; she would document the wounds accurately then put a communication note for the wound care nurse and place under the door to the wound care nurse office. LVN K stated if the resident did not have wound orders she would be responsible to notify the doctor and get orders. LVN K stated she may call the hospital if the resident did not come with paperwork from the hospital to find out if there were wound orders. LVN K stated it was her responsibility to document everything and to ensure the CNAs would complete their documentation and communicate with the nurses.Interview on 05/16/26 at 2:54PM, CNA L worked 2 PM to 10 PM, stated he had received many different in-services recently. CNA L stated residents were more prone to developing pressure ulcers if they were unable to reposition themselves. CNA L stated to prevent pressure ulcers he would reposition his residents every 2 hours and change their briefs often because moisture can cause skin breakdown and can make existing wounds worse. CNA L stated wounds develop quickly especially in older individuals. CNA L stated he would report any change in condition including skin changes such as redn

Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident CR# 1) reviewed for neglect.The facility failed to develop and implement an effective system to accurately identify, assess, and treat residents with wounds when CR#1 had wounds (unstageable DTI of the right, medial heel, stage 4 pressure wound of the left hip, stage 3 pressure wound of the right sacrum, and unstageable [due to necrosis] scrotum) that were not identified upon initial assessment, reported to physician, or treated for 12 days which resulted in worsening of wounds and development of new wounds. The facility failed to notify the physician immediately when there were no orders for the skin injuries noted upon admission on [DATE].An Immediate Jeopardy (IJ) situation was identified on 05/15/2026. While the IJ was removed on 05/16/26, 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 of neglect and adverse outcomes.Findings included:Record review of CR#1's face sheet, dated 04/28/26, revealed a [AGE] year-old who was first admitted to the facility on [DATE]. CR #1 had diagnoses which included sepsis (blood infection), muscle wasting, anemia (deficiency of healthy red blood cells), malnutrition (lack of proper nutrition), Dementia (a decline in cognitive function), legal blindness, heart disease, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), partial intestinal obstruction, acute kidney failure, traumatic hemorrhage (bleeding) of brain.Record review of CR#1's admission MDS resident assessment, dated 03/17/26, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. CR#1 had impairment to both sides of the upper extremities. CR #1 was dependent on staff assistance for all ADLs. CR#1 had one unstageable deep tissue injury that was present upon admission and was receiving nutrition interventions to manage skin problems as well as pressure ulcer/injury care. Record review of CR #1's hospital records, dated 3/12/26, revealed a wound first assessed on 3/11/26 and present on original admission: pressure injury to the right posterior hip and a wound first assessed on 3/12/26: pressure injury to the left lateral foot, present on original admission. The CT of the abdomen and pelvis revealed a possible soft tissue abscess over the left lower pelvis or bursitis. CR #1 was receiving Zosyn 3.375g IV every 8 hours starting 03/12/26 for sepsis secondary to suspected skin/soft tissue abscess infection.Record review of CR #1's completed, discontinued, on hold orders with the date range: 02/28/28 to 04/30/26 revealed orders for:Zosyn 3-0.375gm/50ml IV every 6 hours for ischial (bony prominence of the lower pelvis) abscess until 3/24/26.Left lateral foot/DTI: skin prep to area three times a week daily and PRN, order date was 03/16/26. Further review revealed there were no additional treatment orders from 3/13/26 to 3/25/26 for the other wounds until orders were written on 03/25/26 for the following:Right medial heel DTI: apply betadine once daily and PRN, order date was 3/25/26. Left hip/stage 4 wound: apply Daikin's, skin prep to peri wound (the skin immediately surrounding a wound) daily and PRN, order date was 03/25/26.Right sacrum/stage 3 wound: cleanse area with wound cleanser, pat dry, apply leptospermum honey, calcium alginate, skin prep peri wound, daily and PRN, order date was 3/25/26. Scrotum/unstageable necrotic wound: cleanse area with wound cleanser, pat dry, apply calcium alginate/silver, apply abd pad, skin prep peri wound, daily and PRN, order date was 3/25/26. Low air loss mattress to promote wound healing every shift, order date was 3/25/26. Left ischium/stage 4 wound: cleanse area with wound cleanser, pat dry, apply Santyl, calcium alginate, skin prep peri wound, daily and PRN, order date was 4/15/26. Right distal lateral hip wound: cleanse area with wound cleanser, pat dry, apply xeroform, skin prep peri wound, daily and PRN, order date was 4/15/26. Record review of CR #1's March 2026 MAR/TAR revealed three times a week treatment for left lateral foot DTI were documented as started on 3/18/26. Further review revealed documented daily treatments for the right medial heel DTI, left hip stage 4 wound, right sacrum/stage 3 wound, and unstageable scrotum wound were started on 3/26/26. Record review of CR #1's last care plan review completed on 03/23/26 revealed: Focus - CR #1 had a DTI to left lateral foot with potential for further pressure injury development r/t decreased mobility and incontinence, date initiated was 03/18/26. Interventions included - administer medications as ordered, administer treatments as ordered. Focus - CR #1 has infection of the Ischial (lower pelvis bone) Abscess, dated initiated was 03/14/26. Interventions included - give antibiotics as ordered. Focus - CR #1 has the potential to for pressure ulcer development r/t decreased mobility, date initiated was 03/15/26. Interventions included - check for incontinence during rounds, keep skin clean and dry. Further review of the resident centered care plan did not include interventions for the DTI to the right hip, DTI to the right heel, stage 4 pressure injury to the right sacrum and unstageable wound to the scrotum.Record review of Resident CR#1's admission Braden Scale for Predicting Pressure Ulcer Risk written by LVN A and dated 03/13/26 was scored 12. The resident's category was high risk for the development of pressure ulcers.Record review of the facility's admission progress note, dated 03/13/26 and written by LVN A, revealed CR#1 was noted to have a DTI to the right hip and left outer foot.Record review of CR #1's Initial Wound Evaluation and Management Summary by the Wound Care NP, dated 03/16/26, read in part: .Site 1 - unstageable DTI of the left lateral foot. duration >5days, noted to be present upon admission per staff.Wound size (L x W x D): 1.5cm x 1cm x not measurable cm.Skin: intact with purple/maroon discoloration.Record review of CR #1's weekly skin review: effective date 03/20/26 and signed by LVN B (a wound care nurse) revealed a DTI to the right hip and left lateral outer foot. Further review revealed no details such as wound type, stage of the wound or measurements.Record review of CR #1's Wound Care Physician note dated 03/25/26 read in part: .Site 1 - unstageable DTI of the left lateral foot.wound size (L x W x D): 2.7cm x 2.3cm x not measurable cm. Site 2 - unstageable DTI of the right, medial heel, duration >8 days noted to be present upon admission per staff.Wound size (L x W x D): 2.9cm x 2.9cm x not measurable cm. This visit's measurements are noted by the clinician to be exactly the same as the previous visit.Site 3 - stage 4 pressure wound of the left hip.duration >7 days noted to be present upon admission per staff, wound size (L x W x D): 5.8cm x 9.5cm x 0.2 cm.Site 5 - stage 3 pressure wound of the right sacrum. wound size (L x W x D): 2.7cm x 1cm x 0.2 cm. duration >7 days noted to be present upon admission per staff.Site 6 - unstageable (due to necrosis) scrotum. duration >7 days noted to be present upon admission per staff. Wound size (L x W x D): 7cm x 6.5cm x not measurable cm.Record review of CR #1's weekly skin review: effective date 03/27/26 and signed by LVN C revealed redness location to the groin, and sacrum. Wound assessment: wound type was pressure, DTI to the lateral left foot. Measurements: 2.7cm (length), 2.3cm (width) and depth was N/A. Wound #2: wound type was pressure, DTI to the right medial heel. Measurements: 2.9cm (length), 2.9cm (width), depth was N/A. Wound #3: Wound type was pressure, stage 4. Measurements: 5.8 (length), 9.5 (width), depth (0.2cm). Wound #4: wound type as pressure, stage 3 to the sacrum. Measurements: 2.7cm (length), 1cm (width), 0.2cm (depth). Wound #5: wound type was pressure to the groin. Measurements: 7cm (length), 6.5cm (width), depth N/A. The RP and Primary Care Physician were notified on 03/27/26.Record review of the progress notes, dated 04/24/26 and written by LVN I, revealed CR#1 was discharged to the emergency room via 911 due to congestion in both lungs, abnormal vital signs and blood in the urine.In an interview on 4/29/26 at 2:30 PM, LVN C, who was the primary wound care nurse and who worked Monday to Friday, stated there were wound care nurses who worked on the weekends and expected the weekend nurses to do complete nursing treatment tasks. LVN C stated she was off work when CR #1 admitted on Friday (3/13/26) and the weekend wound nurse should have completed a full skin assessment the following day on Saturday (3/14/26) and should have contacted the MD for wound treatment orders and it was not done. LVN C stated the nurse working on 3/14/26 was LVN B. LVN C stated it was the facility policy to do a full skin assessment soon after admission, within the next 36 to 72 hours, was what she was taught to do and that was the purpose of having a treatment nurse daily. LVN C stated when she did a full skin assessment on 3/27/26, she measured all the wounds. LVN C stated she should not have followed the previous skin assessment because it was not a full assessment and did not realize this until recently. LVN C stated she assumed the full skin assessment had already been done. LVN C stated the purpose of full skin assessments were to capture whatever the hospital overlooked or missed. LVN C stated not doing the initial full skin assessment soon after admission affected the residents, because nursing needed to catch skin issues so they could be treated right away, resolved and then move on. LVN C stated CR #1 was in terrible condition when he admitted and he had terrible wounds and was already on antibiotics for sepsis (a systemic blood infection) due to the wounds.In an interview on 4/30/26 at 12:30 PM, the wound care physician stated he could have missed seeing all of CR#1's wounds initially. The wound care physician stated there were times when CR#1 would not allow him to look at all his wounds and that could have been one of the times. The wound care physician stated CR#1 had multiple wounds, and when more developed there were no more places to offload without the opposite side not healing well. The wound care physician stated CR#1 was declining, had multiple comorbidities plus contractures. The wound care physician stated he was particular about his recommendations, especially with large wounds.In an interview on 4/29/26 at 3:30 PM, the DON expected the admitting nurse to conduct the initial head-to-toe assessment, describe what they saw and write a progress note then alert the wound care nurse about the new admit. The DON stated the admitting nurse did only the initial assessment but not the measurements of the wounds. The DON stated it was important to assess the wounds right away because they were an easy portal for infection and nurses needed to know what needed to be done so the facility could implement a plan to attempt to heal the wounds. The wound assessments should be done as early as possible as it could affect the resident as to the reason why the resident was admitted in the first place and to jump start the process of healing. The DON stated on Saturday 3/14/26, LVN B should have completed the full skin assessment and it should have been caught, but it was missed.In an interview on 4/30/26 at 1:26 PM, CNA F stated she was familiar with CR#1 because she worked closely with wound care and only worked with LVN C. CNA F stated when LVN C returned to work after being ill, she recalled CR#1 had wounds to the right hip, left hip, left ischium, right foot and left heel. CNA F stated CR#1 did not always have the podus boots (a medical brace used to protect the ankle and foot) on his feet and after wound care, LVN C would ensure the boots were placed back on CR#1. CNA F stated his boots would be on the floor by the bed and did not know why they were not on his feet. In an interview on 4/30/26 at 1:35 PM, LVN G stated she was familiar with CR#1 and was aware he had several wounds and had an air mattress d/t the wounds. LVN G never conducted a head to toe assessment for CR#1 as it was not needed at the time she took care of him because it wasthe wound care nurses who conducted the weekly skin assessments. In an interview on 5/14/26 at 1:20 PM, LVN A stated CR#1 was admitted later in the day on 3/13/26. LVN A stated CR#1 admitted with a hip wound and wound to the right heel but could not recall which hip. LVN A stated she reported the wounds to the wound care nurse the next day on 3/14/26 but could not recall the name of the wound care nurse. LVN A stated she expected the weekend wound care nurse to lay eyes on newly admitted residents and obtain orders for wounds. LVN A stated she spoke with the on-call doctor to verify orders but did not discuss wounds, because it was the responsibility of the wound care nurses to do so. In a telephone interview on 5/14/26 at 2:10 PM, LVN B stated she worked every other weekend and was the treatment nurse on the weekend of 3/14/26 and 3/15/26. LVN B stated LVN A would put wound orders in and if there were no orders then there was no need for wound care. LVN B stated she did not recall doing a comprehensive skin assessment for CR#1 and could not recall when she saw CR#1 for the first time. LVN B stated if CR#1 admitted on a Friday evening then she would have been responsible for the full skin assessment the next day. LVN B stated she would have asked the charge nurse on Saturday 3/14/26, if there were any new admissions, or saw a note left on the cart, or saw a note in the communication book for wound care nurses or saw a wound care order. LVN B stated she never received any notifications that CR#1 needed a skin assessment on 3/14/26 or 3/15/26. LVN B stated she would be alerted of any new admissions by checking the electronic health care records or report from the charge nurse, but she never received notification. LVN B stated she would have remembered him because his wounds were bad and he admitted with multiple wounds as far as she knew. LVN B stated if there were no wound care orders for a new admission then it was because of poor communication. LVN B stated she did not identify any new wounds, and all the wounds were already there when she started working with him. LVN B stated she remembered he had a wound to the left hip, both ankles, both feet and a sacral wound. LVN B stated it was important to do skin assessments early on to help prevent sepsis. LVN B stated had she been made aware of CR#1 on Saturday 3/14/26 she would have completed a new skin assessment immediately and would not have waited. LVN B stated if there were any concerns she would have notified the wound care physician right away.In an interview on 5/14/26 at 3:50 PM, LVN C stated, as the primary wound care nurse, if she was out sick then one of the weekend nurses would have been asked to come in to do the wound care for the facility. LVN C stated she was not at the facility between 3/13/26 and 3/22/26 but returned on 3/23/26 and did not know how CR#1's wounds were addressed in her absence. LVN C stated whoever was in the position to do wounds should have followed up on getting orders for CR#1. LVN C stated the sooner the full skin assessment was done then wounds could get treatment. LVN C stated by checking the records, she discovered that LVN B clicked on the full skin assessment in the electronic health record on 3/20/26 and conducted a weekly skin assessment which was not the comprehensive assessment. LVN C added when CR#1 was resistant to wound care, she would return later and was always able to complete the daily wound care.In an interview on 5/14/26 at 4:32 PM, CNA H stated she worked with CR#1 and changed his briefs but did not recall seeing any wounds, skin breakdown or wound dressings.In an interview on 05/15/26 at 1:02 PM, the DON stated the wound care nurses would have looked at the from page of the electronic health records for new admissions and that was where CR#1's wound care should have started, and this was what the weekend wound care nurse (LVN B) was educated on during orientation. The DON stated LVN B followed the wound care orders on 3/20/26 and was supposed to do the full skin assessment but did not do so. The DON stated she also expected CNAs to notify the nurse of any skin changes and describe what they saw and for the nurses to assess, document, describe the skin and notify the wound care nurse for MD notification. The DON stated what she expected the nursing staff to do for CR#1 was not put into place until after 4/30/26. The DON stated it was mandated that a full skin assessment be completed upon admission and the staff were not implementing this prior to 4/28/26 and she had to reinforce by conducting in-services, holding the nurses accountable. The DON stated all nurses should be able to assess the skin, describe what was seen and contact the MD for orders if needed. The DON stated the CNAs should have seen CR#1's wounds to the scrotum, sacrum, feet and hips during peri care since they would be the first to see the skin, but it was missed other than the dressings to the left foot. The DON stated communication among the nursing staff was not happening the way she expected. The DON stated she was new to the facility at the time CR#1 was admitted and was in process of addressing the system in question. The DON stated the possible outcomes of not having a system in place for identifying wounds early would be possible neglect.In an interview on 05/15/26 at 1:45 PM, the Administrator stated she was not aware of CR#1's wounds until he was sent out to the hospital via 911 on 4/24/26 and during the morning stand up meeting it was mentioned about his wounds. The Administrator stated she heard the nurse filling in for LVN C did not complete the full skin assessment and therefore not aware of the multiple wounds and CR#1 was very sick, he had multiple comorbidities and may have had a significant decline. The Administrator stated during the conversation about CR#1 she was a part of; she did not consider his condition to be neglect. The Administrator stated if the requirement for a head to toe assessment upon admission was not done then it would be detrimental to the resident. The Administrator stated it would put the facility at risk for failing to complete the requirement of a full skin assessment. The Administrator stated she was from the old school of thought that if it was not in writing then it did not happen. The Administrator stated to help prevent further potential neglect the facility re-educated the staff again on full head to toe assessments and the proper procedures for notifying the wound care nurse about new admissions and their wounds. The Administrator stated disciplinary actions were conducted on all the nurses who were responsible for CR#1's care, in-services were started regarding skin changes, reporting to the nurse continued from there. The Administrator stated there was a communication failure because there was not a lot of follow through with his care and a lot of steps were missing. Record review of the facility's policy for abuse and neglect- clinical protocol, revised on date April 2007, read in part: The Administrator is the Abuse Coordinator. If the Administrator is accused of an abusive act or if someone alleges that they have witnessed the Administrator in the act of abuse, you can contact the Corporate Office and/or the Police. Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include a. Injury assessment (bleeding, bruising, deformity, swelling, etc.).2. The nurse will report findings to the physician. As needed the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear.3.b. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention of care of pressure ulcers.3. The Attending Physician will provide adequate documentation to clarify significant negative outcomes that have resulted from a resident's underlying medical illnesses or conditions, despite appropriate care. Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.Record review of the facility's policy for Wound Care, revised on December 2011, read in part: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure.Documentation: The following information should be recorded in the resident's medical record: 1. The date the wound care was given. 2. The initials of the individual performing the wound care. 3. Any change in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the treatment and the reason(s) why. 6. The signature and title of the person recording the data. Reporting.2. Report other information in accordance with facility policy and professional standards of practice.Record review of the facility's policy for Change in a Resident's Condition or Status, revised on December 2016, read in part: .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.1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an).b. discovery of injuries of an unknown source.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.This was determined to be an Immediate Jeopardy (IJ) on 05/15/2026 at 4:54 PM. The. The Administrator was provided with the IJ template on 05/15/26 at 4:54 PM. The following Plan of Removal submitted by the facility was accepted on 5/16/26 at 2:01 PM:Immediate action:A. CR#1 was discharged to the hospital on 4/24/2026.B. The Medical Director was notified of the IJ for F 600 at 4:48 pm on 5/15/2026.C. On 4/29/2026 the Nurse Managers completed a facility-wide skin assessment audit for all current residents to identify undocumented wounds, untreated wounds, missing physician orders, and missing care plans. No concerns were identified.D. On May 15, 2026, the Administrator received a disciplinary action regarding expectations for oversight, timely follow-up, staff accountability, and compliance with Abuse and Neglect prevention requirements. E. The Regional [NAME] President of Operations re-educated the Administrator, DON, ADON, Unit Manager, and Treatment Nurse on the Abuse and Neglect Policy. Completed on 5/15/2026. F. The Regional [NAME] President of Operations reviewed facility policy on 5/15/2026 regarding Abuse and Neglect and no revisions were deemed necessary. Facility's Plan to ensure compliance quicklyOn 5/14/2026 the Corporate Clinical Services Director reeducated the DON, Nurse Managers, and Treatment Nurse on reviewing the 24-Hour report daily, admission checklist on all admissions, and the wound care policy. All new admissions will receive a complete head-to-toe skin assessment upon admission by the admitting licensed nurse. Any identified skin alteration will require immediate physician notification, treatment orders, and documentation. To ensure compliance moving forward, the DON, Unit Managers, and Wound Care Nurse will oversee and monitor the admission skin assessment process. The DON, Unit Managers, CSD, and RVP will oversee and monitor compliance through daily review of the Skin Management System audit tool, including admission skin assessments, wound documentation, physician notifications, treatment orders, and care plans to ensure timely identification, treatment, and follow-through of all skin integrity concerns. Any identified concerns or deficiencies will be addressed immediately through corrective action, re-education, and ongoing follow-up monitoring to ensure sustained compliance. The daily review of the Skin Management System audit tool was added and will be reviewed daily for 8 weeks and weekly thereafter for 1 month. This will be reviewed monthly in QAPI until sustained compliance is achieved. The wound care nurse will complete a comprehensive skin assessment within 24 hours of admission. Any identified skin alteration will require immediate physician notification, treatment orders, documentation, and care plan initiation. Already part of the facility's policy and is on-going. Nursing staff (full-time, part-time, and PRN) were re-educated on 5/15/2026 by the Administrator/designee regarding abused neglect prevention, skin assessments, physician notification, treatment initiation, documentation, and care planning requirements. No licensed nursing staff will be allowed to work without receiving the in-service work. Newly hired nurses will be in-serviced by the Administrator/designee on the Abuse and Neglect Policy. Completed 5/15/2026. Staff voiced understanding of the Abuse and Neglect in-service and demonstrated understanding through verbal discussion and examples provided during the education. CNAs (full-time, part-time, PRN) were re-educated on 5/15/2026 by the Administrator/designee on abuse and neglect prevention, resident observation, reporting expectations, and the Stop and Watch Early Warning Tool. No CNAS will be allowed to work without receiving the in-service. Newly hired CNAs will be in-serviced by the Administrator/designee on the Abuse and Neglect Policy. Completed 5/15/2026. Staff voiced understanding of the Abuse and Neglect in-service and demonstrated understanding through verbal discussion and examples provided during the education. A daily Skin Management System audit tool was implemented and will continue as an ongoing practice to ensure assessments, physician notifications, treatment orders, documentation, and care plans are completed timely and accurately. The DON/designee will review the audit tool daily for 8 weeks and weekly thereafter for 1 month. This will be reviewed monthly in QAPI until sustained compliance is achieved. The daily review of the Skin Management System audit tool was added, and it is not part of the wound care policy. Quality AssuranceAn impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 5/15/2026 with the Medical Director. The Medical Director has reviewed and agrees with this plan.Monitoring the POR included the following:Observation on 5/16/26 at 1:25 PM, of wound care for Resident #45, RN T performed hand hygiene and put on appropriate PPE. Resident #45 was alert, oriented and lying on her right side on an air mattress. RN T removed the old dressing, the wound was large with a pink center, and the surrounding skin was appropriate skin color for the resident. Resident #45 denied pain. RN T cleansed the area with wound cleanser, dried area with gauze, applied the collagen sheet, calcium alginate, skin prep to the surrounding skin and applied the new border dressing. No issues were noted with the procedure or with infection control. RN T provided wound care as per physician orders. Observation on 5/16/26 at 6:40 PM, revealed Resident #1 was alert and lying on his back, he denied any skin injuries and had no complaints about his care. The resident was clean and no odors were noted. No issues were noted.Observation on 5/16/26 at 6:50 PM, Resident #74 was lying on his back on an air mattress with feet offloaded. The head of bed was elevated, and the tube feeding was infused. Resident #74 was watching TV and said he had no concerns about his care at the facility. There were no odors and the resident was clean and groomed. Further observation of the residents' rooms in 100, 200, 300 and 400 halls revealed most residents were in bed and safe. Observed staff in the hallways walking in and out of resident rooms checking on residents and asking if they needed anything. Observed a few residents sitting in wheelchairs around the nurse station or sitting at the dining table closest to the entrance to the dining room. Residents were not in any distress, were groomed and staff were present at the nurse station or walking around the nurse station.Interview on 5/14/26 3:50 PM, LVN C, who worked day shift, was the primary wound care nurse, said she reviewed the residents who were being seen by the wound care physician and completed an audit of the wound care physician's evaluations and resident care plans. LVN C stated the audit resulted in no issues and wound care orders.Interview on 5/14/26 at 4:30 PM, CNA E who worked day shift, stated wound care interventions included air mattress, turning every 2 hours, repositioning by use of wedges or pillows and keeping resident's skin clean and dry. CNA E stated she was trained to identify skin breakdown, to use the stop and watch forms (a tool used to communicate any change in condition) and to notify the nurse. CNA E stated the risk of not implementing interventions would be further skin breakdown, infection and the wound not healing.Interview on 05/16/26 at 2:10 PM, CNA J stated she worked 2PM to 10PM shift and recently received numerous in-services that included abuse, neglect, prevention of skin injuries and communicating any changes to the resident. CNA J stated any time there was a change in skin or anything that was different on the resident, any open areas, scraps no matter what size she would report to her floor nurse and would always write a notification in duplicate and give to the nurse. CNA J stated she would document in PCC as well and the message would be seen by the Administrator but would always verbally notify her nurse first. CNA J stated the skin on the resident's bottom could be affected if they were not turned every 2 hours. CNA J stated turning every 1-2 hours would be most important to help prevent skin injuries and if a resident did have a wound and was sitting up she would put the resident to bed after meals. CNA J stated prevention included thorough incontinent care because a wound could worsen quickly. CNA J stated she would get information about a resident's mobility assistance from the binder at the nurse station, from the Kardex, or from a verbal report from the nurse. CNA J stated for a newly admitted resident she would pay more attention to the skin on the buttocks and the feet. CNA J stated she did receive in-service on abuse/neglect prior to starting her shift (sometimes she would get in twice in one day) and was able to verbalize her understanding of neglect and she would report to the Administrator. CNA J stated she would call the 1-800 number if nothing was done by the Administrator. CNA J stated if she heard about abuse or neglect from staff she would also report to the nurse and the Administrator.Interview on 05/16/26 at 2:36 PM, LVN K worked 2 PM to 10 PM stated she recently had an in-service regarding pressure ulcers and skin assessments. LVN K stated she was a certified wound care nurse, but this was not her role at the facility. LVN K stated regarding new admissions she would ensure the resident was in bed, collect the paperwork, complete the head to toe skin assessment, check medications and then call the doctor. LVN K stated if a resident admitted with wounds she would uncover the wound if the wound had a dressing then make her assessment; she would document the wounds accurately then put a communication note for the wound care nurse and place it under the door to the wound care nurse office. LVN K stated if the resident did not have wound orders, she would be responsible to notify the doctor and get orders. LVN K stated she may call the hospital if the resident did not co

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes 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 (Resident #12) of 5 residents reviewed for care plans.The facility failed to ensure Resident #12's dentures were on her care plan.This failure could place residents at risk of unmet ADL needs.The findings included:Record review of Resident #12's face sheet, dated 5/13/26, revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included unilateral primary osteoarthritis, right hip (degeneration of cartilage in a single joint due to normal wear and tear without a known cause or underlying injury), schizoaffective disorder, bipolar type (mental health condition that combines symptoms of schizophrenia with episodes of mania or hypomania, and sometimes major depression), and unspecified dementia, moderate, with agitation.Record review of Resident #12's quarterly MDS assessment, dated 3/13/26, revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required supervision or touching assistance with oral hygiene.Record review of Resident #12's care plan last reviewed 3/16/26 revealed she had an ADL self-care performance deficit related to dementia. She required supervision or touching assistance with personal hygiene and oral hygiene. Her dentures were not documented on the care plan.In an interview on 5/12/26 at 3:53 p.m. Resident #12's family member said most of the facility staff could not deal with Resident #12's [NAME] body dementia (the second most common type of dementia). He said the hardest thing to get the staff to do was clean her teeth/dentures. He said staff told him the resident would bite them.During an interview on 5/15/26 at 6:27 p.m. CNA M said she provided care for Resident #12 for the last 2 months. She said the resident was very, very confused and combative. She said Resident #12 had (natural) teeth, did not wear dentures and she had never seen her with dentures. CNA M said the resident would not let her get inside of her mouth; she would fight or attack her. She said she never tried to get inside her mouth. CNA M said the morning shift staff never mentioned removing her dentures. CNA M said if the resident had dentures, she would remove them and place them in a cup with dental solution. She said the electronic medical record would alert her if the resident had dentures and she never saw dentures documented on the Kardex. She said dentures needed to be cleaned because food could get in there. During an interview on 5/15/26 at 6:43 p.m., the PPS Nurse said she was aware Resident #12 wore dentures because of the MDS assessment and because the family member asked the facility to remove them from her mouth and clean them. She said CNAs should be made aware of the dentures by the oral hygiene task indicated under ADL care. She said it would be more helpful to the CNAs if dentures were documented on the care plan, but it should be obvious to staff when providing oral hygiene. She said Resident #12's dentures should be care planned, and it was the tasks of the unit manager or herself to put it on there. During an interview on 5/15/26 at 7:34 p.m., the Unit Manager said she was aware Resident #12 wore dentures because she recalled the struggle of removing them from her mouth. She said new CNAs were informed of her dentures during training and orientation and oral care was also listed on the Kardex. She said she did not update the resident's care plan to include dentures, but it should be care planned, so staff knew she had them and for inventory purposes. She said the MDS nurse would have care planned her dentures. She said she did not foresee any risk to the resident of not having the dentures care planned. Record review of the facility's Care Plans - Comprehensive policy, dated December 2009, read in part, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.

Based on observation, interview and record review, the facility failed to permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse for 1 of 6 residents (Resident #6) reviewed for pharmacy services. The facility failed to ensure that Resident #6 was given medication by a licensed/certified staff member on 05/13/26. This failure could place residents at risk of not receiving the therapeutic benefit of the medication and/or worsening health concerns.Findings included: Findings included:Record review of Resident #6's quarterly MDS assessment, dated 3/26/26. revealed, a [AGE] year-old male admitted on [DATE] with a BIMS of 9 which indicated moderate cognitive impairment. His diagnoses included hypertension (high blood pressure), diabetes mellitus, hyperlipidemia, thyroid disorder, & depression. During an observation of patient care on 05/13/26 at 10:00 am, CNA A was changing Resident #6's brief when Nurse A entered the room with a tube of zinc oxide ointment for Resident #6. Nurse A handed the tube to CNA A & asked her to apply it to Resident #6's buttocks & sacrum. CNA A did as asked & then Nurse A took the tube & left the room. CNA A finished patient care & then Resident #6 asked if there was any cream left because he was supposed to have it applied to his genitals as well. CNA A told Resident #6 that the nurse had already left & taken the cream with him. During an interview on 05/13/26 at 10:40 am, Resident #6 stated he was usually given his cream by a nurse. He said he had not gotten any other cream applied today (5/13/26) so he knew it was not applied to his peri area (the diamond-shaped area located between the thighs, extending from the pubic symphysis to the coccyx) where he was supposed to get it. During an interview on 05/13/26 at 1:31 pm, CNA A stated that she did not know which areas Resident #6 was supposed to have zinc oxide applied to because she was not a nurse & the nurse was who usually applied it. She said she forgot to ask Nurse A if Resident #6 was supposed to have cream applied to his peri area (genitals). She said that Resident #6 hadn't had any other cream applied that shift that she was aware of. She said she reported to the DON that the nurse had asked her to apply the cream. During an interview on 05/13/26 at 1:40 pm, Nurse A stated that zinc oxide is to be given by nurses. He said that he asked CNA A to do it that morning because he made a mistake & was thrown off that he walked into the room where patient care was already happening & a surveyor was there observing. He said that the order states to apply the cream once per shift to Resident #6's buttocks, sacrum, & peri area. He said that he had applied the cream to Resident #6's peri area that morning, but that Resident #6 was sleepy so maybe he wasn't aware I did it. He said it is the expectation to let residents know what medication they were being given & what it was for. He said the risks of a CNA applying ointment could be ineffective application, leading to skin breakdown & rashes.During an interview on 05/13/26 at 3:33 pm, the DON stated, after checking Resident #6's orders, that zinc oxide was a medication so it should be given by a nurse & not a CNA. She said a CNA is not qualified to give a medication & that the CNA should have refused the nurse's request & told him she wasn't allowed to give medication. She also stated that when the resident asked about the ointment being applied to his peri area, she should have notified the nurse so the nurse could assess to see if he needs the medication applied there. Her expectation was that nurses follow physician orders, give medications as ordered, & CNAs refused anything outside their scope of practice. She said the risks of having a CNA apply the ointment were it being applied incorrectly or to the wrong area resulting in the medication being ineffective & leading to skin breakdown.

Based on observation, interview, and record review the facility staff failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #13) reviewed for incontinent care.The facility failed to ensure Resident #13 had a securing device in place for her urinary catheter on 05/13/26.This failure could place residents at risk for skin breakdown, pressure ulcers, infections, pain, and/or decline in quality of life/ADLs.Findings included:Record review of Resident #13's admission MDS assessment, dated 03/09/2026 revealed, a [AGE] year old female, admitted on [DATE], with a BIMS of 13, indicating intact cognition, and diagnoses included multiple fractures of the spine (broken vertebrae in the neck and back secondary to being struck by a vehicle while on foot), neurogenic bladder (lack of bladder control secondary to nerve damage), hypertension (high blood pressure), peripheral vascular disease (condition in which narrowed arteries reduce blood flow to the arms or legs), thyroid disorder (conditions that disrupt the normal function of the thyroid gland, affecting hormone production and metabolism), diabetes mellitus, hyperlipidemia (high cholesterol), & depression. During an interview on 05/13/26 at 9:11 am, Resident #13 stated she had not had a statlock on her catheter (a small, adhesive-based catheter stabilization device designed to securely hold medical tubing in place on the skin) since the day before. She said it must have come off when she had gotten a bath the day before because she remembered seeing it before then. Observation of Resident #13 on 05/13/26 at 9:17 a.m. revealed a foley catheter with privacy bag, 200mL of urine, & the absence of a statlock or any other device securing the urinary catheter to Resident #13's thigh.During an interview on 05/13/26 at 1:31 pm, CNA A stated she had not noticed there was no statlock on Resident #13's leg. She stated that replacing a statlock was a nursing responsibility, but it was her job to report it.During an interview on 05/13/26 at 1:40 pm. Nurse A stated that all residents with urinary catheters should have a statlock in place on the thigh. He stated that he did not notice that Resident #13 did not have a statlock in place that morning. He said that he must have overlooked it somehow. He said that it was a nurse's responsibility to place/replace a statlock and said he would take care of it. He said the risks of not having a catheter secured were the catheter pulling & causing injury, pain, discomfort, & UTI. In an interview on 05/13/26 at 3:33 pm, the DON stated that the facility did a sweep to ensure all statlocks were in place & that they checked every day. She said that statlocks were used to prevent injury, trauma, infection, for safety, & to keep the catheter bag off the floor. She said that CNAs & nurses get training on catheter care & they have check offs. She said nurses are responsible for ensuring statlocks are in place, but that sometimes CNAs notice & notify nurses. She said the risks of not having a statlock in place are injury, trauma, & infection.Record review of the facility policy titled, Catheter Care, UrinaryH5MAPR0048, dated 3/31/2016, indicated, under subsection 'Changing Catheters' Ensure that the catheter remains secured with a securement device such as a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.).

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 good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #7) reviewed for ADLs.The facility failed to ensure Resident #7 was provided with fingernail care.This failure could place residents at risk of infection and discomfort.Findings included:Record review of Resident #7's face sheet, dated 5/15/26, revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included sepsis (life-threatening medical emergency caused by the body's overwhelming response to an infection), abnormalities of gait and mobility, and type 2 diabetes.Record review of Resident #7's significant change in status MDS assessment, dated 5/15/26, revealed a BIMS score of 13 out of 15 which indicated intact cognition. The functional abilities section was blank.Record review of Resident #7's care plan reviewed 4/5/26 revealed she had an ADL self-care performance deficit related to weakness. Her interventions read, .(Resident #7) requires partial/moderate assistance with personal hygiene.During an observation and interview on 5/12/26 at 10:45 a.m., Resident #12's right index fingernail was long. She said she would love to have her fingernails cut but did not have the money. She said her thumb nail was rough and needed to be filed. In an observation on 5/13/26 at 8:41 a.m., RN K told Resident #12 her fingernails needed to be cut, and she would get a staff member to do her nails. Resident #12 replied, yes, that would be nice. In an observation and interview on 5/13/26 at 11:31 a.m. Resident #12's right index fingernail was long. She said her nails had not been cut. During an interview on 5/14/26 at 12:11 p.m., Resident #12 said her fingernails were not cut and needed to be.In an observation and interview on 5/15/26 at 12:02 p.m., LVN J observed Resident #12's fingernails. LVN J said the fingernails were too long and that Resident #12 also told her they were too long. She said nail care should be done on shower days. She said the nurse who previously observed the resident's nails should have addressed them at that time. She said she would cut and clean her nails. During an interview on 5/15/26 at 3:39 p.m., CNA S said she did not notice anything about Resident #12's fingernails when she worked with her and the resident did not ask for them to be cut. She said the Activities dept. would cut the fingernails and she had not personally cut any fingernails. She said no one told her she should cut fingernails. She said she would clean under the fingernails during a shower. She said resident nails should be right past the fingertip to prevent scratching and bacteria from getting under the nails. In an interview on 5/15/26 at 5:12 p.m., RN K said when she worked with Resident #12 on Wednesday (5/13/26), one of her fingernails was long and she informed the resident she would try to get someone to do her nails. RN K said nail care would be provided to the resident during her shower, and the CNAs were supposed to do their nails. RN K said she clipped fingernails all the time but Resident #12's nails were ok to wait until her shower day. In an interview on 5/15/26 at 6:12 p.m. the DON said fingernails should be trimmed during showers and nurses would do the nail care if the resident was diabetic. She said Resident #12's fingernail was long, but the resident liked the length but would accept trimming if someone provided it. She expected every resident to be offered nail care during baths, every day, or if needed. She said fingernail care was a part of ADL care and was the resident's right. She said nail care should be provided because of germs, different infections, and the risk of scratching, skin tears, and abrasions.Record review of the facility's Care of Fingernails/Toenails policy, revised April 2007, read in part, .the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interview, and record review, the facility failed to ensure each resident's bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area for 2 of 7 residents (Resident#4, and Resident#5) reviewed for residents' call system.The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #4 and Resident#5 the ability to safely call for staff for assistance.This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Findings included:1. Record review of Resident #5's quarterly MDS assessment, dated 09/19/25, reflected Resident #5 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension(elevated blood pressure), cerebrovascular Accident(a stroke that occurs when blood flow to the brain is interrupted, either by a blockage or a ruptured blood vessel, causing brain cells to die), Bipolar Disorder (a chronic mental health condition characterized by extreme mood swings, energy level shifts, and difficulty with activity levels, ranging from manic episodes to depressive episodes), and Schizophrenia (a chronic brain disorder that causes a person to lose touch with reality, leading to symptoms like hallucinations, delusions, and disorganized thinking and behavior), muscle weakness, and difficulty walking. Resident #5 had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Under section GG, functional ability, reflected Resident #5 was coded as dependent for lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer.Review of Resident #5's Comprehensive Care Plan, dated 09/22/25, reflected the following: Focus: [Resident #5] has had an actual fall r/t cognitive impairment. Poor balance. Unsteady gait. Goal: Will resume usual activities without further incident through the review date. Intervention/Tasks: Call light in reach while in bed.During an observation and interview on 11/19/25 at 07:22 a.m. Resident #5 was lying in bed, and the call light button was on the floor under the head of the bed. Resident #5 stated he liked to call for help to get some coffee, but he did not know where his call light button was. During an observation and interview on 11/19/25 at 07:23 a.m., UM A entered Resident #5 located the call light cord and button on the floor. UM A picked up the call light button and put it within Resident #5's reach. She stated the call light was on the floor, and not next to Resident #5. She stated the problem was he would not be able to call for help and anything could happen to him. UM A stated if Resident #5 was incontinent or had an emergency, he could not call for help.2.-Record review of Resident #4's quarterly MDS assessment, dated 09/17/25, reflected Resident #4 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Psychotic Disorder (a serious mental illness characterized by a loss of contact with reality, known as psychosis), Schizophrenia (a chronic brain disorder that causes a person to lose touch with reality, leading to symptoms like hallucinations, delusions, and disorganized thinking and behavior), muscle weakness, and unsteadiness on feet. Resident #4 had a BIMS score of 03/15, indicating severe cognitive impairment. Section J1800 reflected: Any Falls Since Admission/Entry or Reentry the answer was coded (1) yes.Review of Resident #4's Comprehensive Care Plan, dated 09/11/25, reflected the following: Focus: [Resident #4] is at risk for falls r/t dementia, gait/balance problems, incontinence, psychoactive drug use. Goal: Resident will be free of injury from falls through the review date. Intervention/Tasks: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests forassistance.During an observation on 11/19/25 at 07:50 a.m., Resident #4 was sleeping in bed, and the call light button was on the floor under the head of the bed. During an observation and interview on 11/19/25 at 07:53 a.m., revealed CNA C entered Resident #4's room and located the call light cord and button on the floor. CNA C picked up the call light button and put it within Resident #4's reach. She stated the call light was on the floor, and not next to Resident #4. She stated the problem was Resident #4 was not be able to call for help and anything could happen to her. CNA C stated if she was incontinent, she could not call for assistance and if there was an emergency she could not call for help.Interview with the CSD on 11/20/25 at 10:59 AM revealed the expectation for call light placement was residents should always have the call light within reach, and the call light should be placed on the resident's dominant side. He stated the risk to residents of not having had their call lights within reach was delayed care, and possible fall and injury. Interview on 11/20/25 at 12:24 PM the Administrator stated her expectation was the call light button should always be within residents' reach clipped to residents' clothes or linen where they could reach it. She stated the risk was the resident could not call for help if they sustained a fall, and not having their needs met. Review of the facility policy titled Resident Call light System, dated June 2020, revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Policy Implementation: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. General Guidelines: .4. Ensure that the call light is easily reachable by the resident.

Based on observation and interview the facility failed to ensure all patient care equipment was in safe operating condition for 1 resident (Resident#2) of 7 residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #2's bed had a working remote control.This failure could place residents at risk of living in an unsafe and un-homelike environment. Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed Resident#2 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), Parkinson's Disease (a progressive brain disorder causing unintended or uncontrollable movements like shaking, stiffness, and balance problems), anxiety disorder (a mental health condition characterized by excessive and overwhelming fear and worry that interferes with daily life), muscle weakness, and lack of coordination. Resident #2 had a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. Record review of Resident #2's care plan, dated 09/02/25, revealed, Problems: [Resident#2] has Parkinson's. Goal: Will remain free of further s/sx, discomfort or complicationsrelated to Parkinson's disease through review date. Intervention/Tasks: Observe for risk of falls. Record review of Resident#2 primary care provider order summary , dated 05/30/25, revealed Place head of the bed elevated not greater than 30 degrees when eating. Please make attempts to feed him when possible.Record review of Resident#2 LVN E progress note , dated 11/19/25 at 4:21 a.m. , revealed, Res ident refused to be changed because bed is broken. In an observation and interview on 11/19/25 at 08:03 a.m. of Resident #2 revealed he was lying flat in bed and holding the bed remote in his hands attempting to elevate the head of the bed to a sitting position. Observed Resident #2 pressed buttons on the bed remote, and the bed did not move. Resident #2 stated staff were aware his bed did not work but was unsure who the staff were. Resident#2 stated he could not eat or sleep since 7:00 p.m. the night before (11/18/25), because the bed remote was not functioning. The bed was in the highest position. The ADON walked into Resident #2's room and tried to reset the bed remote control without success. In interview on 11/19/25 at 08:06 a.m., the ADON stated she was not aware Resident #2's bed remote control was not working. The ADON stated it was everyone's responsibility to ensure call lights were with in reach. She stated the midnight nurse reported the bed remote was not working. She stated the morning nurse logged it in the electronic system for documenting requests for maintenance repairs. The ADON stated the night shift staff should swap Resident #2's bed with one with working conditions. She stated the risk to the resident was shock, being uncomfortable, unable to sleep and the resident's rights to be able to control the function of the bed.Observation on 11/19/25 at 08:50 a.m. revealed Resident #2 did not eat his breakfast yet because of the bed remote control issue. Observation on 11/19/25 at 09:25 a.m. revealed Resident #2 was up in wheelchair in the dining area eating his breakfast, and in his room was the Maintenance Director fixing Resident #2's bed. Record review of the facility meal schedule revealed the schedule for breakfast was 07:30 a.m.-08:30 a.m.In an interview and observation on 11/19/25 at 10:30 a.m., the Maintenance Director stated he was not aware of any issues with Resident #2's bed remote control, and it was reported to him this morning. The Maintenance Director stated he fixed Resident #2's bed remote control. The Maintenance Director stated he was responsible for monitoring the residents' bed and ensuring they worked properly. The Maintenance Director stated if the bed was not working the staff should put the resident in a working bed, the facility had plenty of them and report the issue to him or log it in electronic computer system for maintenance repairs . The Maintenance Director stated the risk to the residents was not able to control their bed and their needs not met. The Maintenance Director stated it was the responsibility of every staff that worked or entered the resident's room to report when there were problems with equipment so he could fix them.In an interview and observation on 11/20/25 at 10:59 a.m., the CSD stated it was the responsibility of the CNAs and nurses working with the resident to report the problem of the bed remote not functioning to the Maintenance Director. He stated the night shift staff should move the resident with his permission to another room with a functioning bed until his bed was fixed. He stated the risk to the resident was infringing on the Resident rights, because he did not have the control over his bed functioning and being able to be in the position he liked to sleep on.In an interview and observation on 11/20/25 at 12:24 p.m., the Administrator stated, she expected the nurse to call for the bed to be fixed, or get the resident out of that bed, and put the Resident in bed that work, they should not leave the resident in a flat bed. She stated the risk the Resident was lying flat he could be unable to breathe, safety issue serious hazard to him.Record review of the facility policy titled Bed Safety dated December 2007 revealed, Our facility shall strive to provide a safe sleeping environment for the resident.The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical condition, comfort, and freedom of movement as well as input from the resident.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. CNA B failed to wear a gown when she performed incontinent care for Resident#6 who was on EBP on 11/18/25.CNA B failed to change gloves and perform hand hygiene when going from dirty to clean during Resident #6's incontinent care on 11/18/25.This failure could place residents at risk of cross-contamination and infections.Record review of Resident #6's quarterly MDS assessment, dated 11/07/25, reflected Resident #6 was an [AGE] year-old male admitted [DATE]. Resident #6 had a BIMS score of 10, meaning his cognition was moderately impaired. He was completely dependent on staff for incontinent care. Resident #6's active diagnoses included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), hypertension (elevated blood pressure), diabetes mellitus and CVA (occurs when blood flow to a part of the brain is interrupted by a blockage or a burst blood vessel, causing brain cells to die).Record review of Resident #6's care plan, dated 11/10/25, revealed he was on Enhanced Barrier Precautions - At risk for infection r/t indwelling medical device, wounds. Goal: Will reduce risk of infection through next review. Interventions: wearing gloves and gown during high-contact care activities for a resident with indwelling medical devices, wounds and colonized (a germ is present and multiplying on or in the body without causing symptoms) or infection with a CDC targeted MDRO. Sanitize hands before entering and leaving the resident's room.During an observation on 11/18/25 at 09:28 a.m. , CNA B entered Resident #6 's room to do his incontinent care. There was EBP signage on the door, and PPE supplies (gown, gloves.) stored on a cart inside the room to the right side of the entrance. CNA B washed hands, wore gloves but did not wear a gown. CNA B opened Resident #6's brief, cleaned Resident #6's front area using disposable wipes. CNA B helped Resident #6 turn to his right side. CNA B cleaned Resident #6's buttocks area, removed the dirty brief, and put it in the trash can. CNA B got the clean brief and put it under Resident#6 without changing her gloves or performing any kind of hands hygiene. CNA B put the clean brief on Resident #6. CNA B removed gloves, washed hands, and exited the room.In an interview on 11/18/25 at 09:41 a.m. CNA B demonstrated an understanding of EBP signage, explaining that PPE was required for any resident with wounds, catheters, or external devices. She stated she forgot to wear a gown. She stated she was supposed to change gloves and sanitize her hands going from dirty to clean task, but she was nervous and forgot. She stated the risk of not wearing appropriate PPE, and not following proper use of gloves was increased risk of infection and possible cross contamination to the residents.In an interview on 11/20/25 at 10:59 AM with the CSD, he said he expected staff to follow the policies for EBP and proper use of PPE. He said they were supposed to wear a gown and gloves when performing high contact care for the residents (transfer, incontinent care.). He said the purpose was to protect the residents from being exposed to an infection and from staff getting an infection.In an interview on 11/20/25 at 12:24 PM with the Administrator, she said she expected staff to wear a gown and gloves when doing resident care and follow proper use of gloves. She said staff were supposed to wear a gown, gloves, and change gloves with hand hygiene going from dirty to clean when performing incontinent care, because it prevented the spread of MDROs.Record review of the facility's policy and procedure on Enhanced Barrier Precautions, dated 04/01/24, revealed in part: This policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: .incontinent care .Record review of the facility's policy Infection Control Guidelines for All Nursing Procedures (revised 2012) revealed in part: .3. Employees must wash their hands.under the following conditions .f. Before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 resident (Resident #2) of 6 residents reviewed for food and nutrition services.The facility failed to assess and provide Resident #2 with an assistive device to help prevent food from accidentally being pushed off the plate while eating during meal service to minimize food spillage. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed Resident#2 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), Parkinson's Disease (a progressive brain disorder causing unintended or uncontrollable movements like shaking, stiffness, and balance problems), anxiety disorder (a mental health condition characterized by excessive and overwhelming fear and worry that interferes with daily life), muscle weakness, and lack of coordination. Resident#2 had a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. Functional ability for eating was coded (5) Setup or clean-up assistance.Record review of Resident #2's care plan, dated 09/02/25, revealed, Problems: [Resident#2] has Parkinson's. Goal: Will remain free of further s/sx, discomfort or complications related to Parkinson's disease through review date. Intervention/Tasks: Diet as ordered. Record review of the primary care provider order summary, dated 05/30/25, revealed, Place head of the bed elevated not greater than 30 degrees when eating. Please make attempts to feed him when possible. Record review on 11/19/25 of Resident#2's weight log for the last six months ( May 2025- November 2025) revealed his weight stable at 141 lbs . In an observation and interview on 11/19/25 at 09:50 AM Resident#2 was up in wheelchair in the dining area. Resident#2 was eating his breakfast that was served in a regular plate (scrambled eggs with pieces of bacon, and a piece of bread toast). Resident#2 was observed unable to get food onto the spoon, and lifting an empty spoon to his mouth. In an observation on 11/19/25 at 11:49 AM Resident#2 was in his bed, with the head of the bed elevated. Resident#2 was eating his lunch that was served on a regular plate (buttered rice, and a piece of toast). Resident#2 was observed unable to get food onto the spoon, and the food spilled on the bedside table. In an observation on 11/20/25 at 09:29 a.m., Resident#2 was in his bed, with the head of the bed elevated. Resident#2 was eating chocolate cookies in a plastic container brought from home. In an interview on 11/20/25 at 09:37 a.m., LVN D stated Resident#2 needed assist with meals. LVN D stated sometimes he did not like to eat his meal, because the family would bring him pizza and he could handle it with his hands. She stated Resident #2 was not referred to OT/ST for assistive devices. She stated a divider play would be good for him. LVN D stated the risk to no resident help was not having the nutrition he needed. In an interview on 11/20/25 at 12:24 PM the Administrator stated her expectation was that if the resident needed assistance with eating the staff should assist him. She stated the nurses should assess the resident and give him the proper plate to help him feed himself. She stated the risk to the resident he could experience weight loss and malnutrition because he was not eating proper nutrition. Record review of a facility's Assistance with Meals policy, dated 07/2017 indicated Residents shall receive assistance with meal in a manner that meets the individual needs of each resident . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Residents Who May Benefit from Assistive Devices: 1- Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. They may include devices such as silverware with enlarged/padded handles, plate guards, and or special cups.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 7 residents (Resident#3) reviewed for ADLs. The facility failed to ensure Resident #3 was provided fingernail care. This failure could place residents at risk for infections and a decreased quality of life. Record review of Resident #3's quarterly MDS assessment, dated 10/10/25, revealed an [AGE] year-old male admitted on [DATE], and readmitted on [DATE]. His diagnoses included Non-Alzheimer's Dementia (Vascular Dementia, Lewy Body Dementia [including Parkinson's dementia], and Frontotemporal Dementia), Cerebrovascular Accident (a stroke that occurs when blood flow to the brain is interrupted, either by a blockage or a ruptured blood vessel, causing brain cells to die), hypertension (Elevated blood pressure), and muscle weakness. Resident#3 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #3's care plan, dated 10/14/25, revealed, Focus: [Resident#3] has an ADL self-care performance deficit r/t muscle weakness. Will be cleaned, well-groomed, appropriately dressed.through next review date. Intervention/Tasks: [Resident#3] requires setup or clean-up assistance with oral hygiene and partial/moderate assistance with personal hygiene.Observation on 11/19/25 at 07:53 a.m. Resident #3 was lying in bed. His fingernails on both hands were about 0.3 cm long and appeared dirty with a brown substance underneath the nails. He stated he liked long nails but he would like his nails cleaned.Interview on 11/19/25 at 07:58 a.m. CSD looked at Resident #3's fingernails and said they were not clean and needed care. She stated it was the responsibility of all residents' care staff to make sure residents' fingernails were cleaned and trimmed to residents' liking. She stated the risk to residents was development of infection. In an interview on 11/20/25 at 10:59 a.m. the CSD said the CNAs were responsible for monitoring and cleaning nails during showers. He said the nurses should cut the nails if the resident was diabetic. He said if nails were not clipped and cleaned it could cause injury and have an effect on infection control and hygiene. He said residents could get sick or injure themselves. In an interview on 11/20/25 at 12:24 p.m. the Administrator stated nail care should be completed as needed and every time CNAs washed the residents' hands. The Administrator stated nails should be observed daily. The Administrator stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The Administrator stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The Administrator stated residents having long and dirty nails could be an infection control issue. Record review of the facility's Care of Fingernails/Toenails policy revised April 2007 revealed in part, .the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #2) of 7 residents reviewed for care plans. The facility failed to ensure Resident #2's care plan was updated to reflect the need for feeding assistance according to his primary care provider on 11/19/2025. This failure could place residents at risk for choking and unwanted weight loss. Findings included:Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed Resident #2 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), Parkinson's Disease (a progressive brain disorder causing unintended or uncontrollable movements like shaking, stiffness, and balance problems), anxiety disorder (a mental health condition characterized by excessive and overwhelming fear and worry that interferes with daily life), muscle weakness, and lack of coordination. Resident #2 had a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. Functional ability for eating was coded (5) Setup or clean-up assistance. Record review of Resident #2's care plan, dated 09/02/25, revealed, Problems: [Resident#2] has Parkinson's. Goal: Will remain free of further s/sx, discomfort or complications related to Parkinson's disease through review date. Intervention/Tasks: Diet as ordered. Record review of the primary care provider order summary dated 05/30/25 revealed Place head of the bed elevated not greater than 30 degrees when eating. Please make attempts to feed him when possible.In an observation on 11/19/25 at 09:50 AM Resident#2 was up in wheelchair in the dining area. Resident#2 was eating his breakfast that was served in a regular plate (scrambled eggs with pieces of bacon, and a piece of bread toast). Resident#2 was observed unable to get food onto the and lifting an empty spoon to his mouth. In an observation on 11/19/25 at 11:49 AM Resident#2 was in his bed, with the head of the bed elevated. Resident#2 was eating his lunch that was served on a regular plate (buttered rice, and a piece of toast). Resident#2 was observed unable to get food onto the spoon, and the food spilled on the bedside table. In an interview on 11/19/25 at 2:16 p.m. PPS MDS Coordinator stated there was a note under nutrition, that mentioned the risk of dysphasia and choking. The PPS MDS Coordinator stated she was not aware of the order dated 05/30/2025, indicating Resident #2's change in the ability to feed himself and it was the responsibility of the nurses to bring it to her attention. She stated when she reviewed the care plan in September 2025 and overlooked the order. She stated, they do dysphagia diet, and she would go and add that order now that it was brought to her attention. In an observation and interview on 11/20/25 at 09:29 a.m. Resident #2 was in his bed, with the head of the bed elevated. Resident#2 was eating chocolate cookies in a plastic container brought from home by his kids. Resident #2 stated he was able to get some good sleep last night, because he could control his bed movement. In an interview on 11/20/25 at 09:37 AM, LVN D stated Resident #2 needed assistance with meals. LVN D stated it was the responsibility of the nurses working with Resident #2 to report his inability to self-feed to the MD, and the IDT to revise the care plan. LVN D stated the risk to the resident was not having the nutrition he needed. In an interview on 11/20/25 at 12:24 PM the Administrator stated the nurses should assess the resident and give him the proper plate to help him feed himself. She stated if the resident refused assistance with eating, it should be care planned. She stated the PPS MDS Coordinator was responsible for updating the care plan. She stated the 05/30/25 MD order was overlooked by the nurse/unit manager, the ADON and DON. Record review of the facility's Policy titled Care Plans, Comprehensive-Person Centered dated December 2016 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.14 The Interdisciplinary Team must review and update the care plan:a.When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on record reviews and interviews, the facility failed to ensure appropriate information was communicated to the receiving health care institution prior to discharge for 1 of 6 residents (Resident #1) reviewed for transfer or discharge. The facility failed to ensure that the discharge destination and continuing care provider could meet the resident's needs prior to the discharge.Resident #1 was discharged on 09/29/25 without ensuring the provider could meet the residents' needs. This failure placed residents at risk of not getting the necessary care and services to meet physical and psychological needs. A record review of Resident #1's admission record dated 11/20/2025 revealed an [AGE] year-old male admitted [DATE] with diagnoses which included muscle wasting and atrophy (the loss of muscle mass and strength), other abnormalities of gait and mobility (the specific way a person walks and moves), muscle weakness (the loss of strength in one or more muscles), and dementia (a decline in memory). A record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] reflected Resident #1 had a BIMS score of zero which could not be assessed which indicated a severe cognitive impairment. During an interview on 11/18/25 at 1:12pm, the Social Worker revealed Resident #1 was considered for transfer for an evaluation due to aggressive behaviors. The Social Worker stated it was her responsibility to submit clinicals for approval to the receiving provider. She stated on 9/29/25, a referral was sent to a behavioral hospital for review to admit Resident #1. She stated when she left for the day on 9/29/25, Resident #1 was not accepted yet. She stated she was informed in the morning meeting on 9/30/25, Resident #1 was transferred to a medical center instead. She stated the DON solely facilitated the transfer to the medical center for Resident #1. During an interview on 11/18/2025 at 12:37pm, the ADON stated the resident was transferred to a medical center 9/30/25 but was transferred back to the facility a few hours later. She stated the medical center was unaware why Resident #1 was transported there. She stated she informed the medical center Resident #1 was transported due to uncontrolled aggressive behaviors including kicking, biting, hitting, and threatening staff. During an interview on 11/20/2025 at 11:00am, the Clinical Services Director revealed a referral was sent on behalf of Resident #1 to the medical center, 09/30/25, but confirmation of acceptance was not received. He stated Resident #1 was transported anyway which was not according to policy. He stated once Resident #1 arrived, the staff at the receiving medical center was unaware why Resident #1 was there. He stated the ADON informed the medical center Resident #1 needed psychiatric services. He stated since the psychiatric team at the medical center was not aware prior to transfer, Resident #1 was transported back to the facility. He stated the DON should have waited for acceptance before transferring Resident #1. He stated the importance of acceptance before transfer was to avoid confusion and ensure residents received the help needed. An interview on 11/20/25 at 12:30pm with the Administrator revealed the DON no longer worked at the facility. The Administrator stated the DON informed her Resident #1 was kicking, biting, hitting, and threatening to kill them and needed to be sent out for his safety and the safety of others. She stated she was unaware Resident #1 was transferred without prior acceptance. She stated the expectation regarding transfer involved the acceptance of the receiving facility prior to transfer of the resident. The Administrator stated without prior acceptance, the receiving facility was unaware of the residents' needs, and residents could be traumatized due to the transfer back to the facility. The Administrator stated prior acceptance minimized the resident's anxiety. Record review of the facility's policy, Transfer or Discharge, Emergency revised date December 2016 read in part . Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: Notify the receiving facility that the transfer is being made.

Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards, and each resident received adequate supervision to prevent accidents for 1 (CR #1) of 7 residents reviewed for accidents and supervision.The facility failed to ensure CR #1 did not leave the facility unattended on 3/21/25. CR #1 was found by another staff member approximately 1 mile away in a parking lot near the freeway. An immediate jeopardy (IJ) was identified on 10/22/25. The IJ template was provided to the facility on [DATE] at 5:01 p.m. While the IJ was removed on 10/24/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.This failure could place residents at risk of accidents hazards.Findings include:Record review of CR #1's face sheet dated 10/22/25 revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 6/27/25 to another nursing facility. His diagnosis included dementia, mood disorder, anxiety, and bilateral hearing loss. Record review of CR #1's Elopement Risk assessment dated [DATE] revealed he was not at risk for elopement/wandering. Record review of CR #1's admission MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was independent with ADLs and there was no wandering behavior exhibited. Record review of CR #1's care plan revealed he had impaired cognitive function/impaired thought processes related to dementia. Interventions were to discuss concerns about confusion and disease process and keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, initiated 2/26/25.Record review of CR #1's Complete Evaluation/Psychosocial dated 2/26/25 written by the Psychologist indicated CR #1 had moderate cognitive loss. On exam he was cooperative and attentive with no gross behavioral abnormalities. The therapy content/clinical summary read in part, .he was open about memory, secondary to dementia. and depression about my (family member) left me recently, after she put me here. he talked about last few months at home being challenging with him wandering out of house and getting very frustrated with his cognitive challenges.Record review of CR #1's Physician/NP/PA/H&P progress note dated 3/6/25 written by NP V indicated the patient had severe deficits in cognition and memory.Record review of CR #1's behavioral complete evaluation dated 3/10/25 written by the Psychiatric Mental Health NP read in part, .Patient carries a diagnosis of dementia, anxiety and depression. Patient was seen in the common area ambulating. He reports my (family member) brought me here since I am not safe at home. Dementia: patient exhibits symptoms of dementia. Symptoms are observable. Onset: (CR #1's) symptoms were first noticed a few years ago. The first symptoms reported were: . got lost in familiar settings and began losing things.Course of illness: (CR #1's) symptoms have been slowly progressive. Recent symptoms suggest that cognitive deficits are moderately severe. His symptoms are chronically present during the whole day. (CR #1) exhibits the following moderate symptoms: He confabulates stories or details to hide defects in memory; restless behaviors like pacing. has increased; He cannot organize thoughts or follow logical explanations; poor judgment is creating safety issues when left alone. (CR #1's) memory problems are prominent. he forgets more frequently than previously. He loses track of what is happening . Exam: . His thoughts are loosely associated in a circumstantial way. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Delusional ideas are expressed. Paranoid ideas are expressed.moderate cognitive loss is present. this patient is not aware of current events. There is difficulty thinking abstractly. He does not correctly give the current date and time. He correctly gives his current location. He correctly gives his name. He is not aware of his current situation. Diffuse memory loss for recent and remote events is present. Periods of confusion with disorientation and memory problems are in evidence. (CR #1) presents as alert. Insight into problems appears to be poor. Judgment appears to be poor. There are signs of anxiety. A short attention span is evident. He is easily distracted.Record review of CR #1's progress note dated 3/11/25 written by NP Q revealed he was confused but was able to provide some insight on current complaints.Record review of an undated soft file document entitled CR #1 Investigation of events - leaving facility unattended provided by the facility on 10/23/25 at 10:00 a.m. read in part, at approximately 2:50 p.m. (LVN K) contacted the facility to report that she observed (CR #1) walking near a restaurant. (LVN K) stated that when she attempted to turn her vehicle around to reach the resident, she lost visual contact and immediately notified the facility. In response, a caravan of facility staff proceeded toward the area to locate the resident. The resident was located within approximately one hour, walking in the direction of the facility. Upon approach, he was calm and cooperative, stating that he was attempting to visit his (family member's) home but decided to return once he realized the distance was too great. The resident demonstrated awareness of his location and route back to the facility. Administrator interview with the resident confirmed his initial statement regarding going to visit his (family member) and realizing that the distance was too far. Resident was last seen by the Administrator approximately 30 minutes prior to (LVN K's) call notifying the facility of the resident's whereabouts. A head-to-toe assessment was conducted upon his return. No injuries or signs of distress were observed. The resident was assigned a wander guard device for additional safety monitoring. The resident's responsible party was notified of the incident and the facility's findings. Immediate Facility Actions: conducted a head-to-toe assessment upon the resident's return; no injuries noted. Conducted monitoring of resident for signs and/or symptoms of distress. Educated resident on notifying staff on desire to leave facility. Initiated a wander guard device for the resident and verified activation. Conducted an audit of all wander guard assignments - confirmed devices were present and operational for all assigned residents. Conducted an audit of the elopement binder - confirmed all documentation and response protocols were current and in compliance. Notified the resident's responsible party of the event and outcomes. Conducted an in-service for all staff titled Identifying residents at risk for leaving unattended. Updated care plan to reflect elopement risk and wander guard use. Recommendations/Follow up: Evaluate all residents for elopement risk to ensure accurate risk coding and care plan alignment. Re-educate staff on maintaining visual supervision during resident transport and outdoor activities.Record review of CR #1's weekly skin assessment dated [DATE] at 3:30 p.m. documented by LVN W revealed a head-to-toe skin assessment was performed. There were no skin tears or ecchymosis (bruise) noted. Record review of CR #1's BIMS on 3/21/25 at 3:37 p.m. conducted by the Social Worker was 3 out of 15 which indicated severe cognitive impairment. Record review of CR #1's nursing note dated 3/21/25 at 4:27 p.m. written by the DON read in part, .rec'd a call from resident's (family member) stating she would prefer he not go out walking beyond our facility gate. She wants him to continue to enjoy sitting in front of the building in the patio area but not any farther (sic). She states there was no need for a wander guard because (CR #1) is very obedient. If she tells him to do something, he does it. (CR #1) was made aware of (family member's) wishes and nurse will continue to monitor. Record review of CR #1's Release of Responsibility for Leave of Absence revealed he was not signed out of the facility on 3/21/25. Record review of CR #1's 15-minute surveillance program dated 3/21/25 revealed he was monitored every 15 minutes from 3/21/25 to 3/26/25.Record review of the facility's Incidents by Incident Type dated 10/21/25 revealed there were no incidents recorded for CR #1 on 3/21/25.Record review of CR #1's Order Summary Report dated 10/27/25 revealed orders for: wander guard: check for proper function daily every day shift, order date 3/26/25; wander guard: check for proper placement every shift, order date 3/26/25. In a telephone interview on 10/22/25 at 9:17 a.m. CR #1's family member said the facility called (on unknown date) and asked her if she picked up CR #1 from the facility. She said no. She said she was notified that he had been missing for two hours. The facility called her back approximately 1 to 1 and 1/2 hours later and said they found him at a nearby business, and he was safe and back in the facility. She said CR #1 left the facility because it was not completely fenced and he did not realize it because of his dementia. She said it was absolutely unsafe for him to be out alone, and it was a miracle of God that they found him. She said when he was at home, he wore a dementia/Alzheimer's bracelet and took long walks around the gated neighborhood to release anxiety. She said the facility was aware of his previous walking habits. She said after the incident she asked the facility to put a wander bracelet on him, which she said took several days. She said the DON demanded that she sit and watch CR #1 over the weekend. She said CR #1 was no longer at the facility and currently resided in a lockdown unit. In an interview on 10/22/25 at 9:59 a.m. the Social Worker said CR #1 typically sat outside in the front of the building. She said one day (3/21/25) around lunchtime they could not find CR #1 and almost every department head looked for him. She said he left the building and walked down to a fast-food restaurant and was unsure who noticed him leave. She checked the perimeter doors and around the building. She said another resident (unknown) saw him walk down the street. She said when he returned to the facility, staff asked her to conduct a BIMS score and CR #1 was anxious. She said the Administration determined he was cognitive enough to make his own decision. She said CR #1's cognition fluctuated, and he knew what was going on. She said on admission his cognition was low, and he would say things such as 'he did not remember. When he first admitted he felt his family member was abandoning him. She said CR #1's family member shared he was getting out of the house and had left when she was not there. She said he was cognitively impaired and had confusion. As CR #1 got familiar with the new setting he established a routine. She said he was not appropriate to walk outside alone because he was familiar with the facility but not the surrounding area. She said it was not safe and there was a highway right there. She said CR #1 had not expressed that he wanted to leave. She said she recently found out that CR #1 would walk around the building. She said staff were supposed to check on the residents who sat outside. She said she was unsure if there was a designated person to watch the residents outside. She said if a resident was a known wanderer or wore a wander guard, a CNA would take them outside, otherwise the resident could sit outside alone. In an interview on 10/22/25 at 10:19 a.m. Resident #15 said CR #1 would walk around the facility and exercise. She said one day he went outside, walked out of the gate, and kept going. She said she was outside that day, and he was also outside but she did not witness him leave the premises. In an interview on 10/22/25 at 10:31 a.m. the DON said on the day of the incident, an unknown resident came in the building from outside and told staff that CR #1 left out of the gate. She said a code white was called and the facility staff immediately searched for the resident. She found CR #1 at a nearby business, and he told her he was going to see his family member whose house was right over there. She said CR #1 was alert and oriented x 3 with some confusion at times. She said it was not appropriate for him to leave alone, he did not sign out of the facility independently, he had not received permission from his family member to leave, and the street was very busy. She assessed the resident, he had no injuries, and she brought him back to the facility. She said all residents, including CR #1, required supervision (not direct) while on the patio and various staff would go out and promote hydration and ensure the residents were brought back in. She said she could see the residents from her workspace inside of the facility and there were no specific staff assigned to monitor. She said if a resident had a wander guard, a staff member would accompany that resident outside. She said CR #1 did not have a wander guard at the time of the incident and she was unaware of any desire for him to leave the facility. She said she notified the MD and family member and conducted training with the staff which included monitoring, abuse/neglect, elopement, and assessment risk. She updated the status of wander guard status and submitted everything to the previous Administrator so she could take care of the reporting. This Surveyor requested documentation of the in-services conducted by the DON but did not receive them prior to survey exit. In an interview on 10/22/25 at 10:52 a.m. the previous Administrator said she recalled when a resident was found down the street at a fast-food restaurant and had not been gone from the facility long. She said she could not recall his BIMS score, but he presented high level. She said the DON found him, brought him back to the facility and conducted a head-to-toe assessment. She said she would not let any resident leave on their own to ensure they were protected. She said she could not recall if she reported the incident but said it was a reportable event because the resident eloped. She said the risk of elopement was that a resident could get hurt. She said any documentation such as in-services, assessments, wander guard information, and safe surveys would be at the facility for review.She said after the incident they placed a wander guard on him, and he could not go outside by himself anymore. In an interview on 10/22/25 at 11:21 a.m. the Administrator said she was not working for the facility when the incident occurred with CR #1. She said he could have been hit and/or killed. She said the residents who sat out front on the patio were monitored by staff and staff checked on them during their frequent rounding. She said she could also see the residents from her office. She said residents who had a BIMS score above 13 would be considered to leave the building. She said the facility had never completed elopement drills previously. She said elopement drills were not required but she would implement monthly drills.In an interview on 10/22/25 at 11:41 a.m. the CSD said he was at the facility the day of the incident (3/21/25). He said CR #1 was going to his family member's apartment and when he discovered it was not the right way he headed back to the facility. Prior to the incident, CR #1 would normally sit outside the building and come back in. He said that was the first time CR #1 left the building. He said for safety reasons residents should let staff know that they want to go off property so the staff can assist. He recalled his BIMS score was 11 out of 15 which indicated cognitive impairment. He said the facility preferred CR #1 to be with someone while out of the facility for safety and to let staff know he wanted to leave the building instead of venturing out on his own. He said when CR #1 returned to the facility he thought his BIMS score was an 11 and did not recall it being a 3. He said a BIMS score of 3 was severe impairment and that would mean it was not safe for him to go out by himself. He said he was unsure how the resident's BIMS score resulted in a 3 and said that would have changed the decision of the incident being reported. He said the facility explored a wander guard at the time and put one on later because they were not sure if the resident would follow through with notifying the facility of his desire to leave. He said CR #1 had not been at the facility that long, was adjusting, and did not know he was not supposed to leave. In an interview on 10/22/25 at 2:04 p.m. CR #1's family member said CR #1 would not know how to get to her apartment and had no idea where she lived. She said her apartment was approximately a 20-minute drive from the facility.In an interview on 10/22/25 at 2:30 p.m. CR #1's MD said CR #1 liked to walk around and enjoyed being outdoors. She said it was not appropriate for him to leave the facility on his own. She said she was aware he went missing on 3/21/25 but could not recall when she was notified. In an interview on 10/22/25 at 2:36 p.m. the RVP said she would look for the soft file that the previous Administrator completed (regarding when CR #1 left the building).In an interview on 10/22/25 at 3:02 p.m. the DON said CR #1 was away from the facility for a maximum of 15-20 minutes. She said he was found in a fast-food restaurant parking lot that required him to cross the street. She said she could not find any additional information regarding the incident in CR #1's record and there was no adequate documentation from the nurse. She said there should have been documentation about the incident because there was a change in behavior and the resident left the grounds. She said there was a notification to the family member documented but she did not see a conversation with the physician and there was no incident report. She said the 15-minute surveillance for monitoring was in the chart. She said everyone was responsible for the whereabouts of the residents and the DON and Administrator were ultimately responsible. She said she was not aware he had stepped out of the facility gate until another resident informed her. She said if a resident wanted to leave the building they should check with the nurse, sign themselves out, and be responsible, safe, and aware independently. She said staff who were more familiar with CR #1 said he was responsible to be on his own but was unsure how that was determined. She said the criteria for residents going out of the building alone was based on BIMS score, family input and MD orders. She said residents who were not cognitively impaired (BIMS score 13 and above) should be able to move around responsibly. She said sometimes residents who had a BIMS score below 13 could also be responsible but it depended on the person. She said everything was so new to her since she just started at the facility when the incident occurred.In an interview on 10/22/25 at 4:00 p.m. Resident #15 said the staff did not come outside to check on residents very often unless there was an exercise activity. She said there was no need for the staff to come outside and monitor. She said the staff never came until after CR #1 left the building. In an interview on 10/22/25 at 4:17 p.m. the CSD said CR #1 was able to verbalize where he was going and knew what he was trying to do. He said he was unsure if CR #1 made prior arrangements with the family member to meet. He said the facility did not classify him as missing and a missing resident would be someone who did not have a clue of what they were trying to do or where they were trying to go. He said the facility did initiate a search of the grounds for the resident. He said CR #1 was conversational, upset, and could not understand why the facility made a big deal of it.In an observation on 10/22/25 at 4:45 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the street at moderate speed. The posted speed limit was 45 mph. The nearby business where CR #1 was found was located near the freeway and on the opposite side of the street from the facility.In an interview on 10/23/25 at 9:45 a.m. CNA AA said CR #1 always wanted to sit out on the patio and had never walked away before. She said she never took CR #1 outside or sat out on the patio prior to the incident. She said she was in the building the day of the incident and heard he was out of the building. She said facility staff instructed everyone to check every room and bathroom. She said after the incident they had an in-service and placed a wander guard on him. In an interview on 10/23/25 at 11:02 a.m. LVN K said CR #1 liked to walk and would walk around the inside and outside of the facility. She said one day when she was leaving work after 2:00 p.m. she saw CR #1 walking down the street in the direction of the freeway. She said she turned the car around to look for him but did not see him, she called the traveling DON to report CR #1 was out of the building. She said before CR #1 left the building, she last saw him at the nursing station around 2:00 p.m. She said he could have gotten hit crossing the street or dehydrated because it was hot that day. She said CR #1 was not capable of signing himself out, was confused and not in his right mind. She said she did not recall any in-services or elopement training given after the incident.In an interview on 10/23/25 at 2:37 p.m. CNA CC said he worked the day of the incident with CR #1. He said facility staff told him CR #1 was missing and to stop what he was doing and look for him. He said he looked on the 400 hall and the outside perimeter. He said the previous Administrator in-serviced staff on code white protocol.In an interview on 10/24/25 at 9:53 a.m. the DON said at the time of the incident (3/21/25) she was not the DON yet and that was why she did not do all the normal training that she would have done with the staff. She said the traveling DON was the active DON at the time and she was in orientation. In an interview on 10/24/25 at 11:23 a.m. the traveling DON said on an unknown date, a nurse saw CR #1 walking on the street. She said she and the DON jumped in the car and went down the street to look for him. She said she saw him headed back towards the facility. She got out of the car and asked if he was ok. She said he told her he left the facility to look for his family member's house/apartment, he realized he did not know how to get there and was headed back to the facility. She said he had no injuries and was not in distress but felt bad he left and was apologetic for leaving and not saying where he was going. She said that was her last day working at the facility and the DON had already taken over and was not working under her. She said she did not conduct any in-services with the staff. The DON and previous Administrator were in charge at the time. In an interview on 10/24/25 at 1:20 p.m. the RVP said the DON was the DON in charge on 3/21/25. She said the DON or charge nurse and was responsible for documenting the incident. In an interview on 10/24/25 at 1:22 p.m. the Administrator said the DON was hired on 3/19/25. In an interview on 10/27/25 at 9:10 a.m. LVN W said the incident with CR #1 occurred during change of shift and he was not assigned to CR #1 yet because CR #1 was not in the building. He said the previous Administrator made an announcement that CR #1 was missing and told everyone to go look for and find the patient. He said he searched around the building, in the trash cans and dumpster. He said a head-to-toe assessment was completed probably by the DON, but he was unsure. He said CR #1 sometimes heard voices in his mind and might have come up with the idea of meeting his family member at the local business. He said CR #1 could hold a basic conversation but anything in depth was not reliable because of his cognition, but he was cognitive enough to not injure himself or others. He said CR #1 was not one to sign himself out of the building and said he did not even know what that was. He said he was not told it was an incident because CR #1 walked off and then walked back to the facility. He said the DON was the lead nurse and took over the documentation. Record review of the facility's in-service training report dated 3/21/25 conducted by the previous Administrator read in part, .Identifying residents at risk for leaving facility. it is important to educate residents on notifying staff that they want to leave the premises. This will provide open dialogue that will address and identify residents at risk for leaving without notice. Residents desiring to leave the premises unattended should be reported to the DON and Administrator. Residents need to be educated on the safety of remaining onsite. The facility can assist with offsite events. There were 56 signatures.Record review of the facility's Elopements policy dated December 2007 read in part, .Staff shall investigate and report all cases of missing residents. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner.3.when a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. examine the resident for injuries; b. notify the attending physician;. d. complete and file report of incident/accident; and e. document the event in the resident's medical record.On 10/22/25 at 5:01 p.m. the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template was provided to the Administrator and a plan of removal was requested at that time. The following Plan of Removal (POR) was submitted by the facility and accepted on 10/23/25 at 11:20 a.m.:PLAN OF REMOVALF-689Date: October 23, 2025(Facility Name) submits the following Plan of Removal for the alleged failure to ensure the resident area remained free of accident hazards, and each resident received adequate supervision to prevent accidents for CR #1.The Texas Department of Health and Human Services entered the facility on October 21, 2025 for a Complaint Survey. During the survey process, on October 22, 2025 an IJ (Immediate Jeopardy) was cited regarding F689 - Accidents/Hazards.The facility failed to ensure CR # 1 did not elope from the facility on 3/21/25 while sitting out on the patio. CR # 1 was found by another staff member approximately 1 mile away in a parking lot near the freeway.Immediate action:.What corrective actions have been implemented for the identified residents? CR #1 discharged from the facility on 6/27/25 to another Nursing Facility and did not return to the facility. On 10/22/2025 at 5:34 pm the Administrator notified the Medical Director of alleged deficient practice. On 10/22/25, the Clinical Service Director in-serviced the nurse managers to include the DON to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiate a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Completion date 10/22/25. On 10/22/25, DON/designees in-serviced all licensed nurses (full-time, part-time, and PRN) to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiating a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Completion date 10/22/25 No Nurse Manager will be allowed to work until training is completed. Completion date 10/22/25 No staff will be allowed to work until training is completed. Completion date 10/22/25 On 10/22/25, all facility residents had an elopement risk assessment completed by the Nurse Managers and no new residents were identified to be at risk. Completion date 10/22/25 On 10/22/25, facility residents' elopement risk assessments were reviewed by the Clinical Services Director to ensure safety measures are in place for residents that are at risk for elopement. All residents that are at risk for elopement have safety measures in place to prevent elopement. Completion date 10/22/25 The DON/ADON will validate all elopement risk assessments are accurately completed during clinical morning meetings, ensure care plans and CNA Kardex are updated to reflect residents at risk for elopement and safety measures that are implemented. The Clinical Services Director reviewed facility Elopement Policy on 10/22/25 no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. Residents that are at risk of elopement have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again?A. Residents assessed to be at risk for elopement will be monitored by staff while sitting on the patio.B. An in-service was initiated on 10/22/25 by the Clinical Service Director, DON, and Nurse Managers with the licensed nursing staff on the Elopement Policy. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 10/22/25.C. An in-service was initiated on 10/22/25 by the Nurse Managers with the facility frontline staff on the procedure to follow when it is deemed there is a missing resident. Completion date 10/22/25.D. Newly hired nurses will be in-serviced by the DON/designee on the Elopement Policy. Licensed nurses will not be allowed to work until they receive this in-service. Completion date 10/22/25. E. Newly hired frontline staff will be in-serviced by the DON/designee on the Elopement Policy. They will not be allowed to work until they receive this in-service. Completion date 10/22/25.F. New Admissions and Readmissions Elopement Assessment and Risk Management will be reviewed daily in the morning meeting to identify residents at risk for elopement and ensure adequate supervision is in place. The Charge Nurse will routinely conduct every 2 rounds and document knowledge of residents' whereabouts throughout their shift on an audit form. Any episode of elopement will be documented in the risk management system portal and notify the DON/Administrator immediately. The DON/designee will monitor the risk management system portal 3 times a week X 6 weeks and document findings on an audit report form. Quality AssuranceAn impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/22/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 10/22/25, DON/Nurse Managers assessed all residents for elopement risks. No new residents were found to be affected. Training conducted with staff to immediately page code white over the paging system whenever it is deemed there is a missing resident, initiate a search throughout the inside of the facility and facility grounds. If the resident is still not located, extend search to the immediate neighborhood. If the resident is still not located within 30 minutes, notify the Police Department for further assistance to search for the missing resident. Training to be conducted during the orientation of newly hired staff (full-time, part-time, and PRN). The DON/designees to provide oversight and ensure compliance. No staff will be allowed to work without receiving the in-service on the regarding the elopement policy.Monitoring for implementation of the POR was conducted on 10/23/25 and 10/24/25:Record review of the facility's undated Off Cycle (ADHOC) QA meeting document read in part, .ADHOC QAAC for identification of a system in need of immediate attention by QAPI Committee was conducted and had 7 signatures. Record review of the facility's Elopement Policy in-service dated 10/22/25 read in part, .Immediately

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 three of three residents (Resident #1, #2 and #3) reviewed for infection control.CNA B failed to perform hand hygiene after pericare for Resident #2 and before exiting the resident's room.CNA B, CNA H and CNA C failed to follow EBP (enhanced barrier precaution) signs and did not wear gowns during high contact resident care activities for Residents #2 and #3.CNA C failed to sanitize the mechanical lift between use for Resident #3 and Resident #2.CNA A failed to put on clean gloves during pericare for Resident #1. CNA A put on gloves from her pocket and not from the box of gloves in the room.CNA A failed to perform hand hygiene between glove changes during peri care, after pericare and before exiting Resident #1's room.These failures could affect residents at risk of infection and hospitalization.Findings included: Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression.Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs including the ability to maintain perineal hygiene. Resident #1 was frequently incontinent of bowel and bladder.Record review of Resident #1's undated care plan included: Focus-Resident #1 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Goal-Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included - Brief Use: the resident uses disposable briefs. Change as needed. Incontinent: Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum.Record review of Resident #1's progress note written on 03/19/25 at 11:13AM by the MD revealed Resident #1 was hospitalized for pneumonia and UTI on 3/11/25.Record review of Resident #1's order summary report dated 10/23/25 revealed an order dated 08/15/25 to 8/22/25 for contact isolation for ESBL (extended Spectrum Beta-Lactamase is an enzyme produced by certain bacteria) in the urine.Record review of Resident #1's infection progress note written on 08/21/25 at 4:42 PM by LVN E revealed the resident was receiving a 7-day course of IV antibiotics for ESBL.Record review of Resident #2's face sheet dated 10/21/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included chronic pulmonary edema (abnormal buildup of fluid in the lungs), diabetes, PVD (peripheral vascular disease: a slow progressive disorder of the blood vessels), aftercare following surgery on the nervous system, fracture of the vertebrae and anxiety. Record review of Resident #2's annual MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #2 required substantial/maximum assistance with toilet hygiene. Resident #2 was frequently incontinent of bowel and bladder. Section M of the MDS revealed Resident #2 had a diabetic foot ulcer.Record review of Resident #2's undated care plan included: Focus - Resident #2 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Interventions included - the resident uses disposable briefs, change as needed. Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum. Focus - Enhanced Barrier Precautions, at risk for infection r/t wounds. Interventions included - sanitize hands before entering and leaving the resident's room, wear gloves and gown during high-contact care activities for residents with indwelling medical devices, wounds. Focus - Resident #2 has actual impairment to skin integrity r/t diabetic ulcer to the left first toe. Interventions included - administer treatment as ordered, follow facility protocols for treatment of injury. Focus - Resident #2 has an ADL self-care performance deficit r/t weakness and Myasthenia Gravis (muscle weakness and fatigue). Interventions included Resident #2 required substantial/maximum assistance with transfers, use Hoyer (a mechanical lift).Record review of Resident #2's progress note dated 10/23/25 and written by RN G revealed Resident #2 had a reopened diabetic wound to toes on the left foot.Record review of Resident #3's face sheet dated 10/27/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included orthopedic aftercare following surgical amputation, paraplegia (paralysis of the legs and lower body), anemia, diabetes, obesity, neuromuscular dysfunction of the bladder (when an injury or disease interrupts the electrical signals between your nervous system and bladder function) and colostomy status. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #3 required supervision for toileting hygiene and personal hygiene. Resident #3 required substantial assistance with lower body dressing. Resident #3 had pressure injuries.Record review of Resident #3's undated care plan included: Focus - Resident #3 had a suprapubic catheter r/t neuromuscular dysfunction of the bladder. Interventions included - Change/empty catheter as indicated. Monitor and document intake and output as per facility policy. Focus - Resident #3 has a colostomy; resident is known to change own colostomy bag. Interventions included - notify nurse if wafer or pouch detaches or becomes loose. Focus - Enhanced Barrier Precautions, at risk for infection r/t wounds. Interventions included - sanitize hands before entering and leaving the resident's room, wear gloves and gown during high-contact care activities for residents with indwelling medical devices, wounds. Focus - Resident #3 has a pressure injury stage 4 to right buttocks and stage 3 pressure injury to the sacrum with potential for further pressure injury development. Interventions included - check/observe dressing to ensure it is intact and adhering. Report loose dressing to treatment nurse. Focus - Resident has actual impairment to skin integrity r/t surgical wound to right posterior lower leg. Interventions included - assist resident with turning and repositioning during rounds. Focus - Resident #3 has an ADL self-care performance deficit r/t Lupus (an autoimmune disease). Interventions included Resident #3 was dependent with transfers using the mechanical lift.Observation of peri care for Resident #2 on 10/22/25 at 9:20 AM, revealed an EBP sign on the door. CNA B and CNA H sanitized hands and put on clean gloves. Resident #2 had loose stools. CNA B and CNA H performed peri care. Resident #2 had a wound on the toes of the left foot. The wound was dressed with a bandage. The wound had drainage that had dried onto the sock. After peri care CNA H performed hand hygiene prior to leaving the room. After peri care was completed CNA B removed the gloves, picked up the garbage bag, walked to the dirty utility room and placed garbage bag into the barrel then walked to Resident #3's room where CNA C was performing resident care. Observation on 10/22/25 at 10:00AM, revealed an EBP sign on Resident #3's door. Observed CNA C empty urine from Resident #3's foley catheter bag. CNA C had gloves on and no gown.Observation on 10/22/25 at 10:05AM, CNA H moved the mechanical lift from Resident #3's room into the hallway. The mechanical lift was not sanitized. CNA B moved the mechanical lift from the hallway to Resident #2's room. CNA B and CNA H donned gloves and transferred Resident #2 into the wheelchair using the resident's individual sling the mechanical lift. In an interview on 10/22/25 at 10:25AM, CNA H stated the sign for EBP was to be followed during direct contact with a resident when doing resident care. CNA H stated she did not put on a gown during care for Resident #3 because the resident did a lot of her own care but then stated that she did change Resident #3's brief and should have put on a gown for infection control. CNA H stated Resident #3 did have a wound, a colostomy and a urinary catheter. When asked what should happen after using the mechanical lift on a resident and before using on another resident, CNA H stated she was PRN staff and usually only performs medication aide tasks but she would wipe down her cart for infection control reasons.In an interview on 10/22/25 at 10:30AM, CNA B stated the EBP sign was for Resident #2's former roommate who was in the hospital and that the sign was not for Resident #2. CNA B stated Resident #2 had loose stools and she should have washed her hands with soap and water as it would be best for infection prevention, prior to leaving the room. CNA B stated she just forgot to and was just not thinking as she was often in a rush. CNA B stated moving forward she would take the time and make sure she washed her hands with soap and water after peri care and prior to leaving the resident's room. CNA B stated she sanitized her hands before putting on gloves to assist CNA C with Resident #3.In an interview on 10/22/25 at 10:40 AM, LVN D stated the EBP signage was for residents who have open wounds, anything that has pierced the skin, any residents with appliances such as colostomies and urinary catheters. LVN D stated she expected nursing staff to wash hands prior to and after peri care. LVN D stated Resident #2 had an EBP sign on the door due to a wound on the toe. LVN D stated the mechanical lift should be sanitized between resident use and that the risks would be transfer of germs from one resident to another. LVN D stated she would re-educate the CNAs on infection control practices.In an interview on 10/22/25 at 10:55 AM the DON stated the EBP and PPE are required when doing close bodily contact with residents who, for example have g-tubes (feeding tubes) or wounds and that the risks to the residents was infection and cross-contamination. The DON stated her expectations that the nursing staff wash hands before leaving the resident room when providing peri care. The DON stated the mechanical lift was moved around the building a lot when used and should be cleaned by wiping down using disinfectant wipes to help stop the spread of infection and transfer of germs. The DON stated she expected nursing staff to wear gloves, gown, and mask when emptying urine from a catheter bag. The DON stated gown and gloves provide barriers from germs that nursing staff encounter and that germs are spread by what are on bodies so wearing PPE helps ensure germs are not carried to residents who may be susceptible to infection.Observation of peri care for Resident #1 on 10/24/25 at 6:45AM, CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA A removed gloves from her pocket and put them on. CNA A told Resident #1 that she was going to clean him up. CNA A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, performed peri care, cleansed the perineal area, buttocks then disposed of the soiled brief. CNA A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA A proceeded with applying a clean brief and assisted the resident with dressing. CNA A and CNA F transferred the resident from the bed to the wheelchair. CNA A removed gloves. CNA A did not perform hand hygiene. CNA A assisted Resident #1 to the dining room by pushing the wheelchair using her hands. CNA A touched a chair and moved it, walked to where the ice chests were and lifted the lids using her hands then walked to the nurse station. CNA A then walked down the hall to Resident #1's room put on clean gloves and began to clean up.In an interview on 10/24/25 at 7:15 AM, CNA A stated the facility policy was to wash or sanitize hands prior to entering resident rooms and stated she did that when she was down the hall before entering Resident #1's room. CNA A stated she should have sanitized between glove changes for infection control and she did not do this because it skipped her mind. CNA A stated she kept gloves in her pocket because some rooms did not have her size gloves. CNA A stated she did not always keep gloves in her pocket. CNA A stated it was not hygienic to keep gloves in pockets and it was not an encouraged habit. CNA A stated she was unaware there was a box of extra large gloves available in the doorway. CNA A stated she was supposed to perform hand hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility's policy on Enhanced Barrier Precaution, effective date April 1, 2024 revealed in part: The policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. Definitions, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EPB are indicated for residents with any of the following:.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing.Transferring.changing briefs.Device care or use.urinary catheter.Wounds generally include chronic wounds.examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.Steps in the Procedure.2. Wash and dry your hands thoroughly.Put on gloves.12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly.Record review of the facility's policy for Using a Mechanical Lifting Machine, revised July 2017, read in part: .Lift Care: 1. Disinfect lift surfaces. 2. Wipe with a clean towel until dry.

Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident#1) reviewed for incontinent care.CNA A failed to wash Resident #1 external urethral orifice (the opening at the end of the urethra where urine exits the body) during perineal care (cleansing of the genital and anal areas to maintain hygiene).This failure could place residents at risk of infection and hospitalization. Findings included:Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression.Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs including the ability to maintain perineal hygiene. Resident #1 was frequently incontinent of bowel and bladder.Record review of Resident #1's undated care plan included: Focus-Resident #1 has bowel and bladder incontinence which places him at risk for skin breakdown and UTI. Goal-Will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included - Brief Use: the resident uses disposable briefs. Change as needed. Incontinent: Check the resident during rounds and as required for incontinence. Wash, rinse and dry perineum.In an interview on 10/22/25 at 3:05PM, the DON stated pericare for both male and female should start with cleansing the urethra first, the actual opening should be cleansed then move further away from opening so not to bring bacteria to the opening of the urethra.Observation of peri care for Resident #1 on 10/24/25 at 6:45AM, revealed CNA A was walking down the hall and entered Resident #1's room. CNA A was holding white square patches in her hand. CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA A removed gloves from her pocket and put them on. CNA A told Resident #1 that she was going to clean him up. CNA A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, used one disposable cleansing wipe and cleaned the left groin area. CNA A then cleansed right groin area with a clean wipe, disposed the wipe and with a clean wipe CNA A wiped from the base of the penis in the direction towards the tip of penis once. CNA A did not cleanse the external urethral orifice of the penis. CNA A assisted Resident #1 in rolling to his left side. Resident #1 had a bowel movement. CNA A cleansed the perineal area, buttocks then disposed of the soiled brief. CNA A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA A proceeded with applying a clean brief and assisted the resident with dressing. CNA A and CNA F transferred the resident from the bed to the wheelchair. CNA A removed gloves. CNA A did not perform hand hygiene. CNA A assisted Resident #1 to the dining room by pushing the wheelchair using her hands. CNA A touched a chair and moved it, walked to where the ice chests were and lifted the lids using her hands then walked to the nurse station. CNA A then walked down the hall to Resident #1's room put on clean gloves and began to clean up.In an interview on 10/24/25 at 7:15 AM, CNA A stated the facility policy was to wash or sanitize hands prior to entering resident rooms and stated she did that when she was down the hall before entering Resident #1's room. CNA A stated she should have sanitized between glove changes for infection control and she did not do this because it skipped her mind. CNA A stated she kept gloves in her pocket because some rooms did not have her size gloves. CNA A stated she did not always keep gloves in her pocket. CNA A stated it was not hygienic to keep gloves in pockets and it was not an encouraged habit. CNA A checked the doorway and stated she didn't know there was a box of extra large gloves available. CNA A stated she did clean Resident #1's penis by wiping with cleansing cloth twice. CNA A stated she learned male peri care when she first stated working at the facility several months ago and had inservices on infection control and peri care for both male and female. CNA A stated she was supposed to perform hand hygiene prior to leaving Resident #1's room but got nervous. CNA A stated the risk of not doing hand hygiene was the germs from hands can get onto items touched and a resident could get infected if they touch the same items.In an interview on 10/27/25 at 12:30 PM, the DON stated she expected nursing staff to change gloves, sanitize or wash hands to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care. The DON stated the CNAs may have been rushing through their work and did not perform hand hygiene as she expected. The DON stated she expected the nursing staff to wash their hands, change gloves to help prevent UTI. The DON stated residents who have a long history of UTIs, and the elderly population are examples or residents who are susceptible to UTIs.Record review of the facility policy for Perineal Care, revised in December 2011, read in part: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.Steps in the Procedure.10. For a male resident.b. Wash perineal area starting with urethra and working outward.12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.18. Remove gloves and 19. Wash and dry your hands thoroughly.

Based on observation, interview, and record review 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 resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 1 of 7 residents (CR #1) reviewed for abuse and neglect. The facility failed to report to HHSC when CR #1 was found to have eloped from the facility on 3/21/25.This failure to report could place the residents at risk for neglect. Findings included:Record review of CR #1's face sheet dated 10/22/25 revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 6/27/25 to another nursing facility. His diagnosis included dementia, mood disorder, anxiety, and bilateral hearing loss. Record review of CR #1's Elopement Risk assessment dated [DATE] revealed he was not at risk for elopement/wandering. Record review of CR #1's admission MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was independent with ADLs and there was no wandering behavior exhibited. Record review of CR #1's care plan revealed he had impaired cognitive function/impaired thought processes related to dementia. Interventions were to discuss concerns about confusion and disease process and keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, initiated 2/26/25.Record review of CR #1's Complete Evaluation/Psychosocial dated 2/26/25 written by the Psychologist indicated CR #1 had moderate cognitive loss. On exam he was cooperative and attentive with no gross behavioral abnormalities. The therapy content/clinical summary read in part, .he was open about memory, secondary to dementia. and depression about my (family member) left me recently, after she put me here. he talked about last few months at home being challenging with him wandering out of house and getting very frustrated with his cognitive challenges.Record review of CR #1's Physician/NP/PA/H&P progress note dated 3/6/25 written by NP V indicated the patient had severe deficits in cognition and memory.Record review of CR #1's behavioral complete evaluation dated 3/10/25 written by the Psychiatric Mental Health NP read in part, .Patient carries a diagnosis of dementia, anxiety and depression. Patient was seen in the common area ambulating. He reports my (family member) brought me here since I am not safe at home. Dementia: patient exhibits symptoms of dementia. Symptoms are observable. Onset: (CR #1's) symptoms were first noticed a few years ago. The first symptoms reported were: . got lost in familiar settings and began losing things.Course of illness: (CR #1's) symptoms have been slowly progressive. Recent symptoms suggest that cognitive deficits are moderately severe. His symptoms are chronically present during the whole day. (CR #1) exhibits the following moderate symptoms: He confabulates stories or details to hide defects in memory; restless behaviors like pacing. has increased; He cannot organize thoughts or follow logical explanations; poor judgment is creating safety issues when left alone. (CR #1's) memory problems are prominent. he forgets more frequently than previously. He loses track of what is happening . Exam: . His thoughts are loosely associated in a circumstantial way. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Delusional ideas are expressed. Paranoid ideas are expressed.moderate cognitive loss is present. this patient is not aware of current events. There is difficulty thinking abstractly. He does not correctly give the current date and time. He correctly gives his current location. He correctly gives his name. He is not aware of his current situation. Diffuse memory loss for recent and remote events is present. Periods of confusion with disorientation and memory problems are in evidence. (CR #1) presents as alert. Insight into problems appears to be poor. Judgment appears to be poor. There are signs of anxiety. A short attention span is evident. He is easily distracted.Record review of CR #1's progress note dated 3/11/25 written by NP Q revealed he was confused but was able to provide some insight on current complaints.Record review of an undated soft file document entitled CR #1 Investigation of events - leaving facility unattended provided by the facility on 10/23/25 at 10:00 a.m. read in part, at approximately 2:50 p.m. (LVN K) contacted the facility to report that she observed (CR #1) walking near a restaurant. (LVN K) stated that when she attempted to turn her vehicle around to reach the resident, she lost visual contact and immediately notified the facility. In response, a caravan of facility staff proceeded toward the area to locate the resident. The resident was located within approximately one hour, walking in the direction of the facility. Upon approach, he was calm and cooperative, stating that he was attempting to visit his (family member's) home but decided to return once he realized the distance was too great. The resident demonstrated awareness of his location and route back to the facility. Administrator interview with the resident confirmed his initial statement regarding going to visit his (family member) and realizing that the distance was too far. Resident was last seen by the Administrator approximately 30 minutes prior to (LVN K's) call notifying the facility of the resident's whereabouts. A head-to-toe assessment was conducted upon his return. No injuries or signs of distress were observed. The resident was assigned a wander guard device for additional safety monitoring. The resident's responsible party was notified of the incident and the facility's findings. Immediate Facility Actions: conducted a head-to-toe assessment upon the resident's return; no injuries noted. Conducted monitoring of resident for signs and/or symptoms of distress. Educated resident on notifying staff on desire to leave facility. Initiated a wander guard device for the resident and verified activation. Conducted an audit of all wander guard assignments - confirmed devices were present and operational for all assigned residents. Conducted an audit of the elopement binder - confirmed all documentation and response protocols were current and in compliance. Notified the resident's responsible party of the event and outcomes. Conducted an in-service for all staff titled Identifying residents at risk for leaving unattended. Updated care plan to reflect elopement risk and wander guard use. Recommendations/Follow up: Evaluate all residents for elopement risk to ensure accurate risk coding and care plan alignment. Re-educate staff on maintaining visual supervision during resident transport and outdoor activities.Record review of CR #1's nursing note dated 3/21/25 written by the DON read in part, .rec'd a call from resident's (family member) stating she would prefer he not go out walking beyond our facility gate. She wants him to continue to enjoy sitting in front of the building in the patio area but not any farther (sic). She states there was no need for a wander guard because (CR #1) is very obedient. If she tells him to do something, he does it. (CR #1) was made aware of (family member's) wishes and nurse will continue to monitor.Record review of CR #1's weekly skin assessment dated [DATE] and documented by LVN W revealed a head-to-toe skin assessment was performed. There were no skin tears or ecchymosis (bruise) noted. Record review of CR #1's BIMS completed 3/21/25 by the Social Worker revealed it was 3 out of 15 which indicated severe cognitive impairment. Record review of CR #1's Release of Responsibility for Leave of Absence revealed he was not signed out of the facility on 3/21/25. Record review of CR #1's 15-minute surveillance program dated 3/21/25 revealed he was monitored every 15 minutes from 3/21/25 to 3/26/25.Record review of the Texas Unified Licensure Information Portal revealed there was no incident report regarding CR #1's elopement on 3/21/25 indicating the facility did not submit a self-report. Record review of CR #1's Order Summary Report dated 10/27/25 revealed orders for: wander guard: check for proper function daily every day shift, order date 3/26/25; wander guard: check for proper placement every shift, order date 3/26/25. In a telephone interview on 10/22/25 at 9:17 a.m. CR #1's family member said the facility called (on unknown date) and asked her if she picked up CR #1 from the facility. She said no. She said she was notified that he had been missing for two hours. The facility called her back approximately 1 to 1 and 1/2 hours later and said they found him at a nearby business, and he was safe and back in the facility. She said CR #1 left the facility because it was not completely fenced and he did not realize it because of his dementia. She said it was absolutely unsafe for him to be out alone, and it was a miracle of God that they found him. She said when he was at home, he wore a dementia/Alzheimer's bracelet and took long walks around the gated neighborhood to release anxiety. She said the facility was aware of his previous walking habits. She said after the incident she asked the facility to put a wander bracelet on him, which she said took several days. She said the DON demanded that she sit and watch CR #1 over the weekend. She said CR #1 was no longer at the facility and currently resided in a lockdown unit.In an interview on 10/22/25 at 9:59 a.m. the Social Worker said CR #1 typically sat outside in the front of the building. She said one day (3/21/25) around lunchtime they could not find CR #1 and almost every department head looked for him. She said he left the building and walked down to a fast-food restaurant and was unsure who noticed him leave. She checked the perimeter doors and around the building. She said another resident (unknown) saw him walk down the street. She said when he returned to the facility, staff asked her to conduct a BIMS score and CR #1 was anxious. She said the Administration determined he was cognitive enough to make his own decision. She said CR #1's cognition fluctuated, and he knew what was going on. She said on admission his cognition was low, and he would say things such as 'he did not remember. When he first admitted he felt his family member was abandoning him. She said CR #1's family member shared he was getting out of the house and had left when she was not there. She said he was cognitively impaired and had confusion. As CR #1 got familiar with the new setting he established a routine. She said he was not appropriate to walk outside alone because he was familiar with the facility but not the surrounding area. She said it was not safe and there was a highway right there. She said CR #1 had not expressed that he wanted to leave. She said she recently found out that CR #1 would walk around the building. She said staff were supposed to check on the residents who sat outside. She said she was unsure if there was a designated person to watch the residents outside. She said if a resident was a known wanderer or wore a wander guard, a CNA would take them outside, otherwise the resident could sit outside alone.In an interview on 10/22/25 at 10:52 a.m. the previous Administrator said she recalled a resident was found down the street at a fast-food restaurant and had not been gone long. She said she could not recall his BIMS score, but he presented high level. She said the DON found him, brought him back to the facility and conducted a head-to-toe assessment. She said she would not let any resident leave on their own to ensure they were protected. After the incident they placed a wander guard on him, and he could not go outside by himself anymore. She said residents could get hurt if they eloped. She said she could not recall if she reported the incident (to HHS) but said any documentation such as in-services, assessments, wander guard information, and safe surveys would be at the facility for review. She said this was a reportable incident because of the elopement but she could not recall reporting it. She said one reason she would not report a reportable incident was if she was directed not to, she said the RVP and CSD would review the incident and confirm whether it was a reportable. She said the Administrator was responsible for reporting incidents. She said she would not report if her managers told her not to. She said the risk of not reporting to HHS would be not following the guidelines and alleviating the oversight.In an interview on 10/22/25 at 11:21 a.m. the Administrator said she was not working for the facility when the incident occurred with CR #1. She said he could have been hit and/or killed. She said residents who had a BIMS score above 13 would be considered to leave the building. She said it was her job to report incidents (to HHS). She said CR #1's BIMS score on admission was an 11, was a 3 (on 3/21/25) and a 3 on the next one (4/18/25). She said the incident should have been reported immediately due to her license. She said the DON was seasoned and could have also reported the incident. In an interview on 10/22/25 at 11:41 a.m. the CSD said he was in the facility the day of the incident. He said CR #1 was going to his family member's apartment and when he discovered it was not the right way he headed back to the facility. Prior to the incident, CR #1 would normally sit outside the building and come back in. He said that was the first time CR #1 left the building. He said for safety reasons residents should let staff know that they want to go off property so the staff can assist. He said he would want CR #1 to be escorted and would have preferred CR #1 to let staff know he wanted to leave the building instead of venturing out on his own. He recalled his BIMS score was 11 out of 15. He said a BIMS score of 11 was cognitive impairment and the facility preferred the resident to be with someone while out of the facility for safety. He said when CR #1 returned to the facility he thought his BIMS score was an 11 and did not recall it being a 3. He said a BIMS score of 3 was severe impairment and that would mean it was not safe for him to go out by himself. He said he was unsure how the resident's BIMS score resulted in a 3 and said that would have changed the decision of the incident being reported. He said any incidents of elopement should be reported. He said an elopement was when a resident tried to get away with no knowledge of what they were doing. He said the Administration discussed the incident and decided not to report it because CR #1 knew what he was trying to do and was trying to come back to the building and was educated.In an interview on 10/22/25 at 1:46 p.m. the RVP said CR #1 had a BIMS score of 11 and was able to say where he was going. He was able to say where he was trying to go and was coming back towards the facility. She said she was not aware of the BIMS he had when he returned to the facility and did not recall if he had a physical address to his family member's house. She said the previous Administrator completed a soft file with in-services. In an interview on 10/22/25 at 2:04 p.m. CR #1's family member said CR #1 would not know how to get to her apartment and had no idea where she lived. She said her apartment was approximately a 20-minute drive from the facility.In an interview on 10/22/25 at 4:17 p.m. the CSD said CR #1 was able to verbalize where he was going and knew what he was trying to do. He said he was unsure if CR #1 made prior arrangements with the family member to meet. He said the facility did not classify him as missing and a missing resident would be someone who did not have a clue of what they were trying to do or where they were trying to go. He said the facility did initiate a search of the grounds for the resident. He said CR #1 was conversational, upset, and could not understand why the facility made a big deal of it. He said the facility follows the provider letter dated 8/24 and needed to report elopements within 24 hours to HHS.In an observation on 10/22/25 at 4:45 p.m. of the street CR #1 allegedly walked down revealed cars consistently drove down the street at moderate speed. The posted speed limit was 45 mph. The nearby business where CR #1 was found was located near the freeway and on the opposite side of the street from the facility.In an interview on 10/23/25 at 11:02 a.m. LVN K said one day when she was leaving work after 2:00 p.m. she saw CR #1 walking down the street in the direction of the freeway. She said she turned the car around to look for him but did not see him, she called the traveling DON to report CR #1 was out of the building. She said before CR #1 left the building, she last saw him at the nursing station around 2:00 p.m. She said he could have gotten hit crossing the street or dehydrated because it was hot that day. She said CR #1 was not capable of signing himself out, was confused and not in his right mind. In an interview on 10/24/25 at 11:23 a.m. the traveling DON said on an unknown date, a nurse saw CR #1 walking on the street. She said she and the DON jumped in the car and went down the street to look for him. She said she saw him headed back towards the facility. She got out of the car and asked if he was ok. She said he told her he left the facility to look for his family member's house/apartment, he realized he did not know how to get there and was headed back to the facility. She said he had no injuries and was not in distress but felt bad he left and was apologetic for leaving and not saying where he was going. She said that was her last day working at the facility and the DON had already taken over and was not working under her. She said she did not conduct any in-services with the staff. The DON and previous Administrator were in charge at the time. In an interview on 10/27/25 at 9:10 a.m. LVN W said the incident with CR #1 occurred during change of shift and he was not assigned to CR #1 yet because CR #1 was not in the building. He said the previous Administrator made an announcement that CR #1 was missing and told everyone to go look for and find the patient. He said he searched around the building, in the trash cans and dumpster. He said a head-to-toe assessment was completed probably by the DON, but he was unsure. He said CR #1 sometimes heard voices in his mind and might have come up with the idea of meeting his family member at the local business. He said CR #1 could hold a basic conversation but anything in depth was not reliable because of his cognition, but he was cognitive enough to not injure himself or others. He said CR #1 was not one to sign himself out of the building and said he did not even know what that was. He said he was not told it was an incident because CR #1 walked off and then walked back to the facility. He said the DON was the lead nurse and took over the documentation. Record review of Long-Term Care Regulation Provider Letter dated 8/29/24 provided by the facility read in part, '.2.1 Incidents that a NF must report to HHSC. A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect. a missing resident.2.4 Reportable Incidents and Timeframes. Do Report: an incident that does not result in serious bodily injury but that involves any of the following: . a missing resident. when to report:. immediately, but not later than 24 hours after the incidents occurs or is suspected . Missing resident: example of a missing resident: A resident is not in his room when staff wake residents up in the morning and the bed appears not to have been slept in. Staff search the facility and cannot find the resident.

Based on observation, 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 8 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to have an authorized staff administer medication to Resident #1. MA-I instructed CNA- A who was not authorized to apply Lidocaine patches to Resident #1's hips. The facility failed to clarify the physician order for Resident #1's Lidocaine patch as to which hip the patch was to be applied. CNA-A applied one patch to Resident #1's right hip and a second patch to the left thigh. This failure could place residents at risk of not receiving medications as ordered by the physician. This failure could place residents at risk of not receiving the desired therapeutic effects of their medications and uncontrolled pain.Findings included: Record review of Resident #1's face sheet dated 10/21/25 revealed a [AGE] year-old first admitted to the facility on [DATE] with diagnoses to include COPD (chronic obstructive pulmonary disease, a lung condition caused by damage to the airway), muscle weakness, abnormalities of mobility, cerebral vascular accident (stroke), anxiety and depression. Record review of Resident #1's quarterly MDS (a resident assessment and care screening tool) dated 08/19/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for all ADLs. Record review of Resident #1's undated care plan included: Focus-Resident #1 was at risk for pain r/t generalized pain. Interventions included - administer analgesics as per ordered. Record review of Resident #1's physician order dated 03/17/2025 revealed a medication order for Lidocaine External Patch 4 %, apply to hip topically one time a day for pain and remove per schedule. Record review of Resident #1's October 2025 MAR (medication administration record) printed in 10/24/25 at 9:14 AM revealed Lidocaine External Patch 4%, Apply to hip topically one time a day for pain and remover per schedule was marked as administered on 10/24/25 at 8:00 AM by LVN J and not MA-I. Observation and interview of peri care for Resident #1 on 10/24/25 at 6:45AM, revealed CNA A was walking down the hall holding white square patches in her hand and entered Resident #1's room. CNA A closed the door and gathered supplies. Resident #1 was alert, oriented and lying on his back with pillows under his knees watching TV. CNA-A removed gloves from her pocket and put them on. CNA-A told Resident #1 that she was going to clean him up. CNA-A helped Resident #1 remove his pants, lowered the head of the bed, unfastened the tabs on the brief, and cleaned the front of Resident #1's peri area. Resident #1 stated the two Lidocaine patches were removed at nighttime and he gets new patches in the morning. CNA-A assisted Resident #1 in rolling to his left side. Resident #1 had a bowel movement. CNA-A cleansed the perineal area and buttocks then disposed of the soiled brief. CNA-A removed gloves, disposed them into trash can, removed gloves from her pocket and put them on. CNA-A proceeded with applying a clean brief. While Resident #1 was still on his left side, CNA-A applied a white patch to the right hip and fastened the tabs of the brief over the patch. Resident #1 rolled to his right side. CNA-A fastened the tabs of the brief on the left hip and applied the second white patch to the upper right thigh, below the brief. CNA-A stated they were pain patches, and the medication aide gave them to her so she could apply them onto Resident #1's skin. CNA-A removed gloves, disposed of them into trash can, removed gloves from her pocket and put them on then proceeded with helping Resident #1 get dressed. CNA-F entered the room and offered assistance. CNA-A and CNA-F transferred the resident from the bed to the wheelchair. CNA-A removed gloves. CNA-A assisted Resident #1 to the dining room by pushing him in the wheelchair. In an interview on 10/24/25 at 7:45 AM, MA-I stated she gave CNA-A two Lidocaine patches because she knew Resident #1 was getting peri care which was the opportunity to apply the Lidocaine patches before he got up and into the wheelchair. MA-I stated she was in the middle of dispensing medications for another resident. MA-I stated that once and awhile she would ask CNAs to help by applying the patches because she may not always get to him before he gets up out of bed. MA-I stated Resident #1 would complain of pain during the day if the Lidocaine patches were not put on before he gets up out of bed. MA-I stated the medication aides and nurses were responsible for administering the Lidocaine patches and that it was not policy to ask a CNA to apply them as she was the one signing off as administered. MA-I stated the patches should be applied to both hip areas where the brief would cover the hip. MA-I stated she was aware she made a mistake in giving the Lidocaine patches to the CNA. In an interview on 10/27/25 at 11:35AM, MA-I stated she did not sign out the Lidocaine patches for Resident #1 on 10/24/25 because someone else took over for her right after the incident and she didn't get a chance to document. MA-I stated the nurse signed it out along with his other medications and she did not know the name of the nurse. MA-I stated the Lidocaine patches were supposed to be applied over both hips because he used to be in another hall and that was what his orders were at the time. MA-I stated the nurses were responsible for confirming the orders and if she discovered a discrepancy in the order she would usually report to the nurse or ADON. MA-I stated she did not report the discrepancy on 10/24/25. In an interview on 10/27/25 at 11:40AM, the MD stated she believed the Lidocaine patch for Resident #1 was for his left hip only but was unsure if it was to be for both hips. The MD stated she would need to clarify the order. The MD stated the Lidocaine patch was for his arthritis and that she checked the resident in the morning and reported that he denied hip pain. In an interview on 10/27/25 at 12:30 PM, the DON stated the nurses and medication aides were responsible for administering Lidocaine patches. The DON stated CNA-A was not a medication aide and was not licensed to administer medications. The DON stated CNAs were not authorized to administer Lidocaine patches. The DON stated it was a silly mistake and not within the CNAs scope of practice. The DON stated that CNA-A had not been trained and would not have known the rights of administration. The DON stated Resident #1 received Lidocaine patches for hip pain and if not applied as ordered the resident could have increased pain. The DON stated she would expect only one patch to be applied since the order reads Lidocaine external patch 4 % apply to hip topically every day for pain. The DON stated she expected the nurses to clarify the order as to which hip to place the patch. The DON stated she would need to speak with the MD first to see if the order was intended for both hips and that everyone knew there was a verbal order for the patches to be applied to both hips. The DON stated her expectation was for the medication aide to notify the nurse that the order was unclear. The DON stated she was unable to find out which nurse would have been responsible for clarifying the order. The DON stated it was considered a medication error; she wrote a medication error report and notified the physician. The DON stated Resident #1 was assessed and had no adverse effects. On 10/27/25 at 2:06PM, an attempt was made to contact LVN J via telephone to confirm she signed out and administered the Lidocaine patch on 10/24/25 8:00AM for Resident #1. No call back was received to confirm whether LVN J signed out and administered the Lidocaine patch. Record review of the facility's policy for Adverse Consequences and Medication Errors, revised on June 2025, read in part: .The interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects.Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include:.b. unauthorized drug - a drug is administered without a provider's order. Record review of the facility's undated job description for Certified Nursing Assistant read in part: .The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and car plan and as may be directed by your supervisors. Record review of the facility's undated job description for Certified Medication Aide read in part: .The primary purpose of your job position is to assist in the administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and the Director of Nursing Services. The administration of medications shall be in accordance with established nursing standard's, the policies, procedures and practices of this facility and the requirements of this state.As a Certified Medication Aide, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Based on observation, record reviews, and interviews, the facility failed to ensure a resident's environment remained as free of accidents and hazards as possible for 1 of 6 residents (CR #1) reviewed for accidents and hazards in that: - The facility failed to ensure the environment remained free of accident and hazards when CNA D and CNA W transferred CR #1 from her wheelchair to the bed on 2/2/25, and she sustained a laceration to her R leg requiring 15 sutures and 18 staples. An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on [DATE] at 4:30pm. While the IJ was removed on 2/28/25 at 4:40pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injuries and hospitalization . Findings included: Record review of Resident CR#1's undated face sheet revealed she was an [AGE] year-old female originally admitted on [DATE], with the most recent admission being 2/2/25. She had diagnoses of muscle weakness, unsteadiness on feet, muscle wasting and atrophy (loss of muscle mass and strength,), end stage renal disease on dialysis (kidneys stopped filtering so a machine does it), reduced mobility, glaucoma (vision loss and blindness damaging the nerve in the back of the eye), lymphedema (swelling caused by buildup of lymph fluid in the body between skin and muscle), and cognitive communication deficit (difficulty communicating that's caused by a brain injury or other cognitive impairment). Record review of CR #1's Admission MDS assessment dated [DATE] revealed a BIMS Score of 11 out of 15, which indicated moderately impaired cognition. She had impairment on one side of her lower extremities. According to the MDS, transfers were not attempted due to CR #1's medical condition or safety concerns. She was dependent on staff (helper does all of the effort and resident does none of the effort. Or the assistance of 2 or more helpers is required.) for ADL's. Record review of CR #1's Care Plan dated 12/26/24 revealed the resident sustained a skin tear to her R lower leg (Initiated: 2/2/25). The goal was to not have any infection to the skin tear through the review date (Initiated: 2/2/25, Target: 4/6/25). Interventions included the resident was transferred to the ED for eval/tx. Keflex (antibiotic) for 10 days. Monitor for s/s of infection and report any negative findings to the MD. The Care Plan also revealed CR #1 had an ADL self-care performance deficit r/t weakness that was initiated on 1/2/25. The goal was to improve the current level of function through the review date and was initiated on 1/2/25 with a target date of 4/6/25. According to the interventions, CR #1 required total assistance with transfers. Record review of CR #1's PT note from 1/31/25 revealed her precautions/contraindications were: High fall risk, HOYER pad in wc at all times. Record review of CR #1's Progress Note from 2/2/25 at 1:55pm by LVN B revealed, Resident was assessed with no new skin issues noted. VS are stable. Denies pain at this time. On call was notified of resident return. Resident alert and oriented and able to voice needs and concerns. Will continue to monitor. Record review of CR #1's Change in Condition Note from 2/2/25 at 2:10pm by LVN B revealed, Resident noted with a large skin tear to right outer LE. Pressure DS applied. Record review of CR #1's Progress Note from 2/2/25 at 2:10pm by LVN B revealed, CNA called this writer to resident room and noted resident in bed with a large skin to the right lower leg with moderate amount of bleeding. Resident denies pain at this time and appears in good spirit. Pressure DSG was applied to area. Both CNAs states that while attempting to transfer resident into bed that resident RLE got caught on the side of the bed resulting in skin tear. Resident states her leg got caught on side of bed while the aides was attempting to sit her on the on the bed . Record review of CR #1's hospital records from 2/2/25 at 4:10pm said the resident presented to the ED with a R leg laceration after getting it caught on a metal bed. According to the records, the resident had a leg laceration [tear or cut in the skin or underlying tissues] and partial skin avulsion [forceful tearing away of tissue or body parts, like skin, muscle, or bone], wound irrigated extensively, multilayer sutures placed along with staples . The laceration was 6.2 inches long and 0.78 inches deep. The resident received 15 sutures and 18 staples according to hospital records. Record review of CR #1's Physician's Orders revealed the following orders from MDS: - Cleanse skin tear one time only for 1 Day RLE with NS and apply pressure dsg. Ordered 2/2/25. - Monitor R Leg wound sight each shift. Ordered 2/2/25. - Remove staple and sutures in 14 days. Ordered 2/2/25. - Keflex (Cephalexin) 500 MG Oral Give 1 capsule by mouth. Ordered on 2/3/25. - Location of wound: Right lateral (outside) calf, skin tear PAIN CODE INTERVENTION, Every shift. Ordered 2/6/25. Record review of the facility's Provider Report from 2/2/25 revealed at about 2:15pm CR #1 arrived at the facility from home via family transportation. The SW grabbed a facility wheelchair, and the family transferred the resident from the family vehicle into the wheelchair and then rolled her into the facility. The family requested CR #1 be transferred into bed, so the SW asked CNA W to transfer CR #1 into bed. CNA W got CNA D to help her with the transfer. The CNAs raised the resident, pivoted her and sat her on the bed. When the aides lifted the resident's legs up on the bed, they noticed a skin tear to the outer portion of her lower leg. According to the Provider Report, The bed was inspected and though there were no jagged edges noted, there appeared to be blood on the side rail located on the base of the bed with a blunt opening. In an interview with CNA D on 2/26/25 at 9:04am she said CNA W asked her to come in and assist with putting CR #1 to bed. She said both CNAs transferred her into the bed. When they went to swing her legs into the bed, she saw blood on her hands. She asked CNA W if that was blood and she said yes, but they didn't see any blood on the w/c. Then they noticed blood on her leg. The blood on her gown was noticeable. In an interview with CR #1's family member on 2/26/25 at 10:21am she said they helped CR #1 into a wheelchair that she grabbed from the facility. She said they rolled CR #1 into the facility and spoke to the SW as soon as they entered the facility. Then they went back to the same room she was in before. She said CR #1 told her the aides were lifting her into the bed and she told them You're tearing my leg. Record review of pictures of CR #1's laceration to her R leg, received on 2/26/25 at 10:41am revealed a deep laceration in the shape of a C, exposing the subcutaneous (the deepest layer of your skin, made up mostly of fat cells and connective tissue) layer. In an interview with CR #1 on 2/26/25 at 10:51 a.m. she said her family member brought her into the facility and they spoke to someone at the nurse's station, but she did not remember who. She said 2 aides transferred her from the wheelchair into the bed. CR #1 said she yelled out and her leg got caught on something on the bed. She said she was wearing a dress when it happened. She said she was out with her family that day and it did not happen before she got back to the facility. In an interview with CNA W on 2/26/25 at 11:10am she said they lined CR #1 up against the bed. They told her on the count of 3 they would transfer her. CNA W said CR #1 said she would help. She said CNA D was on the other side of the bed in case she fell off the other side. CNA W said after she transferred her onto the bed and went to lift her legs, there was blood everywhere. She said she did not see any on the wheelchair but saw some on the bed. CNA W said she did not see anything sticking out of the bed, but she saw something that was supposed to be covered because it looked rough. In an interview with LVN B on 2/26/25 at 11:50am she said she saw CR #1 in the hallway and was talking to her before she went into the room, and she did not have any blood or anything on her before the transfer. She said when the CNA told her to come to the room CR #1 was already lying in the bed and she had a laceration on her leg. LVN B said she saw blood on the floor in CR #1's room, and if it would have happened before she would have seen blood in the hallway. She said CR #1 had a bad skin tear, the worst she's ever seen. LVN B said she put a pressure dressing on it and sent CR #1 out via regular transport. She said the resident came back and she had sutures and staples. LVN B said CR #1 normally used a mechanical lift because she could not do anything. She said the CNAs should have looked at the Kardex (worksheet that summarized patient information) or asked her how the resident transferred. In an interview with the SW on 2/26/25 at 12:06pm she said she was in her office when family stopped by her office and said CR #1 was back, so she went and got a wheelchair, and she notified the nurse. She said she did not notice any blood when the resident came in and the resident was not in any pain. The SW said she did not notice any blood on the floor as she was rolled to her room, in the hallway while she was waiting for her bed to be made, or any blood while she was in the room. The SW said she would have seen the laceration because it was visible. In an interview with the ADM on 2/26/25 at 1:15pm she said CR #1 had just got to the facility and family wanted her to be transferred to the bed. She said 2 aides transferred her into the bed and when the aides moved her legs they noticed the blood. The ADM said she did see the laceration and it looked bad, but she did not know if blood would have been seen dripping through the facility. In an observation with the ADM on 2/26/25 at 2:40pm, revealed the bed that was in CR #1's room was noted to have a 1/4 grab bar attached to the side of the bed with a pipe sticking out without a cap on the end, making it rough and a potential hazard. The facility was asked if they had a policy on Accidents and Hazards, but they did not have one. Record review of the facility's policy and procedure on Safe Lifting and Movement of Residents (Revised October 2009) revealed in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety .medical condition will be incorporated into .decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's mobility (degree of dependency. Resident's size. Weight-bearing ability. Cognitive status .Staff responsible for direct resident care will be trained in the use of manual .and mechanical lifting devices .Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings . An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on [DATE] at 4:30pm. The Plan of Removal was accepted on 2/27/25 at 3:56pm. The plan of removal reflected the following: Name of Facility: {Facility} Date: February 26, 2025 Immediate action: What corrective actions have been implemented for the identified residents? A. On 02/02/2025 CR#1 involved in alleged deficient practice was discharged to the hospital due to a laceration sustained during a transfer from the wheelchair to the bed. B. On 02/02/2025 the incident involving CR#1 was reported to Health and Human Services. C. On 2/02/2025 at 4 pm the Administrator initiated the investigation, and blood was noted on the side of the bed frame on the square opening area. D. On 2/02/2025 CNA D was in-serviced on Referring to Resident POC for Transfer Instruction. E. On 2/02/2025 CNA W was in-serviced on Referring to Resident POC for Transfer Instruction. F. On 2/02/2025 at 5 pm the Maintenance Director conducted an inspection of all beds, and bed frames. Beds that were missing caps on the side of the bed frame were sealed with either a cap or tape. These open areas are generally utilized to attach side rails to the bed frame. G. On 2/02/2025 at 5:20 pm the Maintenance Director placed a tab in the open area identified on CR#1 bed and then aides changed the bed out per family request. H. On 02/03/2025 at 9:00 am the Administrator notified the Medical Director of the alleged deficient practice. I. The Corporate Clinical Service Director reviewed facility policy on 02/03/2025 regarding Safe Lifting and Movement of Residents and no revisions were deemed necessary. J. On 02/02/2025 at 10:09 pm resident CR#1 returned from the hospital with 18 staples and 8 sutures. K. On 2/03/2025 an audit of past incidents was conducted. Two incidents were identified and previously reported to Health and Human Services. Facility's Plan to ensure compliance quickly A. An in-service was initiated on 02/03/2025 by the Administrator and the Assistant Director of Nursing with the aides on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. The aides were not allowed to return to work until they received this in-service. The completion date is 2/13/2025. B. On 02/03/2025 the Director of Rehab and the Assistant Director of Nursing completed a 100% checkoff on Resident Transfers with the certified nursing aides. The aides were not allowed to return to work until they received this in-service. The completion date is 2/13/2025. C. Newly hired nurses will be in-serviced by the Assistant Director of Nursing or designee on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. D. On 2/06/2025 nursing staff were in-serviced by the Assistant Director of Nursing on Reporting Hazardous Equipment Immediately Including Removing Hazardous Equipment. E. The openings identified by Surveyor were covered and a facility wide audit conducted 2/26/2025. Areas of concern addressed immediately. Tape was applied to two Assist Bars that had openings. F. Ambassador Rounding Sheet that was implemented to monitor bed frames on 2/3/25 was updated 2/26/25 to include the monitoring of the Assist Bars. Ambassadors will also check vacant rooms. G. On 2/26/25 nurses were in-serviced by the Director of Nursing on referencing Kardex prior to directing staff including C.N.A.s and staff from other departments on how to transfer residents. The Charge Nurse and Nurse Managers will update the Kardex upon admissions and readmissions with any change(s) in status. H. On 2/27/25 nurses were in-serviced by Director of Nursing instructing Charge Nurses to assess new and readmitted residents to determine transfer status and to communicate findings to the C.N.A.(s) on duty. On 2/28/25 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review revealed on 2/2/25 CNA D was in-serviced on abuse and neglect and transfers by the ADM. The in-services given were about reporting abuse and how the resident had the right to be free from abuse and neglect and the importance of safety measures applied when transferring residents. Record review revealed on 2/2/25 CNA W was in-serviced on abuse and neglect and transfers by the ADM. The in-services were related to reporting abuse and how the resident had the right to be free from abuse and neglect and the importance of safety measures applied when transferring residents. Record review revealed on 2/2/25 the Maintenance Director conducted an inspection of all beds in the facility. The residents' lifts were also checked in all rooms. Record review revealed the following rooms had beds that were taped: 102D, 102W, 103D, 104D, 105W, 106D, 106W, 109D, 109W, 111D, 111W, 113D, 114W, 115W, 202D, 203D, 204D, 205D, 206W, 207W, 208D, 209W, 210D, 211D, 211W, 212D, 213D, 213W, 214W, 215W, 216D, 302D, 302W, 303D, 303W, 304D, 305D, 306W, 307W, 309D, 310D, 313D, 314D, 315W, 316D, 316W, 401W, 402W, 407D, 407W, 408D, 409D, 410W, 411D, 412D, 412W, 414W, 415D, 415W. Record review revealed on 2/3/25 an audit of past incidents was conducted and the 2 incidents that occurred were on [CR #2] on 1/14/25 and [Resident #73] on 1/25/25. Record review revealed on 2/3/25 in-services were given by the ADON and the ADM on safe transfers which included the policy of two-person transfers, safe lifting, and movement of residents. Record review revealed 35 members attended in person and 18 via phone. Record review revealed in-services were given on 2/3/25 by the ADON/ADM on referring to the POC for transfer instructions and was about ensuring staff referenced the POC to properly transfer a resident, and about requiring 2 people for transfers with a Hoyer transfer. There were 52 staff members who attended in person and 11 via phone. Record review revealed on 02/03/25 in-services were given by the ADM on ANE, and transfers. The in-services were about ensuring the resident had the right to be free from abuse and neglect, and to ensure treatment that was provided to residents when transferring, was according to the facility policy and protocol. There were 55 staff members who attended in person. Record review revealed on 2/3/25 in-services were given by the ADON on conducting transfers and newly admitted residents. The in-services were about ensuring new admits and readmits were not transferred prior to being assessed by a nurse, even if family made the request. There were 45 staff in-serviced in person and 18 via telephone. Record review revealed on 02/03/2025 in-services were given by the DOR and the ADON on Two Person Stand-Pivot Transfer Competencies and Mechanical/Hydraulic Lifts. There were 80 staff members signatures. Record review revealed on 2/3/25 the ADON gave a new hire orientation regarding transfers, POC and newly admitted residents. The in-services were about ensuring new admits and readmits were not transferred prior to being assessed by a nurse, even if family made the request. Also ensuring staff were referencing the POC to know how the resident transferred and making sure 2 people use the Hoyer lift. There were 8 staff members that were in-serviced in person. Record review revealed on 2/3/25 the ADM gave a new hire orientation on ANE. There were 8 staff members present. Record review revealed on 02/06/2025 the ADON gave in-services on reporting any hazardous equipment. The in-service explained that any equipment that did not look safe needed to be reported to the maintenance director/ADM or reported in the TELS system. All equipment that was defective should be taken out immediately for service. There were 49 staff members who attended in person and 7 via telephone. Record review of the facility wide audit conducted on 2/26/25, including the Assist Bars, revealed no concerns. Record review revealed the template of the ambassador rounding sheet that would be used to monitor bed frames, assist bars, and ensured the checklist was used for vacant rooms. Record review revealed on 2/26/25 the DON in-serviced the CNAs and Nurses on transfers and Kardex's. The in-services were about ensuring the safety of residents who required assistance and ensuring the CNAs used the Kardex prior to transferring, and if they had questions, to ask the charge nurse. The in-services also talked about having a 1 person or 2 people assist, or total dependence on a Hoyer lift transfer. Record review revealed on 2/27/25 the DON in-serviced the nurses on the transfer status for admits/readmits. Nurses were to ensure assessments were completed on residents and readmissions prior to being transferred by any staff, and to educate CNA's on how to complete the transfer. There were 13 nurses who attended the in-service in person and 18 nurses who completed the in-service via telephone. In an interview on 2/28/25 at 1:15pm, LVN A said she was in-serviced on transferring, like assessing the resident's transfer status at admission, telling the aide what kind of transfer they were, and updating the task on the Kardex. She said she was also in-serviced on CIC, for any change like today when a resident received an x-ray for pain. She was also in-serviced on ANE, and the different types of abuse were sexual, physical, mental, and misappropriation. She would report to the ADM (abuse coordinator). In an interview on 2/28/25 at 1:20pm, CNA C said she had in-services on transfers, and making sure the bed/wheelchair was locked, putting a gait belt on, having the resident put their hands on her shoulders, counting to 3, pivoting, and counting to 3 and then sitting. She said they in-serviced about never using a mechanical lift with just one person because an accident could happen. Also, they talked about looking on the Kardex to see how the resident transferred. CNA C said if she saw any hazardous equipment she would report it. ANE was also in-serviced, and the different types of abuse were physical, verbal, mental, sexual, misappropriation. If she were ever to see ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 2:14pm, Med Aide E said they had in-services on transfers, which included always having 2 people when using the mechanical lift, looking on the Kardex for the type of transfers, and using a gait belt. She said they were in-serviced on hazardous equipment, and they informed the nurse if they saw any, and placed the resident in a safe spot first. ANE was also in-serviced, and the types of abuse were physical, verbal, misappropriation, neglect, sexual, and mental. She said if she were to see any ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 2:38pm, CNA F said he had in-services about the mechanical lift and how it was a 2-person activity, and where to find information on transfers like the POC/Kardex. He said if he came across hazardous equipment he would stop and get the nurse and maintenance. CNA F said if a resident was re-admitting after 1 day and he had not worked with the resident before, he would look on the Kardex to see how to transfer the resident. In an interview with LVN G on 2/28/25 at 2:55pm he said he had in-services on transfers and how there was a book now that was updated as admission/readmissions came in and stated how the resident's transferred. He said he also was in-serviced on ANE, and the different types of abuse were physical, financial, neglect, sexual, mental. He said if he were to see ANE he would report it to the ADM (abuse coordinator). LVN G said he was also in-serviced on mechanical lifts and needing 2 people at all times. He said to find how a resident transferred, you would look at the Kardex. He said if the bed had something wrong with it, he would get a new bed before transferring a resident and report it to maintenance. In an interview on 2/28/25 at 3:02 p.m., LVN H said she received in-services on transfers and having to assess new admits to determine the safest way to transfer, then she informed the CNA and put it in the transfer book. She said staff could find the transfer status of a resident on the Kardex. She also received in-services on ANE. The different types of abuse were sexual, physical, neglect, misappropriation, and mental. She said if she were to see ANE she would report it to the ADM (abuse coordinator). She said if she saw faulty equipment she would report it to maintenance and take it out of rotation. In an interview on 2/28/25 at 3:07pm, Med Aide I said she received in-services on ANE, and the different types of abuse were physical, mental, verbal, neglect, misappropriation, and sexual. She said if she were to see ANE she would report it to the ADM (abuse coordinator). She said she also received in-services on transfers and how mechanical lifts required 2 people, ensuring the mechanical lift did not hit someone, using the right size mechanical lift pad, asking the nurse how to transfer the resident, looking at Kardex, and using a gait belt. In an interview on 2/28/25 at 3:12pm, CNA J said she was in-serviced on transfers and how the transfer status was on the POC/Kardex, always using 2 people for mechanical lifts, always explaining to the resident what was going on, and always using a mechanical lift mat. The CNA said she also received in-services on ANE, and the different types of abuse were verbal, physical, mental, sexual, and misappropriation. She said if she were to see ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 3:21pm, RN K said she received in-services on transfers and about how the admitting nurse was going to determine the resident's transfer status, updated the Kardex, and told the CNA what the transfer status was. She said she also received in-services on mechanical lifts and how 2 people always had to be used, and making sure the right sling was used. ANE was also in-serviced, and the types of abuse were physical, verbal, misappropriation, neglect, and sexual. She said if she ever saw ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 3:27pm, CNA L said she received in-services on transfers and if a resident was a 2 person transfer then they had to use 2 people or they could use a mechanical lift. She also received in-services on the use of a gait belt, and how the admission nurse would have to assess the resident before anyone could transfer the resident, and the transfer status would be entered into the transfer book and in the system. She said she was also in-serviced on ANE, and the types of abuse were verbal, physical, sexual, and neglect. She said if she saw any ANE she would report it to the ADM (abuse coordinator). In an observation on 2/28/25 at 3:43pm, revealed CNA M and CNA F performed a mechanical lift transfer. The CNAs strapped the resident in and gave instructions to the resident regarding the lift. They ensured the lift was locked prior to the transfer of the resident. The CNAs placed the lift mat underneath the resident. Then they clipped the mat to the lift and informed the resident that the mechanical lift would be moving up. The CNAs lifted the resident slowly while 1 used the remote and 1 guided the resident. The resident did not hit anything and was placed into his chair smoothly. In an observation on 2/28/25 at 4:03pm, revealed CNA J and CNA N performed a 2 person transfer from wheelchair to bed. The CNAs started off with the bed being low for transfer and they applied a gait belt to the resident. There was constant communication between the resident and staff to ensure the resident was safe during the process. The resident was asked to put her hands on CNA J's shoulder for her comfort during the transfer. On the count of 3 the 2 CNAs picked up the resident from the gait belt, pivoted and sat her down on the bed. Once the resident was sitting on the edge of the bed, CNA J swung the resident's legs over onto the bed. In an interview on 2/28/25 at 4:10pm, the ADM said she expected staff to follow the plan of care/Kardex and reference that first. She said CNA D and CNA W should have looked at the POC/Kardex or spoke to the nurse before transferring CR #1. She said if the aides did not know the transfer status of the resident there was a risk for injury to the resident. In an interview on 2/28/25 at 4:31pm, the DON said they had in-services on transfers and how the nurses would assess residents when admitting them and determine their transfer status, and then enter the transfer status on the Kardex and inform the CNAs and other staff. She said they also had in-services on ANE and the types of abuse. An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on [DATE] at 4:30pm. While the Administrator was notified the IJ was removed on 2/28/25 at 4:18pm, the facility remained out of compliance at a severity of no actual harm with the potential for minimal harm, that is not immediate jeopardy with a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (CR #1) of 4 residents reviewed for respiratory care. The facility failed to ensure CR #1, who was on continuous oxygen, was provided with sufficient oxygen while out of the facility at an MD appointment on [DATE]. CR #1 was transported to the hospital from the MD appointment. An Immediate Jeopardy (IJ) was identified as past noncompliance on [DATE]. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began on [DATE]. This failure could place residents who received oxygen therapy at risk of respiratory complications, hospitalization and/or death. The findings included: Record review of CR #1's Admission Record dated [DATE] revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), heart failure, pleural effusion (a collection of fluid around your lungs), dementia, chronic kidney disease, and fluid overload. Record review of CR #1's discharge assessment-return anticipated MDS dated [DATE] revealed his cognitive skills for daily decision making was moderately impaired. He required assistance from staff with ADL care. His MDS did not indicate he was on oxygen. Record review of CR #1's care plan revealed he was on oxygen therapy. Interventions were to have oxygen via nasal cannula at ,d+[DATE] L per minute continuously, and to observe for signs and symptoms of respiratory distress and report to MD prn: respirations, pulse oximetry (noninvasive method for monitoring blood oxygen saturation), increased heart rate, restlessness, diaphoresis (excessive and abnormal sweating), headaches, lethargy, confusion, atelectasis (the collapse of a lung or part of a lung), hemoptysis (when you cough up blood from your lungs), cough, pleuritic (two large, thin layers of tissue that separate your lungs from your chest wall) pain, accessory muscle usage, and skin color, date initiated [DATE]. Record review of CR #1's physician's orders revealed an order for O2 at ,d+[DATE] L/minute via nasal cannula continuously every shift, order date [DATE]. Record review of CR #1's O2 saturation revealed it was at 95% out of 100% on [DATE] at 7:12 a.m. on room air. Record review of CR #1's nursing note dated [DATE] at 8:00 a.m. written by LVN D reflected in part, Res up in w/c in dining room eating breakfast. O2 on via n/c at this time. Res aware of doctor appt today and dressed and rdy per staff. Will monitor Record review of CR #1's nursing note dated [DATE] at 8:44 a.m. written by LVN D reflected in part, Res up in w/c alert and responsive. Resp even and unlabored. No distress noted. Appetite good. Will monitor. Record review of CR #1's nursing note dated [DATE] at 10:30 a.m. written by LVN D reflected in part, Res transported to doctor appt at this time. Record review of CR #1's MD progress note dated [DATE] written by MD R reflected in part, On exam pt is seen on home oxygen which was provided by his nursing home. On arrival pt was found to have an O2 saturation of 86% and during the visit developed cyanosis (medical term for when your skin, lips or nails turn blue due to a lack of oxygen in your blood) around his mouth and fingertips. Pt's [family member] reported that this has happened in the past and required prompt change in O2 tanks. Pt's oxygen tank was found to be empty and he was rapidly switched to another tank. Pt's O2 saturation at that time was found to be 72%, and EMS was called. Eventually O2 saturation improved to 92% and all other vitals remained stable and patient was taken to [Hospital Name] ER . Plan . 2. Acute hypoxemic respiratory failure Notes: Pt presented with cyanosis and dyspnea (shortness of breath) after O2 ran out of portable tank. Pt's tank was replaced and cyanosis resolved with replacement of supplemental O2, pt was sent to ER for further evaluation and treatment. Pt advised on importance of securing O2 and dangers of drops in oxygen . Record review of CR #1's hospital record dated [DATE] at 1:25 p.m. reflected in part, Patient is a [AGE] year old with past medical history CHF (progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes who was brought in by EMS with complaints of shortness of breath, chest pain. Patient states that he began having symptoms a few hours ago. Patient states that he has chest pressure rated an 8 out of 10 not worsened or relieved by anything. Patient reportedly with a new diagnosis of CHF but has not been able to get a prescription for home oxygen. Patient denies other significant symptoms at this time. Patient was noticed by nephrology (medical specialty that focuses on the study of the kidneys) staff to be cyanotic which prompted EMS call. EMS states that the patient was hemodynamically stable (patient's vital signs-like heart rate, blood pressure, and oxygen saturation-are within normal ranges) throughout transport, placed on nonrebreather (a medical device used to deliver high concentrations of oxygen to patients in emergency situations) with 100% saturation throughout transport .Primary impression: Acute hypoxic respiratory failure . Secondary Impression: anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), elevated troponin (a protein, a complex chemical molecule, found in certain types of muscle in your body), hyperkalemia (high potassium), pleural effusion, pneumonia (a lung infection that can be caused by bacteria, viruses, or fungi), and thrombocytopenia (low blood platelet count). Record review of CR #1's hospital record dated [DATE] at 12:52 a.m. reflected in part, .Patient was at nephrology appointment and noted to be hypoxic did not have his oxygen, he is on 3 L nasal cannula at his nursing home, he was transported not on oxygen. Patient exhibited shortness of breath and chest pain radiating ,d+[DATE] but resolved once oxygen was placed . called [family member] for collateral information . In an interview on [DATE] at 11:15 a.m. LVN D said CR #1 had an appointment after breakfast (on [DATE]). She said she put a new oxygen tank on him, he went out to his appointment and the tank ran out of oxygen. She said he was on ,d+[DATE] L of continuous oxygen, and it should have lasted around ,d+[DATE] hours. She said she did not think he would run out. She said after the incident, the facility conducted an in-service to ensure the oxygen tank was new and full before the patient went out of the facility. She said since the incident, she would send an extra oxygen tank with the driver if the resident was out of the building for a while. In a telephone interview on [DATE] at 11:39 a.m. CR #1's family member said the MD office informed her his oxygen tank was empty. She said she was unsure if the oxygen tank was working or not. She said he could have had a stroke or died without his oxygen. In an interview on [DATE] at 12:22 p.m. the Corporate DON said 2 L of continuous oxygen should last approximately ,d+[DATE] hours. She said it would last a shorter timeframe if the resident was on a higher Liter. She said when a resident went out to an appointment, facility staff put on a new tank when they left and that should be enough for the allotted time. She said residents were not typically out of the building for longer than ,d+[DATE] hours. If residents were out longer than ,d+[DATE] hours, they could send an extra tank of oxygen with them. In an interview on [DATE] at 12:34 p.m. the Talent and Learning Director said she was previously the respiratory therapist at the facility years ago. She said the facility used E cylinder tanks for portable oxygen and each tank held 2000 psi (a commonly used E cylinder can hold nearly 680 liters of oxygen when filled to 2,000 psi). She said the length of time the oxygen lasted was based on the liter flow. She said if a resident was on 2 L the portable tank could last from ,d+[DATE] hours. She said the tank should be changed at 4 hours when it reached the red area, with 500 psi remaining. She said when she was the respiratory therapist, she ensured to calculate how long the resident would be out of the facility, call the MD office and ask about oxygen availability, and determine what mode of transportation was used. She said if the resident was on 2 L she would send an extra tank with the van in case of an emergency. In a follow up interview on [DATE] at 1:15 pm LVN D said she put a new, full oxygen tank on CR #1 at breakfast time around 7:30 a.m.- 8:00 a.m. She said he left the building for his appointment between 9:30 a.m. - 10:00 a.m. She said she glanced at the oxygen tank when he left the building, and it was a little less than full. She said he was on the oxygen tank for approximately 1 ,d+[DATE] hours when he left the facility. She said no one told her how to ensure the resident had enough oxygen while out of the facility, or how to calculate how much oxygen the resident would need while out of the facility. In a telephone interview on [DATE] at 8:31 a.m. CR #1's Clinic Staff said the first and only time CR #1 was seen in their office was on [DATE]. She said his appointment was scheduled for 11:30 a.m. She said he was in a w/c with an O2 tank, but it was out of oxygen, it was low. She said his O2 saturation was 86% on arrival. She said his O2 tank was found to be empty, and the office rapidly switched the tank. She said CR #1 looked tired and sick, but he was at the MD office for a hospital follow up. She said the nursing facility did not call beforehand to see if the office had oxygen on hand. In an interview on [DATE] at 11:06 a.m. the Administrator said on the day of his MD appt staff put an oxygen tank on CR #1 around 9:30 a.m. She said the same day they were notified he was sent to the hospital from the MD office due to blue tinge on his hand. She said he was sent to the MD's office with a full tank, and they were uncertain when the oxygen ran out due to the uncertain timeline and not being there. She said the resident could be at risk of not receiving the adequate amount of oxygen to support his needs. She said the facility could have anticipated some of the resident's needs but could also glean that the receiving entity would have emergency support. She said the facility should do what they could to provide support to the resident on their end. She said after the incident the facility instituted best practice for worst case scenario and in-serviced nurses on [DATE] to send residents out with 2 tanks and ensure drivers returned any remaining tanks. She said the new procedure was to ensure safety measures were in place. In a follow up interview on [DATE] at 12:44 p.m. LVN D said she sent CR #1 to his appointment with 1 portable O2 tank (the one in use). She said she did not know if the MD office had oxygen on hand and said the resident could be at risk of desaturating if he ran out of oxygen (Respiratory desaturation, known as hypoxemia in medical terms, is when you have low blood oxygen saturation.) In an interview on [DATE] at 1:06 p.m. RN S said she would ensure the resident had a full tank of oxygen if sent out of the facility. She said the tanks typically lasted around ,d+[DATE] hours on 2 L. She said 3 L would last a shorter time. She said she had to know the driving distance, where they were going and how long they would be gone. She said she would send the resident with an extra tank or two. In an interview on [DATE] at approximately 2:07 p.m. LVN C said she would send an extra O2 tank with a patient who went out of the facility. Record review of the facility's in-service entitled, O2 Management for outside appointments dated [DATE] conducted by the previous DON and provided to nurses and CNAs reflected in part, when residents are going out for outside appointments always check O2 tank to ensure it is full or place a brand-new tank when transportation arrives to pick up resident. Always send 1 extra O2 tank with resident to appointment and have transportation to bring both tanks back upon residents return. The in-service had 34 signatures. Record review of the facility's Oxygen Administration policy dated [DATE] reflected in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 for approximately 4 hours after she had a change in condition with sudden onset of mental status and neurological deficits on 10/02/24 at approximately 12:37 p.m. CR #1 was not transported to the ER until approximately 4:39 p.m. where she passed away on 10/15/24. -The facility failed to monitor CR #1 after having a change in condition on 10/02/24 for approximately 4 hours. An IJ was identified on 01/24/25. The IJ template was provided to the facility on [DATE] at 5:34 p.m. While the IJ was removed on 01/26/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). These failures could place residents at risk of not receiving necessary medical care, hospitalization , and death. The findings included: Record review of CR #1's Admission Record, dated 01/24/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included encephalopathy (disease of the brain), unspecified, muscle weakness, paroxysmal atrial fibrillation (type of irregular heart beat that comes and goes), and cognitive communication deficit. Record review of CR #1's Quarterly MDS Assessment, dated 09/12/24, revealed a BIMS score of 3, indicating severe cognitive impairment. Further review revealed resident was dependent (the assistance of 2 or more helpers was required for the resident to complete the activity) with showering and required substantial/maximal assistance (helper does more than half the effort) with toileting and lower body dressing. Record review of CR #1's MAR dated, 10/01/2024-10/31/4, revealed an order for Xarelto tablet 10 mg, 1 tablet by mouth in the evening related to angina pectoris (chest pain or pressure), unspecified. Further review revealed the resident spit out her medication on 10/01/24 and refused the medication on 10/02/24. Record review of CR #1's care plan, last review date completed 09/20/24, revealed the resident had altered cardiovascular status r/t atrial fibrillation, a communication problem r/t hearing deficit, and an ADL self-care performance deficit r/t weakness. Record review of CR #1's progress notes written by Nurse B, dated 10/02/24 at 12:37 p.m., revealed a reported change in condition of Stroke/CVA/TIA/new neurological signs and Other change in condition. Mental status noted altered level of consciousness (hyperalert, drowsy but easily aroused. Functional status noted swallowing difficulty. Neurological status evaluation noted Altered level of consciousness (hyperalert, drowsy but easily aroused. Further review read in part .Nursing observations, evaluation, and recommendations are: Resident sudden onset of mental status, neuro deficits. Resident is usually alert and aggressive from time to time with an adequate appetite. Usually responds with words or nodding of the head .Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER for further evaluation and treatment of neurological Granchanges [sic] .Blood pressure, pulse, respiration rate, pulse oximetry, and blood glucose were taken. No additional vital signs were noted after this time. Record review of CR #1's progress notes, dated 10/02/24 at 17:09 p.m. (4:09 p.m.), read in part .Resident was picked up by transfer service to be taken to [hospital]. Record review of CR #1's hospital records, dated 10/02/24, read in part .clinically suspect patient had a CVA .The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life threatening deterioration in the patient's condition during their evaluation in the ED .MRI brain wo IV contrast, result date 10/03/24 .impression small acute nonhemorrhagic (not causing or associated) bilateral (two-sided) cerebral hemispheric (symmetrical halves of the cerebrum (largest part of the brain) and cerebral infarcts (ischemic stroke), the distribution of which suggests embolic etiology (cause of an embolic stoke) . Record review of CR #1's hospital discharge summary, dated 10/15/24, read in part .presented with AMS and found to have acute CVA .pt passed at 16:06 (4:06 p.m.) . During an interview on 01/24/25 at 10:38 a.m., Nurse B said anytime there was an order to send the resident out to the hospital the doctor would let the facility know if they needed to be sent out regular transport or 911. She said due to the resident's dementia, she was not very verbal, but she could communicate in her own way. She said on 10/02/24 CNA B noticed resident CR #1 was not really wanting to eat and drink and would pocket food in her mouth. She said her vital signs remained perfect, stable. She said she would squeeze her hands. She said she had altered mental status and had to have her food taken out of her mouth. She said resident CR #1 gripped both of her hands, followed her fingers, and pupils were normal, it was more that she was nonverbal and pocketing her food. She said the change in condition occurred approximately between 12:00 p.m. and 1:00 p.m. She said the NP gave the order for the resident to be sent out via regular transport. She said she called the transportation company at approximately 1 p.m. She said the transport company told her it would be 1 1/2 to 2 hours when the resident would be picked up. She said she notified NP, and she said it was okay. She said come end of her shift, 2:00 p.m., she gave a report to the oncoming nurse, Nurse C, and told her about the situation and that if the transportation company did not show up by 3:00 p.m. to follow-up with them and the NP. She said she did not suspect resident was having a stroke and on the change in condition form she marked stroke/CVA/TIA/new neurological signs and other change in condition and listed altered mental status. She said she was just referring to the altered mental status. She said she remembered asking the ADON about what she should mark because she felt the resident was not having a stroke and she said the ADON said to select it and to note altered mental status. She said if there was a place to click neurological symptoms, she would have just clicked neurological symptoms. She said her shift ended at 2: 00 p.m. and she was not aware of what happened after she left. She said the only signs the resident presented with was altered mental status, non-verbal, and pocketing food. She said CR #1's baseline was that one could ask her yes and no questions and she would answer, she would jibber jabber (speech that is or appears to be nonsense) and would always drink water when offered. She said when she left work, resident CR #1 was still at the facility. During an interview on 01/24/25 at 11:22 a.m., CNA B said CR #1 had dementia but would regularly greet her. She said on the morning of 10/02/24, CR #1 was kind of quiet but alert. She said the resident would look at her when she entered her room and then would look at the ceiling but would not speak. She said at breakfast she fed her, and she ate well. She said at lunch she was the same but not as alert. She said she would ask her if she was okay, but she would not speak and would only look at her and around the room. She said for lunch the resident would close her lips like she did not want to eat. She said the resident opened up her mouth and she fed her a spoonful of food. She said she thought she was chewing her food, but she was pocketing her food. She said she told the resident to swallow her food, but she would not. She said she massaged her cheeks and told her to swallow her food, but she spit it out. She said she told another CNA to tell Nurse B and Nurse B came in the room and took over. She said Nurse B checked her vitals and the resident followed her finger. She said the resident was still at the facility when her shift was over at 2:00 p.m. During an interview on 01/24/25 at 1:03 p.m., the DON said she remembered the staff came to her and asked her to look at CR #1. She said she did not know how she normally presented and when asked they told her that she was normally aggressive but recently had been declining as in not eating as much, not being aggressive, and was being treated for an UTI. She said she knew with UTI residents that their mental status could be altered. She said CR #1 was responding, would open her eyes, would follow her, so she told the Nurse B to call the doctor to see what recommendations they suggest. She said Nurse B made the call to the doctor. She said she does not remember if the NP saw the resident earlier that morning but thinks she may have. She said Nurse B told her it was okay to send the resident to the hospital. She said Nurse B did not specify if it was a non-emergent or emergent transport. She said she remembered everything was stable and vital signs were within normal limits. She said she looked at CR #1's chart and saw he was sent out at 5 p.m. She said she did not go back and check on the resident during the time period in between because it was her understanding CR #1 was being sent out to the hospital and she was not notified that the resident was still in the building. She said she is not included in shift reports from one nurse to the other. She said Nurse C never mentioned anything to her about the resident. She said she did not suspect resident was having a stroke. She said days prior to 10/02/24, she was not eating, or her normal self, and it was not a sudden change. She said they had already told the doctor that the resident was eating less. On 01/24/25 at 2:36 p.m., a telephone call made to CNA C, but call went unanswered. Left a voicemail requesting a return phone call. On 01/24/25 at 2:39 p.m., a text message was sent to CNA C requesting she call. During an interview on 01/24/25 at 3:19 p.m., NP said she did not recall the conversation on 10/02/24. She said per her notes, later in the day nurse sent CR #1 out due to acute altered mental status, was not responding to stimuli, was sent to ED. She said she also documented resident was a high risk for rehospitalization . She said she did not see the patient when she had her change in condition so she did not know if it should have been a regular or 911 transport. She said based on her professional opinion, patient not responding to stimuli or is weak, it is usually 911. She said she doubts CR #1 would have been a resident the facility would have sent out regular transport. She said she should have gone out 911 based on their documentation and hers. She said if she had been asked specifically, she would have said to send out 911. She said she did not receive any other follow-ups from the facility about transportation. During a follow-up interview on 01/24/25 at 5:04 p.m., DON she said she knows the transportation company would have done a set of vitals when they arrived. She said she does not know why it took them so long to arrive at the facility to pick the resident up. During a follow-up interview on 01/25/25 at 9:39 a.m., Nurse B said she told the NP she felt CR #1 was having altered mental status, was responding to stimuli, gave her vital signs which were all stable, when attempted to be fed she was holding food in her mouth, CNA encouraged chewing movements, but resident just spit the food out. She said when she would call out resident's name, she would not make any sounds or acknowledgements and would only look at the person who was speaking to her. She would turn her head look at her but did not make any noises. She was blinking when she looked at her. She said the NP said as long as CR #1's vital signs were normal they could use regular transport. She said she took the resident's vital signs approximately 2 additional times but did not document. During an interview on 01/25/25 at 10:09 a.m., EMS Representative said they received a call from the facility on 10/02/24 at 13:12:32 (1:12 p.m.) and picked up at 16:39:11 (4:39 p.m.). He said it was called in as ER altered mental status and vitals showed she was stable. Record review of the facility's Charge Nurse job description, dated 2023, read in part .The primary purpose of your job position is to provide direct nursing care to the residents .to ensure that the highest degree of quality care is maintained at all times . Record review of the facility's Change in a Resident's Condition or Status policy, revised 2016, did not include sending a resident 911 versus regular transport. The Administrator was notified on 01/24/25 at 5:34 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 01/25/25 at 12:31 p.m.: [] Plan of Removal [] submits the following Plan of Removal for the alleged failure to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. By submitting this plan of removal [] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? A. On 10/02/2024 resident CR#1 involved in alleged deficient practice was discharged to the hospital. B. On 01/24/2025 at 6:00 pm the Administrator notified the Medical Director of the alleged deficient practice. C. Nurse Managers completed a 100% assessment of all residents residing in the facility for changes in condition on 01/24/2025, and none were identified. D. On 1/24/2025 LVN B was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room . The facility audited the change in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician 1/24/2025, no concerns were identified. E. On 1/24/2025 LVN C was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room . F. The Corporate Clinical Service Director reviewed facility policy on 01/24/2025 regarding change in condition and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was completed on 1/24/2025 by the Corporate Clinical Service Director with the Director of Nursing on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. B. The Director of Nursing completed an in-service on 1/25/2025 with the licensed nursing staff on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Licensed nurses will not be allowed to return to work until they receive this in-service. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. D. The Director of Nursing or designee completed an in-service on 1/25/2025 with the licensed nursing on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Licensed nurses will not be allowed to return to work until they receive this in-service. a. Use non-emergency transport for stable residents requiring evaluation or treatment for non-urgent conditions, such as worsening chronic symptoms or mild infections. b. Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care. E. On 1/25/2025 CNA's received in-services on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. CNAs will not be able to work until they have completed this in-service. F. Newly hired CNA's will be in-serviced by the Director of Nursing or designee on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes of change in conditions and the documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 01/24/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 01/25/25-01/26/25, surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed on 01/24/25, the facility completed an assessment for all residents in the facility for changes in conditions, and none were identified. Record review revealed on 01/24/25, Nurse B was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room . Record review revealed on 01/24/25 the facility audited changes in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician. Record review revealed on 01/24/25, Nurse C was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room . Record review revealed on 01/24/25, the DON was in-serviced on managing and monitoring changes in resident condition. Record review revealed in-service was completed on 01/24/25 with the DON on Managing and Monitoring Changes in Resident Condition. Record review revealed on 01/25/24, in-service was completed with 40 licensed nursing staff on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Record review revealed, on 01/24/24 in-service was completed with 40 nurses on the ongoing monitoring and assessing of residents scheduled for transport to the hospital. Record review revealed, on 01/24/25 in-service was completed with 40 CNAs and 7 MAs on recognizing a change in condition and who to notify. Interviews were conducted from 01/25/25 to 01/26/25 with staff from all shifts: DON, 2 RNs, 7 LVNs, and 9 CNAs. Licensed Nursing staff verbalized an understanding on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility, the ongoing monitoring and assessing of residents scheduled for transport to the hospital and recognizing a change in condition and monitoring while awaiting transport to the emergency room . CNAs verbalized an understanding on recognizing a change in condition and who to notify The Administrator was notified the Immediate Jeopardy was removed on 01/26/2025 at 11:36 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent development or worsen of pressure ulcers for 1 (Resident #2) of 3 residents reviewed for pressure ulcers. -The facility failed to prevent Resident #2, who was admitted to the facility without pressure ulcers from developing stage IV pressure ulcer on her left heel. This failure placed residents at risk for the development of avoidable pressure ulcers resulting in pain and discomfort. Findings include: Record review of Resident #2's face sheet revealed she was [AGE] years old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's care plan dated 12/01/21 revealed the resident had potential for pressure ulcer development due to decreased mobility. Interventions: turn and reposition during rounds. Notify nurse immediately of any skin breakdown: redness, blister, bruises, and discoloration noted during bath or daily care . Record review of Resident #2's quarterly MDS dated [DATE] revealed BIMS of 03 out of 15 indicating severely impaired cognition. The resident required extensive assistance of one staff for bed mobility and ADL care. There were no skin and ulcer/injury treatment checked. Record review of Resident #2's documentation survey report for ADL for February 2022 revealed no skin issues on resident's left heel. Based on observations, interviews, and record reviews, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent development or worsen of pressure ulcers for 1 (Resident #2) of 3 residents reviewed for pressure ulcers. -The facility failed to prevent Resident #2, who was admitted to the facility without pressure ulcers from developing stage IV pressure ulcer on her left heel. This failure placed residents at risk for the development of avoidable pressure ulcersresulting in pain and discomfort. Findings include: Record review of Resident #2's face sheet revealed she was [AGE] years old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's care plan dated 12/01/21 revealed the resident had potential for pressure ulcer development due to decreased mobility. Interventions: turn and reposition during rounds. Notify nurse immediately of any skin breakdown: redness, blister, bruises, and discoloration noted during bath or daily care . Record review of Resident #2's quarterly MDS dated [DATE] revealed BIMS of 03 out of 15 indicating severely impaired cognition. The resident required extensive assistance of one staff for bed mobility and ADL care. There were no skin and ulcer/injury treatment checked. Record review of Resident #2's documentation survey report for ADL for February 2022 revealed no skin issues on resident's left heel. Record review of Resident #2's progress notes dated 3/3/22 indicated the weekly skin assessment revealed 5 cm by 5 cm unstable purple black area to the left heel. Apply skin prep to left heel cover with dry dressing because it looks like could open soon. Also documented on the progress note was that Resident #2 was seen by wound care doctor on 4/15/22 for unstageable DTL (deep tissues injury) to the left heal which measured 4 x 3.6 x 0.1 cm. light serosanguinous exudate (fluid from wound, yellowish with small amount of blood). 50% thick adherent black necrotic tissue (death of body tissue when too little blood flows to the tissue)50 % granulation tissue. Record review of Resident #2 physician's progress note dated 4/1/22 read in part . left heal measured 5 x 5 cm stage IV . Record review of Resident #2's licensed nurse administration record dated May 2022 read heel floats while in bed every shift start date 4/1/22. Record review of Resident #2's Wound Care Doctor notes dated 4/14/22 read etiology (cause): pressure, unstageable DTI of the left heel full thickness. The wound measured 4 x 3.6 x 0.1 CM (centimeter), wound area 14.40 cm^2. Treatment: primary dressing, Santyl apply once daily for 30 days, gauze sponge non-sterile, apply once daily for 30 days. Recommendations: off load wound (relieve pressure to the wound), turn side to side, and front to back in bed every 1 to 2 hours. Record review of Resident #2's Wound Care Doctor notes dated 4/21/22 read in part . etiology: pressure, unstageable DTI of the left heel full thickness. The wound measured 4 x 3.6 x0.1 CM (centimeter), wound area 14.40 cm^2. Treatment: primary dressing, Santyl apply once daily for 23 days, gauze sponge non - sterile apply once daily for 23 days. Recommendations: off load wound, turn side to side, and front to back in bed every 1 to 2 hours . Record review of Resident #2's TAR (treatment administration record) dated May 2022 read each day shift for prophylactic, cleanse wound to left heel with NS (normal saline), pat dry, apply Santyl and cover with dry dressing QD (every day) order date 5/16/22. Interview on 5/19/22 at 9:06 a.m., with the Wound Care Doctor who said Resident #2 had a pressure ulcer to her left heel and he could not remember the first time he saw her, but it was full thickness DTI. He said the wound may not have developed if the resident's heels had been floated to relieve pressure from the area. The Wound Care Doctor said the resident's heels should be floated while in bed and turned and repositioned the resident every two hours. He said that was his recommendation when he saw Resident #2. Observation on 5/19/22 at 9:30 a.m. of Resident #2's, wound care provided by the Wound Care Nurse revealed the wound on the left heel had some yellow slough and granulating tissues. The wound was cleansed with normal saline, and Santyl was applied to the wound bed, and it was wrapped with gauze. The Wound Care Nurse transferred the resident back to her chair and placed a sock over the dressing. Interview on 5/19/22 at 9:50 a.m. with LVN A who said Resident #2 was bed-bound for a while because she had surgery. She was not sure if the aides and nurses floated her heels before the wound on her left heel developed. She said nurses and aides turn and reposition residents. She said she asked her aides to turn and float residents' heels in bed, and that was how she monitored the aides. She said if the resident heels were not floated and relieved pressure from the bony areas, it would break down. She said the facility protocol was to turn and reposition residents in bed every two hours and float heels. Interview on 5/20/22 at 9:50 a.m., with the Wound Care Nurse who said she was not the Wound Care Nurse when Resident #2 developed the presure ulcer on her left heel. She said she had been working as PRN (as needed). She said if a resident heel was not floated, they may develop a pressure ulcer on the heel. She said the skill check-off for nurses has a section on how to relieve pressure from bony areas. A resident with decreased bed mobility is turned and repositioned every two hours to prevent skin breakdown, and the resident heels are floated while in bed. She said the nurses make rounds and check on residents for turning and repositioning, monitor aides, and make sure they are also turning and repositioning residents. She said it is the facility protocol for all residents in bed to be turned and repositioned every two hours and float heels while in bed. Interview on 5/20/22 at 9:56 a.m. with the DON who said she remembered Resident #2 fell and had a fracture, and when she came back from the hospital, they were concentrating on the surgical site, and she was not sure if her heels were floated. She also said the Wound Care Nurse that was working at the time the resident developed the wound no longer worked for the facility. She said the facility's protocol was to float the resident heel while in bed and turn and reposition the resident every two hours. She said the nurses, and the aides were supposed to turn and reposition the resident every two hours and float the resident heals. The nurses supervised the aides. The nurse management monitors the nurses to make sure the heels were floated while in bed, and if it is not done, the heel might develop a wound. She said Resident #2 developed a deep tissue injury, which worsened to stage IV. She said the nurses and the aides had been trained on the facility protocol on pressure ulcer prevention. During the interview, she checked the Resident #2's readmission skin assessment dated [DATE] and the weekly skin assessment for February. She said there were no indication that the resident had any skin issues on her heels. She also checked the ADL record for February, and she said there was no documentation of any skin issues on the resident heels. During the interview Resident #2's admission skin assessment dated [DATE] weekly skin assessment dated [DATE], was reviewed with DON and revealed no documentation of any skin issues on Resident #2's left heel. Requested the assessment at that time and the Braden Scale but both were not provided upon exit Interview on 5/20/22 at 10/12 a.m. CNA A who said he was working with Resident #2 today, but he had not worked with her when she developed the pressure wound on her left heel. He said the resident was turned and repositioned every two hours, and heels floated while in bed. He said the resident was mostly up in her chair during his shift, but when she was in bed, he applied the boots on her heel. He said if the resident heels are not floated, the resident may develop a wound. He said he was trained on the facility protocol on pressure/skin breakdown. He said the nurses make rounds and check if residents are being turned and repositioned and heels floated. Interview on 5/20/22 at 10:49 a.m. with the Administrator who said the resident heels should be offloaded to prevent pressure on the heel. If that was not done, the resident heels may develop a pressure wound. Record review of the facility policy on pressure ulcer/skin break down clinical protocol dated 2005 MED - PASS Inc, (Revised April 2007) read in part . the nursing staff and attending physician will assess and document an individual's . developing pressure sore: for example, immobility .

Based on interview and record review, the facility failed to provide care and necessary treatments to prevent pressure ulcers, promote healing, and prevent infection for one (CR #1) of two residents reviewed for pressure ulcers. -The facility failed to implement measures, when she was identified at risk of a pressure ulcer, to develop on CR #1's sacrum causing a hospitalization . This failure affected 1 resident and placed her at risk for the development of new pressure ulcers or worsening of pressure ulcers and pain. Findings include: CR #1 Record review of CR #1's face sheet revealed she was a [AGE] year-old woman admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's 30-day MDS dated [DATE] revealed a BIMS of 13, indicating cognitively intact. She needed extensive assistance of 2 staff with bed mobility, toilet use, personal hygiene, transfers, and was incontinent of bowel and bladder. A Stage 4 sacrum pressure ulcer was indicated, but interventions of pressure reducing device for chairs, turning, and repositioning program was not checked. Record review of CR #1's admission Branden Scale dated 6/8/19 revealed a score of 13, indicating moderate risk for skin breakdown. Additional Braden Scale assessments revealed scores indicating low risk for skin breakdown on 6/14/19 score 18, 6/21/19 score 19, and 6/28/19 score 17. Record review of CR #1's care plan dated 6/26/19 read in part . resident had bowel and bladder incontinence which placed her at risk for skin breakdown . Sacral wound . turn and reposition during rounds . air mattress implemented: Date Initiated: 7/3/19 . Record review of CR #1's TAR for (MONTH) 2019 read in part . cleanse sacrum with NS . pat dry, apply santyl and alginate cover with dressing. Order dated 6/27/19 . Record review of CR #1's weekly skin assessments revealed for dates 6/8/19, 6/11/19, 6/18/19, and 6/25/19, there was no discoloration or skin breakdown on her sacrum or buttocks noted. Record review of CR #1's skin assessment dated [DATE] revealed a wound on the sacrum measuring 3 cm x 3 cm x 0.2 cm. Record review of CR #1's MD Wound Care assessment dated [DATE] read in part . stage 4, moderate sero-sanguineous exudate, 76-100% moist yellow slough . measured 3.5 x 4.5 x 3.5 cm . wound was debrided after wound care doctor explained the risk/benefits to family member . Clean wound with normal saline, apply santyl, alginate cover wound with dry absorptive dressing and change daily. Reposition per facility protocol . Record review of CR #1's MD Wound Care assessment dated [DATE] read in part . stage 4, moderate sero-sanguineous exudate, 26-50% moist tallow slough . measured 3.8 x 3.2 x 3.1 cm . wound was debrided after wound doctor explained the benefits and risk to family member . Clean wound with normal saline, apply santyl, alginate cover wound with dry absorptive dressing and change daily. Reposition per facility protocol . Record review of CR #1's MD Wound Care assessment dated [DATE] read in part . stage 4 pressure injury, moderate sero-sanguineous exudate, 26-50% moist yellow slough . measured 3.2 x 4.0 x 3 cm . family does not want to the wound debrided per Wound Care Nurse . Clean wound with normal saline, apply santyl, alginate cover wound with dry absorptive dressing and change daily. Reposition per facility protocol . Record review of CR #1's local hospital record dated 7/24 /19 revealed CR #1 was sent to the hospital for wound evaluation. It noted CR #1 had stage 3 decubitus ulcer with purulent drainage to the sacrum that measured 4 x 3.5 x 1.8 cm, undermining 5.5 cm between 11-4 o' clock, 90 % red viable tissue, 10 % thin slough at base, moderate cloudy yellow drainage, slight wound edges maceration. A wound culture final result dated 7/28/19 revealed two organisms: proteus mirabilis and Escherichia coli. Record review of CR #1's Order Summary Report dated 7/25/19 revealed -Wound care eval and treat, order date 6/27/19 -Treatment order: cleanse sacrum with ns, pat dry apply santyl and alginate cover with dry dressing daily and prn, order date 6/27/19 -[MEDICATION NAME] Liquid (Amino Acids-Protein Hydrolys) give 30 ml by mouth three times a day fro promote wound healing for 30 days, dated 7/1/19 -Vitamin C 500 mg, 1tab qd, for wound healing, order date 7/1/19 -Multvita-M, (multiple vitamins - mineral) 1tab po qd for promotion of wound healing, order date 7/1/19 -low air loss mattress to bed to promote wound healing, order date 7/3/19, -monitor for proper function every shift, order date 7/3/19 -Transfer to hospital for wound observation, order date 7/24/19 Record review of CR #1's MAR for (MONTH) 2019 revealed pain medication .[MEDICATION NAME] HCL 50 mg, give I tablet by mouth every 4 hours as needed for pain, give if pain is greater than 5. Start date 7/1/19 . given on 7/13/19, 7/8/19 and 7/11/19 . [MEDICATION NAME] tablet 800 mg, give 1 tablet by mouth every 6 hours as needed for pain. Give if less than 5 . given on 7/6/19, 7/8/19, and 7/21/19 . Telephone Interview on 7/24/19 at 4:17 p.m. with CR #1's family member, she said that she asked the facility to discharge CR #1 to a local hospital for wound evaluation. She said that the wound looked very bad and she thought that it was infected. She also said that she did not have any open area on her tail bone when she was admitted to the facility. Interview on 8/15/19 at 10:10 a.m. with Wound Care Nurse, she said CR #1 was admitted without a wound on her sacrum and the initial skin Braden scale was 13 (moderate risk). She said the following weekly Braden Scale assessments revealed she was at low risk for pressure injury. She said the Braden Scale assessments were done weekly for four weeks and then quarterly. She said she did skin assessments on Tuesdays for three weeks and CR #1 did not have any wound on her sacrum (large bone at the base of the spine) but there was a friction injury from the transfer board used by therapy. She said an aide told her to look at CR #1's sacrum on Thursday (6/27/19) and that was when she saw the wound. She said the wound measured 3.0 x 3.0 x 0.2 cm, red pink color to the wound bed, a peri wound was purple and burgundy in color, no exudate was seen, and the wound edges were intact and not rolled inward. She said she could not stage the wound because she does not have wound care certification. She said the Wound Care Doctor did not see CR #1 the day after the wound was discovered because she was not in her bed when the Wound Care Doctor was at the facility. She said the Wound Care Doctor said he would see her the next week. She said CR #1 could turn and reposition by herself and she had not been told CR #1 had refused to be turned. She said the CR #1 liked to lay on her back. The Wound Care Nurse said the Wound Care Doctor saw CR #1 on 7/5/19 and 7/12/19 and did a wound debridement on both visits. She said the Wound Care Doctor saw CR #1 on 7/19/19 but did not debride the wound because it was improving and the spouse had refused permission. The Wound Care Nurse said the facility protocol was to turn and reposition the resident every two hours, provide timely incontinent care, use pillows, wedges, offload the heels, and refer residents with wounds to be seen by the dietitian. She said residents were switched to air mattresses if they had stage III or IV wound, and every resident should have a W/C cushion. She said supplements are usually recommended by the doctor or the dietitian as soon as the resident developed pressure injury. She said she was in-serviced on turning and repositioning residents. She said wounds can get very bad when a resident was not turned, kept dry and clean. She said that there were no additional orders to turn and reposition CR #1 until she had developed the pressure ulcer on her sacrum. The Wound Care Nurse said she was not able find when CR #1 was switched to an air mattress, but she was on an air mattress when the wound care doctor saw her on 7/5/19. Interview on 8/15/19 at 11:32 a.m. with Administrator, she said she was made aware that CR #1 had wound after the Wound Care Doctor had debrided it. She said the facility has a wound protocol that included to turn and reposition the resident, give supplements as needed, weekly skin assessments, timely incontinent care, and Braden Scale assessments. She said the Wound Care Nurse did the wound assessments and notified the resident's family and worked with the Wound Care Doctor for orders that resident needed for wound healing. Interview on 8/15/19 at 12:28 p.m. with Interim DON, she said CR #1 did not have any wound on her sacrum at admission, but after a few weeks she developed a pressure ulcer on the sacrum. She said the staff did a skin assessment on admission and weekly skin assessments. She said they turn and reposition residents. She said if resident has a skin issue/wound they notify the doctor, family, and use interventions such as air mattress, vitamins to help with wound healing, in a day or two not a week or more. She said that there was no wound on CR #1's sacrum until the wound care doctor cleaned the biofilm, found necrotic tissue, and he debrided the wound. Interview 8/15/19 at 2:25 p.m. with LVN A, she said the Wound Care Nurse told her CR #1 had developed wound. She said that they had to turn and reposition the resident every two hours, provided incontinent care, and hopefully, the resident was compliant with the care. She said residents can get friction injuries when a resident is dragged instead of lifting the resident during transfers or incontinent care. Interview on 8/15/19 at 3:05 p.m. with RN ADON, she said the Wound Care Nurse did the skin assessments. She said aides and nurses were in-serviced on turning and repositioning, barrier cream use, and boots by the Wound Care Nurse. She said the Wound Care Nurse told her if staff didn't turn and reposition residents once in each shift, provide incontinence care every two hours, it would have a negative effect on the wound. Interview on 8/16/19 at 9:23 a.m. with CNA A, she said that residents were turned and repositioned every two hours and barrier cream applied after incontinent care to help prevent skin breakdown. She said that she would tell her nurse if a resident refused to be turned. Telephone interview on 8/16/19 at 10:34 a.m. with the Wound Care Doctor, he said biofilm covers wounds. He said to read his notes for CR #1, because he puts everything about the care of the resident in them. Interview on 8/16/19 at 12:42 pm, PT and PTA A, she said the Wound Care Nurse told her CR #1 had wound to the sacrum and to stop using sliding board. She said that the sliding board goes on the upper thighs, because the wound was on her sacrum, the board could not have caused the wound. Record review of the facility Prevention of Pressure Ulcer dated 2001 MED-PASS, Inc, Revised (MONTH) 2005 read in part . General Guidelines, # 4. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.) . and/or mental condition . 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed . General Preventive Measures: 1. Identify risk for pressure ulcer development (via Braden Scale Assessment). 2. For a person in bed: a. Change position frequently as needed . 4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging .

Based on observation, interview and record review the facility failed to promptly notify the ordering physician in accordance with facility policies and procedures for 1 (Resident #7) of 8 residents reviewed for radiology findings, in that: -The facility failed to promptly notify Resident #7's physician of x-ray results and continued pain from a fall that occured on 10/29/17. This deficient practice affected one resident and placed 26 residents residing on Hall 400 at risk of their physicians not being promptly notified of their diagnostic results which could lead to a delay in treatment. Findings included: Resident #7 Record review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] revealed he had a BIMS score of 10, indicating moderate cognitive impairment. He required extensive assistance for transfers, locomotion, dressing, toileting and required extensive assistance for personal hygiene. Record review of Resident #7's Care plan initiated on 5/15/17 revealed Resident #7 required assistance from staff for ADL's. Record review of Resident #7's Nurses Progress Notes revealed on 10/29/17 at 10:47 pm Aid called nurse to lobby, on arrival resident noted on floor . Nurse placed call to Dr on call number. Nurse spoke to NP. New order given for cervical spine X-ray. Observation and interview on 10/31/17 at 1:52 pm revealed Resident #7 had facial grimacing and moaning. Resident #7 only spoke Spanish. He kept pointing to his head and ears and repeatedly stating medicino, cervesa and dolor. LVN #16 entered the room after the surveyor pressed the call light for Resident #7. LVN #16 revealed Resident #7 had a fall on 10/29/17. LVN #16 reported the doctor was notified of the resident's fall and ordered an X-ray of the cervical spine. She revealed the X-ray was taken but the results had not returned at this time. Further review of Resident #7's Nurses Progress Notes revealed on 10/31/17 at 2:37 pm, LVN #16 documented (Resident #7) Complains of pain in the head. Call in place to NP and left voice mail message. Cervical spine x-ray pending results. Reported to evening shift nurse. Observation and interview on 11/1/17 at 8:50 am revealed Resident #7 was not in his room. Interview with the DON at the same time revealed Resident #7 was sent to the ER for evaluation of head and neck pain. Record review of Resident #7's medical record revealed a Patient Transfer form dated 11/1/17 which documented Resident fell on [DATE] complains of neck and back of head hurting. MD request to R/O bleed or fx. During an interview on 11/1/17 at 10:45am, DON called the radiology clinic and requested x-ray results for Resident #7. Record review of Resident #7's radiology report indicated the x-ray was completed on 10/29/17 at 4:58 pm. Findings of x-ray revealed the small anterior osteophyte and the small marginal osteophyte's are present. The prevertebral soft tissues are unremarkable. The report noted radiology company notified LVN #30 on 10/29/17 at 6:18 pm. Record review of Resident #7's Nurses Progress Note on 11/1/17 at 4:00 pm revealed Resident #7 returned to the facility. Dx: C2 fracture. Report received from (local hospital). Resident is to wear a Miami J collar at all times until reevaluated by spinal surgical team. CXR and Brain CT normal from (local hospital). Observation on 11/1/17 at 5:56 pm revealed Resident #7 was lying in bed flat with a cervical collar on asleep. Observation and interview on 11/2/17 at 9:08 am revealed Resident #7 was awake and laying flat in bed on his back. Resident was wearing a cervical collar. With facial grimacing, Resident #7 stated dolor, medicino, cervesa and was pointing to his head and ears. Resident's call light was wrapped around the left side of his bed rail and hanging down over the edge out of his reach. Interview on 11/2/17 at 9:11 am, LVN #16 stated Resident #7 returned from the hospital with a cervical collar on. She stated the nursing facility was still waiting on the x-ray from 10/29/17. Interview with DON on 11/2/17 at 12:20 pm revealed if a resident had a change of status the physician and family should be notified immediately. If a change of status was noted the resident should be sent to the ER for an evaluation. Record review of the facility's Fall- Clinical Protocol: Treatment/ Management policy dated April 2007, revealed the following: Monitoring: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The facility census revealed 27 residents resided on Hall 400.

Based on interview and record review, the facility failed to ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation for one (CR #1) of thirteen residents reviewed for abuse, in that: The facility failed to provide adequate supervision and assistance to CR #1 while providing incontinent care, resulting in a fall and a laceration to the head. This failure affected one discharged resident and placed 7 residents who were dependent on staff members for transfers at risk for injury. Findings include: Record review of CR #1's face sheet revealed she was a [AGE] year-old woman who was admitted to the facility on [DATE] and readmitted on [DATE]. CR #1's [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Fibrillation, Cerebral Infarction, [MEDICAL CONDITION] and Dysphagia. Record review of CR #1's MDS dated [DATE] indicated CR #1 had severe cognitive impairment and required extensive assistance from two staff members for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Further review revealed CR #1's was always incontinent of bowel and bladder, exhibited no behavioral symptoms, and had no falls since admission. Record review of CR #1's Care Plan dated 8/7/17 indicated CR #1 required 1-2 staff for bed mobility, personal hygiene and transfers. Record review of CR #1's Fall Risk Assessment completed on 10/12/17 revealed CR #1 had no falls in the last 6 months. Further review of the same record revealed CR #1 was unable to independently come to a standing position, was confined to a chair, and was disoriented. Record review of CR #1's Fall Investigation completed on 10/12/17 at 3:30 pm by LVN #21 indicated the following information: 9a.- CNA was changing CR #1 9b.- and requires supervision. 34a.- checked no for safety intervention in use at the time of incident. Record review of the facility Provider Investigation Report signed 10/20/17 by Administrator indicated on 10/12/17 at 7:25 am CR #1 rolled and head hit nightstand. by CNA #31. The report indicated CNA #31 was providing incontinent care to CR #1 and needed to obtain another pad for the bed. CNA #31 turned away from the bed while the resident was still positioned on her side. As CNA #31 turned back towards the bed she saw CR #1 roll over and hit her head on the bedside table. CNA #31 stated she was able to stop the resident from hitting the floor. CNA #31 called for charge nurse. Charge nurse assessed CR #1 and notified MD, RP and then called 911 to evaluate the laceration. The investigation findings were unfounded by the nursing facility. Record review of CNA #31's written statement of the incident with CR #1 indicated CNA #31 had positioned CR #1 on her side, she turned away to reach for a pad. CNA #31 turned back and CR #1 was going towards the nightstand that was sitting directly beside the bed. CNA #31 explained Her body, half of it starting to fall out the bed, her legs so I ran to catch most of her body as much as I could. CNA #31 continued to report that she stayed with CR #1 and cleaned her urine and feces up. Then I went to report to the nurse. Record review of CR #1's Progress Note (late entry) for 10/12/17 at 7:51pm written by LVN #21 revealed CR #1 was lying supine in bed. Accompanied by nurse aide. Blood noted on the mattress of the patient. CR #1 had a laceration of undetermined size to the back of her head resulting in a fall and hitting the corner of the dresser on the right side of bed. One assisted back into bed. Interview on 11/1/17 at 3:55 pm, DON stated CR #1 was on an air mattress. She indicated she has talked with her CNA's about being more cautious with changing residents with an air mattress. Surveyor questioned DON if CR #1 had a neuro check initiated. DON explained neuro check was not initiated due to 911 was called and sent out immediately. Interview on 11/2/17 at 9:56 am, CNA #37 indicated if a resident is easier to shift around; one CNA can assist with bed mobility for the resident. If a resident is unable to move or is contracted she would use two CNA's for bed mobility. Interview on 11/2/17 at 10:03 am, CNA #26 revealed bed mobility for residents is identified in the plan of care, 24 hour book, and continent/ incontinent documentation. Interview on 11/2/17 at 11:20 am, CNA #29 was asked how they would identify a resident who needed 2 CNA's for bed mobility and transfers versus one CNA. CNA #29 revealed the use of a Hoyer lift would require 2 CNA's or if a resident was heavier, then 2 CNA's would also be required. Record review of the facility Fall Prevention/ Investigation in-service training report on 10/13/17 at 4:30 pm was completed for 13 CNA's including CNA #31. The training included the following: fall prevention/ investigation, ADL care, all staff are responsible for fall precautions are in place. ADL care must be performed every 2 hours and as needed. Staff must ensure that residents care plan is being followed for mobility and ADL care (EX: 1 person, 2 person, ETC .). All falls/ incidences must be reported to the charge nurse immediately. Record review of the facility Falls- Clinical Protocol policy revised April 2007 revealed the following: Assessment and Recognition: #3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Section A. Risk factors for subsequent falling include . gait and balance disorders, cognitive impairment, weakness, confusion The facility CMS form 672 dated 10/31/17 revealed 7 residents dependent on staff members for transfers.

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment, and plan of care for one (Resident #7) of thirteen residents reviewed for quality of care and pain management, in that: The facility failed to immediately consult with Resident #7's physician with the radiology results or a change of status due to head and neck pain after a fall. The facility failed to provide timely intervention and treatment for [REDACTED]. The facility failed to monitor Resident #7 for pain after a fall and did not administer pain medication as needed for pain. The facility failed to provide the necessary care or follow through with physician orders [REDACTED]. These failures affected one resident placed 44 residents who are totally dependent on staff for ADL care at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #7 Record review of Resident #7's face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] revealed he had a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed Resident #7 required extensive assistance for transfers, locomotion, dressing, toileting and personal hygiene with the assistance of one staff. Resident #7's MDS indicated he received scheduled pain medication, but did not have concerns of presence of pain. Resident #7's MDS revealed no documentation of falls at the time of the assessment. Record review of Resident #7's Care plan initiated on 5/15/17 revealed Resident #7 required one staff member with participation for ADL's. Resident #7's care plan also indicated he would verbalize adequate relief of pain or ability to cope with incompletely relieved pain by: -Anticipating his need for pain relief and respond immediately to any complaint of pain. -Assist with ADL's as need related to pain. -Monitor/ record pain characteristics: quality; Severity (1-10 scale); anatomical location; onset; duration; aggravating factors; relieving factors. -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. -Observe/ record/ report to nurse any signs or symptoms of non-verbal pain. Record review of Resident #7's consolidated physician orders [REDACTED]. Resident #7 had a care plan updated 10/17/17 for potential for pressure ulcer development related to decreased independence with mobility and incontinence. With an intervention to: Obtain and monitor lab/ diagnostic work as ordered. Report result to MD and follow up as indicated. He also had interventions for brief use and change PRN. Record review of Resident #7 Nurse's Progress Notes entered by LVN #30 on 10/29/17 at 10:47 p.m. revealed Resident #7 had fallen and initial fall protocol was initiated to include: notifying family, calling the physician, writing a verbal order for a cervical spine x-ray, and giving pain medications. Record review of Resident #7's physician orders [REDACTED].#30 on 10/29/17 at 1:28 p.m. for a cervical spine x-ray. Record review of the facility Incident Report dated 10/29/17 for Resident #7's fall indicated the time of the fall was at 1:00 p.m. Further review revealed Resident #7 fell forward out of his wheelchair onto his knees and stomach. Record review of Resident #7 Radiology report revealed on 10/29/17 a cervical spine x-ray was completed at 4:47 p.m. Impression of X-ray indicated a limited view due to shoulder artifact. If clinically concerned, follow-up was recommended. There were small anterior osteophyte (bone spur) and the small marginal osteophyte's present. This report was called back to the nursing facility on 10/29/17 at 6:18 p.m. to LVN #30. Record review of Resident #7's Nurse's Progress Notes revealed no documentation of the x-ray results called in to LVN #30 on 10/29/17. Record review of Resident #7's Nurse's Progress Notes revealed LVN #16 documented on 10/31/17 at 2:37 p.m. that Resident #7 was on post fall day 2 and complained of pain in his head. Nurse attempted to notify the NP; a message was left. She indicated the cervical spine x-ray was pending. Further review revealed LVN #16 reported this information to the evening shift nurse. Record review of Resident #7's Medication Administration Record [REDACTED]. He also had an order for [REDACTED]. Observation and interview on 10/31/17 at 1:52 p.m. revealed Resident #7 had signs and symptoms of pain as evidenced by facial grimacing, pointing to his head and neck and stating cerveza, medicino, dolor repeatedly. Resident only spoke Spanish. Resident had spilled a moderate amount of liquid onto his linens and the tray that was on his bedside table. The nurse was called into the Resident #7's room. LVN #16 came into the room and reported to surveyor Resident #7 had fallen on 10/29/17 and a cervical spine x-ray had been ordered but the results had not returned yet. During the same observation and interview, the Activity Director was called into the room to translate the conversation with Resident #7 in Spanish. She was able to translate to LVN #16 his report of having pain for 2 days. Resident #7 was repositioned by staff for comfort and his incontinence brief was change. His brief was heavily saturated and soiled. He was unable to identify when his last brief change was. Resident #7 did not have a fall mat present and was not wearing a wander guard. His bed was not at the lowest positon. Observation and interview on 10/31/17 at 3:20 p.m. revealed Resident #7 was lying in bed awake but had a sad expression on his face. A state interpreter was called to assist with communication with the resident. The interpreter revealed that Resident #7 stated Let him be, he's had a good life. Record review of Resident #7's Nurses Progress Notes entered by LVN #24 on 10/31/17 at 5:45 p.m. revealed Resident #7 complained of head hurting at the posterior portion of head along with back of his neck. The physician was notified and orders were given to send to ER for evaluation. Record review of Resident #7's Nurse's Progress Notes entered by LVN #24 on 11/1/17 at 4:00 p.m. revealed Resident #7 returned to the facility with a [DIAGNOSES REDACTED]. Resident wearing Miami J collar at all times until reevaluated by spinal surgical team. Observation on 11/1/17 at 5:46 p.m. revealed Resident #7 was lying flat in bed asleep with a C-Collar on. Resident did not have a fall mat present and was not wearing a wander guard. His bed was not at the lowest positon. Observation on 11/2/17 at 9:08 a.m. revealed Resident #7 was flat in bed with a cervical collar on, he was alert and awake. Resident #7 verbalized cerveza, medicino, dolor and was pointing to his head and ears. Resident did not have a fall mat, or wander guard. His bed was not at the lowest positon. Record review of Resident #7's consolidated physician's orders [REDACTED]. During an interview on 11/1/17 at 12:33 p.m., DON revealed nurses should do a follow-up x 3 days after a resident falls and remains at the facility. Nurses should chart this information in the progress notes. During an interview on 11/2/17 at 9:11 a.m., LVN #16 revealed the resident returned from the hospital with a C-Collar on and she had reported to the CNA's to check on him frequently to make sure he did not take it off. Surveyor questioned LVN #16 if she gave Resident #7 pain medication on 10/31/17 after he reported pain in his head and neck. She stated she did not give him pain medication, it was shift change and she reported to the next shift nurse regarding Resident #7's pain. Record review of the Facilities Falls Clinical Protocol revised April 2007 revealed the following: Treatment/ Management 1. Based on preceding assessment, staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-up 1. The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. The facility CMS 672 form revealed 37 residents on pain management programs.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents, for one (CR #1) of thirteen residents reviewed for accidents, in that: The facility failed to provide adequate supervision and assistance to CR #1 while providing incontinent care, resulting in a fall and a laceration to the head. This failure affected one discharged resident and placed 7 residents who were dependent on staff members for transfers at risk for injury. Findings include: Record review of CR #1's face sheet revealed she was a [AGE] year-old woman who was admitted to the facility on [DATE] and readmitted on [DATE]. CR #1's [DIAGNOSES REDACTED]., Seizures, Hypertension, Atrial Fibrillation, Cerebral Infarction, Chronic Obstructive Pulmonary Disease and Dysphagia. Record review of CR #1's MDS dated [DATE] indicated CR #1 had severe cognitive impairment and required extensive assistance from two staff members for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Further review revealed CR #1's was always incontinent of bowel and bladder, exhibited no behavioral symptoms, and had no falls since admission. Record review of CR #1's Care Plan dated 8/7/17 indicated CR #1 required 1-2 staff for bed mobility, personal hygiene and transfers. Record review of CR #1's Fall Risk Assessment completed on 10/12/17 revealed CR #1 had no falls in the last 6 months. Further review of the same record revealed CR #1 was unable to independently come to a standing position, was confined to a chair, and was disoriented. Record review of CR #1's Fall Investigation completed on 10/12/17 at 3:30 pm by LVN #21 indicated the following information: 9a.- CNA was changing CR #1 9b.- and requires supervision. 34a.- checked no for safety intervention in use at the time of incident. Record review of the facility Provider Investigation Report signed 10/20/17 by Administrator indicated on 10/12/17 at 7:25 am CR #1 rolled and head hit nightstand. by CNA #31. The report indicated CNA #31 was providing incontinent care to CR #1 and needed to obtain another pad for the bed. CNA #31 turned away from the bed while the resident was still positioned on her side. As CNA #31 turned back towards the bed she saw CR #1 roll over and hit her head on the bedside table. CNA #31 stated she was able to stop the resident from hitting the floor. CNA #31 called for charge nurse. Charge nurse assessed CR #1 and notified MD, RP and then called 911 to evaluate the laceration. The investigation findings were unfounded by the nursing facility. Record review of CNA #31's written statement of the incident with CR #1 indicated CNA #31 had positioned CR #1 on her side, she turned away to reach for a pad. CNA #31 turned back and CR #1 was going towards the nightstand that was sitting directly beside the bed. CNA #31 explained Her body, half of it starting to fall out the bed, her legs so I ran to catch most of her body as much as I could. CNA #31 continued to report that she stayed with CR #1 and cleaned her urine and feces up. Then I went to report to the nurse. Record review of CR #1's Progress Note (late entry) for 10/12/17 at 7:51pm written by LVN #21 revealed CR #1 was lying supine in bed. Accompanied by nurse aide. Blood noted on the mattress of the patient. CR #1 had a laceration of undetermined size to the back of her head resulting in a fall and hitting the corner of the dresser on the right side of bed. One assisted back into bed. Interview on 11/1/17 at 3:55 pm, DON stated CR #1 was on an air mattress. She indicated she has talked with her CNA's about being more cautious with changing residents with an air mattress. Surveyor questioned DON if CR #1 had a neuro check initiated. DON explained neuro check was not initiated due to 911 was called and sent out immediately. Interview on 11/2/17 at 9:56 am, CNA #37 indicated if a resident is easier to shift around; one CNA can assist with bed mobility for the resident. If a resident is unable to move or is contracted she would use two CNA's for bed mobility. Interview on 11/2/17 at 10:03 am, CNA #26 revealed bed mobility for residents is identified in the plan of care, 24 hour book, and continent/ incontinent documentation. Interview on 11/2/17 at 11:20 am, CNA #29 was asked how they would identify a resident who needed 2 CNA's for bed mobility and transfers versus one CNA. CNA #29 revealed the use of a Hoyer lift would require 2 CNA's or if a resident was heavier, then 2 CNA's would also be required. Record review of the facility Fall Prevention/ Investigation in-service training report on 10/13/17 at 4:30 pm was completed for 13 CNA's including CNA #31. The training included the following: fall prevention/ investigation, ADL care, all staff are responsible for fall precautions are in place. ADL care must be performed every 2 hours and as needed. Staff must ensure that residents care plan is being followed for mobility and ADL care (EX: 1 person, 2 person, ETC .). All falls/ incidences must be reported to the charge nurse immediately. Record review of the facility Falls- Clinical Protocol policy revised April 2007 revealed the following: Assessment and Recognition: #3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Section A. Risk factors for subsequent falling include . gait and balance disorders, cognitive impairment, weakness, confusion The facility CMS form 672 dated 10/31/17 revealed 7 residents dependent on staff members for transfers.

Based on observation, interview and record review, fhe facility failed to consult with the physician when there was a significant change in the residents physical, mental or psychosocial status for 1 (resident #7) of 13 residents reviewed for change in condition, in that: The facility failed to immediately consult with Resident #7's physician with the radiology results or a change of status due to head and neck pain after a fall. X-ray results indicated that Resident #7 sustained a cervical fracture. Resident #7 made repeated complaints of ongoing pain for 2 days before the physician was consulted and he was sent to the local hospital. These failures affected one resident placed 44 residents who are totally dependent on ADL care at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #7 Record review of Resident #7's face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] revealed he had a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed Resident #7 required extensive assistance for transfers, locomotion, dressing, toileting and personal hygiene with the assistance of one staff. Resident #7's MDS indicated he received scheduled pain medication, but did not have concerns of presence of pain. Resident #7's MDS revealed no documentation of falls at the time of the assessment. Record review of Resident #7's Care plan initiated on 5/15/17 revealed Resident #7 required one staff member with participation for ADL's. Resident #7's care plan also indicated he would verbalize adequate relief of pain or ability to cope with incompletely relieved pain by: -Anticipating his need for pain relief and respond immediately to any complaint of pain. -Assist with ADL's as need related to pain. -Monitor/ record pain characteristics: quality; Severity (1-10 scale); anatomical location; onset; duration; aggravating factors; relieving factors. -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. -Observe/ record/ report to nurse any signs or symptoms of non-verbal pain. Record review of Resident #7's consolidated physician orders [REDACTED]. Resident #7 had a care plan updated 10/17/17 for potential for pressure ulcer development related to decreased independence with mobility and incontinence. With an intervention to: Obtain and monitor lab/ diagnostic work as ordered. Report result to MD and follow up as indicated. He also had interventions for brief use and change PRN. Record review of Resident #7 Nurse's Progress Notes entered by LVN #30 on 10/29/17 at 10:47 p.m. revealed Resident #7 had fallen and initial fall protocol was initiated to include: notifying family, calling the physician, writing a verbal order for a cervical spine x-ray, and giving pain medications. Record review of Resident #7's physician orders [REDACTED].#30 on 10/29/17 at 1:28 p.m. for a cervical spine x-ray. Record review of the facility Incident Report dated 10/29/17 for Resident #7's fall indicated the time of the fall was at 1:00 p.m. Further review revealed Resident #7 fell forward out of his wheelchair onto his knees and stomach. Record review of Resident #7 Radiology report revealed on 10/29/17 a cervical spine x-ray was completed at 4:47 p.m. Impression of X-ray indicated a limited view due to shoulder artifact. If clinically concerned, follow-up was recommended. There were small anterior osteophyte (bone spur) and the small marginal osteophyte's present. This report was called back to the nursing facility on 10/29/17 at 6:18 p.m. to LVN #30. Record review of Resident #7's Nurse's Progress Notes revealed no documentation of the x-ray results called in to LVN #30 on 10/29/17. Record review of Resident #7's Nurse's Progress Notes revealed LVN #16 documented on 10/31/17 at 2:37 p.m. that Resident #7 was on post fall day 2 and complained of pain in his head. Nurse attempted to notify the NP; a message was left. She indicated the cervical spine x-ray was pending. Further review revealed LVN #16 reported this information to the evening shift nurse. Record review of Resident #7's Medication Administration Record [REDACTED]. He also had an order for [REDACTED]. Observation and interview on 10/31/17 at 1:52 p.m. revealed Resident #7 had signs and symptoms of pain as evidenced by facial grimacing, pointing to his head and neck and stating cerveza, medicino, dolor repeatedly. Resident only spoke Spanish. Resident had spilled a moderate amount of liquid onto his linens and the tray that was on his bedside table. The nurse was called into the Resident #7's room. LVN #16 came into the room and reported to surveyor Resident #7 had fallen on 10/29/17 and a cervical spine x-ray had been ordered but the results had not returned yet. During the same observation and interview, the Activity Director was called into the room to translate the conversation with Resident #7 in Spanish. She was able to translate to LVN #16 his report of having pain for 2 days. Resident #7 was repositioned by staff for comfort and his incontinence brief was change. His brief was heavily saturated and soiled. He was unable to identify when his last brief change was. Resident #7 did not have a fall mat present and was not wearing a wander guard. His bed was not at the lowest positon. Observation and interview on 10/31/17 at 3:20 p.m. revealed Resident #7 was lying in bed awake but had a sad expression on his face. A state interpreter was called to assist with communication with the resident. The interpreter revealed that Resident #7 stated Let him be, he's had a good life. Record review of Resident #7's Nurses Progress Notes entered by LVN #24 on 10/31/17 at 5:45 p.m. revealed Resident #7 complained of head hurting at the posterior portion of head along with back of his neck. The physician was notified and orders were given to send to ER for evaluation. Record review of Resident #7's Nurse's Progress Notes entered by LVN #24 on 11/1/17 at 4:00 p.m. revealed Resident #7 returned to the facility with a [DIAGNOSES REDACTED]. Resident wearing Miami J collar at all times until reevaluated by spinal surgical team. Observation on 11/1/17 at 5:46 p.m. revealed Resident #7 was lying flat in bed asleep with a C-Collar on. Resident did not have a fall mat present and was not wearing a wander guard. His bed was not at the lowest positon. Observation on 11/2/17 at 9:08 a.m. revealed Resident #7 was flat in bed with a cervical collar on, he was alert and awake. Resident #7 verbalized cerveza, medicino, dolor and was pointing to his head and ears. Resident did not have a fall mat, or wander guard. His bed was not at the lowest positon. Record review of Resident #7's consolidated physician's orders [REDACTED]. During an interview on 11/1/17 at 12:33 p.m., DON revealed nurses should do a follow-up x 3 days after a resident falls and remains at the facility. Nurses should chart this information in the progress notes. During an interview on 11/2/17 at 9:11 a.m., LVN #16 revealed the resident returned from the hospital with a C-Collar on and she had reported to the CNA's to check on him frequently to make sure he did not take it off. Surveyor questioned LVN #16 if she gave Resident #7 pain medication on 10/31/17 after he reported pain in his head and neck. She stated she did not give him pain medication, it was shift change and she reported to the next shift nurse regarding Resident #7's pain. Record review of the Facilities Falls Clinical Protocol revised April 2007 revealed the following: Treatment/ Management 1. Based on preceding assessment, staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-up 1. The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. The facility CMS 672 form revealed 37 residents on pain management programs.

Based on observation, interview, and record review, the facility failed to ensure one of nine residents (Resident #12) reviewed for falls was properly supervised to prevent further falls from occurring. The facility failed to ensure one of four resident halls (Hall 200), two of two shower rooms (Hall 100/200 and 300/400), and the beauty shop were free of hazard materials. Resident #12 fell out of her wheelchair on 10/9/15 and 10/10/15 and sustained a injury of a laceration to her forehead that required hospitalization and stitches. Hall 200 had hazardous items being stored on the hallway including: plungers, Lysol spray, and tightly wrapped call lights. Shower rooms located on Hall 100/200 and 300/400 were both unlocked and had hazardous materials including: razors, shampoo, and deodorants. Beauty Shop was unlocked and had hazardous materials including: chemicals. These failures affected one resident who had a fall and placed 87 residents at risk of injuries related to falls and placed six residents who wander at risk of ingesting hazardous materials. Findings include: Intake # 8 and # 9 Resident #12 Record review of the face sheet revealed that Resident #12 was an [AGE] year old woman, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 1 indicating she had severely impaired cognitive skills. She had 2 falls without injury since admission. Record review of the Resident #12's Fall Care Plan dated 10/12/15 revealed she was at risk for falls and had actual falls on the following dates (approaches added as a result of the fall are included in the subsequent parentheses): -10/8/14 -11/15/14 (the resident needs activities that minimize the potential for falls while providing diversion and distraction). -11/16/14 -11/26/14 (ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, the resident uses bed/chair alarm ensure the device is in place as needed) -12/12/14 -12/15/14 (referred to therapy) -12/18/14 (reminded to ask for assistance, medication regimen review, remind resident to ask for assistance when needed instead of getting up and walking around without assistance, anticipate and meet the resident's needs) -1/14/15 (referred to therapy, reminded to ask for assistance, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, physical therapy as ordered, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, the resident uses bed/chair alarm ensure the device is in place as needed) -3/4/15 (anticipate and meet the resident's needs, the resident uses bed/chair alarm ensure the device is in place as needed) -4/17/15 (be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, physical therapy as ordered, remind resident to ask for assistance when needed instead of getting up and walking around without assistance, anticipate and meet the resident's needs, the resident uses bed/chair alarm ensure the device is in place as needed) -4/25/15 (encourage the resident to participate in activities that promote exercise, physical activity for strengthening and mobility, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, medication regimen review, physical therapy as ordered, remind resident to ask for assistance when needed instead of getting up and walking around without assistance, anticipate and meet the resident's needs, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, the resident uses bed/chair alarm ensure the device is in place as needed, review information on past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible, educate everyone as to causes) -5/3/15 (be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, medication regimen review, physical therapy as ordered, remind resident to ask for assistance when needed instead of getting up and walking around without assistance, anticipate and meet the resident's needs, the resident uses bed/chair alarm ensure the device is in place as needed) -7/10/15 (staff to monitor resident while transporting her in wheelchair to help prevent her from sliding, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, the resident uses bed/chair alarm ensure the device is in place as needed) - 8/19/15, -10/9/15 -10/10/15 (drop wheelchair seat in the back, bed in low position, floor mat to be placed at the side of bed while patient is in bed, increase activity in involvement and physical therapy evaluation, put resident to bed after each meal). No new interventions were implemented after the fall on 8/19/15. Record review of Resident #12's Care Plan revealed she had a history of [REDACTED]. Record review of Resident #12's hospital records revealed she was admitted to the hospital on [DATE] and was treated for [REDACTED]. Observation on 10/15/15 at 10:00 AM revealed Resident #12 was observed in the Activity room. She was sitting in her wheelchair and was leaning on a table, looking at a magazine. She was alert but not fully oriented as she was confused about the date and time. She was neat and well groomed and had a dressing on her forehead which when removed by LVN #5, revealed a 3 cm laceration with sutures. She had a chair alarm on her wheelchair. In an interview and observation on 0/15/15 at 10:00 AM, Resident #12 stated she got the laceration from a fall in the facility. She stated that she fell in her room in the middle of the night while trying to get up to get a drink of water. When asked if she used the call light, she stated that she had not. She stated she was instructed by staff not to get up. She said when you tell someone not to do a particular thing that's just what the person wants to do it. It does not appear from all other accounts that the resident fell in her room. Observation of the resident's room on 10/15/15 at 10:25 AM revealed that she had a low bed and a fall mat by the side of the bed. Interview on 10/15/15 at 10:10 AM, LVN #5 stated that she was aware that Resident #12 fell twice, first on 10/9/15 and again on 10/10/15. She stated neither fall occurred in the resident's room. She stated the fall on 10/10/15 was while the resident was at the nurses' station about 9:00 AM and that it was from the fall that the resident sustained [REDACTED]. Interview on 10/15/15 at 1:00 PM the DON stated she was in the facility on Saturday 10/10/15 when Resident #12 fell . She stated about 9:00 AM, Resident #12 was observed sitting near the nurses' station, near the corner. She stated after she passed the station, she heard some noise and when she turned back, she saw the resident on the floor. She stated Resident #12 was bleeding from the forehead, was immediately assessed and then sent to the hospital for treatment. The DON stated that the resident had fallen the previous night on 10/9/15 when she slid out of the wheelchair while a CNA was wheeling her on the hall way. She stated Resident #12 did not sustain any injury from the fall on 10/9/15. She stated that the fall on 10/10/15 was also as a result of resident sliding out of the wheelchair. Interview on 10/16/15 at 2:20 PM, LVN #7 stated on 10/10/15, she was inside the medication room when he heard a chair alarm go off. She said that when she came out of the medication room, Resident #12 was lying on the floor next to her wheelchair. She said resident was bleeding from a 2.5 cm laceration on the forehead and that she applied pressure to stop the bleeding. She said Resident #12 was assessed and the physician ordered her to be sent to the ER (emergency room ). She stated also that Resident #12's family member was visiting at the time and was informed. Resident #12 was sent to the ER, accompanied by the family member. When asked if any staff was in the nurses' station at the time, she stated that she did not immediately observe another staff, but that as she bent down to help the resident on the floor, one CNA also came up to help before more people attracted by the noise started showing up. She said DON was present at the facility and was informed of the incident. Record review of the facility's incident report for Resident #12 revealed that the resident fell on [DATE] at 8:45 p.m. and 10/10/15 at 9:46 a.m. Further review revealed: 10/9/15-- read Resident was leaning forward in the w/c. CNA approached resident and resident continued to lean forward. Resident was assisted to floor by CNA. The physician and family were informed and that resident was not sent to the hospital after assessment. 10/10/15-- read The nurse came out of the medication room and observed resident on the floor at nursing station, next to her wheelchair. Resident unable to give (sic) observed bleeding from 2.5 cm laceration at the forehead. Applied pressure dressing. The report revealed that resident left the facility at 11:00 a.m. with 2 EMS and family. Hall 200 Observations on 10/13/15 between 9:15 AM and 10:30 AM revealed: Room 202--one can of Lysol spray on the floor next to the toilet. It read keep out of the reach of children. Room 210--Call light was wrapped tightly around the bathroom grab-bar that could not be pulled. A sign posted next to the call light read Pull call light for help . Room 209--had a plunger next to the toilet. Shower Rooms Observations on 10/14/15 between 1:50 and 2:05 PM revealed the Resident Spa rooms located on hall 100/200 and hall 300/400 were unlocked with unlocked cabinets containing personal hygiene products including razors, shampoos, and deodorants. Beauty Shop Observations on 10/14/15 between 1:50 and 2:05 PM revealed inside the Beauty Shop located on hall 200 was unlocked with cabinets containing hair care products including chemicals. The chemicals read keep out of the reach of children. Interview on 10/13/15 at 10:30 AM, the Maintenance Director stated the keep out of reach items should be locked up and kept away from the residents. He further stated plungers were not allowed to be kept in resident's rooms and for any staff member to remove them immediately. He stated call lights should not be wrapped because it could cause a delay in help and having it wrapped made it more difficult to pull the cord for help. A policy addressing storage of hazardous materials was requested, but was not provided prior to exit. The DON identified six residents who had behaviors of wandering.

Based on interviews and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one of 10 Residents (CR #2) reviewed for swallowing. The speech therapist did not recommend a swallow test for CR #2 who was admitted with [DIAGNOSES REDACTED]. He died 2 days after being readmitted to the facility after a hospital stay. CR #2 was readmitted to the facility under Hospice care after being treated in the hospital for aspiration pneumonia and died in the facility two days later. This failure affected one resident who died and placed 13 current residents, identified with swallowing problems at risk for choking, aspiration, decreased oral intake, and death. Findings include: Complaint # 1 CR #2 Record review of CR #2's face sheet revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of CR #2's previous facility physician's orders [REDACTED]. CR #2's previous diet order was regular diet with mechanical soft texture, thin liquids consistency, and no pork. It further read may have thin liquids per signed waiver. Record review of CR #2's Admission Worksheet, dated [DATE], revealed an admitting [DIAGNOSES REDACTED]. Record review of CR #2's Dietitian's report to Attending Physician, dated [DATE], revealed a nutritional assessment was performed for CR #2. Recommendations were to add med-plus (supplement) three times a day and change diet to mechanical soft, RCS, and no pork, beef or chicken. The report was signed by the attending physician with the 'agree with recommendations' box checked. Record review of CR #2's physician's orders [REDACTED].#2's [DIAGNOSES REDACTED]. Record review of CR #2's Consent for Treatment, dated [DATE], revealed a signed consent for treatment, that included 'physical therapy, occupational therapy, and speech/swallow therapy (possibly including a modified [MEDICATION NAME] swallow test)'. There was no evidence of a modified [MEDICATION NAME] swallow test ordered. Record review of CR #2's quarterly MDS dated [DATE] revealed he had a BIMS score of 8 indicating he had moderately cognitive impairment. He reuqqired limited assistance from one person for all of his activities of daily living. He had a mechanically altered diet. Record review of CR #2's Care Plan, dated [DATE], revealed that he was at risk for coughing/choking when lying down, regurgitation, swallowing problems, dysphagia, and increased gag response. Interventions were: 'Avoid lying down for at least 1 hour after eating. Keep HOB elevated. Encourage to stand/sit after meals. Date Initiated: [DATE]' Record review of CR #2's Medical Chart, revealed no evidence of a signed waiver by the resident or his legal representative to allow him to have thin liquids. Further review revealed no evidence of a [MEDICATION NAME] Swallow Study being conducted prior to his hospitalization on [DATE]. Record review of CR #2's speech therapy notes reviewed his treatment plans focused on language (symbolic function), not on swallowing issues. Interview on [DATE] at 11:40 AM, the Speech Therapist (ST) stated she screened each new admission to determine the need for a complete evaluation for physical therapy, occupational therapy, speech language therapy, and dysphagia, but was not aware of a specific policy for evaluation. When asked what criteria she used to warrant a swallow evaluation, the speech therapist replied: a [DIAGNOSES REDACTED]. Interview on [DATE] at 1:00 PM, the ST further stated CR #2 had received speech language therapy and was discharged from therapy for non-compliance. She stated CR#2 was, . set in his ways and refused to engage in therapy. She stated an evaluation for dysphagia/swallowing problems was not indicated for CR #2. She stated she reviewed CR #2's medical record prior to assessing him. She further stated that she was not aware of any swallowing issues or aspirations risks concerning CR #2 until she was questioned by his family member after his death. Interview on [DATE] at 2:00 PM, the DON stated that the initial assessment was conducted within 72 hours of admission and was a multidisciplinary team effort. She stated that she would expect a swallow evaluation to be conducted on any new admission with a [DIAGNOSES REDACTED]. Record review of CR #2's Progress Note, dated [DATE] at 10:22 PM, revealed CR #2 was found cyanotic, blue nail bed, and blue around the mouth. Physician was notified and requested that CR #2 be sent to hospital by ambulance. Record review of CR #2's Hospital Progress note, dated [DATE] revealed CR #2 was diagnosed with [REDACTED]. Record review of CR #2's Progress Notes, dated [DATE] at 11:20 PM, revealed Resident CR #2 was readmitted to the facility under hospice services. Record review of CR #2's Activity Note progress note, dated [DATE] at 11:35 PM revealed Resident CR #2 was declared dead. The DON identified 13 residents who had dysphagia and swallowing problems.

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practicable and physical and mental well-being for 3 of 4 Residents reviewed for care and management of indwelling catheter care (Resident #1, # 2 and # 3) as evidenced by; -Resident #1 had an indwelling urinary catheter, had penile erosion and Bacteriuria. When he arrived at the hospital emergency on 10/19/13 for evaluation and treatment the penile head and shaft had a long, linear open swollen area from the penile head to the base of the penile shaft with the urethral catheter exposed on the open skin area at the top and base of the penile shaft and covered by skin only at the mid shaft region. The nursing facility did not have evidence of assessments, treatments or physician order [REDACTED]. -Resident#2 had an indwelling urinary catheter inserted on 10/18/13 and the catheter tubing was freely hanging down the side of the bed unsecured. -Resident #3 had an indwelling urinary catheter and the indwelling catheter was hanging freely down the side of the bed and not secured. The failures to secure catheters, assess and document treatments, caused harm of penile erosion and urinary infection to 1 Resident and placed 3 Residents at risk for obstruction of urinary flow, infection, pain, urethral trauma and erosion. Complaint # 8 The findings include: Resident# 1 Record review of the facility face sheet for Resident #1 revealed a [AGE] year old male who was admitted to facility on 08/21/12. His [DIAGNOSES REDACTED]. Resident was admitted to hospital on [DATE] for evaluation and treatment of [REDACTED]. Record review of the Nurse Practitioner's assessment dated [DATE] for Resident #1 included male [MEDICAL CONDITION] assessment revealed no masses, no [DIAGNOSES REDACTED] (redness) to meatus of penis, no scrotal swelling or tenderness. No [MEDICAL CONDITION] noted on inspection/ palpation (touch). Record review of the facility's admission evaluation and interim care plan dated 06/20/13 for Resident #1 revealed admission [DIAGNOSES REDACTED]. Resident#1's behavior was assessed as no obvious problem. The assessment of skin condition revealed Braden score of 15 (at risk of skin breakdown). Both legs were contracted, both arms were bruised, his left foot had a red area, there was an old blister on his left thigh, a rash on his groin area, a wound on his right hip with stitches, an old healing wound on his right hip, an old bone scar on his right leg and a rash on his left side. He was incontinent of bowel and bladder and had an indwelling urinary catheter. Record review of the RCP dated 6/28/13 for Resident #1 revealed he had an indwelling urinary catheter related to surgical flap wound on right iliac crest-to help prevent contamination. The goal was that he would remain free from catheter related trauma through review date of 11/11/13. The interventions included: check tubing for kinks each shift, observe/document pain/discomfort due to catheter, observe/record/report to physician for signs/symptoms of UTI, pain, blood tinged ...altered mental state, change in behavior. Record review of the nurse notes dated from 04/30/13 to 10/19/13 for Resident #1 revealed the only evidence related to indwelling urinary catheter were documented on; -08/02/13 at 8:00 p.m. indwelling urinary catheter was patent to flow, resident had right hip decubitus, -08/27/13 at 2:30 p.m. resident has indwelling urinary catheter, size 16 Fr., patent to urine flow, has wound to right hip stage II to stage III, -09/10/13 at 3:00 p.m. Resident had blood tinged urine in his indwelling urinary catheter, -10/18/13 (without a documented time of entry) dark colored urine in indwelling urinary catheter, physician notified, ordered: to change indwelling urinary catheter, 16 Fr. with 15 cc of sterile water, in at 8:30, clear yellow urine. Record review of the quarterly MDS with assessment reference date of 08/09/13 for Resident #1 revealed he was totally dependent on staff for all activities of daily living. The section on behaviors was documented as not exhibited. Assessment of section on bladder and bowel revealed indwelling urinary catheter. He was assessed at risk for development of pressure ulcer and the presence of pressure ulcer on prior assessment was blank/undocumented. He had a surgical wound. The assessment of skin and ulcer treatments included; pressure reducing device for bed, application of non- surgical dressings other than to feet and application of medications other than to feet. The section on the number of current unhealed pressure ulcers was undocumented/blank. Record review of the monthly physician orders [REDACTED]. Record review of the MAR indicated [REDACTED]. Record review of the TAR dated 08/13 to 10/13 for Resident #1 revealed no documentation of interventions or assessment for indwelling urinary catheter. Record review of the weekly wound treatment and progress records dated 08/28/13 to 10/15/13 for Resident #1 revealed documentation and assessment for only the right iliac (hip) crest pressure ulcer and no evidence for the penile and scrotal skin area. Record review of the weekly skin assessments dated 08/30/13 to 10/15/13 revealed skin assessment of surgical, open area, old with the body diagram presenting a circle on the right hip area and no evidence for assessment of penile and scrotal skin area. Record review of the WTN progress notes dated from 08/30/13 to 10/08/13 for Resident #1 revealed only documentation of unspecified wound status and notification to RP. Record review of the facility's Nurse practitioner's signed progress note dated 09/18/13 for Resident #1 revealed visit the type was "nurse concern". Resident #1 had "abnormal urine analysis, [DIAGNOSES REDACTED] pneumonia was isolated and started [MEDICATION NAME](antibiotic) 2 days ago but microbial is resistant [MEDICATION NAME] sensitivity report". The physical exam section presented with the vital signs as blank/ undocumented and the assessment of [MEDICAL CONDITION] was blank/undocumented. The skin was assessed with [REDACTED]. The assessment/plan was documented as UTI- Bactrim DS (antibiotic) BID p.o. for 10 days, discontinue Cipro. Record review of the Braden scale for predicting pressure sore risk dated 09/23/13 for Resident #1 revealed a score of 15 or at risk. Record review of the facility's 24 hour report dated from 10/17/13 to 10/19/13 revealed documentation of remarks for Resident #1 on: -10/17/13 for 10:00 p.m. to 6:00 a.m. shift of: accu check, fall risk , documented on the 6:00 a.m. to 2:00 p.m. shift was: fall risk, accucheck , foley catheter and on the 2:00 p.m. to 10:00 p.m. shift remarks documented were: fall precautions, BS 340/234 , foley catheter. Record review of the physician telephone orders for Resident #1 revealed an order dated 10/18/13 to change indwelling urinary catheter, 16 Fr. with 15 cc. sterile water. -10/18/13 for 10:00 p.m. to 6:00 a.m. shift of accu check, fall risk, foley catheter, shouting at night and remarks documented on the 6:00 a.m. to 2:00 p.m : changed foley this a.m., urine clear, accu check shift and documented on the 2:00 p.m. to 10:00 p.m. shift were remarks of: fall precautions, BS 214/189, foley catheter. Record review of the hospital's physician consult dated 10/19/13 for Resident #1 revealed a [AGE] year old male presented to emergency for evaluation of [MEDICAL CONDITION] /slow heart rate and altered mental state. Past medical history included; [MEDICAL CONDITIONS], diabetes mellitus, severe dementia, bilateral lower extremity contractures. Laboratory data and diagnostics studies conducted on 10/19/13 included: [MEDICATION NAME] level of 3.5, wound culture positive [MEDICAL CONDITION] and urine culture positive for Morganella and [DIAGNOSES REDACTED] bacteria. The critical plan and assessment included; 1. Severe [MEDICAL CONDITION] and [MEDICAL CONDITION] (low blood pressure) which was improving after Digiband treatment (reduces [MEDICATION NAME] level in body), Urethral erosion by indwelling urinary catheter is seen and evidence of UTI. 2. Renal, evidence of indwelling urinary catheter with penile erosion, will get urology consult. Record review of the hospital's urology consult report dated 10/21/13 for Resident #1 revealed present history of [AGE] year old male well known to me with a history of urethral stricture disease and had a urethral stricture dilation and cystoscopy on 04/04/13 ...Past medical history: significant for [MEDICAL CONDITION] fib, diabetes, hypertension, pneumonia, dementia, anxiety, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Surgical history of back surgery and sacral decubitus ulcer surgery. Physical examination of [MEDICAL CONDITION] revealed mid penile urethral erosion with indwelling urinary catheter draining clear urine. The assessment section revealed: 1. Urethral erosion secondary to prolonged urethral indwelling catheter retention, 2. Bacteriuria versus urinary tract infection. The plan was documented to continue IV antibiotics, continue indwelling urinary catheter exchange every 4 weeks and secure the catheter to reduce tension. Observation on 10/23/13 at 11:30 a.m. in the hospital's intensive care unit revealed Resident #1 was bed with an indwelling urinary catheter. The penile head and shaft had a long, linear open swollen area from the penile head to the base of the penile shaft with the urethral catheter exposed on the open skin area at the base and at the top of the penile shaft with only the mid shaft region of tubing covered by skin. Further observations of Resident #1 revealed evidence of multiple old healed pressure areas, a healing pink red area on the sacrum and on the right hip area was a deep, open area. The gauze removed from the right hip pressure ulcer revealed watery colored discharge and the Resident moaned with any movement of his contracted legs or arms. In an interview on 10/23/13 at 2:15 p.m. with the DON about Resident #1's indwelling urinary catheter and she said she had been employed at the facility for about a year and she had known he had an indwelling urinary catheter for wounds and he had catheters on and off. She further said the resident had become agitated and pulled at the catheter. She further said the resident's penis had a deviated shaft and urethra. The DON was asked if she had been made aware of any problems about the Resident's catheter or condition of the penile /genital tissues and she said nothing was ever reported to her and she was unaware of any problems. In an interview on 10/23/13 at 2:20 p.m. with the WTN about Resident #1 she said she conducted the weekly head to toe skin assessments. The WTN was asked during those weekly assessments did she assess the skin condition of the genital/penile tissue of Resident and she said "no". The WTN was asked why the weekly skin assessments did not reveal any documentation for the genital/penile skin area and she said"I didn't think anything was different as he always had a split in the top part of his penis since I knew him". In an interview on 10/23/13 at 2:30 p.m. with the facility's NP about the NP role he said it is a new position and still developing and he follows concerns expressed by the nurse, he reviews labs result and prescribes with consultation of primary physicians. The NP was asked about his involvement with Resident #1 and he said the spouse expressed concerns about Resident's increased anxiety and another time a lab result for Resident #1 came back related to a urinalysis and antibiotic sensitivity so he changed the antibiotic for the UTI. The NP was asked if he ever conducted a physical assessment of Resident #1 and he said "no". In an interview on 10/23/13 at 5:00 p.m. with the Administrator and DON about Resident #1 the DON said "I can't find any documentation, all I have is what you have and I don't know why there are no orders, MAR indicated [REDACTED]. That's all I have, is what I gave you". Resident # 2 Record review of the face sheet for Resident #2 revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the admission MDS with assessment reference date of 09/20/13 for Resident #2 revealed he had moderate cognitive impairment. Functional status was assessed as totally dependent on staff for ADLs. He was always incontinent and appliances were assessed as none. Record review of the RCP dated 10/18/13 for Resident #2 revealed a he had an indwelling urinary catheter and was at risk for increased urinary tract infections. The goal was documented as will not have signs or symptoms of UTI. The approaches included; 2) monitor urine ...report abnormalities to physician, 4) keep tubing/bag below bladder, do not kink tubing, 5) Catheter care per order. Record review of the physician's telephone orders for Resident #2 revealed on 10/18/13 new order to insert indwelling urinary catheter due to pressure ulcer, done at 11:30 a.m. Observation on 10/22/13 at 1:30 p.m. with LVN A revealed Resident #2 was in bed on his back his indwelling urinary catheter was unsecured. His catheter tube was positioned underneath is left thigh. Observation on 10/22/13 at 3:25 p.m. with LVN B revealed Resident #2 in bed on his back with the heels of his feet directly on the mattress. His indwelling urinary catheter was unsecured and the catheter tube was positioned underneath his left thigh. During this observation, LVN B said "oh that catheter shouldn't be under the leg, I need to get my aides to change and reposition you". Record review of the MAR indicated [REDACTED]. Resident #3 Record review of the facility face sheet for Resident #3 revealed a [AGE] year old male admitted to the facility 12/11/11. His [DIAGNOSES REDACTED]. Record review of the RCP dated 1/18/13 for Resident #3 revealed he had a supra pubic catheter related to [MEDICAL CONDITION] bladder with potential for UTI. The goal was documented as will/be free from catheter related trauma. The approaches included: observe and document for pain/discomfort due to catheter. Record review of the RCP dated 8/22/13 for Resident #3 he had the potential of impairment to skin integrity related to...and limited mobility. The goal was documented as will be free of skin break down. Record review of the quarterly MDS with assessment reference date of 10/08/13 for Resident #3 revealed he was totally dependent on staff for all ADLs. He had an indwelling catheter. Record review of the physician's monthly orders dated for the month of 10/2013 for Resident # 3 revealed: check placement of leg strap to secure indwelling catheter every shift. This order had an initial order date of 09/26/13. The monthly orders included: off-load heels at all times while in bed every shift. Observation on 10/22/13 at 1:50 p.m. with LVN A revealed Resident #3 in bed on his back with the heels of his feet directly on the mattress. His indwelling supra pubic catheter was unsecured and hanging freely down the side of the bed. Posted on a sign at the head of his bed, booties on feet at all times. Observation on 10/23/13 at 10:30 a.m. with the DON revealed Resident #3 in bed on his back with the heels of his feet directly on the mattress. His indwelling supra pubic catheter was unsecured and hanging freely down the side of the bed. In an interview on 10/23/13 at 10:45 a.m. with the DON about the care of a Resident with indwelling urinary catheters, she was asked if a Resident's indwelling urinary catheter should be secured and she said" yes". During this interview the DON was asked if dependent Residents should have the heels of their feet offloaded to prevent pressure ulcers and the DON said "yes". In an interview on 10/23/13 at 11:00 a.m. with the DON about how she ensured the care and services were provided to the residents in accordance with the Resident's plan of care. She said nurses conducted rounds to observe and ensure care was provided as required. She said they conducted a morning meeting with department heads to review new admits, concerns, problems and ensure follow-ups are completed. A clinical meeting was conducted after the daily morning meeting to review 24 hour reports, changes in condition, incidents and accidents, any problems. The DON said she audited charts to ensure documentation was completed. In an interview on 10/23/13 at 5:00 p.m. with the Administrator about how he ensured care and services was provided to the residents in accordance with the Resident's plan of care he said he did rounds several times each day to observe and correct issues. He said he spoke with residents, family members and staff. Each day a morning meeting was conducted with department heads to review new admits, identify concerns or problems and ensure follow ups are conducted, weekly QA meetings conducted with tracking and trending. Record review of the facility's policy and procedure dated 04/12 catheter care, urinary Purpose: ...to prevent catheter-associated urinary tract infections Complications 1. Observe the resident for complications associated with urinary catheters. b. Check urine for unusual appearance... c. notify physician ...if bleeding or catheter is accidentally removed d. report any complaints the resident may have of burning, tenderness or pain in the urethral area e. observes for other signs/symptoms of urinary tract infection... Record review of the American Journal of Nursing, 12/2008, Volume 108 #12: Securing the indwelling urinary catheter: a urinary catheter is any device inserted into the bladder to drain urine such as a Foley (indwelling urinary) catheter or supra pubic catheter, Indications: There are 3 primary reasons to secure a catheter *to control post-operative bleeding with pressure (ensure unobstructed urinary flow after urologic surgery) *to protect surgical reconnections after prostate surgery *to prevent urethral trauma or erosion. The CMS 672 form revealed 4 Residents with indwelling and external urinary catheters.

Based on observation and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 3 (Residents #1 and #82) residents reviewed for [MEDICAL CONDITION] care. - The facility Administrator failed to supervise and monitor the DON who was to ensure licensed staff were trained and supervised in the correct care of residents with tracheostomies. - The DON failed to train and supervise staff to ensure licensed staff were knowledgeable in the correct care of residents with tracheostomies. - The DON failed to observe and monitor [MEDICAL CONDITION] care in order to ensure the competence of staff and the safety of residents. An Immediate Jeopardy was identified on 11/29/2012. While the Immediate Jeopardy was removed on 11/30/2012, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all nursing staff had not been trained and checked off on [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning. This failure affected 2 residents who have tracheostomies, and placed an additional resident who has a [MEDICAL CONDITION] at risk for infection, aspiration, trauma and/or death. Findings include: Resident #82 Record review of Resident #82's Admission Record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. In an Interview on 11/27/2012 at 9:50 AM with Resident #82, when asked who provides [MEDICAL CONDITION] care, Resident #82 stated "Nurses change dressing every day, but they don't clean the [MEDICAL CONDITION] cannula." Resident # 82 also stated "I don't think they know how to." An observation on 11/28/2012 at 10:20 AM revealed LVN D performing [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning. LVN D donned sterile gloves and then picked up a suction catheter. LVN D placed the tip of the catheter in a container of saline and placed a finger over the hole and provided suction. LVN D then placed the suction catheter tip to Resident #82's soiled 4x4 gauze drain sponge and began to suction green mucous that was located on the soiled 4x4 drain sponge and on Resident #82's chest area. LVN D then donned new sterile gloves without washing his hands. With sterile gloved hands, LVN D opened the non-sterile saline container with both gloved hands. LVN D poured the saline into one of the [MEDICAL CONDITION] care kit compartments. LVN D then opened another non-sterile saline container and poured it into another compartment of the [MEDICAL CONDITION] care kit. LVN D then picked up the non-sterile hydrogen peroxide bottle and poured it into one of the saline compartments. LVN D then removed the soiled drain sponge from underneath Resident #82'[MEDICAL CONDITION] and with the same soiled gloves pulled out Resident #82's metal inner cannula and placed it in the hydrogen peroxide/saline compartment. LVN D then removed the [MEDICAL CONDITION] collar using the same soiled gloves and replaced the [MEDICAL CONDITION] collar with a new one. Further observation on 11/28/2012 at 10:20 AM of LVN D performing [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning revealed while attempting to don new sterile gloves, LVN D contaminated the sterile gloves with his unwashed hands. LVN D then turned on the suction machine and then dipped the catheter tip in an open undated non-sterile saline container sitting on the bedside dresser and then placed the catheter tip inside the tip of the [MEDICAL CONDITION] and then applied suction. LVN D continued to suction the outside of the [MEDICAL CONDITION] stoma site and surrounding skin area. LVN D removed his gloves and then donned clean non-sterile gloves, LVN D picked up the inner cannula from the [MEDICAL CONDITION] care kit and began to scrub it with a bristle brush and then placed the inner cannula in the saline compartment of the [MEDICAL CONDITION] care kit. LVN D then donned new non-sterile gloves and placed the inner cannula back into the [MEDICAL CONDITION] site. An observation on 11/29/2012 at 9:07 AM revealed LVN C performing [MEDICAL CONDITION] care to Resident #82. LVN C donned sterile gloves then removed the old soiled 4x4 drain sponge from the [MEDICAL CONDITION] site. LVN C then pulled a sterile drape out of the sterile [MEDICAL CONDITION] care kit with soiled gloved hands. LVN C then donned new sterile gloves and picked up the non-sterile saline container with both gloved hands. LVN C then poured the saline over the 4x4 gauze in one of the [MEDICAL CONDITION] kit compartments. LVN C then donned new sterile gloves and reached into the [MEDICAL CONDITION] care kit and pulled out one of the saline moistened 4x4 gauze, LVN C then cleansed around the stoma site and the surrounding skin area, LVN C repeated these steps two times. In an interview on 11/29/2012 at 10:35 AM with LVN C, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN C stated "Sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN C stated "We had a in-service today and I've had them in the past." When asked if LVN C received a check off on [MEDICAL CONDITION] care, LVN C stated "Yes, I was checked off about six months ago, but I don't remember who checked me off." When asked why Resident #82's inner cannula was not taken out and cleaned, LVN C stated "I did not take it out because I am not familiar with it." LVN C stated "I've never worked the 400 hall." When asked about [MEDICAL CONDITION] suctioning, LVN C stated "I've never suctioned Resident #82, I've never suctioned here in this facility." In an interview on 11/29/2012 at 3:15 PM with LVN D, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN D stated "sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN D stated "I've never been trained on the metal inner cannula." When asked if LVN D has ever been evaluated on [MEDICAL CONDITION] care, LVN D stated "No I've never been checked off. I was walked through the steps and then I performed it." LVN D stated "I don't usually work the 400 hall." When asked what could happen if Resident #82 is not suctioned correctly, LVN D stated "It could decrease oxygen levels, and create trauma or infection." Resident #1 Record review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. An observation on 11/28/2012 at 3:30 PM revealed LVN B providing [MEDICAL CONDITION] care to Resident #1. LVN B set up a [MEDICAL CONDITION] care kit with bare hands and then donned sterile gloves without washing hands. Then she removed the old 4x4 drain sponge and pulled cap from [MEDICAL CONDITION] inner cannula off and removed the inner cannula. LVN B then threw the soiled inner cannula in the trash can and removed her gloves. LVN B applied a face mask and then washed her hands, LVN B turned off the faucet with her washed hands. LVN B then donned sterile gloves and then touched the non-sterile saline container with both gloved hands. LVN B then cleansed underneath the [MEDICAL CONDITION] collar and around the stoma site with one cotton tip applicator and repeated it two times with two separate cotton tip applicators. LVN B then inserted a new disposable inner cannula. In an interview on 11/28/2012 at 3:45 PM with LVN B, when asked if [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN B stated "sterile." When asked if LVN B performed Resident #1's [MEDICAL CONDITION] care using sterile technique, LVN B stated "No, I touched the normal saline container with my sterile gloves." When asked what could happen if [MEDICAL CONDITION] care is not performed using sterile technique, LVN B stated "Resident could get an infection." An observation on 11/29/2012 at 9:35 AM revealed LVN A providing [MEDICAL CONDITION] care to Resident #1. LVN A donned sterile gloves and then touched the non-sterile saline container with both gloved hands. LVN A then pulled out the sterile drape from the [MEDICAL CONDITION] care kit with the same non-sterile gloves and placed it on Resident #1's chest area. LVN A then continued to take supplies out of the sterile [MEDICAL CONDITION] care kit with the non-sterile gloves. LVN A then donned new sterile gloves and then picked up the non-sterile saline container and poured the saline into one of the [MEDICAL CONDITION] compartments. LVN A then removed the old 4x4 drain sponge from Resident #1's [MEDICAL CONDITION] collar. LVN A then donned new gloves and with the moistened gauze started to clean underneath the left side of the [MEDICAL CONDITION] collar and with the same gauze wiped underneath the right side of the [MEDICAL CONDITION] collar. LVN A then donned new gloves and pulled the [MEDICAL CONDITION] cap off the [MEDICAL CONDITION] and then pulled out the disposable inner cannula. In an interview on 11/29/2012 at 10:25 AM with LVN A, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN A stated "sterile." When asked if the saline container is sterile or non-sterile, LVN A stated "The inside is sterile and the outside is non-sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN A stated "We had a in-service yesterday, I have not had much training here, I've only been here going on two months, I would like more training." When asked if LVN A received a check off on [MEDICAL CONDITION] care, LVN A stated "I've never been checked off here, I received a demonstration but nothing hands on, this is my first time, I've never performed the care." In an interview on 11/29/2012 at 11:50 AM with the Corporate Nurse, when asked to provide proof of staff trainings and staff check offs related to [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning, the Corporate Nurse stated "I cannot find the staff training or check offs." When asked for Resident #1's [MEDICAL CONDITION] orders, the Corporate Nurse stated "There are no orders." In an interview on 11/29/2012 at 12:05 PM with the DON, when asked if [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, the DON stated "One hand remains sterile and the other is considered the dirty hand." When asked what could happen if sterile field is not maintained, the DON stated "There could be a negative effect to the resident, like infection." When asked what could happen if a resident with a [MEDICAL CONDITION] does not receive [MEDICAL CONDITION] care, "It could become infected." When asked what could happen with a [MEDICAL CONDITION] that is not suctioned when needed, the DON stated "There could be a negative effect on the resident, the resident could aspirate." The DON stated " I have trained some of the nurses, some of the nurses came up to me and asked for training related to the [MEDICAL CONDITION]." When asked if the trainings were documented, the DON stated "No, and I don't remember who the nurse were." When asked where Resident #1's Respiratory Administration record for October 2012 and November 2012 is, the DON stated "We cannot find it. We realized yesterday that there was not one." In an interview on 11/30/2012 at 2:10 PM with the Administrator, when asked what type of procedures were there to make sure the nursing needs of the residents were being met, he said the facility used resident assessments, followed doctor's orders for residents and ensured residents needs were met. When asked how he monitored staff to ensure the systems they monitor were being done sufficiently, he said rounds were conducted by himself and DON as well as observations of medication pass, incontinent checks, as well as observations of staff by the unit managers and/or DON and respond the best of their ability. He also said they would follow up with nursing concerns brought to their attention and follow the standards of care. He then said they would also review resident charts to ensure the proper care was being provided. The Administrator was asked how he thought the problem resulting in the Immediate Jeopardy came about, he said they had nurses that were nervous from having "the State" watching them. He then said they got nervous and made a mistake. He also said he was not aware of the problem. On 11/29/2012 at 3:38 PM, the survey team determined that the staff's failure to meet the resident's [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning needs placed these residents at risk for serious harm and was an Immediate Jeopardy situation. The facility Administrator was informed on 11/29/2012 at 3:58 PM that an Immediate Jeopardy situation had occurred. They were instructed to provide a plan of removal. The following plan of removal was submitted by the facility on 11/30/2012. It was accepted and included the following: "November 30, 2012 Plan to Remove Immediate Jeopardy Issue Identified: Licensed staff not utilizing appropriate aseptic techniques while conducting [MEDICAL CONDITION] care to ensure appropriate [MEDICAL CONDITION] care. Action Steps: All 3 residents with a [MEDICAL CONDITION] were assess on 11/29/2012, by the DON. No signs and or symptoms of infection or harm noted. A Respiratory Therapist came in and began training with licensed staff on aseptic techniques while conducting [MEDICAL CONDITION] care and suctioning at 12:00 PM on 11/29/2012. Initiated In-services for all licensed staff to ensure they utilize the appropriate techniques. (return demonstration required) ONLY licensed staff that have been checked off and who demonstrated proficiency will be allowed to provide [MEDICAL CONDITION] are and suctioning. Identified LVN's will be trained on the appropriate techniques by Respiratory Therapist prior to working with residents with a [MEDICAL CONDITION] (return demonstration required) by 11/30/2012. A Respiratory Therapist was hired at 6:00PM on 11/29/2012 to assist with training to increase proficiency of licensed staff with [MEDICAL CONDITION] care and suctioning. This individual will stay on PRN until all staff display proficiency with [MEDICAL CONDITION] procedures. Starting 11/29/2012 the DON and or Respiratory Therapist will conduct random observations of [MEDICAL CONDITION] care at least three times weekly with different licensed staff members for the next month. Any additional training will be provided immediately as required. Effective 11/29/2012 all new licensed nurse staff will be trained on [MEDICAL CONDITION] care and suctioning during their floor orientation. These employees will be required to perform a return demonstration to ensure proficiency before they will be allowed to perform independent [MEDICAL CONDITION] care and or suctioning with the resident. Completion Date: 11/30/2012" The facility was notified on 11/30/2012 at 3:00 PM that the Immediate Jeopardy had been removed. There were 3 residents in the facility receiving [MEDICAL CONDITION] care according to the CMS form 672.

Based on observation, interview and record review, the facility failed to provide proper special services treatment and care for 2 of 3 (Residents #1 & #82) residents reviewed for [MEDICAL CONDITION] care by LVN's D, C, B & A. - Resident #82 did not receive [MEDICAL CONDITION] suctioning, sterile [MEDICAL CONDITION] and inner cannula care on 11/28/2012. Resident #82 did not receive [MEDICAL CONDITION] and inner cannula care on 11/29/2012. - Resident #1 did not receive sterile trachesotomy care on 11/28/2012 and on 11/29/2012. An Immediate Jeopardy was identified on 11/29/2012. While the Immediate Jeopardy was removed on 11/30/2012, the facility remained out of compliance at a scope of pattern and a severity of no actual harm that is not immediate jeopardy because all nursing staff had not been trained and checked off on [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning. This failure affected 2 residents and placed an additional resident with a [MEDICAL CONDITION] at risk for infection, aspiration, trauma and/or death. Findings include: Resident #82 Record review of Resident #82's Admission Record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #82's 01/25/2012 Admission Minimum Data Set 3.0 read in part, Section C (Cognitive Patterns) - C0500 (Summary Score) BIMS score - 15 (Cognitively Intact 13-15.) Section O (Special Treatments, Procedures and Programs) - D. Suctioning - checked. E. [MEDICAL CONDITION] care - checked. Record review of Resident #82's 10/23/2012 Quarterly Minimum Data Set 3.0 read in part, Section C (Cognitive Patterns) - C0500 (Summary Score) BIMS score - 15 (Cognitively Intact 13-15.) Section O (Special Treatments, Procedures and Programs) D. Suctioning - blank. E. [MEDICAL CONDITION] care - blank. An observation on 11/27/2012 at 9:50 AM revealed Resident #82 lying in bed with the head of bed elevated at 30 degrees receiving 2 liters of oxygen via nasal cannula. Resident #82 was observed with a metal [MEDICAL CONDITION], with a 4x4 gauze drain sponge secured underneath the [MEDICAL CONDITION] collar with light green mucous on the 4x4 drain sponge. In an interview on 11/27/2012 at 9:50 AM with Resident #82, when asked who provides [MEDICAL CONDITION] care, Resident #82 stated "Nurses change dressing every day, but they don't clean the [MEDICAL CONDITION] cannula." Resident # 82 also stated "I don't think they know how to." An observation on 11/28/2012 at 10:20 AM revealed LVN D performing [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning. LVN D donned sterile gloves and then picked up a suction catheter. LVN D placed the tip of the catheter in a container of saline and placed a finger over the hole and provided suction. LVN D then placed the suction catheter tip to Resident #82's soiled 4x4 gauze drain sponge and began to suction green mucous that was located on the soiled 4x4 drain sponge and on Resident #82's chest area. LVN D then donned new sterile gloves without washing his hands. With sterile gloved hands, LVN D opened the non-sterile saline container with both gloved hands. LVN D poured the saline into one of the [MEDICAL CONDITION] care kit compartments. LVN D then opened another non-sterile saline container and poured it into another compartment of the [MEDICAL CONDITION] care kit. LVN D then picked up the non-sterile hydrogen peroxide bottle and poured it into one of the saline compartments. LVN D then removed the soiled drain sponge from underneath Resident #82'[MEDICAL CONDITION] and with the same soiled gloves pulled out Resident #82's metal inner cannula and placed it in the hydrogen peroxide/saline compartment. LVN D then removed the [MEDICAL CONDITION] collar using the same soiled gloves and replaced the [MEDICAL CONDITION] collar with a new one. Further observation on 11/28/2012 at 10:20 AM of LVN D performing [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning revealed while attempting to don new sterile gloves, LVN D contaminated the sterile gloves with his unwashed hands. LVN D then turned on the suction machine and then dipped the catheter tip in an open undated non-sterile saline container sitting on the bedside dresser and then placed the catheter tip inside the tip of the [MEDICAL CONDITION] and then applied suction. LVN D continued to suction the outside of the [MEDICAL CONDITION] stoma site and surrounding skin area. LVN D removed his gloves and then donned clean non-sterile gloves, LVN D picked up the inner cannula from the [MEDICAL CONDITION] care kit and began to scrub it with a bristle brush and then placed the inner cannula in the saline compartment of the [MEDICAL CONDITION] care kit. LVN D then donned new non-sterile gloves and placed the inner cannula back into the [MEDICAL CONDITION] site. An observation on 11/29/2012 at 9:07 AM revealed LVN C performing [MEDICAL CONDITION] care to Resident #82. LVN C donned sterile gloves then removed the old soiled 4x4 drain sponge from the [MEDICAL CONDITION] site. LVN C then pulled a sterile drape out of the sterile [MEDICAL CONDITION] care kit with his soiled gloved hands. LVN C then donned new sterile gloves and picked up the non-sterile saline container with both gloved hands. LVN C then poured the saline over the 4x4 gauze in one of the [MEDICAL CONDITION] kit compartments. LVN C then donned new sterile gloves and reached into the [MEDICAL CONDITION] care kit and pulled out one of the saline moistened 4x4 gauze, LVN C then cleansed around the stoma site and the surrounding skin area, LVN C repeated these steps two times. In an interview on 11/29/2012 at 9:25 AM with LVN C after LVN C completed the [MEDICAL CONDITION] care to Resident #82, when asked if [MEDICAL CONDITION] care was completed, LVN C stated "Yes, I'm done [MEDICAL CONDITION] care." In an interview on 11/29/2012 at 10:35 AM with LVN C, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN C stated "Sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN C stated "We had a in-service today and I've had them in the past." When asked if LVN C received a check off on [MEDICAL CONDITION] care, LVN C stated "Yes, I was checked off about six months ago, but I don't remember who checked me off." When asked why Resident #82's inner cannula was not taken out and cleaned, LVN C stated "I did not take it out because I am not familiar with it." LVN C stated "I've never worked the 400 hall." When asked about [MEDICAL CONDITION] suctioning, LVN C stated "I've never suctioned Resident #82, I've never suctioned here in this facility." In an interview on 11/29/2012 at 3:15 PM with LVN D, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN D stated "sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN D stated "I've never been trained on the metal inner cannula." When asked if LVN D has ever been evaluated on [MEDICAL CONDITION] care, LVN D stated "No I've never been checked off. I was walked through the steps and then I performed it." LVN D stated "I don't usually work the 400 hall." When asked what could happen if Resident #82 is not suctioned correctly, LVN D stated "It could decrease oxygen levels, and create trauma or infection." Record review of Resident #82's November 2012 Respiratory Administration Record read in part, Trache care q shift and PRN. [MEDICAL CONDITION] with NS, pat dry and apply dry dressing q shift and PRN every shift every day. The Respiratory Administration Record was initialed by nursing staff every day, every shift for providing the [MEDICAL CONDITION] care to Resident #82. Record review of Resident #82's Active physician's orders [REDACTED]. Trache care Q shift and PRN - every shift every day. Record review of Resident #82's 11/9/2012 Care Plan read in part, Problem Onset 01/25/2012. May need suctioning for secretion build-up [MEDICAL CONDITION]. Monitor for congestion and suction when needed. Unable to care for [MEDICAL CONDITION]. [MEDICAL CONDITION] every shift, [MEDICAL CONDITION] daily for redness or drainage, listen to lung sounds every shift. Resident #1 Record review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's 11/7/2012 Admission Minimum Data Set 3.0 read in part, Section C (Cognitive Patterns) - C0500 (Summary Score) BIMS score - 13 (Cognitively Intact 13-15.) Section O (Special Treatments, Procedures and Programs) - D. Suctioning - checked. E. [MEDICAL CONDITION] care - checked. An observation on 11/28/2012 at 3:30 PM revealed LVN B providing [MEDICAL CONDITION] care to Resident #1. LVN B set up a [MEDICAL CONDITION] care kit with bare hands and then donned sterile gloves without washing her hands. Then she removed the old 4x4 drain sponge and pulled cap from [MEDICAL CONDITION] inner cannula off and removed the inner cannula. LVN B then threw the soiled inner cannula in the trash can and removed her gloves. LVN B applied a face mask and then washed her hands, LVN B turned off the faucet with her washed hands. LVN B then donned sterile gloves and then touched the non-sterile saline container with both gloved hands. LVN B then cleansed underneath the [MEDICAL CONDITION] collar and around the stoma site with one cotton tip applicator and repeated it two times with two separate cotton tip applicators. LVN B then inserted a new disposable inner cannula. In an interview on 11/28/2012 at 3:45 PM with LVN B, when asked if [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN B stated "sterile." When asked if LVN B performed Resident #1's [MEDICAL CONDITION] care using sterile technique, LVN B stated "No, I touched the normal saline container with my sterile gloves." When asked what could happen if [MEDICAL CONDITION] care is not performed using sterile technique, LVN B stated "Resident could get an infection." An observation on 11/29/2012 at 9:35 AM revealed LVN A providing [MEDICAL CONDITION] care to Resident #1. LVN A donned sterile gloves and then touched the non-sterile saline container with both gloved hands. LVN A then pulled out the sterile drape from the [MEDICAL CONDITION] care kit with the same non-sterile gloves and placed it on Resident #1's chest area. LVN A then continued to take supplies out of the sterile [MEDICAL CONDITION] care kit with the non-sterile gloves. LVN A then donned new sterile gloves and then picked up the non-sterile saline container and poured the saline into one of the [MEDICAL CONDITION] compartments. LVN A then removed the old 4x4 drain sponge from Resident #1's [MEDICAL CONDITION] collar. LVN A then donned new gloves and with the moistened gauze started to clean underneath the left side of the [MEDICAL CONDITION] collar and with the same gauze wiped underneath the right side of the [MEDICAL CONDITION] collar. LVN A then donned new gloves and pulled the [MEDICAL CONDITION] cap off the [MEDICAL CONDITION] and then pulled out the disposable inner cannula. In an interview on 11/29/2012 at 10:25 AM with LVN A, when asked if the [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, LVN A stated "sterile." When asked if the saline container is sterile or non-sterile, LVN A stated "The inside is sterile and the outside is non-sterile." When asked about the facilities trainings related to [MEDICAL CONDITION] care, LVN A stated "We had a in-service yesterday, I have not had much training here, I've only been here going on two months, I would like more training." When asked if LVN A received a check off on [MEDICAL CONDITION] care, LVN A stated "I've never been checked off here, I received a demonstration but nothing hands on, this is my first time, I've never performed the care." In an interview on 11/29/2012 at 11:50 AM with the Corporate Nurse, when asked to provide proof of staff trainings and staff check offs related to [MEDICAL CONDITION] care and [MEDICAL CONDITION] suctioning, the Corporate Nurse stated "I cannot find the staff training or check offs." When asked for Resident #1's [MEDICAL CONDITION] orders, the Corporate Nurse stated "There are no orders." In an interview on 11/29/2012 at 12:05 PM with the DON, when asked if [MEDICAL CONDITION] care is a sterile or a non-sterile procedure, the DON stated "One hand remains sterile and the other is considered the dirty hand." When asked what could happen if sterile field is not maintained, the DON stated "There could be a negative effect to the resident, like infection." When asked what could happen if a resident with a [MEDICAL CONDITION] does not receive [MEDICAL CONDITION] care, "It could become infected." When asked what could happen with a [MEDICAL CONDITION] that is not suctioned when needed, the DON stated "There could be a negative effect on the resident, the resident could aspirate." The DON stated " I have trained some of the nurses, some of the nurses came up to me and asked for training related to the [MEDICAL CONDITION]." When asked if the trainings were documented, the DON stated "No, and I don't remember who the nurse were." When asked where Resident #1's Respiratory Administration record for October 2012 and November 2012 were, the DON stated "We cannot find it. We realized yesterday that there was not one." Record review of Resident #1's November 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Suction [MEDICAL CONDITION] as needed. Change disposable inner cannula daily. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident #1's Active physician's orders [REDACTED]. Record review of Resident #1's 11/9/2012 Care Plan read in part, The resident has [MEDICAL CONDITION]. The resident will have clear and equal breath sounds bilaterally. Check /document respiratory rate, depth and quality as indicated. Suction as necessary. Record review of the Facility's In-service training report dated 9/17/2012 read in part, Multiple Topics. 9.[MEDICAL CONDITION] (no attachment found.) Record review of the Facility's In-service training report dated 11/28/2012 read in part, [MEDICAL CONDITION] Care and Suction [MEDICAL CONDITION]- review of policy and procedure and review skills competency. Record review of the Facility's [MEDICAL CONDITION] Care Policy, Revised June 2005, read in part, The purpose of this procedure is to guide [MEDICAL CONDITION] care and the cleaning and sterilization of reusable metal [MEDICAL CONDITION]. [MEDICAL CONDITION] care 1. Wash hands 2. Put exam gloves on both hands 3. Remove old dressings and ties. Pull soiled glove over dressing and discard into appropriate receptacle. 4. Put on fresh gloves (Note: Sterile gloves must be used for anything other than stoma care.) 5. Set up [MEDICAL CONDITION] care kit 6. Clean tube and site with hydrogen peroxide and saline. 7. Change disposable [MEDICAL CONDITION]. Cleaning Reusable Metal [MEDICAL CONDITION]: 1. Wash hands 2. Put gloves on both hands 3. Soak the tube in hydrogen peroxide for ten minutes 4. Clean with pipe cleaners and brush. Rinse and dry. 5. Remove and discard gloves. Miscellaneous. 2. Gloves must be used on both hands during any or all manipulation of the [MEDICAL CONDITION]. Sterile gloves must be used during aseptic procedures. Record review of the Facility's Suctioning the Lower Airway Policy, Revised March 2004, read in part, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract. General Guidelines 1. Complications of suctioning the lower airway include trauma to the airway, infection, [MEDICAL CONDITION], hypoxemia, and cardiac [MEDICAL CONDITION]. To minimize risk of complications, apply the following guidelines. b. Use sterile equipment to avoid widespread [MEDICAL CONDITION] and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with lower airway must be sterile.) d. Hyper oxygenate the resident by increasing the oxygen flow before the procedure and between suctioning. Steps in procedure. 10. Open suction catheter kit 11. Place sterile drape across the resident's chest. 12. Remove sterile cup, touching only the outside. 13. Fill cup with 100 cc sterile saline.14. Apply sterile gloves. The dominant hand will remain sterile. 15. Holding the catheter in dominant hand and the tubing in the non-dominant hand, connect the catheter to the tubing. 16. Suction a small amount of water from the cup to verify pressure. 18. Instruct the resident to inhale 19. Upon inhalation, insert the catheter into airway. Advance the catheter until resistance is met, pull back 1 to 2cm. 20. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. The survey team determined that these facility failures placed these residents at risk for serious harm associated with their [MEDICAL CONDITION] and respiratory needs and was an Immediate Jeopardy. The Facility's Administrator, DON and Corporate Nurse were notified of the Immediate Jeopardy on 11/29/2012 at 3:58 PM. The following plan of removal, submitted by the facility after corrections, was accepted on 11/30/2012 at 3:00 PM. "November 30, 2012 Plan to Remove Immediate Jeopardy Issue Identified: Licensed staff not utilizing appropriate aseptic techniques while conducting [MEDICAL CONDITION] care to ensure appropriate [MEDICAL CONDITION] care. Action Steps: All 3 residents with a [MEDICAL CONDITION] were assess on 11/29/2012, by the DON. No signs and or symptoms of infection or harm noted. A Respiratory Therapist came in and began training with licensed staff on aseptic techniques while conducting [MEDICAL CONDITION] care and suctioning at 12:00 PM on 11/29/2012. Initiated In-services for all licensed staff to ensure they utilize the appropriate techniques. (return demonstration required) ONLY licensed staff that have been checked off and who demonstrated proficiency will be allowed to provide [MEDICAL CONDITION] care and suctioning. Identified LVN's will be trained on the appropriate techniques by Respiratory Therapist prior to working with residents with a [MEDICAL CONDITION] (return demonstration required) by 11/30/2012. A Respiratory Therapist was hired at 6:00 PM on 11/29/2012 to assist with training to increase proficiency of licensed staff with [MEDICAL CONDITION] care and suctioning. This individual will stay on PRN until all staff display proficiency with [MEDICAL CONDITION] procedures. Starting 11/29/2012 the DON and or Respiratory Therapist will conduct random observations of [MEDICAL CONDITION] care at least three times weekly with different licensed staff members for the next month. Any additional training will be provided immediately as required. Effective 11/29/2012 all new licensed nurse staff will be trained on [MEDICAL CONDITION] care and suctioning during their floor orientation. These employees will be required to perform a return demonstration to ensure proficiency before they will be allowed to perform independent [MEDICAL CONDITION] care and or suctioning with the resident. Completion Date: 11/30/2012" The facility was notified on 11/30/2012 at 3:00 PM that the Immediate Jeopardy had been removed. There were 3 residents in the facility receiving [MEDICAL CONDITION] care according to the CMS form 672.

Based on observation, record review and interview, the facility failed to ensure licensed nursing staff were qualified to provide services according to physician's orders [REDACTED]. sampled residents (#CR1 and Resident #2). ---CR #1's wound vac was allowed to accumulate drainage that clotted and caused a foul odor on 9/12/11. Kitty litter was placed under the resident's bed to absorb the odor. ---Three nurses in the facility (LVN C, LVN N, and LVN O) were not knowledgeable about how to replace CR #1's wound vac. ---The ADON refused to assist staff to replace CR #1's wound vac. ---A CNA was allowed to replace CR #1's wound vac. ---Resident #2's wound vac became inoperable some time on the 6/2 shift on 9/28/11. Two nurses, LVN G and LVN D did not either replace the wound vac or apply an optional treatment. They did not document the change in condition for the resident in the Nurses' Notes or that the physician had been notified. ---Resident #2 had the wound vac dressing in place for over 9 hours when the manufacturer's caution was not to allow the dressing to stay in the wound for more than 2 hours when the machine was not functioning. These failures affected 2 residents and placed 5 other residents with wounds at risk for pain, odors, further skin breakdown, infection, hospitalization and surgery. Complaint # 3 Findings include: CR #1 Record review of CR #1's closed record admission sheet revealed she was admitted on [DATE]. Review of her admission physician's orders [REDACTED]. Review of the resident's Physician's Telephone Orders dated 9/14/11 revealed an order to transfer the resident out to another facility. In a phone interview on 9/28/11 at 8:20 a.m. with CR #1's RP, she said that on Monday, 9/12/11 she went to see the resident and there was a foul smell coming from her room. She said she saw a "kitty litter" box under her bed. She said staff told her it was to absorb the smell coming from her urinary catheter. The RP said the collection section of the wound vac was full of clotted blood. She said she went to three nurses to get them to change the resident's wound vac, but all three nurses said they did not know how to change the wound vac. She then went to the ADON, who would not come out of her office to speak to her. When the ADON finally came out of the office, she told the RP that she had three nurses in the facility and one of them should be able to help her. The ADON refused to help change the wound vac. The RP stated that CNA B said she worked with Treatment Nurse E and felt she (CNA B) could change it. The RP said CNA B changed the wound vac with LVN C assisting her. The RP said the resident came in without a pressure ulcer. She said the wound started out very small and then became much larger. The RP said CR #1 was taken to the hospital from the facility on 9/14/11 for wound care. She said the resident was "currently in the hospital" and might have to have flap surgery on her pressure ulcer to close it. Review of the resident's Admission physician's orders [REDACTED]. Review of the resident's Nurses' Weekly Summary dated 8/3/11 revealed no documentation of any skin problems. Review of the resident's Physician's Telephone Orders dated 8/10/11 revealed an order to clean the wound with normal saline, pat dry, apply Santyl, cover with Calcium Alginate and secure with bordered gauze daily and as needed. On 8/23/11 there was an order for [REDACTED]. It was to be monitored for proper functioning every shift. Further review of the resident's Nurses' Weekly Summary dated 8/24/11 revealed a sacral decubitus with ulcer care. In an interview on 9/29/11 at 11:40 a.m. with CNA B, she said she had started working at the facility in June 2011. She said she helped Tx Nurse E with wound vac treatments by holding legs or holding residents on their sides. When she was asked if she had changed any [DEVICE] by herself, she said yes, for CR #1. She said on 9/12/11 there were three nurses in the facility and none of them could change the wound vac. She said she knew something was wrong when she first came to work at 2 p.m. and there was a really bad odor coming from CR #1's room. She said she went to the Maint. Supervisor to ask him for a spray to get rid of the odor. She said the Maint. Supervisor said he had "something for it." She said she saw him put a box of kitty litter under the bed. She said staff did not know where the smell was coming from. She said they thought it might be the resident needed a shower, but the resident's RP had said she had a shower the day before. Then they thought it might be from her wound. She said the resident's RP came to the facility at 5:30 p.m. and was upset when she saw the kitty litter box under the bed. CNA B said the RP asked the nurses to change the wound vac, but none of the nurses knew how to change it. She said the family member was very upset and went to the ADON's office. She said the RP knocked for about 15 minutes before the ADON would open the door to her office. When the RP asked her why she would not open the door, the ADON said because she knew it was her. She said the RP told the ADON that someone needed to change the resident's wound vac right then. CNA B said she left and did not hear what happened after that. She said a little later the ADON had called the Tx. Nurse, but she could not come in because she had car trouble. CNA B said she talked to the Tx. Nurse on the phone and then the ADON told CNA B to go ahead and change the wound vac. CNA B said that as soon as the wound vac was changed and the old one taken out of the room, the smell went away. She said the RP then took the kitty litter box and threw it in the soiled utility room. She said the RP gave her a big hug and thanked her all evening for changing the wound vac. She said the next day the DON told her she should not have changed the wound vac and to never do anything like that again. Review of the resident's Wound Care Physician's Initial Visit sheet dated 8/12/11 revealed the resident had a history of [REDACTED]. The resident was assessed with [REDACTED]. with bloody/fluid discharge, mild odor, slough, and no granulation. The treatment was to apply Santyl and calcium alginate daily. On 8/26/11 the wound had worsened and measured 4.4 cm x 5 cm x 1 cm with 3.3 cm tunneling at 9 and 2 o'clock. The classification was a likely stage IV with a large amount of bloody/fluid discharge, 40% slough and 60% granulation tissue. The treatment was to apply Santyl to the ulcer and to continue the wound vac and change dressing every other day. On 9/2/11 the wound measured 5 cm x 4 cm x 1.2 cm with 4 cm tunneling at 11 and 3 o'clock. It was a stage IV wound with large amount of bloody/fluid discharge, 30% slough and 70% granulation. The treatment was the same. The last wound assessment was on 9/9/11 and the wound measured 5 cm x 3.5 cm x 1.5 cm with 3 cm tunneling at 11 and 1 o'clock. It was a stage IV wound with large amount of bloody/fluid discharge, 25% slough and 75% granulation. The treatment was the same. In an interview on 9/29/11 at 1:00 p.m. with the ADON, she said CR #1's RP came to her office and said the resident's wound vac needed to be changed. She said LVN C was on the hall and she told the LVN that she could either change the wound vac, use a wet to dry dressing or call the physician. The ADON said the facility had an in-service for the licensed staff before they started taking residents who needed a wound vac. She said the family member was screaming at her and kept coming back to her about why she was not doing anything to help the resident. The ADON said she and the RP had issues previously so she felt it would be better for LVN C to take care of the problem. The ADON was asked if she followed up with why LVN C did not take care of the wound vac. She said the resident's RP was "yelling" and had everyone "frazzled". She said LVN C was at the treatment cart, but did not know where the wound vac supplies were kept. The ADON said she called Tx. Nurse E to find out where the tape was kept. The ADON said that was all that needed to be changed. She said the Tx. Nurse told LVN C that CNA B knew where the tape was. At that point the ADON said she left the building. The ADON denied that she told CNA B to change the wound vac. She said that she would have changed the wound vac herself, before she would let the CNA do it. The ADON denied knowing anything about kitty litter being used in the resident's room until the RP asked about it. In an interview on 9/29/11 at 1:20 p.m. with the Maint. Director, he said a CNA came to him one day asking for the kitty litter box with the absorbent material. He said he gave one to a maintenance helper and told him to put it under the bed. He said the last Administrator had gotten the material because there was a resident whose urinary drainage bag caused odors. He said he only meant for the box to stay under the bed for a short time, but before it could be removed, the family member had come, saw it and got very upset. He said he had left the facility at 5:00 p.m. In an interview on 9/29/11 at 1:35 p.m., the DON said the facility provided two in-services for staff on the wound vac system. She was not able to provide the in-service given before 9/19/11 (after the incident with CR #1). In a phone interview on 9/29/11 at 1:40 p.m. with LVN C, she said CR #1's RP came to her on 9/12/11 and asked her to change the wound vac. She said she was not familiar with it so went to the ADON around 6:30 p.m. to get some help. She said the ADON told her "No", she would not help her. She said the ADON told her it was her responsibility and she needed to "tend to it." LVN C said "luckily" CNA B had watched how the wound vac was applied and she assisted CNA B in changing the wound vac. LVN C said there had been a strong smell coming from the resident's room. She said when she asked about the odor and the kitty litter box under the bed, the ADON told her the odor was coming from her catheter and that the facility had used the kitty litter before. LVN C said the ADON was yelling at the resident's RP saying that she would not help the resident because there were three other nurses on duty and one of them had a Bachelor's Degree and it would be "pretty sad if no one could handle the situation." LVN C said she asked the other two nurses to help her, but they did not know how to change the wound vac either. She said the ADON was on the phone with Tx. Nurse E and then handed the phone to CNA B. She did not hear what was said. She said there had been clots in the wound vac container. She said that was where the smell was coming from because as soon as the wound vac was changed and the old one taken out, the smell went away. LVN C said she quit working at the facility because she could not work at a place where the ADON could be so disrespectful of residents and their families. She said staff called in all the time and she had to work too many double shifts. Reinterview on 9/29/11 at 2:00 p.m. with CNA B, she was asked why they did not just retape the wound vac. She said because the RP wanted the whole wound vac changed because of the clots in the machine and the smell. In an interview on 9/29/11 at 2:15 p.m. with the DON, she said LVN C quit working at the facility after the incident with CR #1. Review of CR #1's clinical record under treatments revealed no treatment sheets for September 2011. Interview on 9/29/11 at 4:45 p.m. with the DON, she was asked for the treatment sheets for CR #1. By the time of exit, the DON said they were not able to find any treatment sheets for CR #1. Record review of the Manufacturer's on-line User Manual for the V.A.C. (Vacuum Assisted Closure) therapy system dated September 2007 revealed on page 15, Changing the Canister, "The ActiV.A.C. canister should be changed when full (the alarm will sound), or at least once a week to control odor. V.A.C. Therapy is already off if addrssing a Canister Full Alarm..." Resident #2 Record review of Resident #2's admission sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. In an interview on 9/28/11 at 8:15 p.m. with LVN D on Hall 200, she said she had not been taught how to apply the wound vac. She said if it needed to be changed, she would call the ADON. She said the ADON did not live very far away and about two weeks ago she had called the ADON and she came to the facility. In an interview on 9/28/11 at 9:25 p.m. with LVN F, he said the facility had an in-service about 1 to 1 1/2 weeks ago on the wound vac system. He said the company that provided the wound vac had technical support and an in-house technical support which would help at any time. He said the number for the support team was on the wound vac machine. He said the wound vac was good for 2 to 3 days depending on if the seal and suction could be kept and if there was not a lot of drainage. He said he knew how to change the wound vac. Record review of the resident's Physician's Telephone Orders dated 9/28/11 (no time given) revealed Tx. Nurse E wrote an order that if the wound vac was discontinued for more than one hour to remove the dressing, clean the wound with normal saline and pack the wound with gauze soaked in normal saline and covered with a dry dressing. In an interview on 9/29/11 at 12:40 p.m. with Tx. Nurse E, she said LVN D had told her in report at the change of shift that she had gotten an order to do wet to dry dressing to the wound, but had not written the order. Tx. Nurse E said that she was also a Unit Manager and was on administrative call to cover when a licensed nurse called in sick. She said she had come in "last night" at 9:00 p.m., worked the 10 to 6 shift and was still at the facility. She said she was trying to go home. Tx. Nurse E said she went ahead and wrote the order for LVN D. She said she did not know why LVN D did not apply the wound vac except that she did not know how to do it. Tx. Nurse E said that when she asked Resident #2 about putting on the wound vac on 9/28/11 at around 11 p.m., she said she was just too tired, her leg hurt and she did not want the wound vac put on. Tx. Nurse E said she did the wet to dry dressing. Record review at this time of the resident's Skilled Nurses' Notes for 9/28/11 revealed nothing documented for the 6 to 2 or 2 to10 shift about the resident's wound vac not functioning, about calling the physician or about the wet to dry dressing order. In an interview at this time with Tx. Nurse E, she said LVN D should have documented about the wound care and calling the physician. During an interview on 9/29/11 at 1:35 p.m., Tx. Nurse E was asked to clarify the information she gave earlier about reporting the wound vac not working and who got the order from the physician. She said that on 9/28/11 she was taking report from the ADON at shift change. She said the ADON told her that LVN G, who worked the 6 to 2 shift, had reported that Resident #2's wound vac tubing had come out and she had called the physician and gotten an order to take out the wound vac dressing and use wet to dry dressing until the wound vac could be reapplied. She said she did not know why LVN G did not go ahead and replace the wound vac on her shift. She said LVN G worked as needed and may not have attended the training in-services. In an interview with the DON, who was present at this time, she said that all the nurses should have been trained on changing the wound vac. She said they had two in-services presented by the company who made the wound vac for the licensed nurses to attend and learn how to change the wound vac. The DON was asked at this time to get the in-services from the in-service log that was on the table. She was only able to find one of the in-services dated 9/19/11. Review of the sign-in sheet revealed only 6 licensed nurses were in attendance, including LVN D. The DON was asked if the in-services were manditory. Tx. Nurse E said the company had a mannequin, equipment, and supplies for the nurses to do hands-on skills checks, "if they wanted to." She said the company even demonstrated how to use the wound vac for a hip wound like what Resident #2 had. She said LVN D was the nurse on the 2 to10 shift on 9/28/11 and she was one of the nurses who had attended the in-service and signed off that she had been trained. Tx. Nurse E did not know why LVN D did not change the wound vac or do the wet to dry treatment. Tx. Nurse E said that when she checked Resident #2's wound around 12 or 12:30 p.m., the wound vac dressing was still in place, the wound vac machine was turned off and the suction tubing was out of the dressing. She said the resident told her she was just too tired to go through having the wound vac replaced, so she did the wet to dry dressing. When Tx. Nurse E was reminded that the resident went over 9 hours without the wound vac functioning or having the wet to dry dressing done, she said the wound was always covered during that time and did not cause the resident any harm. The DON was asked for the second in-service documentation and she said she would look for it. The in-service documentation was not provided by the time of exit. In a phone interview on 9/29/11 at 2:10 p.m. with LVN D, she denied knowing anything about the resident's wound vac not functioning. She said she saw Tx. Nurse E take the dressing off around 10:30 or 11:00 p.m., before she left. Record review of Resident #2's monthly physician's orders [REDACTED]. The wound vac was to be changed every Monday, Tuesday, and Friday using wound vac supplies. The wound vac was to be run continuously to the right hip, "Monitor for proper functioning every shift." During an interview on 9/29/11 at 5:10 p.m. with RN Consultant A, she gave a copy of the facility's P&P for wound care and the manufacturer's booklet about the wound vac. She said several copies of the booklet were kept at the nurses' station for reference. Review of the manufacturer's booklet titled Clinical Guidelines, dated August 2010 revealed the following on page 14: "Foam removal:...Foam left in the wound for greater than the recommended time period may foster ingrowth of tissue into the foam, create difficulty in removing foam from the wound, or lead to infection or other adverse events... Keep V.A.C. (Vacuum Assisted Closure) Therapy On: Never leave a V.A.C. Dressing in place without active V.A.C. Therapy for more than 2 hours. If therapy is off for more than 2 hours. remove the old dressing and irrigate the wound. Either apply a new V.A.C. dressing from an unopened sterile package and restart V.A.C. Therapy, or apply an alternative dressing at the direction of the treating physician. The facility provided a list of 7 residents with wounds.