Every finding on record at Focused Care at Humble

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of 6 residents (Resident #66) reviewed for infection control.CNA A failed to perform hand hygiene with glove changes during incontinent care on Resident #66.These failures could place residents who required incontinent care at risk for cross contamination and infection.Findings included:Record review of Resident #66's face sheet dated 07/14/26 revealed a [AGE] year old admitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses including: Diabetes (a chronic condition that occurs when the body cannot properly use blood sugars), immunodeficiency d/t conditions classified elsewhere (failure of the immune system to adequately protect d/t absence or insufficiency of some component process or substance), vitamin deficiency, Hyperlipidemia ( a condition that causes the high levels of lipids, or fats in the blood), dementia, Schizophrenia (a serious mental disorder, characterized by symptoms such as hallucinations, delusions and disorganized thinking) and extrapyramidal and movement disorders (involuntary or abnormal motor activities caused by a dysfunction in the brain).Record review of the quarterly Minimum Data Set (MDS) resident assessment dated [DATE] revealed Resident #66 had a BIMS score of 7 out 15 indicating severe cognitive impairment. Resident #66 required supervision with toileting hygiene, personal hygiene, toilet transfers and sit to stand positions. Resident #66 was frequently incontinent of bowel and of urine.Record review of Resident #66's undated care plan revealed in part: Focus - Resident #66 was continent of bowel/bladder with episodes of incontinence with bathroom privileges with limited assistance by one staff member for toilet use and incontinent care.Goal - Resident #66 will remain free from skin breakdown due to incontinence and brief use.Interventions - Resident #66 uses disposable brief for incontinent care with changes every 2 hours and as needed.wash, rinse and dry perineum, change clothing PRN after incontinence episodes.Focus - Resident #66 is at risk or potential for frequent infections.r/t diabetes with vision loss.Interventions - observe/monitor/document/report PRN for s/sx of infection to any open areas.Observation and interview on 07/14/26 at 10:45AM, Resident #66 was alert and was getting himself into the bed to lay down. The back of his sweatpants was visibly wet with urine and there was an odor of urine. CNA A brought a bag of supplies into Resident #66's room: clean brief, a package of disposable wipes and one pair of gloves. CNA A provided incontinent care to Resident #66. CNA A put on clean disposable gloves, removed the soiled pants, unfastened the brief, then cleaned the resident's groin and penis using three separate disposable cleansing wipes. The resident turned to his left side and CNA A gathered the soiled brief, placed the brief in a plastic trash bag, then cleaned the buttocks and anal area using separate cleansing wipes. CNA A touched the clean brief, positioned and fastened the brief onto the resident without changing gloves and performing hand hygiene. CNA A touched the clean shorts and assisted the resident in putting them on. CNA A then removed used gloves, placed them into the trash bag. CNA A stated she would usually use hand sanitizer but did not have it with her. CNA A stated usually she was told ahead of time when incontinent care would be observed so she would have all the supplies ready including hand sanitizer. CNA A stated, I guess I will wash my hands, then washed her hands with soap and water in the residents bathroom. CNA A put on clean gloves from the box that was on the bathroom wall then assisted Resident #66 to his wheelchair. CNA A picked up the trash bag, placed the bag in the trash can that was in the hallway and sanitized her hands. CNA A stated the purpose of hand hygiene between glove changes was for hygiene and cleanliness.In an interview on 07/14/26 at 11:00 AM, the DON stated, when performing incontinent care, she expected nursing staff to perform hand hygiene before entering the room, between changing of gloves and before exiting the room. The DON stated the purpose was to control cross contamination. The DON stated she expected the staff to use hand sanitizer and if not available then to use soap and water.In an interview on 07/14/26 at 4:00 PM, the DON and the Administrator stated, when doing incontinent care, the nursing staff should change gloves when moving from clean area to dirty area, then change gloves after the care and before touching clean items to prevent cross contamination.Record review of the facility policy: Infection Control - Hand Hygiene, last revised on 10/24/2022, read in part: Hand hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogen, such as bacteria or viruses, on the hands. 1. You should always perform hand hygiene:.Before applying and after removing personal protective equipment (e.g. gloves.) Before and after providing any type of care.2. You must perform hand hygiene (hand washing or the use of an ABHR) after contact with bodily fluids, such as urine or blood.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 2 (Resident #47, Resident #38) of 17 residents reviewed for medication storage. The facility failed to ensure Resident #47's Tums (a fast-acting antacid that neutralizes stomach acid to relieve heartburn, acid indigestion, and upset stomach) were not left by the bedside on 7/13/26. The facility failed to ensure Resident #38's Systane (lubricant for eye drops) were not left by the bedside on 07/13/2026. This failure could place residents at risk of access to medications not approved for administration by their physician.Findings included:Record review of Resident #47's admission record dated 7/13/26 revealed an [AGE] year-old female who readmitted on [DATE]. Her diagnoses included moderate dementia (middle stage of cognitive decline, where memory loss and confusion become serious enough that a person needs regular help with everyday activities), osteoarthritis (degeneration of joint cartilage and underlying bone, leading to pain, stiffness, and reduced mobility), cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech), need for assistance with personal care, and major depressive disorder.Record review of Resident #47's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Her functional status was not assessed.Record review of Resident #47's care plan revised on 6/8/26 revealed she resided in the secure unit and was at risk for injury from wandering in an unsafe environment related to diagnosis of dementia; as evidenced by impaired safety awareness. interventions included: keep environment free from possible hazards, explain procedures using terms/gestures resident can understand. She also had impaired cognitive function and impaired thought processes; decisions were poor; she required reminders, cues, supervision in planning, organizing, and correcting daily routines related to dementia. Interventions were to administer medications as ordered by the MD and monitor effectiveness.Record review of Resident #47's Order Summary Report revealed orders for:Secure unit placement for safety and security due to elopement risk secondary to dementia, order date 5/12/25;Calcium carbonate chewable 500 mg give 1 tablet by mouth before meals for hypocalcemia (low calcium), order date 9/2/25.In an observation on 7/13/26 at 10:14 a.m. in Resident #47's room on the secure unit, Resident #47 was lying in bed with her eyes closed. There was a broken tablet in a medication cup sitting on her bedside table alongside her bed.In an observation and interview on 7/13/26 at 10:16 a.m. LVN T said Resident #47 had Tums (Calcium carbonate) medication that the resident saved and would not take at the time it was administered. She said staff should not leave medication at the bedside. In an observation at 10:17 a.m. LVN T entered Resident #47's room, picked up the medication cup with the Tums and administered it to the resident. Resident #47 consumed the medication. LVN T said Resident #47 would normally take all her other morning medication but would not consume the Tums unless she (the resident) had it herself. She said that was her bad and staff did sometimes leave the Tums for the resident. LVN T said some residents wandered on the secure unit and there could be a risk of other residents getting into her room.In a continued interview on 7/13/26 at 10:28 a.m. LVN T said she was the nurse who administered Resident #47's medication this morning and thought the resident consumed all her medication. LVN T said she should pay better attention and did not know the resident did not take the Tums.In an interview on 7/14/26 at 11:11 a.m. the DON said no resident on the secured unit self-administered their medication, including Resident #47. She said nursing staff had to watch the resident consume the medication and ensure there was no choking. She said the charge nurses were responsible for ensuring no medications were left at the bedside.Record review of Resident #38's admission record dated 07/15/2026 revealed a [AGE] year-old male who admitted into the facility on [DATE]. His diagnoses included Parkinson's Disease (a brain disorder that affects movement), Lack of Coordination (poor muscle control that causes clumsy, jerky, or unsteady movements), Type II Diabetes (your body either doesn't make enough insulin or ignores the insulin it does make), Contracture of Muscle (when a muscle, tendon, or surrounding tissue tightens, shortens, or stiffens), and Muscle Weakness.Record review of Resident #38's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 07 out of 15 which indicated severe cognitive impairment. His functional range of motion revealed no impairment for upper and lower extremities.Record review of Resident #38's Care Plan revised on 07/07/2026 did not reveal a focus, goal, or interventions pertaining to his eyes.Record review of Resident #38's Physician Order Summary dated 07/15/2026 did not reveal any eye medications or if he could self-administer medications.During an Interview and Observation on 07/15/2026 at 4:12pm with Resident #38, Systane (lubricant for eye drops) was on the bedside table. Resident #38 stated he administered the Systane (lubricant for eye drops) eye drops himself. Resident #38 stated he had recently seen his eye doctor, who told him during the appointment that it was acceptable for him to use the drops on his own. Resident #38 reported that the facility had never told him he could not keep or use the drops and stated he needed them until he received new glasses.[NAME] an Interview on 07/15/2026 at 4:55pm with RN O, she stated that she was not aware of Resident #38 having eye drops on his bedside table. RN O stated the expectation for medication storage is once the medication has been administered, they are supposed to put it on the cart and make sure it is secured. RN O stated the risk of medications being left out is the medication not being secured and another resident could be walking by and taking it. RN O stated that Resident #38 does not have a physician order to administer medication.During an Interview on 07/15/2026 at 4:58pm with RN D, she stated the expectation for medication storage is for medication to be stored, secured and away from residents. RN D stated the risk of medications not being secured is, the medication could be stolen and taken. RN D stated that she was unaware of Resident #38 having any medication in the room.Record review of the facility's Storage of Medications policy revised on 8/2024 read in part, .Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

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 5 residents (Resident CR# 1) reviewed for quality of care.1.The facility failed to provide wound treatment according to the NP orders from 6/9/26 to 6/10/26 and from 6/16/26 to 6/20/26 for CR #1 who experienced a worsening sacral wound that increased in size and became infected. CR #1 was sent to the hospital on 6/20/26 and was diagnosed with severe sepsis with septic shock (life threatening condition where an infection triggers dangerously low blood pressure and organ dysfunction, requiring immediate medical intervention).2.The facility failed to complete a Sepsis UDA assessment for CR #1 on 6/19/26 according to MD orders. An Immediate Jeopardy (IJ) situation was identified on 06/26/2026. While the IJ was removed on 06/27/2026, 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 worsening pressure ulcers, sepsis, hospitalization, and death.Findings included: Record review of CR #1's face sheet, dated 06/24/26, revealed an [AGE] year-old who admitted on [DATE]. Her diagnoses included peripheral vascular disease (a slow and progressive disorder of the blood vessels), Alzheimer's disease, muscle weakness, and need for assistance with personal care. She was discharged to an acute care hospital on 6/20/26.Record review of CR #1's discharge MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She was dependent on staff for toileting hygiene needs and was always incontinent of bowel and urine. She had one unstageable pressure injury presenting as a deep tissue injury. Record review of CR #1's care plan revised on 6/16/26 revealed she was at risk for skin breakdown related to history of fragile skin, vitamin deficiency, decreased sensation, incontinence, physical impairment, decreased mobility, muscle weakness and use of wheelchair for mobility propelled by staff. Interventions included all staff to be aware of resident's skin fragility and follow facility policies/protocols for the prevention/treatment of skin breakdown. CR #1 was also on antibiotics related to wounds. Interventions were to encourage fluids, give all medications and monitor for any adverse reactions report to MD asap, monitor vital signs. CR #1's sacral wound was not care-planned.Record review of CR #1's Braden scale for predicting pressure sore risk dated 4/12/26 revealed she was at high risk with a score of 12 due to very limited ability to respond meaningfully to pressure-related discomfort, very moist degree to which skin is exposed to moisture, chairfast degree of physical activity, very limited mobility, adequate nutrition, and a problem with friction and shear.Record review of CR #1's change in condition evaluation dated 6/6/26 completed by LVN J revealed she had a new open area to the coccyx (tailbone).Record review of CR #1's Wound Assessment Report dated 6/8/26 by Wound Care NP revealed she had a stage 3 sacral wound that measured 4.7 cm (l) x 2.30 cm (w) x 0.20 cm (d). The wound had 50% epithelial (a type of body tissue that forms protective layers covering internal and external surfaces, lining organs, cavities, and glands.), 45% granulation (the formation of granulation tissue, a vital part of the wound healing process that indicates the transition from inflammation to tissue repair), and 5% slough (dead tissue that appears as yellow, white, or tan material and can impede healing if not properly managed). The treatment was to clean the wound with normal saline. The primary treatment was Santyl, calcium alginate, and dry dressing daily. Record review of CR #1's wound initial dated 6/8/26 by Wound Care NP revealed there were no signs of infection of the stage 3 pressure ulcer of sacral region.Record review of CR #1's Wound Assessment Report dated 6/15/26 by Wound Care NP revealed she had a stage 3 sacral wound that measured 7.50 cm (l) x 5.20 cm (w) x 0.20 cm (d). The wound was worsening and had 10% granulation and 90% slough. The peri-wound was fragile, edema (swelling caused by too much fluid trapped in the body's tissues), erythema (superficial reddening of the skin), induration (thickening and hardening of soft tissue due to inflammation). There was moderate serous exudate (clear to pale yellow, thin, watery fluid that is a normal part of the early wound healing process but excess amounts may indicate complications such as infection). The treatment was to clean the wound with Dakins 0.125% solution. The primary treatment was Santyl, calcium alginate and dry dressing daily.Record review of CR #1's Wound Follow Up note dated 6/15/26 by Wound Care NP read in part, .Sacral wound not improved with increase in size, peri wound erythema and induration from 9 o'clock to 12 o'clock, cellulitis (bacterial skin infection) present, increase in necrotic tissue (dead, non-functioning tissue). Change treatment, added Dakin's cleanse. Recommend Bactrim DS BID x 10 days. Monitor for any changes in status or worsening of wound and notify MD/NP. Reviewed with treatment nurse.Signs of wound infection: signs symptoms present, recommend Bactrim DS BID x 10 days.Record review of CR #1's Order Summary Report revealed the following orders: -Stage 3 sacral wound clean with NS, apply Santyl, calcium alginate, cover with dry dressing as needed, order date 6/11/26;-Santyl ointment 250 unit/gm apply to per additional directions every day shift for wound care order date 6/12/26.-Bactrim DS give 1 tablet by mouth two times a day for wound infection for 10 days, order date 6/15/26 (d/c'd),-Bactrim DS give 1 tablet by mouth two times a day for wound infection/cellulitis for 10 days, order date 6/16/26.-Monitor for signs & symptoms of sepsis development throughout the entire antibiotic course and 72 hours post antibiotic completion as well as VS Q 8 hours. Symptoms of possible sepsis may include the following- 1. temperature >100.4 or <96.8 2. Pulse >90 3. O2 sats <90% 4. SBP <90 5. increase in pain level 6. increase need for O2 If any of the above present, complete the Sepsis UDA assessment. Every 8 hours for monitoring for S &S of sepsis until 06/28/2026 13:40 Additional symptoms of sepsis to monitor: skin redness/swelling, decreased urine, c/o of pain, chills, labored breathing, warmth/foul odor in wound, elevated pulse, hot/cold, or clammy skin, urine with foul odor, foul odor of breath, decreased appetite, order date 6/16/26.There were no orders added for Dakin's 0.125% cleanse according to the wound assessment report dated 6/15/26.Record review of CR #1's Medication Administration Record for June 2026 revealed Stage 3 sacral wound clean with normal saline, apply Santyl, calcium alginate, cover with dry dressing every day shift had a start date of 6/11/26 and had no documentation of administration prior to this date. Santyl ointment had a start date of 6/12/26 and there was no documentation of administration prior to this date. On 6/18/26 the order for Stage 3 sacral wound clean with NS, apply Santyl, calcium alginate, cover with dry dressing every day shift and the order for Santyl ointment were blank and had no documentation of administration. Record review of CR #1's temperature revealed on 6/19/26 at 4:48 p.m. it was 100.7 F.Record review of CR 1's administration nursing note dated 6/19/26 at 5:34 p.m. by RN T read in part, .The client took this medication for a fever of 100.8 F at 4:48 p.m., her fever is now 98.9 F .Record review of CR #1's nursing note dated 6/20/26 at 12:07 a.m. by LVN W read in part, .Resident received resting comfortably in bed, no s/s of acute distress. Day 3/10 Bactrim Ds r/t DX cellulitis of wound. tolerated well; no rash or GI upset noted. Upon assessment, initial temp noted at 99.0 F. PRN Acetaminophen 1g PO administered per standing orders at 2336. Reassessed 1 hour later: temp decreased to 96.7 F. Other vitals stable. Wound cellulitis site on sacrum remains localized with moderate redness and warmth; dressing clean, dry, and intact.Record review of CR #1's pulse readings from 6/18/26 - 6/20/26 revealed the following were abnormal (greater than 100):6/18/26 at 9:19 a.m. - 139 bpm (machine)6/19/26 at 4:48 p.m. - 130 bpm (machine)6/19/26 at 4:49 p.m. - 88 bpm (manual) -recheck of the machine reading at 4:48 p.m.6/19/26 at 9:27 p.m. - 117 bpm irregular new onset (machine)6/19/26 at 9:30 p.m. - 113 bpm irregular new onset (machine)6/20/26 at 4:12 p.m. - 118 bpm (machine)Record review of CR #1's assessments revealed there were no Sepsis UDA assessments completed per the MD order.Record review of CR #1's nursing note dated 6/20/26 at 4:22 p.m. by RN T read in part, Day 4/10 Bactrim for sacral wound. The resident was stable until 2:49 p.m. when her temperature read 99.9 F, 2 500 mg acetaminophen were administered and temperature rechecked at 4:03 p.m. and read 98.8 F. At 4:10 her temperature had risen to 100.4 F and she was having tremors. Her BP dropped from 102/74 to 96/63, and pulse went to 118. After ensuring the patients safety . I got on the telehealth app to do a visit for her. She instructed to transport her out so that she can get the infection taken care of. She would meet CR #1 at the local hospital.Record review of CR #1's emergency department notes dated 6/20/26 at 5:33 p.m. revealed CR #1 presented with fever.according to EMS, she had a sacral wound for the past 2 to 3 weeks, facility was concerned for infection. Today, started having body aches and fevers as upon presentation to the ER.CT Chest abdomen pelvis final result 1. Sacral midline pressure wound with a collection of gas and fluid measuring 5 cm x 4 cm x 4 cm, with gas extending into the ishchiorectal fossa (fat-filled, wedge-shaped space situated on either side of the anal canal), lower buttocks, and left gluteus maximus muscle (largest muscle of the buttocks) caudally with associated swelling, consistent with infection with gas-forming organism/gas gangrene (rare, rapidly progressing bacterial infection that destroys muscle and soft tissue and is a medical emergency). Diagnosis as of 6/20/26 at 11:06 p.m. Septic shock. Patient is a 88 y.o. female presenting with sacral wound. On presentation chronically ill-appearing but no distress. Febrile (having or showing the symptoms of a fever) and tachycardic (fast heart rate exceeding 100 beats per minute) on arrival with soft BPs (low blood pressure). Given IV fluids, IV antibiotics. imaging demonstrates findings concerning for necrotizing infection of the sacral wound. Scusset case [sic] with on-call general surgeon who will take patient emergently to the OR for debridement given her critical illness. Will admit to the ICU afterwards.Record review of CR #1's general surgery notes dated 6/20/26 revealed there was a 4 x 6 cm stage 4 sacral decubitus ulcer with overlying eschar (thick, dry, dead layer of tissue that forms over a wound, often appearing dark brown, or black). Under this eschar, there was necrotic fascia ( flesh-eating disease a severe bacterial infection that affects the tissue under the skin called the fascia), gas gangrene, foul smelling, grayish discharge, and area of necrosis, and gas-forming gangrene, and myositis (chronic muscle inflammation) extended all the way to the left gluteal area, then the ischiorectal fossa ((fat-filled, wedge-shaped space situated on either side of the anal canal).the patient tolerated the procedure well and was then discharged to the recovery room in stable condition.In an interview on 6/24/26 at 10:45 a.m. CR #1's family member #1 said the resident was at the local hospital under hospice care. She said CR #1 had gangrene and infection in her blood stream. In an interview on 6/24/26 at 2:26 p.m., WCN said she started the wound care nurse position on 5/25/26. She had not been a wound care nurse before but was knowledgeable because of school. She said on Mondays she rounded with Wound Care NP and put any new treatment orders in when she got them. She said over the weekend (6/6/26 - 6/7/26) one of her colleagues did a change in condition for CR #1's sacrum. The following Monday (6/8/26) she received orders for vitamin therapy, air mattress, and treatment for her sacrum. She said between 6/8/26 and 6/11/26 CR #1's treatment orders were not documented in CR #1's orders but she was sure she was doing the treatments during that time. She said she applied normal saline with calcium alginate and dry dressing without the Santyl but did not remember how she documented the treatment. She said she was not completing the treatment according to MD orders. She said Santyl was a debrider (removal of dead, damaged, infected, or nonviable tissue) and removed the slough and ickiness and Calcium alginate aided wound healing and debridement. She said if Santyl was not applied to the wound, you would have to physically remove the slough with Theraworx (gentle cleanser that supports the skin's natural antimicrobial barrier) for preventative measures and to lessen infections and aid in healing. She said she did not notify Wound Care NP that the Santyl was not applied to CR #1 for 2-3 days. She said treatment orders should be entered into the system within 24 hours and there was no justifiable reason that it was not. She said in just one week (6/15/26) CR#1's sacral wound darkened, hardened and had drainage coming out. She said the Wound Care NP prescribed her Bactrim (antibiotic) and debrided the wound with an instrument because she wanted the area to be beefy red. In an interview on 6/24/26 at 3:55 p.m., LVN J said she was a charge nurse who also helped with wound care on the weekend. She noted CR #1 had a small, open wound in the crease of her buttock. She completed a change in condition, notified the family, and reported it to Wound Care NP. On Monday 6/8/26 she completed wound rounds with Wound Care NP which was a new duty for her. She received the wound orders but did not enter them into the system, and it did not cross her mind to enter them. She said she left the orders in the office for the weekday WCN to enter. She said the nurse who received the order was typically responsible for putting the order in the system, but no one showed her how to put the wound care orders in, and she was not really told to put them in. She said there were gaps in communication. She said when she returned to work a few days later, she noticed the wound care orders for CR #1 were not in, so she put them in the system. She was unsure if the wound was treated before the order was put in. She said Wound Care NP sent a copy of the orders to DCO; and the ADCOs could also enter the orders, but they normally left that task to the nurse. She did not recall nurse management asking her about the wound care orders for CR #1. Observation on 6/24/26 at 4:50 p.m. of CR #1 at the local hospital revealed she was lying in bed asleep with a foley catheter in place. She did not respond to verbal attempts to arouse her.In an interview on 6/24/26 at 4:54 p.m., CR #1's family member #2 said CR #1 had surgery and had not been awake since. He said her wound was necrotic and the hospital staff went in to clean it. In an interview on 6/24/26 at 5:00 p.m., CR #1's family member #3 said CR #1's wound was beyond bad. She said the resident was septic and had MRSA. In an interview on 6/24/26 at 5:34 p.m. CR #1's family member #1 said on 6/6/26, she was at the facility and was informed CR #1 had a sacral wound. She said the hospital MD called her on Sunday 6/21/26 and said CR #1 needed emergency surgery or she would die. She said the surgery went well and all the infection was drained out. She said the resident was placed on hospice care and they did not expect her to make it. In an interview and observation on 6/25/26 at 9:16 a.m., WCN said on 6/8/26, LVN J completed wound care rounds with Wound Care NP. She said LVN J had to leave the building and would be back, but she did not know what happened with the wound care orders. She said she found out about CR #1's treatment orders two days later when she saw it in the MAR. She said on 6/11/26, she had Santyl samples from the representative that she used on CR #1's sacral wound. She said she put the order in for Santyl ointment on 6/12/26. On 6/15/26, she completed wound care rounds with Wound Care NP. She said Wound Care NP ordered an oral antibiotic for CR #1, but did not change the treatment order from Santyl, calcium alginate and dry dressing. She said she treated CR #1's wound according to the order in the system. She said Dakins was another form of wound cleanser, but CR #1 did not have an order for Dakins and she would have applied the normal saline. WCN was shown the treatment order for Dakins cleanse on 6/15/26 from Wound Care NP's report. WCN said she did not recall seeing the Dakins in Wound Care NP's handwritten notes, as she did not review the report. She said she was trained to receive treatment orders written or oral. Review of Wound Care NP's handwritten notes for CR #1 dated 6/15/26 revealed Dakins cleanse was handwritten in the notes. WCN said she missed the order for Dakins cleanse and it was an oversight. She said there was no risk to the resident as Dakins was a cleanser. She said while treating the wound, she could not tell that something (such as negative changes) was going on. She said no swab was done. She said when she accepted the position as wound care nurse, she completed a skills check off with DCO and ADCO. She said the facility offered a wound care certification class and wanted her to be wound care certified, but she had not started it yet. In an interview on 6/25/26 at 9:26 a.m., WCN was asked about the hole/missing treatment documentation for CR #1 on 6/18/26. She said she should have worked on 6/18/26 (but was unable to confirm) and might have forgotten to go back (and document it). She said a check mark on the MAR meant the wound care was done, but she was unsure what the blank space meant.In an interview on 6/25/26 at 11:21 a.m., Wound Care NP said the initial assessment on CR #1's sacral wound was on 6/8/26. She said during rounds, a facility nurse rounded with her and she provided a verbal and a paper report (of her orders and visit). She said Santyl was an enzymatic debrider, not antimicrobial (agent that kills or stops the growth of microorganisms), and debrided dead tissue while Calcium alginate decreased the amount of drainage and promoted autolytic debridement. She said the facility did not mention that they had not applied the Santyl for a few days and said they should do the wound care that was ordered. She said if the facility did not have the Santyl immediately that was pretty typical, because sometimes it took a while to get from the pharmacy. She said Santyl was more aggressive, but she realized it might not be available and other components of the treatment order managed the drainage. She said on 6/15/26, CR #1's sacral had not improved, and the treatment was changed to add Dakins cleanse. The action of Dakins was to assist with debridement and aid with infection. She said she was not notified that the Dakins cleanse was not applied and the main treatment was antibiotic. She said the Dakins would not stay on the wound, and was just ordered to cleanse it. She said CR #1's clinical status and wounds were complex. Her age, immobility, and other complex contributions could contribute to her immune function. She said if there were changes in the resident's status or worsening of the wound, facility staff should notify herself or the MD. In an interview on 6/25/26 at 11:51 a.m., CR #1's NP said her sacral wound was mostly unavoidable; the resident was unable to ambulate. He said once the sacral wound opened it was difficult (to manage). He said he did not have concerns with her wound treatments, but was not aware CR #1 was not treated with Dakins cleanse. He said he ordered Bactrim for CR #1 and was treating the infection empirically. He said staff should monitor for malodorous (smelling very unpleasant) and increased drainage. He stated signs and symptoms of sepsis included fever (temperature over 100.4F) and tachycardia (fast heart rate exceeding 100 beats per minute). He said he would not get too concerned over a temperature of 99 F but might start hydration. He said he was not made aware of anything regarding CR #1 on Friday 6/19/26 when he rounded and she was stable. He said he would have liked to been notified of her fever (100.7F on 6/19/26) He said it might have been a nursing judgement to give Tylenol. He said he would have given the Tylenol once and notified the NP. If the temperature was over 99.6 F, he would also notify the NP but if it was 99.1 he might not have made the call but would complete an assessment. He said if the blood pressure dropped below 100 and heart rate was above 100, he would have tried to send her out to the hospital due to the vital signs. He said he was unsure if the facility knew the signs of sepsis, but vital signs like that would be alarming especially since the resident had a known infection. He said he did not see where any more systemic damage could have been caused, but said it was important to treat residents as soon as possible. He said on Monday morning 6/22/26, he was made aware CR #1 was sent to the hospital on 6/20/26. In an interview on 6/25/26 at 12:19 p.m., RN T said she worked with CR #1 since the beginning of June 2026. She said on 6/6/26 her sacral wound was very tiny and looked chafed (skin damaged or sore by rubbing). She stated she applied Zinc Oxide and notified the wound care nurse. She said it was amazing how quickly the wound got bad due to infection, and she was prescribed antibiotics for cellulitis. She said on 6/19/26 CR #1's heart rate elevated once but did not go above 100. This Surveyor showed RN T where she took CR #1's heart rate on 6/19/26 at 4:48 p.m. and it was 130 bpm. RN T said she did not have a concern about the heart rate of 130 because she rechecked it manually one minute later and it was 88 bpm. She said when CR #1's temperature was 100.7 F (at the same time, on 6/19/26 at 4:48 p.m.) she gave her Tylenol and said that might have been a reason to notify the MD. She said she was not a doctor and was unsure why someone would spike a temperature while on antibiotics. She said if the resident had a known infection, a fever could be a concern. She said it was important to monitor vital signs because the resident could be on the wrong antibiotic and the MD should be notified if the resident was showing signs of sepsis. She said she was monitoring CR #1 for sepsis per the MD order, but did not complete a sepsis UDA assessment because she thought all the vitals had to be abnormal. She said on 6/20/26 CR #1 ate all her lunch and was stable all day. CR #1 then had a temperature of 99.9 F and was shivering, the nurse administered Tylenol. She said the resident then had a temperature of 100.4 F, and her heart rate and temperature increased. She sent CR #1 to the hospital due to her vital signs.In an interview on 6/25/26 at 1:42 p.m. DCO said WCN oversaw order entry for wounds, but no one oversaw WCN to ensure the orders were entered. She said she told staff to review Wound Care NP notes when putting the orders in. She said regarding the treatment orders from 6/8/26, LVN J thought another person was going to enter the orders and there was miscommunication between LVN J and WCN. CR #1's treatment orders from 6/8/26 were put in the system late on 6/11/26. She said her understanding was that the treatments were completed for CR #1 on 6/8/26 and 6/10/26. She said she was unsure if they were done on 6/9/26. She said she expected staff to put orders in the system within 24 hours. She said there was no risk to the CR #1 because of her comorbidities and she was hospice appropriate. She said she found out today (6/25/26) about the Dakins cleanse not being applied and did not see the order for it in CR #1's electronic record. She said Dakins was more of a cleaning agent in combo with whatever else was ordered. She said the purpose of the Sepsis UDA assessment was to see if the resident had signs and symptoms of sepsis. She said she would expect nurses to notify the MD if CR #1 had a fever that would not go down or got higher, or if the vitals did not go down. She said if the vitals were abnormal, she would have completed a sepsis UDA assessment. She said the nurses knew how to identify signs and symptoms of sepsis due to the MD orders and care pathways.In an interview on 6/27/26 at 1:20 p.m., MA A said she could not remember any abnormal blood pressure or heart rate vital signs for CR #1. She said if the heart rate was too high, she would notify the nurse. She said the vital sign was also sent to the computer and the nurse should be able to see it. Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/6/22 read in part, .The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. 2. Prevention. Theraworx skin products will be used for general cleansing after incontinent care to help maintain skin pH balance. 4. Treatment: a licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up.Record review of the facility's Change in Condition policy dated 11/1/2019 read in part, .[facility name] will use the interact definition for a change in condition. It will be the policy that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox.A physical assessment should be completed relative to the symptoms present.This was determined to be an Immediate Jeopardy (IJ) on 6/26/26 at 12:12 p.m. The Administrator, DCO, and AIT was notified. The Administrator was provided with the IJ template on 6/26/26 at 12:24 p.m and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 6/26/26 at 9:12 p.m. On 6/24/26 Complaint Survey was initiated. On 6/26/26 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide wound treatment in accordance with the NP orders from 6/9/26 to 6/10/26 and from 6/16/26 to 6/20/26 for CR #1 who experienced a worsening sacral wound that increased in size and became infected. CR #1 was sent to the hospital on 6/20/26 and was diagnosed with severe sepsis with septic shock. F-686 Action: CR#1 was discharged to hospital 6/20/26, and remains in hospital at time of Plan of Removal report 6/26/26 100% Skin audit initiated and completed by Director of Nurses/Designee, with no wounds noted without proper orders in place. 6/26/26. 100% audit of wound care orders initiated by Director of Nurses/Designee, wound care orders are identified as accurately transcribed as ordered by physician. 6/26/26 The Regional Director of Clinical Operations will provide education on Company's policy related to physician and/or family notification of new orders and/or resident change in condition to the Director of Nurses. The Director of Nursing received this in-service 6/26/26. The Regional Director of Clinical Operations will provide education on company's protocol related to Sepsis Assessment, Sepsis Orders and completion of Sepsis UDA to the Director of Nurses. The Director of Nursing received this in-service 6/26/26. In-Service on company's policy related to Sepsis Assessment, Sepsis Orders and completion of Sepsis UDA by the Director of Nurses. In-Service Read: All nurses must be familiar with the signs and symptoms manifested with sepsis, follow facility protocol and notify the NP/MD immediately. S/S of sepsis includes but is not limited to increased heartrate, decreased BP, SOB, etc. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 6/27/26. This education will also be included in all new nurse orientations for any newly hired nurses. 6/26/26 In-service on company's policy related to physician and/or family notification of new orders and/or resident change in condition to all nursing staff conducted by the Director of Nurses/Designee. Inservice Read: Nursing staff must complete a thorough head to toe assessment on all residents with a noted COC. Doctors/NP must be notified immediately to give nursing staff guidance/orders to follow; Clinical and/or nonclinical staff must complete a stop and watch form for any noted changes and notify the nurse in charge immediately. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 6/27/26. This education will also be included in all new nurse orientations for any newly hired nurses. In-service on company's policy related to following physician orders and properly transcribing new physician orders to include risks related to inaccurate transcription of orders into electronic monitoring system to all nursing staff conducted by the Director of Nurses/Designee. Inservice Read: following physicians written orders for skin or wound care require strict adherence to documented instructions. A compliant order specifies the exact wound location, cleansing solution, dressing changes, and frequency changes. Always verify orders, place the order in [electronic medical record], and document it to ensure safety and clinical efficacy immediately. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by 6/27/26. This education will also be included in all new nurse orientations for any newly hired nurses. Certified Nurse Aides were re-educated on utilization of the Stop and Watch notification in [electronic medical record] for changes in condition to include changes in skin condition on 6/26/26. All expected to be in-serviced prior to the next shift worked. All Certified Nurse Aides expected to be in-serviced by 6/27/26. This education will also be included in all new nurse orientations for any newly hired nurses. Director of Nurses or Assistant Director of Nurses will review new orders related to wound care daily to ensure Weekly Wound Assessment is in place if appropriate and/or change in conditions are happening. Weekend supervisor will review on weekends. At the time of the weekly wound rounds, the Treatment nurse will enter the order immediately into [electronic medical record], while still in the presence of the Practitioner. On the day Wound Care rounds the Director of Nursing/Designee will audit Wound Care Paperwork to verify that all physician orders have been accurately entered into the electronic medical record, treatments are correctly scheduled, and no discrepancies exist between physician orders and treatment documentation. Any identified deficiencies are corrected immediately. This process was put in place effective 6/26/26. Director of Nurses initiated disciplinary actions for Treatment Nurse and Weekend Treatment Nurse for failure to provide wound treatment in accordance with NP orders. 6/27/26 Director of Nurses initiated In-services on Change in Condition, Following Physician Orders, Properly Transcribing Orders, Assessing for Sepsis with Charge Nurses, Treatment Nurse and Weekend Treatment Nurse. All Nurse will be in-serviced by 6/27/26. Staff will not be allowed to provide direct care until training is completed. Competency Checks for wound treatment, transcribing orders in Electronic Medical Records were initiated for Treatment Nurse and Weekend Treatment Nurse. Treatment Nurse and Weekend Treatment expected to be in-serviced, and all competencies completed prior to the next shift worked.6/27/26 Upon finding a new wound, the nurse will obtain a

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 of 5 residents (CR #1) reviewed for care plans.The facility failed to ensure CR #1's stage 3 sacral wound was care planned with interventions from 6/6/26 - 6/20/26.The failure could place residents at risk of worsening pressure ulcers and hospitalization.Findings included:Record review of CR #1's face sheet, dated 06/24/26, revealed a [AGE] year-old who admitted on [DATE]. Her diagnoses included peripheral vascular disease (a slow and progressive disorder of the blood vessels), Alzheimer's disease, muscle weakness, and need for assistance with personal care. She was discharged to an acute care hospital on 6/20/26.Record review of CR #1's discharge MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She was dependent on staff for toileting hygiene needs and was always incontinent of bowel and urine. She had one unstageable pressure injury presenting as a deep tissue injury. Record review of CR #1's care plan revised on 6/16/26 revealed she was at risk for skin breakdown related to history of fragile skin, vitamin deficiency, decreased sensation, incontinence, physical impairment, decreased mobility, muscle weakness and use of wheelchair for mobility propelled by staff. Interventions included all staff to be aware of resident's skin fragility and follow facility policies/protocols for the prevention/treatment of skin breakdown. CR #1 was also on antibiotics related to wounds. Interventions were to encourage fluids, give all medications and monitor for any adverse reactions report to MD asap, monitor vital signs. CR #1's sacral wound was not care-planned and there were no interventions related to her sacral wound.Record review of CR #1's change in condition evaluation dated 6/6/26 completed by LVN J revealed she had a new open area to the coccyx (tailbone).Record review of CR #1's Order Summary Report revealed the following orders: -Stage 3 sacral wound clean with NS, apply Santyl, calcium alginate, cover with dry dressing as needed, order date 6/11/26;-Santyl ointment 250 unit/gm apply to per additional directions every day shift for wound care order date 6/12/26.In an interview on 6/29/26 at 11:20 a.m., WCN said the MDS nurse was mainly covering the care planning for the wounds, but had been out of the facility since Thursday 6/25/26. She (WCN) was new to the position but expected to soon conduct all care plans for the wounds. She said if the MDS nurse did not care plan CR #1's sacral wound then she and the two ADCOs were responsible to do it. She said it was important to ensure CR #1's sacral wound was on her care plan, because it was individualized for treatment, and should include interventions, goals, and everything needed to promote healing for better health. She said almost all staff utilized the care plan. She said there could if not her sacral wound waws not listed. She said something could get missed and could maybe cause more symptoms. She said staff were made aware of interventions through individualized in-services and through the electronic record which populated from the care plan, MD orders, and interviews with resident families.In an interview on 6/29/26 at 11:31 a.m., ADCO said WCN was responsible to care plan wounds. She said the MDS nurse was responsible for quarterly care planning. She said they had weekly standards of care meetings, and if something was needed to be added on the care plan, the MDS nurse would care plan it. She said wound interventions should be care planned immediately so everyone knew the plan of care. In an interview on 6/29/26 at 12:22 pm, DCO said the MDS nurse care planned chronic issues, but nursing staff care planned acute concerns. She said WCN was responsible for care planning wounds. She said WCN was new and they tried to do the care planning during the weekly standards of care meetings. She said the care planning for CR #1's sacral wound was missed, because on the last two Wednesdays when they held the meetings (6/10 and 6/17), she had visitors from the State in the building. She said it should have been caught. The purpose of the care plan was to update changes so everyone was aware. She said there was no risk if CR #1's sacral wound was not on the care plan.Record review of the facility's Comprehensive Care Plan policy revised 4/25/21 read in part, .Every resident will have an individualized interdisciplinary plan of care in place. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The Interdisciplinary Team will review the healthcare practitioner's notes and orders, (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate are needs including but not limited to:. b.Physician orders, g. Skin Prevention, . Any updated information based on the details of the comprehensive care plan, as necessary.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect, for 5 of 5 residents (Resident #1, Resident #2, Resident #4, Resident #8 and Resident #10) reviewed for abuse.The facility failed to ensure Resident #1 was free from abuse when CNA D forcefully pushed the resident down into the couch as the resident attempted to stand, causing the resident to cry and experience distress on 05/20/2026.The facility failed to protect Resident #2 from physical abuse when CNA D slapped the resident on the right arm, then grabbed his left arm and forcefully pulled him into a standing position, causing the resident to become unsteady and cry on 05/20/2026.The facility failed to ensure Resident #4 was treated with dignity and free from verbal and physical abuse when CNA S used vulgar language toward the resident, then grabbed him by the shoulders and forcefully walked him down the hallway to his room on 05/20/2026.The facility failed to protect Resident #8 from verbal and physical abuse when CNA S grabbed the resident by the shoulder and forced her to walk out of the activities room while using vulgar language towards her on 05/20/2026.The facility failed to ensure Resident #10 was free from abuse when Laundry Aide A struck the resident in the face during a physical altercation on 05/02/2026.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 05/20/2026 and ended on 05/21/2026. The facility corrected the non-compliance before the investigation began on 06/03/2026.These failures could place residents at risk for serious injury, trauma, and ongoing exposure to abuse.Findings included:Resident #1Record review of Resident #1's admission record, undated revealed an [AGE] year-old female who admitted into the facility on [DATE] and readmitted on [DATE]. She had diagnosis of symbolic dysfunctions (a group of neurological and cognitive impairments that affect the brain's ability to comprehend, manipulate, or express abstract symbols such as gestures or environmental signs), memory deficit, dementia, major depressive disorder, and cerebrovascular disease (all conditions affecting blood flow and the blood vessels in the brain.Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 01 out of 15, which indicated severe cognitive impairment. Resident #1 is unable to demonstrate basic recall or orientation and requires extensive support, supervision, and cueing for safety and daily decision-making.Record review of Resident #1's Care Plan initiated interventions on 07/29/2025 read. to allow resident to verbalize feelings, encourage residents to be an active participant in decision making, encourage resident to be involved in activities of choice and preference, and provide care in a warm and caring manner. It also read. Resident resides in the secure unit and is at risk for injury from wandering in an unsafe environment R/T DX of dementia and altered cognition. Resident #1 has DX of Anxiety R/T cognitive deficit which could cause anxiousness, trouble concentrating, and episodes of confusion. The interventions involved staff to Observe/Monitor/Document/Report PRN any Adverse Reactions to ANTI-ANXIETY Therapy: Drowsiness, Lack of Energy, Clumsiness, Slow Reflexes, Slurred Speech, Confusion and Disorientation, Depression, Dizziness, Lightheadedness, ImpairedThinking and Judgment, Memory Loss, Forgetfulness, Nausea, Stomach Upset, Blurred or Double Vision. UNEXPECTED SIDE EFFECTS: Mania, Hostility, Rage, Aggressive or Impulsive Behavior, Hallucination.Resident #2Record review of Resident #2's admission record, undated revealed a [AGE] year-old male who admitted into the facility on [DATE] and readmitted on [DATE]. He had diagnosis of repeated falls, lack of coordination, muscle weakness, symbolic dysfunction dysfunctions (a group of neurological and cognitive impairments that affect the brain's ability to comprehend, manipulate, or express abstract symbols such as gestures or environmental signs), dementia, major depressive disorder, altered mental status, and cognitive communication deficit.Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 99, which indicated he was unable to complete, or the interview was unsuccessful due to illness, inability to respond, advanced dementia, communication barriers, and other factors. The staff assessment revealed Resident #2 had a memory problem and is severely impaired and should never/rarely make decisions.Record review of Resident #2's Care Plan revised on 04/14/2026 read. He had Impaired Cognitive Function and Impaired Thought Processes; Decisions are Poor, Requires Reminders, Cues, Supervision in Planning, Organizing, a Correcting Daily Routines R/T DX: Dementia with Alzheimer's with Mood Disorder. The interventions read. Keep Resident's Routine Consistent and try to Provide Consistent Care Givers as much as Possible in Order to Decrease Confusion. On 05/21/2026 there was a focus revision R/T a Behavior Problem of Throwing Him Self on the Ground. The interventions read. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as we pass by. Disrobes self. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, people involved, and situations. Document behavior and potential causes.Record review of the facility's provider report dated 05/28/2026 completed by the Administrator read in part, .During a routine audit of surveillance cameras on the memory care unit for 05/20/2026, CNA D was observed engaging in inappropriate and aggressive interactions with residents on the memory unit. CNA D was observed speaking to Resident #1 in an aggressive manner and repeatedly instructing her to sit down. When Resident #1 did not immediately comply, CNA D was observed using physical force to push the resident down onto a couch . Later during the same shift, CNA D was observed approaching Resident #2 while he was asleep on a couch. Video footage showed CNA D forcefully grabbing Resident #2 and abruptly awakening him. CNA D was then observed physically directing and pushing him down the hallway toward his room. Resident #2 appeared to have little opportunity to respond or comply voluntarily before physical intervention was used. Skin assessments/head to toe assessment were completed for Resident #1 and Resident #2 with no injuries founded. The employee was suspended pending investigation and later terminated. Law enforcement weas contacted and a police report was filed. The residents were assessed, no injuries were found and the investigation findings were confirmed.Observation of video footage in the secure unit activities room on 05/20/2026 at 7:45 p.m. revealed the CNA D forcefully pushing Resident #1 down into the couch and Resident #1 began to cry.Observation of video footage in the secure unit activities room on 05/20/2026 at 8:44 p.m. revealed CNA D walking into the room and slapping Resident #2 on the right arm, pulled his legs down to a sit position, grabbed the left arm to arm, and forcefully pulling him into a standing position. The resident appeared to be confused and was not steady on his feet.Resident #4Record review of Resident #4 admission record, undated revealed a [AGE] year-old male who admitted into the facility on [DATE] and readmitted on [DATE]. He had diagnoses of epilepsy (a chronic brain disorder characterized by two or more unprovoked seizures), Parkinson's disease (movement disorder that occurs when nerve cells in the brain stop producing enough dopamine which leads to tremors, stiffness, and balance issues), cognitive impairment (decline in mental inabilities), insomnia (sleep disorder), seizures (uncontrolled surges of electrical activity in the brain that causes changes in awareness, behavior, movements, or sensations), anxiety disorder, autistic disorder, and lack of physiological development in childhood (failure to meet expected physical, motor, or growth milestones).Record review of Resident #4's Quarterly MDS dated [DATE] revealed no BIMS score but the Staff Assessment for Mental Status revealed Resident #4 had a memory problem. Resident #4 did not exhibit behaviors for the following; physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and any other behavioral symptoms not directed toward others. Resident #4 required substantial/maximal assistance with the following; oral hygiene, toileting hygiene, shower/bath self. Upper body dressing, and lower body dressing.Record review of Resident #4's Care Plan initiated on 05/06/2025 and revised on 05/04/2026 read. has a Behavior Problem R/T Low Frustration Tolerance. He also does not like to be Physically Touched by Others and Will Scream or Strike Himself Repeatedly on the Head. The interventions read . explain all procedures to the resident before starting and allot the resident time to adjust to changes, approach/speak in a calm manner, and caregivers to provide opportunity for positive interaction, attention.Resident #8Record review of Resident #8's admission record, undated revealed an [AGE] year-old female who admitted into the facility on [DATE]. She had diagnosis of dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder.Record Review of Resident #8's MDS dated [DATE] revealed a BIMS score of 04 out of 15 which indicated severe cognitive impairment. Resident #4 struggles with short-term memory, temporal orientation, and recalling words even with cues.*Record review of Resident #8's Care Plan revised on 11/05/2025 read. Resident is on Antipsychotic Medication(Rexulti) R/T Alzheimer's with Dementia with Psychosis with interventions as Observe/Monitor/Record Occurrence of Targeted Behavior and Document per Protocol, Be Conscious of Resident Position When in Groups, Activities, Dining Room toPromote Proper Communication with Others, Encourage Resident to Continue Stating Thoughts Even if Resident is HavingDifficulty: Focus on a Word or Phrase that Makes Sense or Responds to the Feeling Resident is Trying to Express, and Speak on an Adult Level, Speaking Clearly and Slower than Normal; Validate Resident's Message by Repeating Aloud.,Record review of Resident #8's psychological evaluation dated 05/25/2026 revealed a BIMS score of 05 out of 15, which indicated severe cognitive impairment, meaning the resident demonstrated major deficits in memory and orientation and requires staff support and supervision for safety and daily decision making. The psychological evaluation also read. maladaptive communication: high anxiety and the presenting problem was staff requested patient be seen given an incident that occurred at the facility. It also read. interview behavior was childlike, mood was anxious, insight was poor, judgment was poor, memory was poor recent, and functional status was severely impaired.Record review of the facility's provide report dated 05/29/2026 read. On May 21,2026, while completing random video surveillance audit of the Memory Care Unit, CNA S was observed being verbally and physically aggressive with multiple residents. On May 20, 2026, between the hours of approximately 6:00 PM and 9:00 PM, CNA S was observed cursing at Resident #8 and referring to the resident in a derogatory manner, including comments implying the resident appeared to be under the influence of drugs. CNA S was further observed forcefully directing Resident #8 out of the room while continuing to use offensive language. Additionally, CNA S was observed verbally confronting Resident #4 regarding consumption of her coffee. During the interaction, CNA S used profanity, made threatening comments suggesting physical harm, and aggressively pushed Resident #4 down the hallway toward his room. CNA S then demanded that Resident #4 remain in his room and instructed him not to get up. Employee was suspended pending investigation, then later terminated upon completion of investigation. The residents were assessed, no injuries were found and the investigation findings were confirmed.Observation of video footage in the secure unit activities room on 05/20/2026 at 7:57 p.m. revealed Resident #4 walking towards the camera when the CNA S began approaching Resident #4 and said, Resident #4's name you ugly explicit, ugly explicit. CNA S was seen grabbing Resident #4 by his shoulders and forcefully walking him towards his room. It appeared the resident cried while being grabbed and staff laughing at the actions being taken on Resident #4.Observation of video footage in the secure unit activities room on 05/20/2026 at 8:17p.m revealed CNA S entered the activities room and grabbed Resident #8 by the shoulders and forced her to walk out of the room. CNA S made a statement out loud and said, you round here tweaking like you done hit explicit dope.Record review of 72 hours documentation for Resident #1, Resident #2, Resident #4, and Resident #8 revealed the focus related to physiological and psychological distress or changes were recommended to be evaluated by psych, in which the residents involved were seen on 05/25/2026.In interview on 06/03/2026 at 4:04 p.m. with CNA S who stated she has never witnessed or committed physical abuse, nor has she threatened any resident. She stated Resident #4 was unable to communicate and if they did, it was not understandable. She stated about Resident #8 she rarely sleeps and frequently attempted to exit the unit, push doors, go to windows, or enter other residents' rooms. She stated Resident #8 is difficult to redirect and requires constant monitoring. She stated she has used profanity out loud before but stated it was not directed at a resident. She stated her approach was to talk to the residents, offer water, check for incontinence and attempt calming measures. She did not recall the last time she attended an abuse and neglect in-service but identified physical and verbal abuse as prohibited behaviors and stated she has not engaged in either.In interview on 06/03/2026 at 4:35p.m. with CNA D who stated she did not receive abuse and neglect training at the facility but understood that abuse includes verbal, physical, and neglect, and she would report concerns to the Administrator. She stated she did not know the rules because the facility operated differently from her experience. She stated Resident #1 was unstable and stated staff kept her seated to prevent falls. She stated if Resident #1 attempted to stand, she would guide her back to the couch or redirect her to the room. She stated she never witnessed Resident #1 cry. She stated that she does not recall Resident #2 being in the unit. She stated that CNA S spoke loudly and firmly to residents and would tell them to be quiet or shut up, and she had heard CNA S say, sit your explicit down, though she never heard her call resident's derogatory names. She stated she reported to LVN W, who laughed and did not act. She stated on the day of the incident, 05/20/2026, Resident # 4 drank CNA S's espresso coffee after entering the laundry area. She stated she did laugh at CNA S's reaction because CNA S was upset when she was taking Resident #4 to his room. She stated CNA S placed her arm under Resident #4 to help him walk and did not recall the exact words that were spoken.In an interview on 06/03/2026 at 5:07 p.m. with LVN W stated he resigned from his position on 05/27/2026 because the facility was investigating which involved staff using vulgar language. He stated that he could not recall his last abuse-and-neglect in-service but identified verbal, physical, and neglect as types of abuse. He stated he witnessed verbal and physical abuse by CNA L and, to his understanding possibly CNA D. When he observed inappropriate behavior, he said he would tell them not to do it. He stated some staff cursed at residents because residents often cursed at staff, and he believed some staff reacted involuntarily. He stated the Administrator was aware, and staff received in-services for cursing. He stated he did not always hear the exact words because he was focused on medications and charting. He then changed his interview and stated he never witnessed CNA S physically abuse a resident and never saw CNA D physically abuse anyone. He stated he did witness CNA D use verbal language but did not provide specific on who and when. He stated that he never laughed when staff cursed at residents.In an interview on 06/04/2026 at 9:29 a.m. with the Administrator who stated she routinely conducted random camera reviews which was how she found the multiple incidents of abuse on the secured unit. She stated on 05/20/2026 she reviewed video because there were three unrelated incidents that day and she wanted to ensure documentation was accurate and no abnormal events occurred. She stated that staff receive regular abuse and neglect training, including during orientation, through a training packet, virtual modules, follow-up test, and quarterly in-services. She stated additional training was provided any time an incident occurred and there was no reason staff should claim they were not trained. When the allegations were identified, she immediately suspended the involved staff, notified the physician, families, and police, and submitted the state report. She monitored medication practices and reported LVN W to the Board of Nursing. Staff were suspended on 05/21 and terminated on 05/27 following company procedures. She directed nurses to complete full assessments of all residents and implemented safety surveys. She assigned department head monitoring on a two week rotation, with nightly supervisors verifying staffing, resident safety, and compliance. She and the DON also conduct follow up checks. The Administrator stated the following pertaining to the residents and how it could have affected them:Resident #1 She stated they were unable to determine the resident's level of understanding but confirmed the resident's emotional response was affected.Residents #2 and #4 She stated they do not communicate effectively.Resident #8 was assessed; she apologized to her for what happened and noted the resident did not remember the incident.The Administrator stated she was disappointed in LVN W and initially believed he was unaware of what was occurring. The Administrator stated CNA D was described as nonchalant and distant. She stated CNA D did not remember pushing a resident but believed staff needed to be forceful for residents to comply. She stated CNA D admitted for cing a resident to replace a cushion despite knowing the resident did not understand. She stated CND D refused to participate in the final termination meeting and ended the investigation call. The Administrator stated CNA S initially interviewed but later stopped responding after viewing the video footage. The Administrator stated she believed CNA S was fired based on the in-service and planned to obtain an attorney. The Administrator stated that no staff outside the secured unit were aware that abuse was occurring or occurred. She also stated the facility is training a new nurse for the 6p-6a shift in the secured unit.Resident #10Record review of Resident #10's face sheet dated 6/3/26 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included dementia with psychotic and mood disturbance, delusional disorders, major depressive disorder, need for assistance with personal care, bipolar disorder with psychotic features, and anxiety.Record review of Resident #10's discharge assessment - return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making was severely impaired. She had delusions and exhibited physical and verbal behavioral symptoms toward others for 4 to 6 days. She required ADL assistance from staff.Record review of Resident #10's care plan revised on 5/18/26 indicated she had potential to be physically aggressive toward staff and peers due to delusions of thinking this is her house. 5/2/26 physical altercation between resident and staff. Interventions included altercation redirected by nursing staff, labs as ordered, medication review, family at bedside to provide one on one and encourage resident to take medications and have labs drawn. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.Record review of the facility's provider investigation report dated 5/8/26 completed by the Administrator read in part, .Upon entrance to the secure unit (on 5/2/26) (Laundry aide A) was met with (Resident #10) cursing and calling her out of her name. (Laundry aide A) repeatedly tried to passing [sic] (Resident #10), without any issues. However, (Resident #10) continued to place her chair in (Laundry aide A's) path, as she called her many derogatory and very offensive names. As (Laundry aide A), proceeded down the hall (Resident #10) hit her multiple times and pulled a handful of hair, causing (Laundry aide A) to lean over forcefully and digging her nails in her arm. At this point (Laundry aide A) started trying to get herself a loose from (Resident #10), buy [sic] pulling, swinging, yelling, etc. During this entanglement, (Resident #10) was struck by (Laundry aide A), as she was trying to get her to loosen the grip of her hair. upon completion of the investigation, it was determined that (Laundry aide A) did strike (Resident #10), but it was in defense of her grabbing her hair and arm. (Laundry aide A) did attempt to avoid the altercation, but (Resident #10) was clearly having a Psychotic episode. (Resident #10) was admitted to (behavior hospital) for her behaviors.Employee was suspended pending investigation, then later terminated upon completion of investigation. The investigation findings were inconclusive.Record review of LVN P's witness statement dated 5/2/26 and signed by LVN P read in part, .(Laundry aide A) was coming down the hall to deliver clothes. (Resident #10) was blocking the path and she asked to have her moved. (Resident #10) was cussing and reached for (Laundry aide A's) hair at which point all staff members came to intervene. When I came around (CNA H's) left side I witnessed (Laundry aide A) strike her with an open hand to her face.In an interview on 6/3/26 at 11:07 a.m. Resident #10 said she was treated nicely and did not recall anyone hitting her.In an interview on 6/3/26 at 12:29 p.m. Laundry aide A said the incident with Resident #10 happened in April or May (2026). She recalled going to the secure unit and a female resident asked her what she was doing in the unit. The resident grabbed her hair and stuck her nails in her skin. Laundry aide A tried to push the resident off her and could not remember if she hit her or not. She said CNAs were present during the incident. After the incident, the Administrator told her to go home. She was called back to the facility and informed she could not work there. She said she was trained on abuse and neglect prior to the incident and was informed she could not hit the residents or talk to them badly. She said she could not remember if she was abusive or not to Resident #10 and said she did know better and was trained on abuse.In an interview on 6/3/26 at 1:00 p.m. CNA B said on the day of the incident (5/2/26) Resident #10 was in a bad mood and put her nails into CNA H's skin and tried to hit other residents. She said Laundry aide A came to the hallway and Resident #10 blocked her path. The laundry aide asked Resident #10 to please move back and then walked past Resident #10. Resident #10 pulled the laundry aides hair and she and CNA H got in the middle of the altercation to separate them. She said while they were in between the altercation, the laundry aide swung and slapped the resident on the side of her face, the reaction appeared to be a reflex. After the laundry aide hit the resident, the CNAs isolated the resident, and the laundry aide left the secure unit. She said after the incident, Resident #10 called the laundry aide several expletives which lasted for approximately 5-10 minutes but then the resident forgot what happened. She said she was in-serviced on abuse incidents including types of abuse and who to report to. She was also in-serviced on behaviors and redirecting residents.In an interview on 6/3/26 at 1:20 p.m. CNA H said when Laundry aide A entered the secure unit (on 5/2/26) they told her to be careful around Resident #10. Resident #10 called the laundry aide names, kicked her, dug into her skin, and grabbed her by the hair. She said she intervened and tried to separate them and release the laundry aide's hair from Resident #10's grip. She said the laundry aide reached over and made contact with the resident's forehead and was unsure if she punched or slapped her. After the incident the resident sat in her wheelchair, crossed her legs, and called the laundry aide names. The resident did not remember the incident. She said she was in-serviced on abuse incidents including types of abuse and who to report to. She was also in-serviced on deescalating behaviors and what to do if a resident hits you.In an interview on 6/4/26 at 10:09 a.m. the Administrator said LVN P notified her of the incident between Laundry aide A and Resident #10 (on 5/2/26). She said the resident was irate and fighting all day. She was informed the resident pulled the laundry aide down and in self-defense the laundry aide hit the resident. She said the resident had a history of behaviors and interventions included redirection, secure unit training, and only allowing specific people in the secure unit. She said she did not know why the laundry aide responded in that matter; it could have been a natural response. She said staff did not have the right to defend themselves against residents and the laundry aide should have walked away and let the nurse deal with Resident #10. She said the laundry aide informed her that everything moved so fast and if she hit the resident, that was not her intention, she was just trying to get herself loose. She said virtual dementia training was provided to the staff as well as abuse and neglect, resident rights, and redirecting resident.Record review of abuse/neglect in-service on 04/22/2026 for Night Shift/ Hall 200 (Secured-Unit, acknowledgement of in-service being completed before incidents) completed by the DON with the contents or summary of training session included:All forms of abuse must be reported to the abuse coordinator immediatelyImmediate investigations must be conducted on all forms of abuse/neglect reported.The signature page revealed LVN W, CNA B, and CNA D signed.Record review of facility's Action Plan Agenda initiated on 05/21/2026 and followed up on 05/27/2026 read.Issue/Concern- Facility identified substantiated events of physical and verbal abuse towards residents from staff on 05/21/2026.The Measurable Goal:Nursing staff will be in-services on abuse/neglect, resident rights, forms of restraints, Senate [NAME] 9, transfers., secure unit competencies, incidents and accidents, changes of condition and following MD orders, dementia care and involuntary seclusions.Involved staff members will be suspended immediately pending investigations - 05/27/2026 all involves parties terminatedSkin assessment will be completed on all residents residing on the secure unitSecure unit competencies to be completed by staff on paper and/or skilled nursing facility clinicSafe survey assessments completed for residents and staff - 05/27/2026 standard of care review of affected residents and safe survey resultsRecord review of facility's night shift supervisor schedule, effective 05/24/2026 and ongoing for three months revealed the name of the night shift supervisor with their signature of additional monitoring checks completed on the secured unit and throughout the facility. The addendum read. The Administrator and DON will conduct random night shift rounds throughout the schedule period to ensure compliance, support, and operational oversight.Record review of facility's resident safety survey was completed on 05/21/2026 for Resident #8 (Secured Unit), Resident #14 (Secured Unit), Resident #23, Resident #34 (Secured Unit), Resident #49, Resident #54, Resident #72 and Resident #94 who revealed the following:- They felt safe in the nursing home- They felt they were treated with respect and dignity by staff- They feel free from any form of abuse (physical, emotional, verbal, or financial)- Their personal needs are being met- They feel comfortable and can speak up with being heard by staff Record review of staff knowledge and responsibility survey completed on 05/21/2026 for ADOC M, CNA E, RN C, MA A, LVN S, LVN J, LVN L, Housekeeping M, Housekeeping G, Housekeeping J, PTA R, CNA Z, CNA C, and CNA F who revealed the following:- They are familiar with the facility's abuse and neglect policy- They understand the types of abuse and neglect and the signs to look for- They understand their responsibility to report suspected abuse or neglect immediately- They are aware of Senate [NAME] 9 and understand their legal responsibility to report abuse or neglect as required by this law- They feel confident in who to report suspected abuse or neglect in accordance with Senate [NAME] 9- With all marking they have not witnessed abuse or neglect in the facilityRecord review of abuse/neglect in-service, dementia care, and resident rights on 05/21/2026 for all staff completed by the DON with the contents or summary of training session included:All forms of abuse must be reported to the abuse coordinator immediatelyImmediate investigations must be conducted on all forms of abuse/neglect reported.In interview on 06/05/2026 during the times of 9a.m. -1:51p.m. with CNA Z, CNA T, CNA J who worked in the secured unit were interviewed and stated they have received abuse and neglect in-service training including types of abuse, resident rights, dementia care and their responsibility to report concerns. They identified verbal, physical, and neglect as forms of abuse. They were instructed to immediately report any witnessed or suspected abuse to the Administrator and understood that failure to report is a violation of facility policy and state regulations.Record review of the facility's 'Abuse Policy' revised on 01/01/2023 read.POLICYThe purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property.Residents will not be subjected to abuse by anyone, including, but not limited to communitystaff, other residents, consultants, volunteers, staff of other agencies serving the residents,family members or legal guardians, care taker, friends, or other individuals.This includes physical, verbal, sexual, physical /chemical restraint.Training: All employees are required to be trained in issues related to abuse prohibitionpractices. Training includes orientation, and on-going sessions. Training will include appropriate interventions on how to deal with residents with aggression or combative behavior.Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believes that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation.All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation.Protection: It is utmost important that residents(s) suspected of being abused, and all other residents must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm, upon notification of allegation, the Abuse Coordinator or designee will perform the foll

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #4) of 5 residents reviewed for pharmacy services.The facility failed to administer 4 doses of Clonazepam (medication used to treat seizures and anxiety) to Resident #4 between 05/8/26 - 05/10/26 because it was unavailable in the facility. Resident #4 had 3 back-to-back seizures and was sent to the hospital for treatment.This failure could place residents at risk of worsening of conditions and hospitalization.Findings included:Record review of Resident #4's face sheet dated 6/3/26 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included other seizures (5/10/25), epilepsy (seizures), anxiety, Parkinson's disease, mild cognitive impairment, and autistic disorder. Record review of Resident #4's discharge-return anticipated MDS assessment dated [DATE] revealed his cognitive skills for daily decision making were moderately impaired. He required assistance from staff with ADL care. The assessment indicated he was taking an anticonvulsant and an indication was noted.Record review of Resident #4's care plan revised on 5/27/26 revealed he had a history of seizures and was at risk for injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness, revised 10/7/25. His interventions were to administer medications (Clonazepam) as ordered by Physician; observe/monitor for side effects and effectiveness every shift.Record review of Resident #4's physician orders revealed an order for Clonazepam 2 mg give 1 tablet via PEG-tube two times a day for anti-seizure, order date 5/5/26.Record review of Resident #4's Psychoactive medication therapy informed consent form dated 5/6/25 revealed Clonazepam was prescribed to treat the resident's anxiety disorder and seizures. Record review of Resident #4's Medication Administration Record for May 2026 revealed Clonazepam 2 mg was documented with a 9 (other/see progress notes) on the following dates:*5/8/26 at 8:00 p.m.,*5/9/26 at 8:00 a.m., *5/9/26 at 8:00 p.m., and*5/10/26 at 8:00 p.m.Record review of Resident #4's nursing note dated 5/8/26 at 7:29 p.m. by LVN K read in part, Clonazepam 2 mg. ordered.Record review of Resident #4's nursing note dated 5/9/26 at 9:18 a.m. by LVN R read in part, Clonazepam 2 mg. on order.Record review of Resident #4's nursing note dated 5/9/26 at 8:46 p.m. by LVN K read in part, Clonazepam 2 mg.(no documentation).Record review of Resident #4's nursing note dated 5/10/26 at 8:12 p.m. by the ADCO read in part, Clonazepam 2 mg. med on hold until avail from pharmacy md made aware.Record review of Resident #4's nursing note dated 5/11/26 at 10:39 a.m. by LVN B read in part, .Resident noted to have seizure activity with altered responsiveness. Resident experienced 3 episodes with no periods of conscious between episodes. EMS activated and resident sent out to ER for further evaluation and treatment. Vital signs monitored. MD/NP notified and gave order to send out to ER. family contacted no answer, left message. Resident transferred in stable position.Record review of Resident #4's hospital records dated 5/12/26 read in part, .5/11/26 at 2:20 p.m. Patient presents with seizures. Patient brought to ED from (facility name). Patient reportedly had 3 seizure episodes today. History of autism, seizure, Parkinson's, HTN, PEG tube. HPI: the patient is a [AGE] year-old male with autism, seizure disorder, Parkinson's disease, and HTN, who arrives via EMS presenting for reported seizure activity. History is primarily obtained from EMS and the nursing facility. Per report from (facility name) the patient had 3 seizures back-to-back without returning to baseline alertness between episodes. Facility staff described the events as violent seizures lasting about 30 seconds each and stated they did not appear consistent with his baseline dyskinesias/tardive movements. The facility also reported a fever earlier today but did not provide a temperature and did not perform any testing/swabs. EMS temperature was reported as 98 F. at time of ED evaluation he appeared at his baseline per collateral history. Home medication list provided included amlodipine and clonazepam 2 mg BID (used for seizures).Assessment: .Lactate 5 supports recent seizures. Head CT showed no acute intracranial process. Overall presentation most consistent with breakthrough seizures in a patient without a dedicated antiepileptic regimen aside from scheduled clonazepam.History of Present Illness:.at this moment MPOA.states at this moment patient is at baseline and in good spirits.says last seizure was many months ago.In an interview on 6/3/26 at 5:01 p.m. with LVN K, she said Resident #4 missed Clonazepam one or two days and then it came in. She said he did not have any complications such as a seizure or hospitalization from missing it that she knew of. In an interview 6/3/26 at 5:13 p.m. LVN R said Resident #4 was on Clonazepam for seizures, but he never exhibited anything like that. Resident #4 did not normally run out of his Clonazepam and had not had any seizures since September 2025. When he saw Resident #4's Clonazepam was missing he sent the ADCO a picture of the triplicate and said it needed to be redone. He was informed to notify Staff A. He said he could not recall if he notified Staff A but said it would be on the MAR if the medication came in the next day. He said if a medication was not on the cart or in the medication room staff could try to emergency pharmacy kit. He said he did not remember if he tried to pull the Clonazepam from the ekit but said the last time he tried to use it the system was offline or updating. He said Clonazepam was a narcotic and all narcotics required a triplicate (a triplicate prescription was a three-part carbon copy form used to track controlled substances, with one copy for the prescriber, one for the pharmacy, and one for a state agency.) He said on the day he worked with the resident (5/9/26) the resident was ok and at his baseline. In an interview on 6/4/26 at 8:27 a.m. the NP said Resident #4 displayed seizure like symptoms, and she instructed staff to send him out to the hospital. She said he had never had a seizure since summer of 2025. She said the resident was on Clonazepam for anxiety, but the medication could also be used for seizures. She said it was possible that he might have had a history of seizures but did not recall seeing seizures in his history. She said the facility called her for refills all the time. She said there was no effect from the resident missing his Clonazepam 2 mg because he was not on it for seizures. She said if he was on it for seizures there would be an effect, such as him having a seizure.In an interview on 6/4/26 at 9:18 a.m. Resident #4's family member said the resident previously sustained two seizures while at the hospital in March 2025 and was unsure if he had anymore until now. She said he recently went to the hospital (May 2026) and had 3 back-to-back seizures and was unresponsive between them. She said when she arrived at the hospital, he was perfectly fine. She said the hospital did not say how or why the seizures occurred. He was referred to a neurologist. In an interview on 6/4/26 at 9:39 a.m. the ADCO said she was informed Resident #4 had a history of seizures from his family member, but the hospital removed him from the medication. She said his Clonazepam was prescribed for anxiety and people who have seizures also use it. She said she completed his consent form for Clonazepam, and it did indicate it was for seizure and anxiety. She said she worked as his floor nurse on 5/10/26 evening shift and the facility did not have the Clonazepam, so she documented a 9 and documented why it was not given. She said she would have informed the MD and notated what she did. She said every Wednesday the staff were supposed to review the narcotic supply, but it had been so short staffed she was unsure if that was done. She said Clonazepam would need to be called into the pharmacy by the provider. If the medication had not arrived to the facility, staff should call the pharmacy to inquire where it is and call the NP again. In an interview on 6/4/26 at 11:02 a.m. the pharmacy representative said Resident #4's Clonazepam prescription order was received on 5/11/26 and sent to the facility on 5/11/26. She said the pharmacy was waiting for the prescription to be sent to them and there were no issues noted with insurance or anything else.In an interview on 6/4/26 at 11:10 a.m. LVN B said on the day Resident #4 had the seizure (5/11/26) he did not look like himself. She said he began to seizure when she sat him up, was flush, red and was shaking involuntary, and jerking around with his eyes closed. She said he would come out the seizure and was not alert displayed heavy breathing and then went into another seizure. She said he experienced 2-3 back-to-back seizures. She turned him on the side and called for help. She notified the MD who said to send him to the hospital. She said Resident #4 had not had any seizures when she worked with him before. She said he was on seizure medication and could not recall him being out of that medication while she worked.In an interview on 6/4/26 at 12:06 p.m. the DON said Resident #4 had a diagnosis of other seizures but was not on any medication for it when he admitted to the facility. She said she was unsure why the Clonazepam order had for anti-seizure on it and that they nurse would have had to see the diagnosis from the paperwork. She said Clonazepam was also used for anxiety. She noticed he missed his Clonazepam doses before he left for the hospital and inquired about the status with the nurses. She said the nursing staff called the pharmacy and it was supposed to be delivered to the facility. In an interview on 6/4/26 at 12:17 p.m. the DON said Resident #4 missed 4 doses of Clonazepam but said it would take about a week for the medication to get out of his system, which she learned from school. She said she did not think he had a seizure because of the missed doses. She said Resident #4 had other medication for anxiety. To ensure medications are available to administer to the resident the nursing staff review the 24-hour report, conduct a cart and medication room audit checks, and monitor the MARs and TARs. She said nursing staff should notify the charge nurse or nurse manager of a short supply of medication. If the medication is still not available after 3 days call the NP. She said on Wednesdays nurses conduct a triplicate request form and send them to the doctor. She said they might have been out of the Clonazepam in the emergency pharmacy kit.In an interview on 6/4/26 at 3:05 p.m. Administrator said the facility had no challenges with getting medications in on time and there were systems in place to keep the medications from running out.In an interview on 6/4/26 at 3:28 p.m. the DON said the pharmacy and NP were aware the Clonazepam was out for Resident #4. She said the facility staff notified everyone. She said on 5/9/26 a nurse notified the nurse manager, and on 5/10/26 another nurse notified the NP about not having the medication. In an interview on 6/4/26 at 3:37 p.m. the NP said the ADCO sent her a text message about a refill for Resident #4's Clonazepam on the evening of 5/10/26 and the NP called it in to the pharmacy on the morning of 5/11/26.In an interview on 6/4/26 at 9:45 a.m. LVN K said Resident #4 had a history of seizures and anxiety, but the facility did not say much about seizures and the Clonazepam was more for anxiety. She said the indication for the medication would be located on the MAR, but she could not remember what diagnosis was listed. She did not hear anything about the medication being for seizures. When she worked with Resident #4 (on 5/8/26 and 5/9/26) she remembered the Clonazepam being out. She looked for it in the medication room and overflow, but did not see it. She said she probably called the day shift nurse to see if the medication was ordered and was sure it was ordered. She could not say if she called the MD or told the next shift, but said if she did not order it, she saw where someone else ordered it. She said the process for reordering controlled medication would be to notify the physician. She said you could not get in contact with the MD after hours and sometimes MDs and NPs did not respond over the weekend. She said someone ended up reaching out to the MD because the medicine arrived at the facility. In an interview on 6/5/26 at 10:15 a.m. LVN B said she could not remember what Resident #4 was on Clonazepam for. When she called 911, she saw he had a diagnosis of other seizures. She said he should have had another blister pack of Clonazepam 2 mg in the building. She said the nurses on the floor were responsible for notifying the DON and the pharmacy when the medication supply got low around 6-8-day supply remaining. She said she did not remember anyone saying they reordered the Clonazepam and honestly thought it was in the building. She said the nurses had to ensure the medication was available and for the most part nursing staff understood the reordering process and never had medication run out.In an interview on 6/5/26 at 4:38 p.m. ADCO L said Resident #4 was on Clonazepam 2 mg for anxiety and seizures. She had not seen him have a seizure at the facility before. She said LVN R informed her that Resident #4 was running low on Clonazepam. She informed him to reach out to the resident's NP. She said she did not hear anything back from the nurse. She said she normally filled out the triplicates and reminded nursing staff on Wednesdays to send the triplicates to the MD. She said she constantly checked to ensure a 7 day or more supply was available. She said floor nurses provided oversight of the narcotic availability and the providers were responsive to medication request. She said she also never had an issue with LVN R not contacting a provider for medication. Record review of the facility's General Guidelines for Medication Administration policy dated 8-2020 read in part, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Preparation. 11. If a medication with a current, active order cannot be located in the mediation cart/drawer, other areas of the medication cart, medication room, and facility. are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit.Documentation. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a starter dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments, including the storage of schedule II medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access except when the facility uses single unit medication distribution systems in which the quantity stored was minimal and a missing dose can be readily detected for 1 of 6 medication carts (600 hall) reviewed.The facility's medication cart was not kept locked or under direct observation of authorized staff in an area where residents could access it. No medications were taken by residents but the potential for more than minimal harm exists for 1 of 6 medication carts (600 hall) reviewed.The facility failed to ensure medications were stored and secured from unauthorized residents. Findings included:During an observation on 01/02/2026 at 10:22am, 1 lidocaine patch and 2 unidentifiable pills were observed on the top of the nurse medication cart on the 600 hall, in front of a resident room. The medication cart was also observed to be unlocked.In an interview on 01/02/2026 at 10:27am with RN R, she stated the expectation is to not leave medications unattended and medication cart must be locked. RN R stated she was trying to quickly assist another staff member with another resident, and she did not have enough time to put medications away and lock the medication cart. RN R stated the risk of medications being left out and the medication cart being unlocked was residents could take the medications and could possibly get into any needles. In an interview on 01/02/2026 at 10:48am the ADMN stated the expectation was there should be no medications of top of the medication cart. Medication should be locked, along with the medication cart. The risk of medications being left out was that anyone passing by could possibly consume medications that were not prescribed and the same for the medication cart being unlocked. In an interview on 01/02/2026 at 11:11am with MA J stated the expectation for medication pass was to wash hands, compare medications, MAR match, pour medications into cup, lock the cart, provide medications to the resident, and make sure residents are taking their medications. If the medication cart is left unlocked, she would lock it and inform the person who the medication cart belonged to that it was left unlocked and unattended. The last in-service for medication storage was last week. In an interview on 01/02/2026 at 11:27am MA R stated the expectation for medication pass was the resident having the right route, right time, and right to refuse. They are to sanitize hands, check blood pressure if required, lock the medication cart, and speak to the residents to inform them of what they are being given. She stated that she has a habit of locking the medication cart and has never left it unlocked and unattended, but if she did witness medications left out, she would inform the staff. If the medications were left unattended, she would take the medication to the nurse and ensure the cart was locked. The last in-service for medication storage was 01/02/2026.In an interview on 01/02/2026 at 11:47am ADON L stated the expectation for passing medication was to make sure the staff are using the 7 rights when administering medications to the residents, ensure the cart is always locked, and document refusals. If medications are left on top of the medication cart she would take the medications and store them safely and make sure everything is secure. The risk of leaving medications on the cart unattended along with leaving the medication cart unlocked could result in a resident taking the medications, which could cause harm.Medication Storage/Labeling policy requested but was not received by the facility.

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #66) reviewed for advanced directives in that: 1. Resident #66 did not have his code status documented in the electronic record. This deficient practice could all residents as they may change their code status while being a resident at this facility. Findings: Review of Resident #66's face sheet dated [DATE] revealed he was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), Acute on chronic diastolic (congestive) heart failure, and Asymptomatic Human Immunodeficiency Virus (HIV) Infection. Resident is [AGE] years old. Record review of Resident #66's Electronic Medical Record (EMR) Point Click Care (PCC) revealed the Code Status was blank. Review of Resident #66's care plan revealed full code status. Interview on [DATE] at 11:45am with DON revealed the following. When asked how they would find the code status of a resident, DON stated they check the medical record tab at the top of the resident's EMR in PCC. Also, can check the code status book. If there's nothing there, he would be considered a full code. Stated the nurse or social worker places the code status into the chart during admission. DON logged on to PCC to look up Resident #66 code status. Stated it was not listed on his chart. Stated he was recently readmitted to this building from the hospital. Stated code status is for staff to know how to deal with residents appropriately in the event they stop breathing. DON informs SW that Resident #66 was missing a code status in PCC. Interview on [DATE] at 11:55am with SW revealed the following. When asked who puts the code status into the resident's chart, SW stated usually herself unless the resident comes in on the weekend, then the nurse who admits the resident will place it into the chart. Stated code status is used so the nurses will know what to do in the event of a code. They also have a code status book at the nurse's station. Stated Resident #66 was just in the hospital and came back. His face sheet was already in the book. Stated she forgot to redo it in his chart. Stated she does audits on code status of current residents every Monday. After looking at the printout she would replace anyone who is missing a code status. SW said she was not sure how Resident #66 was missed. Interview on [DATE] at 4:55pm with Admin revealed the following. When asked how staff find a resident's code status, Admin stated they check the binder/code status book, which are kept on the crash cart near the nurse's station. The code status are checked by the nurses nightly. Code status should be entered upon admission and readmission. Code status are expected to be updated on readmission. Stated Resident #66 was readmitted from the VA. He left on hospice services and came back skilled. Admin not sure when resident readmitted but was within the last 30 days, sometime in May. Stated in the event it's not listed in PCC, staff should check in the binder on the crash cart. Walked over to the crash cart with Admin and found resident's name and full code was listed. Review of facility policy, titled Advanced directives effective 04/2020 revealed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Advanced directives will be uploaded into the Electronic Medical Record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. -CR #1 walked out of the facility unattended with a wander guard on and was missing for approximately 20 minutes on 8/6/24. The noncompliance was identified as PNC. The IJ began on 8/6/24 and ended on 8/9/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of elopement. Findings Include: Record review of CR #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of falling, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, and type 2 diabetes mellitus with unspecified complications. Record review of CR #1's Elopement assessment dated [DATE] revealed a score of 5 which indicated she was a medium risk. She was cognitively impaired with poor decision-making skills, ambulated independently, and was a new admission who did not accept the new situation. Record review of CR #1's Order Summary Report revealed orders for: Wander guard to right ankle, order date 5/24/23; Monitor wander guard device to right ankle. Ensure that device is activated and working every shift, order date 5/24/23; Monitor every 15 minutes x 72 hours for exit seeking, order date 5/24/23. Record review of CR#1's nursing note dated 6/26/24 at 4:48 p.m. signed by the Social Worker revealed she provided a list of secure unit options to residents' RP. Currently waiting on RP decision of secure unit to send referral. Resident RP emailed Social Worker back informing her that she would like residents' information to be sent to [name] and [name]. Call was placed to both facilities, information has been sent. Record review of CR #1's Progress Note dated 7/13/24 at 2:01 p.m. and signed by LVN W revealed CR #1 was observed exit seeking but was easily redirected without difficulty resident in room at this time but will continue to monitor. Record review of CR #1's Licensed Nurse MAR for August 2024 indicated staff monitored her wander guard device to right ankle twice a day from 8/1/24 - 8/6/24 to ensure it was activated and worked. Record review of CR #1's Incident report dated 8/6/24 at 4:26 p.m. prepared by LVN W read in part, notified by beautician next door name [name] that resident was next door sitting in a chair Resident Description: resident stated I was taking a walk going to meet my daughter .Immediate action taken . head to assessment completed, rp [name] notified, 1:1 applied, NP notified. Wander guard in place to right ankle . Record review of CR #1's nursing note dated 8/6/24 at 4:45 p.m. written by the previous DON read in part, .The nurse and assigned nurse were notified by a neighboring business customer that resident had entered the business and appeared to be lost. Resident's assigned nurse immediately went to retrieve resident. Resident was immediately assessed. Skin assessment was conducted by assigned nurse-no skin issues noted. Resident appeared calm, no distress noted. Resident was immediately placed on 1:1 behavior monitoring. Resident's RP [name] notified, and requested for resident to be transferred out to hospital for eval . Record review of CR #1's nursing note dated 8/6/24 at 4:45 p.m. written by the previous Administrator read in part, .Conducted f/u interview with resident. Resident reports that she went with her [family member] to try to see what it (the beauty shop) was about. She explained that she was walking out with her [family member] and she came back by herself. Resident was in a calm and pleasant mood. No signs or symptoms of distress observed. Record review of CR#1's Care Plan dated 08/09/2024 revealed wander guard device on 06/02/2024, for verbalizations of wanting to leave the facility. CR #1 was an elopement risk/wanderer related to adjusting to the nursing home, impaired safety awareness, and resident wanders aimlessly. CR # 1 wanders around building and exit seeks. Interventions included structured activities, food, conversation, television, and books .Identify pattern of wandering .Provide reorientation strategies including signs, pictures, and memory boxes. Record review of the provider investigation report dated 8/13/24 read in part, .Individual involved: (CR #1) . Independently ambulatory? Yes. Interviewable? Yes. Capacity to make informed decisions? No. Wearing wander guard at time of incident? Yes. History of: wandering . Investigation Summary: During investigation it was noted that (CR #1) who is an [AGE] year-old female waws reported to have walked into a neighboring business. It was reported to the staff at approx. 3:25 p.m. on 8/6/24. The facility interviews with the staff revealed that the resident was last seen in the facility was approx. 3:05 p.m. on 8/6/24. Facility staff brought resident back to the building. The nurse conducted a head-to-toe assessment on resident and there were no injuries, and NO negative outcomes noted. Resident was in a pleasant mood with no s/s of distress noted. Elopement assessment completed on resident. Resident was placed on 1:1 pending further evaluation. A complete facility round and bed check was conducted and all residents were accounted for. Surrounding area grounds was assessed for hazards. The MD/NP was notified. Resident was sent to the ER for evaluation and returned the same day with no new orders. Resident resumed 1:1 until discharged [sic] to another facility with secured unit on 8/9/2024 . The Investigation Findings were confirmed. In an interview on 4/24/25 at 10:43 a.m. the Receptionist stated she had been employed at the community since April 21, 2025. She said she was aware the wander guard alert device was secure throughout the building. She said to her knowledge the residents on hallway two were the only residents who wore a wander-guard device. She stated she had not witnessed residents coming to the front door with the wander guard device and setting off the alert system. She stated she had not observed how the wander-guard worked with a resident trying to elope. She stated she was not trained on the wander-guard elopement protocol. She stated she was aware of where the hotline was posted in the community for reporting purposes, she stated she had no concerns of any abuse, neglect, or elopement. In an interview on 4/24/25 at 10:56 a.m. LVN A stated she worked on hallways two, three, and four. She stated she had been employed at the community for nine months. She said she had residents on halls three and four with the wander guard devices attached to them. She stated the front door was the main focus for resident's entry and exit. She said the other doors were always locked, but she had not witnessed a resident trying to leave. She said CR #1 was a walker/roamer in the community. She said CR #1 was very busy and hard to get her to rest. She said CR #1 was on hallway five and was not one of her assigned residents. She said she did not know the exact details of which door the resident left or the exact time. She said when she was first notified about CR #1 eloping, she was unsure of who CR #1 was. She said the other staff members had to describe the resident to her for her to remember exactly who exited the community. She said CR #1 had a best friend that she always walked with every day, but on 08/06/2024 CR #1's best friend was observed walking in the hallways by herself, so that was very odd behavior. She stated it was very important to monitor residents who roam a lot around lunchtime because families were in and out of the community and would hold the door open for a resident to exit, not knowing they were not capable of leaving the community alone. She said immediately when the elopement was discovered, the facility did a lockdown of the community followed protocol with a resident count and documentation. She stated all concerns of abuse or neglect to be reported to Executive Director of Operations. She said we in-serviced staff on elopement. In an interview on 4/24/25 at 12:55 p.m. the Fire/Safety staff said the magnetic guard and red color notification at the top of the doors throughout the facility indicated if the door was locked, not the keypad to the right of the door. He expressed that all doors had a magnetic lock at the top and could be seen by the indicated color if it was fully active. He stated the safety metal bar on the door was not necessary. He said the keypad was an entry measure and if the code was not entered the door would remain locked. He stated the wander bar at the bottom of the doors would pick up the bracelet attached to residents. He stated the codes were installed as a double measure to prevent exit. In an observation on 4/24/25 revealed the front door, hallway one, and smoking/patio had a wander guard alert system. Hallways 2, 3, 4,5, 6 did not have wander guard protection but had security code pads. In an observation on 4/24/25, a facility staff member demonstrated an attempt to exit with wander-guard attached. The alarm was triggered immediately and sounded until the code was entered. In an interview on 4/24/25 at 1:56 p.m. the Executive Director of Operations stated the community had magnetic locks at the facility for a long time to her knowledge. She said all the doors had codes and could be opened for entry. She stated the front, the smoking area/patio, and hallway one exit doors all led to driveways which were equipped with the wander-guard alert system. She said for emergency purposes the doors had a 15 second hold and could open but would set off the alarm. She said the alarm would sound on all doors. She stated if any resident went out of a wander guard equipped door, the system would go off. She stated the code would have to be entered by a staff member to disarm the alarm when there was an entry or an exit with a wander-guard resident. She said she was not employed at the facility when CR #1 eloped but read the details of the report and was aware that staff were in-serviced and there were currently no additional concerns of elopement. In an interview on 5/8/25 at 9:54 a.m., the previous Administrator said she did not have any recollection of what happened. She said everything was in the Provider Investigation Report. She said CR #1 was ultimately discharged and transferred to another facility. She said elopement training should be in the staff's orientation packet. In an interview on 5/8/25 at 10:06 a.m., the previous DON said staff had to check the light on the wander guard to make sure it was on and had to take the resident to the door to make sure the alarm went off. She said CR #1 walked around the facility with another resident but was not exit seeking. She said the beautician walked her back into the facility and the wander guard alarm sounded upon entry. She said she did not know if anyone was at the receptionist desk. She said she believed the elopement training was quarterly. In an observation on 5/8/25 at 11:35 a.m., the DON tested the wander guard system at the front door which was unlocked and closed. The wander guard sounded approximately one foot away from door and had to be disarmed by the receptionist. In an observation on 5/8/25 at 11:38 a.m., the DON tested the wander guard system at the door which led to the smoking patio area that was unlocked and closed. The wander guard sounded when she was right next to the door, and it had to be unarmed by another staff member. In an interview on 5/8/25 at 11:58 a.m., Hospitality Aide/Medication Aide/previous receptionist said she worked at the facility for 39 years and this month would be 40 years. She said she was the receptionist in August of 2024. She said she worked from 10 a.m. to 3 p.m. on 08/06/24. She said when she sits at desk located by the entrance door, no resident goes out unless the nurse tells her the resident can go out. She said when she left at 3 p.m. the nurses at the nurse's station would take over. She said CR # 1 never walked out the front door in front of her. She said when a resident with a wander guard approached the door, the alarm would sound, and the door would automatically lock. She said the resident was not one that could go outside alone. She said she did not know if the resident wore a wander guard and did not remember if she saw the resident that day. She said if they did give her in-service on elopement procedures, she did not remember but she would not let a resident walk out of the building. The inservice training record was reviewed with the previous receptionist and she confirmed her signature was not on the sign in sheet dated 08/06/24. She said after a resident left out the building it needed to be reported to the charge nurse. Staff would check all the rooms, check outside, and notify the Administrator and the DON. In an interview on 5/8/25 at 12:34 p.m. CNA G said she had been working at the facility for almost 3 years and worked the 2 p.m. to 10 p.m. shift. She said she did not think she was assigned to CR #1 that day but could not remember. She said the resident did have a wander guard on but said she had no idea if the wander guard was working that day. She said the resident had a pattern of trying to leave the facility. She was always walking around and could not remember the last time she saw the resident that day. She said if the resident got close to the door, the door would lock and alarm. She did not know how the wander guard worked when the door was already opened. She said she did not recall if her wander guard sounded that day. She said she received elopement training prior to CR #1's elopement. She said if someone were to elope, she would get help and try to redirect them to the facility. She said the facility has a code pink to alert all staff and locate the resident. In an interview on 5/8/25 at 1:17 p.m. LVN W said at the time of the incident the facility did not have a full-time receptionist. She said the previous receptionist did not work 5 days a week and thinks it was 3 days a week. She said she worked the 6 a.m.-6 p.m. shift and could not remember if the previous receptionist worked on 8/6/24. She said once the receptionist left, it was everyone's responsibility to monitor the doors at that time. She said she was working, and the beauty shop person came to the facility and informed her that the resident was at their beauty shop. She said the person asked if they had a resident who was missing, and she had everyone stop and do a resident count. She said the beauty shop person took her to the shop and the resident was sitting in a stationary chair and the resident said she was okay, no pain, and was taking a walk to get her hair done. She said the beauty shop person took her and the resident back to the facility. She said the back of the salon and the facility were behind each other and approximately 0.3 miles away from the facility. She said they entered through the front door, but as soon as they got close, the door locked, and someone had to let them inside the facility. She said she did not recall who the last person to see the resident was. She said the DON let them back inside. She said she did not have to disarm any wander guard alarms that day. In an interview on 5/8/25 at 12:55 p.m. the Executive Director of Operations said if the exit doors were open the wander guard would still sound and would have to be turned off manually. In an observation on 5/8/25 at 1:53 p.m., a resident demonstrated the use of the wander guard with the door closed and opened. The alarm sounded on both instances. Record review of Elopement in-service dated 2/13/24 and 06/22/24 revealed Hospitality Aide/Medication Aide/previous receptionist was listed. Record review of Elopement in-service dated 6/22/24 and 8/6/24 revealed LVN W was listed. Record review of the facility's undated Elopement policy read in part, Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Examples of criteria that put a resident at higher risk of elopement . cognitive impairment . exit-seeking behaviors . new admission wanting desperately to leave .System Highlights: all residents are assessed by the licensed nurse upon admission, quarterly, or with a significant change in condition for the risk of elopement. Interventions are added to the care plan and monitored for effectiveness. A notebook should be maintained at each nurses station containing a picture and a completed missing resident profile for all residents at risk for elopement. Elopement drills are conducted quarterly as training exercises for staff to practice what to do in case of an elopement. If a resident is missing: Check the resident sing out book and check to see if they are at an appointment, with activities, transportation, or with family. Code pink is called if the resident cannot be immediately located after a search of the inside and outside parameters .

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 of 7 residents (CR #1) reviewed for physician notification. -The facility failed to consult with the physician when CR#1 had a change in condition and continued losing weight, had a physical decline in performing ADL's, stopped eating and developed a burning in his throat. -The facility failed to notify CR#1's Family member when changes occurred. These failures could place residents at risk of not having their physician informed and residents not receiving adequate medical interventions, not having their care needs met, not being seen by physicians, not receiving adequate and timely interventions, which could cause a decline in physical and psychosocial health and even death. Findings included: Record review of CR #1's face sheet dated [DATE] revealed he was a sixty-six-year-old male admitted to the facility on [DATE]. His admitting diagnoses were chronic obstructive pulmonary disease with acute exacerbation (difficulty breathing), unspecified protein-calorie malnutrition, nicotine dependence, anxiety, hypertension (high blood pressure), acute pancreatitis without necrosis (pancreas inflamed), arthritis, osteoarthritis (degenerative joint disease), muscle wasting and atrophy (loss or thinning of muscle tissue), dysphagia (difficulty swallowing), difficulty in walking, cognitive communication deficit and history of Covid. Record review of CR #1's care plan dated [DATE] revealed the following: -CR#1 was on a regular mechanical soft diet with interventions for Dietary Manager to monitor/discuss food preferences, monitor and document intake, offer snacks within diet, serve diet as ordered and offer substitute if less than 50% is eaten, weigh every month and PRN-report 5% loss/gain to MD and responsible party. -CR #1 was at risk for weight loss protein calorie malnutrition. On [DATE] CR#1's Actual weight loss was 7.1% x 30 days and [DATE] was 10% over 6 months. The interventions were to assess resident for food preferences, serve resident food preferences, monitor dietary intake, weigh weekly or monthly as ordered by MD. Offer supplements between meals to enhance caloric intake. Offer substitute if less than 50% of meals is eaten, [DATE] Liquid protein 30 ml daily x 30 days, Ensure Plus 1 carton daily, snacks at 2 am and 2 pm, and house shakes with meals. -CR#1 required pain management for muscle atrophy and wasting, had a swallowing problem, and was at risk for weight loss. CR #1 requested code status of full code (perform all possible measures to save their life in the event of a medical emergency). MDS assessment signed on [DATE] revealed a BIMS summary score of 15 indicating CR#1's cognition was intact. CR#1's functional abilities and goals revealed: Supervision or touching assistance for eating, partial/moderate assistance for upper body dressing and personal hygiene, substantial/maximal assistance for toileting, oral hygiene and lower body dressing and he was dependent on staff for showers and putting on/taking off footwear. CR#1 required partial/moderate assistance for roll left and right, sit to lying, and lying to sitting on side of bed and toilet transfer, and walking 10 feet were not applicable. CR#1's height was 66 inches, weight was 73 lbs., weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, and CR#1 was on a mechanically altered diet. Record review of CR#1's Physician Orders revealed: *Assess Pain every shift for monitoring dated [DATE] *May not exceed APAP 3GM24 hr. dated [DATE] *Monitor SpO2 every shift for monitoring COPD dated [DATE] *O2 at 2L-5Lper NC to maintain SpO2 >90% every 12 hours as needed for SOB Indicate if oxygen was provided this shift by answering yes or no dated [DATE] *Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB dated [DATE] *Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for depression dated [DATE] *Vitamin D3 Tablet 5000 UNIT (Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement dated [DATE] *Clean/Change oxygen concentrator filters every night shift every Sun for Monitoring dated [DATE] *FULL CODE dated [DATE] *Multi-Vitamin/Minerals Oral Tablet (Multiple Vitamins w/Minerals) Give 1 tablet by mouth one time a day for Supplement dated [DATE] *Monitor Blood pressure every 12hours dated [DATE] *Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 tablet by mouth two times a day for Anxiety -Give ,d+[DATE] a tab to equal 0.25 mg dated [DATE] *Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 8 hours for moderate to severe pain Give 2 tablets total 100mg dated [DATE] *Calcium 500 + D3 Oral Tablet ,d+[DATE] MG-MCG (Calcium Carbonate-Cholecalciferol) Give 1 tablet by mouth in the morning for Supplement Prescriber dated [DATE] *Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day dated [DATE] *CBC AND BMP dated [DATE] *Give at least 240 ml of water with medications three times a day dated [DATE] *House Shake with meals for Supplement dated [DATE] *Ensure Plus at bedtime for Supplement -Administer 1 carton PO daily dated [DATE] *Provide snacks BID at 10 am and 2 pm two times a day for snack dated [DATE] *Document Vitals with each breathing treatment as needed for Shortness of *Breath Pre breathing treatment. Record lung sounds as C=Clear, W=Wheezing, CR=Crackles Verbal Active dated [DATE] Megestrol Acetate Tablet 20 MG Give 2 tablet by mouth one time a day for Appetite stimulant for 30 Days Administer 2 tabs to equal 40 mg -Start Date- [DATE] and ended [DATE] *STAT: CBC, BMP, UA with C&S dated [DATE] *CXR Phone Active dated [DATE] *ST clarification order for ST to treat 3x weekly for 30 days for cognitive communication methods and oropharyngeal dysphagia in order to address weight loss. Codes: one time only dated [DATE] *ST to eval and treat as indicated. one time only for 30 Days dated [DATE] *Megestrol Acetate Tablet 20 MG Give 2 tablet by mouth two times a day for Appetite for 14 Days dated [DATE] *Pulmonary Consult dated [DATE] *Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day for shortness of Breath; Cough dated [DATE] *Regular diet pureed texture, regular consistency dated [DATE] *GI Consult Phone dated [DATE] Record review of CR#1's Clinical Records dated [DATE] to [DATE] did not reveal any notes from CR#1's Physician (Physician A). Record review of CR#1's Clinical Records dated [DATE] to [DATE] did not reveal any notes from CR#1's Physician (Physician A) notifying that there was a change in condition. Record review of CR#1's Clinical Records dated [DATE] to [DATE] did not reveal any progress notes #1's indicating there was a physician notification of the change in condition. Record review of CR#1's Change in Condition Evaluation dated [DATE] and signed [DATE] at 11:16 am revealed: List of the other change: cough started [DATE], vitals blood pressure ,d+[DATE], date [DATE]. Record review of CR#1's Change in Condition Evaluation dated [DATE] and signed [DATE] revealed: Poor appetite, general weakness without fever, change in level of consciousness, or other acute symptoms. Record review of CR#1's Percentages Eaten revealed: *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% for dinner *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% dinner *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% dinner *[DATE] - Resident refused Record review of CR#1's Weight Summary dated [DATE] at 10:31 am revealed: *[DATE] - 85 lbs. *[DATE] - 86 lbs. *[DATE] - 83 lbs. *[DATE] - 84 lbs. *[DATE] - 84 lbs. *[DATE] - 81 lbs. *[DATE] - 80 lbs. *[DATE] - 78 lbs. *[DATE] - 79 lbs. *[DATE] - 77 lbs. *[DATE] - 75 lbs. *[DATE] - 77 lbs. *[DATE] - 77 lbs. *[DATE] - 78 lbs. *[DATE] - 77 lbs. *[DATE] - 78 lbs. *[DATE] - 77lbs. *[DATE] - 75 lbs. *[DATE] - 75 lbs. *[DATE] - 73 lbs. *[DATE] - 74 lbs. *[DATE] - 72 lbs. *[DATE] - 73 lbs. *[DATE] - 74.5 lbs. *[DATE] - 71 lbs. *[DATE] - 69 lbs. *[DATE] - 67 lbs. *[DATE] - 67 lbs. *[DATE] - 67 lbs. *[DATE] - 64 lbs. In an interview on [DATE] at 2:48 p.m., the DON stated they were monitoring CR#1's weight weekly because when he came to the facility, he was tiny weighing 85 lbs. and had a history of malnourishment. She stated CR#1 had an order for ensure with meals for supplement, and it had a bunch of protein calories that they gave every meal, snacks twice a day at 10 am and 2 pm, ensure plus at bedtime, megestrol 40 mg (megestrol) twice a day for appetite stimulant, multi vitamin with minerals daily, and mirtazapine 15 mg at bed time for depression and appetite stimulant. The DON stated last Friday, [DATE] CR#1 had a modified barium swallow study . She stated based on those results, she got with the speech therapist for clarification, and she stated CR#1 needed to down grade to a puree diet because he was on mechanical soft diet. The DON stated the speech therapist said CR#1 could be a candidate for a g-tube, so she scheduled a GI consult on [DATE]. The DON stated she put the following interventions in place for CR#1: Weekly weights started on admission [DATE], House shake started on [DATE] with meals active, Snacks twice a day [DATE] based on his diet, when he started, he was on mechanical soft. He did eat and had his moments where he told her not to remove his sandwich stating it took a while for him to eat it, and that he was a slow eater, Ensure plus ,d+[DATE] once a day continued, Liquid protein (active protein supplement 30 mls 1 time a day for 30 days [DATE], Megestrol 40 mg twice a day started [DATE] and ended [DATE] and restarted on [DATE]. The DON stated it was not a medication that continued long term and then they reevaluate to see if they need it again, and Multi Vitamin started on [DATE]. The DON stated as soon as CR#1 admitted to the facility they completed a baseline care plan and he was so little, she had never seen such a little man. She stated CR#1 told her his baseline was in the 70's for his weight. She stated, the RP said he was not a big eater and said she brought him candy. She stated CR#1 was alert and oriented times 4 (alert and oriented to person, place, times and event) and he could tell them everything that was going on. The DON stated on [DATE], she said he continued losing weight, so she spoke with the interdisciplinary team and said they needed a care plan meeting, she spoke with the NP, and she was recommending hospice. The DON stated the NP said, let's get with the family and see what she thinks. The DON stated she called RP and she said she was right around the corner, and she was at the facility within 5 minutes. The DON stated the RP stated CR#1's weight was always a concern and that she was open to hospice, but she wanted CR#1 to be involved with a decision like that. The DON stated she called the RP weeks before and asked them to bring CR#1 some stuff he liked, and the RP brought CR#1 a bunch of snacks and candy because he was a candy eater. The DON stated they spoke with CR#1, and he said he wanted to get better. She stated she asked him why he was not eating, and she asked if he did not like the food and CR#1 said he felt some burning when he swallowed. The DON stated she asked did CR#1 report that to anyone before and he said no, he was reporting it to the DON now. She stated she told CR#1 she would get with the Speech therapist to evaluate him, and she would call the NP as well. She stated when the meeting finished, she spoke with the NP and the NP gave an order for a swallow study and the RP was still there, so she informed them it was approved to do the swallow study. The DON stated they all agreed, and the swallow study was completed on [DATE] from 2 to 4 pm. The DON stated they asked CR#1 again during the meeting about hospice and CR#1 stated hospice was not an option. She stated the RP stated let's focus on the swallow study and CR#1 was informed of the swallow study results and his diet was downgraded to puree. The DON stated she also told CR#1 he was a candidate for G tube/feeding tube, and he said he would be open to that. The DON stated she let the NP know about the results and that he was a candidate for g-tube. The DON stated she did not contact CR#1's physician. The DON stated the NP said to put in the GI consult and Monday she contacted his insurance to get providers that were in network and only 1 responded for [DATE] at 2pm. The DON stated CR#1's [DATE] and [DATE] weight was stabilizing, and the supplements were working. She stated CR#1's weight stabilized, and he was not triggering for weight loss. She stated on [DATE] they got his weight, and he lost 2 lbs. so they called the doctor and got him megestrol to stimulate his appetite for 30 days. The DON stated CR#1 should have gotten a peg tube a long time ago, but the NP is the one who would say. She stated CR#1 was already 85 lbs. when he admitted to the facility, and they do what they could at the facility. The DON stated CR#1's Physician did not have any notes in the computer for CR#1 and she stated the Physician came to the facility in the evening. The DON stated CR#1's Physician came to the facility monthly and that he had his own practice. The DON stated on [DATE] CR#1 had a UTI and they treated it with Rocephin, and antibiotics and he also had a chest x-ray on [DATE] and it was clear of pneumonia. The DON stated CR#1 did a chest x-ray for the burning sensation in his throat to make sure he did not aspirate. In a telephone interview on [DATE] at 4:04 p.m., the NP stated CR#1 was losing weight, and was diagnosed with dysphagia and other comorbidities, declining, refusing to eat, she started him on megestrol, house shakes and supplements, they had a care plan meeting to talk about hospice and other resources. She stated she had been working at the facility for a few years. The NP stated they suggested G-tube placement she did a GI consult for the peg tube placement to be set up. The NP stated the facility was not telling her about CR#1 every month, and that they spoke to her about CR#1 periodically. The NP stated she knew the RP was informed on the care and she did not know if they made a decision for hospice. She stated CR#1 was refusing food and meals when offered. She stated she asked CR#1 about the meals but CR#1 was not really responding to her with the memory loss and everything. The NP stated from the progress notes and him refusing to eat, they just decided to do the consult. She stated she remembered mentioning a peg tube placement with the DON. She stated if someone had spoken with her earlier on, with all the weight loss, she could have suggested earlier on about g-tube placement. The NP stated a G-tube is something they could try to be more aggressive with the weight loss, but sometimes with comorbidities the body will decline even with supplemental feeding. The NP stated it could have been possible for CR#1 to eat food and have the g-tube placement. She stated they had a care plan meeting, and he was eating during the meeting. She stated CR#1 received house shakes, ensure and the staff were providing one on one feeding to assist him with meals. The NP stated any resident that may be refusing to eat was encouraged to eat. The NP stated LVN C was holding the ensure and giving CR#1 sips of ensure. The NP stated she did not know if CR#1's Physician went to see him, she could not speak on the Physician. The NP stated CR#1's Physician was aware of CR#1 In an interview on [DATE] at 3:00 p.m., CR#1's Physician (Physician A) stated CR#1 came to the facility for rehab and he was under weight. Physician A stated in the beginning CR#1 was sick and had falls. He stated CR#1's weight was a problem, and unfortunately when CR#1 came into the hospital his blood pressure was low and was under respiratory distress. The Physician stated his NP was following CR#1, so they were following CR#1. Physician A was asked by State Surveyor A if he had seen CR#1 and he stated he saw CR#1 through the NP Physician A stated his understanding was that CR#1 went up to 90 lbs. The Physician stated he thought CR#1 went up to 90 lbs. He stated an option would have been getting the peg tube placement. He stated if all these measures were failing, then the next option was getting a peg tube placement. He stated unfortunately when CR#1 was brought into the nursing facility he was underweight and they put him on supplements and all these things, but still he lost weight. He stated a few days ago, when he was consistently losing weight, he stated the NP was on top of this. Physician A stated he was trying to see when he spoke with the NP, and they discussed CR#1. He stated the options were to refer to GI and getting a peg placement. He stated he would have said to get the peg tube when he started losing weight. Physician A stated the NP was following CR#1, and at one point they thought about the peg tube. He stated when CR#1 began weighing in the 70's, they want to get a peg tube placement. He stated CR#1 was underweight when he came in and they tried getting megestrol and supplements and they tried, unfortunately nothing worked for him. Physician A stated he would speak with the NP about CR#1 because they discussed it, and they had a plan. He stated they put a GI consult for a peg placement at the time. He stated they ordered it, but unfortunately it was not placed. He stated sometimes a consult and getting the placement takes a little longer. He stated the NP said the GI consult was in place and they had supplements and megestrol to push his appetite. Physician A stated the megestrol was stopped on [DATE], and was not restarted until [DATE], but what happens is when they look at medication it goes for 30 days. He stated he would speak with the NP to talk to the NH about why he was not getting the megestrol for so long. He stated once they started the megestrol they had to see if CR#1 was eating and if he was not eating, they should call them (NP and Physician A). Physician A stated no one informed him CR#1 was still losing weight. Physician A stated he used megestrol all the time because it helped a lot. He stated after 30 days, then they needed to see if CR#1 would eat by himself and he needed to see what happened in the next 2 weeks. The Physician stated he wanted to look into why the gap was there for the medication. In an interview on [DATE] at 3:36 p.m., CR#1's RP stated she had concerns regarding his care and his weight loss. She stated she was not told that he lost weight until 2 weeks before he passed (unknown date). She stated especially the amount of weight that CR#1 lost and at that point they called and asked if she wanted to put him on hospice. She stated she deferred the decision to CR#1, and he said no. She stated CR#1 asked for other plans of care and they said a feeding tube. The RP stated they started the process with a swallow test and that was the Friday before he expired. She stated they were going to feed him, and they did express that he refused to eat on many occasions. She stated the time she was there, she tried to get him to eat something, and he did but he gave her push back. The RP stated he had Vienna sausage during the care plan meeting, and they discussed the feeding tube. She stated she was not sure on the dates and the times. She stated the DON said the only person she could get to come in was at the end of August and she stated he was not going to survive that long. She stated she told the DON, they probably needed to send CR#1 to the hospital and if they saw his condition then the hospital would put the tube in. The RP stated she told the DON this the Friday of the Care plan meeting on [DATE]. She stated she did not know why they did not send him to the hospital on [DATE]. She stated she was disappointed with herself, and she should have said take him to the hospital or she would have done it herself. She stated she was thinking that although he was small, he was still viable, so they went on. She stated on Wednesday, [DATE] she was getting dressed to go to the NH to visit him and she got the call that they were taking CR#1 to the Hospital. She stated when she went to the hospital, she thought she was going to tell them to put the feeding tube in, but when she got there, they were in full emergency mode. The RP stated the DON told her on Wednesday, [DATE] that she had not been able to find anyone for the peg tube and the DON said when she went into the room CR#1 was confused so she called EMS. She stated the DON told her when EMS came CR#1 refused to go to the hospital and she talked him into going. She stated the DON said the EMS said CR#1 told them noonce and they refused to take CR#1 to the hospital. She said that they refused to take him, so she was calling their private transport service and have them to take him to the hospital. She stated CR#1's baseline weight was 86 lbs. and that he lost 16 lbs while at the facility. She stated he stayed around 100 lbs., and it was a battle for him to stay around 100 lbs. She stated he was always small and as he aged, he did not eat as much. She stated the Doctor put him on high proteins, to get his weight up. In an interview on [DATE] at 4:30 pm the Administrator stated she was aware of CR#1's condition. She stated she saw CR#1 in the beginning when he was admitted to the facility, and he was really small. She stated other than that she did not see the residents every day because she was not clinical. She stated she was told that CR#1 came to them malnourished, and the RP said CR#1 ate very little. The Administrator stated CR#1 was seen by NP, the dietician saw him, and they had interventions in place. She stated he was seen by the physical therapist and if there was a big change they go back to the physician if the interventions did not work. She stated it was reported to her CR #1 was 70 lbs. In an interview on [DATE] at 10:35 a.m., Charge Nurse B stated CR#1 was on continuous oxygen and he had anxiety for breathing and took Ativan twice a day. She stated CR#1 did not like to eat, but he liked lemonheads, potted meat, Vienna sausages and drank sweet stuff like punch. She stated ever since she met him, he never had a big appetite. Charge Nurse B stated when CR#1 first admitted to the facility he was eating more off the food tray, but he said he did not like their food and to just give him some Vienna sausage or some potted meat. She stated she did not have a definite date that he started not eating as much. She stated the Nurses did not get the weights. She stated the restorative person got the weights and gave them to the DON. Charge Nurse B stated sometimes the weights came up on their MAR. She stated they did not get the percent of weight loss, and that it went to the DON. She stated the DON talked to the dietician and they decide what supplements and they tell the Nurses about the orders. She stated they got the orders for ensure. She stated the nursing staff did not get the triggers for weight loss. She stated the CNA's put the info for how much food the residents eat and some of them come to tell them how much food they ate. She stated she went to ask the residents why they did not eat lunch, then if the person is alert, then she will ask if they wanted something else to eat. Charge Nurse B stated she encouraged CR#1 to drink the ensure and asked him to at least taste the food and not just eat the Vienna sausages and stuff. She stated she did not know if the CNAs were hand feeding CR#1 because he could feed himself. She stated even at the end he could hold a cup and drink. She stated she did not work the last 2 days before he went out of the facility. She stated she communicated with the NP and rarely or never communicated with Physician A. The DON stated she did not call Physician A regarding CR#1, and that she called the NP. She stated if they could not get in touch with the NP then they contacted the MD. She stated the NP was always available and they were the ones who did rounds the most. She stated she had not seen Physician A here at the facility and she had worked here for 2 years. She stated they had a care plan meeting with everybody with the NP, DON, CR#1 and the RP and after the DON gets the weights, she tracked the residents for the first week and if there was weight loss, she got the order and brought it to the Nurses station. She stated that she saw CR#1 lost weight. She stated CR#1 said he did not want to be on hospice, and he wanted to live, and he wanted to stay full code. She stated they offered him a g-tube and that was what they were going to be working on. She stated she was sure it would have been beneficial for CR#1 to have the g-tube earlier. She stated she did not think CR#1's weight loss was significant at that point, but she did not do the weights. In an interview on [DATE] at 12:07 p.m., the Executive Director stated the NP is the extender of the MD. She stated that she relied heavily on clinical staff, her nurses, Physicians, and NP's. In an interview on [DATE] at 12:08 p.m., the DON stated she had worked in many facilities, and she had always contacted the NP because they were trained to take care of residents and give orders and they report to the MD. She stated they never reached out to the MD. She stated if that was the case that the MD played the primary role, then the NP role would be completely eliminated. She stated what's the point of them being an NP. She stated the residents knew the NP, but they did not know the Physicians. She stated she would get the Physicians a lot more involved. In an interview on [DATE] at 11:43 a.m., LVN D stated she worked the 6pm to 6 am shift. She stated she works the night shift so most of the physicians come in the day shift. She stated she had not seen Physician A in the facility. She stated she texted the NP. She stated she had never met with Physician A and that the NP was more active with the residents. She stated Physician A was more active for medication refills. She stated she had never involved Physician A with CR#1. She stated most of the time she got report from the day shift. She stated she had worked at the facility for 2 years. In an interview on [DATE] at 12:15 p.m., CNA G stated she had never seen Physician A in the facility. In an interview on [DATE] at 12:22 p.m., CNA H stated she had worked at the facility for about 2 years and sometimes she worked the double shift. She stated she had never seen Physician A come into the facility. In an interview on [DATE] at 1:03 p.m., Charge Nurse C stated she had never seen Physician A in the facility until the State came into the building. She stated she had called Physician A if she could not get the NP. Record review of Facility Policy, Weight Surveillance Program revised on ,d+[DATE] revealed, The purpose of this is policy is to establish facility guidelines on how and when the facility obtains and documents residents weights. This policy is also to ensure that the resident maintains the highest quality of life and wellness in the facility. Procedure: Resident Weights: Based on a resident's comprehensive assessment the facility must ensure that a resident: 1. Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless critical condition demonstrates that this is not possible, and 2. Receives a therapeutic diet when there is a nutritional problem Any resident who experiences a significant weight loss or gain must be placed on the Weight Surveillance Program. The Weight Surveillance program consists of the following: Physician, resident and family notification of the weight loss/gain, Observation of the residents eating habits, Initiation of a colored identifying object placed on the resident's meal tray will identify the resident as someone who may need extra assistance, encouragement, substitute meal, or supplements or has current weight loss identified .Dietician recommendations should be implemented or if needed, sent to the physician immediately upon receipt. If the physician has not responded within 72 hours, call the physician's office. Record review of Facility policy, Change in Condition effective [DATE] revealed, It will be the policy that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox .If you are unable to reach the physician within 2 hours, repeat call. If you are still unable to reach the physician, you may call the Medical Director. If the resident/patient condition appears emergent transfer to local ER may occur without physician order. On [DATE] at 5:02 p.m., the DON was notified of the Immediate Jeopardy due to the above failures. The IJ template was provided to the DON and a plan of removal was requested at that time. In an interview on [DATE] at 11:39 a.m., the DON stated the facility had an IJ on F 580 for failure to notify the MD as it states in the policy. The DON stated she could not answer if Physician A came to the facility or not. She stated the NP was at the facility twice a week religiously. In an interview on [DATE] at 12:36 p.m., the Executive Director stated they had an IJ on consulting a physician due to communication directly to the physician. She stated they have dived deep into the situation and there was a communication breakdown. The following Plan of Removal (POR) was submitted by the facility and accepted on [DATE] at 9:02 a.m. and indicated the following: Immediate Jeopardy Plan of Removal F580: Immediate Actions On [DATE] resident CR#1 was sent to the ER for further evaluation. On [DATE] the Director of Nursing or designee reported all residents with significant weight losses to physicians. On [DATE] the Director of Nursing or designee reported all residents with significant weight losses to the registered dietitian. On [DATE] Director of nursing or designee started education with all licensed nurses to report all weight losses to the Medical Doctor that are triggering such as: o 5% in 30 days or less o 7.5% in 90 days o 10% in 180 days The results of the weekly audits conducted during standards of care meeting will be brought to the floor staff for monitoring of efficacy of the interventions This education will be completed by [DATE]. On [DATE] Director of nursing or designee started education with all licensed nurses to report all changes of condition to the medical doctor. This will be completed by [DATE]. On [DATE] Director of Nursing or designee started education with all CNAs that if a resident consumes less than 50% of a meal, it must be reported to the assigned nurse immediately, who will then notify the medical doctor. This education will be completed by [DATE]. On [DATE] the regional director of clinical operations conducted training education with the director of nurses on notifying physicians of resident significant weight losses and the facility weight loss program. RDCO reviewed facility nutrition management policy. This education will be completed by [DATE]. *The below policies were reviewed on [DATE] and there were no changes made to current pol [TRUNCATED]

Based on interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 (CR#1) of 7 residents reviewed for neglect. -The facility failed to provide ADL care for CR#1 when he was transferred to the local hospital on [DATE] and CR#1 was found covered in fresh and dried feces and urine. These failures could place residents at risk of neglect and not having their care needs met, not being seen by physicians, not receiving adequate and timely interventions, which could cause a decline in physical and psychosocial health and even death. Findings included: Record review of CR #1's face sheet dated [DATE] revealed he was a sixty-six-year-old male admitted to the facility on [DATE]. His admitting diagnoses were chronic obstructive pulmonary disease with acute exacerbation (difficulty breathing), unspecified protein-calorie malnutrition, nicotine dependence, anxiety, hypertension (high blood pressure), acute pancreatitis without necrosis (pancreas inflamed), arthritis, osteoarthritis (degenerative joint disease), muscle wasting and atrophy (loss or thinning of muscle tissue), dysphagia (difficulty swallowing), difficulty in walking, cognitive communication deficit and history of Covid. Record review of CR #1's care plan dated [DATE] revealed the following care areas: *CR#1 was on a regular mechanical soft diet with interventions for Dietary Manager to monitor/discuss food preferences, monitor and document intake, offer snacks within diet, serve diet as ordered and offer substitute if less than 50% is eaten, weigh every month and PRN-report 5% loss/gain to MD and responsible party. * CR#1 was at risk for weight loss protein calorie malnutrition. On [DATE] CR#1's Actual weight loss was 7.1% x 30 days and on [DATE] weight loss was 10% over 6 months. The interventions were to assess resident for food preferences, serve resident food preferences, monitor dietary intake, weigh weekly or monthly as ordered by MD. Offer supplements between meals to enhance caloric intake. Offer substitute if less than 50% of meals is eaten, [DATE] Liquid protein 30 ml daily x 30 days, Ensure Plus 1 carton daily, snacks at 2 am and 2 pm, and house shakes with meals. *CR#1 required pain management for muscle atrophy and wasting, had a swallowing problem, and was at risk for weight loss. CR#1 requested code status of full code (perform all possible measures to save their life in the event of a medical emergency). Record review of CR#1's Quarterly MDS assessment signed on [DATE] revealed a BIMS summary score of 15 indicating CR#1's cognition was intact. CR#1's functional abilities and goals revealed: Supervision or touching assistance for eating, partial/moderate assistance for upper body dressing and personal hygiene, substantial/maximal assistance for toileting, oral hygiene and lower body dressing and he was dependent on staff for showers and putting on/taking off footwear. CR#1 required partial/moderate assistance for roll left and right, sit to lying, and lying to sitting on side of bed and toilet transfer, and walking 10 feet were not applicable. CR#1's height was 66 inches, weight was 73 lbs., weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, and CR#1 was on a mechanically altered diet. Record review of CR#1's Nutrition note dated [DATE] at 6:30 pm by Dietician revealed, Current weight 80 lbs., BMI 12.9, Significant weight loss of 5.8% in 30 days. Inadequate oral intake of both calories and fluids. Currently receiving abt for UTI. Weight loss despite good intake of meals reported by resident and already offered house shake BID as well. Diet order: Regular diet, mechanical soft texture, regular consistency. Supplements: Ensure Plus, House shake BID, snacks BID, mvi, vitamin D Plan: Continue previously ordered nutrition supplements and also Give Active protein 30 ml daily x 30 days. Give at least 240 ml water with medications TID. Encourage fluid intake with meals/meds. Record review of CR#1's Nutrition Note dated [DATE] by the Dietician revealed, May monthly weight was 78 lbs., significant weight loss of 9.3% in 90 days. Current weight 75 lbs. ([DATE]), BMI 12.1, usual weight 85 lbs. (At admission [DATE]). Diet order: Regular diet, Mechanical Soft texture, Regular consistency Supplements: house shake TID, snack BID, Ensure Plus q HS, Ca+vitD, mvi. Weight loss has slowed in the last 30 days. However, resident is still underweighting by BMI. His meal intake varies greatly day to day and will not consistently consume house shake or Ensure supplements. Plan: Continue to offer nutrition supplements as tolerated. Encourage adequate fluid intake. Record review of CR#1's Physician Orders dated [DATE] revealed the following: *Assess Pain every shift for monitoring dated [DATE] *May not exceed APAP 3GM24 hr. dated [DATE] *Monitor SpO2 every shift for monitoring COPD dated [DATE] *O2 at 2L-5Lper NC to maintain SpO2 >90% every 12 hours as needed for SOB Indicate if oxygen was provided this shift by answering yes or no dated [DATE] *Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB dated [DATE] *Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for depression dated [DATE] *Vitamin D3 Tablet 5000 UNIT (Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement dated [DATE] *Clean/Change oxygen concentrator filters every night shift every Sun for Monitoring dated [DATE] *FULL CODE dated [DATE] *Multi-Vitamin/Minerals Oral Tablet (Multiple Vitamins w/Minerals) Give 1 tablet by mouth one time a day for Supplement dated [DATE] *Monitor Blood pressure every 12hours dated [DATE] *Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 tablet by mouth two times a day for Anxiety -Give ,d+[DATE] a tab to equal 0.25 mg dated [DATE] *Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 8 hours for moderate to severe pain Give 2 tablets total 100mg dated [DATE] *Calcium 500 + D3 Oral Tablet ,d+[DATE] MG-MCG (Calcium Carbonate-Cholecalciferol) Give 1 tablet by mouth in the morning for Supplement Prescriber dated [DATE] *Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day dated [DATE] *CBC AND BMP dated [DATE] *Give at least 240 ml of water with medications three times a day dated [DATE] *House Shake with meals for Supplement dated [DATE] *Ensure Plus at bedtime for Supplement -Administer 1 carton PO daily dated [DATE] *Provide snacks BID at 10 am and 2 pm two times a day for snack dated [DATE] *Document Vitals with each breathing treatment as needed for Shortness of *Breath Pre breathing treatment. Record lung sounds as C=Clear, W=Wheezing, CR=Crackles Verbal Active dated [DATE] *Megestrol Acetate Tablet 20 MG Give 2 tablet by mouth one time a day for Appetite stimulant for 30 Days Administer 2 tabs to equal 40 mg -Start Date- [DATE] and ended [DATE] *STAT: CBC, BMP, UA with C&S dated [DATE] *CXR Phone Active dated [DATE] *ST clarification order for ST to treat 3x weekly for 30 days for cognitive communication methods and oropharyngeal dysphagia in order to address weight loss.one time only dated [DATE] *ST to eval and treat as indicated. One time only for 30 Days dated [DATE] *Megestrol Acetate Tablet 20 MG Give 2 tablet by mouth two times a day for Appetite for 14 Days dated [DATE] *Pulmonary Consult dated [DATE] *Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day for shortness of Breath; Cough dated [DATE] *Regular diet pureed texture, regular consistency dated [DATE] *GI Consult Phone dated [DATE] Record review of CR#1's Nutritional Risk assessment dated [DATE] revealed CR#1's height was 66 inches, weight was 69 lbs. on [DATE], the BMI was <18.5 Underweight, ideal body weight was 142 lbs., usual body weight was 85 lbs. (At admission [DATE]) and CR#1 did not have any amputations. CR#1's nutrition related medications were megestrol twice a day, buspirone, metformin and mirtazapine and diet order was regular diet, mechanical soft texture, regular consistency and supplement orders were house shake 3 times a day, snack twice a day, ensure plus every night, Calcium with Vitamin D, multivitamin, ice cream twice a day, extra fluids: 240 ml of water with medications 3 times a day. CR#1's food texture was mechanical soft ground, and regular liquid consistency. CR#1's required limited assistance with eating: self-performance with one-person physical assist and the average percentage of the meals eaten was ,d+[DATE]%. CR#1 dined in room and was bed bound and calories were 989 x 1.2 x 1.0 + 500 = 1186 kcal. Protein was 38.64 kg x 1.0 g/kg= <50 with Minimum 50 g protein is recommended for elderly daily. CR#1's fluid was minimum 1500 ml fluids is recommended for elderly daily. Nutrition assessment revealed CR#1 was seen quarterly assessment. Further review reflected the Resident was eating very little, having more difficulty breathing route of COPD. Multiple extra food items (snacks, ice cream) and nutrition supplement drinks (Ensure, shake) are offered several times a day to support adequate calorie intake. Acceptance was poor. He was eating about 50% of meals and accepting snacks, but now consumes <25% of meals. Megestrol has been ordered for appetite stimulant. Nutrition diagnosis: 1. Underweight r/t COPD, history of PCM and inadequate oral intake AEB BMI < 18.5, Nutrition concerns: altered nutrition related labs r/t history of vitamin deficiency, PCM. Goals: no signs and symptoms of dehydration or fluid overload, no significant weight loss of 5% or more in 30 days, no signs and symptoms with difficulty chewing/swallowing on modified texture diet. Nutrition plan/prescription: Encourage fluid intake during hours awake/alert. Continue supplement drinks and extra foods as tolerated. Support comfort care by honoring food preferences as much as possible. Monitor intake, weight, labs, and skin. Record review of CR#1's Care Conference Summary: Description-Change in Condition dated [DATE] and signed [DATE] at 12:05 pm revealed: CR#1's RP notified of resident's weight loss and poor appetite. RP aware of NP recommendation for hospice. RP stated that she would be open for hospice, but she would want resident to take part in that decision. Progress/Goals: Resident stated that he would like to remain a full code and receive full course treatment if needed. MBSS swallow study was ordered due to resident stating that he felt a burning sensation while swallowing. New order for megestrol for appetite stimulant SLT to evaluate and treat MBSS test continue weekly weights. Family agrees with plan of care, family agrees with MBSS test and to determine plan of care based on MBSS test. Record review of CR#1's Change in Condition Evaluation dated [DATE] and signed [DATE] at 11:16 am revealed: List of the other change: cough started [DATE], vitals blood pressure ,d+[DATE], date [DATE]. Record review of CR#1's Change in Condition Evaluation dated [DATE] and signed [DATE] revealed: Poor appetite, general weakness without fever, change in level of consciousness, or other acute symptoms. Record review of CR#1's Percentages Eaten revealed: *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% for dinner *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% dinner *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% for all three meals *[DATE] - ,d+[DATE]% breakfast, ,d+[DATE]% lunch, ,d+[DATE]% dinner *[DATE] - Resident refused Record review of CR#1's Weight Summary dated [DATE] at 10:31 am revealed: *[DATE] - 85 lbs. *[DATE] - 86 lbs. *[DATE] - 83 lbs. *[DATE] - 84 lbs. *[DATE] - 84 lbs. *[DATE] - 81 lbs. *[DATE] - 80 lbs. *[DATE] - 78 lbs. *[DATE] - 79 lbs. *[DATE] - 77 lbs. *[DATE] - 75 lbs. *[DATE] - 77 lbs. *[DATE] - 77 lbs. *[DATE] - 78 lbs. *[DATE] - 77 lbs. *[DATE] - 78 lbs. *[DATE] - 77lbs. *[DATE] - 75 lbs. *[DATE] - 75 lbs. *[DATE] - 73 lbs. *[DATE] - 74 lbs. *[DATE] - 72 lbs. *[DATE] - 73 lbs. *[DATE] - 74.5 lbs. *[DATE] - 71 lbs. *[DATE] - 69 lbs. *[DATE] - 67 lbs. *[DATE] - 67 lbs. *[DATE] - 67 lbs. *[DATE] - 64 lbs. Record review of CR#1's Local EMS Transportation record dated [DATE] revealed: Time phone rang was [DATE] at 6:13 pm, emergent one way, sick person, priority 2 (Emergent), reason for transport was for ER call [CR#1] was in need of emergency care not available at origin, reason for stretcher: monitoring requirement-oxygen administration, [CR#1] was on 10 lpm O2 and had severe muscular dystrophy and could not ambulate. Condition of patient on scene: Emergent , time activated [DATE] at 6:21 pm, time assigned [DATE] at 6:22 pm, time enroute [DATE] at 7:04 pm, minutes spent enroute 30, time on scene [DATE] 7:34 pm, time of patient contact [DATE] 7:35 pm, time transport began [DATE] at 7:49 pm, time at destination [DATE] at 8 pm, Acute symptoms: Digestive: weight loss- abnormal, general: abuse/neglect- suspected. [CR#1] was found at 7:35 pm in emergent condition. [CR#1] was a [AGE] year-old adult male. EMS determined that transportation was justified for ER call [CR#1] was in need of emergency care not available at origin. EMS found [CR#1] to be extremely malnourished and in pain. [CR#1] had been on 3lpm via nasal cannula and was changed to 10lpm via non-rebreather from the crew. [CR#1] had labored breathing and thready pulse rate. [CR#1] required stretcher transportation due to monitoring requirement - oxygen administration ([CR#1] was on 10lpm O2 and had severe muscular dystrophy and could not ambulate.). [CR#1] was moved to the stretcher by two-man assisted lift, then to the ambulance and secured for transport. Transportation started at 7:49 pm, proceeding emergent at emergency traffic speed, and completed after 10 minutes. [CR#1] was verbally responsive (but not alert). Vitals were taken at 7:50 pm, severe hypoxia (SPO2 75), labored breathing with mild tachypnea (RR ,d+[DATE]), mild bradycardia (HR 41), a blood glucose of 128, and decreased responsiveness (verbal) were observed. Vitals were taken again 5 minutes later: since vital signs were last checked, the labored breathing with mild tachypnea (RR ,d+[DATE]) persisted, the thready pulse with mild bradycardia (HR 45) persisted, the decreased responsiveness (verbal) persisted, the severe hypoxia had become moderate hypoxia (SPO2 81). [CR#1] pulse rate was believed to be faulty upon palpating of [CR#1] pulse, pulse rate was found to be significantly faster and around 90 bpm. [CR#1] O2 was raised additionally to 15 lpm during transport at 7:55 pm. There were two acute symptoms recorded during the examination of the patient: Digestive: Weight loss -abnormal (R63.4), and General: Abuse/Neglect - suspected, arrived at [local hospital] at 8:00. Record review of CR#1's Local Hospital Record Imaging dated [DATE] revealed: Hematology [NAME] Blood Count- 13.8 High (normal range is 5XXX,d+[DATE].0). Imaging recent impressions revealed Radiology x-ray chest [DATE] at 8:41 pm revealed: Large right-sided pneumothorax (a collapsed lung, occurs when air builds up in the pleural space between the chest wall and lung) greater than 80%, with compressive atelectasis of the right lung. Record review of CR#1's Local Hospital Record dated [DATE] revealed CR#1's procedures dated [DATE]: Insertion of infusion Dev into, Respiratory ventilation, Insertion of endotracheal airway, and drainage of right pleural cavity with. The primary code set revealed Septicemia or severe sepsis without MV>96 hours with M other code set. General Information revealed discharge diagnosis: multiorgan failure and septic shock. ICU team was consulted for septic shock and multi organ failure. [CR#1] desalted and required intubation. He also became hypotensive and required pressors. Despite our best efforts, resuscitation was futile because [CR#1] was in multiorgan failure. It was discussed with family that persistent measures would be futile and would end up doing more damage than good. Family decided to make [CR#1] DNR/DNI. Withdrawal of care measures were made including the administration of morphine and Ativan. Ventilator and pressor support were withdrawn. [CR#1] expired at 2:39 am. Record review of CR#1's Free Text HPI Notes from Local Hospital records dated [DATE] at 9:50 pm revealed [AGE] year-old male no known past medical history presents today via EMS from nursing home. EMS reports that he has not been eating for a week and the nursing home called due to respiratory distress. [CR#1] presenting is severely cachectic (a wasting syndrome that causes a person to lose weight and muscle mass) and with increased work of breathing. [CR#1] quickly moved to a room and started on albuterol and Bipap. Central line access needed due to lack of peripheral IVs. General: Severely cachectic, increased work of breathing, can tell me his name. HEENT: EOMI, mucous membranes are severely dry. Neck: Atraumatic, supple. Cardiac: Tachycardia, no murmurs or rubs. Respiratory: Decreased air movement in bilateral lungs, diffuse wheezing, severe increased work of. Abdomen: Non-distended, able to see bones of the pelvis and rib. Record review of CR#1's Patient Discharge and Departure: Critical Care at Local Hospital dated [DATE] at 11:14 pm revealed: Critical Care, time spent (minutes): 120, Services performed patient management by me, time spent at bedside, reviewing test results, reviewing imaging, Discussing patient care, documentation in record, time with family surrogate. [CR#1] was critically ill due to acute respiratory failure, hyperkalemia, pneumothorax, septic shock. My treatment and management were fluids, pressor, chest tube, intubation, insulin, dextrose, albuterol. CC Note 1: Total critical care time (120) minutes .CC Note 2: The high probability of sudden, clinically significant deterioration in the patient's condition required the highest level of my preparedness to intervene urgently. The services I provided to this patient were to treat and/or prevent clinically significant deterioration that could result in severe disability or death. Record review of CR#1's Local Hospital's Triage Reassessment dated [DATE] at 5:56 am revealed, [CR#1's] description of reason for visit: [CR#1] presents to ER complaining of failure to thrive. EMS states they arrived at [Nursing facility] and nurse said [CR#1] had not eaten for a week. EMS stated [CR#1] looked anorexic. States he was short of breath, placed on nonrebreather. Disposition: Expired, Chief complaint: Respiratory. Date body pronounced: [DATE], Time body pronounced: 2:39 am Record review of CR#1's Clinical Records from [DATE] to [DATE] did not reveal any notes from CR#1's Physician (Physician A). Record review of CR#1's Nurse Practitioner notes dated [DATE] at 2:10 pm revealed Treatment Goals: Diagnosis: LACK OF COORDINATION, MUSCLE WEAKNESS GENERALIZED, ARTHRITIS MULTIPLE SITES J44.1 COPD WITH ACUTE EXACERBATION. Assessment: PT- Focus on range of motion, strengthening of lower extremities, balance training, transfer training, safety awareness, and energy conservation techniques. Gait training with assistive devices when ready. Care Plan: skin care, reduce friction, prevent/reduce pressure, optimize nutrition, encourage nursing staff to increase oob activity during the day as much as possible and as patient tolerates, monitor bowel and bladder, pain management as appropriate to improve ability to participate in therapy activities; Monitoring and management of pain with Rx per IM/Physiatry collaboration as appropriate, Monitor frequently for change in mental status, neurological status, pulmonary status, cardiovascular status, and UTIs and address as appropriate, F/U Therapy visit ,d+[DATE]x week as appropriate and continue ongoing medical management by PCP/IM. Record review of CR#1's Nurse Practitioner notes dated [DATE] at 4:28 pm revealed Current Medications: Patient has no known medications. Vitals: Height: 66 in. Respiration: 18O2 Sat Additional Comments: [FIELD} {NODATA]Pulse: 67 BP 1: 142 / 89. MEDICATIONS: Acetaminophen Extra Strength Oral Tablet 500 MG Ipratropium-Albuterol Inhalation Solution 0XXX,d+[DATE].5 (3) MG/3ML Vitamin D3 Tablet 5000 UNIT Buspirone HCl Oral Tablet 10 MG Albuterol Sulfate HFA Inhalation Aerosol Solution 108 Mirtazapine Oral Tablet 15 MG Prednisone Oral Tablet 5 MG Multi-Vitamin/Minerals Oral Table Surgical History: colostomy bag .RESPIRATORY: Clear to all bases. diminished No rales, rhonchi, or wheezes. Thorax symmetric with good excursion. No use of accessory muscles. Therapy Evaluation Occupational Therapy Evaluation: Eating = Setup or clean-up assistance Hygiene Oral hygiene = Setup or clean-up assistance Toileting hygiene = Setup or clean-up assistance Transfers Toilet transfer = Setup or clean-up assistance Bathing Shower/bathe self = Supervision or touching assistance Ambulation Walk 10 feet = Supervision or touching assistance Walk 50 feet with Two Turns = Supervision or touching assistance Walk 150 feet = Supervision or touching assistance Walking 10 feet on uneven surfaces = Supervision or touching assistance Assistive Device = Two-wheeled Walker Speech Therapy Evaluation: Executive Function = Within Functional Limits Memory = Within Functional Limits Regular diet, Mechanical Soft texture, Regular consistency Record review of CR#1's Nurse Practitioner Notes dated [DATE] revealed Assessment Care Plan: optimize nutrition, monitor bowel and bladder, pain management as appropriate to improve ability to participate in therapy activities, Monitoring and management of pain with Rx per, Safety Precautions/ Fall Prevention: Activity as tolerated with assistance. Interdisciplinary falls prevention strategies per facility and individualized to reduce risk of falls and injuries. Monitor frequently for change in mental status, neurological status, pulmonary status, cardiovascular status, and UTIs and address as appropriate. Continue ongoing medical management by PCP/IM abt treatment Record review of CR#1's Nurse Practitioner Notes dated [DATE] revealed Vitals: Height: 66 in. Weight: 77 lbs. BMI: 12.4O2 Sat Additional Comments: [FIELD} {NODATA] BP 1: 128 / 76. Chief Complaint: Chief Complaint: evaluation of weakness, impaired mobility and gait, s/p fall. HPI Update Patient seen in room laying in bed, no acute distress. Patient exhibits decline in strength, balance, gait impairment and endurance. Swallowing Difficulties (-) [meaning none]; Chest Pain (-) Respiratory Dyspnea (-); Wheezing (-); Cough (-); Gastrointestinal Abdominal Pain (-); Constipation (-); Diarrhea (-); Nausea (-); Genitourinary dysuria (-) pain(-), dark coke colored urine Musculoskeletal Muscle Weakness (+) muscle atrophy. GENERAL: GENERAL: frail adult in no apparent distress. Alert, calm, and cooperative. RESPIRATORY: Clear to all bases. diminished No rales, rhonchi, or wheezes. Thorax symmetric with good excursion. No use of accessory muscles. OT- Focus on bed mobility, transfers, fine and gross motor coordination, upper and lower body ADLs, self care, grooming/hygiene, and toileting copd- Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, Albuterol Sulfate HFA Inhalation Aerosol Solution 108, O2 at 2L-5Lper NC to maintain SpO2 >90% monitor during therapy sessions SPO2, pain management as appropriate to improve ability to participate in therapy activities, Monitoring and management of pain with Rx per IM/Physiatry collaboration as appropriate, UTIs and address as appropriate, weakness, impaired mobility, and gait impairment following his recent fall. The goal is to improve his functional status, mobility, and quality of life within the long-term care setting. Record review of CR#1's Nurse Practitioner notes dated [DATE] at 1:26 pm revealed Vitals: Height: 66 in. Previous Weight: 77 lbs. Occupational Therapy Evaluation: Eating = Supervision or touching assistance; Personal hygiene Partial/moderate assistance; Toileting hygiene = Substantial/maximal assistance; Regular diet, Mechanical Soft texture, Regular consistency. Care Plan: copd- Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, Albuterol Sulfate HFA Inhalation Aerosol Solution 108, O2 at 2L-5Lper NC to maintain SpO2 >90% monitor during therapy sessions SPO2 Monitor frequently for change in mental status, neurological status, pulmonary status, cardiovascular status, and UTIs and address as appropriate. Record review of CR#1's Nurse Practitioner notes revealed she saw CR#1 in February 2024, [DATE], [DATE] and did not see CR#1 until [DATE]. Record review did not reveal any notes indicating the Nurse Practitioner was informed that CR#1's weight continued to decline to 67 lbs. Record review of CR#1's Nurse Practitioner notes dated [DATE] at 7:30 am revealed Note Text: Chief Complaint: progress note. History of Present Illness: The patient is a [AGE] year-old African American male under the care of Physician A with a diagnosis of COPD. He has a history of severe COPD, anxiety, and hypertension, who comes in with shortness of breath, coughing, and wheezing. He only has albuterol inhaler at home. His chest x-ray was normal. Patient is alert and conversant, he has no complaints or concerns at the moment. No difficulty in breathing noted. Reviewed medical plans, he will continue on current management. He remains afebrile. BP/HR/Pulse continue to monitor for hypertension. Recent UTI resolved with ABT. Physical Examination: BP: ,d+[DATE] Pulse: 77 RR: 18 Temp: 97.3 F Sat: 97. Nose: Mucosa normal, no obstruction, no discharge, nares patent. Throat: Clear, no exudates, no lesions, no erythema. LUNGS: Clear to auscultation bilaterally. No rales, rhonchi, or wheezes. No use of accessory muscles of respiration. Alert and oriented x3; Assessment & Plan: Shortness of breath, Chronic obstructive pulmonary disease, Diet- Regular diet, Mechanical soft texture, regular consistency. COPD - Titrate oxygen ,d+[DATE] via NC to room air if O2 sats is greater than 90. Monitor O2 saturation, respiration, and cough related to COPD. Record review of CR#1's Nurse Practitioner Notes dated [DATE] at 8:10 am revealed LATE ENTRY, Chief Complaint: progress note. History of Present Illness: The patient is a [AGE] year-old African American male under the care of Physician A with a diagnosis of COPD. He has a history of severe COPD, anxiety, and hypertension, who comes in with shortness of breath, coughing, and wheezing. He only has albuterol inhaler at home. His chest x-ray was normal at this moment. He will be participating in ST sessions for improvement on cognitive communication abilities and oropharyngeal dysphagia management. Patient and staff education on aspiration precaution during meals and when drinking medications. IDT meeting with RP to be held to discuss patient's weight loss due to refusal to eat and hospice consult and care. Patient educated on importance of healthy meals and diet. He refuses to eat meals at times, house shakes offered, ensure provided, megestrol ordered to help with weight gain. He has no concerns at the moment. No pain or discomfort noted. We will continue to monitor. Throat: Denies swelling or pain. RESPIRATORY: Denies SOB or cough. Physical Examination: BP: ,d+[DATE] Pulse: 67 RR: 18 Temp: 98.4 F Sat: 97 LUNGS: Clear to auscultation bilaterally. No rales, rhonchi, or wheezes. No use of accessory muscles of respiration. EXTREMITIES: No deformities, no tenderness, no swelling, no erythema. Good tissue perfusion. 2+ PP bilaterally. Diet- Regular diet, Mechanical soft texture, regular consistency. COPD - Titrate oxygen ,d+[DATE] via NC to room air if O2 sats is greater than 90. Monitor O2 saturation, respiration, and cough related to COPD. Record review of CR#1's Physician MBSS Consult Summary dated [DATE] by Physician B revealed, ORAL PHASE: In the Oral Phase, the [CR31] exhibited good bolus acceptance. Decreased mastication d/t missing dentition reduced rotary jaw movement - large pieces of MS swallowed. Delayed A-P transit d/t reduced lingual strength and coordination. Mild residue removed with multiple swallows. Prespill to valleculate and pyriformis. Adequate bilabial seal despite L-sided weakness. Pharyngeal phase: In the Pharyngeal Phase, [CR#1] displayed up to 3 second delay. Residue within valleculate due to decreased BOT retraction, within pyriformis d/t narrowing - multiple swallows, alt solids/liquids, L head turn effective in widening pharynx and reducing retropulsion. Trace amounts of thin and NTL aspirated after swallow - removed with throat clear - improved with cue. Narrowing d/t large osteophytes. Esophageal findings: Normal flow of bolus through Lower Esophageal Sphincter into stomach without stasis in esophagus. No masses, retropulsion, hiatal hernia, diverticulum, stricture or other abnormality that clinically affects the function of the esophagus. Bolus cleared to the stomach without delay. Unable to visualize duodenal bulb due to patient positioning or body habitus. Recommendations: Meal Diet: Pureed, Thin liquids. Strategies for Pills: Choking risk - crush meds, Crush meds or liquid form. Patient will likely benefit from a skilled dysphagia feeding, exercise, and/or management plan directed by a Speech Language Pathologist. Meal diet recommendations: These recommendations are made based on the results of the MBSS and goals of care for the patient. Dietary consult suggested for supplementation option due to reduced oral efficiency and/or low BMI. Consider alternate means of feeding for main source of nutrition and hydration. Consider liquid calorie supplementation. Meal Diet: Solids: Pureed, Liquids: Thin liquids. Strategies for Pills: Choking risk - crush meds, Crush meds or liquid form. Meal compensatory strategies to be trained by the slp: Alternate Bites/Sips, Feed Slowly and Carefully, Small Bites/Sips Verbal/tactile cues, Precautions Recommended During PO Feeding: Cueing for Strategies Allow extra time, Minimize distractions. Post mbss recommendations: Monitor the patient's temperature and pulmonary status. If [CR#1] develops a fever and/or signs or symptoms of respiratory infection, please suggest to the attending physician that a chest X-ray be ordered to evaluate the lungs for aspiration pneumonitis. If the patient does not have a bowel movement within 24 hours, please contact the attending physician to consider ordering an appropriate laxative. Consider alternate means of feeding. Recommend a repeat MBSS be considered in ,d+[DATE] weeks from date of this evaluation to determine neuromuscular function of the swallow post dysphagia treatment. Follow up to be scheduled at discretion of the primary care physician and treating SLP based on patient status at recommended follow up interval. Reflux Precautions. Consider alternate means of calories and fluids. Aspiration of multiple consistencies. Significant malnutrition/adult failure to thrive. Recommend a family care conference to discuss a treatment plan. Consider placement of a peg for nutritional support. Consider a psychiatry consult to assist with anorexia/poor po intake. Treatment plan: Recommendations determined by pathology of swallow function. Tolerance of treatment recommendations to be assessed by facility SLP for appropriateness. Patient will likely benefit from a skilled dysphagia feeding, exercise, and/or management plan directed by a Speech Language Pathologist. SKILLED FEEDING/SWALLOWING PLAN WITH SLP: Skilled Diet: Solids: Trial feedings of ground, to provide rehabilitation and/or train strategies. Advance diet as patient progresses with therapy. Effective Compensatory Strategies - Short term use only (,d+[DATE] weeks) during rehabilitation efforts: Alternate bites/si [TRUNCATED]

Based on interviews and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (CR #1) reviewed for quality of care. The facilities failure to assess CR#1 after she complained of pain during peri care at 5:00am on 06/06/24 but was not sent to the hospital until 06/07/24 at 12:06am which was over 18hours later. After being admitted into the hospital CR#1 was diagnosed with intertrochanteric fracture of the right femoral neck of indeterminate age. On 06/10/2024 at 3:46 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/14/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed residents who experience falls with injuries at risk of further injury, pain and delayed medical treatment. Findings include: Record review of CR#1 face sheet on 06/07/23 at 8:30pm revealed that she was an [AGE] year-old female that was originally admitted into the facility on [DATE]. She had diagnoses of cognitive communication deficit, contracture of muscle left ankle and foot, aneurysm of carotid artery (a bulge in the wall of one of these arteries), constipation, hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (weakness or the inability to move on one side of the body), and insomnia. Record review of CR#1's Quarterly MDS, dated [DATE] revealed CR #1's BIMS score was determined to be 14 due to limited cognitive impairment. The MDS completed by the staff, which indicated CR#1 did not exhibit behavioral symptoms of wandering and required supervision. CR#1 was bed bound and must be encouraged to participate in activities as well as bathing. CR#1 was one-person physical assist for ADLs, but two- person assist when transferring. Record review of CR #1's care plan dated 05/30/24revealed that CR#1 had impaired visual functioning and was at risk for a decrease in ADLs and Injuries. CR#1's contractures did not affect the possibility of being able to perform her ADL's according to her cognitive and physical abilities. CR#1 had a splint in the past that she refused to wear and low motivation to participate with ADL care. Focus: I have an ADL self-care performance deficit r/t Left sided paralysis along with contracture of left arm. Goal: number 1. I will maintain current level of function in eating through the review date. Interventions: 1. Resident requires limited assist of 1 staff for locomotion and eating at times. 2. Resident requires extensive assist with one staff for bed mobility, dressing, incontinent care, and personal hygiene. Interview with CNA-A on 06/08/24 at 12:54pm she stated that on 06/06/24 at around 5:00am she was performing peri care on CR#1 when CR#1 said it's hurting me. CNA-A said that she continued to perform peri care on CR#1 even though she was complaining of pain. CNA-A said that she told the Nurse that CR#1 was complaining of pain. Interview with LVN C on 06/08/2024 at 3:22pm she stated that on 06/06/24 at 5:15am she heard CR#1 telling CNA-A it's hurting me, while CNA-A was administering peri care. LVN-C stated that she offered CR#1 PRN (pro re nata or as needed) pain medication, but she refused. LVN-C said that she did not conduct an assessment on CR#1 because she refused her PRN pain medication and because she was not exhibiting any signs of pain. Interview with LVN A on 06/07/24 at 4:53pm she stated that she read CR#1 Xray report on 06/06/24 and she interpreted it as saying that CR# 1 had no dislocation, no radiographic evidence of avascular necrosis of the femoral head. No acute abnormality of the visualized pelvis was identified. LVN A stated that at 5:33pm on 06/06/24 she sent CR#1's Xray report to the NP via text message. Interview with the facilities' NP on 06/07/24 at 5:01pm, he stated that he did not receive an Xray report stating that CR#1's hip was fractured. He stated that he learned of the fracture the morning of 06/07/24 between the hour of 7:00am and 8:00am when he was checking his voicemail and he had a message from CR#1's guardian informing him that CR#1 was in the hospital. He stated that if he had been notified of the injury to CR#1's hip that he would have given an order to have CR#1 be transported to the hospital immediately for further evaluation. Interview with the facilities DON on 06/07/24 at 3:20pm, the DON stated that she was notified on 06/06/24 at 11:30am by the ADON that CR#1 was complaining of pain to her right hip. The DON at 11:45am directed the ADON to call the facility Doctor so that an Xray could be performed on CR#1. The DON said that she was checking her emails on the night of 06/06/24 at 11:00pm and she reviewed CR#1's Xray report and saw that CR#1 had a fracture to her right hip. The DON stated that she immediately contacted LVN B and had LVN B call the on-call Doctor to get an order and have CR#1 sent out to the hospital immediately . She said that the pain assessment should have been completed by LVN C immediately, unless the resident refused, and documentation should be completed if a resident refused. She said that the facility did not have a policy for completing pain assessment timely. Interview with LVN B on 06/08/24 at 6:15am she stated that the DON sent me an Xray report for CR#1 on 06/06/24 at 11:19pm, and the DON directed me to call the facility Doctor to get an order to send CR#1 to the hospital immediately because she had a right hip fracture. LVN B stated that she called and received the Doctor's order and CR#1 was sent to the Hospital at 12:02am on 06/07/24 via Emergency medical services (EMS ) Interview with CR#1 on 06/08/24 at 10:35am she stated that at night a few days ago a Black female was changing my diaper. When I told her that you're hurting me, but she kept on pushing me from side to side. Record review of CR#1's physician orders dated 03/28/23 revealed that she was prescribed the blood thinner Clopidogrel Bisulfate tablet 75mg once per day by mouth for blood clot prevention. Record review on 06/07/24 of the facility sign in log dated 06/06/24 at 4:30pm revealed that an Xray technician signed in at the facility 12:20pm. Record review on 06/07/24 of CR#1's Xray report dated 06/06/24 revealed that CR#1 Xray was read by the Radiologist at 2:25pm revealed an intertrochanteric fracture of the right femoral neck of indeterminate age on 06/06/2024. Record review of facility policy titled Incident and Accident with effective date 03/01/2017 reflected in part, .3. Licensed nurse will complete a fall investigation report after every fall to include vital signs, pain assessment, and environment assessment It was determined to be an Immediate Jeopardy (IJ) on 06/10/2024 at 3:46 p.m. The Administrator and the DON were both notified. The Administrator was provided with the IJ template on 06/10/2024 at 3:46 p.m. The following Plan of Removal submitted by the facility was accepted on 06/12/2024 at 10:08 a.m. Facility Plan to ensure compliance: Plan to remove immediate jeopardy. 1. Immediate Action: Resident returned to the facility status post-surgery on 6/10/24 with orders for Occupational Therapy (OT ) services. Resident was assessed by the nurse. Pain assessment was completed. The residents care plan was reviewed by the Interdisciplinary Team (IDT) and updated. The facility scheduled a follow up appointment with an orthopedic surgeon. The Resident was being provided with care in the facility and receiving OT services and pain management. On 6/7/24 the Director of Nursing or designee started education with all licensed nurses on ensuring diagnostic results were reported to the Attending Physician/Nurse practitioner as soon as possible via phone and fax. This will guide the clinical team on ensuring that each resident received emergency care immediately. This education will be completed by 6/11/24. On 6/7/24 the Director of Nursing or designee started education with licensed nurses on properly assessing residents for change of condition. This education will be completed by 6/11/24. On 6/7/24 the Assistant Director of Nursing or designee started education with all staff on the facility abuse and neglect policy and procedures. This education will be completed by 6/11/24. On 6/7/24 the Assistant Director of Nursing or designee started education with all staff on repositioning and proper communication during care. This education will be completed by 6/11/24. On 6/7/24 the director of nursing educated the licensed nurse on notification of diagnostic results to physician/nurse practitioner in a timely manner and accurately. On 6/7/24 the CNA-A was suspended pending investigation. On 6/8/24 the Director of Nursing or designee started education with ALL nursing staff on Pain Management and assessing for pain. This education will be completed by 6/11/24. On 6/10/24 the Assistant Director of Nursing started education on resident rights to include patients right to refuse. This education will be completed by 6/11/24. On 6/10/24 the Director of Nursing in-serviced all licensed nurses to report all diagnostic results to the DON upon receipt of results. This education will be completed by 6/11/24. On 6/10/24 the CNA-A received 1:1 education on Abuse and Neglect, repositioning of residents to include residents with contractures, and reporting pain immediately to the charge nurse. On 6/10/24 the Director of Nursing started education with C.N. A's on reporting pain and changes of condition to the nurse immediately. This education will be completed by 6/11/24. On 6/11/24 the Director of Nursing or designee started education with nursing staff on using the Kardex (electronic nursing worksheet that includes a summary of patient information, such as prescribed medications, clinical follow-ups, and daily care schedules) on identifying resident care needs and identifying residents with contractures. This education will be completed by 6/11/24. *The below policies were reviewed on 6/7/24 and there were no changes to the current policy. - Incident and Accident Policy - Pain Assessment and Management Policy On 6/10/24 the Director of Nursing or designee completed an audit for any residents who had a diagnostic conducted in the last 30 days. We identified 8 residents who had a diagnostic conducted and all have been reported to the physician/nurse practitioner. The Director of Nursing or designee completed an audit on 6/11/24 on residents with contractures. On 6/11/24 the Director of Nursing or designee conducted a change of condition audit. On 6/10/24 the facility Administrator notified the Medical Director regarding the immediate jeopardy the facility received related to failure to provide treatment and care in accordance with professional standards and reviewed to sustain compliance. *Staff will not be allowed to provide direct care until in-service training has been completed. Monitoring: Record review of 'In-service Training Report dated 06/07/2024 and titled The Director of Nursing or designee started education with all licensed nurses on ensuring diagnostic results were reported to the Attending Physician/Nurse practitioner as soon as possible via phone and fax. This In-service training was completed on 06/11/24 with all facility Nurses. Record review of in-service training that was conducted on 06/13/24 and revealed that on 6/7/24 the Director of Nursing or designee started education with licensed nurses on properly assessing of residents for change of condition. This education was to be completed by 6/11/24. The in-service was completed by the DON on 06/07/24 with all Nursing staff in attendance. Record review was conducted on 06/12/24 of an in-service dated 6/7/24 and revealed that the Assistant Director of Nursing or designee started education with all staff on the facility abuse and neglect policy and procedures. Record review revealed that this education was to be completed by 6/11/24. Record review was conducted on 06/13/24 of an in-service document dated 6/7/24 and revealed that the Assistant Director of Nursing or designee started education with all staff on repositioning and proper communication during care. This education was to be completed by 6/11/24. Record review was conducted on 06/13/24 of an in-service document dated 6/7/24 and revealed that the Director of Nursing educated the licensed nurse on notification of diagnostic results to physician/nurse practitioner in a timely manner and accurately. Record review of CNA-A disciplinary form was conducted on 06/11/24, and it was dated 06/07/24 , and it read that C.N.A.-A was suspended pending their investigation. Record review was conducted on 06/12/24 and revealed that on 6/8/24 the Director of Nursing or designee started education with ALL nursing staff on Pain Management and assessing for pain. This education was completed by 6/11/24. Record review was conducted on 06/12/24 and revealed that on 6/10/24 the Assistant Director of Nursing started education on resident rights to include the patient's right to refuse. This education was completed by 6/11/24. Record review was conducted on 06/12/24 and revealed that this in-service was conducted and completed on 6/10/24, the Director of Nursing in-serviced all licensed nurses to report all diagnostic results to the DON upon receipt of results. This education will be completed by 6/11/24. Record review was conducted of the in-service and revealed that on 6/10/24 CNA-A did receive 1:1 education on Abuse and Neglect, repositioning of residents to include residents with contractures, and reporting pain immediately to the charge nurse. The in-service was conducted by the facilities DON. Record review was conducted on 6/10/24 and revealed that the Director of Nursing started education with C.N. A's on reporting pain and changes of condition to the nurse immediately. This education will be completed by 6/11/24. Record review was conducted on 06/13/24 of in-service document dated 6/11/24 and revealed that the Director of nursing or designee started education with nursing staff on using the Kardex on identifying resident care needs and identifying residents with contractures. This education was be completed by 6/11/24. Record review was conducted on 06/14/23 of audit documentation forms dated 6/10/24 and revealed that the Director of Nursing or designee completed an audit for any residents who had a diagnostic conducted in the last 30 days. We identified 8 residents who had a diagnostic conducted and all have been reported to the physician/nurse practitioner. The Director of Nursing or designee completed an audit on 6/11/24 on residents with contractures. On 6/11/24 the Director of Nursing or designee conducted a change of condition audit. Interviews were conducted on 06/12/2024 from 10:50 a.m. until 3:00 p.m. with staff on both shifts (6:00 a.m. - 6:00 p.m. and phone interviews with staff from 6:00 p.m. - 6:00 a.m.) The interviews were geared toward what the staff had been in-serviced on. The staff interviewed were Nurses LVN's A, B, C, D, E, F, and G. Interviews were also conducted with CNA's A, B, C, D, E, and F. The staff were able to answer the questions without any concerns. The Administrator and the DON were informed the Immediate Jeopardy was removed on 06/14/2024 at 12:50 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that 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 interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 10 residents (CR#1) reviewed for radiology services: The facilities failure to assess CR#1 after she complained of pain during peri care at 5:00am on 06/06/24 but was not sent to the hospital until 06/07/24 at 12:06am which was over 18hours later. After being admitted into the hospital CR#1 was diagnosed with intertrochanteric fracture of the right femoral neck of indeterminate age. On 06/10/2024 at 3:46 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/14/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was 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 for delayed treatment and hospitalization s. Findings include: Record review of CR#1 face sheet on 06/07/23 at 8:30pm revealed that she was an [AGE] year-old female that was originally admitted into the facility on [DATE]. She had diagnoses of cognitive communication deficit, contracture of muscle left ankle and foot, aneurysm of carotid artery (a bulge in the wall of one of these arteries), constipation, hemiplegia (one-sided muscle paralysis or weakness), hemiparesis (weakness or the inability to move on one side of the body), and insomnia. Record review of CR#1's Quarterly MDS, dated [DATE] revealed CR #1's BIMS score was determined to be 14 due to limited cognitive impairment. The MDS completed by the staff, which indicated CR#1 did not exhibit behavioral symptoms of wandering and required supervision. CR#1 was bed bound and must be encouraged to participate in activities as well as bathing. CR#1 was one-person physical assist for ADLs, but two- person assist when transferring. Record review of CR #1's care plan dated 05/30/24revealed that CR#1 had impaired visual functioning and was at risk for a decrease in ADLs and Injuries. CR#1's contractures did not affect the possibility of being able to perform her ADL's according to her cognitive and physical abilities. CR#1 had a splint in the past that she refused to wear and low motivation to participate with ADL care. Focus: I have an ADL self-care performance deficit r/t Left sided paralysis along with contracture of left arm. Goal: number 1. I will maintain current level of function in eating through the review date. Interventions: 1. Resident requires limited assist of 1 staff for locomotion and eating at times. 2. Resident requires extensive assist with one staff for bed mobility, dressing, incontinent care, and personal hygiene. Interview with ADON on 06/07/24 at 4:00pm she stated that a COTA reported to her at 11:00am that CR#1 was complaining of pain to her right leg. ADON said that she performed a brief assessment by touching CR#1 leg and asked her if it hurt and CR#1 reported a little. The ADON said that she reported the matter to the DON and the DON told her to call for an Xray. The ADON said that at 11:30 called the medical team and provided information regarding CR#1 and she was given an order for an Xray to be performed on CR#1. Interview with the facilities DON on 06/07/24 at 3:20pm. The DON stated that she was notified on 06/06/24 by the ADON that CR#1 was complaining of pain to her right hip. The DON ordered Xray to be done. The DON stated that she was checking her emails on the night of 06/06/24 at 11:00pm and she reviewed CR#1 Xray report and saw that CR#1 had a fracture to her right hip. She stated that she immediately contacted LVN B and had LVN B to call the on-call Doctor to get an order and have CR#1 sent out to the Hospital immediately. CR#1 was sent to the Hospital at 12:02am on 06/07/24 via Emergency Medical Service (EMS). Interview with LVN A on 06/07/24 at 4:53pm she stated that she read CR#1 Xray report on 06/06/24 and she interpreted it as saying that CR# 1 had no dislocation, no radiographic evidence of avascular necrosis of the femoral head. No acute abnormality if the visualized pelvis is identified. LVN A stated that at 5:33pm on 06/06/24 she sent CR#1 Xray report to the NP via text message. Interview with the facilities' NP on 06/07/24 at 5:01pm, he stated that he did not receive an Xray report stating that CR#1's hip was fractured. He stated that he learned of the fracture the morning of 06/07/24 between the hour of 7:00am and 8:00am when he was checking his voicemail and he had a message from CR#1's guardian informing him that CR#1 was in the hospital. He stated that if he had been notified of the injury to CR#1's hip that he would have given an order to have CR#1 be transported to the hospital immediately for further evaluation . Interview with LVN B on 06/08/24 at 6:15am she stated that the DON sent her the Xray report for CR#1 on 06/06/24 at 11:19pm, and the DON direction was to call the facility Doctor to get an order to send CR#1 to the Hospital immediately because she had a right hip fracture. LVN B stated that she called and received the Doctor's order and CR#1 was sent to the Hospital at 12:02am on 06/07/24 via EMS. Record review of the facility sign in log dated 06/06/24 revealed that an Xray tech signed in at the facility at 12:20pm on 06/06/24. Record review on 06/07/24 of CR#1's Xray report dated 06/06/24 revealed that CR#1 Xray was read by the Radiologist at 2:25pm revealed an intertrochanteric fracture of the right femoral neck of indeterminate age on 06/06/2024. This was determined to be an Immediate Jeopardy (IJ) on 06/10/2024 at 3:46 p.m. The Administrator and the DON were both notified. The Administrator was provided with the IJ template on 06/10/2024 at 3:46 p.m. The following Plan of Removal submitted by the facility was accepted on 06/12/2024 at 10:08 a.m. Facility Plan to ensure compliance: Plan to remove immediate jeopardy. 1. Immediate Action: Resident returned to the facility status post-surgery on 6/10/24 with orders for Occupational Therapy (OT) services. Resident was assessed by the nurse. Pain assessment was completed. The residents care plan was reviewed by the Interdisciplinary Team (IDT) and updated. Facility scheduled follow up appointment with ortho. Resident being provided with care in facility and receiving OT services and pain management. On 6/7/24 the Director of Nursing or designee started education with all licensed nurses on ensuring diagnostic results are reported to the physician/Nurse practitioner as soon as possible. This will guide the clinical team on ensuring that each resident receives emergency care immediately. This education will be completed by 6/11/24. On 6/7/24 the director of nursing educated the licensed nurse on notification of diagnostic results to MD/NP in a timely manner and accurately. On 6/10/24 the Director of nursing in-serviced all licensed nurses to report all diagnostic results to the DON upon receipt of results. This education will be completed by 6/11/24. On 6/10/24 reviewed the policy and procedure with the diagnostic vendor to ensure reporting was distributed to the facility fax, facility email, and verbal notifications to be done for any abnormalities. This education will be completed by 6/11/24. *The below policies were reviewed on 6/7/24 and there were no changes to the current policy. - Incident and Accident Policy - Pain Assessment and Management Policy - Diagnostic Policy On 6/10/24 the Director of Nursing or designee completed an audit for any residents who had a diagnostic conducted in the last 30 days. We identified 8 residents who had a diagnostic conducted and all have been reported to the NP/MD. On 6/11/24 the director of nursing or designee conducted a change of condition audit. *Staff will not be allowed to provide direct care until in-service training has been completed Monitoring: Record review was conducted on 06/12/24 of Nurses notes and the following was confirmed via record review. Resident returned to the facility status post-surgery on 6/10/24 with orders for OT services. Resident was assessed by the nurse. Pain assessment was completed. The residents care plan was reviewed by IDT and updated. Facility scheduled follow up appointment with ortho. Resident being provided with care in facility and receiving OT services and pain management. Record review was conducted on 06/12/24 of the in-service dated on 6/7/24, the Director of Nursing or designee started education with all licensed nurses on ensuring diagnostic results are reported to the physician/Nurse practitioner as soon as possible. This will guide the clinical team on ensuring that each resident receives emergency care immediately. This education was completed by 6/11/24. Record review was conducted 06/12/24 of the in-service dated on 6/7/24, the Director of Nursing educated the licensed nurse on notification of diagnostic results to MD/NP in a timely manner and accurately. Record review was conducted on 06/12/24 and it was revealed that the Director of Nursing in-serviced all licensed nurses to report all diagnostic results to the DON upon receipt of results. This education was completed by 6/11/24. Record review was conducted on 06/12/24 and it was revealed that the policy and procedure with the diagnostic vendor to ensure reporting was distributed to the facility fax, facility email, and verbal notifications to be done for any abnormalities. This education was completed by 6/11/24. Record review was conducted on 06/12/24 and it was revealed that, the Director of nursing or designee completed an audit for any residents who had a diagnostic conducted in the last 30 days. We identified 8 residents who had a diagnostic conducted and all have been reported to the NP/MD. On 6/11/24 the Director of Nursing or designee conducted a change of condition audit. Interviews were conducted on 06/12/2024 from 10:50 a.m. until 3:00 p.m. with staff on both shifts (6:00 a.m. - 6:00 p.m. and phone interviews with staff from 6:00 p.m. - 6:00 a.m.) The interviews were geared toward what the staff had been in-serviced on. The staff interviewed were Nurses LVN's A, B, C, D, E, , F, and G. Interviews were also conducted with CNA's A, B, C, D, E, and F. The staff were able to answer the questions without any concerns. The Administrator and DON were informed the Immediate Jeopardy was removed on 06/14/2024 at 12:50 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of 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 store and serve food under sanitary conditions per professional standards for food service safety for one out of one kitchen and dining. -The facility failed to follow proper sanitation and food handling practices. -The facility failed to keep clean the ice machine used to distribute ice to the residents. -The DFS, FSA SS, and FSA TT did not follow proper sanitization procedures. -FSM QQ, FSA SS, and FSA TT did not follow proper food handler procedures. These deficient practices could put all 65 residents who received meals from the facility kitchen at risk of foodborne illnesses. Findings included: 1. Observation on 03/26/24 at 8:15 AM showed two staff members, the DFS and FSM QQ, in the kitchen without hairnets. The DFS was pouring juice from the Fountain System into different pitchers. FSM QQ was observed cleaning the kitchen counter. In an interview on 03/26/2024 at 8:16 AM, the DFS said she left her hairnet in her office and that FSM QQ's hairnet just fell off her head. Observation on 03/26/2024 at 11:37 AM showed FSA SS in the kitchen transporting food tray without a beard net. Observation on 03/27/2024 at 1:29 PM showed FSA RR in the kitchen with no hair net. In an interview on 03/27/2024 at 1:30 PM, FSA RR said she would wear a hair net before entering the kitchen. She said she forgot to wear it earlier. She said she would usually wear a hair net before entering the kitchen and proceed to wash her hands. In an interview on 03/27/2024 at 1:34 PM, the DFS said staff should wear a hair net before entering the kitchen and wash their hands immediately afterward. She said the hair net container was outside by the kitchen door for that purpose. If staff did not wear hair nets, hair could get in the food and cause sickness to the residents. 2. An observation on 03/26/2024 from 8:33 AM to 9:01 AM showed that FSA TT removed sanitized dishes from the dishwasher machine and placed them on a rack. In an interview on 03/26/2024 at 8:35 AM, FSA TT said she did not take the water temperature and PPM measurements this morning. She said she would do it when she finished sanitizing the dishes. She said she was not working on 03/24/2024 and 03/25/2024 and did not know why the log was not completed for those days. She said she and the other staff always make the logs when they finish washing the dishes. She said she would use the PPM testing trips to measure the water PPM after sanitizing the dishes. She said she was taught to check the ppm after sanitizing the dishes. She said she did not know if she had to check it before or during sanitizing. She said she started working as the dishwasher staff about two years ago and had always checked the water temperature and the PPM after the sanitizing process was completed. A review of the dishwasher machine water temperature log and PPM showed no records for the dishwasher water temperature and PPM for 03/24/2024, 03/25/2024, and the morning of 03/26/2024. 3. On 03/26/2024, at 8:57 AM, a pair of eyeglasses was observed in the dry storage on top of a bag of brown sugar. In an interview on 03/26/2024 at 8:59 AM, the DFS said the glasses belonged to FSA SS and should not have been there. 4. Observation of the meal service on 03/26/2024 from 12:01 PM to 12:33 PM showed FSM QQ fixing a salad on a plate with her bare hands, then handing it to the DFS. The DFS placed the plate on the kitchen table inside the kitchen. Further observation showed FSA TT holding the residents' cups by the rim, not the body. In an interview on 03/26/2024 at 12:05 PM, the DFS said she was preparing a chef salad for a resident. This State Surveyor informed the DFS that FSM QQ used her bare hands to fix the salad. The DFS threw the salad in the trash and requested a new one. She said the staff was not wearing gloves because the dietitian told them to stop wearing gloves in the service line. 5. Observation on 03/27/2024 at 9:43 AM showed FSA SS transferring sanitized silverware from the sanitizing tray to a container with his bare hands touching all parts of the silverware. Further observation showed FSA SS scratching his head and touching the temperature log, and then, he transferred the sanitized silverware from the sanitizing tray to a container. In an interview on 03/27/2024 at 9:45 AM, FSA SS said he did not take the water temperature or check the PPM this morning and would do it after he had cleaned and sanitized the dishes. He said the DPO recorded the values for this morning, not him. When asked what the purpose of taking the temperature after washing and sanitizing the dishes was, he said he did not know, and that was what the DFS had taught him. A review of the dishwasher water temperature and PPM logbook showed the water temperature was 100 F and PPM 150 for the morning of 03/27/2024. In an interview with the DFS on 03/27/2024 at 10:06 AM, she said that she did not teach the staff to measure the water temperature and check the ppm after sanitizing. She said she taught them to do it before and during the process. She said she conducted in-services with the staff on 03/26/2024 on the sanitizing process and went over the process with FSA SS in the morning of 03/27/2024 before he started cleaning the dishes. She added that she would ask the staff to sanitize the silverware again because they were not handled in a manner that prevented cross-contamination. She said she wrote the missing information for 03/24/2024 and 03/25/204 because she realized the staff did not do it. She said she did not know what the measurements were for those days. She said she wrote those numbers because that was the number it had always been. 5. Observation of the meal service on 03/27/2024 at 12:01 PM showed FSA SS scratching his head, touching his clothes, and pulling his pants while passing the food trays. In an interview on 03/27/2024 at 12:10 PM, the DFS said that staff members who do not follow proper sanitization procedures can cause cross-contamination and pass on whatever they have to somebody else. She said the residents could get sick or die depending on what the staff passes on to them. In an interview on 03/27/2024 at 12:12 PM, FSA SS said he could cause cross-contamination and get the residents sick. He said he knew he had to wash his hands whenever he touched any body parts. He said he should have stopped and washed his hands after scratching his head or touching his body. He said he did not wash his hands because he did not think him scratching his head and touching any parts of his body without washing his hands was a big deal. 6. Observation on 03/26/2024 at 12:35 PM showed the water fountain located in hall 300 was dirty with a white/yellowish stain. Observation on 03/28/2024 at 8:54 AM showed CNA U filling up the residents' water pitcher from the ice machine. In an interview on 03/28/2024 at 8:55 AM, CNA U said a guy would come and service the machine about a month ago and change the filter. She said the housekeeper would come to clean the machine when she was done getting water. She said she did not verify if the machine was clean before she got the water but thought it had already been cleaned from yesterday. She said the nozzles were clean enough. She said that she would get the housekeeper to clean the machine when she was done distributing the water to the residents. She said the resident would get sick from bacteria if the ice machine was not clean. In an interview on 03/28/2024 at 1:46 PM, the Admin said that the ice machine is deep cleaned quarterly by a company. She added that the housekeeper also cleans it every day. She said anyone can wipe the machine down if there are spots or stains. In an interview on 03/28/2024 at 1:52 PM, the DPO said the ice machine was the only one the resident used to drink out of. He said there was only one in the hallway. He said the machine did not belong to the facility. He said the company always deep-cleaned it, but it always looked dirty. He said the white and yellowish stains were calcium buildup, and they could not remove it. He said the facility did not keep a cleaning log for the ice machine. In an interview on 03/28/2024 at 2:02 PM, HK BBB said she had just started working at the facility on 03/19/24 and that today would be her first time cleaning the ice machine. IAW FDA Food Code 2022 Chapter 2-103.11, The PERSON IN CHARGE shall ensure that: (N) EMPLOYEES are preventing cross-contamination of READY-TO-EAT FOOD with bare hands by properly using suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. IAW FDA Code 2022 Chapter 2-401.11, . Insanitary personal practices such as scratching the head, placing the fingers in or about the mouth or nose, and indiscriminate and uncovered sneezing or coughing may result in food contamination . IAW FDA Food Code 2022 Chapter 2-301.14, (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (I) After engaging in other activities that contaminate the hands. According to the TAC 483.60(i)(1)-(2), . Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that staff involved in food preparation and services consistently utilize good hygienic practices and techniques. According to the facility's Food Preparation and Service Policy revised on 10/2017, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. A review of the facility's Food Preparation and Service with revised date 10/2017 parts 6 read, Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. A review of the facility's Sanitization Policy revised on 10/2008 part 8 read, Dishwashing machines must be operated using the following specifications: High-Temperature Dishwasher (Heat Sanitization) a. Wash temperature (150 - l65 F) for at least forty-five (45) seconds: b. Rinse temperature (165 - I80 F) for at least twelve (12) seconds. Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120 F); b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds.

Based on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one of seventeen staff (CNA O) reviewed for staff qualifications. The facility failed to ensure CNA O was appropriately certified to practice and provide CNA care in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained. The findings included: Interview on [DATE] at 12:39 PM with CNA O, she said she had last worked at the facility on [DATE]. CNA O said she worked on an as needed basis, and she had not worked many hours at the facility recently. CNA O said she believed her CNA license was current. CNA O said she sent her license renewal paperwork to the State in January of 2024 when she learned it was expired. CNA O said she learned the license was expired when the facility staff informed her. CNA O said she could not recall who had informed her. CNA O said she had not received any information from the State that her license was current. CNA O said she was instructed by the facility to check the State's website to determine if her license was valid, but she had not done so. CNA O was informed that per the State's license verification website, her license had been expired since [DATE]. CNA O said she had worked at the facility many times since [DATE]. CNA O said she was first licensed as a CNA on [DATE]. Interview on [DATE] at 12:53 PM she said she had spoken with the corporate HR department regarding CNA O's expired license. The Admin said the corporate office did not have CNA O on the list of expired license's. The ADMIN said the corporate office also said that the State had provided an extension on licensing as the State had changed licensing systems and was now exclusively online, and there had been delays with the new system. The Admin said the extension was through [DATE]. Interview on [DATE] at 1:18 PM with the Admin, she said based on the language of the State's CNA license extension, CNA O's license would not have been valid. The Admin said the facility's corporate informed the staff if his/her license was expired, but the State did so as well. The Admin said because CNA O did not have an active license and was able to work with residents, she may not have known updated expectations for her license. The Admin said CNA O received her initial CNA training, and the facility also provided continuous training to the CNA's. Telephone interview on [DATE] at 1:25 PM with the Corporate HR Designee, she said she did not complete the staff EMR review for the facility on [DATE]. The Corporate HR Designee said the corporate talent acquisition group completed the background checks and EMR checks. The Corporate HR Designee said based on the state's CNA license extension policy granting CNA's with an active license on [DATE] an extension until [DATE], CNA O's license did not qualify. The Corporate HR Designee said CNA O's license would have been expired. The Corporate HR Designee said she believed that all CNA's licenses had been extended until [DATE]. The Corporate HR Designee said she believed the misconception was either miscommunication or misunderstanding the State's CNA license extension by the corporate head nurses. The Corporate HR Designee said the corporate head nurses had provided information to the facilities and corporate staff related to the State's CNA license extension. The Corporate HR Designee said if CNA O had been involved in an incident at the facility, the facility and corporation would have been liable for allowing an unlicensed employee access to the residents. Record review of CNA O's timecard statements from [DATE] through [DATE] revealed she worked a total of 647.62 hours during that time. The statement documented she worked a total of 7.15 hours in [DATE], on [DATE]. Record review of CNA O's license verification report dated [DATE] revealed her license had expired on [DATE]. CNA O's identification was verified utilizing her social security number. Record review of the facility's undated staff roster, provided by the facility on [DATE], revealed CNA O was listed as an active Resident Care Provider. Record review of the facility's EMR review completed on [DATE] at 2:46 PM revealed CNA O's license was expired. The review documented the license expired on [DATE]. Record review of the State's website on [DATE] at 1:09 PM revealed the state had approved all CNA's with a license active on [DATE] an extension on their license until [DATE]. (Note CNA O's license expired on [DATE] and was outside this extension). Record Review of the facility's undated Focused Post Acute Care Partners job description for CNA's revealed the facility's CNA's would be responsible for assisting residents with ADL's. The job description documented the qualifications for the position included a high school diploma or GED, and that CNA's must have a current nurse aide certification in the State.

Based on observations, interviews, and record review the facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented for 1 (Resident #37) of 4 residents reviewed for clinical records. The facility failed to input treatment orders and document administration of those orders into the electronic health record for Resident #37's stage 3 pressure injury to right ischium, stage 3 pressure injury to right posterior thigh, and stage 3 pressure injury to left posterior thigh. These failures could place residents at risk for additional skin breakdown and inadequate care. Findings included: Record review of Resident # 37 face sheet dated 3/27/24 revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included type 2 diabetes, end stage renal disease, morbid obesity, bipolar disorder, and heart failure. Record review of Resident # 37's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. She was dependent on staff for toileting hygiene and shower/baths. She was at risk of developing pressure ulcers/injuries. She did not have unhealed pressure ulcers/injuries. She had moisture associated skin damage. Record review of Resident # 37 care plan dated 3/8/24 revealed she had a stage 3 pressure injury to the right ischium. The interventions were to administer treatments as ordered and monitor for effectiveness, assess/monitor wound healing daily, and monitor dressing daily to ensure it is intact and adhering. Record review of Resident #37's nursing note dated 3/7/24 written by LPN D read in part, .Resident arrived at facility via stretcher with EMS. Resident is AAOx4, skin is warm and dry to touch . incontinent to bowel and bladder . Sacrum wound noted, left post thigh non pressure wound, redness noted underneath both breasts, under stomach and groin area Record review of Resident # 37's initial wound MD visit report dated 3/18/24 revealed she had 3 pressure wounds. Wound #1 was a stage 3 pressure injury on the right ischium, not healed. The measurements were 2.6 cm length x 2.5 cm width x 0.1 cm depth, with an area of 6.5 sq cm and a volume of 0.65 cubic cm. There was a moderate amount of serous drainage (a type of fluid that comes out of a wound with tissue damage) noted with no odor. The wound bed was 20% granulation (the development of new tissue and blood vessels in a wound during the healing process), 20% slough (necrotic tissue that needs to be removed from the wound for healing to take place), 60% epithelization (an essential component of wound healing used as a defining parameter of a successful wound closure). The wound order for the right ischium was to cleanse/irrigate wound with normal saline/water, apply calcium alginate, honey-based ointment and cover with dry dressing every day and as needed. Wound #2 was a stage 3 pressure injury to the right posterior thigh, not healed. Initial measurements were 3.6 cm length x 5.1 cm width x 0.1 cm depth. There was a moderate amount of serous drainage noted with no odor. Wound bed was 40% granulation, 20% slough, and 40% epithelization. The wound orders for Wound #2 were to cleanse/irrigate wound with NS/water, apply calcium alginate, honey-based ointment with dry dressing every day, and as needed. Wound #3 was a stage 3 pressure injury to the left posterior thigh. Measurements were 7.1 cm length x 3.6 cm width x 0.1 cm depth, light amount of serous drainage with no odor. Wound bed had 20% granulation, 20% slough, and 60% epithelialization. The wound orders for Wound #3 were to cleanse/irrigate wound with NS/water and apply 40% zinc oxide every shift and as needed. Record review of Resident # 37's Order Summary Report for March 2024 dated 3/26/24 at 1:48 p.m. revealed there were no active wound orders for her stage 3 pressure injury to the right ischium, stage 3 right posterior thigh, or stage 3 left posterior thigh. Record review of Resident # 37's MAR for March 2024 dated 3/26/24 at 2:08 p.m. revealed the wound treatments for the stage 3 right posterior thigh and stage 3 left posterior thigh ordered by the physician on 3/18/24 were not listed on there and had no record of administration. The treatment for the stage 3 pressure injury to right ischium was listed and indicated WCN administered the treatment daily from 3/9/24 - 3/25/24. Record review of Resident #37's Order Summary Report for March 2024 dated 3/27/24 at 10:34 a.m. revealed there were no active, completed, or discontinued wound orders for her stage 3 right posterior thigh or stage 3 left posterior thigh. There was a discontinued order for: Cleanse stage 3 wound to right ischium with NS, pat dry, apply Honey and calcium alginate, cover with border gauze dressing every day shift, order date 3/8/24. Record review of Resident #37's Order Audit Report dated 3/27/24 at 10:38 a.m. revealed the order for: Cleanse stage 3 wound to right ischium with NS, pat dry, apply Honey and calcium alginate, cover with border gauze dressing every day shift, order date 3/8/24 was created on 3/26/24 at 1:57 p.m. by WCN and discontinued on 3/26/24 at 11:01 p.m. by WCN with an effective discontinued date of 3/25/24. Record review of Resident #37's administration history for the treatment order: Cleanse stage 3 wound to right ischium with NS, pat dry, apply Honey and calcium alginate, cover with border gauze dressing every day shift, order date 3/8/24 revealed all entries were documented on the MAR as administered on 3/26/24 by WCN. In an interview on 3/26/24 at 4:46 p.m. Resident #37 said she had a wound on her butt and the facility only put cream on it. In an observation on 3/27/24 at 11:01 a.m. of Resident #37's skin with WCN revealed there was excoriation on her back and inner thighs. The wound on the ischium was approximately 2.5 cm by 2.0 cm and had about 10% slough and 70% granulation tissue. In an interview on 3/28/24 at 12:19 p.m. the DON said the wound orders for Resident #37 were carried out by the WCN and her wounds were improving but said the WCN may not have put the wound orders in the system on time. She said there was an order in the electronic system for the stage 3 pressure injury to right ischium with an order date of 3/8/24 that was created by WCN on 3/26/24. She said the created date was the day the order was created and recently learned that an order could be back dated. She said she would conduct a one-to-one in-service with WCN on entering physician orders in a timely manner and charting/documenting immediately. She said all nurses were to enter MD orders in a timely manner and all must be documented and charted immediately. She said wound MD orders should be entered into the system in a timely manner and failure to do so would result in disciplinary action. She said failure to input orders timely could delay treatment and worsen the wound. In an interview on 3/28/24 at 2:24 p.m. the WCN said she put Resident #37's wound orders in late (on 3/26/24) because she got behind. She said she did the wound care but did not document that it was being done. She said it was in her mind to put the orders in the system, but she was too busy. She said it was important to document the order and administration so other nurses would know what to do if she was not in the facility. She said if the documentation was not in the system, it was considered not done. In an interview on 3/28/24 at 4:08 p.m. the Administrator said she expected wound orders to be entered into the system timely per the physician and get carried out. She said she understood staff got behind, but the expectation was for staff to document as things occurred. She said residents could have a delay in care if orders were not entered timely. Record review of the facility's Skin Management: Prevention and Treatment of Wounds dated 11/1/2019 read in part, .The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds . Procedure .4. Treatment: a licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up .

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 10% based on 3 errors out of 28 opportunities, which involved 2 of 6 residents (Residents #34 and #27) reviewed for medication errors. MA I administered the wrong medication to Resident #34 according to Physician orders. MA JJ administered the wrong medication to Resident #27 and did not administer Vitamin D 50,000 units to Resident #27 as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: 1.Record review of Resident #34's face sheet dated 3/28/24 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) affecting the right dominant side, cognitive communication deficit, type 2 diabetes, hyperlipidemia (elevated cholesterol), and hypertensive heart disease (a serious condition caused by chronic high blood pressure that affects the heart and blood vessels). Record review of Resident #34's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required supervision to maximum assistance from staff with ADL care. Record review of Resident #34's order summary report for March 2024 revealed an order for Allergy Relief oral tablet 10 mg (Loratadine) give 1 tablet by mouth one time a day for allergies, order date 2/29/24. Observation on 3/28/24 at 8:21 a.m. with MA I revealed she prepared Resident #34's morning medication which included Cetirizine 10 mg (an allergy relief medication) - 1 tablet, Spironolactone 25 mg - 1 tablet, Memantine 10 mg - 1 tablet, Losartan 100 mg - 1 tablet, Duloxetine 20 mg DR - 1 capsule, Amlodipine 10 mg - 1 tablet, Vitamin B12 500 mcg - 2 tablets, and Lactulose 30 mL. She entered the room and administered the medications to Resident #34. She did not prepare and administer Loratadine as prescribed by the physician. In an observation and interview on 3/28/24 at 8:29 a.m. MA I said Cetirizine was in the same drug family and had the same dose as Loratadine and thought it was the same medication. She said if the name of medication did not match the order, she should ask the nurse. She said she normally gave the Cetirizine instead of Loratadine and previously confirmed with a nurse. She said when administering medication she checked the name of the medicine, dosage, and name of patient on the eMAR to make sure it matched the medication bottle. MA I looked in her medication cart and confirmed that she had Loratadine 10 mg available on her cart. In an interview on 3/28/24 at 12:51 p.m. the DON said nursing staff should compare the MD order to the medication to ensure the proper medication was given. She said staff should verify the right medication, dose, time, and patient to prevent medication error. In an interview on 3/28/24 at 4:08 p.m. the Administrator said Cetirizine and Loratadine were different antihistamines and she expected nursing staff to follow the MD orders. 2.Record review of Resident #27's face sheet dated 3/28/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vitamin D deficiency, mild cognitive impairment, and congestive heart failure. Record review of Resident #27's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #37's order summary report for March 2024 revealed orders for Ergocalciferol capsule (Vitamin D) 50,000 units give 1 capsule by mouth one time a day every Wednesday for supplement, order date 9/28/23; Multiple Vitamin give 1 tablet by mouth one time a day for supplementation - wound healing, order date 9/28/23. Record review of Resident #37's Medication Administration Record for March 2024 revealed a 4 was documented on 3/27/24 at the 9:00 a.m. administration time by MA JJ for Ergocalciferol 50,000 units. A 4 indicated vitals outside of parameters for administration. In an observation on 3/27/24 at 8:30 a.m. with MA JJ revealed she prepared and administered Resident #37's morning medication which included Multivitamin with mineral - 1 tablet, ascorbic acid 500 mg - 1 tablet, ferrous sulfate 325 mg - 1 tablet, docusate 100 mg - 1 tablet, zinc 50 mg - 1 tablet, and Eliquis 5 mg - 1 tablet. MA JJ did not administer Ergocalciferol to Resident #37 and administered multivitamin with minerals instead of multiple vitamin as ordered by the MD. In an interview on 3/27/24 at 8:35 a.m. MA JJ said she would check with the nurse on the availability of Vitamin D 50,000 units (Ergocaliferol). She said Resident #37's physician order did not say to administer multivitamin with minerals. She said she had a bottle on the medication cart without minerals but said she was not sure which one to give. She said when the order indicated to give multiple vitamin for supplementation, she gave the one with the minerals. In an interview on 3/28/24 at 8:37 am MA JJ said she was unable to administer the Vitamin D 50,000 units to Resident #37 (on 3/27/24) because the pharmacy did not deliver it. She said the medication was ordered from the pharmacy but had not arrived yet. She said she normally reordered a medication 72 hours in advance so the medication would not run out. In a continued interview on 3/28/24 at 8:53 a.m. MA JJ said she documented 4 - vitals outside of parameters on Resident #37's MAR because there was no other exception that matched the reason it was not given. She said the reason Vitamin D was not given was because it was not available. She said Resident #37's vitals were fine. In an interview on 3/28/24 at 12:41 p.m. DON said the dietitian told her the multiple vitamins and multiple vitamins with minerals were equivalent, but the medication aides had to follow the MD orders. She said medications were expected to be available for residents so that the nurse could provide the medication for their condition. She said she audited the carts weekly for medication availability and the medication aides should notify her or WCN if a medication needed to be reordered. In an observation and interview on 3/28/24 at 1:12 p.m. of the medication aide cart for 600 hall with the DON revealed she retrieved the multiple vitamin without minerals bottle and said that was the medication that matched Resident #37's physician order and the one that should have been administered. Record review of the facility's Oral Medication Administration policy revised 8/2020 read in part, .Procedures . 2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident

47072 Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for one of twelve residents (Resident #43) reviewed for care plans. -The facility failed to care plan for Resident #43 received hospice care services, or the hospice care services he was provided. These failures placed residents at risk of not receiving required medical and end of life care in a timely manner, of a full understanding of the care needs. Findings Included: Resident #43 Record review of Resident #43' face sheet dated 3/27/2024 revealed a [AGE] year-old resident admitted on [DATE]. The face sheet documented his diagnoses included senile degeneration of the brain (various conditions involving progressive brain degeneration), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events), hypertension (high blood pressure), GERD (Gastroesophageal Reflux Disease, chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), pressure ulcer (injury to the skin and the tissue below the skin due to pressure on the skin for a long time), contractures (abnormal shortening of muscle tissue), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (progressive and degeneration or shrinkage of muscles or nerve tissues), lack of coordination, amputation (removal of a limb, completely or partially as a preventative measure) of the left leg below the knee, colostomy (surgical process that creates an opening for the colon through the abdomen) status, and type 2 diabetes mellitus (condition resulting from insufficient production of insulin, causing high blood sugar). Per the face sheet, Resident #43 had a hospice care provider. Record review of Resident #43's admission MDS assessment dated [DATE] with an ARD of 2/20/2024 revealed a BIMS score of 13 indicating minimal cognitive impairment. The MDS documented that he had an impairment of one lower extremity, and he used a wheelchair for mobility. Per the MDS, Resident #43 required assistance with all ADL's except eating. The MDS revealed he had an indwelling catheter and an ostomy. The MDS documented he had one unhealed stage 4 pressure wound that was present at admission. Per the MDS, Resident #43 utilized a pressure reducing device for his bed, he received pressure wound care, and had received surgical wound care. The MDS revealed he received hospice care services. Record review of Resident #43's undated care plan revealed a focus on his penchant to remove his colostomy bag several times daily with interventions including monitoring for the behaviors, attempting to determine the cause, and documenting potential causes. The care plan documented a focus on his stage four pressure ulcer of the sacrum with interventions to include treatment administration as ordered, monitor the wound for healing daily, monitor his dressing every shift, monitor and any changes of his skin condition, and use of a low-pressure mattress. The care plan included a focus on Resident #43 colostomy with interventions to include changing it daily as needed and monitor and/or obtain lab work as needed. The care plan did not include any focus on his hospice care services. Record review of physician's orders report dated 3/27/2024 revealed an order dated 3/6/2024 to admit Resident #43 to a local hospice care provider. Record review of Resident #43 wound care physician's report dated 2/12/2024 revealed he had wounds of the left below the knee amputation site, right forefoot, and sacrum. Per the report, Resident #43 was receiving hospice care services. Record review of Resident #43 wound care physician's report dated 3/25/2024 revealed he had a wound of his sacrum. Per the report, Resident #43 was receiving hospice care services. In an interview on 3/28/2024 at 1:49 PM with Resident #43, he said he was receiving hospice care services. Resident #43 said he had no concerns with the care. Resident #43 said the hospice care provider came routinely to provide care. In an interview on 3/27/2024 at 12:49 PM with the WCN, she said Resident #43 was receiving hospice care services. In an interview on 3/27/2024 at 2:08 PM with the DON, she said Resident #43 was receiving hospice care services. The DON said if a resident was receiving hospice care services, that should be documented in the resident's care plan. In an interview on 3/28/2024 at 8:28 AM with the MDS Nurse, she said she had been employed since September 6, 2022. The MDS Nurse said her duties included completing the residents' MDS assessments, ensuring the residents' PASRR was complete and correct, and ensuring residents' care plans were updated and correct. The MDS nurse said the purpose of a care plan was to inform the nursing and CNA staff how to care for a resident. The MDS Nurse said the care plan also informed staff of resident idiosyncrasies that could present such as refusing care, sitting on the ground, or becoming combative. The MDS nurse said a resident receiving hospice care services should have a focus on his/her care plan related to those services. The MDS Nurse said Resident #43 should have had a focus in his care plan related to his hospice care services. The MDS nurse said she did not know why she had missed Resident #43's hospice care plan focus, but it could have been because there were numerous residents admitted at the time he was. The MDS Nurse said if a resident's care plan was incorrect the staff may not know what care the staff needed. The MDS Nurse said staff may not know who to call for Resident #43's care needs because his care plan did not include a focus on his hospice care services. In an interview on 3/28/2024 at 1:59 PM with the DON, she said a care plan allowed staff to know how to care for a resident, the resident's goals, and any interventions. The DON said if a resident receiving hospice care services did not have a focus in his/her care plan, the staff may not know how to care for him/her. The DON said she did not think the nurses would not know how to care for a resident receiving hospice care services because the physician's orders would be in the EHR. The DON said care plans for all residents were important, but the nurses would know a resident was receiving hospice care services because the hospice care providers entered orders for the residents and the nurses followed the orders. The DON said the expectation was to update care plans as soon as possible. Record review of the facility's Comprehensive Care Plan policy dated 4/25/2021 revealed a policy statement which read in part .Every resident will have an individualized interdisciplinary plan of care in place .The Care Plan process is an ongoing review process . The policy documented the comprehensive care plan was to be developed within twenty-one days of admission and after each care plan review. Per the policy, the care plan would include physician's orders, advanced directives, and pain management. The care plan revealed the policy would be updated with any updated information as needed. 47572

Based on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for one of twelve residents (Resident #58) reviewed for care plans. - The facility did not develop and implement a comprehensive person-centered care plan to address Resident #58' needs within 21 days of admission. - Resident #58's comprehensive person-centered care plan initiated on 01/25/2024 was not signed. These failures placed residents at risk for not receiving care and services to meet their medical, physical, and psychosocial needs. Findings Included: A review of Resident #58's face sheet revealed he was a [AGE] year-old-male admitted to the facility on [DATE] and diagnosed with other secondary Hypertension, Type 2 Diabetes Mellitus without complications, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia - unspecified, Chronic Kidney Disease - unspecified, Chronic Obstructive Pulmonary Disease (diseases that cause airflow blockage and breathing-related problems) - unspecified, Mood Disorder Due to known physiological condition - unspecified, unspecified Dementia - unspecified severity - without behavioral disturbance - Psychotic Disturbance - mood disturbance - and Anxiety, Cerebral Infarction (the brain tissue has not received enough blood - stroke) - unspecified, muscle weakness - generalized, other abnormalities of gait and mobility, other lack of coordination, Cognitive communication deficit, other Frontotemporal Neurocognitive Disorder (group of brain diseases that mainly affect the frontal and temporal lobes of the brain), Muscle Wasting And Atrophy (when muscles waste away) - not elsewhere classified - multiple sites. A review of Resident #58's comprehensive person-centered care plan showed that it was initiated on 01/25/2024, 40 days after his admission. The plan was not signed by any entity, the resident himself, or his representative. In an interview on 3/28/2024 at 8:28 AM with the MDS Nurse, she said she had been employed since September 6, 2022. The MDS Nurse said her duties included completing the residents' MDS assessments, ensuring the residents' PASRR was complete and correct, and ensuring residents' care plans were updated and correct. The MDS nurse said the purpose of a care plan was to inform the nursing and CNA staff how to care for a resident. The MDS Nurse said the care plan also informed staff of resident idiosyncrasies that could present such as refusing care, sitting on the ground, or becoming combative. The MDS Nurse said if a resident's care plan was incorrect the staff may not know what care the staff needed. In an interview on 03/28/2024 at 11:12 AM, the MDS nurse said she did not remember to do Resident #58's care plan by day 21 after admission. She said she may have had 5 to 6 admissions and/or Care Plans to do every day, and that she missed doing a care plan. She said she did not have any excuses. She said the residents' quality of care could be affected if there had not been a comprehensive person-centered care plan in place for the residents. In an interview on 3/28/2024 at 1:59 PM with the DON, she said a care plan allowed staff to know how to care for a resident, the resident's goals, and any interventions. The DON said if a resident receiving hospice care services did not have a focus in his/her care plan, the staff may not know how to care for him/her. Record review of the facility's Comprehensive Care Plan policy dated 4/25/2021 revealed a policy statement which read in part .Every resident will have an individualized interdisciplinary plan of care in place .The Care Plan process is an ongoing review process . The policy documented the comprehensive care plan was to be developed within twenty-one days of admission and after each care plan review. Per the policy, the care plan would include physician's orders, advanced directives, and pain management. The care plan revealed the policy would be updated with any updated information as needed.

Based on observations, interviews, and record review the facility failed to ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infections for 1 out of 5 residents (Resident #222) reviewed for incontinent care. - CNA B did not separate Resident #22's labia to clean and wiped from back to front during incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices and decreased quality of life. Findings included: Record review of Resident #22's face sheet dated 03/27/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 diagnoses which included hypertension (a condition which the blood vessels have persistently raised pressure), neuropathy (nerve problem that cause pain, numbness, tingling swelling in different parts of the body), and heart failure (heart muscle cannot pump enough blood to meet the needs for the body). Record review of Resident #22's significant MDS dated [DATE] read in part . Resident #22's BIMS score of 11 which indicated moderately impaired cognition. Resident #22 functional status revealed resident needed extensive assistance with all ADLs . Record review of Resident #22's care plan initiated date 03/27/24 read in part .Resident #22 had ADL self-care performance deficit related to disease processes, confusion, and musculoskeletal impairment. Interventions: for shower revision date 03/27/24 . read the resident is totally dependent on 1 staff to provide showers on Monday, Wednesday, and Friday, initiated date 03/27/24 . resident requires extensive assistance of 1 staff for toilet use . During an observation on 03/26/24 at 10:31 a.m., incontinent care was provided for Resident #22 by CNA CC and assisted by CNA N. During incontinent care, CNA CC did not separate Resident # 22's labia, and she wiped the resident from back to front. During an interview on 03/26/24 at 10:56 a.m., CNA N said CNA CC did not separate Resident #22's labia. CNA CC should have separated the labia and cleaned it properly, which would have prevented Resident #22 from getting an infection (UTI). CNA N said CNA CC cleaned Resident #22 from back to front, and CNA CC could have contaminated the peri area with the bacteria from the rectum. CNA N said she had an in-service on peri care last week and a skills check-off on incontinent care too. CNA N said the nurse monitors the aides when the nurse makes rounds. During an interview on 03/26/24 at 12:00 p.m., CNA CC said she did not separate Resident #22's labia and cleaned the area three times. CNA CC said that if the labia was not cleaned properly, Resident #22 could get an infection. CNA CC said she made a mistake when she cleaned Resident #22 from back to front, which could have caused Resident #22 to get an infection. CNA CC said she had an in-service on incontinent care last week, and she had a skills check- off which included incontinent care. CNA CC said the nurse monitored the aide when the nurse made rounds. During an interview on 03/28/24 at 9:40 a.m., RN A said CNA CC should have separated Resident #22's labia and cleaned it three times: side, side, and then the middle part last. RN A said if Resident #22's labia was not cleaned properly, Resident #22 could get an infection. RN A said CNA CC should not have cleaned Resident # 22 from back to front to prevent contaminating Resident #22's private area with any bacteria from the rectum. RN A said he had a skills check-off, including incontinent care. During an interview on 03/27/24 at 3:45 p.m., the DON said CNA CC should not have wiped Resident # 22 from back to front because of contamination, an infection control issue. The DON said Resident #22's labia were supposed to be spread apart, and CNA CC should have cleaned each side and then the center. The DON said if Resident #22's labia was not appropriately cleaned, Resident #22 could get infection. Record review of the facility policy on perineal care effective date 10/01/21 read in part . to provide cleanliness and comfort to the resident, to prevent infection . steps in procedure #8b .wash perineal area, wiping from front to back #8d (1) . separate labia and wash area downward from front to back . 47572

Based on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to provide an environment that was free from accident hazards over which the facility had control and provide supervision and assistive devices for one (Resident #36) of three residents reviewed for falls. Resident #36 sustained six falls between 08/21/2021 and 10/20/2021.The facility failed to investigate to determine the causative factors of the falls to help prevent and/or reduce risk for falls and implement new fall interventions, if needed, and failed to ensure fall interventions were implemented to help prevent falls. Resident #36 fell on [DATE] and sustained a left wrist fracture. The facility also failed to fully investigate an unauthorized departure from the facility for one (Resident #351) of one resident reviewed for elopement. This had the potential to affect one resident (Resident #351) who was identified as the only resident who had an unauthorized departure from the facility in the prior 120 days. Findings Included: Resident #36 Record review of Resident #36's face sheet indicated the facility admitted Resident #36 on 03/22/2016 with diagnoses that included abnormalities of gait and mobility, cognitive communication deficit, difficulty in walking, muscle weakness, lack of coordination, dementia, and Alzheimer's disease. A record review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #36 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated significant cognitive impairment. Resident #36 required extensive assistance of one person with bed mobility, dressing, eating, and toileting. Resident #36 required extensive assistance of two persons with transfers. Resident #36 has had two or more falls since last assessment. A record review of the care plan, initiated on 09/08/2021, indicated the resident was at risk for falls related to poor balance, poor communication/comprehension, psychoactive drug use, and unsteady gait. Further review revealed interventions in place were to check range of motion (ROM) daily, monitor for signs and symptoms of pain, bruising or change in condition, for no apparent injury determine causative factors from falls, mattress at floor as requested by family. A further review of the care plan indicated the last update to the care plan was on 10/20/2021 which indicated a fall mat had been placed. A record review of the falls risk assessment completed on 09/11/2021 indicated the resident scored a 65, which meant the resident was considered a high fall risk. A record review of an incident report, dated 08/21/2021, indicated staff observed the resident rolling in a wheelchair on the hall approaching the nurses' station, when staff observed the resident sliding out of the wheelchair onto the floor. When asked by staff how it happened, the resident stated, Because it's slippery. A further review of the incident report indicated no causal factors related to the fall were identified and that no interventions were initiated. A record review of an incident report, dated 09/17/2021, indicated staff entered the resident's room and observed the resident sitting on the floor with their back against the wall. When asked by staff how it happened, the resident stated, I don't know. A further review of the incident report indicated no causal factors related to the fall or that any interventions were identified. A record review of an incident report, dated 09/19/2021, indicated staff heard a loud bumping sound down the hall and cries of, I fell . When staff entered the resident's room, staff observed the resident in the bathroom, lying on the floor on their left side with pants below their knees and feces on the floor. When asked by staff how it happened, the resident was unable to provide a description. Extremities were checked, and when the left hand was moved, the resident voiced pain. A further review of the incident report indicated no causal factors related to the fall or that any interventions were identified. A record review of the radiology results, dated 09/20/2021, indicated two views of the left wrist were taken with findings of an acute nondisplaced distal radial fracture noted with overlying soft tissue swelling. A record review of an incident report, dated 09/21/2021, indicated staff observed the resident lying on the floor by the bed in their room. When asked by staff how it happened, the resident was confused and stated, [the resident] was trying to go home. A further review of the incident report indicated no causal factors related to the fall or that appropriate interventions were identified. A record review of an incident report, dated 10/18/2021, indicated while staff were making rounds, they observed the resident sitting on the floor on their buttocks. When asked by staff how it happened, the resident was unable to provide a description. A further review of the incident report indicated no causal factors related to the fall or that appropriate interventions were identified. A record review of an incident report, dated 10/20/2021, indicated that staff observed the resident in the resident's room, sitting on the floor on their buttocks. When asked by staff how it happened, the resident was unable to provide a description. No progress note was documented in relation to the fall. A further review of the incident report indicated no causal factors related to the fall, but a fall mat was placed in the room by the resident's bed at the request of the family. The care plan was updated on 10/20/2021, showing the fall mat placed. Observation on 11/01/2021 at 9:05 AM, revealed Resident #36 in their room sitting in a wheelchair. Resident #36 did not respond to any questions. During an interview on 11/03/2021 at 11:54 AM, Licensed Vocational Nurse (LVN) G stated that when a fall occurred, nursing staff should assess the resident first, then, if safe to do so, transfer the resident back to the prior position. LVN G stated staff should notify the Director of Nursing (DON), the family, and the physician. LVN G stated nursing staff started neuro checks if the fall was unwitnessed or if a head injury was suspected. LVN G stated staff should have completed an incident report, progress note, and fall assessment. LVN G stated nursing staff did not identify causal factors or update the care plan because the Assistant Director of Nursing (ADON) and DON completed that. LVN G stated that was why she did not update the care plan after the fall incident reports that she completed for Resident #36. During an interview on 11/03/2021 at 12:58 PM, Certified Nurse Assistant (CNA) J stated Resident #36 was non-compliant and would attempt self-transfers without requesting help from staff. CNA J stated that the staff should be checking on the resident every two hours. CNA J stated the only current intervention that she was aware of was that the resident had a floor mat beside the resident's bed. During an interview on 11/03/2021 at 2:50 PM, CNA F stated Resident #36 was a high fall risk. CNA F stated Resident #36 was cognitively impaired and did not know to ask for assistance and would attempt to transfer without staff assistance. CNA F stated that staff should be monitoring the resident frequently or trying to keep the resident within the staff's view. CNA F stated that Resident #36 did have a fall mat at the resident's bedside that was requested by the family. CNA F stated he was not aware of any other interventions currently in place for the resident. During an interview on 11/04/2021 at 8:36 AM, Licensed Vocational Nurse (LVN) A stated the facility did not have a falls coordinator but that the staff notified the Director of Nurse (DON) after a fall occurs. LVN A stated that when a fall occurred, nursing staff should have assessed the resident, asked the resident about the fall if they were cognitive, started neuro checks, and reported the fall to the family, the physician, and the DON. LVN A stated staff should have completed an incident report related to the fall. LVN A stated that nursing staff did not identify root cause, but they may have talked to other nursing staff about a resident fall, and that would not be documented in the medical record. LVN A stated the DON was responsible for identifying interventions and updating the care plans. LVN A stated Resident #36 was non-compliant due to the resident's impaired cognition and the resident would attempt transferring without staff assistance. LVN A stated that Resident #36 had a fall mat by their bedside, but the resident still tried to get up without asking for assistance. LVN A stated she was not aware of any other interventions to address falls. During an interview on 11/04/2021 at 10:09 AM, LVN B stated that after a fall occurred, nursing staff should have assessed the resident and checked their vitals to ensure there was no injury. LVN B stated staff should have reported the fall to the family, physician, and Administrator and should have completed an incident report. LVB B stated he was not aware of what root cause was or who was responsible for identifying it after a fall. LVN B stated the DON was responsible for identifying interventions and updating the care plan. LVN B stated Resident #36 was a fall risk and the resident did not call staff for assistance. LVN B stated Resident #36 had a fall mat at their bedside, and staff tried to keep the resident up and out of bed, but he was not sure of any other interventions in place. During an interview on 11/04/2021 at 12:50 PM, the Director of Nursing (DON) revealed that after a fall occurred, nursing staff should have completed a head-to-toe assessment of the resident and notified the family, physician, DON, and Administrator. The DON also stated that an incident report and progress note should have been completed and documented. The DON stated she was responsible for identifying the root cause of the fall, and the interdisciplinary team (IDT) would discuss falls and identified interventions to initiate. The DON stated that MDS nurse was responsible for updating the care plan, but the DON stated she was responsible for ensuring the care plan was updated. The DON was not able to explain why Resident #36 did not have causal factors and interventions identified after the falls or why the care plan did not have any appropriate interventions until 10/20/2021 after six falls. During an interview on 11/04/2021 at 1:05 PM, the Regional MDS Coordinator nurse stated the MDS nurse was not responsible for updating the care plan. The Regional MDS Coordinator nurse stated it was an IDT approach, and that care plan interventions and care plan updates were completed as a team. During an interview on 11/04/2021 at 1:10 PM, the Administrator stated nursing staff completed the falls incident reports and that the nursing staff should be exploring root cause of falls and documenting that. The Administrator stated falls were discussed during morning meetings but not in detail. The Administrator stated he was aware that care plan updating was a current issue, and the facility was currently in the process of getting them all updated and current. The Administrator stated the facility was doing more to address falls, but there was no documentation to provide to show what had been done. The Administrator stated the IDT should have been ensuring root cause and interventions were being identified and documented and that he would monitor that process going forward to ensure it is being done. Resident #351 A record review of Resident #351's comprehensive care plan with an initiated date of 09/27/2019 indicated the resident was an elopement risk/wanderer and was at risk for possible injury related to impaired safety awareness. A record review of an Elopement Assessment, dated 05/12/2021, indicated Resident #351 was at high risk for elopement. Per the assessment, interventions to help prevent elopement included safety alarm devices (Wander-Guard departure alert bracelet ordered on 02/27/2021), frequent monitoring, information in the wander book, and staff awareness. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date of 08/07/2021 indicated Resident #351 had diagnoses which included [CONDITION(S)] disorder, unspecified dementia, and [CONDITION(S)] disorder. The resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated severe cognitive impairment. Per the MDS, the resident required supervision with activities of daily living. A record review of a Behavior Note, dated 08/24/2021 at 4:17 PM, indicated Resident #351 packed a bag and walked out of facility through a door leading to a patio used for smoking. Certified Medication Aide (CMA) Q followed the resident outside to a food retail place (snow cone stand). Per the note, Resident #351 shoved CMA Q and refused to turn back to the facility. CMA Q called Licensed Vocational Nurse (LVN) G for assistance. LVN G and the note author went outside to help CMA Q bring the resident back inside. The note contained no information regarding the status of the resident's Wander-Guard bracelet. During an interview on 11/03/2021 at 9:54 AM, LVN G confirmed the resident exited the building on 08/24/2021 with CMA Q walking behind the resident. LVN G was unaware how the resident was able to exit the building. LVN G identified that an in-service was conducted, and the code was changed to all doors after the event. During an interview on 11/03/2021 at 5:29 PM, CMA Q stated Resident #351 was walking the halls on 08/24/2021. CMA Q realized the resident's current whereabouts were unknown and found Resident #351 going out the door to the smoke patio. Resident #351 then opened the gate and walked toward a snow cone stand. In lieu of restraining the resident, CMA Q walked in front of the resident and ultimately brought the resident back to the facility, maintaining line-of-sight of Resident #351 during the entire event. Per CMA Q, Resident #351 knew the code to the patio door leading to the smoking area. In response to the event, CMA Q noted the facility conducted abuse/neglect in-services and informed the Administrator of the event. During an interview on 11/03/2021 at 4:11 PM, the Administrator stated Resident #351 was upset on 08/24/2021 and wanted a snow cone. The Administrator stated that, in lieu of restraining Resident #351, CMA Q accompanied the resident to the snow cone stand and walked Resident #351 back to the building. On 11/04/2021 at 3:55 PM, the Administrator was asked to provide interventions resulting from Resident #351's unauthorized exit from the facility on 08/24/2021. The Administrator provided a document titled In-Service Training Report and dated 08/24/2021. The document identified the subject of the in-service as Elopement, Abuse, Neglect, Exploitation. The document contained 24 staff signatures. During an interview on 11/04/2021 at 9:01 AM, the Administrator stated the Wander-Guard system was checked in response to Resident #351's unauthorized departure on 08/24/2021. The Administrator confirmed that the Wander-Guard system was working properly, noting an elopement in-service was conducted with staff. Per the Administrator, the facility notified the nurse practitioner and monitored the resident for behaviors via assessment. The Administrator confirmed that the medical record contained no documentation of behavior monitoring after Resident #351 left the building unauthorized on 08/24/2021. A record review of a document titled Elopement-Internal Investigation 08/24/21 received from the Administrator on 11/04/2021 at 1:40 PM revealed no search was needed in response to the unauthorized departure because a staff member maintained line-of-sight of Resident #351 when the resident exited the building unauthorized. Per the document, post-event interventions consisted of an all-staff in-service on elopement, a check of Wander-Guards to ensure functionality, a check of all exit doors to ensure functionality, and initiation of an abuse/neglect and resident rights in-service. After the 08/24/2021 event when Resident #351 exited the facility without authorization, there was no documentation to indicate that the facility conducted a follow-up elopement assessment or updated the care plan to denote the event or any planned/implemented interventions to help prevent future unauthorized departures. A record review of a Nurse's Note, dated 08/29/2021 at 6:42 PM, indicated, CNA [certified nurse assistant] informed this nurse that resident was not in the building and another resident saw [resident in question] jumping the fence. All facility staff started to look for resident in building and around outside campus. Two staff members also drove through the neighborhood searching for resident. This nurse called advised [sic] to call police, administrator, and DON [Director of Nursing], police called by this writer and reported elopement. Police will drive neighborhood then come and gather information. Received news that resident found at Memorial [NAME] Hospital NE [Northeast]. Patient will get checked out at hospital. Per Resident #351's care plan, the resident left the building without staff knowledge on 08/29/2021 and was found at a hospital. Per the care plan, staff was directed to provide one-to-one supervision until the resident was transferred to a secure unit. The care plan indicated a head-to-toe assessment identified no injuries and a provider and the responsible party were notified. Staff were to ensure the Wander-Guard was functioning and in place. A record review of an Elopement Assessment with a date of 08/29/2021 revealed the resident remained at high risk for elopement. A record review of a Nurse's Note, dated 08/29/2021 at 10:53 PM, indicated, Resident #351 eloped and, per a charge nurse, was found by police at a local hospital. The police brought the resident back to the facility with one-to-one resident monitoring initiated. A head-to-toe assessment identified no injuries. When asked why the resident left, the resident stated he/she did not want to be in the facility anymore and would leave again tonight. The nurse practitioner was notified, and an order was obtained to transfer Resident #351 out of the facility. A One on One Monitoring Form with a date of 08/29/2021 contained documentation that one-to-one monitoring occurred from 7:30 PM to 10:00 PM until the resident was transferred to a secure unit. On 11/02/2021 at 12:26 PM, the Administrator provided a document titled, In-Service Training Report, dated 8/29/2021, containing the documentation, Elopement, Abuse, Neglect, Exploitation with 24 staff signatures. During an interview on 11/03/2021 at 9:03 AM, Medical Records staff stated Resident #351 was missing on 08/29/2021. The Medical Records staff stated that CNA F was informed by another resident that Resident #351 jumped over a fence. CNA F could not subsequently find Resident #351. The Medical Records staff stated the resident previously exited the facility unauthorized with CMA Q following behind the resident on 08/24/2021. She stated the Wander-Guard system was working on 08/29/2021 but the resident went out through a smoking area since the resident knew the code for the door. The Medical Records staff stated they did not know how the resident knew the code. During an interview on 11/03/2021 at 2:26 PM, Certified Nursing Assistant (CNA) F stated he responded to a resident's call light on 08/29/2021. The resident told CNA F that Resident #351 had scaled a fence. CNA F went to the nurses' station to inform staff that Resident #351 was missing. Per CNA F, a search was started. CNA F spoke to Resident #351 upon the resident's return to the facility, who endorsed putting their walker up to the gate and climbing over the gate. CNA F stated the smoking area door was open for residents, but the gate latch was closed and the Wander-Guard system was working. CNA F then stated a code must be inputted to open the smoking exit door and that CNA F did not know the code to get out the door. CNA F clarified that he did not hear the Wander-Guard sound when the resident exited. CNA F described that Resident #351 normally wandered not without a purpose, not aimless wandering. There was no documentation in the investigation that Resident #351's unauthorized departure on 08/24/2021 was fully investigated by obtaining witness statements from all involved parties. For the 08/24/2021 or 08/29/2021 elopements, there was no documentation of causal factors. There was also no documentation that the Wander-Guard system or exit doors were checked on the day of 08/24/2021 or that behavior monitoring was completed after the 08/24/2021 event. During an interview on 11/04/2021 at 2:15 PM, the Administrator stated a search was initiated for Resident #351 after the 08/29/2021 elopement. Per the Administrator, the authorities were contacted, and the resident's responsible party was notified. The Administrator stated that, shortly after, the resident was found at a hospital by the police, who returned the resident to the facility. The Administrator stated that an assessment was conducted, and the facility initiated one-to-one monitoring. The Administrator stated that a decision was made that the resident was not safe at the facility, despite changing the door code and utilizing a Wander-Guard bracelet. As a result, the resident was transferred out. The Administrator explained that, between the unauthorized departures on 08/24/2021 and 08/29/2021, the facility in-serviced staff on elopements, checked the Wander-Guards for all residents, checked the exit doors, and started an abuse/neglect and resident rights in-service. The Administrator denied that Resident #351 normally wandered or threatened to leave the building prior to the 08/24/2021 event, which the Administrator described as the first time the resident attempted to leave for the month the Administrator had been working in the facility. The Administrator stated Resident #351 had a Wander-Guard bracelet on during the unauthorized departure on 08/24/2021. During the unauthorized departure, CMA Q watched Resident #351 exit the facility per the Administrator. The Administrator stated that the doors would open after pushing on the bar to the door for a certain period, which was how Resident #351 was able to exit. The Administrator stated the information regarding how the resident was able to exit was documented in an internal investigation document. Record review of the investigation report contained no documentation that Resident #351 held the bar to the door to exit. The Administrator denied interviewing all witnesses to the 08/24/2021 event but confirmed that doing so was required to conduct a full investigation. The Administrator confirmed that no elopement assessment was completed after the 08/24/2021 event and was unable to find documentation of behavior monitoring after the 08/24/2021 event. The Administrator confirmed that all events surrounding an elopement required a full investigation to determine the root cause(s) to help prevent another elopement event. The Administrator confirmed the facility lacked documentation to show that the 08/24/2021 unauthorized departure was fully investigated. The Administrator stated staff failed to respond to the Wander-Guard alarm on 08/29/2021 when Resident #351 eloped, which was not found in documentation of the facility's in-depth review of the event. There was no documentation in the investigation that Resident #351's unauthorized departure on 08/24/2021 was fully investigated by obtaining witness statements from all involved parties. For the 08/24/2021 or 08/29/2021 elopements, there was no documentation of causal factors or new/ different interventions for either unauthorized departure event. There was also no documentation that the Wander-Guard system or exit doors were checked on the day of 08/24/2021 or that behavior monitoring was completed after the 08/24/2021 event. A record review of the facility's policy, Incident/Accident System, undated, indicated staff should complete a fall investigation report after every fall to include vital signs, pain assessment, and environmental assessment. A record review of a facility policy titled, Subject: Elopement Risk Assessment, with a revision date of 02/2016, indicated, 2. All patients/residents are re-assessed for elopement potential by the licensed nurse/Social Service or designee quarterly throughout a patient's/residents stay and with a significant change .10. A licensed nurse documents in the nurse's notes and behavior monitoring flow record any exit seeking behavior on an on-going basis and interventions are adjusted as needed. A record review of a facility policy titled, Subject: Elopement, with a revision date of 04/2017, indicated, Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. A record review of an undated facility policy, titled, Wandering and Elopements indicated, .the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Texas Administrative Code TAC §554.901(14)(B) Tag 1477. This requirement is not met as evidenced by: For evidence of violation, refer to CMS form 2567 dated 11/04/2021, F689.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent development of pressure ulcers and promote healing of the wound for 1 of 9 residents (Resident #1) reviewed for pressure ulcers. Resident # 1 acquired a stage II pressure ulcer on the coccyx while at the facility which was not identified by facility staff. This failure affected 1 resident and placed 39 other residents at risk of developing or worsening of pressure ulcers. Findings include: Intake # 8 Record reviewed of Resident # 1's face sheet revealed she admitted to the facility on [DATE] and readmitted on [DATE], [DIAGNOSES REDACTED]. She was [AGE] years old. Observation of Resident #1 on 6/18/15 at 10:20 am revealed Resident #1 was in a low bed on her right side. The mattress was not a pressure relieving device. AM care was being provided by C.N.A A: a brief was removed from underneath Resident #1 that was soiled with feces. At this time, a wound was observed on the coccyx to be open with no dressing on it. C.N.A A wiped the area off with the disposable wipes. The wound appeared yellowish and red in color approximately a nickel size. C.N.A A turned and repositioned her to the left side. Record reviewed of the facility's pressure ulcer risk report did not include Resident # 1 in the list for at risk of pressure ulcer. Record reviewed of nurse's note dated 4/3/15 revealed Resident # 1 required extensive assistance and had sacral redness. Record reviewed of nurses' notes for Resident #1 dated 4/6/15 read in part sacral redness noted Record reviewed of clinical records for Resident # 1 revealed discharged information sheets dated 4/25/15 - 5/8/15 which was a skin assessment done while Resident # 1 went to a local hospital (because of [MEDICAL CONDITION], Failure to thrive, and [DEVICE] placed) exhibited evidence of a stage II on Resident # 1's coccyx. Record reviewed of Resident #1's clinical records revealed a nurse's note dated 5/8/15 read in parts arrived to HHC via ambulance/stretcher from a local hospital . incontinent of B&B not able to ambulate, needs assistance with ADLs [DEVICE] in place .Resident has . Stage II on sacral area. Record reviewed of physician orders [REDACTED]. Record reviewed of Resident # 1's 14 day MDS dated [DATE] revealed checked under section of skin condition; risk determination; has ulcer, scar, or dressing; is resident at risk of developing pressure ulcer? Yes Record reviewed of nurses' notes for Resident #1 dated 6/4/15 read in part wounds to sacral which is pink in color with no open area no noted drainage edges are smooth and flat measuring 4.0x4.0 with no depth. Record Review of TAR for Resident #1 dated April 2015, May 2015, and June 2015 revealed an order for [REDACTED]. Further review of Resident #1 clinical records revealed no documentation describing the sacral area with dressing changed every 7 days; no descriptions of the coccyx area with weekly skin checks; and no follow up or monitoring for sacral redness as recorded in the nurses notes. An attempted interview with Resident #1on 6/18/15 at 10:20 revealed the resident was not responsive. In interview with C.N.A A on 6/18/15 at 10:20 am, she stated Resident # 1 had an opening on the Coccyx. She said, Resident # 1 was wearing a diaper because there was no pressure relieving device on the bed. She further stated, Residents with pressure ulcers was on a pressure relieving device, did not wear diapers, and was cleaned, turned and repositioned every two hours according to their policy. After cleansing the sacral area C.N.A A said, she did not put a diaper on Resident #1 because of the wound on her Coccyx. She said when she worked with Resident # 1 previously (2 days ago) there was no opening on the coccyx area. She further stated they reported skin issues (such as a wound) to the Charge Nurses and the Treatment nurse. An interview with the Wound Care Nurse on 6/18/15 at 1:00 pm she said she treated the wounds Monday through Friday on the weekends the Charge Nurses were responsible to do their own treatments. She said they used Braden scaled to identify Resident at risk for pressure ulcers. They used pressure relieving devices, turned and repositioned Residents every two hours. She did the weekly skin assessments when A was documented it meant abnormal and was accompany a note detailing the abnormality. She said Resident # 1 had pressure sores on her foot, had a scar tissue on her bottom and taught she documented it, but was not sure. She said she did the weekly skin assessment on Resident # 1 that was recorded in the TAR dated Monday 6/15/15, Monday 6/8/15 and Monday 6/1/15. She said there was no wound on Resident # 1. She further stated she was not aware of a wound on Resident # 1's bottom until today (day of investigation after surveyor observed the wound). She said the C.N.A just reported it to her. She went and assessed the area and decided it was un-stageable Observation of Resident #1 on 6/18/15 at 1:35 pm revealed she was lying on the same side (left) since repositioned after am care at 10:20 am. An interview with Charge Nurse LVN A on 6/18/15 at 1:40 pm she said the C.N.A s turned and repositioned the residents every two hours but sometimes it could be three. She said the C.N.As were pretty good at notifying of changes. C.N.As reported skin changes to the treatment nurse. The Charge Nurses did the treatments when the wound care nurse was off. She said they did skin assessment on admission and weekly skin assessment was done by the wound care/treatment nurse. She further stated the last time she was doing the treatment Resident# 1 had a little pink area it had been there but was not open. She documented it and had the nurse's notes. Observation on 6/18/15 at 3:35 pm revealed Resident # 1 was lying on the same side (left) again. An interview with the DON on 6/18/15 at 3:40 pm she said they turned and repositioned the residents every two hours. They did weekly skin checks on every Resident. She said she looked at Resident # 1 's bottom last week and it was not open. According to the DON, the wound was un-stageable because they did not know what was underneath due to slush or eschar. She said the reason there was no dressing on the wound on Resident # 1 's coccyx was because it may have fallen off An observation of Resident # 1 on 6/19/15 at 9:45 am revealed no dressing on the wound on her coccyx. Resident # 1 was lying on her right side with a pressure relieving mattress, and no diapers. An interview with Resident # 1 at this time revealed she was alert and verbal. She said she was doing fine, but was not able to provide any information regarding the wound or the care she received at the facility. An interview with C.N.A B on 6/19/15 at 9:45 am she said the Resident # 1's bottom been like this. She could not remember the last time she saw the skin intact to the sacral area. The Treatment Nurse was notified she said. She further stated she had been on vacation and did not know exactly what happened before she returned to work. In interview with the Treatment/Wound Nurse on 6/19/15 at 1:50 pm she said she discontinued the preventative dressing to the sacral area because at this point it was not a preventative care anymore. She obtained a new treatment order and would be going to apply it to the wound. She searched their computer system and the chart, but still could not locate any documentation to support the skin condition regarding Resident # 1's coccyx area. At this time, the DON came in and helped her search, but there was no documentation and both finally stated they did not have it. The DON nodded her head yes when surveyor asked if she were aware of the discharged report from the hospital and the Nurse's note dated 5/8/15 reveled a stage II on the resident 's sacral area. Record review of the facility 's policy for pressure ulcer prevention program all revised October 2010 documented in part: Standard: All residents will be assessment for risk of pressure ulcer development . Based on the results of this assessment, specific interventions will be implemented to prevent the development of avoidable pressure ulcers, or, to treat existing pressure ulcers. Procedures: 2. Resident identified at being at risk will have interventions identified in their plan of care to prevent the occurrence of pressure ulcers. 4. All residents will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident 's medical record. Based on the facility CMS form 672 there were 40 residents identified as having pressure sores or at risk of developing pressure sores.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible. - The exterior air conditioning vent on the building was observed to have dryer lint built up around the air vent inside the lint trap. Cigarette butts were observed around the lint trap and one lit cigarette was observed one foot from the lint trap in an urn type ashtray. Lint was also observed on the fascia board, wall and door surrounding the lint trap. An Immediate Jeopardy (IJ) situation was identified on 02/13/14 at 4:45 p.m. While the IJ was lowered to a non-immediate Jeopardy on 02/14/14 at 3:00 p.m. The facility remained out of compliance at widespread with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's Plan of Removal of Immediate Jeopardy was accepted at 1:00 pm on 02/14/14 by notification of the Administrator. This failure placed all 85 residents in the facility at risk for fire injuries, smoke inhalation, burns, hospitalization , and/or death. Non-Immediate Jeopardy -There were 2 bottles of peri-wash on the dresser in Resident # 23's room (who was a confused resident). -There were 2 bottles of peri-wash in the bathroom of Resident #26's room (who was a confused resident). -There was a liquid on the bathroom floor and a jagged mirror propped behind the sink faucet in Resident # 60's bathroom (who would self toilet). -CNA H transferred Resident # 83 on 12/25/13 without using the lift and by herself, causing Resident # 83 pain in her knee. - Observations on 2/13/2014 of the facility's exterior physical environment revealed resident safety hazards in different areas surrounding the building. - The shower room on Hall 2 (secure unit) was observed to be unlocked with an open bottle of shampoo/body wash sitting on a shower chair. - Exposed wires were observed hanging from the wall in the facility's restorative dining room. Findings include: An observation on 2/13/2014 at 3:02 PM of the facility's exterior dryer vent and lint trap revealed the lint trap to be a large metal container approximately 4 feet tall and 3 feet wide with a perforated front to allow for air flow sitting in front of the dryer vent coming out of the facility wall. The dryer was operating at the time of the observation and the metal lint trap was observed to be very hot to the touch. The lint trap was observed sitting on a rotten wood pallet. There was a large amount of lint surrounding the dryer vent inside the lint trap and lint was observed caked against the inside surface of the lint trap. Lint was also observed on the surrounding wall, the fascia board above the lint trap and on the door next to the dryer vent. The door was observed to be in a state of rot and disrepair. Numerous cigarette butts were observed on the ground surrounding lint trap and one cigarette butt laying on the lint in between the lint trap and wall of the facility. A concrete urn style container was observed approximately one foot from the lint trap and contained cigarette butts and one lit cigarette with smoke coming from the cigarette. The lint trap was also observed to be under a pole with power lines coming from the pole and leading to the building. The facility's main power box was observed on the same wall as the lint trap a few feet away and the main generator was observed approximately 10 feet from the lint trap. In an interview with the Housekeeping/Laundry Supervisor on 2/13/2014 at 3:14 PM when asked about the dryer vent and lint trap, he said they cleaned the lint trap on the outside of the building once a month. When asked if he documented when he cleaned the lint trap each month, he said no. He also said the area surrounding the dryer vent was a non-smoking area and staff should not be smoking there. He said there was not a "no smoking" sign in the area. He said he last cleaned the lint trap about one month ago. He also said he had not cleaned behind the lint trap. When asked what could happen with the cigarettes and the dryer lint and the heat from the dryer vent, and he said "fire". He also said he did not remember how long the lint trap was sitting on the rotten pallet. He said the chairs and ashtray had been there since December 2013. Record review of the facility's "Fire Hazards in the Laundry" policy and procedure read in part; "Purpose: Laundry personnel are trained to clean lint screens in dryers. Potential Hazard: Increased fire hazard because of lint build-up on ceilings and other surfaces such as heat producing equipment. Lint build-up in lint traps can also be a hazard. As dryers run, lint will accumulate inside the dryers. To keep the lint from traveling up to the top of the dryers, near the flame, the dryers are equipped with a screen to catch lint and hold it away from the flame. These screens will eventually be covered with lint and must be cleaned. If not cleaned, the screens will prevent air from circulating through the dryers and is a definite fire hazard. Possible Solutions: Routine cleaning surfaces of lint, and emptying of lint traps." This document was not dated. There was no specific documentation related to cleaning the dryer vent and lint trap on the outside of the building. Record review of the facility's plan of removal for the immediate jeopardy read as follows: Plan of Removal of Immediate Jeopardy relating to Accidents/Hazards-Fire Safety ISSUE- Removal of lint from dryer vent by the laundry area on 2/13/14 as identified by Fed/ State Surveyor. Immediate action: Maintenance Director was notified by State that dryer vent is packed with lint and staff is smoking in the areas at 3:30 pm. Maintenance director notified Administrator immediately. An action plan of resolving the identified issue was put in place. - Removed lint trap and old wooden pallet from the identified area at 3:45 pm 2/13/14. - Cleaned lint trap and lint from area around dryer exhaust. Installed non -flammable cement blocks as the base at 4:30 pm 2/13/14. - Cleaned lint trap was reinstalled on base to complete the project of cleaning the dryer vent and area at 4:45PM 2/13/14. - Chairs were removed form area and a non-smoking sign was placed in the identified location at 4:55 pm 2/13/14. - Completed removal of lint hazard was at 5 pm 2/13/14 by administrator and maintenance staff. Available staff inservice was initiated at 4:30 pm 2/13/14 on service area by laundry designated non-smoking area and staff new smoking area will be located on back patio same as resident smoking area. Staff not present will be inserviced prior to starting assigned shifts. Maintenance supervisor was inserivced 1:1 by Administrator on procedure and frequency of cleaning lint trap at 5 pm on 2/13/14. Documentation of daily checks of lint trap and area will be documented in TELS monitoring systems program which records dates and information pertaining to action taken by maintenance supervisor. While the IJ was lowered to a non-immediate Jeopardy on 02/14/14 at 3:00 p.m. The facility remained out of compliance at widespread with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's Plan of Removal of Immediate Jeopardy was accepted at 1:00 pm on 02/14/14, after verification of the plan of implementation had occurred. Non-Immediate Jeopardy Resident # 23 Observation on 2/11/14 at 8:40 AM revealed in Resident # 23's room there were 2 bottles of peri-wash on the dresser. Record review of Resident # 23's quarterly MDS dated [DATE] revealed his BIMS was 8 (moderately intact cognition), wandered and had a [DIAGNOSES REDACTED]. In an interview on 2/11/14 at 8:40 AM, CNA C stated the peri-wash sprays are not supposed to be left out as a resident could open it and drink it. She stated Resident # 23 was confused. Resident # 26 Observation on 2/11/14 at 8:50 AM revealed in Resident # 26's room there were 2 bottles of peri-wash sitting on the toilet tank. Record review of Resident # 26's quarterly MDS dated [DATE] revealed he had short and long term memory deficits, moderately impaired decision making, required limited assistance with walking and had a [DIAGNOSES REDACTED]. In an interview on 2/11/14 at 8:50 AM, CNA C stated the peri-wash should not be left out as Resident # 26 was confused. She stated the peri-wash should be in a bag and kept at the bottom of the linen cart. Resident # 60 Observation on 2/11/14 at 10:30 AM revealed in Resident # 60's bathroom there was a liquid on the floor and a mirror was propped up behind the sink faucet, leaning against the wall. The mirror had a rough edge to one corner. Record review of Resident # 60's quarterly MDS dated [DATE] revealed her BIMS was 7 (severely impaired cognition), required supervision for walking and toileting and was always continent. In an interview on 2/11/14 at 10:30 AM, CNA D stated both residents in room were fall risks, including Resident # 60 who used the bathroom on her own. When asked about the liquid on the floor, she stated "I see it now" and that it would put the resident at risk for a fall. When asked about the mirror, CNA D stated "I guess they need to stick it on the wall." She stated she did not know how long the mirror had been like that and that it was not okay for it to just propped up like that because it could cut someone. In an interview on 2/11/14 at 10:46 AM, CNA D stated she had removed the mirror from Resident # 60's bathroom and let the nurse and maintenance know about the concerns in the bathroom. Resident # 83 Record review of Resident # 83's face sheet revealed [AGE] year old admitted to the facility on [DATE] and had the following diagnoses; late effect cerebrovascular disease, esophageal reflux, osteoporosis, affective personality, depression, hypertension and constipation. In an interview with Resident # 83 on 2/13/14 at 4:20 PM, she stated she was transferred from a shower chair to bed by 1 CNA since the other CNA did not want to help several weeks ago. She stated when this happened, her knee got hurt. Observation on 2/13/14 at 4:20 PM revealed Resident # 83's bilateral feet were contracted and she used an electric wheel chair for mobility. Record review of Resident # 83's admission history and physical dated 11/27/12 revealed she had bilateral foot drop. Record review of Resident # 83's physician progress notes [REDACTED]. Record review of Resident # 83's quarterly MDS dated [DATE] revealed there was no limitation of range of motion to her lower extremities (hip, knee, ankle and foot). Record review of Resident # 83's nurse note dated 12/25/13 at 4:15 PM read, in part, "Resident was being transferred from shower chair to wheelchair. Resident slipped out of shower chair during transfer. Resident left leg went backwards and the knee area assessment done per nurse. No swelling at this time. Resident complained of pain upon palpitation to area above knee. Schedule Norco given as directed. MD notified. New order x-ray of left knee and femur..." Record review of Resident # 83's 12/25/13 x-ray report of her left knee revealed no acute fracture. It revealed there were degenerative changes, possible prior fracture and displaced or subluxed patella. This x-ray was review by Resident # 83's physician on 12/26/13 who wrote "exam of the knee reveals no pain, no swelling. She had permanent contractures to that knee." In an interview on 2/13/14 at 5:55 PM, CNA H stated she had been working with Resident # 83 on 12/25/13. She stated she could not find anyone to help transfer the resident out of the shower chair and admitted she transferred the resident by herself into bed. She stated she did not have the lift pad under her in the shower chair, so when she tried to transfer her, she said my feet hit her feet and caught and bent her knee. She stated neither of them actually fell . CNA H stated Resident # 83 was usually transferred with a lift or with 2 people. In an interview on 2/14/14 at 7:15 AM, the DON stated on 12/25/13 CNA H did transfer Resident # 83 by herself because another CNA would not help her. The DON stated she had counseled the CNAs and the one CNA who would not assist with the transfer no longer worked at the facility. Observations on 2/13/2014 of the facility's exterior physical environment revealed the following: - 2:06 PM: A metal shed was observed on the outside of the building which had a mud floor. There was also standing water in the shed floor. A light bulb was observed on the ground in the mud in the shed. There was also a water pump with cords plugged into it laying in the mud. - 2:08 PM: An exterior hot water heater was observed in a room on the side of the building. The door to the hot water heater was observed to be rotted and only partially intact. Water was observed dripping under the hot water heater and a pool of water was observed standing on the concrete floor under the water heater. - 2:16 PM: A black cable was observed laying on the soggy ground between a power pole approximately 50 feet away from the facility, leading to a "Telecom" box next to the facility wall. - 2:32 PM: A wooden and metal park bench was observed inside the resident's fenced smoking area. The bench was observed to have rotten and broken wood slats which exposed pieces of rusted metal on the bench. - 2:32 PM: A large pile of tangled water hoses were observed against a wall inside the resident's fenced smoking area. - 2:34 PM: Cigarettes which were not properly extinguished or disposed of were observed sitting on the window sills and on the ground in the resident smoking area. - 2:34 PM: One chair in the resident smoking area was observed to be constructed of wood and cloth. The cloth was observed to be dirty with bird excrement on the seat. - 2:36 PM: Large amount of bird excrement was observed covering the resident use table and chairs in the resident smoking area. Bird excrement has the potential to carry an illness called histoplasmosis. - 2:38 PM: A concrete pig was observed in the resident smoking area which had two protruding rusty metal wires coming from the top of the head where there pig ' s ears used to be. - 2:44 PM: An unsecured storage shed at the back of the facility was observed which contained tools, wood, paint and containers marked "Corrosive". Outside of the storage shed was observed a broken night stand, pile of boards with rusty nails sticking out of them, toilet and a large bin containing empty soda cans was observed with bees swarming around the cans. Also outside of the storage shed were 2 active fire ant beds and standing water on either side of the drive in front of the shed which was approximately 3 feet wide by 15 feet long. - 2:54 PM: An unsecured large shipping container at the back of the facility was observed which contained assorted facility equipment such as wheelchairs and furniture. Observation on 2/11/2014 at 10:20 AM of the secure unit's (Hall 2) shower room revealed the door to the shower room to be unlocked and a gallon jug of "Shampoo and Body Wash" was observed sitting on a shower chair with no lid on the bottle. Observation on 2/12/2014 at 12:38 PM of the facility's restorative dining room revealed on either side of the dining room, 2 wires were coming out of the wall and hanging approximately 4 feet off the floor. The ends of the wires were observed to be exposed. In an interview with the DON on 2/14/14 at 4:15 PM she was asked about the resident smoking area, she stated the area should be cleaned. She stated the bird dropping could be a way to contract a disease and was " nasty. " Record review of the CDC website definition of Histoplasmosis read in part; "Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. The fungus lives in the environment, usually in association with large amounts of bird or bat droppings. Lung infection can occur after a person inhales airborne, microscopic fungal spores from the environment. ...The symptoms of histoplasmosis are similar to pneumonia, and the infection can sometimes become serious if it is not treated." http://www.cdc.gov/fungal/diseases/histoplasmosis/index.html Record review of the facility's "Cleaning Schedules" policy and procedure read in part; "Policy Statement: Cleaning schedules shall be developed and implemented to ensure that our facility is maintained in a clean and comfortable manner. Policy Interpretation and Implementation: 1. Cleaning schedules are developed and implemented to assure that each area of our facility is maintained in a safe, clean and comfortable manner." This document was not dated. Record review of the facility's "Facility Smoking Policy" policy and procedure read in part; "Safe Smoking Environment: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for facility smoking privileges." This document was dated 2/21/2013. Record review of the facility's "Cleaning and Disinfection of Environmental Surfaces" policy and procedure read in part; "Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. ...Non Resident Care Areas: 7. Detergent and water will be used for cleaning surfaces in non resident care areas. ...Housekeeping Surfaces: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled." This document was dated 8/2009. Record review of the facility's policy Safe Lifting and Movement of Residents, revised October 2009, read 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 left and move residents ...12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies..." A request was made during the survey for a policy and procedure related to cleaning/removing garbage and/or trash from the facility's property. This document was not provided prior to exit. According to CMS 672 the census as 85.

Based on observation, interview and record review the facility administration failed to develop and implement a plan for identifying and eliminating potential fire hazards in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facilities when: - The Administrator failed to communicate all safety recommendations adopted by the Safety Committee to the appropriate department within the facility. - The exterior air conditioning vent on the building was observed to have dryer lint built up around the air vent inside the lint trap. Cigarette butts were observed around the lint trap and one lit cigarette was observed one foot from the lint trap in an urn type ashtray. Lint was also observed on the overhang, wall and door surrounding the lint trap. An Immediate Jeopardy (IJ) situation was identified on 02/13/14 at 4:45 p.m. While the IJ was lowered to a non-immediate Jeopardy on 02/14/14 at 3:00 p.m. The facility remained out of compliance at widespread with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's Plan of Removal of Immediate Jeopardy was accepted at 1:00 pm on 02/14/14 by notification of the Administrator. This failure placed all 85 residents in the facility at risk for fire injuries, smoke inhalation, burns, hospitalization , and/or death. Finding Include: An observation on 2/13/2014 at 3:02 PM of the facility's exterior dryer vent and lint trap revealed the lint trap to be a large metal container approximately 4 feet tall and 3 feet wide with a perforated front to allow for air flow sitting in front of the dryer vent coming out of the facility wall. The dryer was operating at the time of the observation and the metal lint trap was observed to be very hot to the touch. The lint trap was observed sitting on a rotten wood pallet. There was a large amount of lint surrounding the dryer vent inside the lint trap and lint was observed caked against the inside surface of the lint trap. Lint was also observed on the surrounding wall, the fascia board above the lint trap and on the door next to the dryer vent. The door was observed to be in a state of rot and disrepair. Numerous cigarette butts were observed on the ground surrounding lint trap and one cigarette butt laying on the lint in between the lint trap and wall of the facility. A concrete urn style container was observed approximately one foot from the lint trap and contained numerous cigarette butts and one lit cigarette with smoke coming from the cigarette. The lint trap was also observed to be under a pole with power lines coming from the pole and leading to the building. The facility's main power box was observed on the same wall as the lint trap a few feet away and the main generator was observed approximately 10 feet from the lint trap. In an interview with the Housekeeping/Laundry Supervisor on 2/13/2014 at 3:14 PM when asked about the dryer vent and lint trap, he said they cleaned the lint trap on the outside of the building once a month. He also said the area surrounding the dryer vent was a non-smoking area and staff should not be smoking there. He said there was not a "no smoking" sign in the area. He said he last cleaned the lint trap about one month ago. He also said he had not cleaned behind the lint trap. When asked what could happen with the cigarettes and the dryer lint and the heat from the dryer vent, and he said "fire". He also said he did not remember how long the lint trap was sitting on the rotten pallet. He said the chairs and ashtray had been there since December 2013. In an interview with the Administrator on 2/14/14 at 5:00 PM he stated he did not know staff was smoking by the outside dryer lint trap. He stated he did not know there was a big build up of lint outside the laundry room. He stated he conducted staff interviews and was than made aware that staff was smoking outside by the dryer lint trap. The staff began smoking there sometime in December when the weather became very cold. The lint trap blew out hot air and the staff was using it as a heater while on their breaks. He said no one thought about it as a fire trap. Continued interview with the Administrator on 2/14/14 at 5:00 PM he stated all staff members were in-serviced before the start of their shift. The wooden pallet was removed and cement blocks were placed underneath the lint trap. The lint trap and the surrounding areas was cleaned of all lint and cigarette butts. The chairs and ash trays were removed from the area. The area was designated a non-smoking area and a no smoking signs were posted outside on the door and next to the dryer lint trap. He stated if anyone is catch smoking in that area they will be discipline immediately. He stated to accommodate the staff and to ensure their compliance they designated a staff smoking area next to the resident smoking area. They began daily checks of the outside lint trap and the surrounding area. The checks will be documented in their TELS monitoring systems program which records dates and information pertaining to action taken by maintenance supervisor. Record review of the facility's "Hazardous Areas in the Facility, 2001 MED-PASS, inc. (Revised December 2007)" read in part, "All hazardous areas in the facility shall be identified with appropriate precautionary signs. 1. All hazardous areas are so designated and can be identified on floor plans posted throughout the facility. 2. Hazardous areas, such as power rooms, boiler rooms, oxygen or other flammable liquids storage rooms, etc., are posted with No Smoking signs. 3. Smoking is prohibited in all hazardous area. 4. The facility's Safety Committee shall recommends measures to ensure that residents cannot access hazards areas in the facility. 5. The Administrator is responsible for communicating all safety recommendations adopted by the Safety Committee to the appropriate department within the facility..." Record review of the facility's "Facility Smoking Policy" policy and procedure read in part; "Safe Smoking Environment: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for facility smoking privileges." This document was dated 2/21/2013. The Administrator was notified on 2/13/14 at 4:45 PM that an Immediate Jeopardy situation was identified due to the above failures. The facility submitted their first plan of removal on 2/14/14 at 10:00 AM. The facility's final Plan of Removal was accepted on 2/14/14 at 1:00 PM and included: Immediate action: Removed lint trap and old wooden pallet from the identified area at 3:45 PM 2/13/14. Cleaned lint trap and lint from area around dryer exhaust. Installed non-flammable cement blocks as the base at 4:30 PM 2/13/14. Cleaned lint trap was reinstalled on base to complete the project of cleaning the dryer vent and area at 4:45 PM 2/13/14. Chairs were removed from area and a non-smoking sign was placed in the identified location at 4:55 PM 2/13/14. Completed removal of lint hazard was at 5 PM 2/13/14 by Administrator and maintenance staff. Available staff in-service was initiated at 4:30 PM 2/13/14 on service area by laundry designated non-smoking area and staff new smoking area will be located on back patio same as resident smoking area. Staff not present will be in-serviced prior to starting assigned shifts. Maintenance supervisor was in-serviced 1:1 by Administrator on procedure and frequency of cleaning lint trap at 5 PM on 2/13/14. Documentation of daily checks of lint trap and area will be documented in TELS monitoring systems program which records dates and information pertaining to action taken by maintenance supervisor. Review of the facility's "Inservice Training Report" dated 2/13/14 read "effective immediately the only smoking area is the back patio by the dining room. Smoking is no longer allowed outside the laundry. Failure to comply may result in termination of employment." Signatures from employee CNA's, Nursing staff, Dietary staff, Maintenance staff, and Housekeeping staff on the 6 AM - 2 PM, 2 PM - 10 PM and 10 PM to 6 AM shifts were noted on the inservice. Review of the facility's "Inservice Training Report" dated 2/13/14 at 5:00 PM read "Make daily routine rounds of service area. Checking the dryer lint trap and area around for any hazard of lint accumulation. Take immediate action to remove lint if hazard is found. Document observation and/or any action taken in your TELS monitoring system program" the maintenance manager signature was noted on the inservice. The surveyors confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ by: Lint was removed from the external lint trap cage, the surrounding walls, the fascia board, the door, the door cracks and vents and the surrounding grounds. A no smoking sign was posted on the door next to the external dryer lint trap. The ash trays, chairs and cigarette butts were removed from the area. The lint trap was placed on a cement blocks. The IJ was lowered to a non-immediate Jeopardy on 02/14/14 at 3:00 p.m. The facility remained out of compliance at widespread with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. According to the facility's 672 the census was 85.

Based on observation, interview and record review the facility failed to provide the necessary care and services to prevent the development or worsening of pressure ulcers and to promote the healing of pressure ulcers for 3 of 4 Residents (Resident # 75, # 30, and # 35) who were reviewed for pressure ulcer care and management as evidenced by; -Resident # 75 developed an unstageable pressure ulcer to her left heel on 1/29/2014 and was not assessed by a physician until 16 days later. The facility failed to develop a care plan or implement interventions to address risk for pressure ulcers following a significant change in her ADL functions in December 2013. -Resident #30 had a facility acquired stage 4 pressure ulcer which developed on 9/26/12 was last assessed by a wound care physician on 5/1/2013. The wound depth has increased since that date with no documentation of additional assessments for the pressure ulcer. -Resident # 35 readmitted to the facility on [DATE] subsequent to a fall and fractured humerous. Despite being assessed as a " moderate risk for skin breakdown " on 1/20/14, the Resident developed new pressure areas to her sacral area (1/27/14) and her left hip (2/13/14). There was no documentation by Resident #35 ' s attending physician or the facility ' s dietician of any implemented interventions to prevent pressure sores. These failures affected 3 residents and placed 54 additional residents that were bedfast or in the chair most of the time at risk for development of pressure sores, decline in health, pain and need for additional treatment. Findings included: Resident # 75 Record review of Resident # 75's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. She was [AGE] years old. Record review of Resident # 75's Admission MDS assessment with 7/24/2013 ARD date revealed she was admitted to the facility on [DATE]. Her BIMS score was 9 out of 15 which means the resident was moderately cognitively impaired. It further revealed she was independent with bed mobility, transfers, ambulation in her room, and toilet use. She required supervision with set up only with personal hygiene, and bathing. She had no limitations in range of motion. She was always continent of bowel and bladder and did not have an indwelling urinary catheter. She was checked no for the presence of pain. The skin condition section of the assessment revealed she was not a risk for developing a pressure ulcer and did not have a pressure ulcer. Record review of Resident # 75's quarterly MDS assessment with 10/21/2013 ARD date revealed she usually understands others. Her BIMS score was 6 out of 15 which means the resident had a severe cognitively impairment. It functional status section of the assessment revealed she needed supervision- oversight, encouragement or cueing for with bed mobility, dressing, eating, and toilet use. She was independent with transfers and ambulation in her room. She required supervision with set up only with personal hygiene. She required extensive assistance of one person for bathing. She had no limitations in range of motion. She was always continent of bowel and bladder and did not have a indwelling urinary catheter. She was checked no for the presence of pain. The skin condition section of the assessment revealed she was not a risk for developing a pressure ulcer and did not have a pressure ulcer. Record review of Resident # 75's Braden Scale - Predicting Pressure Score Risk revealed the following: -A resident was at severe risk with a score of less than 9. -A resident was at high risk with a score of 10 -12. -A resident was at moderate risk with a score of 13-14. -A resident was at mild risk with a score of 15 - 18. -The 7/19/2013 assessment revealed the Resident's score was 22. - The 10/18/2013 assessment revealed the Resident's score was 22. Observation was conducted of PTA B and PTA C providing wound care for Resident # 75 on 2/12/2014 at 11:00 AM. Before the care began the resident said her foot was hurting. PTA B asked the resident if her pain was less than 5 the resident told her yes. Resident # 75 did not give a specific number on a scale of 1 to 10. The pressure ulcer was on the back of the left heel. The pressure ulcer had black eschar covering most of the pressure ulcer. The surrounding area especially on the inner heel was red in color with peeling thick areas of skin. When the dressing change was completed the resident told the PTAs that her foot felt like it was scraped. PTA B started the e-stim therapy. At that time the resident again said her heel was hurting "a little bit right now." PTA B rolled a towel under the lower part of the back of the resident lower leg/ankle area. She then asked the resident if the foot was hurting more or less. At that time the resident told her she did not know. PTA C said she would ask nursing to give the resident something for pain. PTA C did not leave the room at that time. PTA B washed her hands and when she came out of the bathroom the resident reported "it is really aching." PTA B told PTA C to ask if the resident could have something for pain. In an interview with LVN B on 2/12/2014 at 7:40 AM she said she did the weekly skin assessments for the whole facility. She stated when Resident # 75's pressure ulcer was found (1/29/2014) it was an unstageable pressure sore. In an interview with CNA E on 2/14/2014 at 11:52 AM she said she was working on the floor when she discovered Resident # 75's wound. She said she was getting the resident ready to get the resident out of bed, had socks on and told CNA E her foot was hurting. CNA E said she took her socks off and she had a discolored wound on her heel. She said she got LVN B and she got the DON and took her right then and there to see the wound. CNA E said the resident had been sick and been in bed. She further stated the resident had been going back and forth to the doctor. She said the resident had not been feeling well and had not been getting out of bed. She further stated the resident ' s appetite had been good. In an interview with PTA C on 2/12/2014 she said Resident # 75 did not usually complain of pain when she had been in her room. She said she provided Resident # 75's wound care occasionally when PTA B was not working. PTA C said Resident # 75 did not complain of pain when she was ambulating or standing. She further stated the resident was walking in the hall with therapy and then all of the sudden she was told she had a wound (after 1/29/2014). She said the resident could move by herself in the bed and roll, but when she came back from the hospital she needed some assistance. In an interview with PTA B on 2/13/2014 at 1:12 PM she said she notified nursing of Resident # 75's pain. When asked about the resident ' s pain level of 5 before treatment she said she should notify nursing and reposition the resident to try and make her more comfortable. When asked about Resident # 75's wound care plan she said the care plan read to pre-medicate for pain prior to the treatment. She further stated she did not ask anyone if the resident had been pre-medicated for pain prior to the treatment. She said LVN B told her the resident had necrotic tissue and it was not healing. When asked about cleaning the wound in a back and forth motion she said it can disturb the granulation tissue and you could have contamination from one part of the wound to another part of the wound. When asked what training she had received in wound care she said she had on the job training in another building. She further stated she had been watched providing wound care by the LVN B and PTA C and maybe the DON, Record review of resident # 75's 12/6/2013 skilled daily nurse's notes at 3:45 PM :"Resident complained to CNA that she had fell and put herself back in chair. Resident shaky with complaints of pain shooting down her leg to her ankle form left hip. (Dr. # 1) notified. Son notified requesting she be sent to hospital . . . PRN Tylenol 325 mg, (two) admin for pain per PRN order . . ." Record review of Resident # 75 ' s medical record revealed she had been hospitalized from12/6/2014 to 12/11/2013. Record review of Resident # 75's 12/11/2013 Resident Summary revealed the resident was being readmitted . The resident summary under pain section read: " (no) pain voiced upon entry. " The summary revealed she had no [MEDICAL CONDITION], her appetite was good and she had no skin breakdown. It also revealed she could ambulate alone, transfer herself, and position herself independently. Record review of Resident # 75's Braden Scale - Predicting Pressure Score Risk revealed the following: -The 12/11/2013 assessment revealed the Resident's score was 22. Record review of Resident # 75's significant change MDS assessment with ARD date of 12/18/2013 revealed the resident had a short term and long term memory problem with modified independence with cognitive skill for daily decision making. The functional status section of the assessment revealed she needed extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Ambulation did not occur during the assessment period. She had total dependence with locomotion on and off the unit of one person and with bathing. She had a range of motion limitation on one side of the lower extremity. The bladder and bowel section of the form revealed she had an indwelling urinary catheter and was always incontinent of bowel. She was not able to answer the question of the presence of pain. It further revealed the staff assessment did not reveal the presence of pain. The skin section revealed the resident was at risk of developing a pressure ulcer but currently did not have pressure ulcer. She had a pressure reducing device on the bed. The Care Area Assessment (CAA) Summary revealed the following areas for care area triggered and a care plan decision: ADL function, urinary incontinence/indwelling catheter, nutritional status, and pressure ulcer. Record review of Resident # 75's care plan revealed the following care plans were updated on 12/18/2013: -I require extensive assist for all ADLs related to stroke with generalized weakness. There were no interventions related to skin. -I am always incontinent of bowel. The approaches include: Observe my skin daily for irritation and redness. There was no care plan related to pressure sores and prevention prior to the undated care plan for the unstageable pressure ulcer. -I have potential for episodes of mild pain related to past stroke, Tylenol as needed. The Goal was I verbalize full relief of pain with 3/18/2014 target date. the approaches included: Evaluate my pain daily using 1 - 10 scale. My pain goal is 2. Administer my pain medication as ordered. Monitor for worsening of my pain symptoms and report to physician. In an interview with the DON on 2/13/2014 at 2:10 PM she was asked if she saw any interventions for pressure ulcer prevention in Resident # 75's 12/18/2013 care plans. She looked through the care plans and said no. She said Dr. # 1 comes to the facility every two weeks. She further stated the physician was supposed to see the resident every month for the first 90 days and then every 60 days. Record review of Resident # 75's 12/18/2013 [MEDICATION NAME] lab result revealed the level was 13.1 with a reference range of 18.0 - 45.0. This test indicates recent protein loss. Protien is needed for wound healing. Record review of Resident # 75 ' s medical record revealed she was hospitalized from [DATE] to 12/24/2014. Record review of Resident # 75's 12/24/2013 Resident Summary revealed she was readmitted . It further revealed she was alert, confused and understood information but had difficulty. She had no pain and her skin was clear. It further revealed the resident could ambulate alone, transfer herself, and position herself. It further revealed she had a fall on 12/17/2013. It also revealed the resident had a urinary tract infection and was on an antibiotic. Record review of Resident # 75's 12/24/2013 admission orders [REDACTED] -Head to toe skin assessment every week. Record review of Resident # 75's Braden Scale - Predicting Pressure Score Risk revealed the following: -The 12/24/2013 assessment revealed the Resident's score was 22. Record review of Resident # 75's January 2014 Treatment sheet revealed she had a weekly head to toe skin assessment on 1/23/2014 revealed the skin was clear. It further revealed the skin was abnormal on 1/29/2014 and 1/30/2014. In an interview with the DON on 2/12/2014 at 11:35 AM she said the CNA's document any skin checks they do in the computer. She further stated LVN B did the weekly skin assessments for each resident for the whole building. She said she would mark the skin assessment with C for clear or an A for abnormal. Record review of Resident # 75's Functional Status - Activities of Daily living (ADL) Assistance revealed she was cared for by CNA F and CNA E between 1/23/2014 and 1/29/2014. It further revealed she had total dependence to the need for extensive assistance of one person for bed mobility, transfers, dressing, eating, toilet use and personal hygiene according to the documentation of the care provided. There was no area regarding skin problems on the document. In an interview with CNA F on 2/12/2014 at 1:05 PM she said she normally worked on the floor and provided showers. When asked when she documented in the computer she said she normally documented two times per day in the morning and after lunch. She said when she provided a shower she checked the resident's skin to see if it was clear or had any open areas. She further stated when she was working on the floor she checked the skin on the bottom and private areas when she got the resident out of bed or sat them up. When asked if she looked at resident's feet she said she did. When asked about Resident # 75 she said she did not see any wounds on the resident a couple of weeks ago. She further stated the resident did not complain about hurting in her feet. CNA F said she did notice the resident started wearing boots on her feet (protective boots). She further stated if she saw a new wound she would tell (LVN B) and the nurses if it was on the weekends. She said Resident # 75 received her showers on the evening shift. CNA C said again she had never seen any wound on Resident # 75 and she had not seen her wound at all. Record review of resident # 75's 1/29/2014 skilled daily nurse's notes and nurse revealed there was not a time for the following entry "New order P/T to eval and treat as needed Lt heel. Boots to bilat feet in and out of bed. Doppler to lower ext. DX Pain/Lt heel ulcer unstageable . . ." It further revealed wound care order by Dr. # 1. This was the first documentation of the pressure sore. Record review of Resident # 75's 1/24/2014 - 1/29/2014 Physical Therapy Progress Report revealed a wound care evaluation was completed of left heel wound size 3.0 time 5.0 cm, unable to determine depth, wound was covered by 100 percent eschar. Record review of Resident # 75's Wound Skin Healing Record revealed the date of onset for the wound was 1/29/2014 and it was an unstageable to her left heel. -1/29/2014 it measured 3.0 by 5.0 with an unknown depth. There was granulation tissue and dark eschar. It further revealed the surrounding skin was normal for skin. The resident had no pain. Record review of Resident # 75's 1/29/2014 physician telephone order revealed the following orders: -Unstageable left heel, cleanse with wound cleanser pat dry. Apply Santyl to the wound cover with 4 by 4's and wrap with soft - foam. Change every day. This was a verbal order that revealed it was written by LVN B and received from Dr. # 1. There was no time on this order. -Physical therapy to evaluate and treat as needed left heel. This was a verbal order that revealed it was written by LVN B and received from Dr. # 1. There was no time on this order. -Physical Therapy clarification order: skilled Physical therapy (Monday - Friday) times 30 days for wound care to left heel. Cleanse with normal saline. Selectively debride (cut away or remove tissue). Apply E-stim and wound dressing with Santyl, [MEDICATION NAME] (non-adherent dressing)/kerlix (rolled gauze). Nursing to change dressing every Saturday, Sunday and holidays. Record review of Resident # 75 ' s undated care plan revealed the following: -A care plan with the problem/need I have an unstageable pressure ulcer. Hand written in was Unstageable left heel. There was no target date for the goal. The approaches included: reposition me every 2 hours, place a gel cushion on my chair. Encourage me to weight shifts while up in a chair. Teach me the risk factors for development of pressure ulcers. Administer my pain medications at least 1 hour prior to initiating treatment. I need a referral to a dietician to evaluate nutritional status. I need daily observation of skin with routine care. I need a full skin evaluation weekly with bath/shower. Adjust my treatment plan if no healing within 2 - 4 weeks. I need float heels on my pillow. Boots to bilateral feet in and out of bed. Monitor for changes in my skin status that may indicate worsening of my pressure ulcer and notify the physician. Record review of Resident # 75's Braden Scale - Predicting Pressure Score Risk revealed the following: -The 1/29/2014 assessment revealed the score was 18. This assessment revealed the resident had no impairment in sensory perception, was occasionally moist and was chairfast. It further revealed she had very limited mobility and excellent nutrition. She had a potential problem for friction and shear. In an interview with LVN B on 2/12/2014 at 11:45 AM she was asked what the process was for her skin assessments. She said she did the skin assessment for a hall on a specific day for the hall. She further stated she looked at the resident from head to toe. She said sometimes she looked at the resident's skin in the shower. LVN B said the CNAs were supposed to report new wounds and should be reporting new wounds. She stated the last time she did a skin check on Resident # 75 prior to the wound being discovered was on 1/23/2014. When asked if she thought the resident could have clear skin and then have an unstageable wound in 6 days she said if the resident were just lying in the bed. She said Resident # 75 was receiving therapy and getting out of bed. LVN B said the facility did not have a physician that specializes in wound care come to the facility weekly but they could have one come to the facility. When asked if the resident's primary care physician had seen the wound she said she was not sure. She further stated he was notified of the new pressure ulcer. When asked what the pressure sore looked like when she saw it for the first time she said the heel was discolored, one side had a leather like black eschar and the other side was vicious red in color. One side of the heel was very tender. LVN B said she also spoke to the corporate nurse responsible for wound care. She said that nurse whose name she could not remember was available via e-mail. LVN B said the corporate wound care nurse did not come to the facility to look at Resident # 75's wound. When asked about the date on the care plan she said she would have to look at the medical record to see when the wound was identified for the date when the care plan was initiated. In an interview with LVN B on 2/14/2014 at 7:35 AM she was asked how she was informed of Resident # 75's unstageable pressure sore. She said one of the CNAs informed her and he went and assessed the wound. She further stated she discussed the wound with therapy, with PTA C. LVN B said she told her it was discovered that day (1/29/2014) and she wrote an order for [REDACTED].# 75's doctor that the wound had eschar. When asked if the primary care physician looked at wounds she said he did look at wounds. When asked when Resident # 75's care plan was initiated she said she was going to have to look at the order (for the wound care). She said the care plan did not have a target date on the goal. When asked what was being done to prevent pressure ulcers for Resident # 75 she said she had a gel cushion on her wheelchair, repositioning every two hours, weight shifts, and teaching how to report to nurse (intervention done after 1/29/2014 pressure sore developed). She looked at the care plan and said it said to administer pain medication before wound care. She said nursing was doing Resident # 75's wound care on the weekends and holidays. LVN B said the staff should ask the resident what her pain level was on scale of 1 to 10 before wound care. She further stated if their pain level was a 5 they should administer as needed pain medication and not touch them under after the medication. She said you needed to address pain and if the resident cannot say the level of pain the staff should assess for moaning, groaning, grimacing and their breathing. When asked when wound treatments should be changed she said if it was the same for a while. She further stated wounds were evaluated every 2 weeks by the doctor. She said she did not know if the doctor had looked at Resident # 75's wound. She said she had received an update and training on wound care. LVN B said the DON was with her weekly when she performed wound care. In an interview with the DON on 2/12/2014 at 12:30 PM she said (RN A) was the regional wound clinical specialist. She further stated RN A did their training on wounds and watched wound care with the wound care nurse. Record review of Resident # 75's Physical Therapy Evaluation and Plan of Treatment revealed the Certification Period was 1/29/2014 - 3/29/2014. The wound analysis revealed the first wound was 3.0 cm length by 5.0 cm width, Edge was indistinct and it had adherent soft black eschar, The necrotic tissue amount was 75 to 100 percent. Under the intervention section it read: "Was conventional wound care provided prior to (start of care)? = Yes, patient received 30 days of conventional care to address wounds, (without) measurable signs of healing. The assessment summary impressions revealed the resident presented with left heel ulcer that had not responded to conventional treatment. This was signed by Dr. # 1 and the signature date was 2/5/2014. In an interview with PTA B on 2/13/2014 at 1:12 PM she said was asked if the Plan of Care was accurate she said "as far as I know the plan of care was accurate." When asked if she had done any research or review prior to starting Resident # 75's wound care she said she did not. When asked about the plan of care reporting that the resident wound care had been done by nursing for 30 days prior to the initiation of therapy she said the companies said the wound must be under nursing for 30 days. She said LVN B told her the resident had necrotic tissue and it was not healing. When asked if the plan of care was accurate if the wound was identified on 1/29/2014 she said it was not accurate. Record review of Resident # 75's Wound Skin Healing Record revealed the date of onset for the wound was 1/29/2014 and it was an unstageable to her left heel. -2/5/2014 the wound measured 3.8 by 7.4 with an unknown depth. It further revealed the wound had no odor had granulation tissue with black/brown eschar. The surrounding skin color was pink and white and there was maceration on the surrounding tissue/wound edges. The resident had no pain. Record review of the facility's week of 2/5/2014 Weekly Pressure Wound QI Log revealed Resident # 75 had an unstageable left heel pressure sore that measured 3.8 by 7.4 with unknown depth. In an interview with CNA E on 2/12/2014 at 3:15 PM she said when giving a Resident a bath or a shower you were to check the whole body for any sores or wounds. She further stated she documented anything observed in the computer. She stated there was a question that asked if the resident had any new skin abrasion and you would have to check yes or no. She said there was not a place for an explanation. CNA E further stated the nurse would then look on the computer and call you to the desk to ask what was going on. She said she would also tell the wound care nurse about any new skin issues. When asked about the documentation for the care provided, she said turning, repositioning was all on the computer and you were supposed to document every two hours. She further stated you were no supposed to wait until the end of the day to document. She said she documented every two to two and a half hours. She further stated the nurse reviewed their notes. In an interview with LVN C on 2/12/2014 at 3:20 PM she was asked about the CNA documentation. She stated they document in the computer and she did not review their documentation. She further stated if there was anything different with the resident they come and tell her. She said she did check to make sure they had done their work and there was nothing in red in the computer. She said if she thought a resident was at risk for skin breakdown she would leave a note for LVN B. LVN C said that LVN B did the wound care but if a CNA got a dressing wet LVN C or the nurse caring for the resident would have to change the dressing herself. When asked about Resident # 75 she said she knew the resident wore a boot on her left leg and she had the wound for several weeks. She said the nurses only provided wound care for Resident # 75 on the weekends. She further stated that sometimes Resident # 75 refused her wound treatment. Record review of Resident # 75's 2/7/2014 - 2/13/2014 Physical Therapy Progress Report revealed a post a note on top of the notes with the resident ' s name and the following measurements 3.7 by 7.0 by undetermined. Under the continued skill section it revealed the following notations: decrease complaints of pain, facilitate wound healing, decrease risk of infection, and relieve pressure for decreased risk of skin breakdown. Record review of Resident # 75's Wound Skin Healing Record revealed the date of onset for the wound was 1/29/2014 and it was an unstageable to her left heel. -2/13/2014 note revealed the wound was unstageable and measured 3.7 com in length and 7.0 cm in width with an unknown depth. Under the pain section was the resident experiencing pain yes was checked. The hand written note read "unable to say pain going back and forth (with) her answers." Record review of Resident # 75's Daily PT Wound CPT and Progress Documentation revealed the following. 1/30/2014 note revealed the pressure ulcer had eschar. It further revealed the resident had discomfort. There was no further identification of pain level. There was a note that read "no complains pt responded well." 1/31/2014 note revealed the resident had discomfort which was not further clarified. Under response to treatment and skilled need statement it read patient education on elevating both lower extremity feet. -2/3/2014 note revealed the pain level was 7 on a scale of 1 to 10 to left heel. There was no other documentation of the note regarding pain. -2/4/2014 note revealed the pain level to left heel was 8 on a scale of 1 to 10. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue to education for pressure relief was documented. -2/5/2014 note revealed the pain level to left heel was 8 on a scale of 1 to 10. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue caregiver education to decrease pressure in bed. -2/12/2014 note revealed the pain level was less than 5 on scale of 1 to 10 before dressing change. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue caregiver training for positioning. In an interview with PTA B on 2/13/2014 at 1:12 PM she said the pain documented on Daily PT Wound CPT and Progress Documentation was documented after the resident had received her treatment. She said she notified nursing of Resident # 75's pain. She said she did not document the pain level before the treatment. She clarified that the pain level documented was after the treatment. There was no documentation regarding the pain level prior to the treatment. When asked about the resident pain level 5 before treatment she said she should notify nursing and reposition the resident to try and make her more comfortable. When asked Resident # 75's about wound care plan she said the care plan read to pre-medicate for pain prior to the treatment. She further stated she did not ask anyone if the resident had been pre-medicated for pain prior to the treatment. PTA B said she assessed resident pain before treatment and if it was 5 or more she would notify nursing to make sure they pre-medicate. In an interview with the DON on 2/13/2014 at 3:00 PM she said Resident # 75 was not at risk for pressure ulcers. She was shown how her ADL had changed on her significant change MDS from her previous MDS and she said she was at risk. She was asked what interventions were place to prevent pressure sores for Resident # 75 she said there were no interventions in the care plan for prevention. The DON said Resident # 75 had [MEDICAL CONDITION]. At that time she was asked to see documentation of [MEDICAL CONDITION]. She looked through the record and did not find documentation of [MEDICAL CONDITION]. In an interview with the DON on 2/13/2014 at 6:00 PM she asked about what were the concerns with Resident # 75's pain. She was informed the resident had pain 7 and 8 on scale of 1 to 10 and did not receive pain medication every time. When asked if the facility had a wound care physician that came to facility, she said not under contract. When asked who could assess a wound she did not respond. In an interview with the DON and RCS on 2/14/2014 at 7:05 AM they were asked what staff should do before wound care. The DON said they staff should assess for pain and if the resident report pain it should be addressed with pain medication. At that time they were shown Resident # 75's Daily PT Wound CPT and Progress Documentation where her pain had been 7 to 8 out 10. They asked where that had been found and were informed it was not in the medical record but provided by therapy staff. When shown Resident # 75's pain assessment and asked if complete RCS said it was not filled out and incomplete. When asked what should be done if a resident cannot answer what their pain level was on scale of 1 to 10 the DON said the other pain assessment should be completed. When asked if Resident # 75's therapy Plan of Care was accurate with the notation resident had received wound care from nursing 30 days prior to therapy they said it was not accurate. In an interview with Dr. # 1 on 2/14/2014 at 8:55 AM he said he tried to see resident once per month. He said he had another doctor in his office that generally came to the facility every six months. He said would see a resident right away when admitted to the facility within 48 hours. He stated when he came to the facility he did one row of Resident records and if a resident had a problem he would address it. He said currently all of the progress notes were on the medical records, he had checked the office notes. When asked about a resident with a new wound he said usually the wound care doctor for the facility would see the wound. When he was informed the facility had not had a wound physician since May 2013 he said he was unaware. He further stated if (LVN B) brought him down to a resident he would assess the wound. Regarding Resident # 75 Dr. # 1 said the resident was living in the secured unit the last time he saw her and then she went to the hospital. He further stated he did not see her after she was readmitted and he generally saw resident when they were readmitted . Dr. # 1 said there were 3 residents in the facility with the same last name as Resident # 75 and he saw one of the other residents with that last name. He further stated personally he did not use Santyl on eschar. He said if the resident did not have a wound but just escha

Based on interview and record review the facility failed to ensure 1 of 17 residents (Resident # 75) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident # 75's pain was not effectively controlled. Despite complaints by the Resident of pain due to a pressure sore, the facility failed to accurately complete (2) pain assessments in December 2013, and failed to administer pain medications to the Resident after (3) remarkable complaints of pain in February 2014. This failure affected 1 resident whose pain was uncontrolled and placed 42 residents on pain management at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings Include: Resident # 75 Record review of Resident # 75's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. She was [AGE] years old. Record review of Resident # 75's Admission MDS assessment with 7/24/2013 ARD date revealed she was admitted to the facility on [DATE]. Her BIMS score was 9 out of 15 which means the resident was moderately cognitively impaired. The assessment was checked no for the presence of pain. The skin condition section of the assessment revealed she was not a risk for developing a pressure ulcer and did not have a pressure ulcer. Record review of Resident # 75's quarterly MDS assessment with 10/21/2013 ARD date revealed she usually understands others. Her BIMS score was 6 out of 15 which means the resident had a severe cognitively impairment. The assessment was checked no for the presence of pain. The skin condition section of the assessment revealed she was not a risk for developing a pressure ulcer and did not have a pressure ulcer. Observation/Interview of Resident # 75 on 2/11/2014 at 3:00 PM revealed the resident was sitting in a wheelchair in her room. She had a protective boot to her left lower leg and a dressing to her left foot. At that time the resident said her left heel was hurting and felt like it was "raw" and "scraping." She said she had not told the staff she was in pain. She further stated she did not know how to get in touch with them. At that time the call light was pushed. LVN G came into the room to answer the call light and assessed the resident's pain. She said she would look and see if the resident had anything ordered for pain. In an interview with LVN G on 2/11/2014 at 3:15 PM she said she was going to medicate Resident # 75 with 2 Tylenol. Observation was conducted of PTA B and PTA C providing wound care for Resident # 75 on 2/12/2014 at 11:00 AM. Before the care began the resident said her foot was hurting. PTA B asked the resident if her pain was less than 5 the resident said yes but did not give a specific number of her pain on a scale of 1 to 10. The pressure ulcer was on the back of left heel in an area that rested on the bed when she was lying on her back. The pressure ulcer had black eschar covering on the back of the heel and covering most of the pressure ulcer. The surrounding area was red in color with peeling thick areas of skin. When the dressing change was completed the resident told the PTAs that her foot felt like it was scraped. PTA B started the e-stim therapy (electrical stimulation therapy to promote wound healing). At that time the resident again said her heel was hurting "a little bit right now." PTA B rolled a towel under the lower part of the back of the resident lower leg/ankle area. She then asked the resident if the foot was hurting more or less. At that time the resident told her she did not know. PTA C said she would ask nursing to give the resident something for pain. She did not leave the room at that time. PTA B washed her hands and when she came out of the bathroom the resident reported "it is really aching." PTA B told PTA C to ask if the resident could have something for pain. In an interview with PTA C on 2/12/2014 at 4:30 PM, she said Resident # 75 did not usually complain of pain when she had been in her room. She said she provided Resident # 75's wound care occasionally when PTA B was not working. PTA C said Resident # 75 did not complain of pain when she was ambulating or standing, and the Resident was able to walk in the hallway. PTA C stated that another staff member told her Resident #75 had a wound. She said the resident could move by herself in the bed, roll but when she came back from the hospital she needed some assistance. Observation was conducted of CNA G providing catheter and peri-care for Resident # 75 on 2/13/2014 at 11:37 AM. The resident was in bed with protective boot to her left lower leg. At that time the resident said her heel felt like it was "rotting". In an interview with PTA B on 2/13/2014 at 1:12 PM she was asked about the resident pain level 5 before treatment. She said she should notified nursing and repositioned the resident to try and make her more comfortable. When asked Resident # 75's wound care plan she said the care plan read to pre-medication for pain prior to the treatment. She further stated she did not ask anyone if the resident had been pre-medicated for pain prior to the treatment. PTA B said she assessed resident pain before treatment and if it was 5 or more she would notify nursing to make sure they pre-medicate. Record review of resident # 75's skilled daily nurse's notes and nurse notes revealed the following: -12/6/2013 note read at 3:45 PM: "Resident complained to CNA that she had fell and put herself back in chair. Resident shaky with complaints of pain shooting down her leg to her ankle form left hip. (Dr. # 1) notified. Son notified requesting she be sent to hospital . . . PRN Tylenol 325 mg, (two) admin for pain per PRN order . . ." Record review of Resident # 75's 12/6/2013 SBAR revealed the situation was pain and the background was leg pain. The appearance section of the form revealed no documentation of pain level. It further revealed the pain was constant and the intervention was Tylenol 325 mg, 2 by mouth. Under the reported to section it read in part: ". . . Send to ER per family request, x-ray new order." Record review of Resident # 75's medical record revealed she was hospitalized from [DATE] to 12/11/2013. Record review of Resident # 75's 12/11/2014 Resident Summary revealed the resident was being readmitted . It further revealed "(no) pain voiced upon entry." Record review of Resident # 75's 12/11/2013 Pain Evaluation revealed that yes was checked for did the resident have any [DIAGNOSES REDACTED]. The form revealed that Debility was documented for the area that read: "If yes, describe cause, origin of pain, [MEDICAL CONDITION] of pain, and prior treatment. There was no documentation to the question Have you had pain or hurting in the last 5 days? Under the Wong - Baker pain rating scale the picture of the smiling face with "no hurt" was circled. The only other documentation on the evaluation was under the section does the resident receive a as needed medication. [MEDICATION NAME] 325 mg two tablet by mouth every four hours as needed was documented. Record review of resident # 75's skilled daily nurse's notes and nurse notes revealed the following: -12/12/2013 note revealed the resident complained of pain in her inner thigh and she was medicated with Tylenol. It further revealed the resident said her pain was better. There was no pain scale documented or which leg the pain was located in. -12/14/2013 note revealed the resident complained of pain to bilateral lower extremities. -12/15/2013 note revealed the resident complained of pain all over and was medicated with Tylenol. Record review of Resident # 75's 12/15/2013 Psychiatric Review/Mental Status Exam revealed the resident had pain in legs and said she did not know if she could walk or not. Record review of resident # 75's skilled daily nurse's notes and nurse notes revealed the following: --12/16/2013 note revealed the resident received a scheduled pain medication for thigh pain. There was no documentation of the pain level. -12/17/2013 note revealed the resident companioned of thigh pain and was medicated with Tylenol for complaints. There was no pain level documented. Record review of Resident # 75's significant change MDS assessment with ARD date of 12/18/2013 revealed the resident had a short term and long term memory problem with modified independence with cognitive skill for daily decision making. The assessment revealed the resident was not able to answer the question of the presence of pain. It further revealed the staff assessment did not reveal the presence of pain. The skin section revealed the resident was at risk of developing a pressure ulcer but currently did not have pressure ulcer. Record review of Resident # 75's 12/18/13 updated care plan revealed the following: -I have potential for episodes of mild pain related to past stroke, Tylenol as needed. The Goal was I verbalize full relief of pain with 3/18/2014 target date. The approaches included: Evaluate my pain daily using 1 - 10 scale. My pain goal is 2. Administer my pain medication as ordered. Monitor for worsening of my pain symptoms and report to physician. Record review of the Resident # 75's Controlled Drug Record for [MEDICATION NAME] APAP 5 - 325 ([MEDICATION NAME]) revealed the resident received the medication of the following dates and times. -12/20/2013 at 1:00 AM -12/20/2013 at 8:00 AM Record review of Resident # 75's medical record revealed she was hospitalized from [DATE] to 12/24/2013 Record review of Resident # 75's 12/24/2013 Resident Summary revealed she was readmitted . It further revealed she was alert, confused and understood information but had difficulty. She had no pain and her skin was clear. It further revealed the resident could ambulate alone, transfer herself, and position herself. It further revealed she had a fall on 12/17/2013. It also revealed the resident had a urinary tract infection and was on an antibiotic. Record review of Resident # 75's 12/24/2013 Pain Evaluation revealed that yes was checked for did the resident have any [DIAGNOSES REDACTED]. The form revealed that Debility was documented for the area that read: "If yes, describe cause, origin of pain, [MEDICAL CONDITION] of pain, and prior treatment. There was no documentation to the question Have you had pain or hurting in the last 5 days? Under the Wong - Baker pain rating scale the picture of the smiling face with "no hurt" was circled. The only other documentation on the evaluation was under the section does the resident receive a as needed medication. [MEDICATION NAME] 325 mg two tablet by mouth every four hours as needed was documented. Record review of resident # 75's skilled daily nurse's notes and nurse notes revealed the following: -12/25/2014 note revealed that the resident complained of her body hurting all over no specific area. Record review of the Resident # 75's Controlled Drug Record for [MEDICATION NAME] APAP 5 - 325 ([MEDICATION NAME]) revealed the resident received the medication of the following dates and times. -12/26/2014 at 5:00 PM Record review of resident # 75's skilled daily nurse's notes and nurse notes revealed the following: -1/29/2014 note revealed there was not a time for the following entry " New order P/T to eval and treat as needed Lt heel. Boots to bilat feet in and out of bed. Doppler to lower ext. DX Pain/Lt heel ulcer unstageable . . . " It further revealed wound care order by Dr. # 1. Record review of Resident # 75's January 2014 Pain Flowsheet revealed initials or 0 on each day of the month to indicate no pain except for 1/31/2014 for the 6 to 2 PM shift and the 2:00 PM to 10:00 PM shift there was no documentation. There was documentation on 1/3/2014 that the resident was medicated for left leg pain at 3:00 PM but the level of pain was unreadable. She received repositioning and then had no pain. Record review of the Resident # 75's Controlled Drug Record for [MEDICATION NAME] APAP 5 - 325 ([MEDICATION NAME]) revealed the resident received the medication of the following dates and times. -1/3/2014 at 4:00 PM -1/28/2014 at 9:00 PM Record review of Resident # 75's January2014 MAR indicated [REDACTED] -[MEDICATION NAME] 325 mg. 2 tablets by mouth every 4 hours as needed for pain or temperature. There was no documentation that -[MEDICATION NAME] 5/325 mg, one tablet every 6 hours as needed for pain. There was documentation that the resident received this medication 1/3/2014 and 1/28/2014. Record review of Resident # 75's 1/24/2014 - 1/29/2014 Physical Therapy Progress Report revealed a wound care evaluation was completed of left heel wound size 3.0 time 5.0 cm, unable to determine depth, wound was covered by 100 percent eschar. Record review of Resident # 75's Wound Skin Healing Record revealed the date of onset for the wound was 1/29/2014 and it was an unstageable to her left heel. -1/29/2014 it measured 3.0 by 5.0 with an unknown depth. There was granulation tissue and dark eschar. It further revealed the surrounding skin was normal for skin. The resident had no pain. Record review of the Resident # 75's Controlled Drug Record for [MEDICATION NAME] APAP 5 - 325 ([MEDICATION NAME]) revealed the resident received the medication of the following dates and times. -2/3/2014 at 5:00 AM -2/8/2014 at 1:00 AM -2/12/2014 at 11:30 AM Record review of Resident # 75's February 2014 Pain Flowsheet revealed there 0's marked in all the spaces except on 2/2/2014 and on 2/8/2014 for the 10 to 6 AM shift that was nothing documented. On 2/2/2014 it revealed the resident had been medicated at 5:00 AM for generalized pain, there was no level of pain documented. Below that at 10:00 it revealed the resident was medicated for pain a 10:00 AM for generalized pain a 6, she received repositioning and her pain level was then a 2. Record review of Resident # 75's February 2014 Physician order [REDACTED]. -[MEDICATION NAME] 5/325 mg one tablet every 6 hours as needed for pain. This medication had a order date of 12/24/2013. -[MEDICATION NAME] 325 mg, 2 tablets = 650 mg by mouth every 4 hours as needed pain/temperature greater than 101. Record review of Resident # 75's February 2014 MAR indicated [REDACTED] -[MEDICATION NAME] 325 mg. 2 tablets by mouth every 4 hours as needed for pain or temperature. She received it on 2/11/2014. There was no time documented. On the back of the MAR indicated [REDACTED]. There was no level of pain documented. -[MEDICATION NAME] 5/325 mg, one tablet every 6 hours as needed for pain. There were initials to indicate it was administered on 2/3/2014 and 2/8/2014 Record review of Resident # 75's Wound Skin Healing Record revealed the date of onset for the wound was 1/29/2014 and it was an unstageable to her left heel. --2/5/2014 the wound measured 3.8 by 7.4 with an unknown depth. It further revealed the wound had no odor had granulation tissue with black/brown eschar. The surrounding skin color was pink and white and there was maceration on the surrounding tissue/wound edges. The resident had no pain. -2/13/2014 note revealed the wound was unstageable and measured 3.7 cm in length and 7.0 cm in width with an unknown depth. Under the pain section was the resident experiencing pain yes was checked. The hand written note read "unable to say pain going back and forth (with) her answers." Record review of Resident # 75's 2/7/2014 - 2/13/2014 Physical Therapy Progress Report revealed a post a note on top of the notes with the resident's name and the following measurements 3.7 by 7.0 by undetermined. Under the continued skill section it revealed the following notations: decrease complaints of pain, facilitate wound healing, decrease risk of infection, and relieve pressure for decreased risk of skin breakdown, Record review of Resident # 75's Daily PT Wound CPT and Progress Documentation revealed the following. 1/30/2014 note revealed the pressure ulcer had eschar. It further revealed the resident had discomfort. There was no further identification of pain level. There was a note that read "no complains pt responded well." 1/31/2014 note revealed the resident had discomfort which was not further clarified. Under response to treatment and skilled need statement it read patient education on elevating both lower extremity feet. -2/3/2014 note revealed the pain level was 7 on a scale of 1 to 10 to left heel. There was no other documentation of the note regarding pain. -2/4/2014 note revealed the pain level to left heel was 8 on a scale of 1 to 10. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue to education for pressure relief was documented. -2/5/2014 note revealed the pain level to left heel was 8 on a scale of 1 to 10. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue caregiver education to decrease pressure in bed. -2/12/2014 note revealed the pain level was less than 5 on scale of 1 to 10 before dressing change. There was no other documentation on the note regarding pain. Under response to treatment and skilled need statement: continue caregiver training for positioning. In an interview with PTA B on 2/13/2014 at 1:12 PM she said the pain documented on Daily PT Wound CPT and Progress Documentation was documented after the resident had received her treatment. She said she notified nursing of Resident # 75's pain. She said she did not document the pain level before the treatment. She clarified that the pain level documented was after the treatment. There was no documentation regarding the pain level prior to the treatment. When asked about the resident pain level of 5 before treatment she said she should notified nursing and repositioned the resident to try and make her more comfortable. When asked Resident # 75's wound care plan she said the care plan read to pre-medication for pain prior to the treatment. She further stated she did not ask anyone if the resident had been pre-medicated for pain prior to the treatment. PTA B said she assessed resident pain before treatment and if it was 5 or more she would notify nursing to make sure they pre-medicate. In an interview with the DON on 2/13/2014 at 6:00 PM she asked about what were the concerns with Resident # 75's pain. She was informed the resident had pain 7 and 8 on scale of 1 to 10 and did not receive pain medication every time. In an interview with the DON and RCS on 2/14/2014 at 7:05 AM they were asked what staff should do before wound care. The DON said they staff should assess for pain and if the resident report pain it should be addressed with pain medication. At that time they were shown Resident # 75's Daily PT Wound CPT and Progress Documentation where her pain had been 7 to 8 out 10. They asked where that had been found and were informed it was not in the medical record but provided by therapy staff. When shown Resident # 75's pain assessment and asked if complete RCS said it was not filled out and incomplete. When asked what should be done if a resident cannot answer what their pain level was on scale of 1 to 10 the DON said the other pain assessment should be completed. In an interview with LVN B on 2/14/2014 at 7:35 AM she said the staff should ask the resident what their pain level was on scale of 1 to 10 before wound care. She further stated if their pain level was a 5 they should administer an as needed pain medication and not touch them until after the mediation. She said you needed to address pain and if the resident cannot report the level of pain on scale of 1 to 10, the staff should assess for moaning, groaning, grimacing and their breathing. In an interview with Dr. # 1 on 2/14/2014 at 8:55 AM he said he tried to see resident once per month. He said he had another doctor in his office that generally came to the facility every six months. He said would see a resident right away when admitted to the facility within 48 hours. He stated when he came to the facility he did one row of Resident records and if a resident had a problem he would address it. He said currently all of the progress notes were on the medical records, he had checked the office notes. When asked about a resident with a new wound he said usually the wound care doctor for the facility would see the wound. When he was informed the facility had not had a wound physician since May 2013 he said he was unaware. He further stated if (LVN B) brought him down to a resident he would assess the wound. Regarding Resident # 75 Dr. # 1 said the resident was living in the secured unit the last time he saw her and then she went to the hospital. He further stated he did not see her after she was readmitted and he generally saw residents when they were readmitted . Dr. # 1 said there were 3 residents in the facility with the same last name as Resident # 75 and he saw one of the other residents with that last name. Record review if the facility's revised December 2010 Pain Clinical - Protocol read in part: "Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain . . . It also includes a revise for any treatments that the resident currently is receiving for pain, including complementary )non-pharmacological) treatments. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. a. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level. b. the staff will observe the resident (during rest and movement) for evidence of pain, for example grimacing while being positioned or having a wound dressing changed. 4. The nursing staff will identify any situations or intervention where an increase in the resident's pain may be anticipated; for example wound care, ambulation, or repositioning . . . As part of the medical assessment, the physician will help identify the extent to which underlying causes of pain can be addressed or reversed . . . With input from the resident and/or advocate, the physician and staff will establish goals of pain treatment: for example, freedom form pain with minimal medication side effects . . . improved functioning, mood, and sleep . . . The staff will reassess the individuals pain and related consequences at regular intervals, at least each shift for acute pain or significant change in levels of chronic pain . . . The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting intervention accordingly . . ." Record review of the facility's revised October 2010 Pain Assessment and Management policy and procedure read in part: ". . . The pain management program is based on a facility-wide commitment to resident comfort. 2. ' Pain Management is defined as the process of alleviating the resident ' s pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain. g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary . . ." According to CMS For 672 there were 42 residents on a pain management program.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free from ants in rooms in 6 of 6 Halls (Hall 100, 200, 300, 400, 500, and 600) as evidenced by: -Resident #1 received numerous ant bites while laying in bed. Due to her disease process, she was unable to alert staff of the ants or physically remove herself from the bed. Resident #1 also had an allergic reaction to the ant bites and was hospitalized for [REDACTED]. -Resident #3 was bitten by ants while in bed. -Resident #5 was bitten by ants while in bed. -Staff, residents, and a family member reported ants on Hall 100, 200, 300, 400, 500, and 600, which included residents totally dependent on staff for ADLs. Failure to ensure that pest control for ants was effective affected 3 residents and placed an additional 100 residents at risk for receiving ant bites that could result in pain and psychological distress, as well as the potential need for medical treatment. Findings Include: Incident # 9 Complaint # 6, 3, and 0 Resident #1 Record review of Resident #1's CR face sheet revealed that she was admitted to the facility 1/06/06 and readmitted on [DATE]. It further revealed that the resident was discharged on [DATE]. The resident had the following Diagnoses: [REDACTED]. An interview was conducted with the DON on 8/30/11 at 12 noon. She said that Resident #1 lived on the secured unit in room 208. The DON said that when the CNA went to change the resident on her last round around 5:30 AM (8/14/11) she found ants on Resident #1's bed. She further stated that the resident was taken to the shower. The DON said that the resident had "quite a reaction" to the ants. She said that the doctor was notified. The resident was medicated and sent to the hospital. The DON said that CNA A was caring for Resident #1 and she told her that she made her previous rounds at approximately 3:30 AM. She further stated that she told her that she saw a couple of ants on the floor and she killed them, but she did not see any ants in the resident's bed at that time. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 8/14/11 at 6:25 AM. This document read in part; " Witnesses: (CNA A) and (CNA C) ...Description of the Allegation: Resident (Resident #1) found with ants on person and in her bed ...Description of Injury: Raised welt areas left side of trunk, left arm and posterior left leg ...Provider Response: Resident was immediately showered to remove the ants. Physician was notified, [MEDICATION NAME] given as ordered and transferred to (Hospital A)... Room treated for [REDACTED]. ...Investigation Summary: Resident has severe dementia and does not speak so she was unable to alert staff of ants in her bed. There was a dried substance on the floor that may have attracted the ants. It appears ants came in under the baseboard in the corner of the room next to bed. (pest control company) put out ant bait on their visit 6/9/11 and used lawn granules for ants on 7/27/11...Rooms 406 B, 210 B and 504 B were found to have a few ants and treated. The resident in 504 B was noted to have red pustules on her left arm suspicious for ant bites...". Record review of the facility's "Incident/Accident Report" dated 8/14/11 revealed Resident #1 had raised areas on the her left side and back from ant bites. This document revealed the resident was treated with [MEDICATION NAME] by the nurse and sent to (Hospital A). Record review of Resident #1's CR 8/14/11 nurse's notes revealed an entry at 6:45 AM that read: "CNA reported to charge nurse that res had ant bites on her. Went to see her and she had large raised area on her (left) side (and) back of (left) leg. Dr. (A) notified res to be sent (Hospital A)". Record review of Resident #1's CR 8/14/11 telephone physician orders [REDACTED]. Record review of Resident #1's Hospital A medical record revealed that the resident arrived at the emergency room at 7:41 AM . It further revealed the resident had generalized hives and possible insect bites. The clinical impression read in part: "skin rash, acute allergic reaction". The type of bite/wound was "ant bite". It revealed that the resident had the bites and hives in the following locations: left shoulder, left arm, left hand, both legs, above her buttocks, and on her abdomen. The document read in part: "found in the NH covered in ants". Record review of the Resident #1's Hospital A Case management report read in part: " . . . patient admitted with ant bites/hives. . . patient having hundred of ant bites to the left side of her body . . .Admission coordinator at Humble Health Care Center. . . reports patient was found in bed with ants. . .". This report further revealed that the resident was discharged from the hospital to another nursing facility. Record review was conducted of Resident #1's List Patient notes (nurse's notes). They revealed that the resident was medicated with [MEDICATION NAME] by IV twice on 8/15/11 for itching and once on 8/16/11. The note also revealed that she was discharged from the hospital on [DATE]. Record review of the facility's "Witness Form" revealed CNA A witnessed the incident. This document read in part; "Describe what you saw: Ants on resident and her bed. When bed was removed from wall they (ants) were crawling on wall. ...What did you notice about the area where the incident/accident occurred? Dried substance couldn't get up as it was dried. Present when previous shift changed ants congregating there. ..." This document was dated 8/14/11. An interview was conducted with Resident #14 on 8/30/11 at 1:15 PM. He said that he had a jar full of ants this morning. He said that the jar had candy in it. Resident #14 said that the staff took the jar away and sprayed for the ants. Resident #14 resided on Hall 300. An interview was conducted with Resident #15 on 8/30/11 at 1:30 PM. She said that she had seen ants in her room near the window in the last couple of weeks. She further stated that she told the facility staff and they sprayed. Resident #15 resided on Hall 100. An interview was conducted with Resident #15 on 9/7/11 at 10:00 AM. Resident #15 said that she had seen ants in the past but they had gotten worse. Interview was conducted with a Resident #16 from the Hall 100 on 9/7/11 at 10:25 AM. The resident said a couple of weeks ago she saw ants on her floor by her bed. An interview was conducted with Resident #4's family member on 8/30/11 at 2:55 PM. She said that she visited her mother at the facility every other day. She said that over the past weekend there were ants on her mother's clothes when a CNA got the clothes out of the closet. Resident #4's room was on Hall 200. An interview was conducted with the Administrator on 8/30/11 at 2:10 PM. He said this morning was the first time he was aware the facility had ants since the pest control companies last treatment 8/17/11. He said that the facility had sprayed a resident's room and treated outside. The Administrator stated that the pest control company came out once a month. He further stated that they identified any problems and treated them specifically. The Administrator said that when something needed to be addressed by maintenance, it was recorded in the work order book. An interview was conducted with the DON on 8/30/11 at 3:05 PM. She said that after the incident with Resident #1 the facility had sprayed three more rooms when ants were identified by the night shift. She stated that staff left notes when they had seen ants for these three rooms, so the rooms could be sprayed. Observations of the outside of building and grounds on 8/31/11 from 7:10 AM to 7:45 AM revealed evidence of ants and live ant beds in the following areas: -near the end corner of the Hall 100, outside corner, a pole coming out of the ground with wires going up. -by the exit door on the ground outside Hall 200. -outside of the Resident smoking area, the window closest to the smoking area. -in the fenced area near the smoking patio there was a fire ant hill. -to the right of the kitchen, the forth window from the end. -in the grass off to the side of Hall 400. -by the sixth window down on Hall 400 by the kitchen. -near the exit door that leads to the entrance to the laundry room there were ants behind laundry bins crawling on the concrete. -the outside wall at the end of Hall 500 there were ants crawling along the wall to the left side of the door. -ants were crawling on the concrete pad outside of the Hall 500 emergency exit door. In addition to the ants identified during this time frame, the following vulnerable areas were also observed: -Hall 200 third window from the end of the building cracks in the mortar on the window sill. The end brick on the window sill the mortar was missing. -Hall 200 second window from the end of the building cracks in the mortar on the window sill. Under the air conditioner unit on the same window there was a large gaping hole where the brick was missing. The hole was approximately 1 and ? feet long by 4 inches high. -last window on Hall 400 the stucco was pulling away from the window. An interview was conducted with Maintenance B, Regional Maintenance Director on 8/31/11 at 8:17 AM. Maintenance B was shown cracks and holes in the building and ant beds that had been observed. He said that he used to be the Maintenance Director for the facility and would return to the position next week. He said that the facility checked for ants twice a week. He said that they were to check for ants outside immediately if it rained. He said that ants were looking for places to get into the facility to get out of the heat. An interview was conducted with the DON on 8/31/11 at 8:45 AM. She said that the staff saw ants a couple of days after the incident. She that if the staff saw even one ant, the facility was going to spray. She said that ants were seen in room 601. An interview was conducted with the DON on 9/7/11 at 8:10 AM. When she was asked if the facility had seen any ants recently, she said that an ant bed was discovered outside yesterday. An interview was conducted with the Maintenance Director B on 9/7/11 at 9:30 AM. He said that maintenance was doing rounds of the building daily to check for ants. He further stated that the pest control company had been back to the facility "the other day" (8/31/11). An interview was conducted with the Housekeeper Supervisor on 9/7/11 at 12:05 PM. He said that it was "weeks ago" when they came and sprayed the whole building. He said that he did spray for bugs and ants sometimes. He further stated that he did not document when he sprayed. Interview was conducted with Maintenance A and B on 9/7/11 at 2:40 PM. Maintenance A said that when ants and bugs were discovered he treated as soon as he was notified. He said that he had seen ants on Hall 400 around some crumbs. He said that he personally sprayed for ants on 8/16/11 and put the granules outside. He said that he sprayed all the hallways and the problem rooms. He further stated that the pest control company came out the next day. Maintenance A said that if the housekeeping did any pest control treatments on the weekends, they probably would not tell maintenance. He said that the housekeeper had the key to the maintenance office. Maintenance B said during the week the housekeeper would come straight to maintenance to get them to do the treatment. Record review of a note dated 8/14/11 revealed ants were discovered in room 208 B (Resident # 1's room). This note also revealed the room, hallway, outside and bathroom was treated for [REDACTED]. Record review of a note dated 8/15/11 that the administrator identified as his notes for day read in part; "Check room spray. ...done, check outside of building - treat ...done, housekeeping check for food/drink source, call (Pest Control Company)...done 8/15/11 (priority call), check other rooms Hall #2 ...done." This note was provided by the Administrator on 9/8/11. Record review of the facility's maintenance repair log sheet revealed ant treatments were conducted on 8/15/11 in rooms 313 B and 504 B. This document also revealed an ant treatment was conducted on 8/30/11 in room 310 when ants were found at the room's window sill. Record review of the facility's list of ant treatment chemicals and treatments performed dated 8/16/11 revealed the following chemicals and treatments: " [MEDICATION NAME] Advanced - Complete Insect Killer (For soil and turf ready-to-spread granules) Spread on entire property outside the building. Ortho Home Defense Max (Perimeter and indoor insect killer) Sprayed each hall and the dining room inside the building. Combat Max Ant Bait Injection System (Fipronil based caulking) Applied in problem rooms where ants were found: around base boards and the corners of the window seals. " This document was signed by the former Maintenance Director. Record review of a receipt from the home improvement store provided by the Administrator revealed the facility purchased the following: "Handy Green II Handheld, 1.33 Gallon Home Defense Max and two 20 pound Complete Lawn Insect." This receipt was dated 8/16/11. An interview was conducted with the Administrator and the DON on 9/8/11 at 12:20 PM. They were asked why when the incident occurred on 8/14/2011 was the facility not treated until 8/16/11 and the pest control company did not make a visit until 8/17/11. The administrator said that the usual employee from the pest control company that serviced the facility was in the hospital. The administrator said the note from maintenance with the treatment date of 8/16/11 must have been a mistake. When he was informed that the hardware store receipt for the products used was dated 8/16/11 he said that the facility used the products that they had on hand to do the earlier treatments. The Administrator said that he had been talking to the pest control company since 8/15/11 about adding an Ant Program. He further stated that the pest control company was coming out today to start the Ant Program. They said that if housekeeping or a CNA were to see ants in a bed they were supposed to report it to maintenance. They further stated that the bed was to be striped, the mattress wiped and the room cleaned. They said that the room should them be sprayed. Record review of the invoice from the facility's pest control provider dated 8/17/11 revealed the pest control service treated for [REDACTED]. The chemicals used for the treatment include Tempo Ultra WP in the resident rooms and Wisdom Lawn Granular for the exterior area. Record review of the invoice from the facility's pest control provider dated 8/10/11 revealed the pest control service treated the facility for rats, mice, flies and cockroaches. The chemicals/devices used to treat the facility include: "Firststrike Soft Bait, Tin Cat Trap, Stealth Maxima Glueboard and Borid." Record review of the invoice from the facility's pest control provider dated 7/27/11 revealed the pest control service treated the facility for rats, mice, cockroaches, ants and flies. The chemicals/devices used to treat the facility include: "Firststrike Soft Bait, Tin Cat Trap, Borid, Wisdom Lawn Granular (ants), and Stealth Maxima Glueboard." The ant treatment was a "spot" treatment to the exterior area of the building. Record review of the invoice from the facility's pest control provider dated 6/16/11 revealed the pest control service treated the facility for cockroaches. The chemicals used to treat the facility include: "Borid and Advion Roach Gel Bait". Record review of the invoice from the facility's pest control provider dated 6/8/11 revealed the pest control service treated the facility for flies, rats, ants and cockroaches. The chemicals/devices used to treat the facility include: "Stealth Maxima Glueboard, Firststrike Soft Bait, Advance Carpenter Ant Bait and Borid". The ant treatment was applied to the exterior area of the building. Record review of the facility's in-service training report revealed an in-service was conducted on 8/15/11 covering "Ants in Rooms". This document read; "Check rooms for food trays, crumbs on tables, food on floor, and any signs of ants in rooms. Pick up old snacks, report any site (sic) of ants to keep housekeeping, maintenance immediately." This document was signed by 31 staff members. Record review of the facility's "Pest Control" policy and procedure read in part; "Our facility shall maintain an effective pest control program. 'Policy Interpretation and Implementation' 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents...6. Maintenance services assist, when appropriate and necessary, in providing pest control services." Resident #3 Record review of Resident #3's "Face Sheet" revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. An interview was conducted with Resident #3 on 8/30/11 at 1:45 PM. She said that she was bitten by ants when she came back from the hospital. She said that the ants were in her bed. Resident #5 Record review of Resident #5's "Face Sheet" revealed that the resident was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. An interview was conducted with CNA B on 9/7/11 at 9:40 AM. She said that she had seen ants on Hall 500 and Hall 600. She said that last month she saw ants in (Resident #5's) room when she went to make the bed. She said that she let the nurse and housekeeping know. CNA B said that she knew that the room was sprayed. She said that the resident had bites on her arm. CNA B said that the treatment nurse put cream on the resident's bites. She said that she had also seen ants in room 601 but the resident ate lunch in the room and would drop food on the floor. She said that both maintenance and housekeeping both spray for bugs. An interview was conducted with Resident #5 on 9/7/11 at 9:50 AM. She said that she had seen ants in her bed about three weeks ago. She said that she had maybe 15 bites on her arm. She said that her arm was next to the wall/window during the night. Resident #5 stated that she saw the ants the next morning in the bed and she told someone. She further stated that she had discomfort and itching from the bite and that staff put cream on it. According to the Administrator the facility census was 102.

Based on observation, interview and record review the facility failed to ensure that the resident environment was free of accidental hazards for 3 of 12 sampled residents (Resident #1, #3, and #5). -Resident #1 received numerous ant bites while laying in bed. Due to her disease process, she was unable to alert staff or physically remove herself from the bed. -Resident #3 was bitten by ants while in bed. -Resident #5 was bitten by ants while in bed. These failures affected one resident who had an allergic reation to the ant bites and was hospitalized for [REDACTED]. Findings included: Incident # 9 Complaint # 6, 3, and 0 Resident #1 Record review of Resident #1's CR face sheet revealed that she was readmitted to the facility on [DATE]. It further revealed that she was discharged on [DATE]. The resident had the following Diagnoses: [REDACTED]. She resided on hall 200. Record review of Resident #1's 6/29/11 quarterly MDS revealed that the resident had unclear speech-slurred/mumbled words, and the resident was rarely/never understood. Resident #1's cognitive skill for daily decision making was "severely impaired". The MDS revealed that Resident #1 required extensive assistance with ADLs. An interview was conducted with the DON on 8/30/11 at 12 noon. She said that Resident #1 lived on the secured unit in room 208. The DON said that when the CNA went to change the resident on her last round around 5:30 AM (8/14/11) she found ants on Resident #1's bed. She further stated that the resident was taken to the shower. The DON said that the resident had "quite a reaction" to the ants. She said that the doctor was notified. The resident was medicated and sent to the hospital. The DON said that CNA A was caring for Resident #1 and she told her that she made her previous rounds at approximately 3:30 AM. She further stated that she told her that she saw a couple of ants on the floor and she killed them, but she did not see any ants in the resident's bed at that time. Record review of the facility's "Provider Investigation Report" revealed the incident occurred on 8/14/11 at 6:25 AM. This document read in part; " Witnesses: (CNA A) and (CNA C) ...Description of the Allegation: Resident (Resident #1) found with ants on person and in her bed ...Description of Injury: Raised welt areas left side of trunk, left arm and posterior left leg ...Provider Response: Resident was immediately showered to remove the ants. Physician was notified, Benadryl given as ordered and transferred to (Hospital A)... Room treated for [REDACTED]. ...Investigation Summary: Resident has severe dementia and does not speak so she was unable to alert staff of ants in her bed. There was a dried substance on the floor that may have attracted the ants. It appears ants came in under the baseboard in the corner of the room next to bed. (pest control company) put out ant bait on their visit 6/9/11 and used lawn granules for ants on 7/27/11...Rooms 406 B, 210 B and 504 B were found to have a few ants and treated. The resident in 504 B was noted to have red pustules on her left arm suspicious for ant bites...". Record review of the facility's "Incident/Accident Report" dated 8/14/11 revealed Resident #1 had raised areas on the her left side and back from ant bites. This document revealed the resident was treated with Benadryl by the nurse and sent to (Hospital A). A telephone interview was conducted with CNA A on 9/7/11 at 8:20 AM. She was the CNA caring for Resident #1 on the day of the incident with the ants. She stated the resident was "full of ants" when she went to check on her during her last round. She further stated that she saw ants on the bedspread and on the left side of (Resident #1's) body there was "a bunch, a lot". CNA A said Resident #1 had ant bites all over her left side. She stated that they picked her up and took her to the shower to try to get the ants off of her. CNA A stated that after a while the bites started to make little bumps. She said that they went to get the charge nurse, but she was with another resident so LVN B came to check on the resident. CNA A said that LVN B pulled the bed away from the wall and ants were seen in the corner of the wall. She said that she had not seen ants the previous day, but another CNA had seen ants in another room. CNA A stated "I feel bad because she (Resident #1) can't speak or holler, was just laying in bed". She said that she had seen one or two ants earlier in the room and she killed them. She further stated that there was something on the floor by the bed. She said that she tried to get it up by putting a wet towel on it but she could not get it up. When she was asked approximately how many ants Resident #1 had on her and how many ant bites, CNA A said "She had quite a few bites". She further stated "from the time they got her out of bed to shower, they had welts on them. Looked like little welts, like allergic ant bites". A telephone interview was conducted with RN A on 9/7/11 at 9:05 AM. He said that he was notified by the charge nurse that a patient had been "eaten by ants" and went to investigate. He said that the resident was in the shower. RN A stated that it looked like a reaction and his immediate response was to get the resident to the emergency room to be evaluated. He said that it looked like "raised area rash, inflammation almost welt". He further stated that the whole left side of the resident's body was red, trunk to beginning of left leg. RN A stated that he saw a few ants in the resident's room, sprayed around it and got housekeeping. He further stated that he did not find out where the ants were coming from. He said that once before he had seen ants and notified housekeeping. He stated that he could not remember when it was. A telephone interview was conducted with CNA C on 9/7/11 at 4:30 PM. She said on the day of the incident she was called into Resident #1's room by CNA A. She further stated when she entered the room there were "ants crawling all over (Resident #1). CNA C said that she told CNA A they needed to get the ants off of Resident #1 immediately. CNA C said "the ants, especially in Texas, bite". When CNA C was asked approximately how many ants were on the resident she said "a lot, can't answer the question of amount. Maybe 100 to 200 on her, on bed clothes, on her clothes, on wall". She said that the ants were streaming on the wall. She stated that the resident was just lying there, not crying. CNA C said Resident #1 became red on the left side of her body while in the shower. She stated that it developed quickly. CNA C said that earlier in the shift, CNA A had called her into Resident #1's room to look at a spot on the floor. She further stated they had tried to get it up and were unable to do so. CNA C said now when she was working she was pulling beds away from the wall and observing for ants. A telephone interview was conducted with LVN B on 9/8/11 at 5:00 AM. She said that the CNA C came and told her there were ants on (Resident #1). She stated that she got Resident #1 out of bed and was knocking the ants off of the resident. LVN B said that they then got the resident into the shower. She stated that there were "a bunch in the bed". LVN B said that Resident #1 "had a bad reaction. Didn't look like ant bites, looked like whelps". She said that she had seen ants before in room 404, 406, and 409, always by the window. She further stated that she had seen some ants in the closet of room 405. When she was asked if she had ever seen them in the residents' beds she said "yes". LVN B said that when she saw ants she knocked them off and killed them. She said that she had seen them in Resident #5's room. She further stated that (Resident #5) had bumps on her left arms and ants in her bed. She said that she left a note for maintenance and in the 24 hour book. She stated that she also told the nurses. LVN B said "Just can't stand over someone; looking for ants while person in next room gets ate up by ants". She stated when the facility sprayed for ants "they just move to another hall". A telephone interview was conducted with LVN A on 9/8/11 at 5:15 AM. She said she saw Resident #1 in the shower and she had "whelps" on her body. Interview was conducted with CNA D on 9/7/11 at 11:00 AM. She said she had seen ants two weeks ago when she was caring for Resident #6. She said that she had seen the ants crawling down the window sill by the resident. CNA D said a few days earlier another resident (Resident #1) had been bitten by ants and sent to the emergency room . She stated that she was coming on shift and Resident #1 was getting ready to go out to the emergency room . CNA D stated "It was horrible, she couldn't scratch". She further stated the bites were in big clusters on the resident's neck, chest and arm. An interview was conducted with CNA E on 9/7/11 at 1:00 PM. She said that she had seen ants in Resident #1's room. She said that they were on the floor. CNA E said "it's messed up what happened to (Resident #1), couldn't speak, bit her lying there". She stated that when the residents were put to bed the staff did not get the food off of them. Record review of Resident #1's 8/14/11 CR nurse's notes revealed an entry at 6:45 AM that read: "CNA reported to charge nurse that res had ant bites on her. Went to see her and she had large raised area on her (left) side (and) back of (left) leg. (Dr. A) notified res to be sent (Hospital A)". Record review of Resident #1's 8/14/11 CR telephone physician orders [REDACTED]. Record review of Resident #1's Hospital A medical record revealed that the resident arrived at the emergency roiagnom on [DATE] at 7:41 AM . It further revealed the resident had generalized hives and possible insect bites. The clinical impression read in part: "acute allergic reaction . . . type of bite/wound: ant bite". It revealed that the resident had the bites and hives in the following locations: left shoulder, left arm, left hand, both legs, above her buttocks, and on her abdomen. The document read in part: "found in the NH covered in ants". The 8/14/11 Hospital A patient note (ER nurse's note) revealed that (Resident #1) arrived covered in ant bites, swelling, hives on all extremities and torso. It further revealed that the resident had dementia and was nonverbal. Record review of the Resident #1's Hospital A Case Management Report read in part: "Comments: . . Patient admitted with ant bites/hives. . . Patient having hundred of ant bites to the left side of her body . . .Admission coordinator at Humble Health Care Center. . . reports patient was found in bed with ants. . .". This report further revealed that the resident was discharged from the hospital to another nursing facility. Record review of Resident #1's Hospital A Patient notes (nurse's notes) revealed that the resident was medicated with Benadryl by IV twice on 8/15/11 for itching and once on 8/16/11. The note also revealed that the resident was discharged from the hospital on [DATE]. Record review of the facility's "Witness Form" revealed CNA A witnessed the incident. This document read in part; "Describe what you saw: Ants on resident and her bed. When bed was removed from wall they (ants) were crawling on wall...What did you notice about the area where the incident/accident occurred? Dried substance couldn't get up as it was dried. Present when previous shift changed ants congregating there...". This document was dated 8/14/11. Record review of the facility's "Witness Form" revealed CNA C witnessed the incident. This document read in part; "Describe what you saw: Ants crawling up wall, onto resident bed and resident. Multiple, uncountable overlapping bites with welt-like appearance, primarily on left side of trunk, left arm, posterior left leg ...What did you notice about the area where the incident/accident occurred?: Noticed dried substance at 11:00 PM couldn't get all up ...ants congregating there also. Present when previous shift changed...". This document was dated 8/14/11. An interview was conducted with Resident #13 on 8/30/11 at 12:40 PM. She said that she had seen ants in the facility several months ago and she resided on Hall 300. An interview was conducted with Resident #14 on 8/30/11 at 1:15 PM. He said that he had "a jar full of ants this morning". He said that the jar had candy in it. Resident #14 said that the staff took the jar away and sprayed for the ants. He said that he resided on Hall 300. An interview was conducted with Resident #15 on 8/30/11 at 1:30 PM. She said that she had seen ants in her room near the window in the last couple of weeks. She further stated that she told the facility staff and they sprayed. Resident #15 resided on Hall 100 in the room next to Resident #3 with a connecting wall. An interview was conducted with a Resident #16 on 9/7/11 at 10:25 AM. The resident said "a couple of weeks ago" she saw ants on her floor by the bed. Resident #16 lived on hall 100. An interview was conducted with Resident #15 on 9/7/11 at 10:00 AM. She said that the last time she saw ants there were 10 to 15 ants. Resident # 15 said that she had seen ants in the past but they had gotten worse. She further stated that her dining room table mate (Resident #5) had been bitten by ants. An interview was conducted with the family member of Resident #4 on 8/30/11 at 2:55 PM. She said that she visited her mother at the facility every other day. She said that over the past weekend when she came, there were ants on her mother's clothes when they were removed from the closet by a CNA. Resident #4's room was on Hall 200. Resident #3 Record review of Resident #3's "Face Sheet" revealed that the resident was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. An interview was conducted with Resident #3 on 8/30/11 at 1:45 PM. She said that she was bitten by ants when she came back from the hospital. She said the ants were in her bed. An interview was conducted with Resident #3 on 9/7/11 at 10:05 AM. She said that she had ant bites on her left side and right shoulder. She said that she saw ants in her bed and the CNA saw them when she picked up the blanket. Observation of Resident #3 on 9/7/11 at 10:15 with LVN C revealed three small (less that the size of pea) scabbed areas. There were two on the resident's left side at the waist area and one her right shoulder. An interview was conducted with CNA E on 9/7/11 at 1:00 PM. She said that she saw ants in Resident #3's bed while she was cleaning. She stated that they were coming in on the wall near the window. She said that she told LVN C. She further stated that she told the housekeeper, and he came and sprayed. CNA E said that when Resident #3 was bitten by the ants she had a red dot where they bit her. She said she that went into her room at 7:00 AM and the resident did not know there were ants in her bed. She stated that the resident had the light on. CNA E said that Resident #3 told her the night shift did not check on her. CNA E stated "if they had checked on her, I think it would have been prevented". She said that LVN C told her to move the bed and get the resident out of the bed. Interview was conducted with LVN D on 9/7/11 at 2:15 PM. She stated a CNA said Resident #3 had ants in her room. She stated that the bed was moved from the wall, they got the resident in a wheelchair, and stripped the bed. Interview was conducted LVN C on 9/7/11 at 2:30 PM. She said that the facility had an "ant problem". She said that she came in the morning and there were a few on the wall in Resident #3's room. LVN C said that they moved the bed away from the wall and got the resident out of bed. She said that there were a few ants on the mattress. A telephone interview was conducted with LVN E on 9/7/11 at 7:40 PM. She said that she had treated two residents for ant bites (Resident #3 and #5) while she was doing the treatments for the facility. She stated that hydrocortisone cream was used for both residents. LVN E said that Resident #5's bites went away. She stated Resident #3 had two spots on her left side, just below her rib cage. She said that a CNA found ants in Resident #3's and #5's bed. A telephone interview was conducted with LVN A on 9/8/11 at 5:15 AM. She said that Resident #3 had ants in her bed. She stated that they brushed them out of the bed and changed the sheets. She said that she did not report the incident with Resident #3. Record review of Resident #3's physician orders [REDACTED]. The only date this medication was documented as given was 8/24/11. Record review of Resident #3 nurse's notes revealed no documentation concerning ants or ant bites. Resident #5 Record review of Resident #5's "Face Sheet" revealed that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. An interview was conducted with CNA B on 9/7/11 at 9:40AM. She said that she had seen ants on Hall 500 and Hall 600. She said that last month she saw ants in (Resident #5's) room when she went to make the bed. She said that she let the nurse and housekeeping know. She said that the resident had bites on her arm. CNA B said that the treatment nurse put cream on the resident's bites. She said that she had also seen ants in room 601 and the resident ate lunch in the room and would drop food on the floor. An interview was conducted with Resident #5 on 9/7/11 at 9:50 AM. She said that she had seen ants in her bed about three weeks ago. She said that she had maybe 15 bites on her arm. She said that she had the arm where she had been bitten by the ants was next to the wall during the night. Resident #5 stated that she saw the ants the next morning in the bed and she told someone. She further stated that she had discomfort and itching from the bites, and the staff put some cream on it. An interview was conducted with LVN D on 9/7/11 at 2:15 PM. She stated that when she came on shift Resident #5 already had the ant bites. LVN D said that it was written in the 24 hour report. She said that she had a resident on Hall 600 who reported ants. LVN D said that one of the CNAs told her about ants in room 310. Record review of Resident #5's "Nurse's Notes" revealed Resident #5 reported pustules to her left arm and abdominal area. A new order was given on 8/15/2011 for hydrocortisone cream 1% to be applied as needed. This document also revealed on 8/20/2011 at 11:00 AM, nursing staff noticed a blistered ant bite to left forearm and right hand redness to surrounding area. Nursing staff cleansed area with "saf-clens" (wound cleanser), patted dry and applied hydrocortisone cream. Record review of Resident #5's treatment sheet revealed a treatment for [REDACTED]. This document also revealed the only dates documented as given were 8/15/11, 8/20/11 and 8/24/11. An interview was conducted with the Administrator on 8/30/11 at 2:10 PM. He said this morning was the first time he was aware the facility had ants since the pest control company's last treatment (8/17/11). He said that the facility had sprayed the resident's room and treated outside. The Administrator stated that the pest control company came out once a month routinely. He further stated that they identified any problems and treated them specifically. The Administrator said that when something needed to be addressed by maintenance, it was recorded in the work order book. Observations of the outside of building and grounds on 8/31/11 from 7:10 AM to 7:45 AM revealed evidence of ants and live ant beds in the following areas: -near the end corner of the Hall 100, outside corner, a pole coming out of the ground with wires going up. -by the exit door on the ground outside Hall 200. -outside of the Resident smoking area, the window closest to the smoking area. -in the fenced area near the smoking patio there was a fire ant hill. -to the right of the kitchen, the forth window from the end. -in the grass off to the side of Hall 400. -by the sixth window down on Hall 400 by the kitchen. -near the exit door that leads to the entrance to the laundry room there were ants behind laundry bins crawling on the concrete. -the outside wall at the end of Hall 500 there were ants crawling along the wall to the left side of the door. -ants were crawling on the concrete pad outside of the Hall 500 emergency exit door. In addition to the ants identified during this time frame, the following vulnerable areas were also observed: -Hall 200 third window from the end of the building cracks in the mortar on the window sill. The end brick on the window sill the mortar was missing. -Hall 200 second window from the end of the building cracks in the mortar on the window sill. Under the air conditioner unit on the same window there was a large gaping hole where the brick was missing. The hole was approximately 1 and ? feet long by 4 inches high. -last window on Hall 400 the stucco was pulling away from the window. An interview was conducted with Maintenance B, Regional Maintenance Director on 8/31/11 at 8:17 AM. He said that the facility checked for ants twice a week. He said that they were to check for ants outside immediately if it rained. He said that ants were looking for places to get into the facility to get out of the heat. An interview was conducted with the DON on 8/31/11 at 8:45 AM. She said that the staff saw ants a couple of days after the incident. She that if the staff saw even one ant, the facility was going to spray. She said that ants were seen in room 601. An interview was conducted with the DON on 9/7/11 at 8:10 AM. When she was asked if the facility had seen any ants recently, she said that an ant bed was discovered outside "yesterday". An interview was conducted with Housekeeper A on 9/7/11 at 11:55 AM. She said that she had seen ants in one of rooms on Hall 400 by a trash can that had candy in it. Record review of a note dated 8/14/11 revealed ants were discovered in room 208 B. Record review of a note dated 8/15/11 that the administrator identified as his notes read in part; "Check room spray. ...done, check outside of building - treat ....done, housekeeping check for food/drink source, call (pest control company) ....done 8/15/11 (priority call), check other rooms Hall #2 ....done." This note was provided by the Administrator on 9/8/11. Record review of the facility's in-service training report revealed an in-service was conducted on 8/15/11 covering "Ants in Rooms". This document read; "Check rooms for food trays, crumbs on tables, food on floor, and any signs of ants in rooms. Pick up old snacks, report any site (sic) of ants to housekeeping, maintenance immediately." This document was signed by 31 staff members. Record review of the facility's "Pest Control" policy and procedure read in part; "Our facility shall maintain an effective pest control program. 'Policy Interpretation and Implementation' 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects...Maintenance services assist, when appropriate and necessary, in providing pest control services". Record review of the facility's "Incidents and Accidents Prevention System" read in part; " Investigation Guidelines: 1. Immediately initiate an investigation. 2. Ask ...who, what, when, where, how and why! 3. Use investigation protocol as necessary. 4. DON/designee completes investigations, follow-up and determines steps to prevent reoccurrence". According to the Administrator the facility census was 102.