Every finding on record at Ft Worth Southwest Nursing Center

Based on interview, observation and record review, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 1 facility reviewed for storage.The facility failed to secure 10- 1 oz Zinc Oxide Ointment tubes observed on three linen cart pockets and 2- 1oz Zinc Oxide Ointment in a resident open top-drawer.This failure could place residents at risk of unauthorized access to over-the-counter drug or prescription. Findings included:During an observation on 05/20/26 at 8:25 A.M., there were two 1oz tubes of Zinc Oxide ointment in a open top drawer.During an observation on 05/20/26 at 10:10 A.M., of the linen cart side pocket revealed 2-1oz tubes of Zinc Oxide ointment. During an observation on 05/20/26 at 10:15 A.M., of the linen cart side pocket revealed 3-1oz tubes of Zinc Oxide ointment.During an observation on 05/20/26 at 10:20 A.M., of the linen cart side pocket revealed 5- 1oz tubes of Zinc oxide ointment.During an interview on 05/20/26 at 10:30 A.M., CNA A stated Zinc Oxide ointment was in the resident drawers and in the pockets of the linen carts to be used on the residents for skin breakdown.During an interview on 05/10/26 at 10:38 A.M., CNA B stated that when she opened a tube of the Zinc Oxide ointment and she carried the tube with her and used it on each resident until it was gone.During an interview on 05/20/26 at 10:56 A.M., the Restorative Aide stated the Zinc Oxide ointment was found in the resident top drawer and on the linen cart in the side pocket.During an interview on 05/20/26 at 3:24 P.M., the Treatment Nurse stated the Zinc Oxide ointment was not left out in the resident's rooms but in their top drawer and in the side pocket of the linen cart. The Treatment Nurse stated the Zinc Oxide ointment was purchased from the supply vendor and not the pharmacy. The Treatment Nurse stated the Zinc Oxide ointment was used as a preventable measure to prevent resident skin breakdown. During an interview on 05/20/26 at 3:45 P.M., the DON stated the Zinc Oxide ointment was readily available inside the pockets of the linen cart pockets for staff to use on residents. The DON stated there was no risk to residents because the Zinc Oxide ointment was like lotion. Record review of the facility policy, titled Storage of Medication reflected, Medications and biologicals are stored safely, securely and properly.The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.2 Medication rooms, carts, and medication supplies are locked when not attended by authorized person.

Based on interview, observation, and record revie, the facility failed to provide a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to provide a space free of severe hoarding of various items that left a narrow walkway of approximately 1 foot wide from Resident #1 door to bed. This failure could place residents at risk of an unsafe, unclean and uncomfortable environmentFindings included:Record review of Resident #1's face sheet, dated 05/20/26, reflected a [AGE] year-old female admitted [DATE] and readmitted on [DATE], diagnoses included unsteadiness of feet (an indicate various underlying issues, often related to balance problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), major depressive disorder, depressive disorder, recurrent, severe with psychotic (psychotic symptoms such as hallucinations or delusions. This condition significantly impairs an individual's ability to function in daily life) and cognitive communication deficient (Symptoms may include difficulty with attention and focus, memory problems, disorganized thoughts, reduced problem-solving abilities, difficulty understanding complex information, and social communication challenges).Record review of Resident #1's care plan, dated 05/16/26 reflected room full of purchases. Items included shelving and bins to store her purchases in. The care plan indicated, [Resident #1] has a hoarding behavior and is not willing to stop purchasing and she is not willing to let staff remove any of her purchases. [Resident #1] is keeping mayonnaise in her room. [Resident #1] has been educated that the mayonnaise needs to be refrigerated, and bacteria can grow in the mayonnaise that could cause serious injury to her. [Resident #1] refuses to let staff remove mayonnaise.[Resident#1] has been asked to clear some items out of her room as she has so much stuff in the room it takes up both sides of the room. [Resident #1] has called the police to facility because she has been asked to clean. Items update, initiated on 02/03/2020 and revised on 06/12/2024. Further record review of Resident #1's care plan indicated intervention/task, initiated on 03/12/26 included, Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by.Record review of Resident #1's quarterly MDS assessment, dated 02/21/26, reflected Resident #1 had a BIMS of 15, indicating cognition was intact.During an observation and interview on 05/20/26 at 10:15 A.M., Resident #1 bathroom was full of items on the floor and stacked up along the walls. Observation indicated both sides of the resident room were full of different items and Resident #1 had a narrow path that led to her bed. Observation further indicated molded bread on top of Resident #1's refrigerator. Resident #1 stated she could not clean her room because her hip hurt and she did not have time to clean her room. Resident#1 stated she does not like all the staff in her room. Resident #1 stated she had problems with ants before, but no ants were observed in Resident #1's room at that time. Resident#1 was observed seated on the side of her bed fully dressed without a roommate.Record review of Resident #1 progress notes dated 03/20/26 to 05/20/26 reflected, no documentation related to the facility's efforts to address the hoarding/shopping behaviors.Record review of psychological progress notes, dated 03/30/26, reflected Resident #1's short term therapy goal included reducing the number of items in her room to a level deemed safe by facility staff according to state guidelines within one month. Progress made was 3-Moderate.Record review of QAPI, dated 04/23/26 provided after exit reflected, resident#1 safety plan with department heads and medical director. Record review of Resident #1's fall risk assessment, dated 04/23/26, reflected a score of 5.0 which indicated a moderate risk. Record review of Resident #1's progress notes, dated 05/20/26, reflected no reported falls in the last 90 days. During an interview on 05/20/26 at 3:45 P.M., the DON stated Resident #1 had made improvements on her room. The DON stated Resident #1 used to have items all the way to the ceiling. The DON stated they had a plan of action and were in the process of organizing her room and moving items to an outside storage shed for her. During an interview on 05/20/26 at 4:00 P.M., the Administrator stated they had worked on the room with Resident #1, and she only allowed certain staff to move items around and organize. The Administrator stated Resident #1's room had improved over the last couple of years. Record review of the facility policy, revised 08/2020, titled, Resident Rooms and Environment, reflected, Purpose: To provide residents with a safe, clean, comfortable and homelike environment. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order.

Based on interview and record review, the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 3 of 6 residents (Resident #2, Resident #3, and Resident #76) reviewed for Comprehensive Care Plan.The facility failed to ensure Resident #2, Resident #3, and Resident #76 and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meeting.This failure could place residents at risk of a loss of independence, loss of opportunity to participate in planning of their care, psychosocial health, and quality of care.In a record review of Resident #2's face sheet, dated 05/08/2026, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and was his own responsible party. His diagnoses included Depression (serious medical illness causing persistent sadness, loss of interest, and decreased energy that interferes with daily life), Generalized Anxiety Disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, lasting for at least 6 months), Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events), and Dysphagia (difficulty swallowing).In a record review of Resident #2's MDS, completed on 04/10/2026, reflected Resident #2's BIMS score was 14/15, and indicated that a person was cognitively intact. Resident #2 required partial to moderate assistance (indicated staff did less than half the effort) with care for toileting, bathing, and lower body dressing and setup or clean-up assistance (staff sets up or cleans up); Resident #2 completed the activity for oral hygiene and upper body dressing.In a record review on 05/08/2026 of Resident #2's assessment tab in the facility's EMR revealed that Resident #2's care conference was 11 days overdue. Further review of the EMR showed no documentation indicating that Resident #2 had been invited to or participated in his care conference. During an interview with Resident #2's on 05/08/2026 at 12:02 p.m., he said he had never received notice of a care conference or care plan meeting with staff and had never been provided with a copy of his care plan. He further stated that he was concerned about not being involved in his care and felt that his care was not being provided according to his preferences.In a record review of Resident #3's face sheet, dated 05/07/2026, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and was his own responsible party. His diagnoses included Acute hematogenous osteomyelitis (a bone infection commonly caused by bacteria via the bloodstream), Asthma (a chronic, long-term disease), Morbid (severe) obesity due to excess calories (excessive fat accumulation), Atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart's arteries without causing chest pain), End-stage renal disease (the final stage of kidney failure), and Unspecified atrial fibrillation (an irregular, often rapid heart rate where the upper chambers quiver).In a record review of Resident #3's MDS, completed on 02/23/2026, reflected Resident #3's BIMS score was 15/15, indicated that a person was cognitively intact. Resident #3 required substantial to maximal assistance (which meant staff does more than half the effort) with care for toileting, bathing, lower body dressing, and putting on/taking off footwear.In a record review on 05/07/2026 of Resident #3's assessment tab in the facility's EMR revealed that Resident #3's care conference was 42 days overdue. Further review of the EMR showed no documentation indicating that Resident #3 had been invited to or participated in his care conference. During an interview with Resident #3 on 05/08/2026 at 12:18 p.m., he said he had never received notice of a care conference or care plan meeting with staff and had never been provided with a copy of his care plan. He further stated that he would have liked to meet with staff to discuss his care and understand the goals established to help him return home.In a record review of Resident #76's face sheet, dated 05/08/2026, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and was his own responsible party. His diagnoses included Muscle atrophy (loss of muscle mass, strength, and function), Contracture of Muscle (the permanent shortening, stiffening, and tightening of muscles, tendons, or skin, causing reduced mobility and joint deformity), Major Depressive Disorder (a serious, common mental health condition characterized by persistent sadness, loss of interest, and low energy for at least two weeks), Dysphagia (difficulty swallowing), and Cognitive Communication deficit (often caused by brain injury or neurological disease).In a record review of Resident #76's MDS, completed on 02/13/2026, reflected Resident #76's BIMS score was 11/15, indicated moderate impairment in cognitive function. Resident #76 required dependent assistance (which meant staff did all the effort) with care for bathing, upper and lower body dressing, oral hygiene, toileting hygiene, personal hygiene, and putting on/taking off footwear.In a record review on 05/08/2026 of Resident #76's assessment tab in the facility's EMR revealed that Resident #76's care conference was 16 days overdue. Further review of the EMR showed no documentation indicating that Resident #76 had been invited to or participated in his care conference.During an interview with Resident #76 on 05/08/2026 at 12:43 p.m., he said he did not remember the last time he received notice of a care conference or care plan meeting with staff, and he had never been given a copy of his care plan. He also stated that he would have liked to have been involved in his care, as it would have made him feel that the staff cared about him.During an interview on 05/08/26 at 1:15 p.m., the SW revealed she had only been working at the facility for a couple of months. She stated that she noticed care conferences had not been completed and that she had been working to correct the issue. She further stated that she had been providing written notices to residents a couple of days prior to their scheduled care conference date.During an interview on 05/08/26 at 1:32 p.m., the DON stated that care conferences were completed quarterly and that the Social Worker sent letters to the responsible party or to the resident if the resident was their own responsible party. She further stated that when residents were not involved in their care, it could make them feel left out.During an interview on 05/08/26 at 1:43 p.m., the Administrator stated that the facility's care conference process needed improvement and stated that an improvement plan had been implemented. She reported that the plan included sending written notices to residents and/or their responsible party regarding scheduled care conferences. She further stated that when residents were not involved in their care planning process, it could make them feel excluded from decisions regarding their care.Review of the facility policy, Care Planning, revised 06/2020, reflected: Policy.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.Procedures.II. Once the Baseline Care Plan is completed, the Facility must provide the resident and/or the resident's representative with a written summary of the Baseline Care Plan that includes: A. Initial goals of the residentB. Summary of medications and dietary instructionsC. Services or treatments to be administeredD. Updated information based on completion of the Comprehensive Care Plan, as indicatedE. The Facility may choose to provide a copy of the Baseline Care Plan instead of a summary as long as it includes the required information.XI. The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals:A. The Attending Physician;B. The Resident Assessment Coordinator;C. The Licensed Nurse who has responsibility for the resident;D. The Dietary Supervisor and/or registered dietician;E. Social Service staff member responsible for the resident;F. The Activity Director;G. Therapists as applicable;H. Consultants (as appropriate);I. The Director of Nursing (as applicable);J. Certified Nursing Assistants and/or RNAs responsible for the resident's care;K. The resident and/or his/her family or legal representative;i. If the resident and his/her resident representative participation is determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record.L. Other individuals as appropriate or necessary.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure the handwashing sinks #1 and #2 garbage receptacle contained only paper towels.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.The facility failed to ensure to discard spoiled items stored in the walk-in refrigerator.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the #1 handwashing sink's garbage receptacle on 05/06/2026 at 8:56 a.m., the following was revealed: #1 and #2 handwashing sinks garbage receptacles contained items other than disposable paper towels, including used gloves and plastic wrapping.During an observation of the dry storage room on 05/06/2026 at 9:30 a.m., the following was revealed:1x cream of celery soup 50 oz. (3 lbs. 2 oz.) written date 03/26/2026, best by date 12/09/2027, 2 dents on the bottom seal.1x Diced pears 105 oz. (6 lbs. 9 oz.) written date 04/30/2026, no best by date, dent on the side of the can.1x Tomato juice 46 fl. oz (1 qt. 14 oz.) written date 02/26/2026, best by date 07/14/2027, dent on the bottom seal.1x Refried Beans 112 oz. (7 lbs.) written date 04/02/2026, best by date 10/29/2028, dent on the top seal.During an observation of the walk-in refrigerator on 05/06/2026 at 9:39 a.m., the following was revealed:1x Sliced dill pickles 128 fl. oz (1 gallon), written on the side of the jar was received date 03/19/2026, open date 04/11/2026, and out date 04/31/2026, the manufacturers best by date 07/31/2027.1x Prepared mustard 128 fl. oz (1 gallon), written on the side of the jar was received date 02/26/2026, open date 04/11/2026, and out date 04/31/2026 with no manufacturers best by date.Teriyaki sauce 1 gallon, written on the side of the jar was in date 03/26/2026, open date 04/05/2026, and out date 04/30/2026 with no manufacturers best by date.During an interview on 05/06/2026 at 9:43 a.m., the [NAME] said everyone is responsible for inspecting cans for dents. He said the received date is written on cans that are delivered and refrigerated items should have 3 dates written on them if they are opened, the received date, opened date, and out date. He explained that the out date is the day it is no longer good. He said if residents were to eat expired food they could become very ill or even end up in the hospital.During an interview on 05/06/2026 at 9:55 a.m., the Dietary Manager stated that the individuals responsible for unloading the delivery truck were also responsible for inspecting cans for dents. She explained that the size of the dent did not matter. She said damaged cans were placed on a designated dented-can shelf and returned to the vendor for credit. She said the receive date or the in date was the date the product was delivered, the out date was the date the item needed to be thrown away, and the open date was the date they opened the product. She added that they do not keep products that have been open for more than 15 days. She further stated that the use of dented or damaged cans or expired food could result in residents vomiting or going to the hospital. During an observation of the #2 handwashing sink garbage receptacle on 05/07/2026 at 11:48 a.m., the following was revealed: #2 of #2 handwashing sinks garbage receptacle contained items other than disposable paper towels, including plastic wrap, used gloves, and paper.Observed the Dietary Manager put her dirty gloves in the #2 sinks garbage receptacle.During an interview on 05/07/2026 at 11:48 a.m., the Dietary Manager stated that she had always disposed of her dirty gloves in the #1 and #2 sinks garbage receptacles and reported that she had not been aware that this was inappropriate.In a record review of the facility's Food Storage policy, revised 12/2020, revealed: Procedures.Raw Meat/Poultry/Seafood Guidelines.II. Frozen Meat/ Poultry and Food Guidelines.III. Eggs, Milk, and Cheese Storage Guidelines.IV. Frozen Eggs Storage Guidelines.V. Frozen Cheese Storage Guidelines.VI. Fresh Fruits Storage Guidelines.VII. Frozen Fruit Storage Guidelines.VIII. Canned Fruit Storage Guidelines.Dented or bulging cans should be placed in separate storage area and returned for credit.IX. Fresh Vegetables Storage Guidelines.X. Frozen Vegetable Storage Guidelines.XI. Canned Fruit Storage Guidelines.Dented or bulging cans should be placed in separate storage area and returned for credit.Fresh Milk and Dairy Products Storage Guidelines.Dry Storage Guidelines.There was nothing in the facility policy pertaining to the walk-in refrigerator storage.Review of the U.S. FDA Food Code 2022 reflected: . Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for catheter care for 3 of 6 residents (Resident #1, Resident #14, and Resident #122) reviewed for infection control.Resident #14's catheter bag was touching his fall mat. Resident #1 and Resident #122's catheter bags hung under their wheelchairs and touched the floor in the physical therapy room. This failure could place residents at risk for infection.Findings included: Resident #14 Record review of Resident #14's face sheet revealed a [AGE] year-old male admitted with a primary diagnosis of atherosclerotic heart disease (arteries become narrow due to build of plaque, reducing blood flow to heart). Other pertinent diagnoses include congestive heart failure (heart cannot pump enough blood), cerebral infarction (stroke), and hypertension (high blood pressure). Resident #14 was on hospice services. Record review of Resident #14's care plan, revised on 05/06/2026, revealed he was care planned for falls and a low bed, a foley catheter and to maintain the drainage bag off the floor, and was on enhanced barrier precautions due to the foley catheter. During an observation on 05/06/2026 at 11:48 a.m., Resident #14's catheter bag was touching the floor mat at his bedside. The resident was sleeping at this time and was unable to be interviewed. Resident #1 Record review of Resident #1's face sheet, dated 05/06/2026, revealed a [AGE] year-old male, admitted with a primary diagnosis of chronic osteomyelitis with draining sinus left ankle and foot (persistent bone infection that requires prompt medical treatment). Other pertinent diagnoses included sepsis (infection resulting in overactive immune response, can lead to damaged organs), proteus (proteus mirabilis and proteus morganii, bacteria that can cause urinary tract infection, wound infections, and sepsis) infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter (infection and inflammation due to catheter and resident receives continued treatment and monitoring for condition), resistance to vancomycin (resistance to antibiotic), methicillin resistant staphylococcus aureus infection (bacterial infection resistant to antibiotics), acute cystitis (infection or inflammation of bladder), metabolic encephalopathy (brain disorder that occurs when a chemical imbalance of the blood affects the brain) and cognitive communication deficit. Record review of Resident #1's care plan, revised 05/04/2026, revealed he was care planned for antibiotic therapy, intravenous antibiotic medication, wounds, and foley catheter with interventions to maintain the drainage bag off the floor. Resident #122 Record review of Resident #122's face sheet, dated 05/13/2026, revealed an [AGE] year-old female, admitted with primary diagnosis of heart failure (heart cannot pump enough blood). Other pertinent diagnoses included stage 4 chronic kidney disease (severe reduction in kidney function) and neuromuscular dysfunction of bladder (impaired bladder control). An observation on 05/07/2026 at 10:46 a.m., revealed Residents #1 and #122 were both sitting in their wheelchairs in physical therapy with their catheter bags hanging from under their wheelchairs and touching the floor. During an interview on 05/08/2026 at 10:43 a.m., LVN B said infection control was ensured with catheter bags by making sure the bag was off the floor. He said even when a resident bed was in the lowest position, it must not touch the floor. LVN B said when residents go to therapy, catheter bags must hang on the wheelchair. He said catheter bags touching the floor could lead to infection by collecting what was on the floor (bacteria, dirt, dust, etc). During an interview on 05/08/2026 at 2:51 p.m., the DON revealed staff should follow the catheter policy and physician orders for catheter care when it comes to infection control. She said the catheter bag should be kept below the bladder and kept off the floor. The DON said the risk of catheter bags touching the floor was floors could be dirty and expose the bag to bacteria. The DON said it was important to prevent infections and watch for any signs and symptoms in residents. The DON said Resident #14 was a fall risk and having a low bed was a recent intervention and she would brainstorm ideas on keeping him safe while maintaining infection control. She said when residents were in wheelchairs, catheter bags should not touch the ground. Record review of the facility's Catheter- Care of policy, dated 06/2020, reflected: PurposeTo prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary.Procedure.III. Proper Techniques for Urinary Catheter Maintenance.D. Urinary Flow - an unobstructed flow of urine should be maintained. In order to achieve a free flow of urine:i. Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor.F. Collection Bags -i. Take care to ensure the collection bag goes not touch the floor at any time.

Based on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #32 and Resident #139) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #32 and Resident #139.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #32 and Resident #139.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record review of Resident #32's face sheet, dated 05/07/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Chronic Obstructive Pulmonary Disease (acute flare-up, worsening of symptoms, increased breathlessness, cough, or sputum production beyond normal daily variations), Cognitive Communication deficit (often caused by brain injury or neurological disease), Type 2 Diabetes mellitus without complications (the presence of high blood sugar but without established damage to nerves, eyes, kidneys, or the cardiovascular system), and Atherosclerotic heart disease of native coronary artery without angina pectoris (where plaque builds up in the heart's original arteries without causing chest pain).A record review of Resident #32's MDS, dated [DATE], reflected that Resident ##32's BIMS score was 15/15, indicated that a person was cognitively intact. Resident #32 required dependent assistance (which meant staff did all the effort) to partial to moderate assistance (indicated staff did less than half the effort) with care.A review of Resident #32's progress note dated 03/19/2026 revealed that Resident #32 complained of chest pain and shortness of breath, order was given to send Resident #32 to the hospital. There was no evidence that a transfer or discharge notice had been provided to Resident #32 in writing or to the State LTC Ombudsman.During an interview on 05/06/2026 at 11:28 a.m., Resident #32 revealed she had never received a written letter when she was sent to the emergency room. She also stated she would have liked to have received a letter from the facility so she could review it later.2. A record review of Resident #139's face sheet, dated 05/07/2026, revealed the resident was an [AGE] year-old female initially admitted to the facility on [DATE], she was her own responsible party. Her diagnoses included Metabolic encephalopathy (a brain dysfunction resulting from chemical imbalances or organ failure rather than structural damage), Dysphagia (difficulty swallowing), Cognitive Communication deficit (often caused by brain injury or neurological disease), Obstructive Sleep Apnea (where breathing repeatedly stops and starts because throat muscles relax too much, causing the airway to collapse and block airflow during sleep), and Chronic Obstructive Pulmonary Disease (increased breathlessness, cough, or sputum production beyond normal daily variations).A record review of Resident #139's MDS, dated [DATE], reflected that Resident #139's BIMS score was 11/15, indicated moderate impairment in cognitive function. Resident #139 required dependent assistance (which meant staff did all the effort) to substantial to maximal assistance (which meant staff does more than half the effort) with care. A record review of Resident #139's progress notes dated 03/01/2026 revealed that she had altered mental status and an order was given to send Resident #139 to the hospital. There was no evidence that a transfer or discharge notice had been provided to Resident #139 in writing or to the State LTC Ombudsman. During an interview on 05/06/2026 at 1:33 p.m., Resident #139 revealed she had never received a written letter when she was sent to the emergency room. She also stated she would have liked to have received a letter from the facility so she could review it later.During an interview on 05/07/2026 at 12:28 p.m., the Social Worker revealed that she had not provided a written notification to the residents or their representatives regarding the transfer or discharge, including the reason for the transfer or discharge. She also stated that she had not sent a copy of the notice or a list of discharged residents to the State LTC Ombudsman, because she thought someone else at the facility sent them. During an interview on 05/08/2026 at 1:32 p.m., the DON revealed that the nursing staff only provide a transfer sheet to the hospital and the hospital sends clinicals back to the facility when the resident returns to the facility, so if the resident had questions after they returned nursing staff can answer those questions.During an interview on 05/08/2026 at 1:43 p.m., the Administrator revealed that the facility did not provide letters to residents or the resident's representative(s) when they discharged to the hospital. She added that the Social Worker sent a monthly list of residents who had been discharged to the State LTC Ombudsman.A record review of the facility's Transfer and Discharge policy revised 06/2020 states: .IV. Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge. Situations that may prevent 30 days' notice include:.C. The resident is experiencing urgent medical needs;.V. Cases in which 30 days' notice is not possible, notice of transfer or discharge should be provided to the resident of his/her responsible party as soon as practicable.VI. Documentation of written or telephone acknowledgement of the resident's transfer by the resident's personal representative may occur after the transfer in an emergency situation.Procedure .III. Prior to transfer/discharge, Social Services Staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged .IV. The Facility may use Notice of Transfer/Discharge or another comparable form to provide the resident of his/her personal representative with advance notice of the transfer or discharge. The notice will include the following information:A. The reason the resident is being transferred/discharged ;B. The effective date of the transfer/discharge;C. The name, complete address and telephone number to which the resident is being transferred;D. A statement that the resident has the right to appeal the action to the state, contact information for the state entity which receives appeal hearing requests, and information for how to request an appeal;E. The name, address, and telephone number of the State Long Term Care Ombudsman;F. For residents with intellectual or developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals; andG. For residents with a mental disorder, the mailing address and telephone number of the agency responsible for the protection and advocacy for individuals with mental disorders.V. The Facility will also send a copy of the Notice of Transfer/Discharge to the State Long Term Care Ombudsman for Facility initiated discharges.VI. If the information in the notice changes prior to the transfer or discharge, the Facility will provide updated information to the recipients of the notice as soon as practicable.A. If the changes to the notice are significant, such as a change is discharge destination, a new notice must be given that clearly describes the change(s) and resets the transfer/discharge date in order to provide 30-day advance notification.VII. Bed [NAME]. Before the Facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the Facility will provide written information to the resident or his/her personal representative which specifies:i. The duration of the bed-hold during which the resident is permitted to return and resume residence in the nursing facility; andii. The Facility's policies regarding bed-hold periods permitting a resident to return.B. At the time of transfer, the Facility will provide to the resident and a family member or personal representative written notice which specifies the duration of the bed-hold policy, and will inform the resident of his or her right to exercise a bed hold provision.According to eCFR S483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and(iii) Include in the notice the items described in paragraph (c)(5) of this section.S483.15(c)(4) Timing of the notice.(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged .(ii) Notice must be made as soon as practicable before transfer or discharge when-(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or(E) A resident has not resided in the facility for 30 days.S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:(i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged ;(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Based on observation, interview, and record review, the facility failed to ensure that residents were free of accident hazards for 1 of 6 (Resident #72) residents reviewed for accidents hazards and supervision.The facility failed to ensure Resident #72 did not obtain electronic cigarettes in her room.This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injuries.Findings included:Record review of Resident #72's face sheet, dated 05/07/2026, revealed a [AGE] year-old female admitted to the facility with a primary diagnosis of idiopathic epilepsy (seizures that occur without a known cause). Other pertinent diagnoses include abnormalities of gait and mobility (abnormal walking pattern), type 2 diabetes mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), mild cognitive impairment (noticeable cognitive decline, normal with aging), dementia (brain disease that alters brain function, causing cognitive decline), schizophrenia (severe mental disorder affecting how a person thinks, feels, and behaves, leading to hallucinations, delusions and disordered thinking), bipolar disorder (serious mental illness that causes mood swings, changes in energy, thinking, behavior, and sleep) and major depressive disorder (persistent feeling of sadness and loss of interest).Record review of Resident #72's MDS (a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident) revealed she had a BIMs (a standardized assessment to measure long and short-term memory) of 15, indicating intact cognitive function. Resident #72 was assessed as an active tobacco user.Record review of Resident #72's care plan, revised 05/01/2026, revealed Resident #72 was care planned for behavior problems, was resistive to care, and was found with a nicotine vape in her possession. Interventions included to intervene as necessary to protect the rights and safety of others, to praise the resident's appropriate behavior, and to educate the resident and family of the possible outcomes of not complying with treatment or care.Record review of Resident #72's progress notes revealed:- 02/03/2026: .Resident found to have a vape in her possession, resident gave to nurse, resident provided extensive education in regard to smoking policy, resident verbalized being very upset with nurse on duty .- 04/27/2026: [sic] Resident seen in courtyard with lit cigarette smoking after hours. Reminded of the smoking times. Resident then requested staff members to buy smoking device (vape) and that she would pay for it. Reminded resident that this was prohibited. Resident then asked staff if one of them could transport her to the [gas station] to pick up a vape device. Informed resident this was prohibited.During an observation on 05/06/2026 at 1:55 p.m., Resident #72 room door completely open, when the state surveyor walked by, Resident #72 was observed to have an object near her mouth. The state surveyor made eye contact with Resident #72, and she placed the object into the seat of her rollator. An interview at this time revealed Resident #72 was a smoker and she used electronic vapes. Resident #72 said she did not keep her electronic cigarettes with her; she said the facility had a box for smoking devices and it was locked. She said during smoking times, she would go outside to use her electronic cigarette. Resident #72 said she charged her electronic cigarettes herself during smoking times because she preferred to be the one to charge it. Resident #72 said she did not have issues with getting her electronic cigarettes during smoking times. She said she loved living at the facility.During an observation and interview on 05/07/2026 at 10:03 a.m., Resident #72 approached and used her rollator to sit next to the state surveyor. While talking to Resident #72, her cellphone rang, she stood up, opened the lid on the seat of her rollator to answer the cellphone call. Resident #72 left the lid open on the seat of her rollator and the state surveyor observed two electronic cigarettes in her rollator seat. During an interview on 05/07/2026 at 4:15 p.m., LVN A said she found electronic cigarettes in Resident #72's room before. She said she would tell the ADM when she found electronic cigarettes in the room, because Resident #72 was violating the smoking policy and residents were not allowed to smoke or use electric cigarettes in their rooms. LVN A said Resident #72 was cognitive enough to make decisions, indicating Resident #72 knew she was not supposed to use electronic cigarettes in her room.During an interview on 05/08/2026 at 10:43 a.m., LVN B said if he found a resident with an electronic cigarette in their room, he would report it immediately to the ADM and DON. He said the resident would have to fill out a smoking violation form. LVN B said the risk of residents smoking or using electronic cigarettes in their room was the roommate could have a health condition like COPD (chronic obstructive pulmonary disease, progressive lung disease making it difficult to breathe) or the resident could burn down the facility.During an interview on 05/08/2026 at 1:05 p.m., the SW said she was an integral part of the smoking program, by providing the smoking schedule, policy, and reinforcing when there was noncompliance. She said if a resident was noncompliant and had electronic cigarettes in their room, she would ask the resident to turn it in voluntarily for their safety and everyone else's. The SW said on 05/07/2026, she and the ADM had removed electronic cigarettes from Resident #72's room. She said they really had to talk to Resident #72 to get both electronic cigarettes. The SW said if a resident was noncompliant with the smoking policy, there were smoking violation forms that she and the ADM filled out with the residents. She said if a resident continues to be noncompliant with the smoking policy, then the resident would be discharged to a safe environment. The SW said resident safety trumps rights.During an interview on 05/08/2026 at 1:46 p.m., the ADM revealed she had done a room search on Resident #72 the night before on 05/07/2026. The ADM said staff reviewed Resident #72's hospital records from 05/07/2026 and it said she had used her electronic cigarette in the hospital waiting room, so she had to do a room search because of the hazard. The ADM said she and the SW went to Resident #72's room and Resident #72 initially refused to give up the electronic cigarettes but finally did. The ADM said she was unsure of how Resident #72 got the electronic cigarettes, but it could be from a family member that visited often. She said Resident #72 had violated the smoking policy before and had filled out the smoking violation form once. She said the behavior was not consistent but was a hazard and resident safety was paramount (more important than anything else).The ADM said if the family member was providing the electronic cigarettes, the family member's visitation would have to limited and supervised. She said there were consequences for the resident and family member, if they violated the smoking policy.Record review of the facility's Smoking by Residents policy, dated 06/2020, reflected: PurposeTo respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers.PolicyI. Smoking is not allowed anywhere inside the Facility.II. The Facility permits smoking only in the area(s) designated by the Facility's Safety Committee.III. The Facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely.VI. This policy applies to the use of both cigarettes and e-cigarettes.Procedure.IX. All smoking materials will be stored in a secure area to ensure they are kept safe.X. Smoking sessions will be limited to 15-minute segments.A. The Facility shall determine the times of smoking sessions and post that informationXI. All smoking sessions will be supervised by Facility Staff members.

Based on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for treatment documentation. 1. The facility failed to document timely when Resident #1 refused to leave the courtyard area of the facility until 1:00 AM on 10/08/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Record review of Resident #1's face sheet, dated 10/10/25, reflected a [AGE] year-old male, with an initial admission date of 06/17/25, and a readmission date of 10/02/25. Resident #1 had a diagnoses of Parkinson's Disease (progressive disorder that affects movement, balance, and coordination), Type 2 Diabetes (body does not use insulin properly or cannot produce enough insulin), Schizoaffective Disorder (disorder with delusions, hallucinations, disorganized thinking, depressed mood, and manic behavior), Bipolar Disorder (mental health condition with extreme mood swings), Anxiety Disorder (excessive worry, fear, or nervousness), Chronic Pain, Blindness in one eye and low vision in the other eye, Essential Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (airflow obstruction and breathing difficulties), and Dysphagia (difficulty swallowing). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 12, which meant Resident #1 had moderate cognitive impairment. Record review on 10/10/25 of the progress notes on Resident #1's electronic record, reflected no note about Resident #1's refusal to leave the courtyard until 1:00 AM. In an interview on 10/10/25 at 12:29 PM, LVN C stated he was the one that repeatedly checked on Resident #1 in the courtyard of the facility on the night of 10/08/25. LVN C stated when his shift started that night around 10:00 PM, the previous shift staff informed him Resident #1 was in the courtyard and was not ready to come back into the facility. LVN C stated he checked on Resident #1 about every 20-30 minutes. LVN C stated Resident #1 kept saying he was enjoying the fresh air and was not ready to leave the courtyard. LVN C stated finally, around 1:00 AM, Resident #1 was ready to leave the courtyard. He stated he was then taken back to his room. LVN C stated the residents have rights, and he could not make Resident #1 leave the courtyard. LVN C stated he felt there was no risk of not documenting when Resident #1 did not want to leave the courtyard, because he went to the courtyard often, but he normally would not be out there as late as he was on 10/08/25. Record review on 10/14/25 of the progress notes on Resident #1's electronic record reflected a late entry note, added on 10/13/25 at 3:16 AM on the incident on 10/08/25, when Resident #1 refused to leave the courtyard at the facility until around 1:00 AM. In an interview with the Administrator and the DON on 10/14/25 at 3:08 PM, the DON stated the risk of late documentation when Resident #1 refused to come inside was important information missing from the resident's electronic record that needs to be shared with the clinical team. The Administrator stated she agreed with the DON about the risk of late documentation on a resident's electronic record. The Administrator stated the staff will be reviewing documentation during the morning review to ensure information is not missed. Record review of the facility's policy titled, Documentation-Nursing, dated, 01/2025, reflected the following: PurposeTo provide documentation of resident status and care given by nursing staff.PolicyNursing documentation will be concise, clear, pertinent, accurate and evidence based.K. Documentation will be completed by the end of the assigned shift.

Based on observation, interview, and record review the facility failed to adhere to the federal requirements regarding residents' rights. The facility failed ensure a safe and decent living environment for two (Resident #2 and Resident #3's rooms) of five rooms reviewed for decent living environment. 1. The facility failed to ensure Resident #2's room was free of dirt, debris, and sticky floors on 10/10/25.2. The facility failed to ensure Resident #3's broken window was repaired. These failures could place residents at risk or diminished quality of life due to the lack of a well-kept environment. Findings included: Record review of Resident #2's face sheet, dated 10/10/25, reflected a [AGE] year-old male, with an admission date of 03/31/25. Resident #2 had a diagnosis of Convulsions (involuntary, uncontrollable muscle contractions), Dysarthria (difficult or unclear articulation of speech), Need for Assistance with Personal Care, Chronic Viral Hepatitis C (long term infection of the liver), and Vascular Dementia (changes in thinking and memory) Record review of Resident #3's face sheet, dated 10/14/25, reflected a [AGE] year-old female, with an admission date of 06/30/25. Resident #3 had a diagnosis of Dementia (changes in thinking and memory), Muscle Weakness, Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Acute Respiratory Failure (lungs cannot adequately exchange oxygen and carbon dioxide), and Emphysema (chronic lung disease that causes irreversible damage to air sacs in the lungs). In an observation and interview on 10/10/25 at 8:30 AM, Resident #2's room had many large brown crumbs on the floor near the television area, cheese balls under the edge of his bed, and had a sticky fall mat with crumbs on it. Resident #2 did not reply back to Surveyor when Surveyor attempted to speak with him. In an observation on 10/10/25 at 10:27 AM, in Resident #2's room, reflected the large crumbs near the television were gone and the floor looked like it was recently swept and mopped, but there were still cheese balls at the edge of his bed. The floor mat still had sticky spots and crumbs on it.In an interview on 10/10/25 at 2:18 PM, the Administrator stated the expectation was for the resident rooms to be cleaned well. She stated the risk of a resident's room not being cleaned was the responsible staff member having to speak with her regarding the violation of resident rights.In an interview on 10/10/25 at 3:05 PM, Housekeeping Supervisor E stated he would check to see who was responsible for cleaning Resident #2's room. Housekeeping Supervisor E stated he was not sure why the room was not cleaned properly, but his staff were trained on how to properly clean a resident's room. He stated Resident #2's room was now fully cleaned. Housekeeping Supervisor E stated the risk of an uncleaned room was infection control and pest issues. In an observation on 10/10/25 at 4:00 PM, from the parking area, outside of the facility, Surveyor noticed a resident room window with large cracks about a foot in diameter, with pink curtains that covered the inside of the window. The specific resident room was not identifiable from the parking area. In an interview on 10/14/25 at 1:15 PM, The Maintenance Director stated he was new at the facility and had a lot of work to complete. He stated he was aware of the broken window and had already purchased some material to repair it. The Maintenance Director stated he started working at the facility on 09/15/25, and the window was broken then. The Maintenance Director stated he would be fixed today. He stated the risk of a broken window in a resident room was the resident could cut themselves on it.In an observation and interview on 10/14/25 at 1:21 PM, reflected Resident #3's room was the room with the broken window. Upon further observation, the broken window had green tape of some of the cracks. There was a broken, open area with no coverage. The window was open. Resident #3 stated she did not realize the window was that bad. Resident #3 stated she was not sure how long the window had been broken. She stated she was not sure who opened the window. Resident #3 stated she hoped maintenance would repair the window soon, and she hoped it would be repaired the same day. In an interview on 10/14/25 at 3:08 PM, the Administrator stated the risk of a broken window in a resident's room was pest control concerns. In an interview on 10/15/25 at 1:21 PM, Resident #2's Family Member stated they had complained to the facility two times in the past regarding his room not being cleaned. The Family Member stated it was mostly on the weekend, and the facility staff told them there were not as many housekeepers who worked on the weekend. The Family Member stated they would like Resident #2's room to be cleaned more consistently. Record review of the facility's policy titled, Resident Rights, dated 08/2020, reflected the following: Purpose To promote and protect the rights of all residents at the facility. Policy All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of five (Resident #1 Room) resident rooms reviewed for pharmacy services. The facility failed to ensure a tube of Zinc Oxide Ointment and a bottle of Antiseptic Skin Cleanser were not left in Resident #1's room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.Findings included:In an observation and interview on 10/10/25 at 10:11 AM, an uncapped, 1 oz tube of Zinc Oxide ointment was observed on Resident #1's nightstand, and a 4 oz bottle of Antiseptic Skin Cleanser was observed on top of Resident #1's refrigerator, which sat on top of the nightstand. Resident #1 stated staff must have left those items in his room this morning. Resident #1 stated the staff kept all of his medications.In an interview on 10/10/25 at 10:45 AM, RN A stated the aides were responsible for applying creams and ointments. She stated prescription creams and antiseptic would be administered by a nurse. RN A stated the zinc oxide was applied by Aide B this morning, and she stated she was not sure where the antiseptic came from. RN A stated she did not put any antiseptic on him this morning and was not sure if it was from Resident #1's home or the facility. RN A stated those items should not be left in Resident #1's room where a resident could have access to those items. In an interview on 10/10/25 at 11:03 AM, Aide B stated she did use the zinc oxide on Resident #1 this morning while changing him. Aide B stated she was rushing to answer another call light and must have left the ointment in his room. She stated she did not have the antiseptic skin cleanser and was not sure who was responsible for it. Aide B stated she was not supposed to leave ointment in the resident's room, but she was rushing and forgot. Aide B stated the risk was Resident #1 could have got it or touched it.In an interview with the Administrator and the DON on 10/10/25 at 2:18 PM, the DON stated those items should not be left in Resident #1's room. He stated the facility started an in-service to remind staff not to leave medications, ointments, and cleansers in the residents' rooms. The DON stated the risk of leaving those items in Resident #1's room was there was potential for harm, like the resident ingesting something. The Administrator stated the risk of leaving those items in Resident #1's room was possible sickness.Record review of the facility's undated policy, titled, Medication Administration, reflected the following: PurposeTo provide practice standards for safe administration of medications for residents in the Facility. VIII. Medications will not be left at the bedside.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 3 residents reviewed for accident hazards/devices. The facility failed to ensure CNA A and CNA B used the required assistive device (gait belt) to transfer Resident# 1 to prevent accidents. This failure could place residents at risk of avoidable falls, injuries, and reduced safety during transfers.Findings included: Record review of Resident #1's MDS Assessment, dated 08/01/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had a BIMS score of 09, indicating moderate cognitive impairment. His diagnoses included Anemia (A condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), hypertension (a condition where the blood pressure is lower than normal), Renal Insufficiency (a condition where the kidneys do not function properly and cannot filter waste products from the blood), Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels that occur when the body does not produce enough insulin or does not use insulin effectively), Parkinson Diseases(a progressive neurodegenerative disorder that affects movement, balance, and coordination), Anxiety, and schizophrenia (Schizophrenia is a serious mental health condition that affects how people think, feel and behave). Record review of Resident #1's care plan, initiated 08/28/2025, reflected the following: Focus: The resident has an ADL Self Care Performance Deficit r/t blind. Interventions/Tasks transfer: The resident requires 2 staff total participation with transfers. In an observation on 09.24.2025 at 11:49AM revealed CNA A and CNA B entered Resident#1's room. CNA A and CNA B introduced themselves and notified Resident# 1 that they were going to transfer him from the wheelchair to the bed. CNA A was on the right side and CNA B was on the left side. CNA A and CNA B placed their arms under the resident's arm and pulled the resident to a standing position, then pivoted the resident toward the bed. No gait belt was used in the transfer. In an interview on 09/24/2025 at 11:55AM with CNA A revealed that Residents# 1 required two people for transfers. She stated that she should have used a gait belt. She stated that the risk to the residents when a gait belt was not used was fall and injuries to the resident's shoulder. CNA A stated she had been in serviced on how to transfer with a gait belt. In an interview on 09/24/2025 at 11:57 AM with CNA B revealed that she did not work with Resident#1 and was assisting CNA A with the transfer. She stated that she knew she should have used a gait belt to transfer Resident#1 and there was no reason why they did not use one. She stated that the risk to the resident when a gait belt was not used was injury to the resident and the resident could fall. CNA B stated she had been in serviced on how to transfer with a gait belt. In an interview with 09/24/2025 at 12:00PM with LVN C revealed that Resident#1 required two people for transfers. She stated that every resident should be transferred using a gait belt. She stated that the risk to the resident when a gait belt was not used with transfers was injuries such as broken bones due to falls. In an interview on 09/24/2025 at 12:49PM with the DON revealed that his expectation was that staff used a gait belt with all transfers. He stated that the risk to the resident was fall, injury to the resident and the staff and skin issues. He stated that staff had been in-serviced on safe transfers and the use of gait belts with all transfers unless contraindicated. He stated that Resident#1 had no restrictions for gait belt use. Record review of the facility's policy, revised 06/2020, and Titled Transfer of Residents Reflected: To provide the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure. i. A Licensed Nurse and/or the Director of Rehabilitation Services assess and determine lifting and transfer requirements, and the procedure used for each resident. the procedure is recorded in the residents 's care plan. ii. Residents must be lifted or transferred according to the determined procedure. iii. Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift. iv. Member of the Nursing Staff are trained to use good body mechanics, knowing the proper procedures and properly operating assistive devices. v. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. B. Two-Person Assisted Transfer i. Place the chair on the convenient side of the bed with the back of the chair parallel to the foot of the bed and facing the head of the bed. ii. If using a wheelchair, make sure footrests are not in the way and wheels are locked. iii. Place appropriate pressure-reducing devices into chairs. iv. Turn residents onto their side and pivot the residents to sitting positions, with legs dangling over the side of bed. v. Assist residents in daily attire as requested. vi. May apply gait belt (unless contraindicate) around residents' waist securely enough to prevent sliding up over ribs. vii. Each person will stand facing the resident with one on either side of the resident. viii. Provide a broad base of support by spreading feet and placing foot farthest from the resident slightly in front of the other. ix. Each person will extend their arm closest to the resident forward between the resident side and elbow. With fingers pointing downward, grasp the gait belt firmly. x. Instruct the residents to place their hand between your body and your arm grasping the gait belt holding onto the back of your upper arm, if used. xi. On a verbal command, draw the resident gently but firmly forward and upward to a standing position, brace his knee with yours to prevent buckling. xii. Pivot or turn the resident so that their back is towards the chair. xiii. Remove gait belt, if used xiv. Make sure the resident is comfortable. xv. Utilize Postural support and/or positioning devices per attending Physician order and resident need. xvi. Make sure the call bell is within residents reach before leaving.

Based on observation, interview, and record review, the facility failed to assure drugs and biologicals were secured properly in 1 (400 hall medication cart) of 6 Medication carts reviewed for drug storage. The medication cart on 400 hall was unlocked and no staff in view of the cart. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. The findings included: Observation on 04/25/25 at 6:45 AM revealed the medication cart was unlocked and parked on the far end of 400 hall at the nursing station with the drawers facing the hallways towards the exit doors. Observed no staff in view of the medication cart. Observation on 04/25/25 at 6:59 AM revealed LVN-PRN came out of a residents room and opened the top drawer of the medication cart. Interview on 04/25/25 at 7:00 AM LVN -PRN stated the medication cart should be locked when you are not using it. LVN-PRN stated residents could overdose on medication or take medications that did not belong to them. Interview on 04/25/25 at 9:01 AM RN stated the medication cart should be locked when you step away from the cart. RN stated locking the cart was a safety precaution and could prevent residents from overdosing on medication. Interview on 04/25/25 at 9:24 AM MA stated when medication cart was not in view you must lock the cart and put the key in your pocket. MA stated this would stop residents from getting into the medication cart and taking the wrong medication. Interview on 04/25/25 at 9:39 AM DON stated the medication cart should be locked when staff are not using the cart. DON stated medications in the medication cart could alter the resident state of mind if the wrong medication was taken. Record review of facility policy titled, storage of Medications, revised 08/20 reflected, 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 .Medication carts and medical supplies are locked when they are not attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to ensure that it is free of medication error rates of five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved two (Resident #107 and Resident #78) of six residents reviewed for medication administration. 1. On 2/4/25 at 7:12 AM, MA F failed to administer a medication as ordered to Resident #107 by crushing Depakote DR (an anti-seizure medication) a medication that should not be crushed and attempted to administer prior to surveyor intervention. 2. On 2/4/25 at 7:40 AM, LVN C failed to administer medications as ordered to Resident #78 when he administered Morphine extended release 15 mg instead of morphine 15 mg immediate release as ordered. LVN C administered Geri-kot (generic form of Senekot-a laxative) 8.6 mg instead of the ordered dose of Senekot Plus 8.6-50 mg (Senekot plus docusate). These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: 1. Record review of Resident #107's Admission Record dated 2/5/25 reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #107's Annual MDS assessment dated [DATE] reflected she had a BIMS score of 3 indicating severe cognitive impairment. Her diagnoses included pulmonary embolism (blood clot in the lung); stroke, aphasia (speech disorder commonly caused by a stroke); and cognitive communication deficits. Record review of Resident #107's Care Plan reflected the following entry dated 5/6/24: [Resident #107] has impaired cognitive function/dementia or impaired thought processes. Interventions included review medications and record possible causes of cognitive deficit: Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Record review of Resident #107's physician orders reflected the following orders: Depakote Oral Tablet Delayed Release 125 mg give 1 tablet by mouth two times a day .do not crush medication. Order Date 8/20/24. Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT. Order date 4/12/24. Multi-Vitamin/Minerals Oral Tablet Give 1 unit by mouth one time a day. Order date 4/22/24. Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day. Order date 5/6/24. Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day HOLD for SBP (systolic blood pressure) less than 100. Order date 10/19/24. Magnesium Oxide -Mg Supplement Oral Tablet 250 MG Give 1 tablet by mouth one time a day. Order date 5/3/24. May crush oral medications or open capsules and mix all medications together for administration with medium of resident's choice. Record review of Resident #107's Medication Administration Record dated 2/1/25-2/28/25 reflected: Depakote Oral Tablet Delayed Release 125 mg . give 1 tablet by mouth two times a day .do not crush medication. An observation and interview during medication pass on 2/4/25 at 7:12 AM revealed MA F stated she was preparing medications for Resident #107. She sanitized her hands, donned gloves and checked the resident's blood pressure which read 132/88. MA F sanitized the BP cuff and her hands and began to pour the medications. She poured the Depakote 125 mg 1 tablet, Apixaban 5 mg 1 tablet, multivitamin with minerals 1 tablet, Senna plus 8.6/50 mg 1 tablet; lisinopril 23 mg 1 tab, and magnesium oxide 250 mg 1 tablet into the same cup. She then poured all the tablets together into a small plastic bag, crushed them together and poured them back into a medication dose cup. She retrieved a container of yogurt and stated she was going to mix the yogurt with the medications because that was how Resident #107 preferred to swallow them. She was asked to check the order for Depakote and how she determined which medications could be crushed. MA F stated, according to the nurse, the medications can be crushed if the resident can't swallow. She can't swallow pills well so it's ok to crush them. She stated if a medication can't be crushed, the pharmacy will send them in liquid form, these are OK. When the medication card was reviewed with MA F, she stated she did not know what DR meant and she had not had any guidance on it. She stated, We can crush the med unless the order says not to. She checked her MAR on her computer and stated it did not say we can't crush. Resident #107's Charge Nurse, RN G approached and was asked about crushing medications. She stated some medications cannot be crushed and they were usually noted by the pharmacy. She reviewed Resident #107's Depakote medication card with MA F and pointed out the instructions that reflected do not crush medication and DO NOT CRUSH OR CHEW printed on the label. RN G stated the medication was delayed release and should not be crushed because the dose would be given all at once and not slowly. She stated there was a risk for adverse side effects. MA F stated she had missed the notes when she poured the medication. She discarded the poured medications and repoured and crushed all the medications except for the Depakote. She administered the Depakote whole in a spoonful of yogurt to Resident #107 who swallowed the pill without difficulty (the resident was eating a regular breakfast tray at the time). She administered the crushed medications mixed with yogurt. 2. Record review of Resident #78's Admission Record dated 2/5/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #78's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating he was cognitively intact. His diagnoses included: Hypertension (high blood pressure); other fracture and dislocation of the right humerus (upper arm). He was receiving scheduled and offered PRN pain medication. Record review of Resident #78's Care Plan reflected the following entries: [Resident #78] requires pain management. Intervention included administer analgesia (pain medications) as per orders. Date initiated 12/5/23. [Resident #78] is on Pain medication therapy r/t muscle pain. Interventions included, Administer medication as ordered and Monitor/document for side effects of pain medication. Observe for constipation . Date initiated 12/5/23. Record review of Resident #78's physician orders reflected the following entries: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Senna Plus Oral tablet 8.6-50 mg (sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for constipation. Order date 5/6/24. Aspirin Low Dose Oral Tablet Chewable 81 MG. Give 1 tablet by mouth one time a day. Order date 11/19/23. Sertraline HCl Oral Tablet 25 MG Give 2 tablet by mouth one time a day. Order date 3/5/24. Finasteride Oral Tablet 5 MG Give 1 tablet by mouth one time a day. Order date 12/4/23. Gabapentin Oral Capsule 400 MG Give 1 capsule by mouth three times a day. Metoprolol Tartrate Oral Tablet 25 MG Give 1 tablet by mouth two times a day for HOLD FOR SBP <115 DBP <70 HR <55. Record review of Resident #78's Controlled Drug Administration Record dated received 1/9/24 reflected: morphine sulfate ER 15 mg tab. An observation and interview during medication pass on 2/4/25 at 7:40 AM revealed LVN C was standing outside Resident #38's room He stated he had just taken the blood pressure for Resident #78 and showed a reading on the BP cuff of 112/76. He sanitized the cuff and his hands. LVN C poured the following medications: Geri-kot 8.6 mg (generic form of Senekot) 1 tablet, Aspirin 81 mg 1 tablet, sertraline 25 mg 2 tablets, finasteride 5 mg 1 tablet, gabapentin 400 mg 1 tablet, and morphine ER 15 mg 1 tablet. LVN C stated he was holding Resident #78's metoprolol because his blood pressure was below the ordered parameters. He administered the medications to Resident #78 who was observed sitting up in his room, in his wheelchair. During an interview on 2/4/25 at 11:22 AM, the DON stated RN G had told him about MA F crushing the Depakote tablet. He stated he had conducted and in-service training with MA F and noted she was not reading her MAR correctly. He stated the medications instructions were not in an expanded view on her computer so she could not see the note. He stated she should have seen the instructions on the medication card. The DON stated he had called the physician and the pharmacy and had Resident #107's order changed to Depakote sprinkles so that the medication can be swallowed easier. He stated he was conducting in-service training for all nurses and MAs as a refresher. He stated the risk for crushing extended or delayed release medications is the resident would receive all the medication at once instead of over a period of time which could result in too much medication received and too short of a duration period. During an interview on 2/5/25 at 8:22 AM, the DON stated they had called Resident #78's physician and his morphine was always supposed to be extended release. He stated there had been a transcription error with a reorder of the medication and it should have been caught sooner when the medication dose did not match the order. He stated the risk of medication errors depended upon the medication and could cause unintended consequences or side effects. He stated administering Geri-kot (generic form of Senekot which only contained senna) instead of Senna plus meant the resident did not get the added docusate and had an increased risk of constipation. The DON stated LVN C usually worked night shift and had been picking up an extra shift on 2/4/25. On 2/5/25 at 8:31 AM, an attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview on 2/5/25 at 10:10 AM, ADON E stated she had called Resident #78's pain physician about his morphine order and reported the administration of the ER dose. She stated the physician sent the order for the medication straight to the pharmacy himself and the order should have been extended release all along. She stated he told her to correct the order in the computer to reflect ER. ADON E stated the nurse should have caught the error while administering the medication because the orders are to be checked against the medication every time it was administered. She stated the Charge Nurses were responsible for ensuring the medications in their carts were correct and the risk was adverse effects. ADON E stated she was aware of Resident #107's medication error where the MA crushed a delayed release tablet. She stated the risk was adverse effects of the medication, receiving too much at once and not getting the therapeutic effect of a longer acting medication. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. Record review of the facility's policy titled, Oral Medication Administration, dated revised 08/2020 reflected: Policy: Medications will be administered in a safe and effective manner .Special Considerations 1. Refer to crushing guidelines prior to crushing any medication for confirmation that it can be pulverized .Procedures .2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident .

Based on observation, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #23 and Resident #1) of five residents, three of five pill crushers, and two of two washing machines observed for infection control. 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #23. 2. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. 3. The facility failed to ensure the pill crushers used on Medication Carts 1, 2, and 3 were clean. 4. The facility failed to ensure the facility's two washing machines were clean. These failures placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of Resident #23's annual MDS assessment, dated 01/17/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 6 indicating his cognitive status was severely impaired. His diagnoses included diabetes, stroke, and Non-Alzheimer's dementia. The resident was dependent on staff for toileting. The resident was frequently incontinent of bowel and bladder. Record review of Resident #23's care plans, dated 05/19/21 reflected: The resident had an ADL Self Care Performance Deficit related to hemiplegia (on-sided weakness or paralysis). Facility interventions included: The resident required 1 staff participation for toileting. An observation on 02/04/25 at 12:57 PM of incontinence care for Resident #23 revealed the resident was lying in bed on his back. CNA A folded down the top of the resident's brief. CNA A grabbed cleaning wipes and cleaned the penis and scrotum of the resident. The resident was assisted to turn to his side and the CNA grabbed cleaning wipes and cleaned the resident's buttocks. CNA A pushed the used brief underneath the resident. CNA A did not change her gloves or perform hand hygiene. CNA A grabbed a clean brief and placed it under the resident. The resident was turned back, and the CNA pulled out the used brief, fastened the clean brief, and repositioned the resident. An interview on 02/04/25 at 1:10 PM with CNA A revealed she only needed to change her gloves and perform hand hygiene after completing the incontinence care. She said she was the only staff changing the resident and did not know how she was supposed to change her gloves and perform hand hygiene if she was by herself providing the care. 2. Record review of Resident #1's annual MDS assessment, dated 01/14/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive status was severely impaired. His diagnoses included heart failure, renal failure, and diabetes. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #1's care plans, dated 04/02/23 reflected: The resident had an ADL Self Care Performance Deficit related to impaired balance. Facility interventions included: The resident required 1 staff participation for toileting. An observation on 02/04/25 at 1:50 PM revealed Resident #1 was lying in bed. His brief was soiled with urine and bowel movement. CNA B folded down the resident's brief and cleaned the peri-area and the inner thighs of the resident. The CNA did not clean the penis or the foreskin. CNA B rolled the resident over and cleaned his buttocks. The CNA folded the brief under the resident. The CNA did not change gloves or perform hand hygiene. The CNA grabbed a new brief and placed it under the resident. The CNA started to fasten the brief. The Surveyor asked if the CNA was going to clean the resident's penis and she said no. CNA B fastened the brief and left the room. An interview on 02/04/25 at 2:00 PM revealed CNA B said she did not clean Resident #1's penis because he did not like his penis to be cleaned. CNA B said it was important to clean the penis to reduce infection. CNA B said she did not know why she did not change her gloves and perform hand hygiene but had been trained to. She said failure to change gloves and perform hand hygiene could cause infection. An observation and interview on 02/04/25 at 1:27 PM of Medication Cart #1 revealed the back of the pill crusher was dirty. It had dust, rust, and a dirt-looking substance on it. LVN C said he cleaned it after use with purple wipes. He said there was a risk of infection if the pill crusher was not kept clean. An observation and interview on 02/04/25 at 1:35 PM of Medication Carts #2 and #3 revealed the back of their pill crushers was dirty. They had dust, rust, and a spilled-looking substance on them. RN D said she cleaned the side and top of her pill crusher, but she did not clean the back of it. An observation and interview on 02/05/25 at 12:45 PM revealed the laundry washers were both dirty on the inner ring of the front-loading doors. There was heavy layer of a crusty-tan substance that was wet on the inner ring of the door. The Laundry Staff said she was not able to clean the area because she could not reach them. She said the areas were not accessible. She said she cleaned the outside of the machines every day. An interview on 02/05/25 at 12:50 PM with the Maintenance Director revealed the staff did not clean the inner rings of the doors. He said he would have to contact the machine company to find out how to access the part to clean it. He said he would add it to the cleaning schedule to ensure it was kept clean. An interview on 02/04/25 at 2:07 PM with the Infection Preventionist revealed staff were supposed to change gloves and perform hand hygiene after cleaning the resident. She said it was important to keep infection down. The Infection Preventionist said the nurses were responsible for cleaning the pill crushers after using them. She said the use of dirty pill crushers could cause infection. An interview on 02/05/25 at 12:54 PM with the DON and Administrator revealed staff were supposed to change gloves and perform hand hygiene after cleaning the resident to prevent potential infection. The DON said the nurse was responsible for cleaning the exterior portion of the pill crusher. The DON said there was no risk of infection with using dirty pill crushers because the medications were kept in strong pill crusher plastic bags. The facility Administrator and DON did not know about the washing machine door seals being dirty. The Administrator said she would have to talk with maintenance and the vendor to find out how to clean it. The DON said he would need to look at it to see if there was any risk to the resident. Review of the facility policy, Infection Prevention and Control Program, revised June 2020, reflected: Purpose: The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection . Review of the facility policy, Hand Hygiene, revised June 2020, reflected: Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited too . A. Wash hands with soap and water: .iii. When soiled with visible dirt or debris; iv. After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other body fluids, wound drainage and soiled dressings; v. After contact with intact and non-intact skin, clothing and environmental surfaces of residents with active diarrhea even if gloves are worn . vii. Upon starting of the shift viii. After removing personal protective equipment PPE and before moving to another resident in the same room or exiting the room . B. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. Immediately upon entering a resident occupied area (single or multiple bed room, procedure or treatment room) regardless of glove use; ii. Immediately upon exiting a resident occupied area (e.g., before exiting into a common area such as a corridor) regardless of glove use; iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of glove use; VI. Hand hygiene is always the final step after removing and disposing of personal protective equipment. VII. The use of gloves does not replace hand hygiene procedures. Review of the facility document, Pill Crusher, Cleaning and Maintenance Instructions, not dated, reflected: The frequency in which the pill crusher is cleaned is dependent on a facility's cleaning and disinfection protocol. The Silent Knight Pill Crusher . may be cleaned regularly with a damp cloth. A facility approved disinfectant wipe may also be used when indicated. Review of an email received from the Administrator on 02/05/25 at 3:22 PM regarding the facility washing machines reflected: I do not have a specific policy for this. We clean the machine when it is visibly soiled.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for three (Residents #27, #99, and #107) of five residents and all 29 residents in the 100 Hallway reviewed for safe, clean, homelike environment. 1. The facility failed to ensure the ceiling A/C vents for Resident #27, #99 and #107's rooms were clean and not dusty on 02/03/2025. These failures could affect residents that reside on the 100 Hallway and place them at risk for not having a safe and sanitary homelike environment. Findings included: 1. Record review of Resident #27's Face Sheet, dated 02/03/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Type 2 diabetes, schizophrenia, which is a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions and behaviors, and oropharyngeal dysphasia, which involves difficulty during swallowing food and the movement of food or liquid from the mouth to the esophagus. Record review of Resident #27's MDS assessment, dated 01/10/25, revealed the resident had a BIMS score of 15 indicating her cognition was intact. During an observation and interview on 02/03/24 at 11:10 AM with Resident #27 in her room revealed the resident was alert and sitting on her bed. The A/C vents above Resident#27's bed were dusty and uncleaned. Resident #27 was observed coughing during her interview. She stated that she did not remember when the last time staff cleaned the A/C vents above her bed, and she was not aware that both A/C vents were dirty and not cleaned. She stated that she has been having a dry cough lately and would like somebody to come clean the A/C vents in her room above her head. Resident #27's roommate was Resident #99. 2. Record review of Resident #99's Face Sheet, dated 02/05/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included acute and chronic respiratory failure with hypoxia, which refers to a long-term condition where the body is unable to adequately exchange oxygen and carbon dioxide in the lungs, resulting in persistently low levels of oxygen in the blood due to underlying lung diseases like chronic obstructive pulmonary disease. Resident #99 also has a diagnosis of chronic obstructive pulmonary disease, which is a group of lung diseases that cause ongoing inflammation and narrowing of the airways, leading to breathing difficulties. Record review of Resident #99's MDS assessment, dated 01/14/25, revealed the resident had a BIMS score of 12 indicating moderate cognitive impairment. Record review of Resident #99's Care Plan, dated 01/10/25, revealed: Focus: COPD Date Initiated: 01/16/2025. Revision on: 01/16/2025. Goal: of poor oxygen absorption through the review date. Date Initiated: 01/16/2025. Revision on: 01/21/2025. Target Date: 04/10/2025. Interventions/Tasks: o oxygen apparatus. Date Initiated: 01/16/2025. o Give medications as ordered by physician. Monitor/document side effects and effectiveness. Date Initiated: 01/16/2025. o Prevent abdomen compression and respiratory embarrassment by routinely checking the residents position so that he or she does not slide down in bed. Date Initiated: 01/16/2025. o Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 01/16/2025. Focus: Resident #99 has Shortness of Breath r/t ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA 01/16/25 Resident refusing to wear Bi-Pap at this time. States No, I can't do it, I don't want it on I can't breath. Explained to her she is getting oxygen through the mask. She pulled the mask off her face and said No, I can't do it. Educated her on the risk of not wearing her bipap and that she has critical CO2 level and it is important for her to comply with MD orders. Date Initiated: 01/16/2025. Revision on: 01/16/2025 . Goal: Resident #99 will have no complications related to SOB though the review date. Date Initiated: 01/16/2025. Revision on: 01/21/2025. Target Date: 04/10/2025. Interventions/Tasks: o Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs. Date Initiated: 01/23/2025. Revision on: 01/23/2025. o Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Date Initiated: 01/23/2025. o Monitor/document/report to MD prn ongoing s/sx of depression unaltered by CNA Focus: The resident has a terminal prognosis r/t dmit Amatus Hospice: [PHONE NUMBER] dx CHRONIC RESPIRATORY FAILURE It is expected resident will have weight loss, skin breakdown, dehydration, fecal impaction, gradual or rapid loss of ability to move, use of narcotic to control pain and anxiety, anti-anxiety, and hypnotic medications r/t terminal prognosis. Date Initiated: 01/31/2025. Revision on: 01/31/2025. Goal: The resident's comfort will be maintained through the review date. Date Initiated: 01/31/2025. Revision on: 01/31/2025. Target Date: 04/10/2025. Interventions/Tasks: o Adjust provision of ADLS to compensate for resident's changing abilities. Encourage particpation to the extent the resident wishes to participate. Date Initiated: 01/31/2025. o Consult with physician and Social Services to have Hospice care for resident in the facility. Date Initiated: 01/31/2025. o Delegation of duties meeting between Magnolia hospice and facility staff to determine appropriate plan of care specific for this resident. Date Initiated: 01/31/2025. LVN o Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Date Initiated: 01/31/2025. o Refer for Psychiatric/Psychogeriatric consult if indicated Date Initiated: 01/31/2025. o Review resident's living will and ensure it is followed. Involve family in discussion. Date Initiated: 01/31/2025. o Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Date Initiated: 01/31/2025. o Work with nursing staff to provide maximum comfort for the resident. Date Initiated: 01/31/2025. Focus: The resident was on Antibiotic Therapy r/t infection (PNA ). Resident started on Levaquin 750 mg daily x 7 days. Date Initiated: 02/03/2025. Revision on: 02/03/2025. Goal: o Resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Date Initiated: 02/03/2025. Revision on: 02/03/2025. Target Date: 04/10/2025. Interventions/Tasks: o Administer medication as ordered Date Initiated: 02/03/2025. o Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Date Initiated: 02/03/2025. o Observe for possible side effects every shift Date Initiated: 02/03/2025. During an observation and interview on 02/03/25 at 11:21 AM with Resident #99 in her room revealed the resident was alert and laying on her bed. Resident #99 was observed with a nasal cannula and an oxygen concentrator was observed on the floor at bedside. Resident #99 reported that she was currently on Hospice and has COPD. She stated that she has been at the facility for about a month. Resident #99 was advised that the A/C vents above Resident#27's bed were dusty and uncleaned. Resident #99 was observed coughing throughout her interview. She stated that she did not remember when the last time staff cleaned the A/C vents above Resident #27's bed were cleaned. Resident #99 stated that she was unaware that both A/C vents were dirty and not cleaned. She stated that with her being on oxygen, dust and dander and dirt are not good for her health. She reported that would like somebody to come clean the A/C vents in her room to ensure good air quality. Resident #99's roommate was Resident #27. 3. Review of Resident #107's face sheet, dated 02/05/25, revealed Resident #107 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #107's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Record review of Resident #107's MDS assessment, dated 09/10/24, revealed the Resident #107 had a BIMS score of 04 indicating severe cognitive impairment. Observation on 02/03/25 at 11:45 AM with Resident #107 in her room revealed the ceiling vent was dusty, and there were black marks on the ceiling around the vent opening. During an observation and interview on 02/03/25 at 11:53 AM with Resident #107 revealed that she was alert and sitting in her wheelchair and was coughing. Resident #107 stated that she had been coughing a lot lately. She reported that she did not know that there was dust in the vent above her bed and that may be the reason why she had been coughing lately. She reported that since she has been at the facility, she cannot remember if staff have cleaned the A/C vent above her bed. She stated that she wanted someone to come into her room and clean the A/C vent above her bed now that she noticed the dust on the vent but did not know who to contact to clean the A/C vent. In an interview with Maintenance Director on 02/05/25 at 9:07 AM in the 100 Hallway revealed that there were several rooms in the 100 Hallway that had dusty A/C vents. He stated that he would speak with one of his staff members in Maintenance and he would have them come to the Conference Room to discuss the dirty A/C vents in the 100 Hallway. He reported that the Maintenance and Housekeeping Departments are both responsible for ensuring that the A/C vents were clean in the residents' rooms. In an interview with Maintenance Staff L on 02/05/25 at 9:15 AM in the 100 Hallway revealed that he had been employed at the facility for almost 7 years. He stated that his supervisor notified him that it was brought to his attention by a State Surveyor that the A/C vents in the residents' rooms on the 100 Hallway were not clean. He stated that he was unaware that the A/C vents were not clean until it was brought to his attention. He stated that staff are required to complete a Maintenance Request in the Maintenance Log on issues such as dirty A/C vents. He stated that the Maintenance Request Log was located at the Nurses Station on the 100 Hallway. He stated that he has not seen any requests in the Maintenance Log regarding the A/C vents needing to be cleaned on the 100 Hallway. He reported that the Maintenance Director will give each Maintenance Staff member a sheet with their Work Orders, and he will complete the Work Orders as they are completed. Maintenance Staff L was shown the A/C vents in Resident #27, Resident #99 and Resident #107 rooms. Maintenance Staff L agreed that the A/C vents in the rooms he observed were not clean. He stated that it is the responsibility of the Nursing Staff to notify the Maintenance and Housekeeping Departments if there is something like dust in the A/C vents in a resident's room. He stated that both departments work hand in hand with each other regarding keeping the A/C vents in residents' rooms clean. He stated he would take full responsibility for making sure that the A/C vents in the 100 Hallway are cleaned, and he would be working closely with the staff to ensure they were cleansed on a regular basis. He stated the risk of the ceiling vents being unclean is that if the dust blew onto residents they could be affected, especially those allergic to dust and have breathing issues. He also stated resident's rooms should be clean and safe. Record Review of the facility's Maintenance Request Log at the 100 Hall's Nurses Station, revealed no entries regarding dusty A/C vents in the 100 Hallway. In an interview with CNA M on 02/05/25 at 1:32 PM revealed that she stated that he had been employed at the facility for 8 months. She stated that her primary assignment was the 100 Hallway. She reported that she has not noticed that the A/C vents covers above the beds of residents in A bed were not clean. She stated that if she was to observe the A/C vents in a resident's room not clean, she would notify Maintenance and complete the Maintenance Request in the Maintenance Log at the Nurses Station. She stated that if the A/C vents in resident's room are not cleaned on a regular basis, residents can be at risk for respiratory infection from the dust being clogged up in the vents and breathing issues and/or problems. She stated that dirty A/C vents can cause a resident to having breathing issues, which can lead or cause lung issues due to the resident or residents not being able to breath properly. In an interview with CNA N on 02/05/25 at 1:38 PM revealed that he stated that he had been employed at the facility for 2 years. He reported that he was unaware that the A/C vents covers about the beds of residents in A bed were not clean. He stated that Housekeeping was responsible for ensuring that the A/C vents in residents' rooms are cleaned. He reported that he could not recall the last time that anyone from the Housekeeping Department cleaned the A/C vents in residents' rooms. He stated that if he notices that the A/C vents are not cleaned, he will report it to Maintenance via completing the Maintenance Request Log. CNA N reported that the Maintenance Request Logs for the 100 Hallway are kept at the Nurses Station. He stated that if the A/C vents in a resident's room was not cleaned regularly, it can cause for the resident or residents in the room to have respiratory issues. He stated that the residents could be harmed by not being able to breathe, having breathing issues and can cause them to have allergies. In an interview with Housekeeping Supervisor on 02/05/25 at 2:39 PM revealed he was unaware that Resident #27, Resident #99, and Resident #107 and majority of the rooms on the 100 Hallway had unclean A/C vents. He stated that his department alongside the Maintenance Departments are responsible for the cleaning and upkeep of the air vents with help from the housekeepers. He reported that there was not a schedule of when the A/C vents are to be cleaned. He stated that the last time the A/C vents in residents' rooms on the 100 Hallway was a week ago. He reported that his Housekeepers, which include about 13 staff members should be cleaning the A/C vents, as needed when they make their daily rounds to each resident's room. He stated he did not have any reason why the vents in the residents' rooms in the 100 Hallway were dirty. He stated residents should reside in a clean and safe environment. He stated that if the A/C vents in the residents' rooms are not cleaned, there was a risk for residents to have infections caused by breathing in dust and inhaling dust can get into a person's lungs and was not good for anyone especially if they already have breathing issues and are on oxygen. In an interview with the DON on 02/05/25 at 2:52 PM revealed that he was unaware that the A/C vents covers above the beds of residents in A bed in the 100 Hallway were not dusty and unclean. He reported that his staff are to do Q2 rounds, or as needed in the 100 Hallway. He reported that his expectation was that staff notify himself, management or housekeeping if they observe something like the A/C vent covers needing to be cleaned or any repairs that need to be done. He stated that the Maintenance Log at the Nurses Station on the 100 Hallway would be used for something such as dusty A/C vents. He stated that the responsibility of the A/C vents being cleaned falls upon the Maintenance and Housekeeping departments, not his nursing staff. DON stated that the A/C vents in a resident's room were not a risk for infection and everyone's vents in their homes, including new build homes and the State Surveyors homes were probably not clean and dirty. He stated that there was a potential for harm due to the A/C vents being harmful, but dust was in everyone's vents any place you go. He stated that going forward, he would have his staff put in any work orders regarding the cleaning or the A/C vents. He stated, he will relay to his staff, if it doesn't seem right, fix it. Record review of the facility's Resident Room Cleaning policy revised August 2020 did not provide any information regarding cleaning of A/C vents.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #78) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #78 received the correct dosage of morphine 15 mg as ordered by his physician on 11/19/2023 when the pharmacy delivered morphine ER (extended release) 15 mg tablets on 01/09/2024. The medication had been signed as administered 37 times between 1/15/25 and 2/5/25. The discrepancy had not been detected until surveyor inquiry on 02/05/2025. This failure placed the residents at risk of not receiving medications as ordered by the physician and a not receiving the intended therapeutic effect of their medications. Findings included: Record review of Resident #78's Admission Record dated 2/5/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #78's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating he was cognitively intact. His diagnoses included: Hypertension (high blood pressure); other fracture and dislocation of the right humerus (upper arm). He was receiving scheduled and offered PRN pain medication. Record review of Resident #78's Care Plan reflected the following entries: [Resident #78] requires pain management. Intervention included administer analgesia (pain medications) as per orders. Date initiated 12/5/23. Record review of Resident #78's physician orders reflected: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Record review of Resident #78's Medication Administration Record dated 2/1/25- 2/28/25 reflected the following entries: Morphine Sulfate Oral Tablet 15 mg. Give one tablet two times a day for pain. Order date 11/19/23. Record review of Resident #78's Controlled Drug Administration Record dated received 1/9/24 reflected: morphine sulfate ER 15 mg tab. The medication had been signed out as administered 37 times between 1/15/25 and 2/5/25. An observation and interview during medication pass on 2/4/25 at 7:40 AM revealed LVN C was standing outside Resident #38's room He stated he had just taken the blood pressure for Resident #78 and showed a reading on the BP cuff of 112/76. He sanitized the cuff and his hands. LVN C poured the resident's medications which included morphine ER 15 mg 1 tablet. He administered the medications to Resident #78 who was observed sitting up in his room in his wheelchair. During an observation and interview on 2/5/25 at 7:51 AM, LVN I stated she usually worked another hall but was helping on Resident #78's hall that day. Resident #78's morphine card and narcotic sign out sheet was reviewed along with the orders. Both the medication card and sign out sheet reflected morphine sulfate ER 15 mg and the order reflected morphine sulfate 15 mg. LVN I stated she had overlooked the discrepancy and had already administered the medication that morning. She stated the risk of administering an ER dose instead of immediate release was the medication would take longer to get in your system and would stay in your system longer than intended. During an interview on 2/5/25 at 7:55 AM, the DON stated he was unaware of the discrepancy between Resident #78's morphine orders and the medications received. He stated he would research the issue. During an interview on 2/5/25 at 8:22 AM, the DON stated they had called Resident #78's physician and his morphine was always supposed to be extended release and had been on previous orders. He stated there had been a transcription error with a reorder of the medication and it should have been caught sooner when the medication dose received did not match the order. He stated the risk of medication errors depended upon the medication and could cause unintended consequences or side effects. The DON stated LVN C usually worked night shift and had been picking up an extra shift on 2/4/25. On 2/5/25 at 8:31 AM, an attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview on 2/5/25 at 10:10 AM, ADON E stated she had called Resident #78's pain physician about his morphine order and reported the administration of the ER doses. She stated the physician sent the order for the medication straight to the pharmacy himself and the order should have been extended release all along. She stated he told her to correct the order in the computer to reflect ER. ADON E stated the nurse should have caught the error while administering the medication because the orders are to be checked against the medication every time it was administered. She stated the Charge Nurses were responsible for ensuring the medications in their carts were correct and the risk was adverse effects and not receiving the therapeutic effect needed. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an interview with the DON on 2/5/25 at 10:46 AM stated when medications were received from the pharmacy, the nurse checking in the medications was responsible for checking the actual medication received against the manifest provided by the pharmacy. He stated they were checking to ensure the correct amount of medication was received. The DON stated whatever nurse stocked the cart was responsible for ensuring the medications matched the orders. He stated, ultimately the Charge Nurse was responsible for ensuring the medications administered matched the order from the physician. On 2/5/25 at 2:47 PM, another attempt to reach LVN C via telephone for an interview was unsuccessful. A voicemail message was left. During an observation and interview on 2/5/25 at 3:04 PM, RN H stated she worked PRN and had worked on Resident #78's hall the previous week. She reviewed Resident #78's morphine sign-out sheet and orders and stated she had administered the dose on 2/3/25. She stated she had overlooked the discrepancy between the extended and immediate release order and should have called for a clarification. She stated the risk of administering an extended-release medication when an immediate release medication was ordered was unintended side effects. Record review of the facility's policy titled, Oral Medication Administration, dated revised 08/2020 reflected: Policy: Medications will be administered in a safe and effective manner .Procedures .2. Review and confirm medication orders for each individual resident on the MAR prior to administering medications to each resident .

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #221) of five residents reviewed for baseline care plans. The facility failed to complete Resident #227's baseline care plan within 48 hours of admission that included the minimum required healthcare information including physician orders, dietary orders, therapy services, and social services. Resident #227 was admitted to the facility on [DATE] and her baseline care plan was not completed until 02/03/25. This failure placed residents at risk of not receiving effective and person-centered care. Findings included: Review of Resident #221's Face Sheet, dated 02/05/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including acute on chronic diastolic heart failure (a sudden worsening of symptoms related to diastolic heart failure) and methicillin resistant staphylococcus aureus infection (a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). Review of Resident #221's electronic medical record on 02/05/25 reflected Resident #221's Baseline Care Plan was not completed until 02/03/25. During an interview with ADON E on 02/05/25 at 1:35PM, she stated she was under the impression that baseline care plans were required to be completed within 72 hours of a resident's admission. She stated Resident #221 was admitted on Friday, 01/31/25, and her baseline care plan was completed on Monday, 02/03/25. She said there was not a plan in place to ensure baseline care plans were completed for new admissions over the weekend, as baseline care plans were completed by various department heads. ADON E stated she did not believe there was a risk in baseline care plans not being completed within the required 48 hours of admission. Review of the facility's Care Planning policy, dated 06/2020, reflected, .The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .

Based on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #90) reviewed for PASRR Level I screenings. The facility's PASRR Level 1 Screening dated 10/25/2023 had no indicators of dementia as a primary diagnosis or evidence of mental illness, the PASRR did not correctly identify Resident #90 as having a mental illness of bipolar disorder onset date 10/25/2023 when the facility did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Record review of Resident #90's Admission Record dated 2/5/25 reflected a [AGE] year-old male was originally admitted to the facility on [DATE]. Record review of Resident #90's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 00 indicating severe cognitive impairment. His diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, bipolar depression, and psychotic disorder. Record review of Resident #90's Diagnoses Report dated 2/5/25 reflected his primary diagnosis was muscle wasting and atrophy-onset date 1/30/24. His secondary diagnoses included: bipolar disorder-onset date 10/25/23; major depressive disorder-onset date 10/25/23; and unspecified dementia-onset date 10/25/23. Record review of Resident #90's PASRR Level 1 Screening dated 10/25/23 reflected there were no indicators of dementia as a primary diagnosis or evidence of mental illness. During an interview on 2/5/25 at 11:43 AM, MDS Coordinator J stated he had submitted the PASRR information for Resident #90. He stated he submitted the information as it was provided to him from Resident #90's previous facility, and he was not allowed to change it. He stated he only completed the PASRR on admission and the resident was negative due to dementia. He denied ever sending a correction form. During an interview on 2/5/25 at 12:49 PM MDS Coordinator J stated he should have submitted a correction form upon noting the resident's mental illness diagnoses. He stated he had initiated a correction and submitted it to the physician for review. MDS Coordinator K stated, if they receive a PASRR that was incorrect, they were supposed to contact the provider who sent the PASRR and request a corrected one. She stated, if the provider failed to send a corrected form, they submitted the one they were provided along with a State Form 1012 to determine if a correction was needed. During an interview on 2/5/25 at 2:56 PM, the DON stated the MDS nurses were responsible for ensuring the PASRRs were complete and accurate. He stated the risk for incorrect PASRRs was residents may not get access to services for which they qualify. During an interview on 2/5/25 at 3:48 PM, the Administrator stated she had been made aware of the PASRR concerns and would ensure they were corrected. She stated the MDS Nurses were responsible for the submission of PASRR documents. She stated the risk to residents was they may not get additional services they could use. Record review of the facility's policy titled, Pre-Admission Screening Resident Review (PASRR) dated revised 06/2020 reflected: Purpose: To ensure that all facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated .Policy: I. The Facility, as a Medicaid certified nursing facility, that Level I of the Preadmission Screening Resident Review (PASRR) is completed prior to admission of all applicants, regardless of payor, to determine if they have a Mental Disorder (MD) or Intellectually Disables (ID) .V. A negative Level I PASRR permits admission to proceed and ends the PASARR process, unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #1) reviewed for incontinence care. 1. The facility failed to ensure CNA B thoroughly cleaned Resident #1 during incontinence care. This failure could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #1's annual MDS assessment, dated 01/14/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 5 indicating his cognitive status was severely impaired. His diagnoses included heart failure, renal failure, and diabetes. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #1's care plans, dated 04/02/23 reflected: The resident had an ADL Self Care Performance Deficit related to impaired balance. Facility interventions included: The resident required 1 staff participation for toileting. There was no documentation to indicate Resident #1 did not want his penis cleaned. An observation on 02/04/25 at 1:50 PM revealed Resident #1 was lying in bed. His brief was soiled with urine and bowel movement. CNA B folded down the resident's brief and cleaned the peri-area and the inner thighs of the resident. The CNA did not clean the penis or the foreskin. CNA B rolled the resident over and cleaned his buttocks. The CNA folded the brief under the resident. The CNA did not change gloves or perform hand hygiene. The CNA grabbed a new brief and placed it under the resident. The CNA started to fasten the brief. The Surveyor asked if the CNA was going to clean the resident's penis and she said no. CNA B fastened the brief and left the room. An interview on 02/04/25 at 2:00 PM revealed CNA B said she did not clean Resident #1's penis because he did not like his penis to be cleaned. CNA B did say it was important to clean the penis to reduce infection. An interview on 02/04/25 at 2:07 PM with the Infection Preventionist revealed staff were supposed to clean the penis when performing incontinence care for a man. She said it was important to keep the penis clean to prevent infection and yeast. An interview on 02/05/25 at 12:54 PM with the DON revealed staff were supposed to clean the penis when performing incontinence care for a man. He said it was important to keep the penis clean to prevent infection. Review of the facility competency, Pericare / Incontinent Care Evaluation, not dated, reflected: Male - retract foreskin - clean head of penis in circular motion - pat dry- and replace retracted foreskin. Wash complete shaft of penis working down the shaft - pat dry. Wash scrotum top and underside and wash perineum - remember front to back.

Based on observation, interview, and record review, the facility failed to ensure residnets right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Residnet #1) of eight residents reviewed for abuse. The facility failed to protect Resident #1, who was unable to give consent for sexual activity, from sexual abuse after Resident #2 was discovered in her bed with his pants off and buttocks exposed, laying behind her on 06/30/24. The facility failed to put interventions in place to protect Resident #1 after allegations were made that Resident #2 placed his penis in her mouth on 06/30/24. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all residents at risk for abuse and psychosocial harm. Findings include: Record review of Resident #1's Face Sheet dated 07/03/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: unspecified sequalae cerebral infarction (stroke), cognitive communication deficit (trouble participating in conversation), aphasia (loss of ability to understand or express speech, caused by brain damage), dysarthria and anarthria (motor speech disorder), bipolar disorder (mental disorder causing unusual shift in mood, energy, and concentration), and major depressive disorder, recurrent, severe with psychotic symptoms (depression along with loss of touch with reality). Record review of Resident #1's quarterly MDS Assessment, dated 06/25/2024, reflected no BIMS score, indicating it was not able to be completed. She had short- and long-term memory problems, cognitive and daily decision-making skills reflected moderately impaired - decisions poor, cues/supervision required. Signs and symptoms of delirium reflected and altered level of consciousness. Resident #1 exhibited no behaviors and used a wheelchair to ambulate. She was totally dependent for toileting, showering, dressing, transfers, and personal hygiene. Record review of Resident #1's BIMS assessment dated [DATE] and signed by the Social Worker reflected, severely impaired cognition. Record review of Resident #1's Care Plan dated 11/28/2023 - Present, reflected, Problem: [Resident #1] The resident has impaired cognitive function or impaired thought processes. Goal: will be able to communicate basic needs on a daily basis through the review date. Problem: The resident has a communication problem r/t aphasia. Intervention: Anticipate and meet needs. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Problem: [Resident #1] has an ADL Self Care Performance Deficit. Intervention: requires 1 staff participation to use toilet and all ADLs. Record review of Resident #2's Face Sheet dated 07/03/2024, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included: encephalopathy (group of conditions that cause brain disfunction), major depressive disorder (mental health condition that causes persistent depressive mood), intermittent explosive disorder (repeat sudden bouts of impulsive, aggressive outbursts), type 2 diabetes (problem in the way the body regulates and used sugar as fuel), hypertension (pressure in blood vessels is too high), and schizoaffective disorder (combination schizophrenia and mood disorder displayed by manic moods and hallucinations). Record review of Resident #2's quarterly MDS Assessment, dated 05/30/2024, reflected a BIMS score of 15, which indicated no cognitive impairment. No behaviors were exhibited. He was independent for all functional abilities and ADLs. Record review of Resident #2's Care Plan dated 06/14/2024 - Present, reflected, no prior sexually inappropriate behavior. The care plan was updated on 07/03/2024 and reflected, Problem: Behavior: Sexually inappropriate AEB: noted to have sexual urges at the facility. Date Initiated: 07/03/2024. Interventions: [Resident #2] to remain on one-on-one watch until further notice, Date Initiated: 07/04/2024. Report incidents of target behavior to charge nurse, Date Initiated: 07/03/2024. Staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances (avoid self-disclosing personal information), Date Initiated: 07/04/2024. Record review of the facility incident report, dated 07/03/2024 at 10:51 AM and signed by the DON, reflected, It was reported to this writer that [Resident #2] allegedly put his penis in [Resident #1's mouth. When asked if anyone touched [Resident #1] she indicated No. When asked if anyone placed their penis in her mouth she indicated No. Head to toe assessment completed with no visible injuries noted. Resident sent out to the ER for SANE evaluation. MD notified. Local law enforcement notified. Attempted no notify family but number is not working. Record review of the facility's transfer record dated 07/03/2024 at 2:30 PM and signed by ADON A, reflected Resident #1 was transferred to hospital. Record review of the Facility's Investigation Report, dated 07/03/2024, reflected, on 07/03/2024, a [State Surveyor] entered the facility on a complaint investigation and brought to [DON's] attention a situation of potential sexual abuse. The [State Surveyor] informed the [DON] that [Resident #2] told him that he had intention to get a blow job from [Resident #1]. [Resident #2] realized that it was wrong and decided not to act on that. [Resident #2] has been placed 1:1 and family and local law enforcement has been notified. Also included were 6 safe surveys, dated 07/01/2024 and signed by the Social Worker. The DON's interview on 6/30/24 with LVN D, reflected, [CNA G] reported to me that during her last rounds she found [Resident #2] in the bed of [Resident #1]. I quickly went to [Resident #1's] room and assessed her. No visible or emotional distress noted. I noted that she was fully clothed. I asked her if she wanted him in her room and she stated yes. [Resident #1] said that he was her friend and that she wanted him there. The DON's interview on 07/01/2024 with CNA G, reflected, During my last rounds on Sunday, [06/30/2024], I entered [Resident #1's room] and noticed [Resident #2] in [Resident #1's] bed with [Resident #1]. [Resident #1] was laying on her side facing the wall. [Resident #2] was laying behind her on his side as well. When asked if both residents were fully clothed, [CNA G] indicated that [Resident #1] had pants and shirt on and brief intact and that [Resident #2] had his pants and shirt on. [Resident #2] quickly got up and left the room. Record review of Resident #1's Hospital Record, dated 07/03/2024 at 3:39 PM, reflected, Chief Complaint: Sexual assault exam referral. Per EMS NH sent pt for SANE exam after finding another resident in her bed on Sunday, NH reported incident to state and state requested an exam. Pt is aphasic d/t CVA. Unable to contact family and patient was unable to consent due to her aphasia and dementia. Discussed case with sexual assault nurse examiner and she said that we would need a court order to pursue further investigation. For now, we are going to send the patient back to the nursing home with close monitoring. Patient was unable to consent for examination, so the patient was returned to the nursing home with instructions to contact the police department in family for further plan of action. 4:42 PM -initial contact made with patient. Patient is aphasic and unable to communicate and to consent to exam. Patient does responds uh huh or no when questioned but answers are inconsistent. Record review of Resident #1's nurse notes dated 07/03/2024 at 1:10 PM and signed by Corporate, reflected, Attempted to call family, number is not working. Resident seen by [Mental Health Services] today. Record review of Resident #2's Psychological Services Progress Note, dated 07/03/2024, reflected, Intervention: Discussed a recent incident in which the pt was discovered in a female resident's room with his pants removed. Utilized open-ended questioning to investigate patient's version of events and potential precipitating factors. Identified inappropriate sexual behavior and processed patient's feelings of guilt and shame. Provided psychoeducation in the importance of maintaining boundaries to protect his own safety and the safety of others. Response to Intervention: Saw pt in a private area to discuss a recent incidence of sexual misconduct. Pt presented as anxious with a blunted affect. He was fully cooperative and expressed remorse regarding his behavior. Pt admitted to entering the female resident's room and removing his pants. He vehemently asserted that there was no sexual conduct during the encounter. Pt claimed that he was walking by the room when he heard a voice call his name. Pt indicated that he was aware that the female resident in question was nonverbal and hypothesized that the voice was a hallucination. In response to the voice, he entered the female resident's room. Pt alleged that the female resident made sexual advances after he entered the room (touched his leg, moved her head toward his groin area). He stated that he removed his pants because the female resident indicated her intention to provide oral sex. Pt then stated that he changed his mind prior to sexual contact and was attempting to pull up his pants when a staff member discovered him. Pt responded positively to therapeutic interventions and admitted that his behavior was inappropriate. He said that he felt guilty about the entire incident and said that he intended no harm. Pt was also receptive to psychoeducation on maintaining boundaries and stated that he would not enter a female's room again. Pt demonstrated understanding of the importance of boundaries in maintaining his safety and the safety of others. In an interview on 07/03/2024 at 9:17 AM, Resident #1, was not able to answer questions with words. She did not make any gestures of verbal comments that reflected her understanding of questions asked of her regarding the incident. In an interview on 07/03/2024 at 9:49 AM, the DON stated Resident #2 had no previous history of any sexual behaviors. He said when LVN D called him on 06/30/2024 at about 9:30 AM to inform him that Resident #2 had been found in bed with Resident #1, he wanted to find out whether Resident #1 invited Resident #2 into her bed. He stated Residents #1 and #2 were friends and often watched television together in the television room. The DON stated LVN D did not complete an incident report and he did not immediately start an investigation about regarding the incident. The DON stated Resident #1 had a BIMS of 0 but that was related to her inability to speak clearly. He said Resident #1 was able to understand and could give consent to a sexual act. He said when LVN D called him, he got on the phone with LVN D and Resident #1, and Resident #1 was able to say some words and responded yes / friend when asked if she wanted Resident #2 in her room. He said he did not ask if Resident #1 wanted Resident #1 in her bed with her but did not feel the need to immediately investigate the incident further. He stated on 07/01/2024, he asked the Social Worker and ADON A to speak to Resident #1. He said they completed a verbal BIMS Assessment on Resident #1, which resulted in no score, which indicated severely cognitively impaired. He said Resident #2 had a BIMS of 15 which indicated no cognitive impairment. He stated he and the Administrator talked to Resident #2 and he denied any type of sexual inappropriate behavior. The DON said he did not refer Resident #1 to the hospital for a SANE exam and did not contact the police. In an interview on 07/03/2024 at 10:50 AM, Resident #2 stated, on 06/30/2024 at about 9:30 AM, he was walking past Resident #1's room and she was in bed and waved him into her room. He said she waved at everyone in that way, but he felt she wanted him to come in. He said he knew Resident #1 because they occasionally watched television together in the day room. He said he did go into Resident #1's room because he was looking for a blow job, [oral sex]. He said he took his pants off and got into bed with Resident #1. He said when he was in bed with her, he started to feel bad and was about to get out of the bed when CNA G entered the room and saw him in bed with Resident #1. He said CNA G did not say anything and left the room and closed the door. He said he got up and put his pants on and heard CNA G call for LVN D. Resident #2 said he left the room and returned to his room. He denied he had done this with any other residents in the facility. Resident #2 said he did not place his penis in Resident #1's mouth and denied any penetration of any kind. He stated the Administrator talked to him about the incident on 07/01/2024 and told him if this type of behavior happened again he would call the police. In an interview on 07/03/2024 at 11:16 AM, CNA F said she heard from LVN D the Resident #2 was found in Resident #1's room, with his penis in Resident #1's mouth on 06/30/2024. She stated that in a similar incident involving different residents, a few years ago, the facility managers immediately sent the offending resident out of the facility and called police. CNA F stated she felt that should have occurred this time but had not. She said the Administrator and DON should have placed Resident #2 on some kind of supervision while they investigated the incident to ensure the safety of all residents in the facility. She said if what she heard was true, Resident #2 had access to Resident #1 and all other residents until today when he was placed on 1:1 supervision. She said she has worked at the facility for [AGE] years and was familiar with the facility's abuse policy because she received training on the policy almost weekly. She stated she did not report the incident to the Abuse Coordinator and was not sure if LVN D reported it. She stated she assumed it was reported. In an interview on 07/03/2024 at 12:00 PM, the DON stated the alleged incident between Resident #1 and Resident #2 was not discussed in the manager's stand-up meeting. He said not every manager needed to know about every incident that occurred. He said after the stand-up meeting on 07/01/2024, the Social Worker and ADON A interviewed Resident #1 and reported to him that Resident #1 answered no when they asked if Resident #2 did anything to her. The DON stated, [Resident #2] did not tell him any intentions to get oral sex from Resident #1. He stated at the time, he did not feel there was any sexual abuse so there was no need to report to police or the state. He stated he did not investigate further because he felt there was no evidence the incident was of a sexual nature and therefore did not move Resident #2. He said, Looking back, we did not get the full truth from [Resident #2] and [Resident #1's] BIMS does limit her ability to consent. He said, We should have called police to follow up with a SANE exam and placed Resident #2 on 1:1 supervision to ensure all residents' safety. He stated Resident #1 was sent to hospital, police have been called, Resident #2 was placed on 1:1 supervision, and the incident was reported to state today. In an interview on 07/03/2024 at 12:10 PM, the Regional Director of Operations (RDO) stated the incident between Residents #1 and #2 should have been thoroughly investigated. He said Resident #2 should have been put on 1:1 supervision to ensure the safety of all residents, Resident #1 should have been sent to the hospital for examination, law enforcement should have been called, the incident should have been reported to the state agency, and a facility investigation started. He said based on Resident #1's BIMS, it was not clear she could have consented to anything, and the facility's policy was in place to ensure the safety of all residents during an investigation of any allegation of abuse. He stated, We should have confirmed what we observed was what happened through investigation in order to ensure the safety of [Resident #1]. An observation and interview on 07/03/2024 at 12:40 PM revealed Resident #2 in his room sleeping on his bed. CNA I was observed outside the room. CNA I stated she was directed to supervise Resident #2 and document wherever he when in the facility. In a telephone interview on 07/03/2024 at 12:54 PM, LVN D stated she was at the nurses' station on 06/30/2024 at about 9:30 AM, when CNA G called her to Resident #1's room. She stated when she went down the hall she saw Resident #2 leaving Resident #1's room. CNA G told her she opened Resident #1's room door and saw Resident #2 in bed with Resident #1. She stated Resident #1 was facing the wall and Resident #2 was in the bed behind her also facing the wall. LVN D stated CNA G did not say she witnessed Resident #2's penis in Resident #1's mouth. She said CNA G told her Resident #2 told her he was talking to his friend. She said she observed Resident #2 with clothes on when he left Resident #1's room but did not observe Resident #2 in the bed. LVN D said she observed Resident #1 in bed with her clothes on. LVN D said she asked Resident #1 what happened, and Resident #1 only nodded no. She stated Resident #1 was not crying and did not appear in distress. She said Resident #1's brief was on and did not appear to be tampered with. LVN D said she felt like Resident #1 could give consent but could not verbalize the consent. LVN D said she could not be sure if she consented to any sexual act of to have Resident #2 in her bed. LVN D said she called the DON when the incident occurred and was instructed to do an emotional assessment. She stated she talked to Resident #1 and she seemed to have her normal demeanor. She did not appear to be afraid and did not behave differently from how she normally did. She said she did not document any assessment of Resident #1 and did not complete an incident report, she said she did not know why she did not document the incident. She said Resident #2 was not on 1:1 watch at the time of the incident on 06/30/2024 but looking back believed he should have been to ensure the safety of all residents while the incident was investigated. She said Resident #1 should have been sent out for a SANE exam rather than assuming nothing happened. In an interview on 07/03/2024 at 1:17 PM, ADON A stated she became aware of the incident between Residents #1 and #2 on 07/01/2024 when the DON asked her and the Social Worker to talk to Resident #1 about the Resident #2 being in her bed. She said they tried to assess Resident #1's ability to consent and her cognitive ability. ADON A stated Resident #1's competency level was very low, and she would not answer any of the BIMS questions. ADON A said she did not feel that Resident #1 had the capacity to invite Resident #2 into her bed. She said she told the DON Resident #1 did not seem like she was able to consent to anything. ADON A said she did not know where the incident investigation went from there but Resident #2 was not on any kind of supervision until 07/03/2024 when the State Surveyor started asking questions about the Incident. She said Resident #1 was sent to the hospital for a SANE exam and the police were called earlier today as well. In an interview on 07/03/2024 at 1:31 PM, the Social Worker stated Resident #1 was not able to point to correct answers for any of the BIMS Assessment questions. She said Resident #1 was severely cognitively impaired and did not believe she had any capacity to concert to Resident #2's alleged actions. She said she shared this information with the DON and did not hear anything else about the incident. She stated Resident #1 should have been sent to the hospital for SANE exam and police notified. She said Resident #2 should have been placed on 1:1 to ensure all residents' safety. In an interview on 07/03/2024 at 1:49 PM, LVN C stated CNA F told her that LVN D told her that Resident #2 was found with his penis in Resident #1's mouth. She said she did not ask CNA F if the incident was reported to the Administrator and said she did not report it either. She stated she assumed the issue had been addressed and reported to the Abuse Coordinator. LVN C said she had worked in the facility about a year and was regularly in-serviced on abuse policy. She said she did not recall when the last in-service was. In a telephone interview on 07/03/2024 at 4:42 PM, CNA G stated on 06/30/2024 at about 9:15 AM, she opened Resident #1's door and saw her in the bed facing the wall. CNA G stated she saw Resident #2 in bed with Resident #1, behind her and also facing the wall. She stated she did not see if Resident #1 had clothes on but did see Resident #2's bare butt sticking out of the covers. She stated she did not know if Resident #2 had his pants all the way off or just around his ankles. CNA G said she left the room and called for LVN D. She stated LVN D came down the hall within a few seconds and Resident #2 opened Resident #1's room door and went across the hall to his room. She said LVN D called the DON and they talked to Resident #1 over the phone. She said she did not report the incident because LVN D had called the DON and she assumed they were addressing the issue. She said she had never seen Resident #2 display any type of sexual inappropriate behavior in the past. She stated LVN D did not send Resident #1 to the hospital and Resident #2 was not placed on 1:1 supervision. She said when she returned to work on 07/01/2024, staff told her that LVN D said Resident #2 was found with his penis in Resident #1's mouth. CNA G said she did not see Resident #2's penis in Resident #1's mouth when she entered the room on 06/30/2024. In an interview on 07/03/2024 at 4:50 PM, Law Enforcement Officer #4664 stated she was called today to respond to allegations of sexual assault. She said since the incident occurred on 06/30/2024, the facility should have called then and sent Resident #1 to the hospital for a SANE exam. She said the facility told her they sent Resident #1 to the hospital today. Record review of the facility's policy titled, Abuse prevention and prohibition program, revised 08/2020, reflected, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements . IV. Prevention: A. Staff, residents and families will be able to report concerns, incidents, and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring . VI. Investigation: A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts . C. The Facility ensures protection of residents during abuse investigations . I. While the investigation is underway, accused individuals who are not Facility Staff may not have any unsupervised access to residents . IX. Reporting/Response: A. Facility Staff are Mandatory Reporters . C. Reporting Requirements: i. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential Internet reporting tool as required by state and federal regulations. X. Special Considerations for Reporting Suspected Incidents of Rape: A. Anyone who suspects that a rape has been committed against a resident must immediately report this information Administrator and to the Director of Nursing Services. B. The Director of Nursing Services or designee will immediately report this information to the Attending Physician. C. The Administrator then acts to ensure the following steps are taken: i. The proper authorities and individuals are notified immediately or within 24 hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey and certification agency, and any others necessary. ii. A Licensed Nurse assesses the resident (alleged victim) for possible injuries. iii. The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing. iv. The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives. v. The resident's clothing is not changed to avoid disturbing or destroying evidence. vi. The resident is not bathed or, if female, douched, to avoid compromising potential evidence. vii. The resident is transported to the hospital or other destination as instructed by law enforcement. The DON and Regional Director of Operations were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 07/03/2024 at 5:32 PM, due to the above failures and the IJ template was provided. The Administrator / Abuse Coordinator was on personal leave and not able to be interviewed, at the time of investigation. The facility's Plan of Removal was accepted on 07/04/2024 at 11:52 AM and included: Identify responsible staff/ what action taken: 1. Director of Nursing submitted a self-report to HHSC on July 3, 2024, regarding the incident 2. [Local Law Enforcement Agency] were notified on July 3, 2024, by Regional Nurse Consultant and an officer responded. 3. Attending Physician of Resident #1 was notified of the incident on July 3, 2024, by Assistant Director of Nursing. 4. Social Worker conducted a trauma assessment with Resident #1 on July 4, 2024. 5. Attempts to contact family of Resident #1 on July 3, 2024, were unsuccessful due to non-working phone number. They visit frequently and will be notified upon first opportunity and contact will be updated. Family of Resident # 2 were notified July 3, 2024, by facility social worker. 6. Resident #2 was placed on 1:1 monitoring on July 3, 2024, to consist of line-of-sight monitoring by facility staff. 7. Licensed Nurse conducted a head-to-toe assessment to assess for possible injuries on July 3, 2024. 8. Resident #1 was sent out for a SANE test at local hospital. Resident was unable to consent and per hospital no test was performed, and she will be returned to the facility with no new orders. 9. Director of Nursing began obtaining witness statements from staff. 10. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with all interviewable residents. Head to toe assessments were completed with all non-interviewable residents by facility Treatment Nurses. All were completed July 3, 2024. 11. Resident #1 and Resident #2 were referred to [mental health services] on July 3, 2024, for psychological assessment and to be picked up on services if needed. In-Service conducted: Regional Nurse Consultant and Director of Nursing (after [NAME]-servicing below) in-serviced all facility staff on: 1. On 7/3/24 Director of Nursing and Administrator were in-serviced on Abuse & Neglect Policy and Texas HHSC LTCR Provider Letter PL19-17 by Regional Director of Operations. 2. An all-staff in-service was initiated on 7/3/24. All staff members were educated to report all allegations of abuse immediately upon notification or observation to the Administrator who is the abuse coordinator. All staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. The expected completion date will be 7/4/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. Implementation of Changes: Staff will immediately inform the Administrator who is the abuse coordinator immediately when being made aware of the any abuse allegation or observation. The administrator or director of nursing will ensure competency through verbalization of understanding by staff through successful completion of Abuse/Neglect Post test. In the absence of Administrator abuse allegations will be reported to the Director of Nursing. The Administrator, abuse coordinator will be responsible for implementation of the process and will review process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents. 10 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week. 2. Administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements. Findings will be documented on Abuse & Neglect monitoring form. 3. RDO and RNC will conduct ten random staff interviews per month. 4. RDO or RNC will review grievances weekly which are located in the facility grievance binder for three months. 5. Any adverse outcomes will be reported to QAPI Committee Involvement of Medical Director: The Medical Director was notified about the Immediate Jeopardy on 7/3/2024. Involvement of QA: On July 3, 2024, an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? Administrator and Director of Nursing will be responsible for implementation of new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/3/2024. On 07/04/2024 at 12:05 PM the surveyor began monitoring the facility's Plan of Removal. An observation on 07/04/2024 at 11:45 AM revealed Resident #1 in her wheelchair in the television room. No concerns were noted. She was watching television with another resident in a chair beside her. In an interview on 07/04/2024 at 12:05 PM, the Regional Director of Operations stated he re-educated the Administrator and DON on the facility's abuse, neglect, and exploitation policy which included: Their initial response to this incident and the need to investigate immediately - rather than wait or make assumption. He said there was a step-by-step process for investigating all incidents and a process to ensure residents' safety during the investigation. He said he also in-served them on reportable incidents and, if in doubt then it needs to be reported. He stated the Administrator and DON did not validate the information they received from staff or follow up with an investigation when they received the information. He said they began in-servicing staff in the abuse policy on 07/03/2024. In an interview on 07/04/2024 at 12:10 PM, the Regional Nurse Consultant stated, she worked with the DON to follow up with reports to law enforcement and in-servicing the staff on the facility's abuse, neglect, and exploitation policy. She stated the staff in-services included a post test, and information on reporting all abuse or suspicion of abuse. She stated she will assist the POR to ensure compliance. She said Resident #2 was placed on 1:1 supervision starting about noon on 07/03/2024. In an interview on 07/04/2024 at 12:18 PM, the DON stated he failed to validate the information he received from the incident. He stated he and the Administrator assumed that Resident #1 invited the Resident #2's advances and therefore stopped the investigation. He stated he wanted to ensure he got all the information and in [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #1 was safe from sexual abuse when Resident #2 was found in her bed on 06/30/2024. Resident #2 had not been on any supervision from the time the incident occurred through 07/03/2024. The facility failed to follow their policy and investigate the alleged or suspected sexual abuse of Resident #1 and provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all residents at risk for abuse and psychosocial harm. Findings include: Record review of Resident #1's Face Sheet dated 07/03/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: unspecified sequalae cerebral infarction (stroke), cognitive communication deficit (trouble participating in conversation), aphasia (loss of ability to understand or express speech, caused by brain damage), dysarthria and anarthria (motor speech disorder), bipolar disorder (mental disorder causing unusual shift in mood, energy, and concentration), and major depressive disorder, recurrent, severe with psychotic symptoms (depression along with loss of touch with reality). Record review of Resident #1's quarterly MDS Assessment, dated 06/25/2024, reflected no BIMS score, indicating it was not able to be completed. She had short- and long-term memory problems, cognitive and daily decision-making skills reflected moderately impaired - decisions poor, cues/supervision required. Signs and symptoms of delirium reflected and altered level of consciousness. Resident #1 exhibited no behaviors and used a wheelchair to ambulate. She was totally dependent for toileting, showering, dressing, transfers, and personal hygiene. Record review of Resident #1's BIMS assessment dated [DATE] and signed by the Social Worker reflected, severely impaired cognition. Record review of Resident #1's Care Plan dated 11/28/2023 - Present, reflected, Problem: [Resident #1] The resident has impaired cognitive function or impaired thought processes. Goal: will be able to communicate basic needs on a daily basis through the review date. Problem: The resident has a communication problem r/t aphasia. Intervention: Anticipate and meet needs. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Problem: [Resident #1] has an ADL Self Care Performance Deficit. Intervention: requires 1 staff participation to use toilet and all ADLs. Record review of Resident #2's Face Sheet dated 07/03/2024, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included: encephalopathy (group of conditions that cause brain disfunction), major depressive disorder (mental health condition that causes persistent depressive mood), intermittent explosive disorder (repeat sudden bouts of impulsive, aggressive outbursts), type 2 diabetes (problem in the way the body regulates and used sugar as fuel), hypertension (pressure in blood vessels is too high), and schizoaffective disorder (combination schizophrenia and mood disorder displayed by manic moods and hallucinations). Record review of Resident #2's quarterly MDS Assessment, dated 05/30/2024, reflected a BIMS score of 15, which indicated no cognitive impairment. No behaviors were exhibited. He was independent for all functional abilities and ADLs. Record review of Resident #2's Care Plan dated 06/14/2024 - Present, reflected, no prior sexually inappropriate behavior. The care plan was updated on 07/03/2024 and reflected, Problem: Behavior: Sexually inappropriate AEB: noted to have sexual urges at the facility. Date Initiated: 07/03/2024. Interventions: [Resident #2] to remain on one-on-one watch until further notice, Date Initiated: 07/04/2024. Report incidents of target behavior to charge nurse, Date Initiated: 07/03/2024. Staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances (avoid self-disclosing personal information), Date Initiated: 07/04/2024. Record review of the facility incident report, dated 07/03/2024 at 10:51 AM and signed by the DON, reflected, It was reported to this writer that [Resident #2] allegedly put his penis in [Resident #1's mouth. When asked if anyone touched [Resident #1] she indicated No. When asked if anyone placed their penis in her mouth she indicated No. Head to toe assessment completed with no visible injuries noted. Resident sent out to the ER for SANE evaluation. MD notified. Local law enforcement notified. Attempted no notify family but number is not working. Record review of the facility's transfer record dated 07/03/2024 at 2:30 PM and signed by ADON A, reflected Resident #1 was transferred to hospital. Record review of the Facility's Investigation Report, dated 07/03/2024, reflected, on 07/03/2024, a [State Surveyor] entered the facility on a complaint investigation and brought to [DON's] attention a situation of potential sexual abuse. The [State Surveyor] informed the [DON] that [Resident #2] told him that he had intention to get a blow job from [Resident #1]. [Resident #2] realized that it was wrong and decided not to act on that. [Resident #2] has been placed 1:1 and family and local law enforcement has been notified. Also included were 6 safe surveys, dated 07/01/2024 and signed by the Social Worker. The DON's interview on 6/30/24 with LVN D, reflected, [CNA G] reported to me that during her last rounds she found [Resident #2] in the bed of [Resident #1]. I quickly went to [Resident #1's] room and assessed her. No visible or emotional distress noted. I noted that she was fully clothed. I asked her if she wanted him in her room and she stated yes. [Resident #1] said that he was her friend and that she wanted him there. The DON's interview on 07/01/2024 with CNA G, reflected, During my last rounds on Sunday, [06/30/2024], I entered [Resident #1's room] and noticed [Resident #2] in [Resident #1's] bed with [Resident #1]. [Resident #1] was laying on her side facing the wall. [Resident #2] was laying behind her on his side as well. When asked if both residents were fully clothed, [CNA G] indicated that [Resident #1] had pants and shirt on and brief intact and that [Resident #2] had his pants and shirt on. [Resident #2] quickly got up and left the room. Record review of Resident #1's Hospital Record, dated 07/03/2024 at 3:39 PM, reflected, Chief Complaint: Sexual assault exam referral. Per EMS NH sent pt for SANE exam after finding another resident in her bed on Sunday, NH reported incident to state and state requested an exam. Pt is aphasic d/t CVA. Unable to contact family and patient was unable to consent due to her aphasia and dementia. Discussed case with sexual assault nurse examiner and she said that we would need a court order to pursue further investigation. For now, we are going to send the patient back to the nursing home with close monitoring. Patient was unable to consent for examination, so the patient was returned to the nursing home with instructions to contact the police department in family for further plan of action. 4:42 PM -initial contact made with patient. Patient is aphasic and unable to communicate and to consent to exam. Patient does responds uh huh or no when questioned but answers are inconsistent. Record review of Resident #1's nurse notes dated 07/03/2024 at 1:10 PM and signed by Corporate, reflected, Attempted to call family, number is not working. Resident seen by [Mental Health Services] today. Record review of Resident #2's Psychological Services Progress Note, dated 07/03/2024, reflected, Intervention: Discussed a recent incident in which the pt was discovered in a female resident's room with his pants removed. Utilized open-ended questioning to investigate patient's version of events and potential precipitating factors. Identified inappropriate sexual behavior and processed patient's feelings of guilt and shame. Provided psychoeducation in the importance of maintaining boundaries to protect his own safety and the safety of others. Response to Intervention: Saw pt in a private area to discuss a recent incidence of sexual misconduct. Pt presented as anxious with a blunted affect. He was fully cooperative and expressed remorse regarding his behavior. Pt admitted to entering the female resident's room and removing his pants. He vehemently asserted that there was no sexual conduct during the encounter. Pt claimed that he was walking by the room when he heard a voice call his name. Pt indicated that he was aware that the female resident in question was nonverbal and hypothesized that the voice was a hallucination. In response to the voice, he entered the female resident's room. Pt alleged that the female resident made sexual advances after he entered the room (touched his leg, moved her head toward his groin area). He stated that he removed his pants because the female resident indicated her intention to provide oral sex. Pt then stated that he changed his mind prior to sexual contact and was attempting to pull up his pants when a staff member discovered him. Pt responded positively to therapeutic interventions and admitted that his behavior was inappropriate. He said that he felt guilty about the entire incident and said that he intended no harm. Pt was also receptive to psychoeducation on maintaining boundaries and stated that he would not enter a female's room again. Pt demonstrated understanding of the importance of boundaries in maintaining his safety and the safety of others. In an interview on 07/03/2024 at 9:17 AM, Resident #1, was not able to answer questions with words. She did not make any gestures of verbal comments that reflected her understanding of questions asked of her regarding the incident. In an interview on 07/03/2024 at 9:49 AM, the DON stated Resident #2 had no previous history of any sexual behaviors. He said when LVN D called him on 06/30/2024 at about 9:30 AM to inform him that Resident #2 had been found in bed with Resident #1, he wanted to find out whether Resident #1 invited Resident #2 into her bed. He stated Residents #1 and #2 were friends and often watched television together in the television room. The DON stated LVN D did not complete an incident report and he did not immediately start an investigation about regarding the incident. The DON stated Resident #1 had a BIMS of 0 but that was related to her inability to speak clearly. He said Resident #1 was able to understand and could give consent to a sexual act. He said when LVN D called him, he got on the phone with LVN D and Resident #1, and Resident #1 was able to say some words and responded yes / friend when asked if she wanted Resident #2 in her room. He said he did not ask if Resident #1 wanted Resident #1 in her bed with her but did not feel the need to immediately investigate the incident further. He stated on 07/01/2024, he asked the Social Worker and ADON A to speak to Resident #1. He said they completed a verbal BIMS Assessment on Resident #1, which resulted in no score, which indicated severely cognitively impaired. He said Resident #2 had a BIMS of 15 which indicated no cognitive impairment. He stated he and the Administrator talked to Resident #2 and he denied any type of sexual inappropriate behavior. The DON said he did not refer Resident #1 to the hospital for a SANE exam and did not contact the police. In an interview on 07/03/2024 at 10:50 AM, Resident #2 stated, on 06/30/2024 at about 9:30 AM, he was walking past Resident #1's room and she was in bed and waved him into her room. He said she waved at everyone in that way, but he felt she wanted him to come in. He said he knew Resident #1 because they occasionally watched television together in the day room. He said he did go into Resident #1's room because he was looking for a blow job, [oral sex]. He said he took his pants off and got into bed with Resident #1. He said when he was in bed with her, he started to feel bad and was about to get out of the bed when CNA G entered the room and saw him in bed with Resident #1. He said CNA G did not say anything and left the room and closed the door. He said he got up and put his pants on and heard CNA G call for LVN D. Resident #2 said he left the room and returned to his room. He denied he had done this with any other residents in the facility. Resident #2 said he did not place his penis in Resident #1's mouth and denied any penetration of any kind. He stated the Administrator talked to him about the incident on 07/01/2024 and told him if this type of behavior happened again he would call the police. In an interview on 07/03/2024 at 11:16 AM, CNA F said she heard from LVN D the Resident #2 was found in Resident #1's room, with his penis in Resident #1's mouth on 06/30/2024. She stated that in a similar incident involving different residents, a few years ago, the facility managers immediately sent the offending resident out of the facility and called police. CNA F stated she felt that should have occurred this time but had not. She said the Administrator and DON should have placed Resident #2 on some kind of supervision while they investigated the incident to ensure the safety of all residents in the facility. She said if what she heard was true, Resident #2 had access to Resident #1 and all other residents until today when he was placed on 1:1 supervision. She said she has worked at the facility for [AGE] years and was familiar with the facility's abuse policy because she received training on the policy almost weekly. She stated she did not report the incident to the Abuse Coordinator and was not sure if LVN D reported it. She stated she assumed it was reported. In an interview on 07/03/2024 at 12:00 PM, the DON stated the alleged incident between Resident #1 and Resident #2 was not discussed in the manager's stand-up meeting. He said not every manager needed to know about every incident that occurred. He said after the stand-up meeting on 07/01/2024, the Social Worker and ADON A interviewed Resident #1 and reported to him that Resident #1 answered no when they asked if Resident #2 did anything to her. The DON stated, [Resident #2] did not tell him any intentions to get oral sex from Resident #1. He stated at the time, he did not feel there was any sexual abuse so there was no need to report to police or the state. He stated he did not investigate further because he felt there was no evidence the incident was of a sexual nature and therefore did not move Resident #2. He said, Looking back, we did not get the full truth from [Resident #2] and [Resident #1's] BIMS does limit her ability to consent. He said, We should have called police to follow up with a SANE exam and placed Resident #2 on 1:1 supervision to ensure all residents' safety. He stated Resident #1 was sent to hospital, police have been called, Resident #2 was placed on 1:1 supervision, and the incident was reported to state today. In an interview on 07/03/2024 at 12:10 PM, the Regional Director of Operations (RDO) stated the incident between Residents #1 and #2 should have been thoroughly investigated. He said Resident #2 should have been put on 1:1 supervision to ensure the safety of all residents, Resident #1 should have been sent to the hospital for examination, law enforcement should have been called, the incident should have been reported to the state agency, and a facility investigation started. He said based on Resident #1's BIMS, it was not clear she could have consented to anything, and the facility's policy was in place to ensure the safety of all residents during an investigation of any allegation of abuse. He stated, We should have confirmed what we observed was what happened through investigation in order to ensure the safety of [Resident #1]. An observation and interview on 07/03/2024 at 12:40 PM revealed Resident #2 in his room sleeping on his bed. CNA I was observed outside the room. CNA I stated she was directed to supervise Resident #2 and document wherever he when in the facility. In a telephone interview on 07/03/2024 at 12:54 PM, LVN D stated she was at the nurses' station on 06/30/2024 at about 9:30 AM, when CNA G called her to Resident #1's room. She stated when she went down the hall she saw Resident #2 leaving Resident #1's room. CNA G told her she opened Resident #1's room door and saw Resident #2 in bed with Resident #1. She stated Resident #1 was facing the wall and Resident #2 was in the bed behind her also facing the wall. LVN D stated CNA G did not say she witnessed Resident #2's penis in Resident #1's mouth. She said CNA G told her Resident #2 told her he was talking to his friend. She said she observed Resident #2 with clothes on when he left Resident #1's room but did not observe Resident #2 in the bed. LVN D said she observed Resident #1 in bed with her clothes on. LVN D said she asked Resident #1 what happened, and Resident #1 only nodded no. She stated Resident #1 was not crying and did not appear in distress. She said Resident #1's brief was on and did not appear to be tampered with. LVN D said she felt like Resident #1 could give consent but could not verbalize the consent. LVN D said she could not be sure if she consented to any sexual act of to have Resident #2 in her bed. LVN D said she called the DON when the incident occurred and was instructed to do an emotional assessment. She stated she talked to Resident #1 and she seemed to have her normal demeanor. She did not appear to be afraid and did not behave differently from how she normally did. She said she did not document any assessment of Resident #1 and did not complete an incident report, she said she did not know why she did not document the incident. She said Resident #2 was not on 1:1 watch at the time of the incident on 06/30/2024 but looking back believed he should have been to ensure the safety of all residents while the incident was investigated. She said Resident #1 should have been sent out for a SANE exam rather than assuming nothing happened. In an interview on 07/03/2024 at 1:17 PM, ADON A stated she became aware of the incident between Residents #1 and #2 on 07/01/2024 when the DON asked her and the Social Worker to talk to Resident #1 about the Resident #2 being in her bed. She said they tried to assess Resident #1's ability to consent and her cognitive ability. ADON A stated Resident #1's competency level was very low, and she would not answer any of the BIMS questions. ADON A said she did not feel that Resident #1 had the capacity to invite Resident #2 into her bed. She said she told the DON Resident #1 did not seem like she was able to consent to anything. ADON A said she did not know where the incident investigation went from there but Resident #2 was not on any kind of supervision until 07/03/2024 when the State Surveyor started asking questions about the Incident. She said Resident #1 was sent to the hospital for a SANE exam and the police were called earlier today as well. In an interview on 07/03/2024 at 1:31 PM, the Social Worker stated Resident #1 was not able to point to correct answers for any of the BIMS Assessment questions. She said Resident #1 was severely cognitively impaired and did not believe she had any capacity to concert to Resident #2's alleged actions. She said she shared this information with the DON and did not hear anything else about the incident. She stated Resident #1 should have been sent to the hospital for SANE exam and police notified. She said Resident #2 should have been placed on 1:1 to ensure all residents' safety. In an interview on 07/03/2024 at 1:49 PM, LVN C stated CNA F told her that LVN D told her that Resident #2 was found with his penis in Resident #1's mouth. She said she did not ask CNA F if the incident was reported to the Administrator and said she did not report it either. She stated she assumed the issue had been addressed and reported to the Abuse Coordinator. LVN C said she had worked in the facility about a year and was regularly in-serviced on abuse policy. She said she did not recall when the last in-service was. In a telephone interview on 07/03/2024 at 4:42 PM, CNA G stated on 06/30/2024 at about 9:15 AM, she opened Resident #1's door and saw her in the bed facing the wall. CNA G stated she saw Resident #2 in bed with Resident #1, behind her and also facing the wall. She stated she did not see if Resident #1 had clothes on but did see Resident #2's bare butt sticking out of the covers. She stated she did not know if Resident #2 had his pants all the way off or just around his ankles. CNA G said she left the room and called for LVN D. She stated LVN D came down the hall within a few seconds and Resident #2 opened Resident #1's room door and went across the hall to his room. She said LVN D called the DON and they talked to Resident #1 over the phone. She said she did not report the incident because LVN D had called the DON and she assumed they were addressing the issue. She said she had never seen Resident #2 display any type of sexual inappropriate behavior in the past. She stated LVN D did not send Resident #1 to the hospital and Resident #2 was not placed on 1:1 supervision. She said when she returned to work on 07/01/2024, staff told her that LVN D said Resident #2 was found with his penis in Resident #1's mouth. CNA G said she did not see Resident #2's penis in Resident #1's mouth when she entered the room on 06/30/2024. In an interview on 07/03/2024 at 4:50 PM, Law Enforcement Officer #4664 stated she was called today to respond to allegations of sexual assault. She said since the incident occurred on 06/30/2024, the facility should have called then and sent Resident #1 to the hospital for a SANE exam. She said the facility told her they sent Resident #1 to the hospital today. Record review of the facility's policy titled, Abuse prevention and prohibition program, revised 08/2020, reflected, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements . IV. Prevention: A. Staff, residents and families will be able to report concerns, incidents, and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring . VI. Investigation: A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts . C. The Facility ensures protection of residents during abuse investigations . I. While the investigation is underway, accused individuals who are not Facility Staff may not have any unsupervised access to residents . IX. Reporting/Response: A. Facility Staff are Mandatory Reporters . C. Reporting Requirements: i. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential Internet reporting tool as required by state and federal regulations. X. Special Considerations for Reporting Suspected Incidents of Rape: A. Anyone who suspects that a rape has been committed against a resident must immediately report this information Administrator and to the Director of Nursing Services. B. The Director of Nursing Services or designee will immediately report this information to the Attending Physician. C. The Administrator then acts to ensure the following steps are taken: i. The proper authorities and individuals are notified immediately or within 24 hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey and certification agency, and any others necessary. ii. A Licensed Nurse assesses the resident (alleged victim) for possible injuries. iii. The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing. iv. The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives. v. The resident's clothing is not changed to avoid disturbing or destroying evidence. vi. The resident is not bathed or, if female, douched, to avoid compromising potential evidence. vii. The resident is transported to the hospital or other destination as instructed by law enforcement. The DON and Regional Director of Operations were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 07/03/2024 at 5:32 PM, due to the above failures and the IJ template was provided. The Administrator / Abuse Coordinator was on personal leave and not able to be interviewed, at the time of investigation. The facility's Plan of Removal was accepted on 07/04/2024 at 11:52 AM and included: Identify responsible staff/ what action taken: 1. Director of Nursing submitted a self-report to HHSC on July 3, 2024, regarding the incident 2. [Local Law Enforcement Agency] were notified on July 3, 2024, by Regional Nurse Consultant and an officer responded. 3. Attending Physician of Resident #1 was notified of the incident on July 3, 2024, by Assistant Director of Nursing. 4. Social Worker conducted a trauma assessment with Resident #1 on July 4, 2024. 5. Attempts to contact family of Resident #1 on July 3, 2024, were unsuccessful due to non-working phone number. They visit frequently and will be notified upon first opportunity and contact will be updated. Family of Resident # 2 were notified July 3, 2024, by facility social worker. 6. Resident #2 was placed on 1:1 monitoring on July 3, 2024, to consist of line-of-sight monitoring by facility staff. 7. Licensed Nurse conducted a head-to-toe assessment to assess for possible injuries on July 3, 2024. 8. Resident #1 was sent out for a SANE test at local hospital. Resident was unable to consent and per hospital no test was performed, and she will be returned to the facility with no new orders. 9. Director of Nursing began obtaining witness statements from staff. 10. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with all interviewable residents. Head to toe assessments were completed with all non-interviewable residents by facility Treatment Nurses. All were completed July 3, 2024. 11. Resident #1 and Resident #2 were referred to [mental health services] on July 3, 2024, for psychological assessment and to be picked up on services if needed. In-Service conducted: Regional Nurse Consultant and Director of Nursing (after [NAME]-servicing below) in-serviced all facility staff on: 1. On 7/3/24 Director of Nursing and Administrator were in-serviced on Abuse & Neglect Policy and Texas HHSC LTCR Provider Letter PL19-17 by Regional Director of Operations. 2. An all-staff in-service was initiated on 7/3/24. All staff members were educated to report all allegations of abuse immediately upon notification or observation to the Administrator who is the abuse coordinator. All staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. The expected completion date will be 7/4/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. Implementation of Changes: Staff will immediately inform the Administrator who is the abuse coordinator immediately when being made aware of the any abuse allegation or observation. The administrator or director of nursing will ensure competency through verbalization of understanding by staff through successful completion of Abuse/Neglect Post test. In the absence of Administrator abuse allegations will be reported to the Director of Nursing. The Administrator, abuse coordinator will be responsible for implementation of the process and will review process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents. 10 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week. 2. Administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements. Findings will be documented on Abuse & Neglect monitoring form. 3. RDO and RNC will conduct ten random staff interviews per month. 4. RDO or RNC will review grievances weekly which are located in the facility grievance binder for three months. 5. Any adverse outcomes will be reported to QAPI Committee Involvement of Medical Director: The Medical Director was notified about the Immediate Jeopardy on 7/3/2024. Involvement of QA: On July 3, 2024, an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? Administrator and Director of Nursing will be responsible for implementation of new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/3/2024. On 07/04/2024 at 12:05 PM the surveyor began monitoring the facility's Plan of Removal. An observation on 07/04/2024 at 11:45 AM revealed Resident #1 in her wheelchair in the television room. No concerns were noted. She was watching television with another resident in a chair beside her. In an interview on 07/04/2024 at 12:05 PM, the Regional Director of Operations stated he re-educated the Administrator and DON on the facility's abuse, neglect, and exploitation policy which included: Their initial response to this incident and the need to investigate immediately - rather than wait or make assumption. He said there was a step-by-step process for investigating all incidents and a process to ensure residents' safety during the investigation. He said he also in-served them on reportable incidents and, if in doubt then it needs to be reported. He stated the Administrator and DON did not validate the information they received from staff or follow up with an investigation when they received the information. He said they began in-servicing staff in the abuse policy on 07/03/2024. In an interview on 07/04/2024 at 12:10 PM, the Regional Nurse Consultant stated, she worked with the DON to follow up with reports to law enforcement and in-servicing the staff on the facility's abuse, neglect, and exploitation policy. She stated the staff in-services included a post test, and information on reporting all abuse or suspicion of abuse. She stated she will assist the POR to ensure compliance. She said Resident #2 was placed on 1:1 supervision starting about noon on 07/03/2024. In an interview on 07/04/2024 at 12:18 PM, the DON stated he failed to validate the information he received from the incident. He st [TRUNCATED]

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for one (Resident #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy and investigate an alleged or suspected sexual assault when Resident #2 was found in Resident #1's bed on 06/30/2024. The facility did not provide notification and information to the proper authorities according to state and federal regulations. An IJ was identified on 07/03/2024. The IJ template was provided to the facility on [DATE] at 5:32 PM. While the IJ was removed on 07/04/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all residents at risk for abuse and psychosocial harm. Findings include: Record review of Resident #1's Face Sheet dated 07/03/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: unspecified sequalae cerebral infarction (stroke), cognitive communication deficit (trouble participating in conversation), aphasia (loss of ability to understand or express speech, caused by brain damage), dysarthria and anarthria (motor speech disorder), bipolar disorder (mental disorder causing unusual shift in mood, energy, and concentration), and major depressive disorder, recurrent, severe with psychotic symptoms (depression along with loss of touch with reality). Record review of Resident #1's quarterly MDS Assessment, dated 06/25/2024, reflected no BIMS score, indicating it was not able to be completed. She had short- and long-term memory problems, cognitive and daily decision-making skills reflected moderately impaired - decisions poor, cues/supervision required. Signs and symptoms of delirium reflected and altered level of consciousness. Resident #1 exhibited no behaviors and used a wheelchair to ambulate. She was totally dependent for toileting, showering, dressing, transfers, and personal hygiene. Record review of Resident #1's BIMS assessment dated [DATE] and signed by the Social Worker reflected, severely impaired cognition. Record review of Resident #1's Care Plan dated 11/28/2023 - Present, reflected, Problem: [Resident #1] The resident has impaired cognitive function or impaired thought processes. Goal: will be able to communicate basic needs on a daily basis through the review date. Problem: The resident has a communication problem r/t aphasia. Intervention: Anticipate and meet needs. Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Problem: [Resident #1] has an ADL Self Care Performance Deficit. Intervention: requires 1 staff participation to use toilet and all ADLs. Record review of Resident #2's Face Sheet dated 07/03/2024, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included: encephalopathy (group of conditions that cause brain disfunction), major depressive disorder (mental health condition that causes persistent depressive mood), intermittent explosive disorder (repeat sudden bouts of impulsive, aggressive outbursts), type 2 diabetes (problem in the way the body regulates and used sugar as fuel), hypertension (pressure in blood vessels is too high), and schizoaffective disorder (combination schizophrenia and mood disorder displayed by manic moods and hallucinations). Record review of Resident #2's quarterly MDS Assessment, dated 05/30/2024, reflected a BIMS score of 15, which indicated no cognitive impairment. No behaviors were exhibited. He was independent for all functional abilities and ADLs. Record review of Resident #2's Care Plan dated 06/14/2024 - Present, reflected, no prior sexually inappropriate behavior. The care plan was updated on 07/03/2024 and reflected, Problem: Behavior: Sexually inappropriate AEB: noted to have sexual urges at the facility. Date Initiated: 07/03/2024. Interventions: [Resident #2] to remain on one-on-one watch until further notice, Date Initiated: 07/04/2024. Report incidents of target behavior to charge nurse, Date Initiated: 07/03/2024. Staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances (avoid self-disclosing personal information), Date Initiated: 07/04/2024. Record review of the facility incident report, dated 07/03/2024 at 10:51 AM and signed by the DON, reflected, It was reported to this writer that [Resident #2] allegedly put his penis in [Resident #1's mouth. When asked if anyone touched [Resident #1] she indicated No. When asked if anyone placed their penis in her mouth she indicated No. Head to toe assessment completed with no visible injuries noted. Resident sent out to the ER for SANE evaluation. MD notified. Local law enforcement notified. Attempted no notify family but number is not working. Record review of the facility's transfer record dated 07/03/2024 at 2:30 PM and signed by ADON A, reflected Resident #1 was transferred to hospital. Record review of the Facility's Investigation Report, dated 07/03/2024, reflected, on 07/03/2024, a [State Surveyor] entered the facility on a complaint investigation and brought to [DON's] attention a situation of potential sexual abuse. The [State Surveyor] informed the [DON] that [Resident #2] told him that he had intention to get a blow job from [Resident #1]. [Resident #2] realized that it was wrong and decided not to act on that. [Resident #2] has been placed 1:1 and family and local law enforcement has been notified. Also included were 6 safe surveys, dated 07/01/2024 and signed by the Social Worker. The DON's interview on 6/30/24 with LVN D, reflected, [CNA G] reported to me that during her last rounds she found [Resident #2] in the bed of [Resident #1]. I quickly went to [Resident #1's] room and assessed her. No visible or emotional distress noted. I noted that she was fully clothed. I asked her if she wanted him in her room and she stated yes. [Resident #1] said that he was her friend and that she wanted him there. The DON's interview on 07/01/2024 with CNA G, reflected, During my last rounds on Sunday, [06/30/2024], I entered [Resident #1's room] and noticed [Resident #2] in [Resident #1's] bed with [Resident #1]. [Resident #1] was laying on her side facing the wall. [Resident #2] was laying behind her on his side as well. When asked if both residents were fully clothed, [CNA G] indicated that [Resident #1] had pants and shirt on and brief intact and that [Resident #2] had his pants and shirt on. [Resident #2] quickly got up and left the room. Record review of Resident #1's Hospital Record, dated 07/03/2024 at 3:39 PM, reflected, Chief Complaint: Sexual assault exam referral. Per EMS NH sent pt for SANE exam after finding another resident in her bed on Sunday, NH reported incident to state and state requested an exam. Pt is aphasic d/t CVA. Unable to contact family and patient was unable to consent due to her aphasia and dementia. Discussed case with sexual assault nurse examiner and she said that we would need a court order to pursue further investigation. For now, we are going to send the patient back to the nursing home with close monitoring. Patient was unable to consent for examination, so the patient was returned to the nursing home with instructions to contact the police department in family for further plan of action. 4:42 PM -initial contact made with patient. Patient is aphasic and unable to communicate and to consent to exam. Patient does responds uh huh or no when questioned but answers are inconsistent. Record review of Resident #1's nurse notes dated 07/03/2024 at 1:10 PM and signed by Corporate, reflected, Attempted to call family, number is not working. Resident seen by [Mental Health Services] today. Record review of Resident #2's Psychological Services Progress Note, dated 07/03/2024, reflected, Intervention: Discussed a recent incident in which the pt was discovered in a female resident's room with his pants removed. Utilized open-ended questioning to investigate patient's version of events and potential precipitating factors. Identified inappropriate sexual behavior and processed patient's feelings of guilt and shame. Provided psychoeducation in the importance of maintaining boundaries to protect his own safety and the safety of others. Response to Intervention: Saw pt in a private area to discuss a recent incidence of sexual misconduct. Pt presented as anxious with a blunted affect. He was fully cooperative and expressed remorse regarding his behavior. Pt admitted to entering the female resident's room and removing his pants. He vehemently asserted that there was no sexual conduct during the encounter. Pt claimed that he was walking by the room when he heard a voice call his name. Pt indicated that he was aware that the female resident in question was nonverbal and hypothesized that the voice was a hallucination. In response to the voice, he entered the female resident's room. Pt alleged that the female resident made sexual advances after he entered the room (touched his leg, moved her head toward his groin area). He stated that he removed his pants because the female resident indicated her intention to provide oral sex. Pt then stated that he changed his mind prior to sexual contact and was attempting to pull up his pants when a staff member discovered him. Pt responded positively to therapeutic interventions and admitted that his behavior was inappropriate. He said that he felt guilty about the entire incident and said that he intended no harm. Pt was also receptive to psychoeducation on maintaining boundaries and stated that he would not enter a female's room again. Pt demonstrated understanding of the importance of boundaries in maintaining his safety and the safety of others. In an interview on 07/03/2024 at 9:17 AM, Resident #1, was not able to answer questions with words. She did not make any gestures of verbal comments that reflected her understanding of questions asked of her regarding the incident. In an interview on 07/03/2024 at 9:49 AM, the DON stated Resident #2 had no previous history of any sexual behaviors. He said when LVN D called him on 06/30/2024 at about 9:30 AM to inform him that Resident #2 had been found in bed with Resident #1, he wanted to find out whether Resident #1 invited Resident #2 into her bed. He stated Residents #1 and #2 were friends and often watched television together in the television room. The DON stated LVN D did not complete an incident report and he did not immediately start an investigation about regarding the incident. The DON stated Resident #1 had a BIMS of 0 but that was related to her inability to speak clearly. He said Resident #1 was able to understand and could give consent to a sexual act. He said when LVN D called him, he got on the phone with LVN D and Resident #1, and Resident #1 was able to say some words and responded yes / friend when asked if she wanted Resident #2 in her room. He said he did not ask if Resident #1 wanted Resident #1 in her bed with her but did not feel the need to immediately investigate the incident further. He stated on 07/01/2024, he asked the Social Worker and ADON A to speak to Resident #1. He said they completed a verbal BIMS Assessment on Resident #1, which resulted in no score, which indicated severely cognitively impaired. He said Resident #2 had a BIMS of 15 which indicated no cognitive impairment. He stated he and the Administrator talked to Resident #2 and he denied any type of sexual inappropriate behavior. The DON said he did not refer Resident #1 to the hospital for a SANE exam and did not contact the police. In an interview on 07/03/2024 at 10:50 AM, Resident #2 stated, on 06/30/2024 at about 9:30 AM, he was walking past Resident #1's room and she was in bed and waved him into her room. He said she waved at everyone in that way, but he felt she wanted him to come in. He said he knew Resident #1 because they occasionally watched television together in the day room. He said he did go into Resident #1's room because he was looking for a blow job, [oral sex]. He said he took his pants off and got into bed with Resident #1. He said when he was in bed with her, he started to feel bad and was about to get out of the bed when CNA G entered the room and saw him in bed with Resident #1. He said CNA G did not say anything and left the room and closed the door. He said he got up and put his pants on and heard CNA G call for LVN D. Resident #2 said he left the room and returned to his room. He denied he had done this with any other residents in the facility. Resident #2 said he did not place his penis in Resident #1's mouth and denied any penetration of any kind. He stated the Administrator talked to him about the incident on 07/01/2024 and told him if this type of behavior happened again he would call the police. In an interview on 07/03/2024 at 11:16 AM, CNA F said she heard from LVN D the Resident #2 was found in Resident #1's room, with his penis in Resident #1's mouth on 06/30/2024. She stated that in a similar incident involving different residents, a few years ago, the facility managers immediately sent the offending resident out of the facility and called police. CNA F stated she felt that should have occurred this time but had not. She said the Administrator and DON should have placed Resident #2 on some kind of supervision while they investigated the incident to ensure the safety of all residents in the facility. She said if what she heard was true, Resident #2 had access to Resident #1 and all other residents until today when he was placed on 1:1 supervision. She said she has worked at the facility for [AGE] years and was familiar with the facility's abuse policy because she received training on the policy almost weekly. She stated she did not report the incident to the Abuse Coordinator and was not sure if LVN D reported it. She stated she assumed it was reported. In an interview on 07/03/2024 at 12:00 PM, the DON stated the alleged incident between Resident #1 and Resident #2 was not discussed in the manager's stand-up meeting. He said not every manager needed to know about every incident that occurred. He said after the stand-up meeting on 07/01/2024, the Social Worker and ADON A interviewed Resident #1 and reported to him that Resident #1 answered no when they asked if Resident #2 did anything to her. The DON stated, [Resident #2] did not tell him any intentions to get oral sex from Resident #1. He stated at the time, he did not feel there was any sexual abuse so there was no need to report to police or the state. He stated he did not investigate further because he felt there was no evidence the incident was of a sexual nature and therefore did not move Resident #2. He said, Looking back, we did not get the full truth from [Resident #2] and [Resident #1's] BIMS does limit her ability to consent. He said, We should have called police to follow up with a SANE exam and placed Resident #2 on 1:1 supervision to ensure all residents' safety. He stated Resident #1 was sent to hospital, police have been called, Resident #2 was placed on 1:1 supervision, and the incident was reported to state today. In an interview on 07/03/2024 at 12:10 PM, the Regional Director of Operations (RDO) stated the incident between Residents #1 and #2 should have been thoroughly investigated. He said Resident #2 should have been put on 1:1 supervision to ensure the safety of all residents, Resident #1 should have been sent to the hospital for examination, law enforcement should have been called, the incident should have been reported to the state agency, and a facility investigation started. He said based on Resident #1's BIMS, it was not clear she could have consented to anything, and the facility's policy was in place to ensure the safety of all residents during an investigation of any allegation of abuse. He stated, We should have confirmed what we observed was what happened through investigation in order to ensure the safety of [Resident #1]. An observation and interview on 07/03/2024 at 12:40 PM revealed Resident #2 in his room sleeping on his bed. CNA I was observed outside the room. CNA I stated she was directed to supervise Resident #2 and document wherever he when in the facility. In a telephone interview on 07/03/2024 at 12:54 PM, LVN D stated she was at the nurses' station on 06/30/2024 at about 9:30 AM, when CNA G called her to Resident #1's room. She stated when she went down the hall she saw Resident #2 leaving Resident #1's room. CNA G told her she opened Resident #1's room door and saw Resident #2 in bed with Resident #1. She stated Resident #1 was facing the wall and Resident #2 was in the bed behind her also facing the wall. LVN D stated CNA G did not say she witnessed Resident #2's penis in Resident #1's mouth. She said CNA G told her Resident #2 told her he was talking to his friend. She said she observed Resident #2 with clothes on when he left Resident #1's room but did not observe Resident #2 in the bed. LVN D said she observed Resident #1 in bed with her clothes on. LVN D said she asked Resident #1 what happened, and Resident #1 only nodded no. She stated Resident #1 was not crying and did not appear in distress. She said Resident #1's brief was on and did not appear to be tampered with. LVN D said she felt like Resident #1 could give consent but could not verbalize the consent. LVN D said she could not be sure if she consented to any sexual act of to have Resident #2 in her bed. LVN D said she called the DON when the incident occurred and was instructed to do an emotional assessment. She stated she talked to Resident #1 and she seemed to have her normal demeanor. She did not appear to be afraid and did not behave differently from how she normally did. She said she did not document any assessment of Resident #1 and did not complete an incident report, she said she did not know why she did not document the incident. She said Resident #2 was not on 1:1 watch at the time of the incident on 06/30/2024 but looking back believed he should have been to ensure the safety of all residents while the incident was investigated. She said Resident #1 should have been sent out for a SANE exam rather than assuming nothing happened. In an interview on 07/03/2024 at 1:17 PM, ADON A stated she became aware of the incident between Residents #1 and #2 on 07/01/2024 when the DON asked her and the Social Worker to talk to Resident #1 about the Resident #2 being in her bed. She said they tried to assess Resident #1's ability to consent and her cognitive ability. ADON A stated Resident #1's competency level was very low, and she would not answer any of the BIMS questions. ADON A said she did not feel that Resident #1 had the capacity to invite Resident #2 into her bed. She said she told the DON Resident #1 did not seem like she was able to consent to anything. ADON A said she did not know where the incident investigation went from there but Resident #2 was not on any kind of supervision until 07/03/2024 when the State Surveyor started asking questions about the Incident. She said Resident #1 was sent to the hospital for a SANE exam and the police were called earlier today as well. In an interview on 07/03/2024 at 1:31 PM, the Social Worker stated Resident #1 was not able to point to correct answers for any of the BIMS Assessment questions. She said Resident #1 was severely cognitively impaired and did not believe she had any capacity to concert to Resident #2's alleged actions. She said she shared this information with the DON and did not hear anything else about the incident. She stated Resident #1 should have been sent to the hospital for SANE exam and police notified. She said Resident #2 should have been placed on 1:1 to ensure all residents' safety. In an interview on 07/03/2024 at 1:49 PM, LVN C stated CNA F told her that LVN D told her that Resident #2 was found with his penis in Resident #1's mouth. She said she did not ask CNA F if the incident was reported to the Administrator and said she did not report it either. She stated she assumed the issue had been addressed and reported to the Abuse Coordinator. LVN C said she had worked in the facility about a year and was regularly in-serviced on abuse policy. She said she did not recall when the last in-service was. In a telephone interview on 07/03/2024 at 4:42 PM, CNA G stated on 06/30/2024 at about 9:15 AM, she opened Resident #1's door and saw her in the bed facing the wall. CNA G stated she saw Resident #2 in bed with Resident #1, behind her and also facing the wall. She stated she did not see if Resident #1 had clothes on but did see Resident #2's bare butt sticking out of the covers. She stated she did not know if Resident #2 had his pants all the way off or just around his ankles. CNA G said she left the room and called for LVN D. She stated LVN D came down the hall within a few seconds and Resident #2 opened Resident #1's room door and went across the hall to his room. She said LVN D called the DON and they talked to Resident #1 over the phone. She said she did not report the incident because LVN D had called the DON and she assumed they were addressing the issue. She said she had never seen Resident #2 display any type of sexual inappropriate behavior in the past. She stated LVN D did not send Resident #1 to the hospital and Resident #2 was not placed on 1:1 supervision. She said when she returned to work on 07/01/2024, staff told her that LVN D said Resident #2 was found with his penis in Resident #1's mouth. CNA G said she did not see Resident #2's penis in Resident #1's mouth when she entered the room on 06/30/2024. In an interview on 07/03/2024 at 4:50 PM, Law Enforcement Officer #4664 stated she was called today to respond to allegations of sexual assault. She said since the incident occurred on 06/30/2024, the facility should have called then and sent Resident #1 to the hospital for a SANE exam. She said the facility told her they sent Resident #1 to the hospital today. Record review of the facility's policy titled, Abuse prevention and prohibition program, revised 08/2020, reflected, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements . IV. Prevention: A. Staff, residents and families will be able to report concerns, incidents, and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring . VI. Investigation: A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts . C. The Facility ensures protection of residents during abuse investigations . I. While the investigation is underway, accused individuals who are not Facility Staff may not have any unsupervised access to residents . IX. Reporting/Response: A. Facility Staff are Mandatory Reporters . C. Reporting Requirements: i. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential Internet reporting tool as required by state and federal regulations. X. Special Considerations for Reporting Suspected Incidents of Rape: A. Anyone who suspects that a rape has been committed against a resident must immediately report this information Administrator and to the Director of Nursing Services. B. The Director of Nursing Services or designee will immediately report this information to the Attending Physician. C. The Administrator then acts to ensure the following steps are taken: i. The proper authorities and individuals are notified immediately or within 24 hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey and certification agency, and any others necessary. ii. A Licensed Nurse assesses the resident (alleged victim) for possible injuries. iii. The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing. iv. The area where the alleged incident occurred is not disturbed or accessed by anyone before law enforcement arrives. v. The resident's clothing is not changed to avoid disturbing or destroying evidence. vi. The resident is not bathed or, if female, douched, to avoid compromising potential evidence. vii. The resident is transported to the hospital or other destination as instructed by law enforcement. The DON and Regional Director of Operations were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 07/03/2024 at 5:32 PM, due to the above failures and the IJ template was provided. The Administrator / Abuse Coordinator was on personal leave and not able to be interviewed, at the time of investigation. The facility's Plan of Removal was accepted on 07/04/2024 at 11:52 AM and included: Identify responsible staff/ what action taken: 1. Director of Nursing submitted a self-report to HHSC on July 3, 2024, regarding the incident 2. [Local Law Enforcement Agency] were notified on July 3, 2024, by Regional Nurse Consultant and an officer responded. 3. Attending Physician of Resident #1 was notified of the incident on July 3, 2024, by Assistant Director of Nursing. 4. Social Worker conducted a trauma assessment with Resident #1 on July 4, 2024. 5. Attempts to contact family of Resident #1 on July 3, 2024, were unsuccessful due to non-working phone number. They visit frequently and will be notified upon first opportunity and contact will be updated. Family of Resident # 2 were notified July 3, 2024, by facility social worker. 6. Resident #2 was placed on 1:1 monitoring on July 3, 2024, to consist of line-of-sight monitoring by facility staff. 7. Licensed Nurse conducted a head-to-toe assessment to assess for possible injuries on July 3, 2024. 8. Resident #1 was sent out for a SANE test at local hospital. Resident was unable to consent and per hospital no test was performed, and she will be returned to the facility with no new orders. 9. Director of Nursing began obtaining witness statements from staff. 10. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with all interviewable residents. Head to toe assessments were completed with all non-interviewable residents by facility Treatment Nurses. All were completed July 3, 2024. 11. Resident #1 and Resident #2 were referred to [mental health services] on July 3, 2024, for psychological assessment and to be picked up on services if needed. In-Service conducted: Regional Nurse Consultant and Director of Nursing (after [NAME]-servicing below) in-serviced all facility staff on: 1. On 7/3/24 Director of Nursing and Administrator were in-serviced on Abuse & Neglect Policy and Texas HHSC LTCR Provider Letter PL19-17 by Regional Director of Operations. 2. An all-staff in-service was initiated on 7/3/24. All staff members were educated to report all allegations of abuse immediately upon notification or observation to the Administrator who is the abuse coordinator. All staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. The expected completion date will be 7/4/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. Implementation of Changes: Staff will immediately inform the Administrator who is the abuse coordinator immediately when being made aware of the any abuse allegation or observation. The administrator or director of nursing will ensure competency through verbalization of understanding by staff through successful completion of Abuse/Neglect Post test. In the absence of Administrator abuse allegations will be reported to the Director of Nursing. The Administrator, abuse coordinator will be responsible for implementation of the process and will review process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents. 10 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week. 2. Administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements. Findings will be documented on Abuse & Neglect monitoring form. 3. RDO and RNC will conduct ten random staff interviews per month. 4. RDO or RNC will review grievances weekly which are located in the facility grievance binder for three months. 5. Any adverse outcomes will be reported to QAPI Committee Involvement of Medical Director: The Medical Director was notified about the Immediate Jeopardy on 7/3/2024. Involvement of QA: On July 3, 2024, an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? Administrator and Director of Nursing will be responsible for implementation of new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/3/2024. On 07/04/2024 at 12:05 PM the surveyor began monitoring the facility's Plan of Removal. An observation on 07/04/2024 at 11:45 AM revealed Resident #1 in her wheelchair in the television room. No concerns were noted. She was watching television with another resident in a chair beside her. In an interview on 07/04/2024 at 12:05 PM, the Regional Director of Operations stated he re-educated the Administrator and DON on the facility's abuse, neglect, and exploitation policy which included: Their initial response to this incident and the need to investigate immediately - rather than wait or make assumption. He said there was a step-by-step process for investigating all incidents and a process to ensure residents' safety during the investigation. He said he also in-served them on reportable incidents and, if in doubt then it needs to be reported. He stated the Administrator and DON did not validate the information they received from staff or follow up with an investigation when they received the information. He said they began in-servicing staff in the abuse policy on 07/03/2024. In an interview on 07/04/2024 at 12:10 PM, the Regional Nurse Consultant stated, she worked with the DON to follow up with reports to law enforcement and in-servicing the staff on the facility's abuse, neglect, and exploitation policy. She stated the staff in-services included a post test, and information on reporting all abuse or suspicion of abuse. She stated she will assist the POR to ensure compliance. She said Resident #2 was placed on 1:1 supervision starting about noon on 07/03/2024. In an interview on 07/04/2024 at 12:18 PM, the DON stated he failed to validate the information he received from the incident. He stated he and the Administrator assumed that Resident #1 invited the Resident #2's advances and therefore stopped the investigation. He stated he wanted to ensure he got all the information and

Based on interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents reviewed for accidents. LVN A failed to apply two footrests on a wheelchair prior to transporting Resident #1 for dialysis. The resident suffered an injury when the foot fell off the footrest two times. The resident was admitted to the hospital and diagnosed with a fracture of the left tibial tuberosity (area of bone just below the knee). This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #1's MDS quarterly assessment, dated 06/04/23 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (kidney failure) and cerebrovascular accident (stroke). The resident had moderately impaired cognition. The resident was totally dependent on staff for transfers. Review of Resident #1's undated care plan revealed the resident attended dialysis and required staff assistance for activities of daily living. Review of Resident #1's progress notes reflected: 06/05/23 9:47 PM General Progress Note Resident complained of bilateral foot pain and stated, when I was coming back from dialysis, my foot fell off the footrest of my wheelchair and turned inward. Foot assessment completed and no open areas noted. Tramadol (pain medicine) and Tylenol administered. Physician notified and bilateral foot x-rays ordered. - LVN B 06/06/23 5:14 AM General Progress Note 06/05/23 10:10 PM 911 arrived in building. Resident complained of legs hurting. Resident transported on stretcher with 2 attendants. DON notified. - LVN A 06/06/23 12:25 AM Hospital called and said x-rays were done with no fractures noted and pain medicine administered. - LVN C 06/7/23 1:25 PM General Progress Note Late Entry: Resident's family here and she is concerned because resident is complaining of pain in both her legs. Family also concerned about resident missing a couple days of dialysis. Resident was medicated with pain medication about an hour ago. Family decided she wants the resident to be transferred to the emergency room for evaluation and to get dialyzed. This writer notified charge nurse to get paperwork together to be transferred and to notify the Physician. - LVN D Review of the X-ray results, dated 06/05/23, of the left knee for Resident #1 reflected: Osteoarthritis (arthritis) of the left knee with no fracture. Review of Computerized Tomography (CT) scan results, dated 06/09/23, of the lower extremities for Resident #1 reflected: Osteopenia (soft bones) and fracture of the left tibial tuberosity (area of bone just below the knee). An interview on 06/22/23 at 12:45 PM with the family of Resident #1 revealed on 06/05/23 the resident was placed in a manual wheelchair and pushed down the hall by LVN A. While in the wheelchair, the resident's leg became stuck under the wheelchair. The family member said x-rays were completed (did not reveal a fracture) and a CT scan was completed on 06/09/23 due to continued pain and the resident had a fracture. Interviews on 06/22/23 at 2:00 PM and 4:35 PM with LVN A revealed on the morning of 06/05/23 she got a wheelchair for Resident #1 to transport her to the van for dialysis. She said the wheelchair had one footrest and she placed one foot on the footrest and the other leg she placed over the leg on the footrest. LVN A said while she was pushing the wheelchair, the resident's foot fell off the footrest. LVN A said the foot did not go under the wheelchair. LVN A said she repositioned the foot back on the footrest. She said that the facility had additional chairs and additional footrests, but she did not go get one, because it was at the other station . LVN A said she did not do an incident report or tell anyone, because the foot just fell off the foot rest. An interview on 06/22/23 at 2:20 pm with LVN B revealed she was waiting for evening shift report and the transport driver brought the resident back to the facility from dialysis. LVN B said the driver told her to make sure the wheelchair had two footrests the next time she went on transport. LVN B said later that evening on 06/05/23 the resident said her foot was hurting because her foot dropped off the footrest and turned inwards when the transport driver was bringing her back to the facility. LVN B said she medicated the resident, and an x-ray was ordered. An interview with the DON on 06/22/23 at 12:40 PM revealed he said Resident #1's foot got caught on the wheelchair during dialysis transport on 06/05/23. He said the resident was sent to the hospital on 06/05/23 and returned to the facility with no fracture. He said the resident had a contusion (bruise). He said the resident was sent to the hospital on 06/07/23 because she kept refusing dialysis. He said he did not know the resident was diagnosed with a fracture. Review of the facility policy and procedure, Safety - Resident, dated May 2017 reflected: It is the policy of this home that residents' safety will be maintained during all aspects of care . 8. Be sure the resident is adequately secured when being transported. Protect resident's extremities during transportation.

Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment for 12 (Residents #5, #20, #24, #55, #18, #35, #60, #61, #85, #92, #93 and #354) of 29 Residents and three (#100, #300 and #400) of three halls and one (400 hall storage room) of three storage rooms reviewed for infection control. The DON and MDS Coordinator LL failed to identify Resident #354 readmitted on [DATE] with [CONDITION(S)], until HHSC State Surveyors told them. The facility failed to adequately train staff and monitor to ensure staff followed their infection control policy. ADON A was the Infection Control Preventionist and failed to follow the facility's infection control policy. Resident #60's wounds deteriorated due to the lack of infection control practices and became septic. ADON A failed to conduct skin assessment and wound care for several of the residents properly, she started at the resident's feet and worked her way up the resident's body, touched fecal matter and did not wash her hands and change her gloves. The facility staff (ADON A, DON, LVN's, CNA's, COTA's and Housekeepers) failed to properly wash their hands and change their PPE during patient care, wound care assessments/treatments, therapy sessions and housekeeping services. The facility failed to store PPE properly; it was stored in the hopper room in the 400 hall Quarantine/Warm zone unit. The facility failed to properly store gloves in the 400 warm zone hall unit because they were stored loosely inside of a blue net bag that contained trash located on the side of the linen cart. The facility failed to ensure staff followed the appropriate PPE procedures when they entered and exited the 400 hall Quarantine/warm zone. The facility failed to ensure CNA's and LVN's wore gloves, practiced hand hygiene and removed contaminated trash from the Quarantine/warm zone properly. The facility failed to ensure LVN G sanitized the blood pressure cuff and stethoscope after each use. An Immediate Jeopardy (IJ) was identified on 07/21/21 at 5:00 PM and while the IJ was removed on 07/27/21 at 5:10 PM the facility remained out of compliance at a severity level of Actual harm that was not Immediate Jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of their plan of correction. These failures placed all residents at risk of infectious diseases which could result in debilitating illnesses, a decreased quality of life and psycho-social well-being. Findings included: A. 1) Review of Resident #354's face sheet, dated 07/22/21, revealed he was a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #354's Quarterly MDS assessment, dated 05/04/21, revealed the resident had a BIMS score of 07 which indicated his cognition was severely impaired. The resident required extensive assist with ADL's, was always incontinent to bowel and bladder, was at risk of developing pressure ulcer/injuries. The MDS further reflected for unhealed pressure ulcer/injuries it was blank. Review of Resident #354's hospital discharge paperwork, dated 07/16/21 revealed, Assessment: 1. Left heel ulceration with necrosis of the bone, left calcaneal [CONDITION(S)], left heel abscess s/p, left foot incision and drainage through the bone cortex, partial excision of the left calcaneus done on 07/11/21 .2. Left heel infection-surgical left heel deep soft tissue cultures positive for [CONDITION(S)], group A Strep .3.[CONDITION(S)] .4. Afib .5. Diabetes type 2, hypertension .6. Old [CONDITION(S)] with right [CONDITION(S)] .7. History of COVID .8. History of C-diff [CONDITION(S)] [MEDICATION(S)] 750 mg IV x 1 after hemodialysis on Monday Wednesday and Friday .stop date 08/22/21 Review of Resident #354's Progress note by MDS Coordinator LL and printed 07/23/21 and dated 07/16/21 at 1:33 PM, revealed Late entry effective Type: Skilled evaluation: Resident admitted on [DATE] receiving skilled nursing services with skilled Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .vitals . Review of Resident #354's Doctor Order Summary Report dated 07/19/21 revealed no Contact Isolation Order or [CONDITION(S)] added to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #354's Nurse Progress Notes printed 07/23/21 revealed, from 07/16/21 to 07/22/21 there was no documentation about the resident's [CONDITION(S)] or contact isolation precautions. Review of Resident #354's Nurse Progress Note printed 07/23/21 and dated 07/22/21 at 8:28 AM Late Entry Effective: by MDS Coordinator LL revealed, General Progress note: Resident continues contact isolation for [CONDITION(S)] to wound to left heel, continues eating and doing activities alone in room. Interview on 07/21/21 at 12:50 PM with the DON revealed she was responsible for reviewing and approving hospital discharge records. She stated she reviewed Resident #354's the discharge records r Resident #354 and did not recall they had [CONDITION(S)] of a wound. She stated she was told the resident was receiving [MEDICATION(S)] for an infection but did not ask the reason for the antibiotic usage. She stated the receiving nurse also took the report from the hospital. She denied knowledge of his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 7/22/21 at 11:04 AM, MDS Coordinator LL stated she was told about Resident #354's pending to re-admit from the hospital during the morning meeting 07/15/21 and stated in addition, the Admissions Director or Marketing Director sent emails to all department heads. She stated she was told Resident #354 would be readmitted at night and she reviewed his hospital documentation on the same day 07/15/21 and the next day after he returned 07/16/21 and Resident #354's hospital admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated [CONDITION(S)] was the resident's skilled diagnosis, they treated Resident #354 for whatever the hospital was treating him for and said she was not aware Resident #354 had IV [MEDICATION(S)] orders with an [CONDITION(S)] diagnosis. Interview on 07/22/21 at 9:04 AM, CCO, accompanied by the Administrator stated the former DON was terminated and no longer working at the facility and the Interim DON would work in her place. Interview on 07/22/21 at 9:15 AM, CCO, accompanied by the Administrator both stated they were not sure how Resident #354's [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/21/21 at 2:06 PM, Resident #354's room on the 400-warm zone/Quarantine hall door was open and they were not in it and no contact isolation precautions or notices were on or around their room door. Interview on 07/21/21 at 2:07 PM, LVN H (on the 400-unit warm zone/quarantine hall) stated they had no contact isolation residents including any with [CONDITION(S)]. He stated this was the warm zone hall, where they had to wear masks, gowns gloves, face shields, and gloves which were on the nurses station cart and in the resident's rooms. He stated droplet precautions was like a cough and contact isolation was like C-diff, [CONDITION(S)] meaning anytime the staff entered the room they had to gown up and wear all PPE and they have to put notice at the door to see the nurse. Interview on 07/21/21 at 2:20 PM, Medication aide MM (on the 400-unit warm zone/quarantine hall) stated the hall had no contact isolation precaution residents and for those residents it was different because staff would have to change everything, their masks, gowns not just the gown and there's a sign that would be placed on the resident's door. She stated it had been awhile since they had any contact isolation residents. Interview on 07/21/21 at 4:13 PM, the Administrator stated she was not aware Resident #354 readmitted to this facility with a [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Review of Resident #60's face sheet, dated 07/16/21, revealed a [AGE] year-old male who admitted to the facility 12/23/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/17/21 at 1:37 PM of Resident #60's skin assessment revealed ADON A obtained a paper tape measuring device and began measuring the right lateral ankle wound. After measuring the right ankle wound, ADON A wrote the measurements on the back of the measuring device and then moved to the resident's heel where she measured a wound and then continued to move up the body. The resident's buttocks wounds and sacral wound contaminated with feces and she continued to measure the wounds on his back and his scrotum with the same fecal contaminated measuring device. Observation on 07/17/21 at 2:22 PM of Resident #60 with ADON A revealed the resident had on black heavily soiled boots. ADON A removed her tape measure from the table and began to measure the resident's sacral wound as she wrote on the back of the tape measure the measurements she obtained from the sacral wound. She then began to pack the sacral wound with Dakin's soaked gauze and then covered it with a Duoderm dressing. She then taped the dressing in place stating that it would not stay in place due to him having a bowel movement. ADON A began to measure the other Resident# 60's both sides of the buttock's wounds resident using the same tape measure t she used to measure the sacral wound with and had been writing measurements on the back of to document measurements. said winds ADON A then applied ParaGard to the entire buttocks area and calcium alginate to the right lateral malleolus. She then applied an abdominal pad and wrapped with kerlix at the right lateral foot. She measured all wounds using same tape measure. In an observation on 07/20/21 at 4:55 PM Resident #60 had soiled, black- padded boots to both feet. CNA EE removed resident #60's boots from both feet which revealed wounds without dressings on them, which could possibly be a source of wound contamination with having on soiled boots. Interview on 07/27/21 at 3:09 PM, Resident #60's Hospital Nurse said Resident #60 came from a healthcare facility on 07/25/21 and had an incision and debridement procedure of a sacral and bilateral ischium decubitus ulcer and placement of a wound vac on 07/26/21. She stated the hospital physician noted some foot wounds and noted Resident #60 had the sacral wound for the past nine months, that was treated at the healthcare facility, but now had significant infection, necrosis and [CONDITION(S)]. She said Resident #60's treatment plan was ordered for a wound vac and two IV antibiotic medications with dressings to his wounds . Interview on 07/27/21 at 2:50 PM, Resident #60, while at the hospital stated they had surgery yesterday 07/26/21 on the wound of their bottom and the hospital staff said a fist could fit into it and said they did not know their wounds were this bad. 3) Review of Resident #35's face sheet, dated 07/18/21, revealed a [AGE] year-old male who admitted to the facility 08/06/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's MDS, dated [DATE], revealed he had a BIMS score of 01, which indicated he had severe cognitive impairment, was always incontinent with bowel and bladder at risk for pressure sores, and had no wounds. Observation on 07/16/21 at 11:25 AM, revealed Resident #35 skin assessment, their bed was at a 45-degree angle and ADON A and the Central Supply Clerk started with the resident's feet first. 4) Review of Resident #61's Annual MDS, dated [DATE], revealed, a [AGE] year-old male who admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/14/21 at 9:55 AM revealed, on the 400/quarantine hall, LVN H answered Resident #61's call light, LVN H then entered Resident #61's room without performing hand hygiene, put on gloves, and then obtained an oral swab from bedside table and began to swab the resident's mouth. When he exited the resident's room he removed his gloves but did not perform any hand hygiene and did not remove his gown. He then exited Resident #61's room and failed to remove his gown and wash his hands before entering Resident #93's room, He wore the same gown he used for #61 and #93 then went into Resident #85's room where he touched the feeding pump of Resident #85 while looking at the feeding formula. 5)Review of Resident #85's face sheet, dated 07/16/21, revealed, the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/20/21 at 11:32 AM of Resident #85 skin assessment revealed, the DON touched and smeared white cream away to see skin in groin area and then adjusted the track tube with soiled her soiled gloves. She continued to do the skin assessment with the same soiled gloves. Foley catheter not anchored or secured. Peg site clean and open to air without dressing. Dark drainage around tube site crusted. Resident was coughing and had difficulty clearing sputum from airway and needed suctioning. A fly flew over the bed. Sputum creamy in the [CONDITION(S)] tubing cavity that was filling up with sputum as resident coughed. Resident was moving his head from side to side in distress. Fly few over the bed. DON went for a nurse to come and suction the resident .11:41 LVN H came and suctioned resident . O2 sat was 96%. There was a soiled washcloth on the headboard with tan substance and tape on the washcloth. When asked, the DON said, It is trash-a washcloth and tape. I asked, from the [CONDITION(S)]? the DON responded Probably. 6)Review of Resident #93's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with LVN H on 07/14/2021 at 10:02 AM he was asked about changing his gown when he exited Resident #93's room. He stated he had been in-serviced on PPE use on the quarantine unit, and he was told that he could wear his same gown, and N95 mask the entire time he was on the quarantine unit but if he left the hall he must change gowns. He confirmed he performed oral care on Resident #93 but did not think he was contaminated so he didn't change his gown., and he didn't think of washing his hands because he didn't think his hands were contaminated. LVN H stated he had been in-serviced by ADON R about a month ago that he should wear PPE at all times and he could wear the same gown into any of the rooms on the warm hall, but should remove the gown if he left the hall. When asked about the effects of not changing gowns in between residents, he replied Well if I don't change gowns in between residents then I could carry something to the next resident; so I should change my gown and wash my hands. 7) Review of Resident #18's Admission MDS, dated [DATE], revealed the resident was [AGE] year-old male who admitted to the facility 04/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 07/20/21 at 10:50 AM revealed ADON A began a skin assessment on Resident # 18. As she moved up to his buttocks, the resident had a large BM in which ADON A pushed his brief to the side of his buttocks and attempted to continue the assessment. The BM was visibly stuck on her gloves as she touched his back. The Regional Nurse was overheard whispering to ADON A wash your hands. ADON A went to the bathroom and washed her hands. ADON A then proceeded with the resident's skin assessment as she moved into his armpit area, there was a small brown speck on the sheet. ADON A picked it up with her gloved hand and stated, it's bowel movement. She did not remove her soiled gloves and did not wash her hands. She then continued to touch other areas of his body to complete the skin assessment. ADON A then obtained clean linen and applied clean linen to his bed with same soiled gloves. An observation and interview on 07/20/21 at 3:54 PM revealed ADON A entered Resident #18's room and began skin assessment at the feet of resident who had dry dirt and grime in between his toes, as well as a scabbed area to top of left great toe. 8) Review of Resident #20's Annual MDS, dated [DATE], revealed the resident was a [AGE] year-old female who admitted to the facility 02/09/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 07/20/2021 at 11:05 AM revealed ADON A removed a contaminated trash bag from the treatment cart with bare hands and took the trash to the soiled utility room. Upon exiting the soiled utility room she did not perform any hand hygiene. She proceeded to Resident #20's room and began a skin assessment. Observation on 07/20/2021 at 10:34 AM revealed as ADON A measured Resident #20's wound she got BM on her gloves. ADON A proceeded to complete the skin assessment, touching other parts of the resident's body with gloves that had BM on them. She touched the residents G-tube tubing from one side of the body to the other 9) Review of Resident #55's face sheet, dated 07/16/21, revealed the resident was a [AGE] year-old who female admitted to the facility 09/24/10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 07/20/21 at 2:19 PM revealed ADON A revealed performing wound care to Resident #55. She was observed measuring the resident's wounds on the right foot, the left foot, and the buttocks wounds with the same paper measuring ruler. After measuring each wound, ADON A wrote the measurements on the back of the paper ruler. 10) Review of Resident #5's face sheet, dated 07/22/21, revealed the resident was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS, dated [DATE], revealed, BIMS score 00with severe cognitive impairment, extensive 2-3 person ADL assistance, always incontinent to bowel and bladder, at risk for pressure ulcer/injuries. Observation on 7/20/21 at 8:51 AM, Resident #5's skin assessment revealed, ADON A began the resident's assessment at resident's feet and the resident had dried bowel movement that extended up their buttocks and onto sheet underneath the resident. ADON A wiped bowel movement away with her gloved hand as she continued to push the soiled brief out of the way, again surveyor asked her to remove the brief and clean the resident for better viewing, at which time she obtained some wipes from the bedside table and cleaned the resident's buttocks. There still remained dried bowel movement on his upper buttocks, and ADON A had visibly soiled gloves at this point. Resident #5's right hand was contracture, nails very long possibly digging into hand, unable to open his hands for viewing his palm. Resident #5 had five yellow bruises to upper left arm, various stages of healing. ADON A and Regional Nurse then assisted to turn resident onto his left side exposing resident's back and right buttocks. Sheets completely soaked and brief completely soaked and wet with dark urine and dried dark blood on the upper part of the sheet, ADON A reached behind Resident #5 and her hand came out with red frank blood. ADON A rolled him to his left side, once resident was on his left side his back was exposed and there were three open soft reddish areas to right upper back, Dry flaky skin to entire back and a yellow crust that covered the entire back with a blue tint that ADON A stated was epithelial,. ADON A then then used her soiled gloved hands with visible bowel movement on her gloves, to touch and measure the open areas to Resident #5's back. 11) Review of Resident #92's Admission MDS, dated [DATE], revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 12) Review of Resident #24's Face Sheet dated 07/22/21 revealed [AGE] year-old male who admitted [DATE] with COVID-19, [CONDITION(S)], Abnormalities of gait and mobility, repeated falls, contracture, joint, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, overactive bladder, etc. Review of Resident #24's Quarterly MDS dated [DATE] revealed, BIMS score 09 with severely impaired cognition, extensive one to two person ADL assistance, at risk for developing pressure ulcer/injuries, skin conditions: BLANK. Review of Resident #24's Weekly Skin Check Sheet dated 07/17/21 at 9:35 AM revealed, Left toe scab around nail, Vertebrae rash with current treatment, Left lower (front) leg small scabs, no redness, dry no pain. Review of Resident #24's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .apply miconazole cream topically to left underarm qday and prn . Observation on 07/20/21 at 10:50 AM of Resident #24 skin assessment revealed, the resident was complaining of their back itching, there was a very large rash on their back that was scaly and scabbed skin in the left shin area. Resident's groin area was very moist and oily, ADON A stated it was an skin barrier ointment. Resident #24 had a large Bowel movement in their brief and ADON A attempted to pull the resident's brief down around and the HHSC surveyor asked ADON A to obtain some wipes to clean the resident up for better viewing of the buttocks. ADON A left room and returned with a brief and wipes and began to clean the resident and once she was done cleaning him she left bowel movement on his bottom. Resident was asked how long he had been dirty and he replied since breakfast. Regional Nurse whispered to ADON A to wash her hands which ADON A did however but there was dried bowel movement still on the resident's skin so ADON A had to wipe harder to remove it. Resident #24 Left buttock crease had a darkened area that was 5 cm x 0.5 cm and tender to touch the resident stated it is from the dirty brief, they always put it on too tightly. After ADON A finished cleaning the resident she did not change gloves and proceeded to move the resident then a small piece of bowel movement was on draw sheet then ADON A picked up and stated it is bowel movement. Resident #24 had a small scratch in the upper buttocks/hip region, nontender. Red under left under arm, red and moist and resident complained of the area hurting .resident denied anyone putting anything on the area and stated he did not have any deodorant to use. Resident #24 stated he had a boil under his left under arm area. ADON A used same gloves to place clean linen on bed, gloves were soiled from cleaning bowel movement then ADON A carried the trash with dirty brief to her trash on the side of her treatment cart and the linen was taken to the soiled utility room with ungloved hands and after she left the utility room she did not wash her hands or perform hand hygiene. Observation on 07/14/21 at 10:19 AM of HSK S revealed she entered the rooms of Residents #61, #93, and #92 without changing the gown in between contact with items during cleaning of each room. An observation on 07/14/21 at 9:05 AM revealed CNA T removed trash from two resident rooms on the quarantine unit without wearing gloves. An observation on 07/14/21 at 9:47 AM of the Central Supply Clerk revealed she exited the quarantined unit with boxed PPE then entered the non-quarantined halls of the facility and began to stock a PPE cart. An observation on 07/14/2021 at 9:50 AM, revealed in the warm zone/quarantine hall CNA T exited the quarantine unit with a contaminated trash cart onto hall 300. In an interview on 07/14/2021 at 10:16 AM COTA KK stated he had been in-serviced that he could wear the same gown the entire time he was on the quarantine unit, no matter his resident contact. He stated he would wash his hands once he got back to the therapy room because they had a small sink in there. Observation on 7/17/21 at 12:00 PM revealed ADON A entered the room of Resident #354 and began the assessment of his wounds on feet. She measured his wound with wound vac on his left heel before measuring wounds on 5th toe right foot, then the right buttock, right gluteal fold, then measured the wounds on his bilateral ears. An observation on 07/14/2021 at 10:19 AM revealed HSK S exited the quarantined unit with her housekeeping cart to the non-quarantined hall 300 of the facility. Observation on 07/14/21 at 10:08 AM, COTA KK and CNA MM did not don or doff required PPE nor perform hand hygiene before or after going from the quarantine unit to the nonquarantine halls. Interview on 7/14/21 at 10:23AM with COTA KK in front of therapy gym revealed he worked at the facility when needed but he provided occupational therapy to residents on and off the warm hall. When asked if he just provided services to residents on one side or the other each day as to keep the isolation practice separated daily, he replied No I go all over the building on the days that I work. Observation on 7/17/21 at 11:40 AM revealed ADON A and Regional Nurse entered the 300 cold zone hall with a contaminated wound care treatment cart from the 400-hall warm zone after they completed wound care to 400 hall warm zone residents without disinfecting the cart. Observation on 07/21/21 at 2:05 PM revealed there were no gloves outside or inside of the residents PPE bins in the 400 hall Quarantine/Warm zone. Observation and interview on 07/21/21 at 2:45 PM, inside of the 400 warm zone/quarantine unit, Medication Aide MM took the HHSC surveyors to the hopper room (used for rinsing out contaminated laundry soiled with blood, feces, urine) were several boxes of PPE were stored there was approximately five large boxes of gowns, two medium sized boxes of face shields , two medium size boxes of goggles, a box of N95 masks. Medication Aide MM stated they had approximately 100-150 N95 masks, 20 face shields, 20 goggles, and 4 large boxes of gowns. She stated the central supply room had over the counter medication an ancillaries. And the storage room to the right of the hopper room had supplies and approximately 500 pairs of gloves and 12 packs of wipes, N95 masks. Medication Aide MM stated the other PPE was stored in the hopper room because they had no other place to store it. Observation on 07/21/21 at 2:50 PM, inside of the 400-hall warm zone/quarantine unit and on the side of the linen cart there was approximately three of four pair of gloves inside of a blue net bag with an empty peanut trash wrapper in it. An interview on 07/14/21 at 10:02 AM with CNA T revealed after the trash had been removed from the quarantine unit, she used a cart to take the contaminated trash through a nonquarantined hall to the dumpster. CNA T stated she had been employed at the facility for 4-5 months and worked PRN. She stated she was not always assigned to the warm hall (quarantine unit); that she worked all over the building. She stated yesterday (07/13/21) she worked the cold hall 300 (non-quarantine). When asked about her exit out of the warm hall (400) into the cold hall (300) with contaminated trash, she stated that she had always taken the trash from the warm hall out of the door entering into the cold hall, 300. She said, Today central supply clerk stopped me as I got out the door and told me to not take the trash out that door today; she told me to go out the back door off of the 400 hall. She stated she had been in-serviced about 2 weeks ago on when to change gowns and said, When I leave this hall (400) and/or come back onto this hall. Interview on 7/14/21 at 10:13 AM with CNA MM revealed he was a restorative aide that worked the entire building. When asked what services he provided to the residents on the warm hall he replied, I come over here every day and I do weights and exercises to them. He stated there were 3 restorative aides in the facility and that any of them came over to the warm hall every day. When asked when he was last in-serviced on COVID-19, he stated he attended an in-service last month (June 2020) and they were told that when they entered the warm hall they were to wear a gown, N95 mask and face shield or goggles. He denied anyone ever telling him that he should not be crossing over from cold to warm halls during. In an interview on 07/14/21 at 12:37 PM the DON stated, Staff do not have to glove when removing or handling trash unless they can see it is visibly soiled or contaminated for both the quarantine unit and the other halls in the facility. She stated the infection control policy for handling infectious waste was staff did not have to wear gloves when handling trash. After the surveyor went over the facility's policy on handling infectious waste with the DON, the DON then said she had to get clarification on the policy. The DON stated she was asked about staff crossing over from warm hall to cold hall during their shift and not being designated to one hall. The DON replied no one crossed over. She stated the trash was removed from the warm hall by the maintenance director; so that the aides did not have to take the trash from the hall. The DON stated there were three restorative aides employed at the facility and two were assigned each day and they should not be crossing over from nonquarantined hall (cold halls) to quarantined hall (warm hall). She stated if someone had to cross over to the warm hall, then they must be vaccinated; if they were not COVID-19 vaccinated then they didn't cross over. She stated for the Spanish-speaking staff members they were in-serviced by Receptionist L. The DON then clarified that staff should not have transported the contaminated trash from the quarantined unit though the other halls of the facility. She said the maintenance director removed the trash from the quarantine hall at least once a day and took it to the dumpster. She said staff did not remove the trash but if they had to then they should exit the back door of the quarantine hall and should not cross over into the other facility halls. The DON she stated staff should be changing their gowns and gloves every time they exited a resident's room on the quarantine unit. The DON stated that staff are assigned to one side or the other and should not be crossing over as there are plenty of staff to cover both sides (quarantine hall and nonquarantined halls) and that this is stated in the facility policy. Interview on 7/14/21 at 12:45 PM w [TRUNCATED]

Based on observations, interviews and record reviews the facility failed to ensure residents had the right to be free from neglect for 10 (Residents #5, #19, #24, #44, #54, #60, #78, #99, #101 and #354) of 29 residents and one (Resident #56) of two residents reviewed for Abuse. A)The facility only had one wound care nurse which resulted in the facility not providing adequate skin assessments and treatments for residents with skin conditions and pressure ulcers/injuries. ADON A failed obtain more wound care training, her Wound care certification was from April 2016. The facility failed to adequately train staff and monitor to ensure staff followed their infection control policy. ADON A was the Infection Control Preventionist and failed to follow the facility's infection control policy. ADON A failed to properly conduct wound care assessments by not washing her hands and changing gloves when in contact with feces, urine and other contaminants. The facility failed to have enough CNA's to provide showers and incontinent care. An Immediate Jeopardy (IJ) was identified on 7/16/21 at 9:17 PM and while the IJ was lowered on 7/27/21 at 5:10 PM to a severity level of Actual harm that was not Immediate Jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. These failures could place the residents at risk of increased pain, infections, wounds and abuse which could decrease their psycho-social well-being and quality of life. Findings included: A 1)Review of Resident #60's Face Sheet dated 07/16/21 revealed a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Quarterly MDS (minimum data set) dated 06/14/21 revealed a BIMS (Brief interview for mental status) score was 13 with intact cognition, extensive two person ADL assistance, a catheter and always incontinent to bowel .at risk of developing pressure ulcers with unhealed ulcers (one stage III pressure ulcer and 4 stage IV pressure ulcers) . Review of Resident #60's Care plan dated 07/08/21 revealed, Care plan for pressure ulcers including one The resident has a stage IV pressure ulcer to sacrum or potential for pressure ulcer development r/t (related to) disease process, Goal: BLANK, Interventions/Tasks: an healing progress .Report declines to the MD (medical doctor). Review of Resident #60's Nurses Progress Notes by ADON A dated 06/30/21 at 2:44 PM revealed, Received a call from facility doctor regarding continued use of antiretroviral medication was instructed to follow up with specialist if continued use was necessary .call was placed to specialist and new order to discontinue antiretroviral medication, facility doctor and resident notified of change. Review of Resident #60's Order Summary Report dated 07/19/21 revealed, No antiretroviral medication the resident's medication profile . Review of Resident #60 Lab results report dated 07/13/21 at 12:22 PM revealed, (WBC) 19.8 (H) Normal values on scale 3.8 - 10.1 k/mm3 and (RBC) 3.02 (L) Normal values on scale 4.40 - 5.80 M/mm3. Review on 07/16/21 of the facility's binders of shower sheets revealed, they were three to four months old and Resident #60 had no shower sheets in any of the binders. Review of Resident #60's ADL Care Tasks in the facility's Electronic Medical Record revealed the last documented shower was system generated on 03/13/21. Review of Resident #60's showers sheets were requested on 07/27/21 at 11:36 AM and Administrator said at 4:50 PM she could not locate them because the former DON and ADON A kept up with them. Review of Resident #60's Facility's Wound care Doctor Progress note dated 12/31/20 revealed six unstageable wounds and two diabetic wounds and one initial encounter stage IV sacrum pressure injury (moderate amount of serous drainage no odor) measurements: 5.5 cm length x 3.5 cm width x 1 cm depth. Review of Resident #60's Facility Wound care Doctor Progress note dated 07/17/21 revealed, Two abrasions, two trauma ulcers and three stage IV pressure ulcers: Sacrum (coccyx to the bone exposed) measurements: 7.5 cm length x 4.3 cm width x 3.0 cm depth. Review of Resident #60's Nurse's Progress notes from 05/20/21 at 9:21 AM to 07/25/21 at 6:15 AM, the resident had taken several antibiotics by mouth and IV antibiotics for wound infections and ([CONDITION(S)]) Urinary tract infections. Observation of Resident #60 on 07/17/21 at 2:34 PM, Resident #60 assessment of wounds revealed, wound #1 large open area with yellow slough approximately the size of a dollar bill left lateral buttocks. Wound #2 large open area to right medial buttock open wound with crust and eschar present and uneven wound edges approximately the size of a dollar bill. Wound #3 right lower buttocks fold appeared to be a split or a cut appearance was bloody in appearance no drainage noted. ADON A stated, oh this is new, it appears like it is an abrasion. Wound #4 left clavicle area more medial to spine crusty area. Wound #5: Right lower clavicle region with dry crusty skin with redness surrounding crust. Wound #6: Sacral wound very large in size appeared to be a stage IV pressure in (in my professional opinion), approximately size of a dollar bill. Wound #7: left lateral upper calf region, scabbed area approximately 3 long. Wound #8: left medial buttocks a cluster of 4 open areas each lesion being approximately the size of a dime. Wound #9: large open area just below sacral wound, approximately 6 in diameter, wound exposed the bone a small bit, wound bed with yellow slough, small edge of eschar, granulation present to wound bed. Wound #10: right medial lower buttocks, quarter size open area wound bed red in appearance. Wound #11: Medial buttocks dressing removed, wound blue in color approximate size of half dollar. Wound #12: Sheering red (blood tinged) area to bilateral scrotum. Wound #13: Small open area to (abrasion) to rt. Medial distal foot. Wound #14: Nickel size red area to anterior/lateral right knee. Wound #15: Right lateral malleolus, ½ dollar size open area with white slough, area appears to be a stage IV pressure wound, wound edges uneven and red (inflamed appearance), tender to touch for resident as he grimaced and said ouch when ADON A touched it. Wound #16: Right anterior foot at bend of foot, small scabbed area approximately 2 in length. Wound #17: Right lateral foot, small scabbed area with eschar present, approximately size of a dime. Wound #18: Right foot on top of small toe (5th digit), dime size scabbed area. Wound #19: left medial heel size of ½ dollar size, crusted wound. Wound #20: Ulceration to front of right testicle 2cm x 2.3cm in size (ADON A measured this, stating this was new too). Review of Resident #60's Nurses Note dated 07/22/21 at 3:51 PM revealed, Wound care Doctor here to resident Right lateral malleolus 1.4 x 1.4 x 0.5 40 slough 20 necrotic 40 granulation with moderate drainage, continue same treatment. Sacrum 7.5 x 4.3 x 3.0 30 slough 40 necrotic, 30 granulation with coccyx bone exposed, moderate green purulent drainage, undermining 4.5 3-9 o'clock. Continue same treatment. Left ischium 7.8 x7.5 x 1.0 80 slough, 10 granulation 10 epithelial with moderate draining. Treatment changed to calcium alginate and a dry dressing daily. Right ischium 8.0 x 5.5 x.0.4 20 slough 70 necrotic 10 granulation with moderate drainage. Treatment changed to calcium alginate daily. Right med heel 4.0 x4.5x 0.2 100 necrotic with no drainage. Continue with same treatment. Right 5th lateral toe 4.0 x1.5 x0.2 60 necrotic 40 epithelial with no drainage. Continue same treatment . Review of Resident #60' Weekly Skin Checks dated 07/13/21 revealed, Sacrum wound treatment in progress, right ankle (outer) treatment in progress, right 5th toe abrasion treatment in progress, right ischium treatment in progress, left ischium treatment in progress, right heel medial heel blood blister. Review of Resident #60's Skin/wound note dated 07/21/21 at 9:16 AM revealed, Resident seen yesterday by Wound care Doctor for weekly wound evaluation. Wound care Doctor reporting that despited [sic] good and consistent wound care and bedside debridement resident would further benefit from a OR debridement and would like to have them referred to a specialty hospital for an evaluation. Facility Doctor notified and agreed with the recommendation. Review of Resident #60's Skin/Wound note dated 07/21/21 at 3:46 PM revealed, Spoke with specialty hospital representative regarding possible admission for in-patient wound care, after review of benefits/insurance she reports the resident does not have a payor source for specialty hospital admission .call Wound care doctor for further instruction and or other options. Review of Resident #60's Skin/Wound note dated 07/21/21 at 3:58 PM revealed, Spoke to Wound care doctor about with the resident not having a payor source for specialty hospital admission, Doctor is recommending since this is a non-urgent situation we could contact county hospital and get them set up in their clinic for an appointment with general surgeon for evaluation and assessment and possible surgical debridement of sacral wound Scheduler in facility notified of appointment need. Resident educated. Review on 07/26/21 of Resident #60's Electronic Medical Record dated 07/25/21 at 6:00 PM revealed, The Change in condition's reported . skin wound or ulcer .at 6:15 PM may transfer pt. to hospital for eval and treat for possible [CONDITION(S)] . Interview on 07/27/21 at 3:09 PM, Resident #60's Hospital Nurse said Resident #60 came from a healthcare facility on 07/25/21 and had an incision and debridement procedure of sacral and bilateral ischium decubitus ulcer and placement of a wound vac on 07/26/21. She stated the hospital physician noted some foot wounds and noted Resident #60 had this sacral wound for the past nine months, that was treated at the healthcare facility, but now had significant infection, necrosis and [CONDITION(S)]. She said Resident #60's treatment plan was ordered for a wound vac and two IV antibiotic medications with dressings to his wounds . Review of Resident #60's Hospital Records dated 07/25/21 revealed, Hospitalist History and Physical - Chief complaint: I have a wound and they aren't turning me .Labs: (WBC) White Blood Count: 22.08 (H) [scale 4.00 -11.00 k/ul], Red Blood Count: 3.08 (L) [4.00 -5.80 M/ul]- .Plan: [CONDITION(S)], turn patient q 2 hours, boot heel protectors, wound care, consult with doctor, a/w [CONDITION(S)] .will start broad spectrum antibiotics .seen by specialist doctor .[CONDITION(S)] (HCC) Thrombocytosis (HCC), suspected source is skin soft tissue .severe [CONDITION(S)] is thought possibly present with evidence of acute injury .Radiology: Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/27/21 at 2:50 PM, Resident #60 at the hospital, stated they had surgery yesterday 07/26/21 on the wound of their bottom and the hospital staff said a fist could fit into it and said they did not know their wounds were this bad. 2)Review of Resident 354's Face Sheet dated 07/16/21 revealed a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #354's Quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 07 extensive assist with ADL's .always incontinent to bowel and bladder .at risk of developing pressure ulcer/injuries .unhealed pressure ulcer/injuries: BLANK . Review of Resident #354's Care Plan dated 05/06/21 revealed, Extensive one person assist, always incontinent to bowel and bladder and at risk for pressure ulcer/injuries. Review of Resident #354's Wound care Doctor's progress noted dated 03/23/21 revealed, On 10/22/20 Resolved scrotum wound today .On 03/21/21 asked to assess a recently discovered wound on a previous wound care patient .Assessment: Wound left buttock is an abrasion and has received a status of not healed. Subsequent wound encounter measurements are 2.5 cm length x 3 cm width x 0.2 cm depth. Review of resident #354's Skin/wound by ADON progress note dated 06/15/21 at 2:45 PM revealed, Resident seen by wound Medical Doctor for weekly evaluation .Left stage III heel deteriorated from previous week. New treatment order given to start .dressing to wound bed qday . Review of Resident #354's Skin/wound note by ADON dated 07/06/21 at 4:38 PM revealed, Resident seen by Wound Medical Doctor for weekly visit. Wound to Left heel is deteriorating and is noted with purulent drainage as well as peri wound [CONDITION(S)], suspected [CONDITION(S)] .call placed to doctor . Review of Resident #354's Wound care Doctor note dated 07/06/21 Wound #13 Left Heel is a Stage IV Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are: 1.5cm length x 1cm width x 0.5cm depth, with an area of 1.5 cm and a volume of 0.75 cubic cm. There is a heavy amount of drainage noted which has no odor. Wound bed has 5% slough, 95% granulation. General Notes: [CONDITION(S)] and bone exposed Wound #15 Left Fifth Toe Clustered is a Diabetic Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1cm length x 2cm width x 0.3cm depth, with an area of 2 cm and a volume of 0.6 cubic cm. There is a moderate amount of drainage noted. Wound bed has 50% epithelialization, 10% slough, 40% granulation. Review of Resident #354's Skin/wound note by ADON A dated 07/08/21 at 4:30 PM revealed, Resident noted with increased [CONDITION(S)], increased drainage with odor and increased pain to wound that is extending up the back his leg. Despite the start of antibiotic this wound is showing rapid deterioration from previous day .send resident to ER for further evaluation for deteriorating wound and MRI for further diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 354's Hospital Discharge paperwork dated 07/16/21 revealed, Assessment: 1. Left heel ulceration with necrosis of the bone, left calcaneal [CONDITION(S)], left heel abscess s/p, left foot incision and drainage through the bone cortex, partial excision of the left calcaneus done on 07/11/21 .2. Left heel infection-surgical left heel deep soft tissue cultures positive for [CONDITION(S)], group A Strep .3.[CONDITION(S)] .4. Afib .5. Diabetes type 2, hypertension .6. Old [CONDITION(S)] with right [CONDITION(S)] .7. History of COVID .8. History of C-diff [CONDITION(S)] . Observation of Resident #354' Skin assessment on 07/20/21 at 1:55 PM revealed, Left heel pressure wound . Stage IV with bone and muscle showing .4 sutures at proximal end of the wound. 7.0 x 4.0 x 0.5 cm with serosanguinous scant drainage. No undermining, no tunneling. No odor. Peri-wound blanchable. Pain evident by resident's facial grimacing . DON said dietary interventions included shakes and I'll have to see Low air loss mattress. DON stated the wound was debrided today . Cluster of bruising on left forearm (large areas of ecchymosis). 17.5 x 18cm Cluster of bruising on left hand (ecchymosis) 8cm x 6.0 cm Left upper arm scar. Lest wrist purple. Double lumen port. Resident gets [CONDITION(S)] . Dressing undated and DON stated that is a [CONDITION(S)] dressing. Faint Left thigh bruise 3.0 x 3.5 cm Scab on Right knee 0.2 x 0.3 cm Hernia right of umbilicus. Red excoriated line on right upper thigh/groin area that goes toward the back of right buttock (shape of a Foley catheter). 18.5 x 1.0. Left toes red around nails and red skin between toes. Left 5th toe 1.5 x 1.5cm. lateral 5th toe 1.0 x 1.0 cm. Left top of foot and ankle cluster. Left lateral foot DTI. 0.5 x 1.3 cm gray. PAD diagnosis. Discoloration on lower left leg. Right groin line mentioned extended to right buttock and had another thin red line 5.5 x 0.5 cm. Right side upper back with what appeared to be a broken blood vessel. Open Right buttock 0.5 x 1.3 x 0. Right lower buttock pealing 1.0 x 1.0 x 0. Left upper thigh discoloration. Left lower back with pink area. Left buttock scar. Right ankle on outer side cluster of reddened areas (1.0 x 1.0, 1.0 x 0.2, 0.3 x 0.2, 0.2 x 0.2) . Right hand brace. Bruises on dorsal side of hand. Cluster of bruises 6.0 x 7.5 cm. Bruise and scrape 2.5 x 2.0 on right forearm . Resident #354's Wound vac was observed hanging at the foot of the bed, not connect to the resident. DON stated the wound vac was not connected because they knew surveyor were coming to see the wound and the dressing will have to be taken off. 3)Review of Resident #5's Face Sheet dated 07/22/21 revealed an [AGE] year-old who male admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive 2-3 person ADL assistance, always incontinent to bowel and bladder, at risk for pressure ulcer/injuries Review of Resident #5's Care Plan dated 06/25/21 revealed, The resident has potential for pressure ulcer development r/t history of pressure ulcers, limited mobility and incontinence .Bowel and bladder incontinence and at risk for pressure ulcer/injuries. Review of Resident #5's Weekly Skin Sheet dated 07/04/21, 07/11/21 and 07/13/21 revealed, no skin impairments. Review of Resident #5's Weekly Skin Sheet dated 07/17/21 revealed, Vertebrae upper mid Moisture Associated Skin Damage 1.0 cm x 1.0 cm x 0.1 cm and vertebrae upper mid Moisture Associated Skin Damage 10.0 cm x 10.0 cm x .01 cm. Observation on 7/20/21 at 8:51 AM, Resident #5's skin assessment revealed, ADON A began their assessment at the resident's feet and the resident had dried bowel movement that extended up their buttocks and onto sheet underneath the resident. ADON A wiped bowel movement away with her gloved hand as she continued to push the soiled brief out of the way, again surveyor asked her to remove the brief and clean the resident for better viewing, at which time she obtained some wipes from the bedside table and cleaned the resident's buttocks. There still remained dried bowel movement on his upper buttocks, and ADON A had visibly soiled gloves at this point. Resident #5's right hand was contracture, nails very long possibly digging into hand, unable to open his hands for viewing his palm. Resident #5 had five yellow bruises to upper left arm, various stages of healing. ADON A and Regional Nurse then assisted to turn resident onto his left side exposing resident's back and right buttocks. Sheets completely soaked and brief completely soaked and wet with dark urine and dried dark blood on the upper part of the sheet, ADON A reached behind Resident #5 and her hand came out with red frank blood. ADON A rolled him to his left side, once resident was on his left side his back was exposed and there were three open soft reddish areas to right upper back, Dry flaky skin to entire back and a yellow crust that covered the entire back with a blue tint that ADON A stated was epithelial,. ADON A then then used her soiled gloved hands with visible bowel movement on her gloves, to touch and measure the open areas to Resident #5's back. 4)Review of Resident 19's Face Sheet dated 07/22/21 revealed an [AGE] year-old female who admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's MDS dated [DATE] revealed BIMS score 00 with severely impaired cognition, extensive 1-2 person assist with ADL's, always incontinent with bowel and bladder and at risk for pressure ulcers/injuries . Review of Resident #19's Care plan dated 06/17/21 revealed, Resident has potential for pressure ulcer development r/t limited mobility and incontinence Review of Resident 19#'s Weekly Skin check dated 07/05/21 and 07/12/21 revealed, No skin issues. Review of Resident 19's Weekly Skin check dated 07/20/21 revealed, Sacral Fissure between the middle of buttock . Review of Resident 19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .everyday shift for fissure. Interview and observation of Resident #19 on 07/20/21 at 9:21 AM, upon HHSC Surveyor observation of two coccyx open areas while Resident #19 was laying on a standard bed, the DON stated this was a crack and then said it was a fissure. Full depth opening. Pink wound bed. No odor, no signs/symptoms of infection, no exudate. Blanchable. One measured 0.5 x 0.2 x 0. Another wound measured 2.0 x 0.5 x 0. Interview on 07/20/21 at 9:38 AM, when asked if Resident #19's wounds had already been identified the DON responded, Identified already but have to verify. Review of Resident #19's Weekly Skin Check dated 07/05/21 and 07/12/21 revealed, No skin impairments. Review of Resident #19's Weekly Skin Check dated 07/20/21 revealed, Sacrum: Fissure between the middle of buttocks .Callous to right lateral heel. 5)Review of Resident #24's Face Sheet dated 07/22/21 revealed [AGE] year-old male who admitted [DATE] with COVID-19, [CONDITION(S)], Abnormalities of gait and mobility, repeated falls, contracture, joint, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, overactive bladder, etc. Review of Resident #24's Quarterly MDS dated [DATE] revealed, BIMS score 09 with severely impaired cognition, extensive one to two person ADL assistance, at risk for developing pressure ulcer/injuries, skin conditions: BLANK. Review of Resident #24's Care Plan dated 07/22/21 revealed, Risk of skin breakdown .non-compliance will encourage . Review of Resident #24's Weekly Skin check sheet dated 07/05/21 revealed, No skin impairments. Review of Resident #24's Weekly Skin check sheet dated 07/09/21 revealed, Vertebrae (upper-mid) rash. Review of Resident #24's Weekly Skin check sheet dated 07/13/21 revealed, Vertebrae (upper-mid) rash treatment continued. Review of Resident # 24's Weekly Skin Check Sheet dated 07/17/21 at 12:50 AM revealed, This resident did not have any skin impairments. Review of Resident #24's Weekly Skin Check Sheet dated 07/17/21 at 9:35 AM revealed, Left toe scab around nail, Vertebrae rash with current treatment, Left lower (front) leg small scabs, no redness, dry no pain. Review of Resident #24's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .apply miconazole cream topically to left underarm qday and prn . Observation on 07/20/21 at 10:50 AM of Resident #24 skin assessment revealed, the resident was complaining of their back itching, there was a very large rash on their back that was scaly and scabbed skin in the left shin area. Resident's groin area was very moist and oily, ADON A stated it was an skin barrier ointment. Resident #24 had a large Bowel movement in their brief and ADON A attempted to pull the resident's brief down around and the HHSC surveyor asked ADON A to obtain some wipes to clean the resident up for better viewing of the buttocks. ADON A left room and returned with a brief and wipes and began to clean the resident and once she was done cleaning him she left bowel movement on his bottom. Resident was asked how long he had been dirty and he replied since breakfast. Regional Nurse whispered to ADON A to wash her hands which ADON A did however but there was dried bowel movement still on the resident's skin so ADON A had to wipe harder to remove it. Resident #24 Left buttock crease had a darkened area that was 5 cm x 0.5 cm and tender to touch the resident stated it is from the dirty brief, they always put it on too tightly. After ADON A finished cleaning the resident she did not change gloves and proceeded to move the resident then a small piece of bowel movement was on draw sheet then ADON A picked up and stated it is bowel movement. Resident #24 had a small scratch in the upper buttocks/hip region, nontender. Red under left under arm, red and moist and resident complained of the area hurting .resident denied anyone putting anything on the area and stated he did not have any deodorant to use. Resident #24 stated he had a boil under his left under arm area. ADON A used same gloves to place clean linen on bed, gloves were soiled from cleaning bowel movement then ADON A carried the trash with dirty brief to her trash on the side of her treatment cart and the linen was taken to the soiled utility room with ungloved hands and after she left the utility room she did not wash her hands or perform hand hygiene. 6)Review of Resident #44's Face Sheet dated 07/16/21 revealed a [AGE] year-old female who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive two person ADL assistance, always incontinent to bowel and bladder, at risk of developing pressure ulcers/injuries, and no unhealed pressure ulcers/injuries. Review of Resident #44's Care Plan undated revealed, The resident has the potential for pressure ulcer development r/t limited mobility and incontinence. Review of Resident #44's Weekly Skin Check dated 01/22/20 revealed, The resident had no skin impairment. Review of Resident #44's Wound care Doctor note dated 07/06/21 revealed, Right anterior ankle is an arterial ulcer and has received a status of not healed. Measurements:1 cm x.0.9 cm x 0.3 cm, no odor .and Right anterior leg is a skin tear and has received a status of not healed. Measurements: 6 cm x 2 cm x .03 cm, no odor. Review of Resident #44's Weekly Skin Check dated 07/13/21 revealed, Right lower leg (front) skin tear treatment continues and right anterior ankle wound treatment continues. Review of Resident #44's Wound care Doctor note dated 07/13/21 revealed, Right anterior ankle is an arterial ulcer and has received a status of not healed. Measurements: 2 cm x1 cm x 0.3 cm, no odor .and right anterior leg is a skin tear and has received a status of not healed. Measurements: 4 cm x 2 cm x 0.3 cm. Observation and Interview on 07/18/21 at 10:39 AM with HHSC State Surveyor, Resident #44 was severely hard of hearing in both ears but used a whiteboard for communication to staff, ADON A began assessment, noted: resident's socks (which left indentions to bilateral ankle area. Noted scabbed red and inflamed dime size area extending up from left ankle, ADON A said, this is from their socks. Resident had a cluster of four open areas to left anterior ankle, and cluster of approx. eight small open areas to right lower lateral shin. Resident #44 had multiple ecchymosis areas to right lower extremity from knee down through ankle. Resident stated pointing to their ankles that hurts, pointed to area of pressure from socks, where visible indentations were seen. Left lower extremity (shin area) scabbed area approximately 3 in length. Multiple scabbed areas to bilateral knees (ADON A stated that resident crawled on floor that caused wounds to their knees). In between 4th and 5th digit on left foot, large amount of grime and dirt build up in between those two digits. Fingernails on both hands were dirty and appeared to have dirt underneath them. Observation under bilateral breasts revealed white residue, in which resident stated, I put deodorant under my breasts. Large dollar bill size red, blanchable area to upper right buttocks. Resident has a red blanchable area to right posterior ankle approximate size of a nickel. Right lateral foot at 5th digit lateral, large (approximately 4) very red and inflamed, small crusted center to this area, this redness extended down the lateral side of the 5th digit, possibly a stage 1 pressure wound with a stage 2 in the center. 7)Review of Resident #54's Face Sheet dated 07/22/21 revealed an [AGE] year-old female who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive 2 person ADL assistance, always incontinent to bladder and bowel, at risk of pressure ulcers/injuries. Review of Resident #54's Care Plan dated 06/24/21 revealed, Resident at risk for pressure ulcer or potential for pressure ulcer development r/t red and yeast like area . Review of Resident #54's Weekly Skin Check dated 07/06/21 and 07/13/21 revealed, No skin impairments. Review of Resident #54's Weekly Skin Check dated 07/16/21 revealed, Dry abrasion to left lower leg .Perianal and buttock blanchable redness .red area to left groin. Observations and Interviews of Resident # 54 on 07/16/21 at 10:57 AM with HHSC Surveyor revealed, 3 bruises in various stages of healing to right lower leg. ADON A started with feet peeling skin on top of 2nd right toe, g-tube, breakdown under abdomen fold left side 4 cm x 0.3cm, breakdown to coccyx 9cm x 6cm blanchable, scabbed area left lower leg 0.5cm x 3.5cm x 2 scratches, had wound on right heel. 8)Review of Resident # 78's Face sheet dated 07/22/21 revealed, a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's Admission MDS dated [DATE] revealed, BIMS score 15 with intact cognition, extensive two person assist, occasionally incontinent to bladder and always incontinent to bowels, at risk for pressure ulcer/injuries and no unhealed ulcer/injuries. Review of Resident #78's Quarterly MDS dated [DATE] revealed, BIMS score 11 with moderately impaired cognition, extensive 2 person assist with ADL care, occasionally incontinent to bladder and always incontinent to bowels and at risk of pressure ulcer/injuries and two unhealed ulcer/injuries. Review of Resident #78's Care Plans dated 07/27/21 revealed, The resident has stage IV pressure ulcer to left post knee r/t disease process, immobility and wound deterioration noted, treatment order changed. Interview and observation of Resident #78 skin assessment on 07/20/21 at 8:55 AM with HHSC State Surveyor revealed, A Right 3rd, 4th, and 5th finger digits with small scabs. Bilateral tight shiny dependent LE [CONDITION(S)] with superficial veins visible. Left upper buttock 1.5 x 04 closed discoloration. DON said it was shear. Left lateral upper calf 4.2 x 3.0 x 0.3 cm open area with serosanguinous drainage on bandage dated 7/17/21. DON said it was three times a week change. DON said he had Peripheral Vascular Disease . Left heel dry. Left great toe knuckle 0.4 x 0 [TRUNCATED]

Based on observations, interviews and record reviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 10 (Residents #5, #19, #24, #44, #54, #60, #78, #99, #101, #354) of 29 residents reviewed for Pressure ulcers/injuries. ADON A failed obtain more wound care training, her Wound care certification was from 2016. The facility failed to properly assess and treat Resident #60's skin infected wounds who had abnormal labs with an elevated white blood CBC on 07/13/21 and not sent to the hospital until 07/25/21. The facility failed to properly assess and treat Resident #354, when he had a documented deterioration of his wounds on 06/15/21 and was not sent to the hospital until 07/08/21. The facility failed to properly identify, treat and document resident's with skin conditions such as bruises, skin tears, abrasions and ulcers/injuries for residents (#5, #19, #24, #44, #54,# 60, #78, #99, #101, #354). ADON A failed to accurately document the actual condition of Residents (#5, #19, #24, #44, #54, #78, #99, #101) skin conditions until HHSC surveyors conducted skin assessments with ADON A and DON. These failures placed residents at risk of increased pain, infections, wounds, abuse which could decrease their psycho-social well-being and quality of life. An Immediate Jeopardy (IJ) was identified on 7/16/21 at 9:17 PM and while the IJ was lowered on 7/27/21 at 5:10 PM the facility remained out of compliance at a severity level of Actual harm that was not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings included: 1)Review of Resident #60's Face Sheet dated 07/16/21 revealed a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Quarterly MDS (minimum data set) dated 06/14/21 revealed a BIMS (Brief interview for mental status) score was 13 with intact cognition, extensive two person ADL assistance, a catheter and always incontinent to bowel .at risk of developing pressure ulcers with unhealed ulcers (one stage III pressure ulcer and 4 stage IV pressure ulcers) . Review of Resident #60's Care plan dated 07/08/21 revealed, Care plan for pressure ulcers including one The resident has a stage IV pressure ulcer to sacrum or potential for pressure ulcer development r/t (related to) disease process, Goal: BLANK, Interventions/Tasks: an healing progress .Report declines to the MD (medical doctor). Review of Resident #60's Nurses Progress Notes by ADON A dated 06/30/21 at 2:44 PM revealed, Received a call from facility doctor regarding continued use of antiretroviral medication was instructed to follow up with specialist if continued use was necessary .call was placed to specialist and new order to discontinue antiretroviral medication, facility doctor and resident notified of change. Review of Resident #60's Order Summary Report dated 07/19/21 revealed, No antiretroviral medication the resident's medication profile . Review of Resident #60 Lab results report dated 07/13/21 at 12:22 PM revealed, (WBC) 19.8 (H) Normal values on scale 3.8 - 10.1 k/mm3 and (RBC) 3.02 (L) Normal values on scale 4.40 - 5.80 M/mm3. Review on 07/16/21 of the facility's binders of shower sheets revealed, they were three to four months old and Resident #60 had no shower sheets in any of the binders. Review of Resident #60's ADL Care Tasks in the facility's Electronic Medical Record revealed the last documented shower was system generated on 03/13/21. Review of Resident #60's showers sheets were requested on 07/27/21 at 11:36 AM and Administrator said at 4:50 PM she could not locate them because the former DON and ADON A kept up with them. Review of Resident #60's Facility's Wound care Doctor Progress note dated 12/31/20 revealed six unstageable wounds and two diabetic wounds and one initial encounter stage IV sacrum pressure injury (moderate amount of serous drainage no odor) measurements: 5.5 cm length x 3.5 cm width x 1 cm depth. Review of Resident #60's Facility Wound care Doctor Progress note dated 07/17/21 revealed, Two abrasions, two trauma ulcers and three stage IV pressure ulcers: Sacrum (coccyx to the bone exposed) measurements: 7.5 cm length x 4.3 cm width x 3.0 cm depth. Review of Resident #60's Nurse's Progress notes from 05/20/21 at 9:21 AM to 07/25/21 at 6:15 AM, the resident had taken several antibiotics by mouth and IV antibiotics for wound infections and ([CONDITION(S)]) Urinary tract infections. Observation of Resident #60 on 07/17/21 at 2:34 PM, Resident #60 assessment of wounds revealed, wound #1 large open area with yellow slough approximately the size of a dollar bill left lateral buttocks. Wound #2 large open area to right medial buttock open wound with crust and eschar present and uneven wound edges approximately the size of a dollar bill. Wound #3 right lower buttocks fold appeared to be a split or a cut appearance was bloody in appearance no drainage noted. ADON A stated, oh this is new, it appears like it is an abrasion. Wound #4 left clavicle area more medial to spine crusty area. Wound #5: Right lower clavicle region with dry crusty skin with redness surrounding crust. Wound #6: Sacral wound very large in size appeared to be a stage IV pressure in (in my professional opinion), approximately size of a dollar bill. Wound #7: left lateral upper calf region, scabbed area approximately 3 long. Wound #8: left medial buttocks a cluster of 4 open areas each lesion being approximately the size of a dime. Wound #9: large open area just below sacral wound, approximately 6 in diameter, wound exposed the bone a small bit, wound bed with yellow slough, small edge of eschar, granulation present to wound bed. Wound #10: right medial lower buttocks, quarter size open area wound bed red in appearance. Wound #11: Medial buttocks dressing removed, wound blue in color approximate size of half dollar. Wound #12: Sheering red (blood tinged) area to bilateral scrotum. Wound #13: Small open area to (abrasion) to rt. Medial distal foot. Wound #14: Nickel size red area to anterior/lateral right knee. Wound #15: Right lateral malleolus, ½ dollar size open area with white slough, area appears to be a stage IV pressure wound, wound edges uneven and red (inflamed appearance), tender to touch for resident as he grimaced and said ouch when ADON A touched it. Wound #16: Right anterior foot at bend of foot, small scabbed area approximately 2 in length. Wound #17: Right lateral foot, small scabbed area with eschar present, approximately size of a dime. Wound #18: Right foot on top of small toe (5th digit), dime size scabbed area. Wound #19: left medial heel size of ½ dollar size, crusted wound. Wound #20: Ulceration to front of right testicle 2cm x 2.3cm in size (ADON A measured this, stating this was new too). Review of Resident #60's Nurses Note dated 07/22/21 at 3:51 PM revealed, Wound care Doctor here to resident Right lateral malleolus 1.4 x 1.4 x 0.5 40 slough 20 necrotic 40 granulation with moderate drainage, continue same treatment. Sacrum 7.5 x 4.3 x 3.0 30 slough 40 necrotic, 30 granulation with coccyx bone exposed, moderate green purulent drainage, undermining 4.5 3-9 o'clock. Continue same treatment. Left ischium 7.8 x7.5 x 1.0 80 slough, 10 granulation 10 epithelial with moderate draining. Treatment changed to calcium alginate and a dry dressing daily. Right ischium 8.0 x 5.5 x.0.4 20 slough 70 necrotic 10 granulation with moderate drainage. Treatment changed to calcium alginate daily. Right med heel 4.0 x4.5x 0.2 100 necrotic with no drainage. Continue with same treatment. Right 5th lateral toe 4.0 x1.5 x0.2 60 necrotic 40 epithelial with no drainage. Continue same treatment . Review of Resident #60' Weekly Skin Checks dated 07/13/21 revealed, Sacrum wound treatment in progress, right ankle (outer) treatment in progress, right 5th toe abrasion treatment in progress, right ischium treatment in progress, left ischium treatment in progress, right heel medial heel blood blister. Review of Resident #60's Skin/wound note dated 07/21/21 at 9:16 AM revealed, Resident seen yesterday by Wound care Doctor for weekly wound evaluation. Wound care Doctor reporting that despited [sic] good and consistent wound care and bedside debridement resident would further benefit from a OR debridement and would like to have them referred to a specialty hospital for an evaluation. Facility Doctor notified and agreed with the recommendation. Review of Resident #60's Skin/Wound note dated 07/21/21 at 3:46 PM revealed, Spoke with specialty hospital representative regarding possible admission for in-patient wound care, after review of benefits/insurance she reports the resident does not have a payor source for specialty hospital admission .call Wound care doctor for further instruction and or other options. Review of Resident #60's Skin/Wound note dated 07/21/21 at 3:58 PM revealed, Spoke to Wound care doctor about with the resident not having a payor source for specialty hospital admission, Doctor is recommending since this is a non-urgent situation we could contact county hospital and get them set up in their clinic for an appointment with general surgeon for evaluation and assessment and possible surgical debridement of sacral wound Scheduler in facility notified of appointment need. Resident educated. Review on 07/26/21 of Resident #60's Electronic Medical Record dated 07/25/21 at 6:00 PM revealed, The Change in condition's reported . skin wound or ulcer .at 6:15 PM may transfer pt. to hospital for eval and treat for possible [CONDITION(S)] . Interview on 07/27/21 at 3:09 PM, Resident #60's Hospital Nurse said Resident #60 came from a healthcare facility on 07/25/21 and had an incision and debridement procedure of sacral and bilateral ischium decubitus ulcer and placement of a wound vac on 07/26/21. She stated the hospital physician noted some foot wounds and noted Resident #60 had this sacral wound for the past nine months, that was treated at the healthcare facility, but now had significant infection, necrosis and [CONDITION(S)]. She said Resident #60's treatment plan was ordered for a wound vac and two IV antibiotic medications with dressings to his wounds . Review of Resident #60's Hospital Records dated 07/25/21 revealed, Hospitalist History and Physical - Chief complaint: I have a wound and they aren't turning me .Labs: (WBC) White Blood Count: 22.08 (H) [scale 4.00 -11.00 k/ul], Red Blood Count: 3.08 (L) [4.00 -5.80 M/ul]- .Plan: [CONDITION(S)], turn patient q 2 hours, boot heel protectors, wound care, consult with doctor, a/w [CONDITION(S)] .will start broad spectrum antibiotics .seen by specialist doctor .[CONDITION(S)] (HCC) Thrombocytosis (HCC), suspected source is skin soft tissue .severe [CONDITION(S)] is thought possibly present with evidence of acute injury .Radiology: Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/27/21 at 2:50 PM, Resident #60 while at the hospital, stated they had surgery yesterday 07/26/21 on the wound of their bottom and the hospital staff said a fist could fit into it and said they did not know their wounds were this bad. 2)Review of Resident 354's Face Sheet dated 07/16/21 revealed a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #354's Quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 07 extensive assist with ADL's .always incontinent to bowel and bladder .at risk of developing pressure ulcer/injuries .unhealed pressure ulcer/injuries: BLANK . Review of Resident #354's Care Plan dated 05/06/21 revealed, Extensive one person assist, always incontinent to bowel and bladder and at risk for pressure ulcer/injuries. Review of Resident #354's Wound care Doctor's progress noted dated 03/23/21 revealed, On 10/22/20 Resolved scrotum wound today .On 03/21/21 asked to assess a recently discovered wound on a previous wound care patient .Assessment: Wound left buttock is an abrasion and has received a status of not healed. Subsequent wound encounter measurements are 2.5 cm length x 3 cm width x 0.2 cm depth. Review of resident #354's Skin/wound by ADON progress note dated 06/15/21 at 2:45 PM revealed, Resident seen by wound Medical Doctor for weekly evaluation .Left stage III heel deteriorated from previous week. New treatment order given to start .dressing to wound bed qday . Review of Resident #354's Skin/wound note by ADON dated 07/06/21 at 4:38 PM revealed, Resident seen by Wound Medical Doctor for weekly visit. Wound to Left heel is deteriorating and is noted with purulent drainage as well as peri wound [CONDITION(S)], suspected [CONDITION(S)] .call placed to doctor . Review of Resident #354's Wound care Doctor note dated 07/06/21 Wound #13 Left Heel is a Stage IV Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are: 1.5cm length x 1cm width x 0.5cm depth, with an area of 1.5 cm and a volume of 0.75 cubic cm. There is a heavy amount of drainage noted which has no odor. Wound bed has 5% slough, 95% granulation. General Notes: [CONDITION(S)] and bone exposed Wound #15 Left Fifth Toe Clustered is a Diabetic Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1cm length x 2cm width x 0.3cm depth, with an area of 2 cm and a volume of 0.6 cubic cm. There is a moderate amount of drainage noted. Wound bed has 50% epithelialization, 10% slough, 40% granulation. Review of Resident #354's Skin/wound note by ADON A dated 07/08/21 at 4:30 PM revealed, Resident noted with increased [CONDITION(S)], increased drainage with odor and increased pain to wound that is extending up the back his leg. Despite the start of antibiotic this wound is showing rapid deterioration from previous day .send resident to ER for further evaluation for deteriorating wound and MRI for further diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 354's Hospital Discharge paperwork dated 07/16/21 revealed, the resident had been on IV [MEDICATION(S)] since 07/09/21, for seven days and Assessment: 1. Left heel ulceration with necrosis of the bone, left calcaneal [CONDITION(S)], left heel abscess s/p, left foot incision and drainage through the bone cortex, partial excision of the left calcaneus done on 07/11/21 .2. Left heel infection-surgical left heel deep soft tissue cultures positive for [CONDITION(S)], group A Strep .3.[CONDITION(S)] .4. Afib .5. Diabetes type 2, hypertension .6. Old [CONDITION(S)] with right [CONDITION(S)] .7. History of COVID .8. History of C-diff [CONDITION(S)] .[MEDICATION(S)] 750 mg IV x1 after each hemodialysis on Mondays, Wednesdays and Fridays .stop date 08/22/2021. Observation of Resident #354' Skin assessment on 07/20/21 at 1:55 PM revealed, Left heel pressure wound . Stage IV with bone and muscle showing .4 sutures at proximal end of the wound. 7.0 x 4.0 x 0.5 cm with serosanguinous scant drainage. No undermining, no tunneling. No odor. Peri-wound blanchable. Pain evident by resident's facial grimacing . DON said dietary interventions included shakes and I'll have to see Low air loss mattress. DON stated the wound was debrided today . Cluster of bruising on left forearm (large areas of ecchymosis). 17.5 x 18cm Cluster of bruising on left hand (ecchymosis) 8cm x 6.0 cm Left upper arm scar. Lest wrist purple. Double lumen port. Resident gets [CONDITION(S)] . Dressing undated and DON stated that is a [CONDITION(S)] dressing. Faint Left thigh bruise 3.0 x 3.5 cm Scab on Right knee 0.2 x 0.3 cm Hernia right of umbilicus. Red excoriated line on right upper thigh/groin area that goes toward the back of right buttock (shape of a Foley catheter). 18.5 x 1.0. Left toes red around nails and red skin between toes. Left 5th toe 1.5 x 1.5cm. lateral 5th toe 1.0 x 1.0 cm. Left top of foot and ankle cluster. Left lateral foot DTI. 0.5 x 1.3 cm gray. PAD diagnosis. Discoloration on lower left leg. Right groin line mentioned extended to right buttock and had another thin red line 5.5 x 0.5 cm. Right side upper back with what appeared to be a broken blood vessel. Open Right buttock 0.5 x 1.3 x 0. Right lower buttock pealing 1.0 x 1.0 x 0. Left upper thigh discoloration. Left lower back with pink area. Left buttock scar. Right ankle on outer side cluster of reddened areas (1.0 x 1.0, 1.0 x 0.2, 0.3 x 0.2, 0.2 x 0.2) . Right hand brace. Bruises on dorsal side of hand. Cluster of bruises 6.0 x 7.5 cm. Bruise and scrape 2.5 x 2.0 on right forearm . Resident #354's Wound vac was observed hanging at the foot of the bed, not connect to the resident. DON stated the wound vac was not connected because they knew surveyor were coming to see the wound and the dressing will have to be taken off. 3)Review of Resident #5's Face Sheet dated 07/22/21 revealed an [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive 2-3 person ADL assistance, always incontinent to bowel and bladder, at risk for pressure ulcer/injuries Review of Resident #5's Care Plan dated 06/25/21 revealed, The resident has potential for pressure ulcer development r/t history of pressure ulcers, limited mobility and incontinence .Bowel and bladder incontinence and at risk for pressure ulcer/injuries. Review of Resident #5's Weekly Skin Sheet dated 07/04/21, 07/11/21 and 07/13/21 revealed, no skin impairments. Review of Resident #5's Weekly Skin Sheet dated 07/17/21 revealed, Vertebrae upper mid Moisture Associated Skin Damage 1.0 cm x 1.0 cm x 0.1 cm and vertebrae upper mid Moisture Associated Skin Damage 10.0 cm x 10.0 cm x .01 cm. Observation on 7/20/21 at 8:51 AM, Resident #5's skin assessment revealed, ADON A began the residents assessment at resident's feet and the resident had dried bowel movement that extended up their buttocks and onto sheet underneath the resident. ADON A wiped bowel movement away with her gloved hand as she continued to push the soiled brief out of the way, again surveyor asked her to remove the brief and clean the resident for better viewing, at which time she obtained some wipes from the bedside table and cleaned the resident's buttocks. There still remained dried bowel movement on his upper buttocks, and ADON A had visibly soiled gloves at this point. Resident #5's right hand was contracture, nails very long possibly digging into hand, unable to open his hands for viewing his palm. Resident #5 had five yellow bruises to upper left arm, various stages of healing. ADON A and Regional Nurse then assisted to turn resident onto his left side exposing resident's back and right buttocks. Sheets completely soaked and brief completely soaked and wet with dark urine and dried dark blood on the upper part of the sheet, ADON A reached behind Resident #5 and her hand came out with red frank blood. ADON A rolled him to his left side, once resident was on his left side his back was exposed and there were three open soft reddish areas to right upper back, Dry flaky skin to entire back and a yellow crust that covered the entire back with a blue tint that ADON A stated was epithelial,. ADON A then then used her soiled gloved hands with visible bowel movement on her gloves, to touch and measure the open areas to Resident #5's back. 4)Review of Resident 19's Face Sheet dated 07/22/21 revealed an [AGE] year-old female who admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's MDS dated [DATE] revealed BIMS score 00 with severely impaired cognition, extensive 1-2 person assist with ADL's, always incontinent with bowel and bladder and at risk for pressure ulcers/injuries . Review of Resident #19's Care plan dated 06/17/21 revealed, Resident has potential for pressure ulcer development r/t limited mobility and incontinence Review of Resident 19#'s Weekly Skin check dated 07/05/21 and 07/12/21 revealed, No skin issues. Review of Resident 19's Weekly Skin check dated 07/20/21 revealed, Sacral Fissure between the middle of buttock . Review of Resident 19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .everyday shift for fissure. Interview and observation of Resident #19 on 07/20/21 at 9:21 AM, upon HHSC Surveyor observation of two coccyx open areas while Resident #19 was laying on a standard bed, the DON stated this was a crack and then said it was a fissure. Full depth opening. Pink wound bed. No odor, no signs/symptoms of infection, no exudate. Blanchable. One measured 0.5 x 0.2 x 0. Another wound measured 2.0 x 0.5 x 0. Interview on 07/20/21 at 9:38 AM, when asked if Resident #19's wounds had already been identified the DON responded, Identified already but have to verify. Review of Resident #19's Weekly Skin Check dated 07/05/21 and 07/12/21 revealed, No skin impairments. Review of Resident #19's Weekly Skin Check dated 07/20/21 revealed, Sacrum: Fissure between the middle of buttocks .Callous to right lateral heel. 5)Review of Resident #24's Face Sheet dated 07/22/21 revealed [AGE] year-old male who admitted [DATE] with COVID-19, [CONDITION(S)], Abnormalities of gait and mobility, repeated falls, contracture, joint, type II diabetes, hypertensive heart and chronic kidney disease with heart failure, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, overactive bladder, etc. Review of Resident #24's Quarterly MDS dated [DATE] revealed, BIMS score 09 with severely impaired cognition, extensive one to two person ADL assistance, at risk for developing pressure ulcer/injuries, skin conditions: BLANK. Review of Resident #24's Care Plan dated 07/22/21 revealed, Risk of skin breakdown .non-compliance will encourage . Review of Resident #24's Weekly Skin check sheet dated 07/05/21 revealed, No skin impairments. Review of Resident #24's Weekly Skin check sheet dated 07/09/21 revealed, Vertebrae (upper-mid) rash. Review of Resident #24's Weekly Skin check sheet dated 07/13/21 revealed, Vertebrae (upper-mid) rash treatment continued. Review of Resident # 24's Weekly Skin Check Sheet dated 07/17/21 at 12:50 AM revealed, This resident did not have any skin impairments. Review of Resident #24's Weekly Skin Check Sheet dated 07/17/21 at 9:35 AM revealed, Left toe scab around nail, Vertebrae rash with current treatment, Left lower (front) leg small scabs, no redness, dry no pain. Review of Resident #24's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .apply miconazole cream topically to left underarm qday and prn . Observation on 07/20/21 at 10:50 AM of Resident #24 skin assessment revealed, the resident was complaining of their back itching, there was a very large rash on their back that was scaly and scabbed skin in the left shin area. Resident's groin area was very moist and oily, ADON A stated it was an skin barrier ointment. Resident #24 had a large Bowel movement in their brief and ADON A attempted to pull the resident's brief down around and the HHSC surveyor asked ADON A to obtain some wipes to clean the resident up for better viewing of the buttocks. ADON A left room and returned with a brief and wipes and began to clean the resident and once she was done cleaning him she left bowel movement on his bottom. Resident was asked how long he had been dirty and he replied since breakfast. Regional Nurse whispered to ADON A to wash her hands which ADON A did however but there was dried bowel movement still on the resident's skin so ADON A had to wipe harder to remove it. Resident #24 Left buttock crease had a darkened area that was 5 cm x 0.5 cm and tender to touch the resident stated it is from the dirty brief, they always put it on too tightly. After ADON A finished cleaning the resident she did not change gloves and proceeded to move the resident then a small piece of bowel movement was on draw sheet then ADON A picked up and stated it is bowel movement. Resident #24 had a small scratch in the upper buttocks/hip region, nontender. Red under left under arm, red and moist and resident complained of the area hurting .resident denied anyone putting anything on the area and stated he did not have any deodorant to use. Resident #24 stated he had a boil under his left under arm area. ADON A used same gloves to place clean linen on bed, gloves were soiled from cleaning bowel movement then ADON A carried the trash with dirty brief to her trash on the side of her treatment cart and the linen was taken to the soiled utility room with ungloved hands and after she left the utility room she did not wash her hands or perform hand hygiene. 6)Review of Resident #44's Face Sheet dated 07/16/21 revealed a [AGE] year-old female who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive two person ADL assistance, always incontinent to bowel and bladder, at risk of developing pressure ulcers/injuries, and no unhealed pressure ulcers/injuries. Review of Resident #44's Care Plan undated revealed, The resident has the potential for pressure ulcer development r/t limited mobility and incontinence. Review of Resident #44's Weekly Skin Check dated 01/22/20 revealed, The resident had no skin impairment. Review of Resident #44's Wound care Doctor note dated 07/06/21 revealed, Right anterior ankle is an arterial ulcer and has received a status of not healed. Measurements:1 cm x.0.9 cm x 0.3 cm, no odor .and Right anterior leg is a skin tear and has received a status of not healed. Measurements: 6 cm x 2 cm x .03 cm, no odor. Review of Resident #44's Weekly Skin Check dated 07/13/21 revealed, Right lower leg (front) skin tear treatment continues and right anterior ankle wound treatment continues. Review of Resident #44's Wound care Doctor note dated 07/13/21 revealed, Right anterior ankle is an arterial ulcer and has received a status of not healed. Measurements: 2 cm x1 cm x 0.3 cm, no odor .and right anterior leg is a skin tear and has received a status of not healed. Measurements: 4 cm x 2 cm x 0.3 cm. Observation and Interview on 07/18/21 at 10:39 AM with HHSC State Surveyor, Resident #44 was severely hard of hearing in both ears but used a whiteboard for communication to staff, ADON A began assessment, noted: resident's socks (which left indentions to bilateral ankle area. Noted scabbed red and inflamed dime size area extending up from left ankle, ADON A said, this is from their socks. Resident had a cluster of four open areas to left anterior ankle, and cluster of approx. eight small open areas to right lower lateral shin. Resident #44 had multiple ecchymosis areas to right lower extremity from knee down through ankle. Resident stated pointing to their ankles that hurts, pointed to area of pressure from socks, where visible indentations were seen. Left lower extremity (shin area) scabbed area approximately 3 in length. Multiple scabbed areas to bilateral knees (ADON A stated that resident crawled on floor that caused wounds to their knees). In between 4th and 5th digit on left foot, large amount of grime and dirt build up in between those two digits. Fingernails on both hands were dirty and appeared to have dirt underneath them. Observation under bilateral breasts revealed white residue, in which resident stated, I put deodorant under my breasts. Large dollar bill size red, blanchable area to upper right buttocks. Resident has a red blanchable area to right posterior ankle approximate size of a nickel. Right lateral foot at 5th digit lateral, large (approximately 4) very red and inflamed, small crusted center to this area, this redness extended down the lateral side of the 5th digit, possibly a stage 1 pressure wound with a stage 2 in the center. 7)Review of Resident #54's Face Sheet dated 07/22/21 revealed an [AGE] year-old female who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Quarterly MDS dated [DATE] revealed, BIMS score 00 with severely impaired cognition, extensive 2 person ADL assistance, always incontinent to bladder and bowel, at risk of pressure ulcers/injuries. Review of Resident #54's Care Plan dated 06/24/21 revealed, Resident at risk for pressure ulcer or potential for pressure ulcer development r/t red and yeast like area . Review of Resident #54's Weekly Skin Check dated 07/06/21 and 07/13/21 revealed, No skin impairments. Review of Resident #54's Weekly Skin Check dated 07/16/21 revealed, Dry abrasion to left lower leg .Perianal and buttock blanchable redness .red area to left groin. Observations and Interviews of Resident # 54 on 07/16/21 at 10:57 AM with HHSC Surveyor revealed, 3 bruises in various stages of healing to right lower leg. ADON A started with feet peeling skin on top of 2nd right toe, g-tube, breakdown under abdomen fold left side 4 cm x 0.3cm, breakdown to coccyx 9cm x 6cm blanchable, scabbed area left lower leg 0.5cm x 3.5cm x 2 scratches, had wound on right heel. 8)Review of Resident # 78's Face sheet dated 07/22/21 revealed, a [AGE] year-old male who admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's Admission MDS dated [DATE] revealed, BIMS score 15 with intact cognition, extensive two person assist, occasionally incontinent to bladder and always incontinent to bowels, at risk for pressure ulcer/injuries and no unhealed ulcer/injuries. Review of Resident #78's Quarterly MDS dated [DATE] revealed, BIMS score 11 with moderately impaired cognition, extensive 2 person assist with ADL care, occasionally incontinent to bladder and always incontinent to bowels and at risk of pressure ulcer/injuries and two unhealed ulcer/injuries. Review of Resident #78's Care Plans dated 07/27/21 revealed, The resident has stage IV pressure ulcer to left post knee r/t disease process, immobility and wound deterioration noted, treatment order changed. Interview and observation of Resident #78 skin assessment on 07/20/21 at 8:55 AM with HHSC State Surve [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for three (Resident's #59, #85 and #100) of three residents reviewed for oxygen orders. The facility failed to provide oxygen therapy (10 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #59 as ordered by the physician. The facility failed to provide oxygen therapy (2 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #85 as ordered by physician. The facility failed to provide oxygen therapy (5 liters per minute of oxygen via [CONDITION(S)] collar) for Resident #100 as ordered by physician. These failures could place residents at risk of receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings included: Review of Resident #59's Face Sheet, dated 7/16/21, revealed Resident was a [AGE] year-old female and she was admitted to the facility 5/08/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's MDS assessment, dated 06/13/21, reflected she had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS BIM's (Brief Interview for Mental Status) score was 03. Record review of Resident #59's electronic Care Plan, dated last reviewed on 06/25/21, revealed a focus of Resident #59 has Oxygen Therapy r/t Respiratory Illness, with an intervention to keep oxygen @ 5L continuous via NC. Review of Resident #59's physician orders, dated 12/22/20, reflected Resident #59 was prescribed 10 liters per minute of oxygen via [CONDITION(S)] collar every shift and as needed. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/13/21 at 10:40 AM of Resident #59 revealed Resident lying supine in bed with head of bed elevated in her room. She had a [CONDITION(S)] collar in place and an oxygen concentrator at her bedside. The concentrator was on and set to 6.5 liters per minute. Resident #59's respiration was even and unlabored. Observation on 7/15/21 at 9:25 AM of Resident #59 revealed Resident lying supine in bed with head of bed elevated in her room. She had a [CONDITION(S)] collar in place and an oxygen concentrator at her bedside. The concentrator was on and set to 6.5 liters per minute. Resident observed to grimace frequently; respirations were even and nonlabored. Review of Resident #85's Face Sheet, dated 7/16/21, revealed Resident was a [AGE] year-old male and he was admitted to the facility 12/13/15 and readmitted [DATE]. Resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #85's MDS assessment, dated 06/28/21, reflected he had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment further revealed he received oxygen therapy and [CONDITION(S)] care. MDS Brief Interview for Mental Status was scored at 03. Record review of Resident #85's electronic Care Plan, dated last reviewed on 04/29/21, revealed plan did not address oxygen therapy. Review of Resident #85's physician orders, dated 7/16/21, reflected Resident #85 was prescribed 2 liters per minute of oxygen via [CONDITION(S)] collar every shift and as needed with no stated diagnosis. Observation on 7/15/21 at 9:32 AM revealed Resident #85 lying supine in bed with head of bed elevated in his room. He had a [CONDITION(S)] collar in place and an oxygen concentrator at his bedside. The concentrator was on and set to 2.5 liters per minute. Resident observed to have even, nonlabored respirations. Review of Resident #100's Face Sheet, dated 7/16/21, revealed Resident #100 was a [AGE] year-old male and he was admitted to the facility on [DATE] and readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's MDS assessment, dated 6/30/21, reflected he had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment further revealed he received oxygen therapy and [CONDITION(S)] care. The MDS Brief Interview for Mental Status score was 12. Record review of Resident #100's electronic Care Plan, dated last reviewed on 07/08/21, revealed a focus of The resident has oxygen therapy related to history of acute and chronic respiratory failure with no oxygen intervention noted. Review of Resident #100's physician orders, dated 7/16/21, reflected Resident #100 was prescribed oxygen 5 liters per minute via [CONDITION(S)] collar every shift. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/13/21 at 11:00 AM of Resident #100 revealed he was lying supine with head of bed elevated in his room. He had a [CONDITION(S)] collar in place and oxygen concentrator at his bedside. The concentrator was on and set to 2.5 liters per minute. Resident #100's respiration was even and unlabored. Observation on 7/15/21 at 9:28 AM of Resident #100 revealed he was lying supine with head of bed elevated in his room. He had a [CONDITION(S)] collar in place and oxygen concentrator at his bedside. The concentrator was on and set to 2.5 liters per minute. Resident #100's respiration was even and unlabored. Interview with LVN H on 7/15/21 at 9:45 AM revealed nurses were the only staff allowed to monitor/adjust resident's oxygen flow rates. The nurse stated he checked flow rates of Resident #59, #85 and #100 once or twice per shift. The nurse stated he did not know why oxygen flow rates were incorrect. LVN H stated flow rates were determined by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with ADON A on 7/15/21 at 1:22 PM revealed all nurses were responsible for verifying oxygen orders and flow rates. ADON A stated she expected nurses to check flow rates at every shift. ADON A stated a Respiratory Therapist had been in facility approximately 3 months ago and in-serviced multiple nurses. ADON A stated failure to titrate oxygen according to orders could cause respiratory distress. ADON A stated if oxygen order for Resident #59 was for 10 LPM she would expect to see oxygen concentrator set on 10 LPM. ADON A stated oxygen delivery is specifically a nurse designated task. During interview with Administrator on 7/16/21 at 6:52 AM she stated she expected oxygen to be titrated according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with LVN J on 7/16/21 at 8:05 AM the nurse stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with RN F on 7/16/21 at 8:18 AM he stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Oxygen Administration Policy dated 6/2020, reflected, Procedure: II. Check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Turn on the oxygen at the prescribed rate.

Based on interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for one (Resident #106) of three residents reviewed for accidents and hazards. Resident #106 left the faciity on [DATE] on pass. -No documentation was provided regarding Resident#106's return date. - Resident #106 was discharged AMA on 06/23/21. - The facility took no action to locate the resident or to ensure his safety. -The facility failed to provide supervision to ensure Resident's 106's safety and well-being. An Immediate Jeopardy (IJ) was identified on 0716//2021 and the IJ template was provided to the facility on [DATE] at 5:06 p.m. While the immediate jeopardy was removed on 07/27/2021 at 4:00 p.m. The facility remained out of compliance at a scope of potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. This failure could affect residents by placing them at risk of serious harm from unexpected or unintentional incidents due to lack of facility action when residents are missing from the facility. Findings included: A) Resident #106 left the faciity on [DATE] on pass. No further documentation provided regarding his return date, until progress note dated 06/23/21 when resident was discharged as AMA. The facility took no action to locate the resident or to ensure his safety. No calls were made to an outside entity or family to alert them of the resident missing. Record review of Resident #106's faces sheet and MDS assessment revealed the resident is [AGE] years old, admitted to the facility on [DATE] and discharged on [DATE]. Per MDS assessment dated [DATE], Resident #106's diagnosis includes [CONDITION(S)], paranoid personality disorder, [CONDITION(S)] IV) disease, major depressive disorder recurrent, unspecified, and pneumonia due to Staphylococcus, unspecified. Record review of progress notes revealed discrepancies in documentation of when Resident #106 was last seen in the facility. Progress Note date 06/16/21 at 4:18a.m. revealed that the resident went out of the facility on 06/15/21, Resident left building at 3 pm on 06/15/21. Has not returned at this time. Follow up progress note dated 06/17/21 at 3:33 p.m. revealed that the resident had not yet returned to the facility resident has not returned at this time. Remains out of building. Additional documentation dated 6/19/21 and 06/23/21 show that the resident had respiratory assessments completed on 06/19/21 and 06/23/21. However, no further notes regarding his leave or discharge were reflected in his chart. Record review of the discharge summary for Resident #106, dated 06/23/21, revealed that he was discharged at 12:00 p.m. on 06/23/21. The discharge summary stated: left facility AMA (against medical advice). An interview with ADON A on 7/15/21 at 4:00 p.m. revealed she was not working when the resident left the facility. ADON A completed the discharge summary. She stated she had written AMA on the discharge summary because in the past Resident #106's doctor had advised him not to leave the facility, but he did and ended up in the emergency room with drugs in his system. ADON A stated the facility never notified the Ombudsman or other authorities regarding Resident #106's discharge and she was unaware if anyone had talked to the resident since he left. In an interview with LVN B on 07/15/21 at 4:20 p.m. she identified Resident #106's signature on the Release of Responsibility for Leave of Absence form and stated the 6 15 next to his signature indicated he signed himself out on leave on 6/15/21. LVN B stated Resident #106 had checked out with her the day he left and said he would be gone for a couple of hours, but she hadn't seen him since. An interview with Receptionist C on 07/15/21 at 4:25 p.m. revealed she was working on the day Resident #106 left the building. She stated that the resident told her he checked out with his nurse and would be back [to the facility] in a couple of hours. The receptionist stated she saw him walk across the street towards the bus stop and had not seen him since. An interview with the Administrator on 07/15/21 at 4:30 p.m. revealed Resident #106 had a history of leaving the facility and had discharged against medical advice back in April 2021. The Administrator said this time they did not have the resident sign an AMA form because, according to the nurse, he said he'd be gone a couple of hours. The Administrator stated the resident was cognitively intact and the facility could not stop him from leaving. She stated that the facility did not contact Adult Protective Services or the Ombudsman when he did not return from leave of absence. An interview with MDS Coordinator A and the Business Office Manager on 07/15/21 at 4:35 p.m. revealed Resident #106 had returned to the facility after 6/15/21 and left again on 6/23/21. They stated that there was no documentation for his return or subsequent discharge, but the electronic Medication Administration Record (MAR) showed nurses administered medications on 6/17/21 - 6/23/21 so they believed he was in the facility on those days. Review of Resident #106's Medication Administration Record (MAR) for June 2021 revealed medications were signed as given by the nurse on 6/15/21 at 5:00 p.m. and 6/17/21 at 6:00 a.m., 8:00 a.m., 9:00 a.m., 12:00 p.m., 1:00 p.m. - times the progress notes indicated he was out of the facility. The MAR also reflected medications were administered on 06/24/21 at 5:00 p.m. and 6:00 p.m., a day after his discharge. A follow-up interview was conducted with LVN B on 07/15/21 at 4:50 p.m. revealed Resident #106 would often leave the facility and come back, and the resident had returned after he left on 6/15/21 and left again. She stated they would generally keep his medications on the cart when he went on a leave of absence because he would normally come back. In an interview with CNA A on 07/15/21 at 5:53 p.m. she stated that she remembered Resident #106 leaving, because it was right before another resident passed. Record review showed the resident she was speaking of passed on 06/22/21 and CNA A said that sounded right. She stated she was very certain that Resident #106 left before the other resident passed away. CNAA further stated she had been asking around about Resident #106 because she did not know if he was okay. On 07/16/2021 at 9:42 a.m. an attempt was made to contact the resident's emergency contact/family member. The phone number listed on the face sheet was not a working number. No other contact information for Resident #106 was on file. An interview with the Administrator on 07/16/21 at 10:12 a.m. revealed if a resident was missing the facility would search the facility and grounds, call the family then notify the authorities. She stated that if a resident left against medical advice, they would have the resident sign an AMA form and they would notify the resident's family and doctor. The Administrator stated she considered Resident #106 to have discharged against medical advice because he had a BIMS score of 15 (meaning he was cognitively intact), was his own responsible party, and had a history of saying he was going to leave and come back then not returning. The Administrator confirmed the resident did not sign any paperwork indicating he was discharging against medical advice. She further revealed the facility did not contact any persons or agencies when Resident #106 did not return because of his history of leaving the facility. Record review of the facility's Discharge Against Medical Advice policy dated 06/2020 reflected, .Nursing staff will document in the progress notes all pertinent information concerning the resident's actions, including the resident's stated reasons for his/her desire to leave the facility. Record review of the facility's Wandering and Elopement policy, dated 08/2020, reflected the facility staff member who finds that a resident is missing will alert facility staff. The Charge Nurse will call CODE PINK and organize a search. If the resident cannot be located, the Charge Nurse will notify administrator/designee, DON, Attending Physician, Responsible Party, Regional leadership of Clinical and Operations . Additionally, the administrator/designee will contact local law enforcement . In an interview with the DON on 07/16/21 at 7:00 p.m. she stated that because there were discrepancies in Resident #106's medical record, nobody knew exactly what time the resident left the facility. The DON stated the Resident's Medication Administration Record revealed he did not receive medications on 06/16/21 but he did receive them from 6/17/21 - 6/23/21. The DON also said she did not know if the Resident left with his medications because the documentation did not say. A telephone interview was conducted with Resident #106 on 07/16/21 at 7:15 p.m. The resident stated on this evening, two facility nurses had driven to the area he was staying [a part of town with several homeless shelters] looking for him and when they found him, they had him call the facility to talk to the surveyor. The resident stated he had been at the facility for years and had left the faciity on pass before and was usually gone only a day or two. The resident revealed he never intended to discharge from the facility but after he left, he went to California and stayed with family. He stated he told the nurse he was leaving for a couple of hours, but he ended up going to California instead. The resident was unclear whether he had taken medication with him when he left the facility but stated he had been out of medications for the past week. Resident #106 further denied leaving the facility on pass for a few days about a week before he left for California. The final Plan of Removal was received on 07/19/21 at 4:50 p.m. including the following: Date: 7/16/21 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 7/16/21, during an annual survey, surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: Abuse & Neglect 1. The facility staff failed to report allegations of abuse to the administrator immediately when staff witnessed alleged verbal abuse of resident #56. Identify residents who could be affected All residents have the potential to be affected. Identify responsible staff/ what action taken 1. The administrator submitted self-report to HHSC on 7/16/21 2. The only alleged perpetrator was suspended pending investigation. No other alleged perpetrators have been identified. Investigation is ongoing. 3. The administrator began obtaining witness statements from staff and residents. During this process it was identified that the alleged incident was reported to a CNA by the resident's fiancé. However, she did not witness the alleged incident. 4. The CNA received 1 on 1 education on Abuse and Neglect and corrective action for failure to report and was suspended on 7/18/21. 5. Safe surveys were conducted by Social Worker on interviewable residents in facility on 7/16/21 A safe survey is an assessment in which residents are asked several questions related to abuse and neglect. 6. Social Worker completed psychosocial assessment on resident #56 with no adverse effect noted. In-Service conducted The administrator and DON initiated in-servicing as follows: 1. On 7/16/21 the administrator and DON were in-serviced on Abuse & Neglect Policy and Texas HHSC LTCR Provider Letter PL19-17 by the Regional Vice President. 2. An all staff in-service was initiated on 7/16/21 on Abuse & Neglect Policy by the Director of Nursing, Assistant Director of Nursing, and Weekend Supervisor. All staff members were educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. All staff will complete an Abuse & Neglect competency test at time of in-servicing. 3. The expected completion date will be 7/18/2021. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. Implementation of Changes Staff will immediately inform the abuse coordinator when being made aware of the any abuse allegation. The administrator or director of nursing will ensure competency through verbalization of understanding by staff which will be documented on abuse and neglect monitoring form. In the absence of the Administrator abuse allegations will be reported to the Director of Nursing. The Administrator, abuse coordinator will be responsible for implementation of the process and will review process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring 1. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents. 2. Administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements. Findings will be documented on Abuse & Neglect monitoring form. 3. RVP and RNC will conduct ten random staff interviews per month. 4. RVP or RNC will review grievances weekly which are in the facility grievance binder for three months. 5. Any adverse outcomes will be reported to QAPI Committee Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 7/16/21. Interviews between 07/25/21 at 2:03 PM and 07/27/21 at 3:45 PM with (LVN K, LVN N, CNA AA, CNA HH, Central Supply, CNA II, CNA CC, CNA Z, LVN W, CNA P, Maintenance Director, MDS Coordinator LL, LVN I, LVN NN, LVN G, LVN B, LVN Y, LVN DD, LVN QQ, CNA M, Dietary Director, Central Supply Clerk, Medical records OO, HSK RR, HSK SS, HSK TT, HSK UU, HSK VV, Floor Tech, RN WW, CNA XX, CNA FF and Cook PP revealed they were provided with in-service trainings: Neglect, Missing residents and Out on Pass. An Immediate Jeopardy (IJ) was identified on 0716//2021 and the IJ template was provided to the facility on [DATE] at 5:06 p.m. While the immediate jeopardy was removed on 07/27/2021 at 4:00 p.m. The facility remained out of compliance at a scope of potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Residents #1) of four residents reviewed for wounds. The facility failed to provide the necessary care and services to prevent Resident #1 from developing a pressure related wound. This failure placed residents at risk for developing and deteriorating of their wounds and infection. Findings included: An interview on 12/05/20 at 10:30 AM with Resident #1's family member revealed the resident was residing at, Nursing Facility B but was transferred to Nursing Facility A for two weeks of quarantine when she was diagnosed with [REDACTED].#1 did not have any skin breakdown or pressure ulcers at that time. Resident #1's family member further stated after her two week quarantine stay, the resident admitted back Nursing Facility B with a massive pressure ulcer to her bottom. Review of Resident #1's nurses notes from the previous facility, dated 11/10/20 by Wound Care Nurse A , revealed the following: Upon initiating the skin assessment, coccyx injury measuring 4.7cm X 4cm X1.5cm with undermining. Tunneling of 2cm on the left side and 3cm undermining on the right side. Wound very malodorous with moderate brown drainage pressure ulcer stage 3 or worse. An interview on 12/06/20 at 2:23 PM with the previous facility's Wound Care Nurse A revealed she applied zinc oxide (skin preventative) to Resident #1's bottom and she did not have any skin breakdown noted before she was transferred to the quarantine facility on 10/29/20. She also stated the family had been there the day before the resident was transferred to the facility and they also noted the resident did not have any skin issues to her bottom. Wound Care Nurse A stated when Resident #1 was readmitted to the previous facility on 11/09/20, she had a significant wound to her coccyx measuring about 4cm X 4cm that had a lot of slough, contained some granulated tissue that needed to be cleaned and required packing. She stated the pressure sore had an odor that went away when she cleaned it and she called the doctor to get wound care orders. She further stated the wound's odor returned two days later and orders for wound cultures was obtained. She stated Resident #1 was started on an antibiotic because the culture showed the wound was growing an organism. An interview on 12/06/20 at 1:55 PM with Nursing Faciltiy B's DON B, revealed Resident #1 was readmitted to the previous facility after her 14-day quarantine with a significant coccyx wound that was either a stage 4 or unstageable. DON B stated Wound Care Nurse A had changed her brief before she was transferred out to the facility and stated there was nothing on her bottom. The Resident #1 admitted to Nursing Facility A from Nursing Facility B from 10/28/20 to 11/09/20, and both facilities were under the same management. Review of Resident #1's clinical record for Nursing Facility A revealed there was no evidence/documentation of initial assessments or weekly skin assessment, ADLs sheets that included bowel and bladder, showers sheets, Review of Resident #1's nurses' notes from Nursing Facility B, dated 10/26/20 and 10/28/20, revealed on 10/26/20 a skin assessment was completed and her skin was warm and dry and intact. The assessment indicate the resident's bilateral buttocks were intact. On 10/28/20 the nurses' notes reflected there were no changes in skin integrity and the resident was only receiving preventative cream or ointment to bilateral buttocks Review of Resident #1's weekly wound progress evaluation from Nursing Facility B, dated 11/09/20, revealed the resident had a pressure injury to the right buttock with moderate drainage, black in appearance and was described as necrotic. The length of the wound was documented at 4.7cm X 4cm X 1.5cm with undermining present. Review of Resident #1's MDS Assessment, dated 10/29/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS reflected Resident #1's cognition was severely impaired with a BIMS of 0. The MDS further reflected she was incontinent of both bowel and bladder. The resident was also marked for being at risk for developing pressure ulcers. The MDS Assessment revealed Resident #1 was identified as not having any pressure ulcers at the time of admission. The MDS also reflected the resident did not have any pressure relieving devices in place and ADLs were coded as not attempted due to medical condition or safety concerns. Review of Resident #1 clinical record at Nursing Home A revealed there was not an initial assessment conducted on Resident #1 from the time she was admitted on [DATE] until she discharged back Nursing Home B on 11/09/20. Further review of the resident's clinical record revealed there was no documented evidence of weekly skin assessments, ADL sheets that included bowel and bladder, shower sheets or any evidence of skin alteration. Interview on 12/06/20 at 12:46 PM with Nursing Facility A's current DON, DON C, revealed she began working 11/10/20 after Resident #1 had been discharged . She stated when she arrived the facility had a COVID-19 positive hall with positive residents from sister facilities. She stated the COVID-19 hall had been staffed with agency staff and the unit was closed after she arrived and the previous administration staff had quit and taken a lot of the staff with them. DON C stated the facility currently did not have agency staff and they were not planning on the using them if they did not have to. DON C stated the Regional RN was overseeing the facility during that time. Upon looking DON C was not able to find any skin assessments for Resident #1 during her stay at the facility. She stated it would have been the admitting charge nurse's responsibility to complete an initial skin assessment and weekly there after. Multiple attempts to contact Agency Nurse G on 12/05/20 and 12/06/20, who admitted Resident #1 to the facility and was on the schedule as having worked more than once on the COVID-19 unit, were unsuccessful. Interview on 12/06/20 at 11:53 AM with the Regional RN revealed they had agency staff working on the COVID-19 unit because facility staff did not want to work with positive COVID-19 residents. She stated ADON D was in charge of overseeing the care of the COVID-19 unit and ADON E was in charge of staffing it. Regional RN stated both ADON's were refusing to enter the COVID-19 unit so they had to bring in agency supervisors on 12-hour shifts. She stated the agency charge nurses were responsible for completing the initial and weekly skin assessments when residents were admitted . She stated it was ADON D's responsibility to follow-up to make sure agency staff were completing the assessments and he was also responsible for coordinating the wound care and making sure it was being completed. Regional RN further stated during the time Resident #1 resided at the facility she was never made aware of any skin issues. She stated after agency staff was no longer working at the facility, they came across some admission that had not been thoroughly completed by the agency staff. She stated residents on the COVID-19 unit were sent back to their previous facilities and there were no care concerns with the ones that remained at the facility. She further stated she had been made aware of Resident #1's pressure ulcer after she had returned to the previous facility. Interview on 12/06/20 at 10:51 PM with ADON D revealed he was the ADON for hall 100 and 200 only and he was not responsible for the COVID-19 unit, hall 400, but the Regional RN would know who was in charge. Interview on 12/06/20 at 2:23 PM with ADON E revealed the COVID-19 unit was being staff by agency and they had their own supervisors. She stated ADON D was responsible for overseeing the COVID-19 unit and making sure their assessments were being done. Interview on 12/09/20 at 10:42 AM with Agency RN F revealed she worked the COVID-19 unit one day because they needed assistance due to the rising number of COVID-19 positive cases the facility was having and were being sent to the unit. She was flushing Resident #1's [DEVICE] and recalls the agency CNA the resident had a wound. She did not recall the CNA's name but she instructed her to let the charge nurse know so she could measure it and document it. Agency RN F did not recall the name of the charge nurse working that day. Interviews with Agency CNAs H, I, J, and K on 12/05/20 revealed they did recall Resident #1 during the time she was Nursing Facility A. Interview on 12/06/20 at 2:43 PM with the Wound Care Doctor revealed she was not able to determine if Resident #1's wound was unavoidable or not because she would need to know the circumstances around the situation. She stated she rarely saw stage 4 wounds develop overnight unless a resident was terminal but if a resident was stable then a wound should not worsen in such short time if being treated. Review of the facility's policy and procedure titled Skin Integrity Monitoring System, dated May 2017, revealed the following: Policy 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed and preventative measures will be in place to prevent development of pressure injuries. Procedure Assessment and Monitoring 1. Braden scale will be completed within 24 hours of admission/readmission and every week for new admits/readmits; prior to transfer out of the home, and prior to a planned discharge . 2. Residents will be screened daily through direct care provided and any deficits identified will be reported 3. All residents will be assessed weekly using the (Weekly Skin Assessment) form for any type of skin integrity complications

Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and not develop pressure ulcers for two (Residents #58 and #94) of nine residents reviewed for pressure ulcers. 1. The facility failed to implement procedures for the timely identification and treatment of [REDACTED].#58. As a result of these failures, Resident #58 developed an unstageable pressure ulcer of the left heel, a pressure ulcer to the underside of the left, great toe, and a pressure ulcer in between the left, fourth and fifth toes that went untreated and were unidentified by the facility and hospice provider. 2. The facility failed to complete skin assessments for Resident #94. As a result of this failure, the facility was unaware of the development of new pressure ulcers on Resident #94. An Immediate Jeopardy (IJ) was identified on 10/04/18. While the Immediate Jeopardy was removed on 10/06/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could result in residents developing new or worsening pressure ulcers. Findings included: 1. Resident #58's MDS assessment, dated 08/15/18, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #58's Care Plan, dated 05/22/18, revealed the resident developed pressure ulcers related to limited mobility, and incontinence. There were measurable goals and interventions in place, including to inform the resident/family/caregivers of any new areas of skin breakdown. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during for daily care. Resident #58's (MONTH) (YEAR) Physician Orders reflected: 05/08/18 Admit the resident to hospice services - [DIAGNOSES REDACTED]. 08/13/18 Stage III Pressure Ulcer on the left ischium - Cleanse with normal saline/wound cleanser. Apply collagen dressing as needed until wound is resolved. The resident's physician orders did not reflect an order for [REDACTED]. Resident #58's most recent Skin assessment, dated 09/24/18, reflected the resident did not have pressure ulcers on her feet or toes. No further skin assessments for Resident #58 were available after the 09/24/18 assessment. An observation on 10/04/18 at 9:30 AM and corresponding interview with WCN C and WCN D revealed Resident # 58 was wearing Podus Boots on both of her feet. WCN C and WCN D removed the boots to assess the resident's feet. Upon removal of the left boot, pressure ulcers were identified on the left heel and toes. The Podus Boot on the left foot had a large amount of moist, blood-tinged drainage and dry yellow drainage. The wounds were measured by the WCN. The wound on the left heel was deep, bloody, and appeared to be a Stage IV pressure ulcer. There was a foul odor present. It measured 4.5 centimeters x 4.4 centimeters x unknown. The pressure ulcer to the underside of the left great toe was black in color, unstageable and measured 2.1 centimeters x 1.0 centimeters. The pressure ulcer between the left, fifth toe was black, unstageable, and measured 1.7 centimeters x 1.1 centimeters. WCN C and WCN D reported it was the first time they had observed the pressure ulcers and felt they were significant wounds. WCN C and WCN D said they had no idea when the boots had been last removed. They said the resident was receiving hospice services and a hospice aide visited daily. The hospice aide provided bed baths for the resident. WCN D revealed she made rounds with the wound care physician on 10/03/18, but the resident's feet were not assessed. WCN C reported residents with wounds had their skin assessments completed by a wound care nurse weekly with the Wound Care Physician. WCN D said she was new to the facility and she was not aware that the wound care nurses were responsible for completing weekly head to toe skin assessments with residents already being treated for [REDACTED]. An interview on 10/04/18 at 11:45 AM with the DON revealed after the new pressure ulcers were discovered by the surveyor on Resident #58's left foot, she went to view them. The DON stated she did not assess the pressure ulcers at that time, but would go back to assess them. An interview on 10/04/18 at 12:30 PM with the DON revealed she had assessed the new pressure ulcers found on Resident #58's left foot. The DON stated her assessment was that the ulcer on the resident's left heel was unstageable, and the ulcers on the toes were deep tissue injuries. An interview on 10/04/18 at 12:47 PM, with LVN N, Charge Nurse for Resident #58, revealed he thought the wound care nurses were responsible for completing skin assessments for all residents. He was not aware of pressure ulcers on the resident's left foot. He said he had changed Resident #58's boots last Thursday or Friday (09/27/18 or 09/28/18) because the boots she was wearing were soiled. He said the resident only had very dry skin on her feet. An interview on 10/04/18 at 1:35 PM with Hospice CNA EE revealed she bathed Resident #58 five days a week and had last bathed her on 10/03/18. She reported she did not remove the resident's Podus Boots for each bath because the resident wore a pulse oximeter on her left foot, second toe that would beep if it was removed. She reported she would just leave the boot on and not touch the pulse oximeter. She reported she had last removed the boots on Monday, 10/01/18, and did not see any wounds on her feet at that time. She reported the Hospice Nurse had not reported any wounds on the resident's feet. An attempt to interview the Hospice Nurse on 10/04/18 revealed she was on vacation and was unavailable for interview. An interview on 10/04/18 at 2:06 PM, with the PCP for Resident #58 revealed she saw the resident on 09/07/18. She was not aware of any new pressure ulcers on the Resident's left foot. The PCP stated she did not know if she had ordered the Podus Boots for this resident. She reported the most likely person to have ordered the Podus Boots was the Wound Care Physician as his primary job was wound consultation. An interview on 10/04/18 at 3:15 PM with charge nurse, RN BB, revealed he was not aware of any new pressure ulcers to Resident #58's left foot, and he had no idea the last time the boots had been removed, or her feet had been assessed. An interview on 10/04/18 at 3:30 PM with the Wound Care Physician for Resident #58 revealed he had treated pressure ulcers on her sacrum and left ischium on 10/03/18. He stated he was not aware of any new pressure ulcers to the resident's left foot at the time of the visit. The doctor said the facility contacted him and asked him to see this resident again today, 10/04/18, because new pressure ulcers had been identified on her left foot. He said the facility usually contacted him if there were any skin issues noted for residents, so he was not sure how the pressure ulcers on Resident #58 were missed. The WCP stated he believed the wound on her heel was a Stage 3, but due to the amount of eschar, it was difficult to tell for sure. He reported he had observed the soiled Podus Boot that had been on the resident's left foot as well as the tissue that was left in the boot from the resident's left heel. The WCP said the wounds on the resident's toes were reopened areas. He said she had a history of [REDACTED]. When asked about whether he had placed the order for the Podus Boots, the WCP stated that he could not recall specifically ordering the boots, but that the resident's heels were supposed to be offloaded and his assistant or the wound care physician before him could have ordered the boots. An interview on 10/05/18 at 11:45 AM with the DON revealed the facility had completed a skin assessment for all residents, and five other residents were identified with new skin integrity issues, including Resident #94. Additionally, the facility identified residents wearing therapeutic devices like Podus Boots. 2. Resident #94's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old-male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was cognitively impaired and required extensive assistance with activities of daily living. At the time of the assessment he had two pressure ulcers that were present on admission. Resident #94's Current Care Plan reflected: 1. Date Initiated: 05/29/18 Resident was receiving Hospice services and it was expected the resident would have skin breakdown. Facility interventions included to work with the Hospice team to ensure the resident's physical needs were met. Hospice CNA to provide care three-five times a week and as needed. Hospice RN to visit weekly and as needed. 2. Date Initiated: 10/26/17 Date Revised: 05/31/18 Resident had a Stage IV pressure ulcer to his right heel. Facility interventions included to assess wounds weekly with measurements, staging, tissue type, exudate type, amount, etc. Monitor for healing and notify physician if no progress noted every 14 days and as needed. Offload pressure areas, turn, and reposition every two hours and as needed. 3. Date Initiated: 09/09/18 Resident had actual impairment to right 1st toe related to abrasion. Facility interventions included use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surfaces. Resident #94's (MONTH) (YEAR) Physician Orders did not have orders to treat the right heel or right first toe. Resident #94's Wound Care Note, signed by the Wound Care Physician, dated 10/03/18, did not have any documented wounds for the right foot or right first toe. Resident #94's Weekly Skin Non-Pressure Injury Assessment, dated 10/03/18, did not have any documented wounds for the right foot or right first toe. Resident #94's Nurse Notes dated 10/04/18 at 4:49 PM reflected the resident was assessed and his right heel had a wound with 25% eschar (scabbed area) and his right great toe had an area of eschar measuring 0.8 centimeters x 0.1 centimeters. An observation with WCN D of Resident #94 on 10/05/18 at 2:05 p.m. revealed the resident was seated in his wheelchair with his legs elevated. He was wearing soft boots. His feet dangled past the edge of the elevated foot rest and wheelchair. WCN D was asked about the positioning of the resident and she stated she would have to speak to therapy about his positioning in order to prevent his feet from dangling over the end of it. WCN D reported the resident previously had a pressure ulcer on his right heel that had healed and a history of bumping his toes resulting in injuries. She stated that she found new wounds on the resident during a facility skin sweep of all residents on 10/04/18. WCN D removed the resident's boots and revealed the resident's right heel had an area of eschar approximately 2.0 x .50 centimeters present over a healed scar. The resident also had an area of eschar on the right great toe that was approximately 0.8 x 0.1 centimeters. The Facilities Skin Integrity Monitoring System, dated (MONTH) (YEAR) reflected: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents assessed, and preventative measures will be in place to prevent the development of pressure injuries . Procedure .2. Residents will be screened daily and through direct care provided in any deficits identified will be recorded. In addition, the nursing assistant daily body observation form may also be used when assistance is provided during showers. 3. All residents will be assessed weekly using the (weekly Skin Assessment) will be documented on the (Weekly Skin Assessment) . Goals Prevent the development of pressure injury by performing routine skin and risk assessments on all residents at admission and specified intervals with appropriate intervention as per policy to prevent tissue destruction . An Immediate Jeopardy was identified on 10/04/18 at 1:30 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The facility's plan of removal revealed: 1. PCP- Medical Director, was notified of IJ status of the home on 10/04/18. WCP saw Resident #58 on 10/04/18. New orders were written for treatment of [REDACTED]. The treatment was given on 10/04/18 in hospice has come out and assessed her. 2. Education: licensed facility nursing staff (nurses and certified nurse aides) are being in serviced on skin monitoring policy to include coordination of care with hospice regarding changes in skin integrity and required documentation by RNC FF, ADON GG, ADON HH, DON. Any employee that has not been in serviced will be in serviced prior to working. Completion date 10/05/18. a. Charge nurse will document and be responsible for residents without wounds. They will complete in document weekly skin assessments and Braden scales weekly times four, then quarterly. b. Treatment nurses will document to be responsible for residents with wounds to document weekly skin assessments, Braden scales weekly time four then quarterly. Treatment nurses will also be responsible for non-pressure and pressure injury assessments for wounds. c. Any new identified skin deficits will have an order from M.D. to ensure appropriate interventions are taken timely and followed. Monitoring will be done daily Monday- Friday by DON/designee to ensure treatment orders are transcribed and completed per MD supporters by reviewing the order listing report in clinical software, 24- hour summary and comparing to the Treatment Administration Record. Initiated 10/04/18 Monitoring: ongoing. 3. Head to toe assessment had been completed on all hospice residents currently in house by WCN C, WCN D, ADON GG, ADON A, and ADON HH, to assure that all skin issues were accurately identified using the CNA body observation form. a. All residents will have had to toe assessment completed by the end of the day and weekly skin assessments will be completed by ADON GG, ADON A, ADON HH, WCN C , and WCN D. b. Monitoring will be done by DON/designee by reviewing the weekly skin assessments for completion during the morning meeting and rounding weekly with the skin/treatment nurse on residents with pressure and non-pressure injury. DON, ADON GG, ADON A, and ADON HH will review clinical software for completion of skin assessments, 24- hour summary for any new treatment orders and check treatment administration record on completion of treatment Sunday to Saturday. RNC II will provide additional monitoring to DON/designee on routine visits and remotely at least weekly. Monitoring: ongoing. 4. Care plan meetings will be conducted with the assigned hospice company for all 18 hospice residents to review each resident's plan of care on a holistic approach include any notes in deficits. Outcome of each care plan will be documented in the resident's care summary. a. Hospice staff will notify DON/designee immediately for any changes of condition regarding the resident. b. Care plan meetings will be held with all IDT members quarterly and as needed for all hospice residents initiated: 10/04/18. Monitoring: ongoing. 5. RNC II will monitor plan of removal. Monitoring interviews were completed with staff beginning on 10/05/18 at 1:46 PM and ended on 10/06/18 at 12:30 PM. Staff were able to communicate: Persons responsible for assessments with residents wearing therapeutic devices (splints, boots, oximeter and oxygen tubing etc.). Persons responsible for weekly skin assessments for residents with wounds. Persons responsible for weekly skin assessments for residents without wounds. Documentation requirements. Procedure to follow if a new wound was identified. Procedure for outside providers to report skin integrity issues and their documentation requirements. Persons responsible for reviewing the outside provider documentation. Persons responsible for obtaining orders and ensuring they were transcribed to the treatment administration records. Persons responsible for auditing to ensure skin assessments were completed. Persons responsible for auditing to ensure residents with therapeutic devices had orders for them. Shifts: 6:00 AM to 2:00 PM - LVN Y, LVN N, CNA T, CNA P, CNA R, CNA S, CNA JJ, CNA I, CNA L, and CNA O. 2:00 PM to 10:00 PM - LVN Z, LVN II, and LVN Q. 10:00 PM to 6:00 AM - CNA X and LVN F. Double weekends 6:00 AM to 10:00 PM - LNV B, LVN G, LVN H, RN KK, MA K, and LVN J. PRN - MA U, LVN W, AND CNA M. 8:00 AM to 5:00 PM - ADON GG, WCN C, WCN D. While the Immediate Jeopardy was removed on 10/06/18, the facility remained out of compliance with the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #106) of six residents reviewed for quality of care. The facility failed to assess Resident #105 immediately following a fall on 08/30/18. The resident was assessed on 08/31/18 for complaints of right shoulder pain. An x-ray was ordered and taken of the right forearm instead of the right shoulder. The facility failed to obtain an accurate x-ray until 09/03/18 when the resident was re-assessed and found to have right shoulder pain and swelling. The resident was diagnosed with [REDACTED]. The resident required surgical repair of the right shoulder fracture on 09/04/18. This failure could affect all residents in the facility placing them at risk for not having timely assessments of falls and follow-up of injuries resulting in pain, delay in treatment, and immobility. Findings included: Resident #105's MDS assessment dated [DATE], reflected the resident was an [AGE] year-old-male admitted to the facility on [DATE]. The resident's cognition was severely impaired, and his [DIAGNOSES REDACTED]. The resident required the extensive assistance of one staff for transfers. Resident #105's Current Care Plans dated 08/31/18 and revised on 09/03/18, reflected the resident had a fall due to poor balance and poor communication/comprehension. Facility interventions included monitor and report as needed for 72 hours to physician any signs and symptoms of pain, bruises, or changes in mental status. Resident #105's Physician order [REDACTED].>08/31/18 STAT (as soon as possible) x-ray to right arm. 08/31/18 [MEDICATION NAME] (pain medicine) 50 milligrams, two tablets by every six hours as needed for pain for three days. 09/03/18 STAT (as soon as possible) x-ray to right shoulder and right humerus. Resident #105's Progress Notes reflected: 08/31/18 10:16 AM Resident complained of pain to his right arm. When the right arm was lifted, the resident moaned and yelled out in pain. The FNP was notified and an order was obtained for an x-ray to his right arm. - LVN LL 08/31/18 12:26 PM Resident continued to complain of pain. A new order was received for [MEDICATION NAME] (pain medication). -LVN LL 08/31/18 2:01 PM X-ray to resident's right arm. Awaiting results. -LVN LL 08/31/18 2:20 PM Per Resident he had a fall but did not report the fall to anyone. -ADON A 09/02/18 7:15 PM Resident complained of pain to the right arm. Medicated resident with [MEDICATION NAME]. X -ray result received with no acute fracture or malalignment of bone noted. -LVN MM 09/03/18 8:27 AM Resident continued to complain of pain to his right arm. Right arm appeared to be swollen and when arm was extended out, the resident grimaced and said it hurt. A STAT x-ray was ordered for the right shoulder and right humerus. -LVN LL 09/03/18 1:24 PM Right humerus (Upper portion of right arm) was positive for fracture. Notified FNP, order received to transfer resident to hospital. -LVN LL Resident #105's Incident Report dated 08/31/18 reflected the resident complained of pain to his right shoulder. The resident was unable to lift his arm without pain. Resident stated he had a fall in his room that was not reported. Resident #105's Facility Investigation dated 09/10/18, reflected on 08/31/18 the resident complained of right shoulder pain. The resident was assessed, and an x-ray was ordered for the right arm. The x-ray company did not x-ray the right shoulder. The forearm was x-rayed instead and was negative for fracture. The resident was medicated for pain. On 09/03/18 the resident continued to have shoulder pain and developed swelling. The right shoulder was x-rayed and revealed a fracture. The resident was transferred to the hospital for surgery. An observation on 10/03/18 at 1:05 PM revealed Resident #105 was seated in his wheelchair with a sling in place to his right upper arm. The resident was not interviewable. An interview on 10/01/18 at 2:35 PM with CNA NN revealed on Thursday, 08/30/18, she returned from lunch and heard Resident #105 calling for help. She found him lying on his mat on the floor with his head leaning on the bed. She told him she was going to find a nurse. She was not able to locate a nurse and went back to his room and assisted him to sit-up. She went to look for the nurse again, but still could not find her. CNA NN stated she went ahead and helped Resident #105 up and put him back in bed. She reported the resident did not have any pain. After assisting the resident to bed, she found LVN OO and reported the incident. An interview on 10/02/18 at 9:35 AM with LVN OO revealed she was assigned to Resident #105 on 08/30/18 for the 2:00 PM - 10:00 PM shift and on 08/31/18 for the 2:00 PM - 10:00 PM shift. She reported on 08/30/18 she was never notified about Resident #105 having a fall. She reported on 08/31/18, she was told in shift report that LVN LL had medicated the resident for pain and that an x-ray had been obtained of the resident's arm. The x-ray result was for the right forearm and the results were negative. She reported she completed a head to toe assessment for the resident and he flinched away when his right arm was assessed. She reported at the end of her shift she informed the night nurse that the resident had right shoulder pain with a suspected fall. She reported as a result of the facility investigation, she was in-serviced on notifying the physician for complaints of pain. An interview on 10/01/18 at 1:30 PM with ADON A revealed on Friday, 08/31/18, Resident #105 complained of right should pain. ADON A assessed him and when she tried to move his right elbow away from his body, he complained of pain in his upper right arm and shoulder. ADON A reported LVN LL received an order for [REDACTED]. She reported she did not understand why the weekend nurse did not figure out the error first. An interview on 10/01/18 at 2:00 PM with LVN LL revealed on Friday, 08/31/18, Resident #105 complained of pain in his right arm and shoulder, so she called the doctor and got x-rays ordered. Before she left work on Friday the results were still pending. When she returned to work on Monday, 09/03/18 the resident was still complaining of pain. She checked the x-ray results and found the company x-rayed the wrong part of the arm. LVN LL reported she did not know why the company did not x-ray the entire right arm as ordered. She reported she found out that on 08/30/18 the resident had fallen. An interview on 10/01/18 at 3:15 PM with CNA PP revealed she was assigned to Resident #105 on 09/02/18. She tried to turn him in bed, but the resident jerked his arm back and he acted like he was in pain. She reported she notified the nurse. An interview on 10/01/18 at 2:50 PM with LVN MM revealed she took care of Resident #105 on 09/02/18 and was told by the previous shift that the resident had been having pain. She reported that during her shift, the CNA reported that while she was turning the resident for repositioning, he complained of pain. LVN MM assessed the resident and found he was having pain. She checked the progress notes and found that an x-ray had been performed and did not show a fracture. She reported the resident was on his side and she did not turn him all the way over to assess his whole arm but found he had facial grimacing. She did not see any swelling. She reported she did not review all of the notes and was not concerned about his shoulder. She reported she did not think an incident report had been completed. An interview on 10/03/18 at 10:05 AM with RN KK revealed she worked double-shifts on 09/01/18-09/02/18 and was assigned to Resident #105. She reported the resident complained of some pain over the weekend and she thought an x-ray had been taken. She reported she did not know the results. She reported she thought she had medicated the resident for pain but there was no documentation present. She reported that when a resident had a change in condition with pain the nurse was supposed to assess the resident, follow-up with the physician, and document the findings. An interview on 10/05/18 at 11:15 AM with LVN QQ revealed she provided care to Resident #105 on 09/01/18 and 09/02/18. She reported he was complaining of arm pain, so she medicated him. The previous shift, 10:00 PM - 6:00 AM, reported to her the resident had a sprain in his arm. She did not assess the resident and reported she did not remember reviewing any x-ray results or documented progress notes. She reported when a resident had a change in condition with pain the nurse was supposed to assess, give pain medicine, and check on them later to see if the pain had subsided. She reported she had not received any in-services following the incident. An interview on 10/01/18 at 3:20 PM with the DON revealed that a facility investigation was completed for Resident #105's fracture. She discovered that CNA NN found the resident on the floor on 08/30/18. The CNA assisted the resident back to bed without notifying the nurse. On 08/31/18, the nurse ordered an x-ray for the resident to his right arm on 08/31/18, but the company did not x-ray the entire arm. The x-ray that was taken was negative for fracture. [MEDICATION NAME] was ordered for pain. On 09/03/18 the resident developed swelling to the right shoulder with pain and limited movement. Another x-ray was ordered, and he was diagnosed with [REDACTED]. An interview on 10/02/18 at 1:45 PM with the Physician revealed he was informed that Resident #105 required multiple x-rays to identify a fracture. He reported when a resident fell , facility staff would contact him to report the fall, identify any injuries, and orders would be given based on the assessment. He reported in this case, the resident's right shoulder should have been x-rayed first. The Facility's Policy on Falls - Evaluation and Prevention, dated (MONTH) (YEAR), reflected: Following a fall, the following steps should be undertaken. Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status. If there was a loss of conscious or the fall was unwitnessed, neuro (neurological) signs should be initiated and checked for at least 72 hours. The Facility's Policy on Change of Condition - Observing, Reporting, and Recording, dated (MONTH) (YEAR), reflected: Procedure. Observing, Reporting and Documenting a Change in Condition: 1. After (a) resident (has a) change in condition including but not limited to falls, injuries . conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable . The Facility's Resident Roster dated 10/01/18 reflected there were 136 residents in the facility.

Based on observation, interview and record review the facility failed to provide the necessary behavioral health care and services to attain or maintain the hightest pracitcable mental and pscyhosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of three residents reviewed for behaviuoral healthcare. 1. The facility failed to notify and consult with the attending physician and psychiatrist/Nurse Practitioner regarding Resident #1 hitting Resident #2, his roommate, on 11/29/17 and failed to have a plan in place to address protection of future roommates. 2. The facility failed to prevent Resident #1 from hitting Resident #3, his new roommate who was vulnerable due to limited range of motion, [MEDICAL CONDITION] and [MEDICAL CONDITION], multiple times on 01/09/18. Resident #3 was transferred to the ER and was diagnosed with [REDACTED]. 3. The facility failed to notify and consult with the attending physician and at times the Psychiatric Nurse Practitioner when Resident #1 refused his medications including [MEDICATION NAME] which was for his diagnosed [MEDICAL CONDITION] Disorder and his behaviors. 3. The facility failed to address Resident #1 refusing his medications even after his [MEDICATION NAME] was changed to a liquid. 4. The facility failed to address Resident #1's aggression toward LVN C and LVN I. These failures could affect all 49 residents who reside on the 300 hall by placing them at risk of harm and injury. An Immediate Jeopardy (IJ) was identified on 02/02/18. Although the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). Findings included: Review of Resident #1's MDS quarterly assessment, dated 12/28/17, reflected Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. The resident had severe cognitive impairment. His [DIAGNOSES REDACTED]. MDS did not reflect any behaviors. Review of Resident #1's Social Service Note Admission Assessment, dated 01/05/16, by the Social Worker, reflected Resident #1 was unable to return his previous nursing facility as he allegedly hit an aide when he was there. Review of Resident #1's Physician Order's dated 05/15/17, reflected Psychiatric Care to evaluate and treat. Review of Resident #1's Physician Order's dated 05/22/17, reflected [MEDICATION NAME] Tablet 0.25 mg ([MEDICATION NAME]) Give 1 tablet by mouth every 8 hours as needed for anxiety. Review of Resident #1's Physician Order's dated 08/31/17, reflected [MEDICATION NAME] HCL Tablet 50 mg Give 0.5 tablet by mouth at bedtime for [MEDICAL CONDITION] Give ½ tab to equal 25 mg. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Care Plan, Revision on 10/19/17, reflected, the Resident has potential to demonstrate verbally abusive behaviors r/t (related to) cognitive deficits of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident misunderstands what room-mate says at times and becomes upset. Interventions initialed on 05/12/17 included; when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Interventions initialed on 06/15/17 included, evaluate for side effects of medications, psychiatric/psychogeriatric consult as indicated. Review of Resident #1's Behavior Nurses Note dated 11/29/17 reflected Resident #1 stated his roommate Resident #2 called him a little girl in front of people. When he confronted him he denied it so Resident #1 hit him and then they moved Resident #2 to a different room. Resident #2 reported the incident to the facility staff. Physician and responsible party notified. Care plan updated, resident #1 placed on 1:1 until calm, psychiatrist to see on next visit. Review of Resident #1's Care Plan revealed there were no additional interventions put in place and care plan did not reflect 11/29/17 incident. Review of Resident #1's Visit Note Psychiatric Nurse Practitioner (NP), encounter date 12/27/17, reflected the resident was at little to no risk of aggression. Assessment/Plan was to continue [MEDICATION NAME]/[MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION] and continue [MEDICATION NAME] for anxiety. Review of Resident #1's Nurses' Progress Note, dated 01/07/18, reflected Resident #1 refused all evening medications and stated to the nurse if you ask me to take my medication and check my blood sugar I will hit you. Review of Resident #1 MAR indicated [REDACTED]. Physician notified, no new orders at this time. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Observation and interview on 02/01/18 at 4:15 p.m. with Resident #1 revealed Resident #1 was alone in his room in his recliner. He stated he was doing good. Observation on 02/01/18 at 5:01 p.m. revealed Resident #1 cursing and yelling alone in his room. The ADON got up and walked by his room. Review of Resident #2's MDS quarterly assessment, dated 01/26/18, reflected Resident #2 was a [AGE] year old male admitted to the facility on [DATE]. The resident was cognitively intact. His [DIAGNOSES REDACTED]. Interview on 02/02/18 at 12:25 p.m. with Resident #2 revealed he was a roommate with Resident #1 since (MONTH) (YEAR) and Resident #1 said he called him a girl. He tried to explain to Resident #1 that he did not call him a girl and Resident #1 hit him. He leaned back when Resident #1 hit him, so it did not hurt. Resident #2 revealed Resident #1 admitted it to staff members when they came into the room. Resident #2 stated Resident #1 turned a table over. It happened in November, around Thanksgiving. He stated they moved him to his current room. He stated he did not know why Resident #1 went off. They did not have any issues before. Resident #2 said Resident #1 talked gibberish, but that was it. Interview on 02/02/18 at 1:20 p.m. with the DON revealed she did not know Resident #1 had an aggressive incident on 11/29/17. She was not in the picture, she only knew the roommates were not getting along and someone else moved him and took care of that. She stated it should have been charted. Interview on 02/02/18 at 1:25 p.m. with the Administrator revealed he was new to the facility and they did have a very young administrator at that time who dictated a lot of things and did not let people do things. He stated this kind of incident should be reported immediately and discussed. The Administrator revealed there should be more communication between staff. Review of Resident #3's MDS admission assessment, dated 12/14/17, reflected Resident #3 was a [AGE] year old male. The resident had moderate cognitive impairment. His [DIAGNOSES REDACTED]. He had upper body impairment on one side and lower body impairment on both sides. Resident #3's Nursing Progress Note dated 12/07/17 reflected he moved into a room. (Note: The new room was Resident #1's room.) Review of the Provider Investigation Report, dated 01/15/18, reflected Resident #1 was independently ambulatory and had a history of [REDACTED].#3 was not ambulatory and required total assistance. On 01/09/18, the housekeeper saw Resident #1 hit Resident #3 three times with his fist. Resident #3 stated he was hit in the head and neck. Resident #1 stated he told his roommate, Resident #3, to turn down his TV because all he wanted was some peace and quiet and the housekeeper witnessed Resident #1 hit Resident #3. Resident #3 requested to go to the hospital and press charges. Head to toe assessments were completed on both residents. No injuries were noted. Resident #3 was sent to the hospital per resident request. Residents were immediately separated and Resident #3 was moved to another room. Psychiatric Nurse Practitioner was notified. Resident #1 had his [MEDICATION NAME] changed from pill form to liquid. Resident #3 was sent to the hospital per his request after police visited with him. Staff were in-serviced on Abuse and Neglect, Behavior Crisis, and Behavior Management: problems and Possible Causes. Care plans were updated. Interview on 02/01/18 11:25 a.m. with the housekeeper with CNA B interpreting, revealed Resident #3 was looking toward the door in his electric wheelchair. The TV was on, and it was loud. Resident #1 told him it was too high. Resident #3 answered something back, turned and went to his side of the room. The housekeeper stated Resident #1 started screaming and saying stuff and got up and started hitting Resident #3 in the back. The housekeeper ran to the halls to find someone, at the time no one was there, and she got the floor technician. By the time the floor technician got there, Resident #1 was not hitting anymore. They told LVN A of the incident when it occurred. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed Resident #1 had an incident with his previous roommate, Resident #2, on a weekend. After the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that had happened at Resident #1's previous facility. She did not report it or document it. She felt it was in a confidential conversation. Review of Resident #3's SBAR Summary, dated 01/09/18, reflected Resident had head and neck pain roommate hit him Resident #3 given pain med (medication) [MEDICATION NAME] 5/325 mg tab PO was effective .the resident appears 'pain' sent to emergency room for eval (evaluation) due to head and neck pain per resident request. Review of Resident #3's After Visit Summary from the emergency room , dated 01/09/18, reflected [DIAGNOSES REDACTED]. Instructions given were start taking [MEDICATION NAME] 50 mg 1-2 tabs by mouth every six hours as needed for pain. Review of Resident #1's Visit Note by NP, encounter dated 01/10/18, reflected Resident #1 was seen for restlessness. Resident was seen for the management for [MEDICAL CONDITION] medications and side effects, and to monitor the effect of medication. Resident's [MEDICAL CONDITION] medication was beneficial in this case to control their psychiatric symptoms and to manage the resident's condition, to prevent relapse or hospitalization and to improve restorative potential. Staff report resident has been refusing care and medications. Assessment/Plan: Continue [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION], change [MEDICATION NAME] from tablet to liquid, continue [MEDICATION NAME] for anxiety. Psychiatric medications were reviewed to determine if benefit outweighs the risk. Benefit does outweigh risk. GDR is clinically contraindicated. Additional attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior. Review of Resident #1's Physician Order's, dated 01/10/18, reflected [MEDICATION NAME] Solution 1 Mg/Ml ([MEDICATION NAME]) Give 3 Ml by mouth two times a day for improve behaviors give 3 ml mixed with beverage of choice po (by mouth) bid (twice daily). Review of Resident #1's care plan, revision date 01/10/18, reflected Resident #1 misunderstands what roommate says at times and becomes upset. Resident became upset and hit room-mate (Resident #3) times three. The goal was for the resident to demonstrate effective coping skills through the review date. Interventions included; evaluate for side effects of medications, immediately separate and maintain safety of residents if any resident on resident physical aggression is suspected or witnessed, psychiatric/psychogeriatric consult as indicated, [MEDICATION NAME] was changed from pill form to liquid. Can be mixed with beverage, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; Review of Resident #3's care plan, revision date 01/10/18, reflected Resident #3 was struck by a roommate, Resident #3 was removed from the room. Nursing assessment shows no apparent injury, Resident #3 request to call police and be sent to hospital for evaluation. All requests followed. The goal was for Resident #3 to feel safe in his environment through next review. Interventions included, separated from room-mate and moved to another room, psych services to eval (sic) for needs of feeling safe. Review of Grievance/Concern Report submitted by Resident #3's family member, dated 01/10/18, reflected that several weeks ago Resident #3's family member advised the Social Worker that Resident #3 and his roommate, Resident #1, were having some difficulty and requested that she move him to another room. The social worker told him there was nothing she could do to help and Resident #1 was not prone to violence and would not hurt Resident #3. Interview on 02/01/18 at 12:15 p.m. with the social worker revealed she had a conversation with Resident #3's family member about changing Resident #3 to a different room but could not recall the date. He did request a roommate change, due to Resident #1 saying some not very nice things to Resident #3. He would say things like get out, you don't belong here, this is not your room. Resident #1 did not typically leave his room. She stated Resident #1 had other roommates before. The social worker was not aware if Resident #1 had any history of aggressive behaviors. The rooms they looked at for Resident #3 were not suitable for various reasons. One had a roommate who already had a power chair as Resident #3 had, and he W had concerns there would not be enough space for both. Another room that was available had a resident with very strong body odor. It was not until after Resident #3 was hit by Resident #1 that a suitable room became available and he was moved there. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed after the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that at Resident #1's previous facility. She stated she did not report it or document it because she felt it was in a confidential conversation. Interview on 02/01/18 at 8:50 a.m. with the DON revealed the Resident #3 discharged to the hospital on [DATE] for evaluation due to he stopped eating, was not feeding himself or talking. They received an update 3 days ago and he is was still frail and his family does did not want him to return to the facility. Review of Resident #1's Nurses' Progress Note, dated 01/14/18, reflected Resident #1 told the nurse if you come any closer I will hit you. Review of his Medication Administration Record [REDACTED].ml to be given two times a day for to improve behaviors. Resident refused medication on the following days: 01/12/18, 01/15/18, 01/16/18, 01/17/18, 01/18/17, 01/19/18, 01/22/18, 01/23/18, 01/24/18, 01/25/18, 01/26/18, 01/29/18, 01/30/18, 01/31/18. Interview on 02/01/18 at 11:13 a.m. with the DON revealed Resident #1 had been refusing his [MEDICATION NAME] frequently. A circle around staff's initials indicated a medication refusal. Review of Resident #1's Nurses' Progress Note By LVN C, dated 01/31/18 reflected Resident #1 was talking loud, shouting, and LVN C asked him to reduce his voice. Resident #1 turned violent, hitting LVN C and trying to hit LVN C on the face. LVN C deflected Resident #1's hits several times and he refused to stop for a long while, even while LVN C was moving back he continued to come after him. Interview on 02/01/18 at 2:22 p.m. with LVN C revealed Resident #1 was talking to himself on 01/31/18 loudly and other residents were complaining about the noise. He went to the room and asked if he could bring down the noise a little bit and he got up and just hit LVN C and could not stop. He just kept trying to hit the LVN in the face. LVN C stated he just kept deflecting the hits and backed away into the hall, about 15 feet away while Resident #1 hit him several times. People were shouting, but no one intervened. LVN C revealed that in the facility they could not have anything they could the resident, He stated no IM (Intramuscular) medication could be given. LVN C said they could not You do anything. LVN C stated he told the DON and ADON that Resident #1 got up and hit him and had been shouting and it may be a good idea to send him out to the hospital for a psychiatric evaluation since he has had not been taking medications for a few days. LVN C sent it in a text message and the DON replied to send him out for a psychiatric evaluation Interview on 02/01/18 at 5:00 p.m. with CMA E revealed he witnessed what happened with Resident #1 and LVN C on 01/31/18. He stated they were are trained to try and calm them, but that was getting out of hand. MA E revealed Resident #1 chased LVN C right into the hall. Interview on 02/01/18 at 8:50 a.m. with the DON revealed Resident #1 had an incident the previous evening, 01/31/18, of yelling and mood swings, they tried to send him to the hospital for an evaluation but he refused to go. Resident remained in the facility on 02/01/18. Interview on 02/01/18 at 1:44 p.m. with the Administrator revealed he was unaware of Resident #1 being assaultive on 01/31/18. He thought he was just refusing medications and they tried to send him out to the hospital and they refused. They facility does not manage resident behaviors, they care for residents. If a resident is aggressive he tells staff toback off and let someone else intervene. Interview on 02/01/18 at 1:50 p.m. with the DON revealed she was contacted via message from LVN C on 01/31/18 and LVN C told her Resident #1 he was shouting and refusing medications. She agreed to send him out for a psychiatric evaluation. The DON discovered that he refused to go the next morning. She stated she did not follow up with staff or check the documentation due to being busy on the skilled floor. The DON revealed she was not aware that Resident #1 hit LVN C. Interview on 02/02/18 at 1:15 p.m. with the DON revealed if she had read all of LVN C's text message regarding Resident #1's aggressive behavior she would have canceled morning meeting and called the police right away. She would not have put Resident #1 on one-to-one. The DON revealed that would be petrol to the fire. She stated Resident #1 responded well to the police. She stated she had no time to read all of that text. Interview on 02/01/18 at 2:56 p.m. with the DON revealed she was going to in-service all the staff on no more texting for all important stuff. Staff will need to call her from now on. The DON stated she only read the first half of the text message LVN C sent and did not read the part about Resident #1 hitting him. She stated did not follow up. The DON revealed on 02/01/18 she was busy, otherwise she would have put the resident on a one-to-one. Interview on 02/01/18 at 4:47 p.m. with LVN C revealed Resident #1's behaviors had been like this for a few months, up and down, with his moods. Interview on 02/01/18 at 4:55 p.m. with LVN D revealed Resident #1 seems to have had more shouting, yelling, and walking around at night. Interview on 02/01/18 at 5:01 p.m. with CNA F revealed for the most part Resident #1 was real quiet but when his mood started he thought people have messed with him he would start to yell. The CNA stated the resident kicked at staff when they tried to put his wanderguard on his ankle. On 02/02/18 at 11:40 a.m. revealed shouting and cursing was heard coming from Resident #1's room. Interview on 02/02/18 at 11:40 a.m. with LVN I revealed she was walking in the hallway with a bag of trash when Resident #1 came out of his room and asked for his wanderguard to be removed. Before she was able to respond, he hit her in the face. Resident #1 was observed in his recliner at that time. Interview on 02/02/18 at 9:05 a.m. with Psychiatric Nurse Practitioner (NP) revealed that she managed all of Resident #1's anti-psychotic medications. Resident #1 should be receiving [MEDICATION NAME] and [MEDICATION NAME] for psychotic symptoms, [MEDICATION NAME] at night, and [MEDICATION NAME] for anxiety and agitation. The effects of not taking one or both of his anti-psychotic medications, the [MEDICATION NAME] and [MEDICATION NAME], would be that he would decline very quickly, become very psychotic, prone to aggressive, impulsive behaviors. It would be up to the NP to decide if a GDR should be done or if an anti-psychotic medication should be discharged . When he takes his medication things are a lot better. The NP has not received a pharmacy recommendation for a GDR, it may have gone to the PCP (Primary Care Physician), but any GDR recommendations should be sent to her. She stated she was under the impression Resident #1 was getting the [MEDICATION NAME]. The Psychiatric NP revealed it was going to be difficult for Resident #1 to re-stabilize if he is was not taking his prescribed medications. She stated with his other medical problems, it is was going to trigger his psychiatric symptoms. She said he was is paranoid, delusional, and can could develop delusions about staff and be very difficult. She stated she could not recall Resident #1 having a history of aggression but it would be in her visit notes if he did. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Give 1 tablet by mouth as needed for restlessness/agitation TID (three times as day) PRN was started on 09/16/16 and discontinued on 11/08/17. discharged per pharmacy recommendation and physician agrees. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Inject 1 tablet intramuscularly as needed for Agitation related to [MEDICAL CONDITION] Disorder TID (Three Times Daily) PRN was started on 12/19/16 and discontinued on 10/11/17 due to pharmacy recommendation with physician approval. The order was confirmed by ADON G, who no longer works at the facility, and signed by Resident #1's PCP. Interview on 02/02/18 at 11:40 a.m. with the RNC revealed they were going to call the police and get an emergency detention to pick Resident #1 up due to aggressive behaviors. Review of facility policy Abuse - Reportable Events, dated (MONTH) (YEAR), reflected neglect is defined by The facility and its employees are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and serves would cause, among other things emotional distress. Physical abuse is defined as the physical action within the definition of abuse, including, but not limited, hitting, slapping, pinching, and kicking. In the event of resident to resident abuse, staff should immediately intervene, separate the residents, give immediately care to any injured resident, if necessary obtain a physician order to send resident to the hospital, speak to cognitively alert resident on proper behavior, immediate notify the Administrator and/or the Director of Nursing, monitor for behaviors, complete incident and accident report, notify physician and responsible party and document in resident's record. Review of the facility policy Behavior Problems and Possible Causes, dated (MONTH) (YEAR), reflected the following behavior problems to correct/relieve: incontinence problems, eating problems, bathing problems, sleeping problems, and wanting to go home. Review of the facility policy Behavior Management Crisis, dated (MONTH) (YEAR), reflected the following procedures; implement measures to ensure safety, summon additional staff if needed, diffuse crisis through calming communication, assess need for additional intervention, remove resident from situation, remove offending stimuli from resident, place resident in safe environment, remove onlookers from the area, contact administrators/designee and family/responsible party, contact physician, contact local police if behavior crisis requires immediate removal from home, document the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence. Review of facility policy Behavior Assessment - Management Interventions, dated (MONTH) (YEAR), reflected Behavior is defined as anything a person does or says in response to how the feel or what they experience. The home should consider resident behavior inappropriate if it: presents a risk of danger or harm to the resident, presents a risk of danger or harm others. Residents with behaviors should be placed on a resident behavior intervention and management program and attempts should be made to alleviate the behaviors. The Administrator, RNC, and DON were notified of the Immediate Jeopardy on 02/02/18 at 11:41 a.m. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 02/02/18 at 4:30 p.m. The Plan of Removal reflected: Plan of Removal 02/02/2018 Failure of Assess/Behavioral Changes/Notification of Reduction in GDR: 1. Resident #1 has been discharged to the emergency room for increased in behavioral outbursts against staff, transfer to (Psychiatric Hospital) on 02/02/18, RNC will review clinical record upon stabilization of resident if it is determined to readmit resident at that time appropriate interventions will be determined. 2. Staff will be in-serviced by adm-Don/designee reporting change of condition in residents to charge nurse/designee Start 02/02/18 and completed on 02/02/18. Staff who are not present at this time will be in-serviced prior to being allowed to work by DON/designee 3. Licensed staff will be in-serviced by ADM/DON/designee on notification to primary care physician and/or psychiatrist regarding changes in conditions. Start- 02/02/18 and completed 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee 4. Staff will be in-serviced by ADM/DON/designee on Behavioral Assessment/Managed Interventions/Behavior Problems and Causes Start- 02/02/18 and completed on 02/02/18- Competency test on Behavior started on 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee A). Wandering b). Difficulty with personal care task c). suspiciousness/paranoia d). agitation-i.e. sundowning or catastrophic reactions e). sleep disturbance f). inappropriate or impulsive sexual behavior 5. DON/Designee will continue to notify MD/psychiatrist of changes in medication regimen. Start- 02/02/18 6. Gradual Dose Reductions identified in the pharmacy consultant in the last 30 days will be pulled and verified for notification to MD/psychiatrist. Any notifications not noted will be completed by 02/02/18. 7. Start 02/02/18- completed 02/02/18 Interviews were conducted at various times on 02/02/18 and 02/03/18 with the following staff: ADON J, CNA K, LVN L, ADON M, Activities Director, Housekeeping Supervisor, CNA E, CNA O, CNA P, LVN Q, LVN R, RN S, CNA T, Dietary Director, CNA U, CNA W. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over reporting a change of condition, notification of MD/psychiatrist of changes in medication regimen, assessment and intervention of behavior problems and causes. On 02/02/18, the Immediate Jeopardy (IJ) was removed. On 02/02/18 at 4:28 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 02/03/18, the facility remained out of compliance at severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Census provided by the DON on 02/01/18 reflected 49 residents resided on the 300 hall. Review of Wanderguard list provided by the DON on 02/02/18 at 4:36 p.m. reflected the facility had 13 residents who had the potential to wander in the building.

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for three (Resident #1, Resident #2 and Resident #3) of 7 residents reviewed for neglect. Facility failed to address and intervene Resident #1's aggressive behaviors. 1. The facility failed to notify and consult with the attending physician and psychiatrist/Nurse Practitioner regarding Resident #1 hitting Resident #2, his roommate, on 11/29/17 and failed to have a plan in place to address protection of future roommates. 2. The facility failed to address Resident #1 aggressive behaviors. Resident #1 physcially attacked Resident #3, his new roommate who was vulnerable due to limited range of motion, [MEDICAL CONDITION] and [MEDICAL CONDITION], multiple times on 01/09/18. Resident #3 was transferred to the ER and was diagnosed with [REDACTED]. 3. The facility failed to notify and consult with the attending physician and at times the Psychiatric Nurse Practitioner when Resident #1 refused his medications including [MEDICATION NAME] which was for his diagnosed [MEDICAL CONDITION] Disorder and his behaviors. 4. The facility failed to address Resident #1 refusing his medications even after his [MEDICATION NAME] was changed to a liquid. 5. The facility failed to address Resident #1's aggression toward LVN C and LVN I. These failures could affect all 49 residents who reside on the 300 hall by placing them at risk of harm and injury. An Immediate Jeopardy (IJ) was identified on 02/02/18. Although the IJ was removed on 02/03/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). Findings included: Review of Resident #1's MDS quarterly assessment, dated 12/28/17, reflected Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. The resident had severe cognitive impairment. His [DIAGNOSES REDACTED]. MDS did not reflect any behaviors. Review of Resident #1's Social Service Note Admission Assessment, dated 01/05/16, by the Social Worker, reflected Resident #1 was unable to return his previous nursing facility as he allegedly hit an aide when he was there. Review of Resident #1's Physician Order's dated 05/15/17, reflected Psychiatric Care to evaluate and treat. Review of Resident #1's Physician Order's dated 05/22/17, reflected [MEDICATION NAME] Tablet 0.25 mg ([MEDICATION NAME]) Give 1 tablet by mouth every 8 hours as needed for anxiety. Review of Resident #1's Physician Order's dated 08/31/17, reflected [MEDICATION NAME] HCL Tablet 50 mg Give 0.5 tablet by mouth at bedtime for [MEDICAL CONDITION] Give ½ tab to equal 25 mg. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Care Plan, Revision on 10/19/17, reflected, the Resident has potential to demonstrate verbally abusive behaviors r/t (related to) cognitive deficits of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident misunderstands what room-mate says at times and becomes upset. Interventions initialed on 05/12/17 included; when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Interventions initialed on 06/15/17 included, evaluate for side effects of medications, psychiatric/psychogeriatric consult as indicated. Review of Resident #1's Behavior Nurses Note dated 11/29/17 reflected Resident #1 stated his roommate Resident #2 called him a little girl in front of people. When he confronted him he denied it so Resident #1 hit him and then they moved Resident #2 to a different room. Resident #2 reported the incident to the facility staff. Physician and responsible party notified. Care plan updated, resident #1 placed on 1:1 until calm, psychiatrist to see on next visit. Review of Resident #1's Care Plan revealed there were no additional interventions put in place and care plan did not reflect 11/29/17 incident. Review of Resident #1's Visit Note Psychiatric Nurse Practitioner (NP), encounter date 12/27/17, reflected the resident was at little to no risk of aggression. Assessment/Plan was to continue [MEDICATION NAME]/[MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION] and continue [MEDICATION NAME] for anxiety. Review of Resident #1's Nurses' Progress Note, dated 01/07/18, reflected Resident #1 refused all evening medications and stated to the nurse if you ask me to take my medication and check my blood sugar I will hit you. Review of Resident #1 MAR indicated [REDACTED]. Physician notified, no new orders at this time. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Observation and interview on 02/01/18 at 4:15 p.m. with Resident #1 revealed Resident #1 was alone in his room in his recliner. He stated he was doing good. Observation on 02/01/18 at 5:01 p.m. revealed Resident #1 cursing and yelling alone in his room. The ADON got up and walked by his room. Review of Resident #2's MDS quarterly assessment, dated 01/26/18, reflected Resident #2 was a [AGE] year old male admitted to the facility on [DATE]. The resident was cognitively intact. His [DIAGNOSES REDACTED]. Interview on 02/02/18 at 12:25 p.m. with Resident #2 revealed he was a roommate with Resident #1 since (MONTH) (YEAR) and Resident #1 said he called him a girl. He tried to explain to Resident #1 that he did not call him a girl and Resident #1 hit him. He leaned back when Resident #1 hit him, so it did not hurt. Resident #2 revealed Resident #1 admitted it to staff members when they came into the room. Resident #2 stated Resident #1 turned a table over. It happened in November, around Thanksgiving. He stated they moved him to his current room. He stated he did not know why Resident #1 went off. They did not have any issues before. Resident #2 said Resident #1 talked gibberish, but that was it. Interview on 02/02/18 at 1:20 p.m. with the DON revealed she did not know Resident #1 had an aggressive incident on 11/29/17. She was not in the picture, she only knew the roommates were not getting along and someone else moved him and took care of that. She stated it should have been charted. Interview on 02/02/18 at 1:25 p.m. with the Administrator revealed he was new to the facility and they did have a very young administrator at that time who dictated a lot of things and did not let people do things. He stated this kind of incident should be reported immediately and discussed. The Administrator revealed there should be more communication between staff. Review of Resident #3's MDS admission assessment, dated 12/14/17, reflected Resident #3 was a [AGE] year old male. The resident had moderate cognitive impairment. His [DIAGNOSES REDACTED]. He had upper body impairment on one side and lower body impairment on both sides. Resident #3's Nursing Progress Note dated 12/07/17 reflected he moved into a room. (Note: The new room was Resident #1's room.) Review of the Provider Investigation Report, dated 01/15/18, reflected Resident #1 was independently ambulatory and had a history of [REDACTED].#3 was not ambulatory and required total assistance. On 01/09/18, the housekeeper saw Resident #1 hit Resident #3 three times with his fist. Resident #3 stated he was hit in the head and neck. Resident #1 stated he told his roommate, Resident #3, to turn down his TV because all he wanted was some peace and quiet and the housekeeper witnessed Resident #1 hit Resident #3. Resident #3 requested to go to the hospital and press charges. Head to toe assessments were completed on both residents. No injuries were noted. Resident #3 was sent to the hospital per resident request. Residents were immediately separated and Resident #3 was moved to another room. Psychiatric Nurse Practitioner was notified. Resident #1 had his [MEDICATION NAME] changed from pill form to liquid. Resident #3 was sent to the hospital per his request after police visited with him. Staff were in-serviced on Abuse and Neglect, Behavior Crisis, and Behavior Management: problems and Possible Causes. Care plans were updated. Interview on 02/01/18 11:25 a.m. with the housekeeper with CNA B interpreting, revealed Resident #3 was looking toward the door in his electric wheelchair. The TV was on, and it was loud. Resident #1 told him it was too high. Resident #3 answered something back, turned and went to his side of the room. The housekeeper stated Resident #1 started screaming and saying stuff and got up and started hitting Resident #3 in the back. The housekeeper ran to the halls to find someone, at the time no one was there, and she got the floor technician. By the time the floor technician got there, Resident #1 was not hitting anymore. They told LVN A of the incident when it occurred. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed Resident #1 had an incident with his previous roommate, Resident #2, on a weekend. After the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that had happened at Resident #1's previous facility. She did not report it or document it. She felt it was in a confidential conversation. Review of Resident #3's SBAR Summary, dated 01/09/18, reflected Resident had head and neck pain roommate hit him Resident #3 given pain med (medication) [MEDICATION NAME] 5/325 mg tab PO was effective .the resident appears 'pain' sent to emergency room for eval (evaluation) due to head and neck pain per resident request. Review of Resident #3's After Visit Summary from the emergency room , dated 01/09/18, reflected [DIAGNOSES REDACTED]. Instructions given were start taking [MEDICATION NAME] 50 mg 1-2 tabs by mouth every six hours as needed for pain. Review of Resident #1's Visit Note by NP, encounter dated 01/10/18, reflected Resident #1 was seen for restlessness. Resident was seen for the management for [MEDICAL CONDITION] medications and side effects, and to monitor the effect of medication. Resident's [MEDICAL CONDITION] medication was beneficial in this case to control their psychiatric symptoms and to manage the resident's condition, to prevent relapse or hospitalization and to improve restorative potential. Staff report resident has been refusing care and medications. Assessment/Plan: Continue [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION], change [MEDICATION NAME] from tablet to liquid, continue [MEDICATION NAME] for anxiety. Psychiatric medications were reviewed to determine if benefit outweighs the risk. Benefit does outweigh risk. GDR is clinically contraindicated. Additional attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior. Review of Resident #1's Physician Order's, dated 01/10/18, reflected [MEDICATION NAME] Solution 1 Mg/Ml ([MEDICATION NAME]) Give 3 Ml by mouth two times a day for improve behaviors give 3 ml mixed with beverage of choice po (by mouth) bid (twice daily). Review of Resident #1's care plan, revision date 01/10/18, reflected Resident #1 misunderstands what roommate says at times and becomes upset. Resident became upset and hit room-mate (Resident #3) times three. The goal was for the resident to demonstrate effective coping skills through the review date. Interventions included; evaluate for side effects of medications, immediately separate and maintain safety of residents if any resident on resident physical aggression is suspected or witnessed, psychiatric/psychogeriatric consult as indicated, [MEDICATION NAME] was changed from pill form to liquid. Can be mixed with beverage, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; Review of Resident #3's care plan, revision date 01/10/18, reflected Resident #3 was struck by a roommate, Resident #3 was removed from the room. Nursing assessment shows no apparent injury, Resident #3 request to call police and be sent to hospital for evaluation. All requests followed. The goal was for Resident #3 to feel safe in his environment through next review. Interventions included, separated from room-mate and moved to another room, psych services to eval (sic) for needs of feeling safe. Review of Grievance/Concern Report submitted by Resident #3's family member, dated 01/10/18, reflected that several weeks ago Resident #3's family member advised the Social Worker that Resident #3 and his roommate, Resident #1, were having some difficulty and requested that she move him to another room. The social worker told him there was nothing she could do to help and Resident #1 was not prone to violence and would not hurt Resident #3. Interview on 02/01/18 at 12:15 p.m. with the social worker revealed she had a conversation with Resident #3's family member about changing Resident #3 to a different room but could not recall the date. He did request a roommate change, due to Resident #1 saying some not very nice things to Resident #3. He would say things like get out, you don't belong here, this is not your room. Resident #1 did not typically leave his room. She stated Resident #1 had other roommates before. The social worker was not aware if Resident #1 had any history of aggressive behaviors. The rooms they looked at for Resident #3 were not suitable for various reasons. One had a roommate who already had a power chair as Resident #3 had, and he W had concerns there would not be enough space for both. Another room that was available had a resident with very strong body odor. It was not until after Resident #3 was hit by Resident #1 that a suitable room became available and he was moved there. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed after the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that at Resident #1's previous facility. She stated she did not report it or document it because she felt it was in a confidential conversation. Interview on 02/01/18 at 8:50 a.m. with the DON revealed the Resident #3 discharged to the hospital on [DATE] for evaluation due to he stopped eating, was not feeding himself or talking. They received an update 3 days ago and he is was still frail and his family does did not want him to return to the facility. Review of Resident #1's Nurses' Progress Note, dated 01/14/18, reflected Resident #1 told the nurse if you come any closer I will hit you. Review of his Medication Administration Record [REDACTED].ml to be given two times a day for to improve behaviors. Resident refused medication on the following days: 01/12/18, 01/15/18, 01/16/18, 01/17/18, 01/18/17, 01/19/18, 01/22/18, 01/23/18, 01/24/18, 01/25/18, 01/26/18, 01/29/18, 01/30/18, 01/31/18. Interview on 02/01/18 at 11:13 a.m. with the DON revealed Resident #1 had been refusing his [MEDICATION NAME] frequently. A circle around staff's initials indicated a medication refusal. Review of Resident #1's Nurses' Progress Note By LVN C, dated 01/31/18 reflected Resident #1 was talking loud, shouting, and LVN C asked him to reduce his voice. Resident #1 turned violent, hitting LVN C and trying to hit LVN C on the face. LVN C deflected Resident #1's hits several times and he refused to stop for a long while, even while LVN C was moving back he continued to come after him. Interview on 02/01/18 at 2:22 p.m. with LVN C revealed Resident #1 was talking to himself on 01/31/18 loudly and other residents were complaining about the noise. He went to the room and asked if he could bring down the noise a little bit and he got up and just hit LVN C and could not stop. He just kept trying to hit the LVN in the face. LVN C stated he just kept deflecting the hits and backed away into the hall, about 15 feet away while Resident #1 hit him several times. People were shouting, but no one intervened. LVN C revealed that in the facility they could not have anything they could the resident, He stated no IM (Intramuscular) medication could be given. LVN C said they could not You do anything. LVN C stated he told the DON and ADON that Resident #1 got up and hit him and had been shouting and it may be a good idea to send him out to the hospital for a psychiatric evaluation since he has had not been taking medications for a few days. LVN C sent it in a text message and the DON replied to send him out for a psychiatric evaluation Interview on 02/01/18 at 5:00 p.m. with CMA E revealed he witnessed what happened with Resident #1 and LVN C on 01/31/18. He stated they were are trained to try and calm them, but that was getting out of hand. MA E revealed Resident #1 chased LVN C right into the hall. Interview on 02/01/18 at 8:50 a.m. with the DON revealed Resident #1 had an incident the previous evening, 01/31/18, of yelling and mood swings, they tried to send him to the hospital for an evaluation but he refused to go. Resident remained in the facility on 02/01/18. Interview on 02/01/18 at 1:44 p.m. with the Administrator revealed he was unaware of Resident #1 being assaultive on 01/31/18. He thought he was just refusing medications and they tried to send him out to the hospital and they refused. They facility does not manage resident behaviors, they care for residents. If a resident is aggressive he tells staff toback off and let someone else intervene. Interview on 02/01/18 at 1:50 p.m. with the DON revealed she was contacted via message from LVN C on 01/31/18 and LVN C told her Resident #1 he was shouting and refusing medications. She agreed to send him out for a psychiatric evaluation. The DON discovered that he refused to go the next morning. She stated she did not follow up with staff or check the documentation due to being busy on the skilled floor. The DON revealed she was not aware that Resident #1 hit LVN C. Interview on 02/02/18 at 1:15 p.m. with the DON revealed if she had read all of LVN C's text message regarding Resident #1's aggressive behavior she would have canceled morning meeting and called the police right away. She would not have put Resident #1 on one-to-one. The DON revealed that would be petrol to the fire. She stated Resident #1 responded well to the police. She stated she had no time to read all of that text. Interview on 02/01/18 at 2:56 p.m. with the DON revealed she was going to in-service all the staff on no more texting for all important stuff. Staff will need to call her from now on. The DON stated she only read the first half of the text message LVN C sent and did not read the part about Resident #1 hitting him. She stated did not follow up. The DON revealed on 02/01/18 she was busy, otherwise she would have put the resident on a one-to-one. Interview on 02/01/18 at 4:47 p.m. with LVN C revealed Resident #1's behaviors had been like this for a few months, up and down, with his moods. Interview on 02/01/18 at 4:55 p.m. with LVN D revealed Resident #1 seems to have had more shouting, yelling, and walking around at night. Interview on 02/01/18 at 5:01 p.m. with CNA F revealed for the most part Resident #1 was real quiet but when his mood started he thought people have messed with him he would start to yell. The CNA stated the resident kicked at staff when they tried to put his wanderguard on his ankle. On 02/02/18 at 11:40 a.m. revealed shouting and cursing was heard coming from Resident #1's room. Interview on 02/02/18 at 11:40 a.m. with LVN I revealed she was walking in the hallway with a bag of trash when Resident #1 came out of his room and asked for his wanderguard to be removed. Before she was able to respond, he hit her in the face. Resident #1 was observed in his recliner at that time. Interview on 02/02/18 at 9:05 a.m. with Psychiatric Nurse Practitioner (NP) revealed that she managed all of Resident #1's anti-psychotic medications. Resident #1 should be receiving [MEDICATION NAME] and [MEDICATION NAME] for psychotic symptoms, [MEDICATION NAME] at night, and [MEDICATION NAME] for anxiety and agitation. The effects of not taking one or both of his anti-psychotic medications, the [MEDICATION NAME] and [MEDICATION NAME], would be that he would decline very quickly, become very psychotic, prone to aggressive, impulsive behaviors. It would be up to the NP to decide if a GDR should be done or if an anti-psychotic medication should be discharged . When he takes his medication things are a lot better. The NP has not received a pharmacy recommendation for a GDR, it may have gone to the PCP (Primary Care Physician), but any GDR recommendations should be sent to her. She stated she was under the impression Resident #1 was getting the [MEDICATION NAME]. The Psychiatric NP revealed it was going to be difficult for Resident #1 to re-stabilize if he is was not taking his prescribed medications. She stated with his other medical problems, it is was going to trigger his psychiatric symptoms. She said he was is paranoid, delusional, and can could develop delusions about staff and be very difficult. She stated she could not recall Resident #1 having a history of aggression but it would be in her visit notes if he did. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Give 1 tablet by mouth as needed for restlessness/agitation TID (three times as day) PRN was started on 09/16/16 and discontinued on 11/08/17. discharged per pharmacy recommendation and physician agrees. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Inject 1 tablet intramuscularly as needed for Agitation related to [MEDICAL CONDITION] Disorder TID (Three Times Daily) PRN was started on 12/19/16 and discontinued on 10/11/17 due to pharmacy recommendation with physician approval. The order was confirmed by ADON G, who no longer works at the facility, and signed by Resident #1's PCP. Interview on 02/02/18 at 11:40 a.m. with the RNC revealed they were going to call the police and get an emergency detention to pick Resident #1 up due to aggressive behaviors. Review of facility policy Abuse - Reportable Events, dated (MONTH) (YEAR), reflected neglect is defined by The facility and its employees are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and serves would cause, among other things emotional distress. Physical abuse is defined as the physical action within the definition of abuse, including, but not limited, hitting, slapping, pinching, and kicking. In the event of resident to resident abuse, staff should immediately intervene, separate the residents, give immediately care to any injured resident, if necessary obtain a physician order to send resident to the hospital, speak to cognitively alert resident on proper behavior, immediate notify the Administrator and/or the Director of Nursing, monitor for behaviors, complete incident and accident report, notify physician and responsible party and document in resident's record. Review of the facility policy Behavior Problems and Possible Causes, dated (MONTH) (YEAR), reflected the following behavior problems to correct/relieve: incontinence problems, eating problems, bathing problems, sleeping problems, and wanting to go home. Review of the facility policy Behavior Management Crisis, dated (MONTH) (YEAR), reflected the following procedures; implement measures to ensure safety, summon additional staff if needed, diffuse crisis through calming communication, assess need for additional intervention, remove resident from situation, remove offending stimuli from resident, place resident in safe environment, remove onlookers from the area, contact administrators/designee and family/responsible party, contact physician, contact local police if behavior crisis requires immediate removal from home, document the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence. Review of facility policy Behavior Assessment - Management Interventions, dated (MONTH) (YEAR), reflected Behavior is defined as anything a person does or says in response to how the feel or what they experience. The home should consider resident behavior inappropriate if it: presents a risk of danger or harm to the resident, presents a risk of danger or harm others. Residents with behaviors should be placed on a resident behavior intervention and management program and attempts should be made to alleviate the behaviors. The Administrator, RNC, and DON were notified of the Immediate Jeopardy on 02/02/18 at 11:41 a.m. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 02/02/18 at 4:30 p.m. The Plan of Removal reflected: Plan of Removal 02/02/2018 Failure of Assess/Behavioral Changes/Notification of Reduction in GDR: 1. Resident #1 has been discharged to the emergency room for increased in behavioral outbursts against staff, transfer to (Psychiatric Hospital) on 02/02/18, RNC will review clinical record upon stabilization of resident if it is determined to readmit resident at that time appropriate interventions will be determined. 2. Staff will be in-serviced by adm-Don/designee reporting change of condition in residents to charge nurse/designee Start 02/02/18 and completed on 02/02/18. Staff who are not present at this time will be in-serviced prior to being allowed to work by DON/designee 3. Licensed staff will be in-serviced by ADM/DON/designee on notification to primary care physician and/or psychiatrist regarding changes in conditions. Start- 02/02/18 and completed 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee 4. Staff will be in-serviced by ADM/DON/designee on Behavioral Assessment/Managed Interventions/Behavior Problems and Causes Start- 02/02/18 and completed on 02/02/18- Competency test on Behavior started on 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee A). Wandering b). Difficulty with personal care task c). suspiciousness/paranoia d). agitation-i.e. sundowning or catastrophic reactions e). sleep disturbance f). inappropriate or impulsive sexual behavior 5. DON/Designee will continue to notify MD/psychiatrist of changes in medication regimen. Start- 02/02/18 6. Gradual Dose Reductions identified in the pharmacy consultant in the last 30 days will be pulled and verified for notification to MD/psychiatrist. Any notifications not noted will be completed by 02/02/18. 7. Start 02/02/18- completed 02/02/18 Interviews were conducted at various times on 02/02/18 and 02/03/18 with the following staff: ADON J, CNA K, LVN L, ADON M, Activities Director, Housekeeping Supervisor, CNA E, CNA O, CNA P, LVN Q, LVN R, RN S, CNA T, Dietary Director, CNA U, CNA W. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over reporting a change of condition, notification of MD/psychiatrist of changes in medication regimen, assessment and intervention of behavior problems and causes. On 02/02/18, the Immediate Jeopardy (IJ) was removed. On 02/02/18 at 4:28 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 02/03/18, the facility remained out of compliance at severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Census provided by the DON on 02/01/18 reflected 49 residents resided on the 300 hall. Review of Wanderguard list provided by the DON on 02/02/18 at 4:36 p.m. reflected the facility had 13 residents who had the potential to wander in the building.

Based on interview and record review, the facility failed to develop and implement written polices and procedures that prohibit and prevent the neglect of residents for three (Resident #1, Resident #2 and Resident #3) of seven residents reviewed neglect. 1. The Administrator failed to implement the facility's written policies and procedures that prohibit and prevent neglect of residents. 2. The facility failed to notify and consult with the attending physician and psychiatrist/Nurse Practitioner regarding Resident #1 hitting Resident #2, his roommate, on 11/29/17 and failed to have a plan in place to address protection of future roommates. 3. The facility failed to prevent Resident #1 from hitting Resident #3, his new roommate who was vulnerable due to limited range of motion, [MEDICAL CONDITION] and [MEDICAL CONDITION], multiple times on 01/09/18. Resident #3 was transferred to the ER and was diagnosed with [REDACTED]. 4. The facility failed to notify and consult with the attending physician and at times the Psychiatric Nurse Practitioner when Resident #1 refused his medications including [MEDICATION NAME] which was for his diagnosed [MEDICAL CONDITION] Disorder and his behaviors. 5. The facility failed to address Resident #1 refusing his medications even after his [MEDICATION NAME] was changed to a liquid. 6. The facility failed to address Resident #1's aggression toward LVN C and LVN I. These failures could affect all 49 residents who reside on the 300 hall by placing them at risk of harm and injury. An Immediate Jeopardy (IJ) was identified on 02/02/18. Although the IJ was removed on 02/02/18, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern due to needing to train staff and monitor their implementation of the Plan of Removal (POR). Findings included: Review of facility policy Abuse - Reportable Events, dated (MONTH) (YEAR), reflected neglect is defined by The facility and its employees are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and serves would cause, among other things emotional distress. Physical abuse is defined as the physical action within the definition of abuse, including, but not limited, hitting, slapping, pinching, and kicking. In the event of resident to resident abuse, staff should immediately intervene, separate the residents, give immediately care to any injured resident, if necessary obtain a physician order to send resident to the hospital, speak to cognitively alert resident on proper behavior, immediate notify the Administrator and/or the Director of Nursing, monitor for behaviors, complete incident and accident report, notify physician and responsible party and document in resident's record. Review of the facility policy Behavior Problems and Possible Causes, dated (MONTH) (YEAR), reflected the following behavior problems to correct/relieve: incontinence problems, eating problems, bathing problems, sleeping problems, and wanting to go home. Review of the facility policy Behavior Management Crisis, dated (MONTH) (YEAR), reflected the following procedures; implement measures to ensure safety, summon additional staff if needed, diffuse crisis through calming communication, assess need for additional intervention, remove resident from situation, remove offending stimuli from resident, place resident in safe environment, remove onlookers from the area, contact administrators/designee and family/responsible party, contact physician, contact local police if behavior crisis requires immediate removal from home, document the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence. Review of facility policy Behavior Assessment - Management Interventions, dated (MONTH) (YEAR), reflected Behavior is defined as anything a person does or says in response to how the feel or what they experience. The home should consider resident behavior inappropriate if it: presents a risk of danger or harm to the resident, presents a risk of danger or harm others. Residents with behaviors should be placed on a resident behavior intervention and management program and attempts should be made to alleviate the behaviors. Review of Resident #1's MDS quarterly assessment, dated 12/28/17, reflected Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. The resident had severe cognitive impairment. His [DIAGNOSES REDACTED]. MDS did not reflect any behaviors. Review of Resident #1's Social Service Note Admission Assessment, dated 01/05/16, by the Social Worker, reflected Resident #1 was unable to return his previous nursing facility as he allegedly hit an aide when he was there. Review of Resident #1's Physician Order's dated 05/15/17, reflected Psychiatric Care to evaluate and treat. Review of Resident #1's Physician Order's dated 05/22/17, reflected [MEDICATION NAME] Tablet 0.25 mg ([MEDICATION NAME]) Give 1 tablet by mouth every 8 hours as needed for anxiety. Review of Resident #1's Physician Order's dated 08/31/17, reflected [MEDICATION NAME] HCL Tablet 50 mg Give 0.5 tablet by mouth at bedtime for [MEDICAL CONDITION] Give ½ tab to equal 25 mg. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Care Plan, Revision on 10/19/17, reflected, the Resident has potential to demonstrate verbally abusive behaviors r/t (related to) cognitive deficits of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident misunderstands what room-mate says at times and becomes upset. Interventions initialed on 05/12/17 included; when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Interventions initialed on 06/15/17 included, evaluate for side effects of medications, psychiatric/psychogeriatric consult as indicated. Review of Resident #1's Behavior Nurses Note dated 11/29/17 reflected Resident #1 stated his roommate Resident #2 called him a little girl in front of people. When he confronted him he denied it so Resident #1 hit him and then they moved Resident #2 to a different room. Resident #2 reported the incident to the facility staff. Physician and responsible party notified. Care plan updated, resident #1 placed on 1:1 until calm, psychiatrist to see on next visit. Review of Resident #1's Care Plan revealed there were no additional interventions put in place and care plan did not reflect 11/29/17 incident. Review of Resident #1's Visit Note Psychiatric Nurse Practitioner (NP), encounter date 12/27/17, reflected the resident was at little to no risk of aggression. Assessment/Plan was to continue [MEDICATION NAME]/[MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION] and continue [MEDICATION NAME] for anxiety. Review of Resident #1's Nurses' Progress Note, dated 01/07/18, reflected Resident #1 refused all evening medications and stated to the nurse if you ask me to take my medication and check my blood sugar I will hit you. Review of Resident #1 MAR indicated [REDACTED]. Physician notified, no new orders at this time. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Review of nurses' notes on Resident #1 MAR indicated [REDACTED]. No new orders. Observation and interview on 02/01/18 at 4:15 p.m. with Resident #1 revealed Resident #1 was alone in his room in his recliner. He stated he was doing good. Observation on 02/01/18 at 5:01 p.m. revealed Resident #1 cursing and yelling alone in his room. The ADON got up and walked by his room. Review of Resident #2's MDS quarterly assessment, dated 01/26/18, reflected Resident #2 was a [AGE] year old male admitted to the facility on [DATE]. The resident was cognitively intact. His [DIAGNOSES REDACTED]. Interview on 02/02/18 at 12:25 p.m. with Resident #2 revealed he was a roommate with Resident #1 since (MONTH) (YEAR) and Resident #1 said he called him a girl. He tried to explain to Resident #1 that he did not call him a girl and Resident #1 hit him. He leaned back when Resident #1 hit him, so it did not hurt. Resident #2 revealed Resident #1 admitted it to staff members when they came into the room. Resident #2 stated Resident #1 turned a table over. It happened in November, around Thanksgiving. He stated they moved him to his current room. He stated he did not know why Resident #1 went off. They did not have any issues before. Resident #2 said Resident #1 talked gibberish, but that was it. Interview on 02/02/18 at 1:20 p.m. with the DON revealed she did not know Resident #1 had an aggressive incident on 11/29/17. She was not in the picture, she only knew the roommates were not getting along and someone else moved him and took care of that. She stated it should have been charted. Interview on 02/02/18 at 1:25 p.m. with the Administrator revealed he was new to the facility and they did have a very young administrator at that time who dictated a lot of things and did not let people do things. He stated this kind of incident should be reported immediately and discussed. The Administrator revealed there should be more communication between staff. Review of Resident #3's MDS admission assessment, dated 12/14/17, reflected Resident #3 was a [AGE] year old male. The resident had moderate cognitive impairment. His [DIAGNOSES REDACTED]. He had upper body impairment on one side and lower body impairment on both sides. Resident #3's Nursing Progress Note dated 12/07/17 reflected he moved into a room. (Note: The new room was Resident #1's room.) Review of the Provider Investigation Report, dated 01/15/18, reflected Resident #1 was independently ambulatory and had a history of [REDACTED].#3 was not ambulatory and required total assistance. On 01/09/18, the housekeeper saw Resident #1 hit Resident #3 three times with his fist. Resident #3 stated he was hit in the head and neck. Resident #1 stated he told his roommate, Resident #3, to turn down his TV because all he wanted was some peace and quiet and the housekeeper witnessed Resident #1 hit Resident #3. Resident #3 requested to go to the hospital and press charges. Head to toe assessments were completed on both residents. No injuries were noted. Resident #3 was sent to the hospital per resident request. Residents were immediately separated and Resident #3 was moved to another room. Psychiatric Nurse Practitioner was notified. Resident #1 had his [MEDICATION NAME] changed from pill form to liquid. Resident #3 was sent to the hospital per his request after police visited with him. Staff were in-serviced on Abuse and Neglect, Behavior Crisis, and Behavior Management: problems and Possible Causes. Care plans were updated. Interview on 02/01/18 11:25 a.m. with the housekeeper with CNA B interpreting, revealed Resident #3 was looking toward the door in his electric wheelchair. The TV was on, and it was loud. Resident #1 told him it was too high. Resident #3 answered something back, turned and went to his side of the room. The housekeeper stated Resident #1 started screaming and saying stuff and got up and started hitting Resident #3 in the back. The housekeeper ran to the halls to find someone, at the time no one was there, and she got the floor technician. By the time the floor technician got there, Resident #1 was not hitting anymore. They told LVN A of the incident when it occurred. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed Resident #1 had an incident with his previous roommate, Resident #2, on a weekend. After the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that had happened at Resident #1's previous facility. She did not report it or document it. She felt it was in a confidential conversation. Review of Resident #3's SBAR Summary, dated 01/09/18, reflected Resident had head and neck pain roommate hit him Resident #3 given pain med (medication) [MEDICATION NAME] 5/325 mg tab PO was effective .the resident appears 'pain' sent to emergency room for eval (evaluation) due to head and neck pain per resident request. Review of Resident #3's After Visit Summary from the emergency room , dated 01/09/18, reflected [DIAGNOSES REDACTED]. Instructions given were start taking [MEDICATION NAME] 50 mg 1-2 tabs by mouth every six hours as needed for pain. Review of Resident #1's Visit Note by NP, encounter dated 01/10/18, reflected Resident #1 was seen for restlessness. Resident was seen for the management for [MEDICAL CONDITION] medications and side effects, and to monitor the effect of medication. Resident's [MEDICAL CONDITION] medication was beneficial in this case to control their psychiatric symptoms and to manage the resident's condition, to prevent relapse or hospitalization and to improve restorative potential. Staff report resident has been refusing care and medications. Assessment/Plan: Continue [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION], change [MEDICATION NAME] from tablet to liquid, continue [MEDICATION NAME] for anxiety. Psychiatric medications were reviewed to determine if benefit outweighs the risk. Benefit does outweigh risk. GDR is clinically contraindicated. Additional attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior. Review of Resident #1's Physician Order's, dated 01/10/18, reflected [MEDICATION NAME] Solution 1 Mg/Ml ([MEDICATION NAME]) Give 3 Ml by mouth two times a day for improve behaviors give 3 ml mixed with beverage of choice po (by mouth) bid (twice daily). Review of Resident #1's care plan, revision date 01/10/18, reflected Resident #1 misunderstands what roommate says at times and becomes upset. Resident became upset and hit room-mate (Resident #3) times three. The goal was for the resident to demonstrate effective coping skills through the review date. Interventions included; evaluate for side effects of medications, immediately separate and maintain safety of residents if any resident on resident physical aggression is suspected or witnessed, psychiatric/psychogeriatric consult as indicated, [MEDICATION NAME] was changed from pill form to liquid. Can be mixed with beverage, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; Review of Resident #3's care plan, revision date 01/10/18, reflected Resident #3 was struck by a roommate, Resident #3 was removed from the room. Nursing assessment shows no apparent injury, Resident #3 request to call police and be sent to hospital for evaluation. All requests followed. The goal was for Resident #3 to feel safe in his environment through next review. Interventions included, separated from room-mate and moved to another room, psych services to eval (sic) for needs of feeling safe. Review of Grievance/Concern Report submitted by Resident #3's family member, dated 01/10/18, reflected that several weeks ago Resident #3's family member advised the Social Worker that Resident #3 and his roommate, Resident #1, were having some difficulty and requested that she move him to another room. The social worker told him there was nothing she could do to help and Resident #1 was not prone to violence and would not hurt Resident #3. Interview on 02/01/18 at 12:15 p.m. with the social worker revealed she had a conversation with Resident #3's family member about changing Resident #3 to a different room but could not recall the date. He did request a roommate change, due to Resident #1 saying some not very nice things to Resident #3. He would say things like get out, you don't belong here, this is not your room. Resident #1 did not typically leave his room. She stated Resident #1 had other roommates before. The social worker was not aware if Resident #1 had any history of aggressive behaviors. The rooms they looked at for Resident #3 were not suitable for various reasons. One had a roommate who already had a power chair as Resident #3 had, and he W had concerns there would not be enough space for both. Another room that was available had a resident with very strong body odor. It was not until after Resident #3 was hit by Resident #1 that a suitable room became available and he was moved there. Interview on 02/02/18 at 8:41 a.m. with LVN A revealed after the incident with Resident #3 on 01/09/18 she spoke with Resident #1's family member, who reported to her that an episode had happened like that at Resident #1's previous facility. She stated she did not report it or document it because she felt it was in a confidential conversation. Interview on 02/01/18 at 8:50 a.m. with the DON revealed the Resident #3 discharged to the hospital on [DATE] for evaluation due to he stopped eating, was not feeding himself or talking. They received an update 3 days ago and he is was still frail and his family does did not want him to return to the facility. Review of Resident #1's Nurses' Progress Note, dated 01/14/18, reflected Resident #1 told the nurse if you come any closer I will hit you. Review of his Medication Administration Record [REDACTED].ml to be given two times a day for to improve behaviors. Resident refused medication on the following days: 01/12/18, 01/15/18, 01/16/18, 01/17/18, 01/18/17, 01/19/18, 01/22/18, 01/23/18, 01/24/18, 01/25/18, 01/26/18, 01/29/18, 01/30/18, 01/31/18. Interview on 02/01/18 at 11:13 a.m. with the DON revealed Resident #1 had been refusing his [MEDICATION NAME] frequently. A circle around staff's initials indicated a medication refusal. Review of Resident #1's Nurses' Progress Note By LVN C, dated 01/31/18 reflected Resident #1 was talking loud, shouting, and LVN C asked him to reduce his voice. Resident #1 turned violent, hitting LVN C and trying to hit LVN C on the face. LVN C deflected Resident #1's hits several times and he refused to stop for a long while, even while LVN C was moving back he continued to come after him. Interview on 02/01/18 at 2:22 p.m. with LVN C revealed Resident #1 was talking to himself on 01/31/18 loudly and other residents were complaining about the noise. He went to the room and asked if he could bring down the noise a little bit and he got up and just hit LVN C and could not stop. He just kept trying to hit the LVN in the face. LVN C stated he just kept deflecting the hits and backed away into the hall, about 15 feet away while Resident #1 hit him several times. People were shouting, but no one intervened. LVN C revealed that in the facility they could not have anything they could the resident, He stated no IM (Intramuscular) medication could be given. LVN C said they could not You do anything. LVN C stated he told the DON and ADON that Resident #1 got up and hit him and had been shouting and it may be a good idea to send him out to the hospital for a psychiatric evaluation since he has had not been taking medications for a few days. LVN C sent it in a text message and the DON replied to send him out for a psychiatric evaluation Interview on 02/01/18 at 5:00 p.m. with CMA E revealed he witnessed what happened with Resident #1 and LVN C on 01/31/18. He stated they were are trained to try and calm them, but that was getting out of hand. MA E revealed Resident #1 chased LVN C right into the hall. Interview on 02/01/18 at 8:50 a.m. with the DON revealed Resident #1 had an incident the previous evening, 01/31/18, of yelling and mood swings, they tried to send him to the hospital for an evaluation but he refused to go. Resident remained in the facility on 02/01/18. Interview on 02/01/18 at 1:44 p.m. with the Administrator revealed he was unaware of Resident #1 being assaultive on 01/31/18. He thought he was just refusing medications and they tried to send him out to the hospital and they refused. They facility does not manage resident behaviors, they care for residents. If a resident is aggressive he tells staff toback off and let someone else intervene. Interview on 02/01/18 at 1:50 p.m. with the DON revealed she was contacted via message from LVN C on 01/31/18 and LVN C told her Resident #1 he was shouting and refusing medications. She agreed to send him out for a psychiatric evaluation. The DON discovered that he refused to go the next morning. She stated she did not follow up with staff or check the documentation due to being busy on the skilled floor. The DON revealed she was not aware that Resident #1 hit LVN C. Interview on 02/02/18 at 1:15 p.m. with the DON revealed if she had read all of LVN C's text message regarding Resident #1's aggressive behavior she would have canceled morning meeting and called the police right away. She would not have put Resident #1 on one-to-one. The DON revealed that would be petrol to the fire. She stated Resident #1 responded well to the police. She stated she had no time to read all of that text. Interview on 02/01/18 at 2:56 p.m. with the DON revealed she was going to in-service all the staff on no more texting for all important stuff. Staff will need to call her from now on. The DON stated she only read the first half of the text message LVN C sent and did not read the part about Resident #1 hitting him. She stated did not follow up. The DON revealed on 02/01/18 she was busy, otherwise she would have put the resident on a one-to-one. Interview on 02/01/18 at 4:47 p.m. with LVN C revealed Resident #1's behaviors had been like this for a few months, up and down, with his moods. Interview on 02/01/18 at 4:55 p.m. with LVN D revealed Resident #1 seems to have had more shouting, yelling, and walking around at night. Interview on 02/01/18 at 5:01 p.m. with CNA F revealed for the most part Resident #1 was real quiet but when his mood started he thought people have messed with him he would start to yell. The CNA stated the resident kicked at staff when they tried to put his wanderguard on his ankle. On 02/02/18 at 11:40 a.m. revealed shouting and cursing was heard coming from Resident #1's room. Interview on 02/02/18 at 11:40 a.m. with LVN I revealed she was walking in the hallway with a bag of trash when Resident #1 came out of his room and asked for his wanderguard to be removed. Before she was able to respond, he hit her in the face. Resident #1 was observed in his recliner at that time. Interview on 02/02/18 at 9:05 a.m. with Psychiatric Nurse Practitioner (NP) revealed that she managed all of Resident #1's anti-psychotic medications. Resident #1 should be receiving [MEDICATION NAME] and [MEDICATION NAME] for psychotic symptoms, [MEDICATION NAME] at night, and [MEDICATION NAME] for anxiety and agitation. The effects of not taking one or both of his anti-psychotic medications, the [MEDICATION NAME] and [MEDICATION NAME], would be that he would decline very quickly, become very psychotic, prone to aggressive, impulsive behaviors. It would be up to the NP to decide if a GDR should be done or if an anti-psychotic medication should be discharged . When he takes his medication things are a lot better. The NP has not received a pharmacy recommendation for a GDR, it may have gone to the PCP (Primary Care Physician), but any GDR recommendations should be sent to her. She stated she was under the impression Resident #1 was getting the [MEDICATION NAME]. The Psychiatric NP revealed it was going to be difficult for Resident #1 to re-stabilize if he is was not taking his prescribed medications. She stated with his other medical problems, it is was going to trigger his psychiatric symptoms. She said he was is paranoid, delusional, and can could develop delusions about staff and be very difficult. She stated she could not recall Resident #1 having a history of aggression but it would be in her visit notes if he did. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Give 1 tablet by mouth as needed for restlessness/agitation TID (three times as day) PRN was started on 09/16/16 and discontinued on 11/08/17. discharged per pharmacy recommendation and physician agrees. Review of Resident #1's Physician Order's, dated 02/02/18, reflected [MEDICATION NAME] Tablet 2 mg Inject 1 tablet intramuscularly as needed for Agitation related to [MEDICAL CONDITION] Disorder TID (Three Times Daily) PRN was started on 12/19/16 and discontinued on 10/11/17 due to pharmacy recommendation with physician approval. The order was confirmed by ADON G, who no longer works at the facility, and signed by Resident #1's PCP. Interview on 02/02/18 at 11:40 a.m. with the RNC revealed they were going to call the police and get an emergency detention to pick Resident #1 up due to aggressive behaviors. The Administrator, RNC, and DON were notified of the Immediate Jeopardy on 02/02/18 at 11:41 a.m. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 02/02/18 at 4:30 p.m. The Plan of Removal reflected: Plan of Removal 02/02/2018 Failure of Assess/Behavioral Changes/Notification of Reduction in GDR: 1. Resident #1 has been discharged to the emergency room for increased in behavioral outbursts against staff, transfer to (Psychiatric Hospital) on 02/02/18, RNC will review clinical record upon stabilization of resident if it is determined to readmit resident at that time appropriate interventions will be determined. 2. Staff will be in-serviced by adm-Don/designee reporting change of condition in residents to charge nurse/designee Start 02/02/18 and completed on 02/02/18. Staff who are not present at this time will be in-serviced prior to being allowed to work by DON/designee 3. Licensed staff will be in-serviced by ADM/DON/designee on notification to primary care physician and/or psychiatrist regarding changes in conditions. Start- 02/02/18 and completed 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee 4. Staff will be in-serviced by ADM/DON/designee on Behavioral Assessment/Managed Interventions/Behavior Problems and Causes Start- 02/02/18 and completed on 02/02/18- Competency test on Behavior started on 02/02/18 Staff who are not present at this time, will be in-serviced prior to being allowed to work by DON/designee A). Wandering b). Difficulty with personal care task c). suspiciousness/paranoia d). agitation-i.e. sundowning or catastrophic reactions e). sleep disturbance f). inappropriate or impulsive sexual behavior 5. DON/Designee will continue to notify MD/psychiatrist of changes in medication regimen. Start- 02/02/18 6. Gradual Dose Reductions identified in the pharmacy consultant in the last 30 days will be pulled and verified for notification to MD/psychiatrist. Any notifications not noted will be completed by 02/02/18. 7. Start 02/02/18- completed 02/02/18 Interviews were conducted at various times on 02/02/18 and 02/03/18 with the following staff: ADON J, CNA K, LVN L, ADON M, Activities Director, Housekeeping Supervisor, CNA E, CNA O, CNA P, LVN Q, LVN R, RN S, CNA T, Dietary Director, CNA U, CNA W. Staff interviewed were representative of various facility shifts. Staff was able to provide return demonstration and competency regarding training over reporting a change of condition, notification of MD/psychiatrist of changes in medication regimen, assessment and intervention of behavior problems and causes. On 02/02/18, the Immediate Jeopardy (IJ) was removed. On 02/02/18 at 4:28 p.m. the Administrator and DON was informed the IJ was removed. While the IJ was removed on 02/03/18, the facility remained out of compliance at severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. Census provided by the DON on 02/01/18 reflected 49 residents resided on the 300 hall. Review of Wanderguard list provided by the DON on 02/02/18 at 4:36 p.m. reflected the facility had 13 residents who had the potential to wander in the building.

Based on interview and record review, it was determined the facility failed to ensure residents were free of any significant medication erros for one (Resident #1) of 10 residents reviewed for medications. The facility failed to administer the physician-order diurectic, [MEDICATION NAME], 2.5 mg to Resident #1, who had a history of [REDACTED]. Resident #1 was hospitalized for [REDACTED]. This failure could affect the 51 residents residing on the 100 hall, by placing them at risk for not receiving physician ordered medications, which could lead to a worsening of their medical symptoms, discomfort and hospitalization . Findings included: The current MDS assessment, dated 02/22/14, reflected Resident #1 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. According to the MDS assessment, the resident required assistance with ADLs, was mobile via wheelchair and on oxygen therapy. The MDS reflected the resident had [DIAGNOSES REDACTED]. Resident #1 was able to make herself understood, and she understood others. The weight record for December 2013 (no date specified) reflected Resident #1's weight was 185 lbs. The weight record for January 2014 (no date specified) reflected Resident #1's weight was 202.6 lbs. (an increase of 17.6 lbs. in one month). Review of the (Admit/ReAdmit) Weekly Weight Status record for January 2014 revealed a weight was entered for Resident #1 for the week of 01/27/14, which was 237.4 lbs, another increase of 19.8 lbs. Resident #1's Physician's Telephone Order, dated 01/28/14, reflected the resident was placed on fluid restriction. Resident #1's Physician's Telephone Order, dated 02/17/14, reflected to weigh her twice a week. A physician's orders [REDACTED]. Resident #1's Care Plan, dated 11/26/13 and updated 02/20/14, reflected she was at risk of electrolyte imbalance related to the use of a diuretic. Approaches included: "Administer medications as ordered [MEDICATION NAME] 40 mg BID" and monitor for [MEDICAL CONDITION]. (Note: Resident #1's [MEDICATION NAME] was discontinued on 02/05/14, per the Physician's Telephone Order dated 02/05/14). An interview with the DON on 03/04/14 at 4:00 PM, revealed the twice a week weights and fluid restriction orders were initiated because the resident experienced a weight gain and was retaining fluid. Resident #1's Physician's Telephone Order, dated 02/14/14, reflected an order for [REDACTED]. Resident #1's Physician's Telephone Order, dated 02/17/14, reflected to continue [MEDICATION NAME] 2.5 mg by mouth every day. Resident #1's February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. An interview with LVN B on 03/05/14 at approximately 11:00 AM revealed she wrote the physician's orders [REDACTED].#1. She acknowledged she did not transcribe it to Resident #1's February 2014 MAR, because she was unsure if the Cardiologist would agree. LVN B also stated she did not mean to write the order. On 03/04/14 at 4:00 PM, the surveyor reviewed the February 2014 Physician orders [REDACTED]. The DON was unable to explain why the [MEDICATION NAME] was not continued or why the 02/17/14 physician's orders [REDACTED]. ADON A stated she was certain the resident had received the medication every day. ADON A checked medical records, but was unable to find any additional MARs for February 2014 for Resident #1. An interview with the DON on 03/04/14 at 4:00 PM revealed she acknowledged Resident #1 experienced unexpected weight gain and was retaining fluid In December and January 2014. Resident #1's February 2014 TAR did not reflect the resident's [MEDICAL CONDITION] was assessed. Resident #1's February 2014 Nurse's Notes did not reflect any staff assessment of the resident for [MEDICAL CONDITION]. Resident #1's Nurse's Notes, dated 02/26/14, reflected she was sent to the hospital on [DATE] for complaints of shortness of breath and not feeling well. Resident #1's hospital History and Physical, dated 02/26/14, reflected she was admitted for Acute [MEDICAL CONDITION] exacerbation, Acute [MEDICAL CONDITIONS] and Dyspnea (difficulty breathing) . Resident #1's hospital Admission Assessment, dated 02/26/14, reflected she had labored respirations, diminished breath sounds and 3+ [MEDICAL CONDITION] to her feet on a scale of 1+ to 4+ with 4+ being the worst. Taber's Cyclopedic Medical Dictionary, Edition 21, Copyright 2005, page 724, reflected the following about [MEDICAL CONDITION]: Pitting [MEDICAL CONDITION] indicated there is evidence of fluid in soft tissues, especially those of of dependent body parts like the lower extremities. When the soft tissue is pressed firmly with a finger, tissues that are swollen with fluid retain the shape of the depression produced by the finger. In an interview with the resident's Responsible Party on 03/04/14 at 3:30 PM, it was revealed the resident remained in the hospital. The RP stated the resident was admitted to the hospital for fluid overload, and the resident was "better now that the fluid is off." In an interview with the Consultant Pharmacist on 03/05/14 at approximately 10:45 AM, he acknowledged the resident had previous episodes of [MEDICAL CONDITION] and [MEDICAL CONDITION] (which indicated she was at risk for problems with fluid balance). The Consultant Pharmacist stated he would in-service staff so that all physician orders [REDACTED]. The facility's current policy and procedure on Medication Orders, revised 11/05/10, reflected: "All medication orders are to be documented in MAR indicated [REDACTED]." The facility census reflected 51 residents currently resided on Hall 100, where Resident #1 resided.

Based on interview and record review, it was determined the facility failed to provide 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 for one (Resident #1) of two residents reviewed for change in condition. The facility failed to administer the physician-order diuretic, [MEDICATION NAME], 2.5 mg to Resident #1, who had a history of [REDACTED]. The facility failed to assess and monitor Resident #1's [MEDICAL CONDITION]. Resident #1 was hospitalized for [REDACTED]. These failures could affect the 51 residents on Hall 100, the same hall Resident #1 resided on and placed them at risk for not being adequately assessed and not receiving physician-ordered treatment resulting in deterioration in their physical health and/or exacerbation of their [DIAGNOSES REDACTED]. Findings included: The current MDS assessment, dated 02/22/14, reflected Resident #1 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. According to the MDS assessment, the resident required assistance with ADLs, was mobile via wheelchair and on oxygen therapy. The MDS reflected the resident had [DIAGNOSES REDACTED]. Resident #1 was able to make herself understood, and she understood others. The weight record for December 2013 (no date specified) reflected Resident #1's weight was 185 lbs. The weight record for January 2014 (no date specified) reflected Resident #1's weight was 202.6 lbs. (an increase of 17.6 lbs. in one month). Review of the (Admit/ReAdmit) Weekly Weight Status record for January 2014 revealed a weight was entered for Resident #1 for the week of 01/27/14, which was 237.4 lbs, another increase of 19.8 lbs. Resident #1's Physician's Telephone Order, dated 01/28/14, reflected the resident was placed on fluid restriction. Resident #1's Physician's Telephone Order, dated 02/17/14, reflected to weigh her twice a week. A physician's orders [REDACTED]. Resident #1's Care Plan, dated 11/26/13 and updated 02/20/14, reflected she was at risk of electrolyte imbalance related to the use of a diuretic. Approaches included: "Administer medications as ordered [MEDICATION NAME] 40 mg BID" and monitor for [MEDICAL CONDITION]. (Note: Resident #1's [MEDICATION NAME] was discontinued on 02/05/14, per the Physician's Telephone Order dated 02/05/14). An interview with the DON on 03/04/14 at 4:00 PM, revealed the twice a week weights and fluid restriction orders were initiated because the resident experienced a weight gain and was retaining fluid. Resident #1's Physician's Telephone Order, dated 02/14/14, reflected an order for [REDACTED]. Resident #1's Physician's Telephone Order, dated 02/17/14, reflected to continue [MEDICATION NAME] 2.5 mg by mouth every day. Resident #1's February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. An interview with LVN B on 03/05/14 at approximately 11:00 AM revealed she wrote the physician's orders [REDACTED].#1. She acknowledged she did not transcribe it to Resident #1's February 2014 MAR, because she was unsure if the Cardiologist would agree. LVN B also stated she did not mean to write the order. On 03/04/14 at 4:00 PM, the surveyor reviewed the February 2014 Physician orders [REDACTED]. The DON was unable to explain why the [MEDICATION NAME] was not continued or why the 02/17/14 physician's orders [REDACTED]. ADON A stated she was certain the resident had received the medication every day. ADON A checked medical records, but was unable to find any additional MARs for February 2014 for Resident #1. An interview with the DON on 03/04/14 at 4:00 PM revealed she acknowledged Resident #1 experienced unexpected weight gain and was retaining fluid In December and January 2014. Resident #1's February 2014 TAR did not reflect the resident's [MEDICAL CONDITION] was assessed. Resident #1's February 2014 Nurse's Notes did not reflect any staff assessment of the resident for [MEDICAL CONDITION]. Resident #1's Nurse's Notes, dated 02/26/14, reflected she was sent to the hospital on [DATE] for complaints of shortness of breath and not feeling well. Resident #1's hospital History and Physical, dated 02/26/14, reflected she was admitted for Acute [MEDICAL CONDITION] exacerbation, Acute [MEDICAL CONDITIONS] and Dyspnea (difficulty breathing) . Resident #1's hospital Admission Assessment, dated 02/26/14, reflected she had labored respirations, diminished breath sounds and 3+ [MEDICAL CONDITION] to her feet on a scale of 1+ to 4+ with 4+ being the worst. Taber's Cyclopedic Medical Dictionary, Edition 21, Copyright 2005, page 724, reflected the following about [MEDICAL CONDITION]: Pitting [MEDICAL CONDITION] indicated there is evidence of fluid in soft tissues, especially those of of dependent body parts like the lower extremities. When the soft tissue is pressed firmly with a finger, tissues that are swollen with fluid retain the shape of the depression produced by the finger. In an interview with the resident's Responsible Party on 03/04/14 at 3:30 PM, it was revealed the resident remained in the hospital. The RP stated the resident was admitted to the hospital for fluid overload, and the resident was "better now that the fluid is off." In an interview with the Consultant Pharmacist on 03/05/14 at approximately 10:45 AM, he acknowledged the resident had previous episodes of [MEDICAL CONDITION] and [MEDICAL CONDITION] (which indicated she was at risk for problems with fluid balance). The Consultant Pharmacist stated he would in-service staff so that all physician orders [REDACTED]. The facility's current policy and procedure on Medication Orders, revised 11/05/10, reflected: "All medication orders are to be documented in MAR indicated [REDACTED]." The facility census reflected 51 residents currently resided on Hall 100, where Resident #1 resided.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #12) of ten residents reviewed for quality of care. LVN C received reports Resident #12 was in pain with moaning, groaning, exhibiting facial grimacing and calling to her mother for help with any movement or touching of her left leg from approximately 6:10 a.m. throughout the morning from CNA D. LVN C failed to assess the resident and administered one dose of one Tylenol 325 mg tab at 11:00 a.m. throughout the LVN's shift. LVN C failed to contact the physician and/or PA for a renewal of Resident #12's [MEDICATION NAME] ,[DATE] mg or [MEDICATION NAME] 7XXX,[DATE] mg (narcotic pain reliever), when the "medication machine" would not give her pain medication for the resident. LVN C and the DON failed to provide Resident #12 with any pain relief when the DON assessed the resident with pain at an eight of ten at 12:50 p.m. LVN C and the DON failed to ensure the physician and/or PA was contacted to get an x-ray ordered and request an order for [REDACTED]. When LVN I contacted the physician/PA and received orders for an x-ray, the LVN failed to request an order for [REDACTED]. The failures to assess the resident's pain and cause of the resident's pain in a timely manner, resulted in the resident having unrelieved pain for over 12 hours and a delay in treatment for [REDACTED]. These failures could affect the facility's 80 residents identified as being on a pain management program. Findings included: The Admission Record Resident Information document dated [DATE] reflected Resident #12, an [AGE] year-old female, was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Resident #12's MDS assessment dated [DATE] reflected the resident had moderately impaired cognition, required extensive assistance with bed mobility, transfers, locomotion, and ADLs. The MDS assessment indicated she was incontinent of both bladder/bowel and had no history of falls. Active [DIAGNOSES REDACTED]. [MEDICAL CONDITION] was not identified as a current diagnosis. Resident #12's care plan dated [DATE] reflected: Problem Onset: Potential for pathological fracture that may occur related to [MEDICAL CONDITION]. Goal and target: Resident will not suffer severe pain/discomfort or injury times 90 days. Approaches: Administer routine medication per physician orders. Assess pain site as needed for deformity, discoloration, swelling, tenderness, decrease in voluntary movement, pain upon movement. Administer as needed [MEDICATION NAME] per physician orders [REDACTED]. Resident #12's care plan dated [DATE] reflected: Problem Onset: Resident was at risk for pain related to a history of fracture of right foot and right femur. Goal and target: Resident will have an effective pain management program in place over the next 90 days. Approaches: Recognize resident's description of pain. ...Monitor for non-verbal signs of pain such as groaning, crying, furrowed brows. Try to determine location of pain and severity... ...Use prescribed pain medications and monitor effectiveness and adverse reactions. On [DATE] at 8:20 a.m., during initial rounds, Resident #12 was observed lying in bed on her side facing the wall with no acute signs of pain. The call light was within reach, the bed was in low position with the side rail up, a fall pad was on the floor and bed alarm was in place. LVN C told the surveyor the resident had returned from the hospital the day before ([DATE]). The LVN stated she had just given Resident #12 pain medication at 8:00 a.m. The facility's Provider Investigation Report dated [DATE] reflected at 12:50 p.m., Resident #12 was experiencing pain of the left hip, which she told the DON. The resident rated her pain at an eight out of ten (on a pain scale from zero to ten with ten being the worst pain ever), Resident #12 told the DON she fell that morning when she and the staff, who was helping her, slipped in the urine on the floor. The resident stated the staff person put her back in bed. a head to toe assessment was conducted by the DON and LVN C. Resident #12 pointed to her left hip. There was no bruising or discoloration present. The Provider Investigation Report continued: Staff who were in contact with Resident #12 were interviewed. According to the interviews, Resident #12 began to complain of pain to CAN F in the shower at approximately 6:30 a.m. Resident #12 complained of pain in her left leg. LVN C was notified of the resident's complaints of pain. The resident was transferred to the w/c after her shower, taken to her room and then taken to the dining room for breakfast, which she ate 50%. At 9:30 a.m., Resident #12 was taken back to her room due to continued complaints of pain and expressed relief from pain when lying in bed. The Report reflected the resident was assessed for pain by LVN C. Interview on [DATE] at 9:39 a.m. with CAN D revealed on [DATE] at about 6:10 a.m., she started Resident #12's morning care and got her ready for a shower. CAN D said Resident #12 complained of pain when she (CAN D) turned her on her left side to clean her. CAN D stated the resident exclaimed, "Oh no mommy! Oh no mommy! I hurt! I hurt!" CAN D stated she reported Resident #12's complaints of pain to LVN C. CAN D stated LVN C told her it was probably her Arthritis, and she would give her some medication. CAN D said she took the resident to the shower room, and CAN F gave her a shower. Interview on [DATE] at 10:46 a.m. with CAN F revealed she had showered Resident #12 on [DATE] at about 6:30 a.m. CAN F stated when she pulled Resident #12 into the shower stall, the resident complained of her left leg hurting. CAN F explained Resident #12 had said, "My leg hurts. My leg hurts." CAN stated Resident #12 did not want the CAN to touch her leg. CAN F stated she asked CAN D if she had reported Resident #12 was complaining of pain. CAN D said she had told LVN C, and LVN C had told her it was probably Arthritis, and she would give her some medication. Further interview on [DATE] at 9:39 a.m. with CAN D revealed after CAN F completed her shower, CAN D took Resident #12 to the dining room for breakfast. After breakfast, at about 7:50 a.m., Resident #12 was taken to her room. She was again complaining of pain and wanted to lie down. CAN D stated Resident #12 was saying, "Please mommy, lay me down. Please mommy, lay me down." CAN D said Resident #12 repeated this several times. CAN D stated about 8:30 a.m., LVN C told her the "medication machine" would not let her have any pain medication, and she would have to call Resident #12's doctor. CAN D said at about 9:30 a.m., she had repositioned Resident #12 before going to lunch, and Resident #12 was continuing to complain of pain. Review of the back page of the [DATE] MAR indicated [REDACTED]. The PRN order for Tylenol was for one tab of Tylenol 325 mg. There was nothing documented on the front of the MAR. Interview on [DATE] at 8:45 a.m. with LVN C revealed she administered Tylenol around 11:00 a.m. and stated there were no reports of Resident #12 falling. LVN C further stated CAN D got Resident #12 up on [DATE] between 6:30 a.m. and 7:00 a.m. and took her to the shower room. LVN C stated the resident was already complaining of pain at that time. LVN C stated Resident #12's pain prescription had expired, and the Pass Port Medication System would not allow her to get medication from the system if the medicine was expired. The physician had to be called for a renewal of the Narcotic prescription. Interview on [DATE] at 11:22 a.m. with LVN H revealed he had worked on [DATE] on the 6:00 AM - 2:00 PM shift. He stated LVN C had told him Resident #12's pain medication was not in the profile. LVN H explained if the resident's medication ran out or the prescription expired, the pharmacy had to be called by a designated agent. A designated agent was a supervisor/employee, whom the physician had designated, to call the pharmacy for narcotics refills. LVN H stated Resident #12's physician did not have a designated agent as the physician wanted to be called personally for a refill on narcotic prescriptions. Once the pharmacy was called, the medication would be available immediately. Review of the Resident #12's [DATE] MAR indicated [REDACTED]. There was no evidence Resident #12 received [MEDICATION NAME] ,[DATE] mg or [MEDICATION NAME] 7XXX,[DATE] mg on [DATE]. Interview on [DATE] at 1:40 p.m. with LVN C revealed she did not perform a physical assessment on Resident #12's left hip related to her having pain. LVN C stated, "If it's not charted, it's not there. It's my fault for not doing it." The Provider Investigation Report continued: Resident #12's family members came to visit at approximately 12:30 p.m. At that time, Resident #12 told her family "she had urinated in (sic) the floor and the aide fell on top of her and then put her back to bed." LVN C and the DON were immediately notified. Resident #12 was medicated for pain (at 11:00 a.m. with one Tylenol 325 mg tab) and her physician was notified. A return call from the physician's PA resulted in orders for a left hip x-ray. During the interview on [DATE] at 9:39 a.m. with CNA D, she stated at about 11:00 a.m., Resident #12's family member had come to feed the resident lunch. The family member asked why Resident #12 was in bed. CNA D told the family member it was because Resident #12 was complaining of pain. As the family member spoke to Resident #12 in her first language, Resident #12 started rubbing her left hip, saying "right here, right here" as she touched her left hip. CNA D stated Resident #12's family member called her back into the room and stated Resident #12 told her there was urine on the floor, and she was dropped. At that time, CNA D said she went and got LVN C. Interview on [DATE] at 9:12 a.m. with CNA E revealed on [DATE] at lunch, Resident #12's family member came to feed her. The family member asked her (CNA E) to tell the nurse her mother was complaining of hip pain. CNA E stated she called LVN C for the family member. CNA D stated LVN C did not do an assessment, but she called the DON to talk to the family. Interview on [DATE] at 8:45 a.m. with LVN C revealed on [DATE], Resident #12's family member came into the facility to feed the resident lunch. During the family member's visit, Resident #12 complained of left hip pain to the family member. The family member told LVN C Resident #12 told him/her a nurse had dropped her that morning and then put her back to bed. Review of Resident #12's Nurses Notes for [DATE] revealed the first documentation for that date was timed at 12:50 p.m. and was written by the DON. (LVN C had not documented the resident's complaint of pain, her administration of Tylenol 325 mg one tab or an assessment of Resident #12.) The Nurse's Notes reflected Resident #12's family member had come to the facility for a visit and found the resident complaining of pain to her left hip. The family member reported Resident #12 had fallen with a nurse that morning. The Notes reflected, "Resident confused at this time. Resident has not had fall. Call placed to MD to order xray to (left) hip due to pain. Medicated by charge nurse (LVN C) (with) Tylenol...." A pain assessment reflected an ,[DATE], indicating the resident had an eight out of ten on a pain scale of zero to ten with ten being the worst pain ever. There was no assessment of the resident's left leg and/or hip. Interview on [DATE] at 5:08 p.m. with the DON revealed on [DATE], around 12:00 p.m., she was called to Resident #12's room by the resident's family member. The DON stated the family member said Resident #12 had said she and a nurse had fallen because they slipped in the urine on the floor. The family member stated the resident told him/her they put her back to bed after the fall. The DON had asked Resident #12 where she was hurting, and she said her left hip. The DON and LVN C assessed Resident #12's skin, and they did not notice any redness, bruising or swelling. The DON stated she instructed LVN C to notify the physician and request an x-ray, a urinalysis, and to give Resident #12 some pain medication. Resident #12's Nurse's Notes dated [DATE] at 1:00 p.m. reflected a phone call was made to the physician's service regarding the resident's left hip and possible UTI. At 1:40 p.m., the physician's PA returned the call and orders were given for an x-ray of the left hip and obtain urine specimen for UA for C&S. (No orders were requested or received for pain medication.) At 2:00 p.m. and at 3:30 p.m., family members of Resident #12 were contacted to provide report on the resident. There was no documentation to indicate the x-ray company had been notified of the physician's orders [REDACTED]. Interview on [DATE] at 1:59 p.m. with LVN I revealed on [DATE] she arrived at work around 1:45 p.m.-1:50 p.m.. She stated when she arrived at the facility, LVN C and the DON were busy with Resident #12 and the resident's family member. The first time she saw Resident #12 was after LVN C and the DON left around 4:00 p.m.. LVN I stated she took the resident's blood sugar at that time, and Resident #12 was grimacing. Then around 5:00 p.m. Resident #12's family member asked LVN I to check if Resident #12's pain medication had come in. When she was asked about an assessment of the resident, LVN I stated she had not done a physical assessment on Resident #12, because of her pain and because she had been told in report Resident#12 had been complaining of a lot of pain. Interview on [DATE] at 4:37 p.m. with Physician N revealed on [DATE], he had been contacted between 3:00 p.m. and 3:30 p.m. and was told Resident #12 was complaining of pain. Physician N stated she/he had ordered an x-ray and Urinalysis. Physician N stated he was never told the resident was out of pain medication or that the prescription had expired. On [DATE] at 2:00 p.m., during a phone interview with staff from the x-ray company, it was revealed the facility did not place an order for [REDACTED]. The x-ray company's computerized tracking form dated [DATE] reflected LVN I called in the physician's orders [REDACTED]. to the facility at 6:18 p.m. and LVN I received the phone call. Interview on [DATE] at 4:55 p.m. with Resident #12's family member revealed he/she came everyday at supper to feed his/her mother. On [DATE], when he/she arrived at around 3:30 p.m., Resident #12 was moaning, and the family member asked the resident if she was hurting, she stated yes, her hip was hurting. The family member said he/she asked LVN I for pain medication, and LVN I stated she would have to call the doctor. The family member stated the x-ray company came around 6:30 p.m., and Resident #12 was taken to the hospital around 7:30 p.m. The next documentation in Resident #12's Nurse's Notes dated [DATE] was at 6:30 p.m. Results had been received from the x-ray reflecting Resident #12 had sustained a left [MEDICAL CONDITION]. At 6:50 p.m., Resident #12's physician answering service was called and at 7:00 p.m., the physician's PA called and gave orders to send the resident to the hospital for evaluation and treatment. The resident left for the hospital at approximately 7:20 p.m. Interview on [DATE] at 2:39 p.m. with CNA J stated she had work on [DATE] and provided care for Resident #12. Around 5:45 p.m., CNA J stated when she lifted the bed pad to turn Resident #12, the resident screamed out. CNA J stated she had never heard the resident scream like that before. CNA J stated she reported the incident to LVN I. Review of SBAR (Physician Communication and Progress Note) dated [DATE] at 7:20 p.m. reflected LVN I communicated with the physician's PA regarding Resident #12's x-ray results identifying the resident's left [MEDICAL CONDITION]. The SBAR reflected LVN I had assessed Resident #12's pain level as 10+. There were no interventions documented for pain relief. Resident #12's Radiology Report dated [DATE] reflected an acute left intertrochanteric (hip) fracture. The x-ray did not include a [DIAGNOSES REDACTED]. Resident #12's Physician Telephone Orders dated [DATE] at 7:30 p.m. and written by LVN I reflected to send Resident #12 to the hospital for evaluation and treatment. The Provider Investigation Report dated [DATE] regarding Resident #12's left [MEDICAL CONDITION] reflected the investigation findings were inconclusive. Provider Action taken post-investigation reflected "[DATE] All Staff in-serviced on reporting falls, importance of timely assessment post fall." Review of the facility's Inservice Attendance Record dated [DATE] revealed the topic was entitled Report all falls to charge Nurse. The documentation included with the Inservice Attendance Record reflected the following: "FALLS A fall is an unplanned descent to the floor. Falls can result in dislocations, sprains, fractures, head injuries or death. CNA - It is our duty to report all falls, even if the patient tells you the fall was days ago. DO NOT attempt to get a patient up from the floor, inform the charge nurse. Report any change you observe in a patient. NURSE - It is your duty to assess for any change of condition including falls and notify the MD and family." Review of Resident #12's History and Physical documented by the resident's primary care physician revealed the resident had a history of [REDACTED]. The History and Physical did not include a [DIAGNOSES REDACTED]. . The facility's current Pain Assessment and Management policy and procedure from the Nursing Services Policy and Procedures Manual dated 2001 and revised [DATE] reflected: "Purpose The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. 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 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. ...5. Conduct a comprehensive pain assessment...whenever there is a significant change of condition, and when there is onset of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain... Steps in the Procedure Recognizing Pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc; c. Changes in gait, skin color, and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite... Reporting Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; ...3. Prolonged, unrelieved pain despite care plan interventions." The facility's Resident Census and Conditions of Residents Form CMS 672, dated [DATE], reflected 80 residents were on a pain management program and the facility had a census of 148 residents.