Every finding on record at Giddings Nursing and Rehabilitation

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of life.The facility failed to ensure Resident #1, Resident #2 and Resident #3 received regular showers.This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes and decreased self-esteem.1. Record review of Resident #1's face sheet, dated 06/23/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included end stage renal disease (kidney failure), type 2 diabetes mellitus with hyperglycemia (high blood sugar), atherosclerotic heart disease (clogged or harden arteries), congestive heart failure (fluid back up and heart can't pump properly), and peripheral vascular disease (narrow or blocked arteries that restrict blood flow). Record review of Resident #1's admission MDS assessment, dated 05/26/2026, reflected Resident #1 had a BIMS score of 15, which indicated no cognitive impairment. The MDS also revealed Resident #1 required partial or moderate assistance for showers.Record review of Resident #1's Care Plan, dated 06/23/2026, reflected [Resident #1] will maintain current ADLs with Intervention- Assist with ADLs.Record review of Resident #1's shower sheets and resident Task log, dated May 2026, reflected Resident #1 did not get her showers during her stay from 05/19/2026 through 05/26/2026. There was no documentation of refused showers on Task log or in nursing notes. 2. Record review of Resident #2's face sheet, dated 06/24/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included rhabdomyolysis (rare muscle injury where you muscle break down), other malaise (discomfort), diabetes mellitus due to underlying condition with diabetic neuropathy (body does not produce enough insulin), metabolic encephalopathy (diffuse brain dysfunction), and hypertension (high blood pressure).Record review of Resident #2's admission MDS assessment, dated 06/01/2026, reflected Resident #2 had a BIMS score of 07, which indicated moderately cognitive impairment. The MDS also revealed Resident #2 required partial or moderate assistance for showers.Record review of Resident #2's shower sheets dated June 2026, reflected Resident #2 was scheduled to have a shower on Tuesday, Thursday, and Saturday. He had a shower sheet dated 06/16/2026. No other sheets were available. There was no documentation of refused showers on Task log or in nursing notes.During an interview with Resident #2 on 06/24/2026 at 9:27 AM he said he had not had a bath in a while and that he probably needs one. He said he had one last week, but he had not received one this week. 3. Record review of Resident #3's face sheet, dated 06/24/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified injury at C4level of cervical spinal cord (damage to the mid neck region of the spine that causes loss of movement), unspecified severe protein-calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss, weakness, and poor overall health), spinal stenosis lumbosacral region (narrowing space in the lower spine) and muscle wasting and atrophy (loss of muscle tissue and strength).Record review of Resident #3's admission MDS assessment, dated 05/01/2026, reflected Resident #3 had a BIMS score of 1, which indicated severe cognitive impairment. The MDS also revealed Resident #1 required substantial or maximal assistance for showers.Record review of Resident #3's Care Plan, dated 06/24/2026, reflected [Resident #3] will have no decline in ADL functioning. With Intervention- Provide total assistance of 1 to 2 persons for bathingRecord review of Resident #3's shower sheets and resident Task log, dated May 2026, reflected Resident #3 received a shower on 05/05/2026, 05/26/2026, 05/29/2026. There was no documentation of refused showers on Task log or in nursing notes.During an interview with Resident #3 on 06/24/2026 at 9:34 am he said the staff had not helped with a bath for several days when he first got here. He said the staff changed his shower schedule and it was much better.During an interview with CNA A on 06/24/2026 at 11:22 AM, she said she had been trained in ADL care and resident rights. She said the residents get showers three times a week. If they refuse, they must tell the nurse. She said she enters the showering on Point Click Care and that she fills out the shower sheets too. She said it was important for residents to get showers because if not they may have skin breakdown or other issues that would not be known. She said she does not think residents were missing baths, but that newer CNAs were not charting it like they should be.During an interview with CNA B on 06/24/2026 at10:15 AM, she said she had been trained on ADL care and resident rights. She said the CNAs were responsible for giving the residents their showers. She said that after they give a resident a shower, they fill out the shower sheet, sign in and give it to the charge nurse and they give it to the DON, or sometimes they fill out on the kiosk on the wall. During an interview with LVN#1 on 06/24/2026 at 10:38 AM, said he has been trained on ADL care and resident rights. He said the CNAs will tell him if the resident refuses a shower. He then goes and asks the residents about why they were not showering. Then he fills out the rest of the shower sheet and gives it to the DON. He said it might be in Point Click Chart but not usually put in chart. LVN#1 said newer residents could be missed but they don't have a lot of new admits. He said if residents don't receive showers, they could have unnoticed skin breakdown or other skin issues if unchecked besides just dirtiness.During an interview with the DON on 06/24/2026 at 11:58 AM she said she was trained in ADL care and resident rights. She said the staff should give the residents showers three times a week. She said it was the responsibility of the entire nursing team to ensure residents were getting their showers. She said the process was the CNA fills out the shower sheet and gives it to the charge nurse. After they finish filling it out it is put in her box. She said sometimes there were not many in her box and she has to go looking for them and they might be at the nurse's station desk. When asked if she knew why Resident #1 and Resident #2 had no showers logged in PCC, she said the system had a glitch with new admits and that was why they had not shown up. She said she has started a new process where she was rounding more to make sure the residents were getting showered and she was checking it off each day. She was also having the staff hand her shower sheets instead of them putting them in her box.During an interview with the ADM on 06/24/2026 at 12:15 PM, she said she was trained in ADLs and resident rights. She said she expects residents to be showered three times a week. She said the nursing staff was supposed to fill out shower sheets and give them to the nurse and then it was turned into the DON. The ADM said she was currently working with Point Click Care documentation to have better access to the ADL task for documenting showering.Record review of Activities of Daily Living (ADL), Supporting Policy, dated 03/2018, reflected Policy Statement- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #2) reviewed for quality of life.The facility failed to ensure Resident #2 received regular showers.This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes and decreased self-esteem. Record review of Resident #2's face sheet, dated 06/24/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included rhabdomyolysis (rare muscle injury where you muscle break down), other malaise (discomfort), diabetes mellitus due to underlying condition with diabetic neuropathy (body does not produce enough insulin), metabolic encephalopathy (diffuse brain dysfunction), and hypertension (high blood pressure).Record review of Resident #2's admission MDS assessment, dated 06/01/2026, reflected Resident #2 had a BIMS score of 07, which indicated moderately cognitive impairment. The MDS also revealed Resident #2 required partial or moderate assistance for showers.Record review of Resident #2's shower sheets dated June 2026, reflected Resident #2 was scheduled to have a shower on Tuesday, Thursday, and Saturday. He had a shower sheet dated 06/16/2026. No other sheets were available. There was no documentation of refused showers on Task log or in nursing notes.During an interview with Resident #2 on 06/24/2026 at 9:27 AM he said he had not had a bath in a while and that he probably needs one. He said he had one last week, but he had not received one this week. During an interview with CNA A on 06/24/2026 at 11:22 AM, she said she had been trained in ADL care and resident rights. She said the residents get showers three times a week. If they refuse, they must tell the nurse. She said she enters the showering on Point Click Care and that she fills out the shower sheets too. She said it was important for residents to get showers because if not they may have skin breakdown or other issues that would not be known. She said she does not think residents were missing baths, but that newer CNAs were not charting it like they should be.During an interview with CNA B on 06/24/2026 at10:15 AM, she said she had been trained on ADL care and resident rights. She said the CNAs were responsible for giving the residents their showers. She said that after they give a resident a shower, they fill out the shower sheet, sign in and give it to the charge nurse and they give it to the DON, or sometimes they fill out on the kiosk on the wall. During an interview with LVN#1 on 06/24/2026 at 10:38 AM, said he has been trained on ADL care and resident rights. He said the CNAs will tell him if the resident refuses a shower. He then goes and asks the residents about why they were not showering. Then he fills out the rest of the shower sheet and gives it to the DON. He said it might be in Point Click Chart but not usually put in chart. LVN#1 said newer residents could be missed but they don't have a lot of new admits. He said if residents don't receive showers, they could have unnoticed skin breakdown or other skin issues if unchecked besides just dirtiness.During an interview with the DON on 06/24/2026 at 11:58 AM she said she was trained in ADL care and resident rights. She said the staff should give the residents showers three times a week. She said it was the responsibility of the entire nursing team to ensure residents were getting their showers. She said the process was the CNA fills out the shower sheet and gives it to the charge nurse. After they finish filling it out it is put in her box. She said sometimes there were not many in her box and she has to go looking for them and they might be at the nurse's station desk. When asked if she knew why Resident #1 and Resident #2 had no showers logged in PCC, she said the system had a glitch with new admits and that was why they had not shown up. She said she has started a new process where she was rounding more to make sure the residents were getting showered and she was checking it off each day. She was also having the staff hand her shower sheets instead of them putting them in her box.During an interview with the ADM on 06/24/2026 at 12:15 PM, she said she was trained in ADLs and resident rights. She said she expects residents to be showered three times a week. She said the nursing staff was supposed to fill out shower sheets and give them to the nurse and then it was turned into the DON. The ADM said she was currently working with Point Click Care documentation to have better access to the ADL task for documenting showering.Record review of Activities of Daily Living (ADL), Supporting Policy, dated 03/2018, reflected Policy Statement- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interviews, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for a safe, clean, comfortable, and homelike environment for reviewed for administration in that:1. The facility failed to ensure the Administrator followed the internal drug and alcohol policy.2. The facility failed to ensure the Administrator had his own residence and did not reside in the facility.3. The facility failed to ensure Area ADMIN followed up on reported concerns of the Administrator being drunk, drinking alcohol at the facility, and smoking in areas that were not designated for smoking.These failures placed residents at risk of inadequate supervision, physical, verbal, and/or psychosocial harm.Findings included: Observation on 5/20/2026 at 9:19 AM, outside the facility revealed a man in a blue hairnet, with a walker smoking in front of the facility. He was identified as the Administrator. Observation on 5/20/2026 at 10:27 AM, revealed room [ROOM NUMBER] appeared to be occupied, no resident's name was on the door. Noted in the room was a suitcase, clothing on the floor, clothing in a fallen over laundry basket, and clothing hanging up in the closet resembled men clothing.In an interview conducted on 05/20/2026 at 2:15 PM, the DON stated information was brought to her attention on the previous day that the Administrator had been seen drunk and that corporate was at the facility to investigate. The DON stated the Administrator was residing in room [ROOM NUMBER]. She stated the Administrator had been living at the facility since a week before her arrival on January 19, 2026. She stated the company paid for her a hotel a few weeks, but she did not know the arrangement for the Administrator. In an interview conducted on 05/20/2026 at 2:37 PM, the SW stated she heard a rumor the previous week that the Administrator had been drunk at the facility, but she had not personally witnessed him drinking alcohol. She stated a nurse came in this morning and reported that the Administrator's car was parked on the grass in front of the facility, and the nurse sent a picture to the DON. The SW started with the facility around March 23, 2026 or March 24, 2026, and she noticed a box of alcoholic beverage in the Administrators office. The SW stated she has noticed the Administrator smoking wherever he wanted, including areas that were not designated smoke areas. She stated corporate is at the facility investigating the Administrator.In an interview on 05/20/2026 at 4:15 PM with the Area Admin, he stated the Administrator was no longer employed at the facility and provided a phone number to reach the former Administrator. In an interview conducted on 05/21/2026 at 11:14 AM, the DTA C stated she smelled alcohol on the Administrators breath on one occasion but did not remember the date. She stated she had not observed him drunk while at work. DTA C stated she had seen the Administrator parked at the local liquor store on occasions. In an interview conducted on 05/21/2026 at 3:24 PM, the ADON stated around May 4, 2026, she noted a person sitting outside for a while by the dumpster in a red car. She stated she was told the person in the red car was the Administrator. The ADON stated when he walked into the building, he appeared impaired in her opinion. She stated her assessment was based on her previous work experience with alcohol and drug -affected patients at the State Hospital. She stated she observed him to look pinkish in color and he walked sideways down the hall.In a phone interview conducted on 05/21/2026 at 3:35 PM, the Administrator stated he lived at the facility five nights a week. He stated he stayed at the facility because the facility needed him. He stated he stayed at the facility longer than expected. The Administrator stated he came to help out his friend, the Area Admin, by taking over the facility. When the Administrator was asked about being drunk in the building, he stated, the building had so many rumors.In an interview conducted on 05/22/2026 at 1:42 PM, the VPHR she said the concerns about the Administrator drinking at the facility. The VPHR said the DON told her she found a notebook being kept by the former HR director that indicated that the former HR director had begun an investigation into the Administrator drinking alcohol, being drunk at the facility. The VPHR said the folder had a note dated 03/14/2026 Dranks by the bus that referred to the Administrator and a note that that said 5 AM both Administrator and [ Resident #2] smoke in the front. The VPHR said because the DON found this folder that indicated the former HR director had collected this information it showed that the DON knew about the concerns about the Administrator and she should have reported it to the Area Admin. The VPHR said the only reason a Administrator would stay at a facility overnight was because of an emergency situation. The VPHR said the facility had a drug free policy. The VPRH said the allegations of the Administrator drinking at work should have been reported to Area Admin immediately. The VPHR said if Area Admin did not report the incidents to the State of Texas or take any action the DON should have reported the alleged incidents to the State of Texas. The VPHR said the former HR director was a mandatory reporter and the HR director should have reported to HHSC any allegations of abuse, neglect, or exploitation. The VPHR said if an employee saw anything unsafe it should have been reported to the facility team and the State of Texas. The VPHR said that after the incident was reported to the State of Texas, the Administrator should have been removed from the facility and facility leadership should have investigated. The VPHR said there would be a concern for the residents in the facility if the Administrator was drinking or was drunk when he was at the facility. The VPHR said the situation should have been reported to the State of Texas in March of 2026 when the former HR director first reported it to DON.In an interview conducted on 05/22/2026 at 04:23 pm with the Area Admin he stated his job was to support the facility. The Area Admin said it was reported to him that the Administrator might have been intoxicated at night or on the weekends when he was at the facility. The Area Admin said he thought this was reported to him about a month ago, but he was unsure and could not confirm the date. The Area Admin said he was not concerned about the Administrator drinking alcohol at the facility because the Administrator lived at the facility. The Area Admin said it was part of the Administrator's employment agreement that the Administrator lived at the facility. The Area Admin said there was no indication that the Administrator was drunk during his normal working business hours and no evidence that he was drunk during non-working hours. The Area Admin said if someone was in the building he expected them to follow the policies and procedures in the building. The Area Admin said he had no information that the Administrator had been drinking alcohol in the building except for the evenings and weekends. The Area Admin said those were allegations and there was no evidence that the Administrator was drunk. The Area Admin said he asked the Administrator if he was drunk while at the facility and the Administrator denied it. The Area Admin said he did not do any kind of investigation. The Area Admin said there was no alcohol substance seen to indicate the Administrator was drinking while at the facility. The Area Admin said if the Administrator was drinking when he was at the facility the Administrator was drinking when the Administrator was not on duty and not during normal working business hours. The Area Admin said that the Administrator was exempt from the policies and procedures of the facility during non-working hours, evenings and weekends, because the Administrator was living at the facility. The Area Admin said his number one concern was for the safety of the residents and it was not brought to his attention that the residents were not safe. He said the facility did not have a policy for administrators living at the facility and agreements for administrators to live at the facility were on a case-by-case basis.In an additional interview conducted on 05/22/2026 at 5:25 PM, the VPHR stated she and the facility management team, with the exception of the Area Admin, were unaware that the Administrator was living in the building. The VPHR said the Area Admin said it was an agreement between him and the Administrator and was only supposed to be for a couple of months. The VPHR said it was not alright for the Administrator to be living at the facility. The VPHR said CMS rules applied to the facility regardless. The VPHR said the Administrator should not have been at the building when he was intoxicated because it was a drug free workplace. The VPHR said the facility policy of a drug free workplace should have been followed by the Administrator whether it was an evening or a weekend. She said if someone at the facility was under the influence of alcohol, it could potentially be a safety issue to the residents.Record review of the facility's policy titled : Drug Free Workplace Policy and Guidelines for Implementation Reasonable Suspicion testing dated April 1, 2025 reflected: With this policy [facility] affirms a commitment to maintaining a Drug-Free Workplace and establishes conditions under which the facility will conduct testing of employees based on reasonable suspicion that the employee has violated this policy and is under the influence of alcohol, intoxicants, illegal or misused prescription or over-the-counter medications while on duty. This policy outlines the practices and procedures designed to correct instances of identified alcohol and drug use in the workplace. This policy applies to all employees and applicants for employment with the facility. Observation of behavior - when a supervisor is notified or suspects an individual may be in violation of the drug free workplace policy the supervisor must observe the behavior of the individual and immediately complete reasonable suspicion testing checklist.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report allegations that the Administrator, who was living at the facility, was drinking alcohol and intoxicated while at the facility.The facility failed to report concerns that the Administrator was entering Resident #2's room in the early morning hours with no valid explanation for entering her room. These findings could result in a lack of oversight of residents, abuse, and harm. Findings included: Record review of Resident #2's face sheet dated 05/20/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side (Hemiplegia (complete paralysis) and hemiparesis (partial weakness) on the left side of the body commonly result from a stroke (cerebral infarction) on the right side of the brain), Injury at c2 level of cervical spinal cord, sequela (a severe, often life-altering, or fatal injury at the top of the neck, affecting vital functions like breathing, movement, and communication), and cognitive communication deficit (struggle with language expression, comprehension, or social interaction because of underlying impairments in cognitive processes). Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated 03/30/2026 revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #2's care plan reflected a focus dated 02/09/2026 that Resident #2 exhibited impulsive behavior such as for asking for cigarettes and sodas, and was at risk for further episodes of impulsive behavior and injury. There was another care plan focus dated 01/03/2026 that Resident #2 had impaired cognition due to poor judgment and poor insight. Record review of an undated anonymous statement reflected, I would like to report what I have seen, but cannot confirm or deny that any sexual Things have happened between [the Administrator] and [ Resident #2]. First instance was at 2 o'clock in the morning, [Administrator] came out of [Resident #2's] room and her lights were off. I was not sure what he was doing in there. But I did say, oh, I thought it was [name of person alleged to be Resident #2's boyfriend] because [name of person alleged to be Resident #2's boyfriend] is her boyfriend and she usually goes to his room. So I asked [the administrator] what are you doing in [ Resident #2's] room [the Administrator] stated well I came to ask her if knew the number to the [NAME] Club' and I then said at 2:00 AM in the morning? but I did not question it because he is the administrator. The next night that I saw the administrator it was between two and three in the morning and I heard someone talking in [ Resident #2's] room and I thought it might be [name of person alleged to be Resident #2's boyfriend] and so as I was about to open the door, when the [Administrator] opened the door and he came out of her room with lights off and [ Resident #2] in the bed. I did not assume anything because he is the administrator and the abuse coordinator. Then the next situation is he and [Resident 2] go and smoke outside in front of the building sometimes between three and four or four and five, they meet outside and they both smoke and the administrator buys her the cigarettes and he bought her Dr. Pepper's. This began to look suspicious to me because I did not understand what he was doing going into her room between the hours of two and three also I did not think it was right for him and [Resident #2] to smoke together every morning between four and five and sometimes two and three in the morning. Record review of TULIP facility complaint dated 05/20/2026 reflected the facility first learned of the incident on 2:17 PM 05/20/2026 from the facility's PM who indicates that there are allegations against the administrator [Administer name] for coming out of a female resident's room (unknown) undressed or disheveled. There are also allegations that [Administrator] was intoxicated during work hours. Record review of notepad kept by the former HR director reflected: *03/14/2026 - 5am both [Administrator] & [ Resident #2] smoke in the front, Pee on the floor/outside by dumpster Dranks by bus *03/15/2026 no time indicated- seen [Administrator] going to [ Resident #2] room *04/15/2026 no time indicted - seen [the Administrator] he was drunk *Undated - 2:00 AM [Administrator] was in [Resident#1's] room and when asked why he was in Resident #2's room he said he was asking for the lion club number *Undated no time indicated - Drunk - Sunday night *Undated no time indicated - Drunk - Monday night *Undated no time indicated - seen [Administrator] he was Drunk- throwing beer in the dumpster Record review of an email dated 05/08/2026 from the DON to the Area Admin with the subject line complaint reflected [Administrator] goes out of the facility and comes back intoxicated at night. Record review of an email date 05/19/2026 from the VPHR to the facility Administrator, RNC, and the FO stated she was updating the team on recent developments and wrote, As I was leaving, an employee asked to speak with me in the DON's office. She reported that on 5/15/26, while in the smoking area, the same housekeeper mentioned that the Maintenance Director, allegedly her husband or boyfriend, was called to pick [the Administrator] up from a bar where he was reportedly allegedly [sic] intoxicated and brought him back to the building. I asked the employee to provide a written statement and updated [Area Admin] with this new information. [Area Admin] recommended proceeding with the search for an interim administrator to serve until the new administrator starts next month. He asked me to meet with him on 5/21/26 to discuss moving forward with the termination. During an interview on 05/20/2026 at 4:15 PM with the Area Admin, he said the Administrator was no longer working at the facility. During an interview on 05/21/2026 at 2:46 PM with Resident #2 she said there was no inappropriate relationship between herself and the Administrator. During an interview on 05/21/2026 at 2:58 PM, by phone with the former HR director, she said she had concerns about the former Administrator being drunk when he was at the facility. The former HR Director said she did not see the former Administrator drunk, but she said she smelled alcohol on him. The Former HR director said she asked him if he had been drinking, and he said he had been drinking the night before and that was why he smelled of alcohol. The former HR director said she received an anonymous statement about the former Administrator being in a resident's room. The former HR director tried to do an investigation, but the staff would not speak up. The former HR director said she informed the Area Admin, but did not give the date she informed the Area Admin. The former HR director said the Area Admin told her there was nothing to report. The former HR director said it was swept under the rug. The former HR director said she felt uneasy about the situation, and she knew the former Administrator and the Area Admin were friends. During an interview on 05/21/2026 at 3:24 pm with the ADON, she said she saw the Administrator drunk at the facility and she believed he was drunk because he was walking sideways and his skin looked pink and he hit the wall every now and then. She said this was around 05/05/2026 or 05/06/2026. The ADON said the Administrator did not interact with any residents, she said he went to his room. During an interview on 05/21/2026 at 3:35 PM, the Administrator said he had been living at the facility and stayed there five nights a week because the facility needed him. He stated he ended up living at the facility longer than he had expected. The Administrator stated he helped out his friend, Area Admin, by taking over the facility. When the Administrator was asked about being drunk in the building, he stated that the building had so many rumors. The Administrator said Resident #2 got up early in the morning and wanted to smoke, and he stated because he also smoked, to make sure Resident #2 smoked safely, he smoked with her. The Administrator said he had never been in Resident #2's room late at night. The Administrator said if he saw Resident #2 in the hallway, Resident #2 would ask him about smoking. The Administrator said that he would not try anything inappropriate with Resident #2 and stated, that's not a pleasant assignment. The Administrator said he had never been inappropriate with Resident #2 at any time, and he said that he had never seen Resident #2 dressed inappropriately. The Administrator stated he was terminated from his job as facility administrator on 05/20/2026. The Administrator stated the facility said the reason for his employment termination was inability to control his staff. During an interview on 05/21/2026 at 3:52 PM with the DON, she said she had not heard any discussions of the Administrator while he was at work, and no one had reported this to her. The DON said there was no discussion of the Administrator having an inappropriate relationship or behavior with any resident. During an interview on 05/22/2026 at 1:42 PM with the VPHR, she said the concerns about the Administrator drinking at the facility and going into [Resident 2's] room were reported to the Area Admin in March of 2026. The VPHR said the DON told her she found a notebook being kept by the former HR director that indicated that the former HR director had begun an investigation into the Administrator drinking alcohol, being drunk at the facility, and entering a resident's room at night. The VPHR said the folder had a note dated 03/14/2026 Dranks by the bus that referred to the Administrator and a note that said 5 AM both Administrator and Resident #2 smoke in the front. The VPHR said because the DON found this folder that indicated the former HR director had collected this information, it showed that the DON knew about the concerns about the Administrator and she should have reported it to the Area Admin. The VPHR said that if the Area Admin did not do anything about the concerns the DON should have reported it to HHSC. The VPHR said the only reason an Administrator would stay at a facility overnight was because of an emergency situation. The VPHR said the facility had a drug free policy. The VPRH said the allegations of the Administrator drinking at work and going into a resident's room at night should have been reported to Area Admin immediately. The VPHR said if Area Admin did not report the incidents to the State of Texas or take any action, the DON should have reported the alleged incidents to the State of Texas. The VPHR said the former HR director was a mandatory reporter, and the HR director should have reported to HHSC any allegations of abuse, neglect, or exploitation. The VPHR said if an employee saw anything unsafe, it should have been reported to the facility's team and the State of Texas. The VPHR said that after the incident was reported to the State of Texas, the Administrator should have been removed from the facility and facility leadership should have investigated. The VPHR said there would be a concern for the residents in the facility if the Administrator was drinking or was drunk when he was at the facility. The VPHR said the situation should have been reported to the State of Texas in March of 2026 when the former HR director first reported it to DON. During an interview on 05/22/2026 at 2:31 PM with the DON, she said on about 05/20/2026 or 05/21/2026 she looked at the notepad from the former HR director about the allegations of the Administrator drinking alcohol and going into Resident #2's room. The DON said when anyone reported any allegation of abuse, neglect, and exploitation or possible safety of the residents it was a reportable incident and she should have reported it to HHSC. The DON said after allegations of abuse, neglect, or exploitation were reported, an investigation was started. The DON said she did not think the Administrator was drinking alcohol on the property. The DON said she knew the Administrator lived at the facility and she did not know if the Administrator was on duty twenty-four hours a day, seven days a week. The DON said she was trained in abuse, neglect, and exploitation by the facility. The DON said it affected the residents if the person who was in charge of the building was drinking when they were in the building. The DON stated if the Administrator was drinking at the facility, he could fall down or maybe share alcohol with other residents. The DON said this was speculation. During an interview on 05/22/2026 at 4:05 PM, the LMH said she thought that the Administrator was under the influence of alcohol about three weeks ago. She said she thought he was under the influence because he was wobbling. He told her he was having trouble walking because he had hip surgery. She said she thought he was under the influence because his attitude was different and the Administrator was real sharp when he spoke. The LMH said the Administrator lived at the facility. The LMH said she spoke with the former HR Director, and the former HR said she would check into it. During an interview on 05/22/2026 at 04:23 pm with the Area Admin, he said his job was to support the facility. The Area Admin said it was reported to him that the Administrator might have been intoxicated at night or on the weekends when he was at the facility. The Area Admin said he thought this was reported to him about a month ago, but he was unsure and could not confirm the date. The Area Admin said he was not concerned about the Administrator drinking alcohol at the facility because the Administrator lived at the facility. The Area Admin said it was part of the Administrator's employment agreement that the Administrator lived at the facility. The Area Admin said there was no indication that the Administrator was drunk during his normal working business hours and no evidence that he was drunk during non-working hours. The Area Admin said if someone was in the building, he expected them to follow the policies and procedures in the building. The Area Admin said he had no information that the Administrator had been drinking alcohol in the building except for the evenings and weekends. The Area Admin said these were allegations and there was no evidence that the Administrator was drunk. The Area Admin said he asked the Administrator if he was drunk while at the facility and the Administrator denied it. The Area Admin said he did not do any kind of investigation. The Area Admin said there was no alcohol substance seen to indicate the Administrator was drinking while at the facility. The Area Admin said if the Administrator was drinking when he was at the facility the Administrator was drinking when the Administrator was not on duty and not during normal working business hours. The Area Admin said that the Administrator was exempt from the policies and procedures of the facility during non-working hours, evenings and weekends, because the Administrator was living at the facility. The Area Admin said his number one concern was for the safety of the residents and it was not brought to his attention that the residents were not safe. He said the facility did not have a policy for administrators living at the facility and agreements for administrators to live at the facility were on a case-by-case basis. During an interview on 05/22/2026 at 5:25 PM with the VPHR, she said the facility management team, with the exception of the Area Admin, were unaware that Administrator was living in the building. The VPHR said the Area Admin said it was an agreement between him and the Administrator and was only supposed to be for a couple of months. The VPHR said it was not alright for the Administrator to be living at the facility. The VPHR said CMS rules applied to the facility regardless. The VPHR said the Administrator should not have been at the building when he was intoxicated because it was a drug free workplace. The VPHR said the facility policy of a drug free workplace should have been followed by the Administrator whether it was an evening or a weekend. She said if someone at the facility was under the influence of alcohol, it could potentially be a safety issue to the residents. Record review of the facility's policy Drug Free Workplace Policy and Guidelines for Implementation Reasonable Suspicion Testing dated O4/01/2025 reflected with this policy at the facility affirms A commitment to maintaining a drug free workplace and establishes conditions under which the facility will conduct a testing of employees based on reasonable suspicion that the employee has violated this policy and is under the influence of alcohol, intoxicants, illegal or misused prescription or over the counter medications while on duty. This policy outlines the practices and procedures designed to correct instances of identified alcohol and drug use in the workplace. This policy applies to all employees and applicants for employment with the facility. Observation of behavior - when a supervisor is notified or suspects an individual may be in violation of the drug free workplace policy the supervisor must observe the behavior of the individual and immediately complete reasonable suspicion testing checklist. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy dated January 2026 revealed the Nursing Facility (NF) ensures that all residents are free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and involuntary seclusion, in accordance with Texas law and federal CMS regulations. The Facility maintains a zero-tolerance policy and will immediately protect residents, initiate investigations, and report all alleged or suspected incidents as required by the Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS). Staff Training RequirementsStaff shall receive:Abuse prevention training prior to resident contactAnnual education on:Abuse PreventionAbuse identification and reportingHandling verbally or physically aggressive resident behaviorsProhibition of retaliationRetraining following incidents or identified trends5. Mandatory ReportingImmediate Resident Protection Upon discovery of an allegation or suspicion:Ensure resident safetyProvide medical and psychosocial careSeparate alleged perpetrator from resident contact when appropriatePreserve evidenceReport Within 2 HoursAbuse (with or without serious bodily injury)

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.1.The facility failed to label and date all food items located in the kitchen prep area, walk-in refrigerator and freezers observed on 5/20/2026, and 5/21/2026. 2.The facility failed to have closed fitting lids on the trash containers on observed on 5/20/2026, and 5/21/2026. These failures could place residents who receive meals from the kitchen and dine in the facility's dining room at risk for foodborne illnesses.The findings included:An observation conducted in the kitchen on 05/20/2026 beginning at 12:05 PM, revealed the following:Kitchen prep area: 1 large gray trash container with no lid that contained trash inside 1 large clear container, labeled white sugar 12/11 with no year or expiration date on top. Walk in refrigerator: 2 large storage bags of macaroni and cheese labeled 5/17/26, no discard date. 1 open package of ham, labeled 5/17/26, no discard date. A plastic rectangular container full with what appeared to be peaches, not labeled nor datedAn observation conducted in the kitchen on 05/21/2026 beginning at 10:5 AM, revealed the following:Kitchen prep area: 1 large gray trash container with no lid that contained trash inside about three fourths full A plastic rectangular container full with what appeared to be peaches, not labeled nor datedWalk in refrigerator: 2 large storage bags of macaroni and cheese labeled 5/17/26, no discard date. 1 storage bag with unidentified meat, resembled cooked chicken breast patty dated 5/16/26, no name, no discard dateFreezer: A box of mixed vegetables opened to air, no open date. A box of cheese omelets, package opened to air, no open date. In an interview conducted on 5/21/2025 at 11:01 AM, [NAME] B stated she had worked for the facility 5 years previously, but returned approximately one year ago. [NAME] B stated the kitchen labeling and dating process included placing the name of the food item, the date, and the year on the stored food items; however, the discard dates were not included. She stated, no one does that. [NAME] B acknowledged that old food could potentially lead to illnesses. She stated she did not typically cook an overflow. [NAME] B stated trash cans in the kitchen were expected to always remain covered with lids to help prevent flies and reduce the risk of food contamination from exposed trash. In an interview conducted on 5/21/2025 at 11:09 AM, DTA C stated that she had been employed at the facility for six years, and worked in the kitchen for the past four years. She reported that she had been trained on all kitchen policies. DTA C stated they were to label and date all items received in the kitchen. She stated that opened food products were labeled with the name, date opened, and discard date for cooked foods. DTA C stated all cooked foods were discarded after three days. DTA C stated the trash must have closed lids at all times. She stated not following any of the kitchen procedures could lead to cross contamination and residents could become sick.In an interview 05/22/2025 at 1:24 PM, the DON stated that she is not familiar with the dietary policy on labeling and dating food, she stated she knows the food should be labeled with the date opened but was unsure of the discard date. The DON also stated she was not familiar with the trash can policy in the kitchen. The DON stated her role with the kitchen was to ensure that orders were entered into the computer for the residents' diets. In an interview conducted on 05/22/2026 at 3:05 PM, the Interim ADMIN stated that was her second day at the facility and she was familiarizing herself with the facility's kitchen process. She stated she would be making sure the Dietary Manager position was posted immediately. She stated she was not yet aware of the labeling and dating process for the kitchen, but she would be checking for compliance. The Interim ADMIN stated she knew the trash cans should always have lids. She stated not having lids could lead to cross contamination and infection control issues.Record Review of facility's Food Safety and Sanitation Policy not dated revealed: 4. Food Storage (see Chapter 3: Food Production and Food Safety for Food Storage)a. Stored food is handled to prevent contamination and growth of pathogenic organisms. Leftovers are used within 72 hours (or discarded). Note: 2022 Federal Food Code guidelines allow 7 days for food safety with the day of preparation counted as day 1 of the 7 days and then food is discarded. Check local and state regulations and if differentfrom the Federal Food Code, determine which regulation should be followed. Perishable foods with expiration dates should be used prior to the use by date on the package. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored. Refrigerated food should be stored at or below 41 F. Frozen food should be stored at a temperature that keeps it frozen solid. Food should be protected from contamination (dust, flies, rodents, and other vermin). When a food package is opened, the food item should be marked to indicate the opendate. This date is used to determine when to discard the food. 11. Proper waste disposal methods will be used.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of Health and Human Services revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (B) With tight-fitting lids or covers when not in use. Must not be placed in a way that contaminates food, equipment and utensils.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for quality of care.The facility failed to ensure Resident #1 was transported back to the facility utilizing contracted transportation services after an appointment on [DATE]. Resident #1 was transported back to facility by the MTD in the MTD's personal car rather than by the arranged contracted transportation. During the transport, the personal vehicle was involved in a motor vehicle accident.This failure could place residents at risk of mental distress, serious injuries, and hospitalization.Findings included:Record review of Resident #1's face sheet, dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis and partial weakness, resulting from stroke), muscle wasting and atrophy (loss of muscle mass and strength), and hypertension (elevated blood pressure).Record Review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 07 which indicated severe cognitive impairment. MDS also reflected Resident #1 utilized a manual wheelchair for mobility.In an observation/interview conducted on [DATE] at 11:20 AM, Resident #1 was observed to be in a manual wheelchair, he rolled it independently. Resident #1 stated he was hospitalized the previous day following a motor vehicle accident, but reported he was doing alright. Resident #1 stated he attended an out -of -town appointment at a bank, and that the facility provided transportation to the appointment through a bus company and he was accompanied by MT Tech A. Resident #1 stated that the contracted transportation was to pick him up following his appointment. However, the MT Tech A called her husband, the MTD, to transport them back to the facility instead. Resident #1 stated while they traveled back to the facility in the MTD's personal vehicle, the vehicle was involved in a wreck. Resident #1 stated that emergency medical services responded to the scene, and transported him to the hospital for evaluation. Resident #1 stated that he had X-rays and was informed that he was okay. Resident #1 stated that he was transported back to the facility by ambulance later that evening.In an interview conducted on [DATE] at 11:40 AM, MT Tech A stated she worked at the facility since [DATE]. She stated she was asked to escort Resident #1 to an appointment at the bank. MT Tech A stated the appointment was out of town and they rode a bus. MT Tech A stated the appointment lasted only five minutes due to Resident #1 not having an identification card. She stated the transportation was scheduled to pick them back up at 2:00 PM. MT Tech A stated Resident #1 started to give her a hard time, so she contacted the facility and spoke to a nurse advising they needed to come pick them up. MT Tech A stated the MTD picked them up in his personal vehicle. She stated on the way back to the facility, they were involved in a wreck in which another vehicle hit them even after the MTD swerved. MT Tech A stated paramedics transported all three of them to the hospital. She stated the MTD's vehicle was totaled. MT Tech A stated she was not aware of a facility transportation policy on transporting residents.In an interview conducted on [DATE] at12:23 PM, the MTD stated he worked for the facility since [DATE]. He stated he went to pick Resident #1 up in his personal vehicle from out of town. He stated the facility did not have a vehicle for transportation. He stated he was instructed by the DON to go pick up Resident #1 and the SW sent him the address. The MTD stated he thought Resident #1 was to be transported back by the transportation that took him to the appointment. He stated he didn't think anything was wrong with the situation. The MTD stated another vehicle was speeding across the road and he tried to [NAME] to lessen the impact of the hit. He further stated he notified the facility right away of the accident, and they all were transported to the hospital. The MTD stated that he didn't think there was anything inappropriate about transporting Resident #1 in his personal vehicle. The MTD stated he was just following the directions of the DON when he transported Resident #1. The MTD stated he has not read any facility policy regarding resident transportation. The MTD further stated he worked as a CNA more than 10 years ago and he was knowledgeable in CPR.In an interview conducted on [DATE] at 2:05 PM, the DON stated the facility had contracted transportation for resident's appointments. The DON stated she did not give a directive to the MTD to transport Resident #1. She stated staff were not to use personal vehicles to transport residents. She further stated she was not the MTD's supervisor. The DON stated she was in a payroll meeting on that day, and the administrator received a call and she could hear something about an accident; and that was the first time she heard of the MTD picking up the resident in his personal car. The DON stated at 7:00 AM, that same morning, the SW told her she would not be escorting Resident #1 to the appointment and that the administrator said the MTD would escort him on the bus, since it was not a medical appointment. The DON stated she found out later the MTD did not escort Resident #1 to appointment, but instead the MT Tech A.In an interview conducted on [DATE] at 2:37 PM, the SW stated transportation was arranged for Resident #1 to be transported to and from the bank by the contracted transportation. The SW stated MT Tech A called the facility in a panicky tone saying she thought Resident #1 wanted to escape. The SW stated she had not known Resident #1 to behave in that manner. The SW stated the MT Tech repeatedly said her husband the MTD needed to pick them up. The SW stated she went to the conference room to tell the administrator that the MTD was leaving to pick up Resident #1 and the MT Tech A, and the administrator responded roughly that they were busy in a meeting and shut the door on her.In a phone interview conducted on [DATE] at 3:35 PM, the Administrator stated the MTD told him the DON gave him permission to pick up Resident #1 that day, because he was in a payroll meeting. The Administrator stated he told everyone that they were not supposed to pick up anyone in their personal cars. However, he stated the facility did not have a transportation policy on transporting residents, but that was what he personally told staff. He stated he was just shown a policy yesterday regarding driving a personal car for company business. The Administrator stated the MTD had insurance on his car, and he felt it was okay since Resident #1 was not going to a doctor's appointment. The Administrator stated his self was terminated from the facility on the previous day.In an interview conducted on [DATE] at 3:05 PM, the Interim ADMIN stated staff should never drive a resident in their personal vehicle. She stated it was not acceptable. The Interim ADMIN stated potential accidents could occur that could harm residents.Record review of the facility policy provided by the Interim Administrator, undated, titled: [Facility] Resident Transportation Policy Non-Emergency Transport 1.Staff are not allowed to transport residents in their personal vehicles, unless there is a disaster. 2.If there is a predicted disaster, such as a hurricane, families and/or responsible parties will be contacted by the Social Worker and Administrator to check if they would be available to come pick up their loved ones to reside with them until the predicted disaster has subsided. For the remaining ambulatory residents, staff will be asked by the Administrator/designee to assist with transporting ambulatory residents to a safe location. 3.Residents will be transported by an approved transportation vendor for scheduled medical appointments, outside of the facility treatment center appointments, or personal appointments, if the family or responsible party is unavailable to assist with transportation needs. 4.Upon admission, transportation for the resident is coordinated with the resident and, if available, their family to determine any transportation needs and to assist with scheduling as needed.

Based on observations, interviews, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for two(2) of four(4) kitchen staff (DTA C, [NAME] B) reviewed for food and nutrition services. 1. The facility failed to ensure DTA C met the requirements for food handling by maintaining a valid Food Handler's Certificate. 2. The facility failed to ensure [NAME] B met the requirements for food handling by obtaining a current and valid Food Handler's Certificate before preparing and serving meals out of the facility kitchen. These failures could place residents at risk of not having their nutritional needs met and foodborne illnesses.Findings included: Record Review of the dietary food handler certificates provided on 05/21/2026 at 4:35 PM revealed DTA C's food handler certificate had expired on 08/25/2024. There was no certificate for [NAME] B.Observation conducted on 05/20/2026 beginning at 12:05pm revealed [NAME] B and DTA C preparing lunch meals in the facility kitchen. The MTD was also present in the kitchen putting away food items. Interview conducted on 05/20/2026, at 12:15 PM, the MTD revealed he was assisting with the kitchen since the termination of the previous dietary manager. He stated he had a food handlers' certificate and showed a current copy from his cell phone with an issue date of 02/09/2026. He stated he also had a dietary manager certification but didn't have a copy with him. The MTD stated everyone's food handlers' certificates were in a folder, but he didn't know where the previous dietary manager left them.Interview conducted with the DON on 5/20/2026, at 12:20 PM, the food handler certificates were requested for all dietary staff and certified dietary management certificate for the MTD. Interview conducted on 5/21/2025 at 11:01 AM, [NAME] B stated she had worked for the facility 5 years previously but returned approximately one year ago. [NAME] B stated she did not possess a current food handler's certificate. She stated she previously obtained a food handler's certificate; however, she estimated that it had expired approximately 10 years ago. [NAME] B stated the previous dietary manager did not inform her that a current certificate was required. She stated she had over 30 years of experience working in restaurant kitchen settings, and she was familiar with general kitchen operations.Interview conducted on 5/21/2025 at 11:09 AM, DTA C stated that she had been employed at the facility for six years and worked in the kitchen for the past four years. She stated she possessed her food handler's certificate.Interview conducted on 5/22/2025 at 1:18 PM, DTA C revealed she was made aware yesterday evening her certificate was expired. She stated the previous dietary manager did not tell her it was expired. She stated she thought once you had one, it did not expire. DTA C stated she completed her training update that morning and she was current. She stated she understood it was important to maintain proper training requirements. DTA C stated if staff were not properly trained, it could lead to residents getting sick if diets are not followed.Interview conducted on 5/22/2025 at 1:24 PM, the DON stated there should be qualified dietary staff in the kitchen, and they should be familiar with all the regulations to carry out the policies in the kitchen. The DON stated they had a dietician that consults remotely with dietary.In an interview conducted on 05/22/2026 at 3:05 PM, the Interim ADMIN stated she would be checking the dietary staff for compliance. She stated that it was her second day at the facility and she was familiarizing herself with the facility's kitchen process. She stated DTA C updated her certificate earlier in the day and [NAME] B was going to complete her training. The Interim ADMIN stated everyone in the kitchen should follow the regulations.Review of the facility's undated policy titled Food Safety and Sanitation reflected: Policy:All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.Procedure:1. Food and Nutrition Services Departmenta. The department will be routinely inspected by the environmental health services of the local public health department, following their accepted standards and regulations. The director of food and nutrition services will have a copy of the applicable regulations on file and should be familiar enough with this information to implement policies and procedures to meet the regulations. Note: Not all states require local health department inspections.b. The state and/or federal survey team as part of the annual survey process will inspect the department.c. The food and nutrition services department will follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility.

Based on observation, interview and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #1) reviewed for accidents and hazards. CNA B failed to check the surroundings and notify LVN A when she heard the door alarm on the secured unit on 02/23/2026 at about 2:00 am. Resident #1 eloped from the facility and was found by local PD on a highway about 0.9 miles away from the facility with in the dark on 02/23/26 at 2:25 am. Resident #1 left the facility's secured unit through the door in the lobby area.The noncompliance was identified as PNC. The IJ began on 02/23/26 and ended on 02/25/26. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization. Findings included: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia unspecified (a chronic, severe mental disorder that disrupts how a person thinks, feels, acts, and perceives reality) , Alzheimer's disease unspecified (a progressive, irreversible brain disorder that causes cognitive decline-including memory loss, thinking, and reasoning problems), Anxiety disorder unspecified (excessive, persistent fear or worry that interferes with daily life, going beyond normal stress). Major depressive disorder, recurrent (a chronic, often lifelong condition characterized by repeated, separate episodes of severe depression). Record review of Resident #1's quarterly MDS assessment, dated 01/02/2026, reflected a BIMS of 2, which indicated a severe cognitive impairment. Section E - Behavior indicated Resident #1 had hallucinations and delusions. Section E-Wandering -presence and frequency indicated behavior of this type occurred 1 to 3 days. Section GG (Functional Abilities and Goals) reflected he utilized a wheelchair and walker. Record review of Resident #1's care plan, revised 02/23/26, reflected Resident #1 resided in the secure unit as evidenced by elopement risk. It also reflected that Resident #1 had an actual elopement on 02/23/2026 and that Resident #1 had poor safety awareness due to diagnoses of Alzheimer's disease and schizophrenia. Record review of Resident #1's elopement assessment dated [DATE] showed he was at risk. Record review of PD's report reflected, on 02/23/2026 at approximately [2:25 am] a Deputy observed an elderly individual walking northbound along [local state highway]. Local nursing homes were notified. [XXX] employees verified the individual. He was then transported back to [XX] facility by Police Officer with no incident. Record review of Resident #1's progress note dated 02/23/2026 at 06:30 am written by LVN A reflected, Officer came to facility to ask if a resident had left the facility, this nurse was not aware that resident had eloped. When this nurse went to unit to do headcount resident was not in his room nor on the unit. Immediately resident elopement was reported to administrator. Resident was then brought back to facility by a police officer. This nurse then did a head-to-toe assessment on residents and no injuries noted at this time. Resident had 3 shirts on, pants, socks and shoes. Resident was in pleasant mood making conversation with nurse. V/S 134/78, 88p, 18r, 97.7T, 98% O2. Called and spoke with NP [XX] no new orders given, RP was called no answer left voicemail to call facility. Resident had eloped from locked unit and walked down the highway and was seen by a police officer. Record review of Resident #1's skin assessment dated [DATE] reflected no abnormality. Record review of Resident #1's elopement assessment dated [DATE] reflected Resident #1 was at risk for elopement. Record review of Resident #1's 1:1 monitoring reflected Resident #1 was placed on 1:1 monitoring on 02/23/2026 at about 2:45 am and continued to be on 1:1 monitoring during the investigation on 02/26/2026. Review of LVN A's undated written statement showed CNA B heard the secure unit alarm approximately 30 minutes before PD arrived, did not notify her and did not look outside to ensure someone went outside. She also said she noticed Resident #1 was missing after PD spoke with her and a head count. During an interview on 02/26/2026 at 10:00 am, CNA D stated she worked the 10:00 pm to 6:00 am shift on the night of Resident #1's elopement and she was doing a 1:1 monitoring with another Resident when Resident #1 eloped from the facility. CNA D stated she found out about the elopement after Resident #1 was brought back to the facility. CNA D stated Resident #1 was put on a 1:1 monitoring immediately after the incident. CNA D stated she was in-serviced on elopement on 02/23/2026 right after the elopement incident and there was also an elopement drill conducted by the ADON. CNA D stated, they were told whenever the door alarms sounded, they should go and look outside and check the surroundings for a Resident. CNA D stated, if a Resident was not seen outside, notify the charge nurse to do a head count of all Residents. CNA D stated, after the head count of Residents, if someone was missing, notify the DON, do a count of everyone in the facility, and if not seen, notify the police. During an interview on 02/26/2026 at 11:23 am MA C stated she worked the 6:00 am to 6:00 pm shift and was not present when Resident #1 eloped from the facility. MA C stated she was in-serviced on elopement when she got back to work on 02/25/2026. MA C stated she was told to listen for the door alarm, and when it sounded to look for which door the sound was coming from. MA C stated she was supposed to go and look outside, checking the surroundings for residents and notify the charge nurse that the alarm went off and whether a resident was seen outside or not. MA C stated the charge nurse would do a head count of the residents and if a resident was missing, they would initiate elopement protocol. MA C stated if the resident was not found in the facility, the administrator or DON would be notified, and the search would extend outside, and the police would be notified. MA C stated Resident #1 had been on 1:1 monitoring since the incident. MA C stated the Maintenance Director added something on the door alarm on the secured unit to make it sound louder. MA C stated Resident #1 did not try to get out of the facility, and most days he was calm but was always talking about trying to go to the store. During an interview and observation on 02/26/2026 at 11:40 am Resident #1 was sitting in the hall on the secured unit and was on a 1:1 monitoring by the Assistant Manager for laundry. Resident #1 stated he went out the other night because he was trying to go home. Resident #1 stated he wanted to go to his family. During an interview on 02/26/2026 at 11:49 am the Assistant Manager for laundry stated she was assigned to do 1:1 monitoring with Resident #1 because he eloped from the facility the other night. The Assistant Manager for Laundry stated they could be within 10 feet of Resident #1 and he had to be visualized at all times. The Assistant Manager for laundry stated they had been in-serviced on elopement. The Assistant Manager for laundry stated she was told whenever the door alarm went off, they are to go and check the surroundings to see if a resident went out. If a resident was out, bring them back in the facility and notify the Administrator and the DON. If a resident was not found outside, notify the charge nurse to do a head count of residents. Continue the search within the facility and outside the facility's premises. Notify the police if the resident was not found within the facility's premises. During an interview on 02/26/2026 at 11:53 am CNA E stated she was employed to the facility through a staffing agency. CNA E stated she was informed Resident #1 had eloped from the facility, and he had been placed on 1:1 monitoring. CNA E stated she was in-serviced on elopement on 02/25/2026 when she first got to the facility. CNA E stated she was told, when you hear the alarm, go out and check your perimeters, and if you do not see anyone outside, you do a head count of your residents. CNA E stated if someone is missing, you notify the Administrator and DON. If a resident is not missing, you will still notify the charge nurse immediately that the alarm went off. The elopement protocol will be activated. During an interview on 02/26/2026 at 12:01 pm CNA F stated she worked the 6:00 am to 2:00 pm shift and was not at work during Resident #1's elopement. CNA F stated Resident #1 had been on 1:1 monitoring since the incident. CNA F stated Resident #1 has always been talking about leaving but had never attempted to leave. CNA F stated she was in-serviced on elopement on 02/24/2026 when she got to work. CNA F stated she was in-serviced on checking the door and the surroundings when the door alarms. CNA F stated she would go check and see if someone is outside, get a count of residents in the building and notify the DON and Administrator and get directions from them. During an interview and observation on 02/26/2026 at about 12:12 pm the Maintenance Director stated after Resident #1's elopement incident on 02/23/2026 he added door stoppers (alerts you to any unauthorized exits and entries through an emergency exit doors and rear doors. Highly visible white STOP/Alarm Will Sound text with graphics against bold red background) to 2 of the doors on the secured unit which made the alarms sound louder on those doors. The Maintenance Director stated the doors had to be pushed very hard before they opened and the alarm would sound once the door was opened. The Maintenance Director stated, once the door is closed, the alarm would stop. Observation revealed all the alarm on the secured unit worked. Observation also revealed a door stopper was added to the door in the lobby of the secured unit from which Resident #1 eloped and at the door at the very end of the secure unit. It was also revealed that the alarm from the lobby of the secured unit could be heard from the door at the very end of the secured unit. The Maintenance Director stated the Administrator in-serviced the staff on elopement and the ADON conducted an elopement drill. During an interview on 02/26/2026 at 12:34 pm the ADON stated she was made aware by the Administrator of Resident #1's elopement on the morning of 02/23/2026 at about 3:00 am. The ADON stated by the time she got to the facility, the Police had already brought Resident #1 to the facility, he was on 1:1 monitoring, LVN A had done a head to toe assessment and there was no apparent injury noted. The ADON stated CNA B was an agency staff assigned on the secured unit but she [CNA B] was not at the facility when she [ADON] got to the facility, and she was told by the Administrator and LVN A that CNA B had refused to give a statement to the Administrator and the police. The ADON stated that was the first time she had seen CNA B at the facility. The ADON stated the Agency staff were usually trained by the agency on dementia care which focused on elopement. The ADON stated she was told CNA B heard the door alarm went off, she assumed that the other resident on the couch was the one that set the alarm off and she did not look outside or notify LVN A. The ADON stated CNA B should have gone out to check if a resident went outside and notified LVN A that the alarm on the unit went off. The ADON stated, if CNA B had told LVN A that the alarm went off, they would have done a head count and initiated the elopement protocol. The ADON stated if a resident was missing, the staff would start searching the rooms, the closets, notify the Administrator and the DON, and continue the search outside the facility. The ADON stated Resident #1 was at risk of injury when he eloped because of the major state highway he was found on. The ADON stated elopement in-service was initiated by the Administrator on 02/23/2026 and she later conducted an elopement drill the same night. The ADON stated another elopement drill was conducted on 02/25/2026. The ADON stated all staff were being trained on elopement before the start of their shifts. During an interview on 02/26/2026 at about 2:04 pm, the DON stated he got a call at about 4:00 am on 02/23/2026 notifying him of Resident #1's elopement. The DON stated by the time he got to the facility, Resident #1 was already brought back to the facility. The DON stated CNA B was an agency staff who was assigned to the secured unit and heard an alarm sounding at the door in the lobby area/sitting area on the secured unit, made an assumption that the resident that was on the couch was the one that set off the alarm on the door. The DON stated CNA B did not tell LVN A about the door alarm going off. The DON stated CNA B should have immediately told LVN A. They should have done an elopement search, looked in the facility, looked in the perimeter of the facility, and if the resident was not found, called the police. The DON stated Resident #1 was immediately put on 1:1 monitoring, assessed to make sure there was no injury, and they contacted Psychiatrist for evaluation. The DON stated they assessed all the residents in the facility for elopement risk, in-serviced the staff on elopement and how to respond to the alarm, did 2 elopement drills, and had an Ad hoc meeting to discuss the elopement. The DON stated Agency staff were trained by the Agency on elopement.During an interview on 02/26/2026 at 2:22 pm, the Administrator stated he was notified by LVN A immediately when she found out Resident #1 had eloped. The Administrator stated LVN A told him the police had come asking if they were missing a resident. The Administrator stated he went to the secured unit and spoke with CNA B and CNA B stated she heard an alarm, saw a resident on the couch close to the secure door and she thought it was the resident on the couch that set the alarm off. The Administrator stated CNA B stated she turned the alarm off and she did not tell anyone, not the charge LVN A. The Administrator stated, about 20-30 minutes after the door had alarmed, the police called to find out if the facility was missing a Resident. The Administrator stated, when the PD arrived at the facility, they attempted to interview CNA B and she refused and stated she did not like their (the Police and Administrator's) attitudes. CNA B stated she made a mistake and she walked out. The Administrator stated Resident #1 was found about 0.9 miles away from the facility.The Administrator stated Resident #1 was assessed by LVN A, immediately placed on 1:1 monitoring, MD was notified, the ADON was notified, elopement in-service was initiated, the Maintenance Director checked the alarms at the door and added a door stopper to increase the sound of the alarm, and the ADON reached out to the staffing agency and was told CNA B would be fired. The Administrator stated he had been in-servicing staff around the clock and ensuring all agency staff were trained on elopement before their shift. The Administrator stated, when CNA B heard the door alarm, CNA B should have looked outside never assumed that the resident on the couch was the one that set off the alarm. The Administrator stated CNA B should have told her charge nurse that she heard the door alarm sound. The Administrator stated CNA B was supposed to do an immediate head count to ensure everyone was present, they would have known someone was missing sooner and notify the police and I. The Administrator stated all staff, agency and fulltime would be in-serviced on elopement before the start of their shift.During an interview on 02/26/2026 at 4:05 pm CNA G stated she was employed through an agency and worked the 2:00 pm to 10:00 pm shift. CNA G stated she did not work on the secured unit. CNA G stated when she got to the facility on [DATE] she was in-serviced on a Resident on the secured unit was on a 1:1 monitoring. CNA G stated when the door alarm went off, she would go and see, make sure no residents left the building and let the nurse know especially on the secured unit. CNA G stated if a resident was not seen outside after checking, she would come back into the facility and make sure all residents were accounted for and let the charge nurse know.During an interview on 02/26/2026 at 4:48 pm LVN A stated she was the Charge Nurse on duty on the night of 02/22/2026 to the morning of 02/23/2026 on the 6:00 pm to 6:00 am shift. LVN A stated she did a nursing round on the secured unit at about 1:00 am and CNA B was sitting in the nurse's office. LVN A stated she asked CNA B to sit close to the two (2) residents in the lobby area of the secured unit. LVN A stated Resident #1 was sitting in his wheelchair and another Resident was on the couch. LVN A stated when she checked back on the unit at about 2:00 am, Resident #1 was not sitting where she last saw him. LVN A stated when she stepped out of the secured unit, a Police officer was at the door, and he asked if they were missing a resident.LVN A stated the Police officer said there was a man in a yellow wheelchair and it sound like Resident #1. LVN A stated she ran back to the secured unit and asked CNA B if a resident went out and CNA B stated no one went out of the facility. LVN A stated she asked CNA B if the door sounded and CNA B stated yes. LVN A stated CNA B told her that when the door alarm sounded, she (CNA B) went and looked and saw a resident on the couch and assumed he was the one that sounded the door alarm. LVN A stated she told CNA B she (CNA B) should have alerted her (LVN A) that the door alarm went off, and she (LVN A) would have done a head count of the residents on the unit. LVN A stated she looked in Resident #1's room and Resident #1 was not in his room. LVN A stated she notified the Administrator and told the Police Officer that person found was a resident of the facility. LVN A stated the Police brought back Resident #1 to the facility, she assessed Resident #1 from head to toe and placed Resident #1 on 1:1 monitoring immediately. LVN A stated CNA B refused talking to the Administrator and the Police Officer, she grabbed her things and left the facility. LVN A stated the Administrator requested a statement from CNA B and CNA B said the Administrator would figure out and walked out. LVN A stated an in-service on elopement was initiated the same night by the Administrator and the ADON. LVN A stated when the morning shift got in the facility, they were in-serviced on elopement before they took over their shift.During an interview on 02/26/2026 at 5:11 pm CNA H stated she worked the 2:00 pm to 10:00 pm shift. CNA H stated she was in-serviced on elopement on 02/25/2026 and she did not work the last 2 days after the elopement incident. CNA H stated when the door alarm went off, she was supposed to go out and check to make sure no resident went outside the facility, come back in the facility, ensure the door was closed and the alarm was back on and, notify the charge nurse to do a head count of the residents to make sure everyone was inside.During an interview on 02/26/2026 at 5:18 pm LVN I stated he was off the last two days after the elopement incident and got back to work on 02/25/2026 for the 6:00 am to 6:00 pm shift. LVN I stated he was in-serviced on 02/25/2026 on elopement. He stated when you hear the door alarm, look outside to make sure a resident did not go outside, do a head count of residents, and notify the authority. LVN I stated Resident # was on a 1:1 monitoring.During an interview on 02/26/2026 at 5:27 pm CNA J stated he was employed through a staffing agency and worked the 2:00 pm to 10:00 pm shift. CNA J stated he worked on 02/24/2026 and he was in-serviced on elopement at the beginning of his shift. CNA J stated Resident #1 had been on 1:1 monitoring due to elopement. CNA J stated if he heard the door alarm, he would check the perimeter outside, come back in, do a head count and alert the charge nurse, the administrator and the DON. CNA J stated even if every resident was accounted for, he would still have to alert the administrator.Attempt made to contact CNA B on 02/26/2026 at 09:48 am and there was no response.Record review of CNA's training records reflected CNA B was trained on Dementia Care Assessment One on an unknown date and passed.The facility immediately implemented the following actions to immediately address Resident #1's elopement incident:PD brought Resident #1 back to the facility on [DATE]Resident #1 was assessed head to toe on 02/23/2026 and had no apparent injuriesResident #1 was placed on 1:1 monitoring on 02/23/2026Resident #1 and all other residents in the facility were reassessed for elopement risk on 02/23/2026Staff were in-serviced on elopement as of 02/23/2026Staff participated in elopement drills twice since Resident #1's incident on 02/23/2026 and 02/25/2026Door stoppers were placed on 2 of the secure unit doors on 02/23/2026The staffing Agency was notified of agency staff actions on 02/23/2026Maintenance checked alarms and door magnetic locksThe MD was notified of the incident on 02/23/2026An Ad hoc was held on 02/23/2026 Record review of facility's in-service initiated 02/23/2026 at 04:00 am provided by the ADON reflected the following: Elopement process- when alarm goes off, check to see resident near or outside the door. Notify nurse and do a head count on your residents notify the DON and Administrator.Record review of facility's elopement drill reflected a drill was conducted on 02/23/2026 from 3:30 to 4:05 pm.Record review of facility's in-service initiated 02/23/2026 at 10:00 am provided by the ADON reflected the following: Monitoring/Reporting--No one is to be sitting behind the glass/nurse's station in the unit. One CNA will remain in the lobby at all times, alternating to provide care on the unit to monitor behaviors. Report behaviors to charge nurse. Record review of investigation document reflected an Ad hoc was held on 02/23/2026 regarding elopement, door alarm and Resident #1 eloping from the secure unit on 02/23/2026 at about 2:00 am. Agency CNA responded to the alarm and assumed another Resident #2 on the couch was the cause of the alarm.Record review of facility's in-service initiated 02/23/2026 provided by the Administrator reflected: ln-service on facility door alarms By: [XXX], AdministratorDate: 02/23/2026IMPORTANTAnytime you hear a door alarm especially in the Secured Unit, never ever assume it's a resident sitting by the door who sounded the alarm! If you hear a door alarm sound, make an immediate search of the perimeter inside and out. Inform your charge nurse and conduct a resident body count to see if any residents are missing.Again, especially on the facility secured unit, never ever assume a resident sitting by a security door is the cause of the alarm going off! Make an immediate search of the perimeter inside and outside and conduct an immediate body count! If a resident is missing contact the police and notify the administrator immediately! Record review of facility's elopement drill reflected a drill was conducted on 02/25/2026 from 5:15 am to 5:30 am. Record review of facility's document titled Preventative Maintenance and Life Safety checklist-daily reflected the alarms were checked on weekdays and were checked on 02/23/2026. There was an indication on the document which reflected: Resident got out of secure door. Checked, door lock is undamaged and alarm sounds. Added exit stoppers to 2 secured doors. Record review of facility's policy titled elopement/missing resident dated [DATE] reflected: A resident is considered to be missing when the resident cannot be located on the facility's interior or exterior grounds. When a resident is considered missing, the Charge Nurse will notify the DON/ Administrator immediately. The DON or designer will implement the Elopement protocol immediately.All personnel will report to the nursing station for search assignments. Information should beobtained and communicated with regard to the last time the resident was seen, a description of the resident's clothing, and the location where the resident was last seen. The noncompliance was identified as PNC. The IJ began on 02/23/2026 and ended on 02/25/2026. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews, the facility failed to protect the resident's right to be free from abuse for one (Resident #5) of 5 residents reviewed for abuse, in that:On 12/25/25 the facility failed to ensure that Resident #5 was not hit multiple times over the head with a plastic trashcan by Resident #4. Resident #5 suffered a laceration, received three staples to his head and required a less than 24-hour hospitalization. This failure could place residents at risk of harm, serious injury and hospitalization.Findings included:Record review of Resident #4's face sheet, dated 01/05/26 revealed a seventy-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses included dementia (severe cognitive decline (memory, thinking, reasoning) impacting daily life, caused by damaged brain cells), schizophrenia (a severe brain disorder causing hallucinations (like hearing voices), delusions (false beliefs), disorganized thinking, and unusual behaviors), and Parkinson's Disease (a progressive neurological disorder affecting movement).Record review of Resident #4' MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a BIMS score of 7 indicating severe cognitive impairment.Record review of Resident #4's care plan reflected a focus, undated, of inappropriate behaviors: Resident #4 had episodes of inappropriate behaviors and was at risk for further episodes and injuries AEB physical aggression: 12/13/25 Resident #4 allegedly kicked and punched the other resident who was on the ground after the resident had entered his room and on 12/25/25 resident to resident altercation with intervention dated 04/08/25 encourage to attend social activities of preference, explain procedures, using terms/gestures resident can understand, give medications per order, monitor labs, report results to MD, monitor and chart behaviors every shift and report progress to MD.Record review of Resident #4's care plan reflected a focus dated 04/02/25 reflected Resident #4 spends limited time in activities. Resident #4 had no involvement in activities and Resident #4 had refused to participate in activities one on one with interventions dated 04/02/25 encourage conversation when assisting/providing care, offer and assist Resident #4 with TV/radio as needed in room activity, and provide 1:1 assistance as needed to participate in activities.Record review of Resident #4's care plan reflected a focus dated 04/09/25 reflected dementia. Resident #4 was at risk for increased confusion and decline in ADLs as the disease progressed, focus dated 04/09/25 of Resident #4 had a diagnosis of schizophrenia and was at risk for manic (a period of abnormally elevated mood, high energy, and increased activity) episodes, focus dated 12/26/25 Resident #4 demonstrated behaviors that made having a trash can in the room unsafe (eg inappropriate use, hygiene concerns, or safety risks), focus dated 04/09/25 Resident #4 resided in the secure unit AEB elopement risk with intervention dated 04/09/25 administer medication as ordered by MD, assist resident with ADLs as needed, reassure Resident #4 when confusion increased, reorient Resident #4 daily as needed, verbal reminders and cues to assist Resident #4 with daily orientation.Record review of physician's order dated 04/03/25 reflected Resident #4 placed on the secured unit due to risk of elopement.Review of the only Elopement Risk Assessment by former DON for Resident #4 dated 06/02/25 reflected no verbal expressions to leave facility and no history of elopement.Record review of Resident #4's progress note by LVN A dated 12/13/25 reflected Pt. [Resident #4] was allegedly kicking and punching another patient who was on the ground after the patient had entered Resident #4's room. Resident #4 was upset because the other resident wandered into Resident #4's room.Record review of Resident #5's face sheet, dated 01/05/26, revealed a 125 (erroneous date) year old man who was admitted to the facility on [DATE] and readmitted on [DATE]. His admitting diagnoses included altered mental status (a significant change in a person's usual brain function, leading to confusion, disorientation, reduced alertness, or odd behaviors), acute kidney failure (the sudden loss of kidney function, causing waste and fluid to build up in the body, with symptoms like reduced urination, swelling, fatigue, nausea, and confusion), and thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury).Record review of Resident #5's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a BIMS score of 0 indicating severe cognitive impairment.Record review of Resident #5's care plan revealed a focus dated 12/26/25 scalp laceration (a cut through the skin of the scalp, which often bleeds profusely due to the rich blood supply in the area) impaired skin integrity (the skin's normal, healthy structure is compromised, making it vulnerable to damage, infection, and breakdown) related to head trauma (occurs from a violent blow, jolt, or penetrating object to the head) as evidenced by three surgical staples (small, often titanium fasteners used by surgeons to quickly close skin wounds or reconnect internal tissues) to the scalp (the skin and tissue covering the top of the head) and a focus dated 05/20/25 of Resident #5 resided in the secure unit AEB elopement risk, need for reduced stimuli, wandering.Record review Resident #5's progress notes dated 12/25/25 reflected CNA (name of CNA not noted) reported that Resident #4 attacked another resident. CNA stated that after hearing commotion in the hall she exited a room and entered the hall to observe Resident #4 holding a plastic trashcan over another resident's head hitting him multiple times, CNA stated she separated the two residents. Resident #4 went back to his room and closed the door and remained there. The other resident [Resident #5] was escorted to the lobby and remained there.Record review of Resident #5's hospital records dated 12/26/25 reflected discharge diagnoses scalp contusion and scalp laceration. The 3 staples need to be removed in 7 days.Record review of psych NP evaluation dated 12/26/25 of Resident #4 revealed facility requested for urgent psych consult for physical aggressive behavior. History of Resident #4 present illness reflected: Psychological: depression, emotional withdrawal, anxiety, irritable, hallucinations, mood swings, paranoia/delusions, agitated, anger and Physical - poor sleep, aggression, social isolation/withdrawal, short tempered/easily annoyed. Examination details reflected the visit was a follow up visit requested by the facility reporting that Resident #4 had a physical altercation with another resident who came into Resident #4's room and resulted in the other resident [Resident #5] being sent to the hospital for stitches. The other resident [Resident #5] had been coming to Resident #4's room repeatedly and had been warned by Resident #4 to leave Resident #4's room on multiple occasions. Resident #4 became frustrated and irritable and hit the resident [Resident #5] on the head with a trashcan. Resident #4 had always been withdrawn and isolated and usually stayed in his room. Resident #4 was very territorial about his environment. Resident #4 was known to the psych NP from a previous facility and Resident #4's behaviors had always been the same with little to no physical altercations which usually occurred when people came into Resident #4's personal space. Resident #4 can be redirected easily. Resident #4 got paranoid when people came around his environment due to his diagnosis. Resident #4 did not leave his room to seek out trouble. Resident #4 could follow directions. Resident # was compliant with his medications and ADL's with minimal assistance.During an interview on 01/05/26 at 1:17 pm with CNA D she stated Resident #5 went by Resident #4's room. Resident #4 thought Resident #5 was trying to get in Resident #4's room. Resident #5 was using Resident #4's door to push from and propel his wheelchair. CNA D said she felt like Resident #4 was trying to protect his house because Resident #4 felt everyone was trying to come into his room and take his things. Resident #5 would try to get into Resident #4's room.During an interview on 01/05/26 at 1:52 pm with the psych NP he stated he was told about the altercation between Resident #4 and Resident #5. The psych NP said he did not have any concerns about Resident #4 getting into another altercation, Resident #4 tried to tell the other residents to get away from his room and Resident #5 did not listen to him. Resident #5 was kicking at Resident #4's door. If no one goes into Resident #4's room there were no problems, Resident #4 always stayed in his room. The psych NP said staff needed to redirect other residents away from Resident #4's room so Resident #4 did not get triggered.During an interview on 01/05/26 with the DOR at 2:31 pm she stated the secured unit had a host of issues and part of it was the staff not recognizing and not being able to pick up on resident cues. She said the staff need dementia and mental health training.During in interview on 01/05/26 at 3:38 pm with CNA E he stated Resident #4 will blow up if residents get in his face.During an interview on 01/05/26 with Resident #4 at 3:40 pm he stated Resident #5 came to his door all the time and he did not want him around. Resident #4 said they [the residents] came to his hallway and they fell all over the place and made noise and he did not want them around.During an interview on 01/05/26 at 4:41 pm with LVN B he stated he remembered an incident between Resident #4 and Resident #5. Resident #5 wandered into Resident #4's room and Resident #4 hit Resident #5 over the head with a trashcan. It was normal for Resident #4 to get aggressive when residents wandered into his room. LVN B said Resident #4 would push residents out. LVN B said Resident #4 naturally stayed in his room and dominated over his bedroom. LVN B said other residents were not cognitive enough to realize the threat of going into Resident #4's room.During an interview on 01/06/26 10:08 am with the Interim Administrator she stated after the incident between Resident #4 and Resident #5 on 12/25/25 Resident #4 was placed on 1:1 until the following day when the 1:1 was lifted by the psych NP. The Interim Administrator reflected they had no other interventions for Resident #4 other than the 1:1 and the removal of his trash can from his room. She said Resident #4 usually did not bother anyone except when residents went into his room. She said they explored putting a stop sign on his door but had not done this yet. She said that because Resident #4 had dementia and aggressive behaviors the secured unit was an appropriate setting for him. She said anything could happen with residents who have cognitive impairment, and she was not sure of any other interventions to put in place.Attempted interview on 01/06/26 at 11:48 am with Resident #5 via telephone translator. Translator was speaking Spanish to Resident #5 and Resident #5 said he did not understand and leaned away from the phone.Attempted interview on 01/06/26 at 3:40 pm with agency CNA F who witnessed the incident between Resident #4 and Resident #5 on 12/13/25. The facility did not have a phone number for agency CNA F. Telephone call was placed to the agency who employed CNA F and asked for agency CNA F's telephone number, and agency did not return the call.During in interview on 01/06/26 at 4:05 pm with CNA G she stated that she usually worked in the secured unit. She said Resident #4 did not want anyone in his space. She said if residents went down the hallway towards his room he got upset and would tell them to get away. She said they tried to quickly redirect residents away from his room, but the residents had a right to go where they wanted. Resident #4 explained to everyone to knock before you enter his room. If you just opened the door, he would try to strike. She said they did in-services about resident-to-resident abuse but there was no specific in-service about dealing with Resident #4.During in interview on 01/06/26 at 4:47 pm with the SW she stated Resident #4 stayed to himself a lot. He would open the door for staff. The SW said Resident #4 had paranoid schizophrenia and if anyone went into his space, even if it was a staff member at his door, he went to the door and tried to provide safety for his space. She said one time he pushed someone away who was in a wheelchair and hit someone with a trashcan. She said Resident #5 wandered into Resident #4's room because Resident #4's room used to be Resident #5's room. She said a care plan was the focus of what goal you were trying to reach for that resident. She said she thought Resident #4 wanting to have his space to himself needed to be care planned because it caused a lot of altercations because of his paranoid schizophrenia. She said there should be interventions to make sure he stayed in the room by himself and to redirect any other residents who wandered close to his room. She said interventions about Resident #4 wanting his own space would be essential for the safety of the residents.During an interview on 01/07/26 at 12:29 pm with Resident #4's RP she stated that someone from the facility called and told her about Resident #4 hitting Resident #5 with a plastic trashcan. The facility told her someone tried to get into Resident #4's space. The RP said Resident #4 always had a chair behind his door to keep people out. She said Resident #4 did not leave his room. She said Resident #4 had a series of thefts when he was at a previous facility and he now did not want to leave his room for fear of his things being stolen. She said she was not concerned about him wanting to exit the facility. She said years ago he had left a facility but now she was not concerned at all about him wanting to leave.During an interview 01/07/26 at 2:08 pm with CNA H she stated she never really knew why Resident #4 was in the secure unit. She said he would not come out of his room CNA H said the only time Resident #4 had a problem was when residents would knock on his door. She had not had any dementia training and had worked in dementia units previously.During an interview on 01/07/26 at 3:42 pm with the SW stated Resident #4 was in the secured because of his paranoid schizophrenia. She said she had never seen him try to leave the facility and did not think he was an elopement risk. She said she was involved in care plans and did rounds visiting with the residents to monitor the effectiveness of the residents care plans. She said the facility had an audit tool to review care plans. She said she was focused on the social services section.During an interview on 01/07/26 at 4:57 pm with the DON she stated she began working at the facility on 11/24/25. She said that Resident #4 wanted his own space and did not bother anyone until someone got in his personal space. She said Resident #4 was in an area where residents were wondering. She said residents were going to forget Resident #4 did not like people at his door and go down there even if you told residents not to go down there. She said interventions should have been updated to address Resident #4's altercations with other residents. She said a possible negative effect of the interventions in his care plan not being updated could be that his care needs would be unsatisfactory. She said the IDT team was responsible for making sure that Resident #4's care needs were addressed on his care plan. She said the care plan was the process that helped a facility look at the needs and address the needs of the residents. She said the care plan should paint a picture of how to take care of the residents and if it was not updated to the behaviors of the residents, the residents might not have their needs meet. She said there was a discussion about putting a Velcro stop sign on Resident #4's door but that did not happen. She said besides placing him on 1:1 after the 12/25/25 incident and the Velcro stop sign discussion; she did not remember any other interventions.During an interview on 01/07/25 at 6:53 pm with the Interim Administrator she stated that she began working in the facility on 12/21/25 and Resident #4 was already in the secured unit. She said she knew that there were twelve residents in the secured unit, and she knew a few of their names and which residents were often sitting in the TV area and some of the residents' behaviors but not all their behaviors. She said the facility had not had an administrator for a period of time and she did not know of anyone else who knew the facility policy and procedures, but she would assume that the DON was responsible for knowing information about the secured unit.Record review of the facility policy Secured Unit Care Program admission Criteria and Process dated January 2026 revealed the goal of the Secured Unit Care Program is to meet the individual needs of residents living with dementia. The program provides a safe, supportive environment that maximizes independence while delivering person-centered care tailored to each resident's abilities, preferences, and needs. The following criteria are generally required for participation in the Secured Unit Care Program. If one or more criteria are not fully met, an exception for admission may be considered at the discretion of the Administrator and Director of Nursing. All exceptions will be reviewed on an individual, case-by-case basis. The resident demonstrates an elopement risk that can be safely managed within the Secured Unit Care Program environment, as identified through the facility's elopement risk assessment process. Each resident admitted to the Secured Unit Care Program will have a physician's order documenting the need for participation in the program. An admission interview will be conducted with the resident and/or family or party responsible to gather information related to the resident's history, preferences, and routines.

Based on interview and record review, the facility failed to have evidence that all alleged violations are thoroughly investigated for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for abuse and neglect.The facility failed to thoroughly investigate an alleged neglect incident reported by Resident #1 on 12/14/2025 when Resident #1 alleged staff were not performing peri-care appropriately.The facility failed to thoroughly investigate an alleged neglect incident reported by Resident #2's family member on 12/21/2025 when Resident #2 fell and was allegedly left on the floor for over an hour.The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #3 on 12/23/2025 in which Resident #3 stated a pillow was placed over his face by staff around the time of his admission in April 2025.The facility failed to investigate an alleged resident-to-resident abuse incident between Resident #4 and Resident #5 that was documented in Resident #4's progress notes dated 12/13/25.This deficient practice placed all residents at risk of harm from abuse/neglect due to not having a thorough investigation done for an abuse and or neglect allegation. Findings included:1.Record review of Resident #1's admission record, dated 01/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Cerebral Palsy (a neurological condition that affects movement, posture, and muscle coordination), diverticulosis of intestine (a formation of small pouches in the lining of the colon/large intestine), schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often with hallucinations and delusions), and chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms).Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15 indicating no cognitive impairment. Section GG - Functional Limitations reflected Resident #1 required maximal assistance for toileting hygiene. Section H - Bladder and Bowel reflected Resident #1 was Always incontinent for both bladder and bowel.Record review of Resident #1's care plan, date initiated 09/21/2025 and last revised 12/30/2025, reflected Resident #1 was at risk for decline in ADL functions and injury with interventions that included Toileting: Provide (total assistance FOR INCONTINENT CARE).Record review of the provider investigation report, dated 12/30/2025 and signed by the DON, reflected Resident #1 complained about not being properly cleaned during pericare. Provider response listed on the investigation report was Staff in-serviced on conducting proper pericare and provider action taken post-investigation was Check-offs for staff and in-services. Provider investigation report included safe surveys performed on residents dated 12/16/2025, 12/17/2025, and 12/18/2025. No new safe surveys were provided. In-services provided were dated 12/15/2025 and 12/16/2025 and were titled Resident on Resident, Abuse & Neglect; Reporting Guidelines, and ANE Res Rights. No in-services or new checkoffs were provided related to the investigation. 2. Record review of Resident #2's admission record, dated 01/05/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Parkinson's disease without dyskinesia (a progressive neurological condition that primarily affects movement but without the involuntary, erratic movements), muscle wasting and atrophy (the thinning of muscle mass), and muscle weakness.Record review of Resident #2's Quarterly MDS, dated [DATE], reflected a BIMS score of 06 indicating severe cognitive impairment. Section J - Health Conditions reflected Resident #2 had not incurred any falls since the previous assessment.Record review of Resident #2's care plan, date initiated 10/10/2024 and last revised on 01/03/2026, reflected Resident #2 was at risk for falls.Record review of Resident #2's nurses notes dated 12/21/2025 and written by LVN A reflected, Pt was found off the bed on her knees on the floor holding on to the table. Pt was assessed with no injuries noted and was placed back into the bed. Pt was assessed by the nurse with no injuries noted. Doctor and family were notified. The patient had notified the family. Nuero[sp?] checks have been started.Record review of the provider investigation report, dated 12/29/2025 and signed by the DON, reflected Resident #2's family member reported a fall occurred and no one assisted for an hour. Provider response listed on the investigation report was call light in reach, frequent monitoring and provider action taken post-investigation was staff in-serviced on abuse and neglect. Provider investigation report included safe surveys performed on residents dated 12/16/2025, 12/17/2025, and 12/18/2025. No new safe surveys were provided. In-services provided were dated 12/15/2025 and 12/16/2025 and were titled Resident on Resident, Abuse & Neglect; Reporting Guidelines, and ANE Res Rights. No in-services were provided related to the investigation.3. Record review of Resident #3's admission record, dated 01/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit), unspecified injury at C4 level of cervical spinal cord, sequela (an unspecified injury to the spinal cord in the neck region that causes residual symptoms such as pain), and pressure ulcer of sacral region, stage 4 (full-thickness tissue loss that exposes muscle, tendon, or bone to the base of the spine).Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 06 indicating severe cognitive impairment.Record review of Resident #3's undated care plan reflected no care plan associated with the allegation.Record review of the provider investigation report, dated 12/29/2025 and signed by the DON, reflected Resident #3 stated around admission time CNA went into room to provide care and CNA placed pillow over his face. Provider response listed on the investigation report was Abuse monitoring completed, in-services provided to staff and provider action taken post-investigation was in-serviced staff when and who to report abuse and neglect to. Provider investigation report included safe surveys performed on residents dated 12/16/2025, 12/17/2025, and 12/18/2025. No new safe surveys were provided. In-services provided were dated 12/15/2025 and 12/16/2025 and were titled Resident on Resident, Abuse & Neglect; Reporting Guidelines, and ANE Res Rights. No in-services were provided related to the investigation.4. Record review of Resident #4's face sheet, dated 01/05/26 revealed a seventy-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses included dementia (severe cognitive decline (memory, thinking, reasoning) impacting daily life, caused by damaged brain cells), schizophrenia (a severe brain disorder causing hallucinations (like hearing voices), delusions (false beliefs), disorganized thinking, and unusual behaviors), and Parkinson's Disease (a progressive neurological disorder affecting movement).Record review of Resident #4's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a score of 7 indicating severe cognitive impairment.Record review of Resident #4's care plan reflected a focus, undated, inappropriate behaviors: Resident #4 had episodes of inappropriate behaviors and was at risk for further episodes and injuries AEB physical aggression: 12/13/25 Resident #4 was allegedly kicked and punched the other patient who was on the ground after the patient had entered his room. Record review of Resident #4's care plan reflected a focus dated 04/09/25 reflected dementia. Resident #4 was at risk for increased confusion and decline in ADLs as the disease progressed, focus dated 04/09/25 of Resident #4 had a diagnosis of schizophrenia and was at risk for manic (a period of abnormally elevated mood, high energy, and increased activity) episodes.Record review of Resident #4's progress note by LVN A dated 12/13/25 reflected Pt. [Resident #4] was allegedly kicking and punching another patient who was on the ground after the patient had entered Resident #4's room. Resident #4 was upset because the other resident wandered into Resident #4's room.5. Record review of Resident #5's face sheet, dated 01/05/26, revealed a 125 (erroneous date) year old man who was admitted to the facility on [DATE] and readmitted on [DATE]. His admitting diagnoses included altered mental status (a significant change in a person's usual brain function, leading to confusion, disorientation, reduced alertness, or odd behaviors), acute kidney failure (the sudden loss of kidney function, causing waste and fluid to build up in the body, with symptoms like reduced urination, swelling, fatigue, nausea, and confusion), and thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury).Record review of Resident #5's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a score of 0 indicating severe cognitive impairment.Record review of Resident #5's care plan revealed a focus dated 05/20/25 of Resident #5 resided in the secure unit AEB elopement risk, need for reduced stimuli, wandering.During an interview on 01/07/2026 at 1:40 pm, LVN A stated he did not notify the Administrator of the incident on 12/13/25 when Resident #4 allegedly kicked Resident #5. He said he should have told the Administrator. The Administrator was the Abuse and Neglect Coordinator, and allegations of abuse and neglect should be reported to the Administrator. He said he was trained in abuse, neglect, and exploitation and the facility did regular in-services on abuse, neglect and exploitation. He said allegations of abuse and neglect should be reported immediately and it was the responsibility of everyone in the facility to report allegations of abuse and neglect. He said the possible negative effect of not reporting abuse and neglect could be serious injury or maybe death.During an interview on 01/07/2026 at 04:56 PM, the DON stated she began working at the facility on 11/24/25. She stated she had been trained on abuse, neglect, exploitation and the investigation process. She stated she was responsible for performing the investigations when the ADM is not available and was responsible from 12/17/2025-12/24/2025. She stated she did not have much responsibility in the investigation related to Resident #1. She stated the previous administrator was working on the investigation when he was terminated from the facility. The DON stated Resident #1 alleged unknown staff at an unknown time did not perform peri-care appropriately and left feces in her vaginal area. The DON stated throughout the investigation they interviewed Resident #1, filed a report with state agency, and verbally talked about peri-care with nursing staff. She stated no formal in-service was done and had an attendance record. She stated the ADON did random monthly skills checkoffs with staff. The DON stated there were not any safe surveys performed to ensure other residents felt safe. The DON stated a new skin assessment was not completed in the chart during the investigation. She stated she was responsible for the investigation for Resident #2. She stated she did a 1:1 in-service with the nurse related to falls, but she did not do in-services with any other staff related to the allegation. She stated there was not a formal skin assessment performed, but just a narrative note from the nurse that stated no injuries. She stated she is unsure how long Resident #2 was on the floor. The DON stated she did not conduct safe surveys with other residents throughout the investigation. The DON stated she was responsible for the investigation for Resident #3 related to an unknown staff member placing a pillow over his face around the time of his admission to the facility. She stated she interviewed Resident #3, but he was not sure of who it was, only that it was a female agency staff, or when it occurred. The DON stated she had on-going in-services related to abuse and neglect from a previous deficiency that she just continued. She stated she did not start a new in-service or safe surveys. She stated she did not attempt to identify the alleged perpetrator. The DON stated she missed a variety of things throughout her investigation. She stated she felt like she was doing what she was trained for investigations but looking back she missed some things. The DON stated if an allegation did not have a thorough investigation, then something could be missed. She stated the incident on 12/13/25 that was documented in Resident #4's progress notes by LVN A was not reported to the State and was not investigated. The DON stated that it was not reported or investigated because LVN A did not make anyone aware of the incident. It was reported in progress notes, but not to the abuse and neglect coordinator. She said it was the abuse coordinator's responsibility to make sure everything gets reported to the state and everything gets investigated. She said the incident was an allegation of physical abuse and should have been both reported to the state and investigated.During an interview on 01/07/2026 at 7:00 PM, the ADM stated she started at the facility on 12/24/2025. She stated she was not involved in the investigations for Resident #1, Resident #2 or Resident #3. She stated she was responsible for the investigations after her hire date. The ADM stated each self-reported incident should have a new in-service started related to the allegations. She stated she expected each self-reported incident to have new safe surveys for the residents. The ADM stated a skin assessment was expected to be documented under the correct form and not in a narrative format in the nurses' notes. The ADM reviewed the facility self-reported investigations for Resident #1, Resident #2, and Resident #3 and stated the investigations were not thorough investigations. She stated for the investigation related to Resident #1, she would expect to see an in-service related to peri-care, skills observations and checkoffs, and interviews with other residents about peri-care. She was unable to locate any of the expected information in the investigation provided. The ADM stated for the investigation related to Resident #2, she would expect to see a personalized in-service for all staff, a new skin assessment and new safe surveys with other residents. She stated the provided in-service was dated prior to the allegation being made, the safe surveys were undated and appeared to be copies of safe surveys used for previous self-reported investigations, and no skin assessment was performed other than the narrative provided by the nurse. The ADM stated for the investigation related to Resident #3, she would expect to see a psychiatric consult, a new skin assessment, new in-services with abuse/neglect posttests, and new resident safe surveys. She stated the skin assessment was not performed until 2 days after the allegation was made, a new BIMS assessment was not done until 6 days after the allegation and a new brief trauma assessment was not completed until 7 days after the allegation was made. The ADM stated those assessments should have been completed the day the allegation was made. She stated the in-services and safe surveys appeared to be copies from previous self-reported investigations. The ADM stated if a thorough investigation is not completed when an allegation is made, then it puts the residents at risk for abuse and neglect and not getting the proper care they need, possible infection control issues, and quality of life issues.Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy, dated 01/2026, reflected: Policy Statement The Nursing Facility (NF) ensures that all residents are free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and involuntary seclusion, in accordance with Texas law and federal CMS regulationsThe Facility maintains a zero-tolerance policy and will immediately protect residents, initiate investigations, and report all alleged or suspected incidents as required by the Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS).Staff Training RequirementsStaff shall receive:.Retraining following incidents or identified trends.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for two of eight residents (Resident #4 and Resident #5) in thatThe facility failed to report to Health and Human Services alleged abuse that occurred on 12/13/25 when Resident #4 allegedly kicked and punched Resident #5. No injuries reported. This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life.Findings included: Record review of Resident #4's face sheet, dated 01/05/26, revealed a seventy-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses included dementia (severe cognitive decline (memory, thinking, reasoning) impacting daily life, caused by damaged brain cells), schizophrenia (a severe brain disorder causing hallucinations (like hearing voices), delusions (false beliefs), disorganized thinking, and unusual behaviors), and Parkinson's Disease (a progressive neurological disorder affecting movement). Record review of Resident #4's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a BIMS score of 7 indicating severe cognitive impairment. Record review of Resident #4's care plan reflected a focus, undated, inappropriate behaviors: Resident #4 had episodes of inappropriate behaviors and was at risk for further episodes and injuries AEB physical aggression: 12/13/25 Resident #4 allegedly kicked and punched the other resident who was on the ground after the resident had entered his room. Record review of Resident #4's care plan reflected a focus dated 04/09/25 reflected dementia. Resident #4 was at risk for increased confusion and decline in ADLs as the disease progressed, focus dated 04/09/25 of Resident #4 had a diagnosis of schizophrenia and was at risk for manic (a period of abnormally elevated mood, high energy, and increased activity) episodes. Record review of Resident #4's progress note by LVN A dated 12/13/25 reflected Pt. [Resident #4] was allegedly kicking and punching another patient who was on the ground after the patient had entered Resident #4's room. Resident #4 was upset because the other resident wandered into Resident #4's room. Record review of Resident #5's face sheet, dated 01/05/26, revealed a 125 (erroneous date) year old man who was admitted to the facility on [DATE] and readmitted on [DATE]. His admitting diagnoses included altered mental status (a significant change in a person's usual brain function, leading to confusion, disorientation, reduced alertness, or odd behaviors), acute kidney failure (the sudden loss of kidney function, causing waste and fluid to build up in the body, with symptoms like reduced urination, swelling, fatigue, nausea, and confusion), and thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury). Record review of Resident #5's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/07/25 revealed a BIMS score of 0 indicating severe cognitive issues. Record review of Resident #5's care plan revealed a focus dated 05/20/25 of Resident #5 resided in the secure unit AEB elopement risk, need for reduced stimuli, wandering. During in interview on 01/06/26 at 10:08 am with the Interim Administrator she stated agency CNA F was the CNA who witnessed the alleged altercation referred to in Resident #4's progress note dated 12/13/25. During an interview on 01/06/26 at 12:42 pm with LVN A he stated he was called by a CNA, he could not remember her name, to come to the hallway outside of Resident #4's room. Resident #4 was standing over Resident #5 and it looked like Resident #4 kicked Resident #5. LVN A assessed the residents and there were no injuries. LVN A said he made a facility incident report and entered a progress note in Resident #4's PCC (electronic health record) and he did not know what happened after that. LVN A said he had been trained in resident-to-resident altercations. He said it sounded like the incident was a resident-to-resident altercation and a resident-to-resident altercation was considered abuse. He said the resident-to-resident altercation was reportable to State. Attempted interview on 01/06/26 at 3:40 pm with agency CNA F who witnessed the incident between Resident #4 and Resident #5 on 12/13/25. The facility did not have a phone number for agency CNA F. Telephone call was placed to the agency who employed agency CNA F and asked for agency CNA F's telephone number, and agency did not return the call. During an interview on 01/07/26 at 1:40 pm with LVN A he stated he did not notify the Administrator of the incident on 12/13/25 when Resident #4 allegedly kicked Resident #5. He said he should have told the Administrator. The Administrator was the Abuse and Neglect Coordinator, and allegations of abuse and neglect should be reported to the Administrator. He said he was trained in abuse, neglect, and exploitation and the facility did regular in-services on abuse, neglect and exploitation. He said allegations of abuse and neglect should be reported immediately and it was the responsibility of everyone in the facility to report allegations of abuse and neglect. He said the possible negative effect of not reporting abuse and neglect could be serious injury or maybe death. During an interview on 01/07/26 at 2:08 pm with CNA H she stated she had been trained in abuse, neglect, and exploitation and if she saw any abuse, neglect, or exploitation she was responsible for reporting it to the Administrator who was the abuse coordinator. The negative effect of not reporting abuse was that the person who was doing the abuse could continue to do it or the abuse might get worse. During an interview on 01/07/26 at 3:42 pm with the SW she stated that she would have reported the incident on 12/13/25 of Resident #4 allegedly kicking Resident #5 to the State. She said she was trained in abuse and neglect and if she was aware of any abuse or neglect, she would report it immediately. She said she would report it to the Administrator who was the abuse and neglect coordinator. She said it was the responsibility of everyone at the facility to report any abuse or neglect. She said the possible negative effect of not reporting abuse and neglect was the neglect could continue. During an interview on 01/07/26 at 4:57 pm with the DON she stated the incident on 12/13/25 was not reported because the nurse did not make anyone aware of the incident. She said it was documented in Resident #4's PCC progress notes but the nurse did not report it to her or the Administrator. The DON said it should have been reported to the State because it was an allegation of abuse. She said it was the responsibility of the abuse coordinator to make sure all allegations of abuse and neglect were reported to the State. The negative effect of not reporting abuse and neglect was that it could have a negative effect on the residents' care. During in interview on 01/07/26 at 6:43 pm with the Interim Administrator she stated that she was trained in abuse and neglect and when to report abuse and neglect. The interim Administrator said the nurse did not inform leadership of the alleged incident between Resident #4 and Resident #5. She said the nurse should have contacted the abuse and neglect coordinator and reported the incident. She said the nurse did not do what he was supposed to do. She said if she had known about the incident she would have investigated and made sure, they had enough evidence and if they had enough evidence she would have reported it to the State. She said there was no due diligence because the nurse did not do what he was supposed to do. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy, dated 01/2026, reflected: Policy Statement The Nursing Facility (NF) ensures that all residents are free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and involuntary seclusion, in accordance with Texas law and federal CMS regulations. The Facility maintains a zero-tolerance policy and will immediately protect residents, initiate investigations, and report all alleged or suspected incidents as required by the Texas Health and Human Services Commission (HHSC) and Centers for Medicare & Medicaid Services (CMS).

Based on observation, interview and record review, the facility failed to permit each resident to remain in the facility and not discharge the resident when the resident exercises his or her right to appeal a discharge notice for 1 of 6 residents (R#1). 1. The facility failed to discharge R#1 to a safe environment on [DATE]. R#1 had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE]. 2. The facility failed to allow R#1 to remain in the facility when he exercised his right to appeal the discharge notice staff served him on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:17 p.m. While the IJ was removed on [DATE] at 5:30 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of worsening medical conditions, injury, hospitalization or death. Review of R#1's admission record, dated [DATE], revealed he was initially admitted to the facility on [DATE]. He had medical diagnoses that included vertebra osteomyelitis (a serious infection and inflammation of the spinal bones), a stage 4 pressure ulcer in his sacral region (a severe, full-thickness wound extending to muscle, bone, or supporting structures, involving tissue loss with potential for dead tissue, deep tunneling, and serious infection risk), neuromuscular bladder dysfunction (nerve damage disrupts signals between the brain and bladder, causing it to not fill or empty properly), paraplegia (paralysis affecting the lower half of the body, including the legs and sometimes the trunk), protein-calorie malnutrition (a serious nutritional disorder from not getting enough protein and/or energy), left lower limb cellulitis (a common bacterial skin infection affecting the skin and tissue of your left leg), and sepsis (life-threatening medical emergency where the body's extreme response to an infection damages its own tissues). He was discharged on [DATE] at 3:02 p.m. to other. Review of R#1's annual MDS, dated [DATE], revealed he had a 15/15 BIMS score, which indicated he was cognitively intact. He required partial/moderate assistance with upper body dressing and bed mobility, substantial/maximal assistance with toileting and showering and dependent on staff for lower body dressing and transfers. He also had one stage 3 pressure ulcer and one stage 4 pressure ulcer. He also had verbal behaviors that occurred 4-6 days but less than daily that did not impact him and others .Review of R#1's care plan report, initiated on [DATE], revealed he had a stage 3 pressure ulcer on his left heel, stage 4 pressure ulcer to his sacral region, right leg amputation and had a suprapubic catheter. He was also at risk for ADL decline and staff were required to provide extensive assistance for bed mobility and upper/lower body dressing, and total assistance with transfers. He also had episodes of exhibiting verbal/physical aggression towards staff and residents who reside in the facility and had a history of manipulative behavior. Nursing staff (CNA, LVN and RN) were required to provide safety, offer alternative time for care, back away, seek assistance if needed, notify the nurse of behaviors, provide medications as ordered, assess reports of behaviors and notify the MD if interventions are not effective if he becomes combative or aggressive. Staff were also required to be direct and firm when approaching him about behavior, clarify from him what he actually was saying or doing, document behavior in clinical record, inform staff on redirect methods for his behaviors when providing care, monitor for mental status changes, and psych services as needed. Review of R#1's order summary report, dated [DATE], showed he required hospice care every shift, a catheter change every shift if it was dislodged, his foley catheter bag drained empty every shift, pain assessed every shift, and left heel pressure ulcer cleaned every night shift. Review of R#1's discharge planning review initiated by the CNO on [DATE] showed it was incomplete . Review of the OMB's email correspondence showed the OMB emailed the ADM on [DATE] and asked if he could let R#1 give him a call to discuss his discharge and attached a copy of the discharge and provider letter. There was no email response to the OMB's request. Review of R#1's notice of immediate discharge, dated [DATE], showed staff served a formal written notice of his immediate transfer and discharge from the facility on [DATE]. The was no address included that R#1 would discharge to. The reasons for this action reflected, On [DATE], you made a direct and credible threat to shoot the ADM, as reported by staff member. You have stated to staff that you have previously served time in prison and 'would go back,' increasing concern for the seriousness of the threat.You routinely leave the community for extended periods and have access to financial resources, creating a credible risk that you could obtain a weapon and return to the facility. Texas Penal Code - Terroristic Threat (threat of violence causing fear and disrupting a licensed healthcare facility) The right to appeal section reflected, You have the right to appeal this discharge to HHSC. If you wish to appeal, you must contact HHSC immediately upon receipt of this notice. You may request a Fair Hearing by calling the HHSC Appeals Division or sending a written request to HHSC Appeals Division. During the appeal process, you have the right to remain in the facility until a final decision is made, except in cases of immediate jeopardy, which applies in this situation. Review of R#1's criminal trespass notice, dated [DATE], showed the VPO was the owner or had the authority to provide an official notice advising R#1 that his future entry onto the facility property was expressly forbidden and would be subject to arrest for criminal trespassing if he entered or remained on or in the facility property or failed to depart from the facility property. PO signed the notice. Review of the facility's discharge report between [DATE] and [DATE] showed R#1 was discharged to other on [DATE]. Review of the facility's in-service on [DATE] showed the DON taught staff to call the police and notify her, the ADON and ADM in the event R#1 arrived on the facility's premises. Review of the OMB's email correspondence showed the OMB emailed the VPO on [DATE] and informed him that R#1 requested to appeal his discharge and wanted to return to the facility until his discharge appeal hearing is completed. The VPO emailed the OMB on [DATE] and informed him that R#1 could not return to the facility during the appeal process and explained the facility community determined R#1 posed an ongoing threat to the health and safety of residents and staff based on repeated verbal threats of violence made toward the ADM and others. Review of R#1's progress notes between [DATE] and [DATE] reflected there were no notes related to the alleged incidents. Review of R#1's progress note created by the MD on [DATE] at 9:59 a.m. reflected, As we discussed, [facility] is issuing an immediate discharge for [R#1] today at 11a r/t his verbal threat to shoot the administrator. He made this threat known to a facility employee. discussed last week regarding previous threat to the corporate leadership and somehow getting hold of their personal contacts and called with threats. Discussed initially with CNO, then I called the administrator back directly -- advised getting the police to the [facility], escort him out directly to an ER, and the ER need to have the psychiatry team evaluate him for admission due to risk of harming others. [sic] Review of R#1's progress note created by the DM on [DATE] at 1:35 p.m. reflected, Resident has had behavioral issues and refuses care as noted previously by nursing. He will be D/C r/t increased aggressive behavior and threatening staff members. Recommend to continue diet with med pass r/t poor po intakes and increased needs r/t altered skin status. Recommended to continue high protein supplements such as prostate 30 ml BID for wound healing and to meet needs. Resident remains on hospice care. Weight loss may be unavoidable as the condition continues to decline. Resident's comfort takes priority overweight goals. Weight loss and decreased intake anticipated in end of life process; deceased intake increases endorphins and dynorphins which enhances comfort and can provide individuals with euphoric experiences and prevention of discomfort. [sic]Review of R#1's progress note created by the DON on [DATE] at 1:45 p.m. reflected, Resident was served immediate discharge documents from the [VPO]. Resident was served in the presence of two Police Officers and one Police Detective. Resident declined to take the document stating, I don't need a mother fucking thing. The [VPO] offered to pay for a hotel stay for five days for resident and have Hospice continue care. Hospice did speak with resident and explain extended services that will/can be provided while staying at the hotel. Resident received all medications and wound care supplies given in a bag. The list of medications given were: Biktarvy, gabapentin, atorvastatin, hydromorphone, glipizide, metformin, and metoprolol, gauze, collagen with xeroform, calcium alginate, abdominal pads, and kerlix dressing. Resident requested his clothes out of his room and the charge nurse assigned to resident got a clean trash bag and put resident's clothes in a bag and put it where the resident requested. Resident stated he was going to return to the building and no one would stop him. The Police Officers did explain to resident he was also getting served with a no trespassing order and it was explained to resident that failure to comply would result in the resident getting arrested. The Detective offered to take the resident to the hospital and the resident declined. Resident requested to speak with social worker. Social worker provided outside resources for resident to look into for continuity of care.spoke with [VPO] and administrator again. [R#1] no making more active threats. as such it's ok to discharge to self-care BUT still will involve the police this morning to ensure safety measures. [R#1] should not be allowed to return to facility because he made threats to multiple staff/employees/team members of physical violence, and even police had to be involved. This is to ensure the safety ofthe facility and employees. [sic]Review of R#1's POC response history for [DATE] showed staff documented there were no behaviors observed on [DATE], [DATE] and [DATE]. There were also no documented entries on [DATE]. Review of the facility's incident log between [DATE] and [DATE] reflected there were no incidents related to the alleged incidents. An observations of R#1's room on [DATE] at 10:09 a.m. showed R#1's room was locked. The surveyor attempted to knock on R#1's door and introduce themself. There was no response. During an interview with the ADM on [DATE] at 10:11 a.m., the ADM stated R#1 was not at the facility. He stated he believed R#1 was at a friend's home as of [DATE]. He stated he did not have confirmation of R#1 being at a friend's home. He stated he attempted to call R#1 on an unknown date and R#1 did not respond and call him back . He stated R#1 was wheelchair bound and provided his own care. He stated CNA A told him on an unknown date that R#1 told her in his room that he was threatening to shoot the ADM on [DATE]. He stated he and staff did not know if R#1 had any firearms or weapons because R#1 refused an inventory check. He stated RN B and CNA C told him on unknown date that they received threats from R#1 on [DATE]. The ADM did not elaborate on the threats that RN B and CNA C received from R#1 on [DATE]. The ADM stated the HR, VPO, and CNO told him on [DATE] that R#1 made threats to them on [DATE]. He stated R#1 made a threat while on the phone with HR and while on the phone with the VPO and CNO on [DATE]. He did not elaborate on the threats that R#1 made to the HR, VPO, and CNO on [DATE]. He stated he did not know why the HR, VPO, and CNO did not inform him on [DATE] of the threats that R#1 made to them on [DATE]. He stated he was not at the facility on [DATE]. He stated he expected staff to notify him of any alleged threats as soon as possible. He stated the VPO notified the police on [DATE]. He stated the police did not arrive at the facility until [DATE] because the police believed it was not an emergency. He stated R#1 was not on 1:1 and did not have any interventions in place from [DATE] through [DATE] because the OMB told him that it would be ineffective because R#1 often went out on pass. He stated the facility was trying to find another facility to transfer R#1 to on unknown date and he was declined by several other facilities. He stated the police arrived at the facility on [DATE] to ensure the discharge process was properly completed. He stated R#1 received an immediate discharge notice on [DATE]. He stated the OMB was aware of R#1's immediate discharge and received a copy of the immediate discharge notice given to R#1 on [DATE]. He stated the police offered to take R#1 to the hospital and R#1 refused on [DATE]. He stated the IDT team ensured residents had a safe and proper discharge. He stated he knew it was important to ensure residents had a safe and proper discharge and said, So they could continue to get care and services and make sure they were safe. Residents would be at risk of being unsafe if they did not have a safe and proper discharge. He stated he believed R#1 had a safe and proper discharge because the VPO offered him a hotel and he declined and the police offered to take him to the hospital and he declined. During an interview with the DON on [DATE] at 10:37 a.m., the DON stated R#1 required transfer and lower body dressing assistance, took care of his catheter and colostomy bag, demonstrated to her how he changed his colostomy bag, did not receive formal or follow-up training on colostomy care, and could independently shower. The ADM told her on [DATE] that R#1 made threats to RN B on [DATE] and the police were called and arrived at the facility on [DATE]. She stated she could not recall the threats the ADM notified her that R#1 made to RN B on [DATE]. She stated the ADM also told her on [DATE] that the HR was present when R#1 made a threat to harm the ADM by gunshot on [DATE]. She stated the CN was also on duty on [DATE]. She stated RN B had staff check on other residents and R#1 called the police and stepped outside on [DATE]. She stated she did not know when the police arrived at the facility on [DATE]. She stated the OMB was notified on unknown date, but before [DATE], of R#1's alleged threat on [DATE]. She stated the VPO was also notified on [DATE] of R#1's alleged threat on [DATE]. She stated she expected staff to immediately notify her of alleged threats. She stated she was unsure of the process for this similar circumstance, but she believed staff would follow ADM's direction. She stated R#1 was not placed on 1:1 and did not have any other interventions implemented from [DATE] through [DATE] because the OMB told her it would be ineffective because R#1 often went out on pass. She stated R#1 was provided with an immediate discharge notice on [DATE] around 12:00 p.m. She stated R#1 was immediately discharged due to the alleged threat he made on [DATE]. She stated the OMB was notified of the immediate discharge on [DATE]. She stated the VPO offered a hotel room to R#1 and he declined it on [DATE]. She stated R#1 was provided with all his medications before he discharged from the facility and documented it in a progress note. She stated the police provided R#1 with a no trespass order on [DATE]. She stated she did not know where R#1 was currently. She stated she believed the ADM had R#1's contact information and it might be listed in his clinical records. She stated she did not make due diligence to contact R#1 after he was discharged on [DATE]. She stated she did not know if staff attempted to contact R#1 after his discharge on [DATE]. She stated no in-services were initiated after R#1's discharge other than the VPO did an in-service on reporting R#1 to the police if he was observed on the facility property on [DATE]. During an interview with the PO on [DATE] at 11:50 a.m., the PO stated R#1 was served with a no trespass order, R#1 tore it, refused to leave the facility, and would not leave the facility until they told R#1 that he would be arrested if he did not leave the facility. During a telephone interview with R#1 on [DATE] at 12:17 p.m., R#1 stated he was paralyzed from the chest and down his body and required assistance from getting in and out of bed and wound care and foley catheter care. He stated the facility staff and police wanted to speak with him on [DATE] and he stepped outside the facility building. He stated he did not know he was being kicked out of the facility. He explained the VPO, ADM, DON, and police officers informed him that he was being immediately discharged on [DATE] due to an alleged threat that staff reported he made on [DATE]. He stated they explained to him that staff reported he threatened that he was going to shoot the ADM on [DATE]. He stated he did not make any threats to shoot the ADM on [DATE] and the allegation was absurd. He stated the police did not arrive at the facility and did not search him for any weapons from [DATE] through [DATE]. He also stated he did not have any weapons. He stated he was trying to get into his wheelchair so he could go out on pass with a friend and get something to eat because he did not receive any snacks or meals on [DATE]. He stated he pressed his call light and no one came for 2-3 hours. He stated he called the HR and told her on [DATE] that he was tired of the ADM picking on him, bullying him and harassing him. He stated he also called the VPO and spoke with him and the CNO on [DATE] and told them that he was not being cared for, not helped out of bed, and felt bullied and picked on by the ADM. He stated the VPO offered to put him in a hotel on [DATE] and he refused because he could not care for himself and needed care and services. He stated no one would help him get into his wheelchair until CNA A, CNA D, and CNA E saw his call light for assistance and responded 2-3 hours after he pressed his call light to get up. He stated he was upset and told CNA A, CNA D, and CNA E to get him into his wheelchair. He stated CNA A, CNA D, and CNA E were trying to transfer him into his wheelchair in his room on [DATE] around 7:00 p.m.-7:30 p.m. He stated CNA A left his room, returned, and told him, CNA D and CNA E that they could not help him get in his wheelchair because RN B told them not to help him in his wheelchair and that the ADM was on his way to the facility. He stated he did not know why RN B told CNA A, CNA D, and CNA E not to help him into his wheelchair. He stated he put himself in his wheelchair, signed himself out on pass, went outside because he was upset, and returned inside the facility on [DATE]. He stated he observed the ADM at the facility on [DATE]. He stated he complained to SW, DOR, DON, ADON and HR on [DATE] about the lack of care that he received on [DATE] and [DATE]. He stated they helped him file a grievance on [DATE]. He stated the staff on duty on [DATE] told them (SW, DOR, DON, ADON and HR) that they did not check on him and did not care for him because they thought he was out on pass on [DATE]. He stated the staff provided him with his medications and did not provide him with wound care supplies on [DATE]. He stated the police offered EMS transport to the hospital and he declined on [DATE]. He also stated the VPO offered a 5-day hotel stay and he declined on [DATE]. He stated no other alternative placement was offered on [DATE]. He stated the police told him that he would be arrested if he did not leave the facility premises on [DATE]. He stated he had nowhere to go, told his hospice he had nowhere to go, and slept in his truck in 37 degree Fahrenheit weather on [DATE]. He stated he did not receive any wound care, colostomy care, ADL care, meals and his wounds smelled. During an interview with the VPO on [DATE] at 1:34 p.m., the VPO stated R#1 relied on his electric wheelchair and was on Medicaid. He stated R#1 often signed in and out of the facility and would take his medication with him. He stated R#1 was at the facility for a little bit, had received very little care, and had the financial means to purchase a firearm. He stated he was not aware if R#1 was in possession of a firearm. He stated he did not know if there were any grievances filed regarding R#1's care. He stated R#1 called him on [DATE] and told him that he was upset and tired of the ADM bullying him and getting rid of people who he got close to. He stated he looped the CNO into the phone conversation. He stated R#1 said, My mind will run and only violence would resolve the issue. He stated he believed R#1 was referring to the ADM. He stated R#1 told him and the CNO that he would make impulsive decisions that he would regret. He stated the police did not arrive at the facility on [DATE]. He stated he did not know why the police did not arrive at the facility on [DATE]. He stated he started investigating the alleged incident on [DATE]. He stated he interviewed CNA A on [DATE] and [DATE]. He stated CNA A told him that she was getting R#1 up when he told her, Put me up in this wheelchair, I'm going shoot up this nursing facility like I did to the other one, on [DATE]. He stated R#1 called the HR, who heard R#1 was upset and arrived at the facility to speak with him. He stated the HR told him on [DATE] that R#1 said, Clear the hallways and put the residents in the dining room. I'm going to shoot [ADM], on [DATE]. He stated R#1 did not threaten to shoot any residents. He stated R#1 was not placed on 1:1 or had any other interventions implemented from [DATE] through [DATE]. He stated he was unsure if the NP and MD gave any special instruction or if psych or behavior services were offered to R#1. He stated he tried to notify the OMB on [DATE], [DATE], and [DATE] about the immediate discharge request. He stated he spoke with the OMB on [DATE] and notified him of the immediate discharge request. He stated he spoke with the OMB again on [DATE] and the OMB told him that he spoke with unknown HHSC staff member and they cleared R#1 immediate discharge due to the threat R#1 made on [DATE] around 4:45pm-5:00pm. He stated he wanted to discharge R#1 on [DATE]. He stated he notified the police on [DATE] that R#1 threatened to shoot the ADM on [DATE], they did not come out to the facility, did not conduct a search and did not explain why they did not come out to the facility. He stated he did not discharge R#1 on [DATE] because he wanted to have something in plan on [DATE]. He stated the CNO called R#1's hospice on [DATE]. He explained he wanted to make sure hospice could visit R#1. He stated he also wanted to make sure R#1 had a place to discharge to. He stated he also had police present when he served the immediate discharge notice to R#1 on [DATE]. He stated R#1 threw the immediate discharge notice back at them and police intervened. He stated Hospice was also present on [DATE]. He stated R#1's friend also showed up to the facility on [DATE]. He stated the police offered EMS transportation to R#1, but he declined. He stated R#1 was provided with his clothes, medications, and an address for where his personal belongings would be sent to. He stated the OMB came to the facility later on in the afternoon of [DATE]. He stated R#1 did not check into the hotel he offered and R#1 declined on [DATE]. He stated he did not know R#1's whereabouts. He stated he knew it was important to ensure residents had a safe and proper discharge and said, The safety of the discharge and ensuring they have a place to go. Residents could be at risk of lack of care if they did not have a safe and proper discharge. He stated residents could stay at the facility during a pending discharge appeal. During an interview with the CNO on [DATE] at 2:23 p.m., the CNO stated she did not know R#1's care or services or if he exhibited any behaviors. She stated R#1 called the VPO on [DATE]. She stated the VPO included her in the phone conversation with R#1. She stated R#1 expressed he was irritated and tired of staff picking on him. She stated the VPO told her that R#1 was referring to the ADM. She stated R#1 said, I can take care of business, the only way things could get settled is through violence. I do things without thinking and then after it's done I regret it. She stated she offered to put R#1 in hotel on [DATE] and he declined. She stated R#1 wanted to speak with the VPO and the VPO told him that he would speak with R#1 on [DATE]. She stated she was informed by the VPO on [DATE] that the ADM reported R#1 made threats to shoot the ADM on [DATE]. She stated the VPO told her that R#1 told a CNA that he would shoot up the entire facility and to get the residents in the dining room so he could shoot the ADM. She stated she was unsure if R#1 made alleged threats to anyone else. She stated she did not know if R#1 had any weapons in his possession to cause harm. She stated R#1 was not placed on 1:1 because it irritated him and staff were scared of him. She stated R#1 remained at the facility from [DATE] through [DATE]. She stated the VPO called the police on [DATE] and she did not know if the police arrived at the facility. She stated the OMB told the VPO on unknown date that HHSC told him there was grounds to immediately discharge R#1. She stated the MD was notified on unknown date of R#1's immediate discharge and agreed with it. She stated R#1's hospice was also notified on unknown date. She stated the VPO served the immediate discharge notice to R#1 on [DATE]. She stated R#1 was provided with his medications and wound care supplies. She stated the VPO made a hotel reservation for R#1 for five days. She stated she did not know if R#1 accepted or declined the hotel reservation. She stated R#1 left with a friend who was a nurse, but she had no confirmation as to whether or not his friend had a current nurse license. She stated she did not know if R#1's friend was providing care and services to R#1. She stated she did not know R#1's whereabouts. She stated she did not know if R#1 reached out to his hospice. She stated the facility was responsible for residents' safe and proper discharge. She stated she knew it was important to ensure residents had a safe and proper discharge and said, It's important for residents so that their care and services continued. Residents could be at risk of not having their care and services continued if they did not have a safe and proper discharge. During an interview with CNA A on [DATE] at 4:13 p.m., CNA A stated her and CNA D were walking back to the memory care unit, observed R#1's call light and walked into his room to answer it [DATE]. She stated CNA E was already in R#1's room and was arguing back and forth with R#1. She stated that she and CNA D intervened. She stated R#1 was upset and said, I just want y'all motherfuckers to get me up in my chair and out the way. She stated CNA E sarcastically said, Oh don't shoot me. She stated as she and CNA D helped CNA E put R#1 into his wheelchair, R#1 said, Yeah because the previous nursing homes I've been in trouble for shooting them up. She stated she, CNA D and CNA E were not in fear and believed R#1 was upset because he told them that he had been waiting 2-3 hours for staff to answer his call light and put him in his wheelchair because he did not receive any snacks or meals. She stated she stepped out of R#1's room because she was receiving a call and then notified RN B that R#1 did not get any meals or snacks and was upset because he waited for 2-3 hours after pressing his call light for assistance with getting up. She stated RN B questioned why she and CNA D answered R#1's call light. She stated RN B told her that she told the staff not to get R#1 out of his bed, the ADM was on his way to the facility, and to tell CNA D and CNA E to get out of R#1's room and not help him out of bed. She stated she did not understand why she, CNA D and CNA E could not get R#1 out of bed and RN B did not give her a reason. She stated CNA D also questioned how they could not transfer R#1 because he requested to get out of bed. She stated RN B told her to not worry about it and that the ADM was on his way. She stated the ADM arrived and was at the facility on [DATE]. She stated the police came to the facility on [DATE] due to a nonemergency call that was unrelated to the conversation. During an interview with the MD on [DATE] at 5:22 p.m., the MD stated R#1 lied in bed, checked himself out of the facility, was mobile with his wheelchair, required some ADL assistance, received wound care and medications, and was placed on hospice care during his admission for pain management and overall ADL decline. He stated R#1 had behaviors and the staff notified him and the NP and documented the behaviors since his admission. He stated the CNO notified him on [DATE] that R#1 made threats to the VPO. He stated he could not recall what threats R#1 made to the VPO on [DATE]. He stated the CNO also notified him on [DATE] at 9:36 a.m. that R#1 threatened to shoot the ADM on an unknown date. He stated he expected the staff to notify the police and escort R#1 to the ER for psychiatric evaluation. He stated he notified the ADM on [DATE] to notify the police and have EMS escort R#1 to the ER if it was an active, direct, credible threat. He stated R#1 was not persistently making threats during his admission at the facility. He stated R#1 had a safe discharge because he was on hospice services, which was a critical piece of his care, and was informed that R#1 was offered a hotel stay despite denying the offer. He stated residents had the right to refuse care and services. He stated he could not recall who transported R#1 after his discharge. He stated he would be concerned if R#1 was not on hospice services and did not receive wound care and medications after discharge. During a telephone interview with R#1 on [DATE] at 6:32 p.m., R#1 stated a friend picked him up, did not sign any paperwork and did not indicate he was going to take care of him on [DATE]. He stated he also did not sign any paperwork. He stated he told his hospice on [DATE] that he had nowhere to go when he was immediately discharged from the facility. During an interview with the CNO on [DATE] at 6:38 p.m., the CNO stated the OMB, hospice, and police were present when R#1 was discharged from the facility on [DATE]. During an interview and record review with CNA A on [DATE] at 9:17 a.m., CNA A stated the ADM called and told her on unknown date that he would type up her statement from [DATE]. She stated she refused and told the ADM that she could come to the facility and handwrite her own statement. She stated the ADM told her, That's okay, that's okay, I'll take care of it, and ended the call. She confirmed that she did not type the following statement the ADM provided the surveyor and believed it was falsified by the ADM, While assisting [R#1], I was asked to get him in his motherfucking wheelchair, he then directed all staff and residents to clear the way. He then stated that we must not know who he is because he will shoot up the place and he has shot up another nursing home. This caused me to call my father to help us out in case of emergency. She stated she never called her father on [DATE]. During an interview with LVN G on [DATE] at 9:18 a.m., LVN G stated she was familiar with R#1 and worked with him during the night shift. She stated R#1 was always very respectful to her, always thanked her, never mistreated her, and never said anything threatening to her. She stated R#1 did not exhibit any behaviors on [DATE] and [DATE]. She stated R#1 did not make any comments about shooting up the facility, shooting the ADM, and having a firearm. She stated she be[TRUNCATE

Based on interviews and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 residents (R#1). 1. The facility failed to ensure a thorough investigation was completed in regard to the validity of witness statements alleged against R#1 on [DATE]. R#1 was discharged from the facility on [DATE] had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE].2. The facility failed to take immediate action to ensure the safety of all residents when there is a credible threat to the health and safety of residents alleged against R#1 on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:41 p.m. While the IJ was removed on [DATE] at 5:30 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of improper discharge, worsening medical conditions, injury, hospitalization or death. Review of R#1's admission record, dated [DATE], showed he was initially admitted to the facility on [DATE]. He had medical diagnoses that included vertebra osteomyelitis (a serious infection and inflammation of the spinal bones), a stage 4 pressure ulcer in his sacral region (a severe, full-thickness wound extending to muscle, bone, or supporting structures, involving tissue loss with potential for dead tissue, deep tunneling, and serious infection risk), neuromuscular bladder dysfunction (nerve damage disrupts signals between the brain and bladder, causing it to not fill or empty properly), paraplegia (paralysis affecting the lower half of the body, including the legs and sometimes the trunk), protein-calorie malnutrition (a serious nutritional disorder from not getting enough protein and/or energy), left lower limb cellulitis (a common bacterial skin infection affecting the skin and tissue of your left leg), and sepsis (life-threatening medical emergency where the body's extreme response to an infection damages its own tissues). He was discharged on [DATE] at 3:02 p.m. to other.Review of R#1's annual MDS, dated [DATE], showed he had a 15/15 BIMS, which indicated he was cognitively intact. He required partial/moderate assistance with upper body dressing and bed mobility, substantial/maximal assistance with toileting and showering and dependent on staff for lower body dressing and transfers. He also had one stage 3 pressure ulcer and one stage 4 pressure ulcer. He also had verbal behaviors that occurred 4-6 days but less than daily that did not impact him and othersReview of R#1's care plan report, initiated on [DATE], showed he had a stage 3 pressure ulcer on his left heel, stage 4 pressure ulcer to his sacral, right leg amputation and had a suprapubic catheter. He was also at risk for ADL decline and staff were required to provide extensive assistance for bed mobility and upper/lower body dressing, and total assistance with transfers. He also had episodes of exhibiting verbal/physical aggression towards staff and residents who reside in the facility and had a history of manipulative behavior. Nursing staff (CNA, LVN and RN) were required to provide safety, offer alternative time for care, back away, seek assistance if needed, notify the nurse of behaviors, provide medications as ordered, assess reports of behaviors and notify the MD if interventions are not effective if he becomes combative or aggressive. Staff were also required to be direct and firm when approaching him about behavior, clarify from him what he actually was saying or doing, document behavior in clinical record, inform staff on redirect methods for his behaviors when providing care, monitor for mental status changes, and psych services as needed. Review of R#1's order summary report, dated [DATE], showed he required hospice care every shift, a catheter change every shift if it was dislodged, his foley catheter bag drained empty every shift, pain assessed every shift, and left heel pressure ulcer cleaned every night shift. Review of R#1's discharge planning review initiated by the CNO on [DATE] showed it was incomplete. Review of the OMB's email correspondence showed the OMB emailed the ADM on [DATE] and asked if he could let R#1 give him a call to discuss his discharge and attached a copy of the inappropriate discharge and provider letter. There was no email response to the OMB's request. Review of R#1's notice of immediate discharge, dated [DATE], showed staff served a formal written notice of his immediate transfer and discharge from the facility on [DATE]. The was no address included that R#1 would discharge to. The reasons for this action reflected, On [DATE], you made a direct and credible threat to shoot the ADM, as reported by staff member. You have stated to staff that you have previously served time in prison and 'would go back,' increasing concern for the seriousness of the threat.You routinely leave the community for extended periods and have access to financial resources, creating a credible risk that you could obtain a weapon and return to the facility. Texas Penal Code - Terroristic Threat (threat of violence causing fear and disrupting a licensed healthcare facility)These behaviors meet the criteria., which stated that a facility may transfer or discharge a resident when:The transfer or discharge is necessary for the resident's welfare and the facility cannot meet the resident's needs orThe safety of the individuals in the facility is endangered due to clinical or behavioral status of the resident.Efforts made to address the situation:The facility consulted with your attending physician regarding your condition and care needs.Alternative placement options were considered; however, your continued presence creates an immediate threat to the safety and well-being of other residents and staff. The right to appeal section reflected, You have the right to appeal this discharge to HHSC. If you wish to appeal, you must contact HHSC immediately upon receipt of this notice. You may request a Fair Hearing by calling the HHSC Appeals Division or sending a written request to HHSC Appeals Division. During the appeal process, you have the right to remain in the facility until a final decision is made, except in cases of immediate jeopardy, which applies in this situation. Review of R#1's criminal trespass notice, dated [DATE], showed the VPO was the owner or had the authority to provide an official notice advising R#1 that his future entry onto the facility property was expressly forbidden and would be subject to arrest for criminal trespassing if he entered or remained on or in the facility property or failed to depart from the facility property. PO signed the notice. Review of the facility's discharge report between [DATE] and [DATE] showed R#1 was discharged to other on [DATE]. Review of the facility's in-service on [DATE] showed the DON taught staff to call the police and notify her, the ADON and ADM in the event R#1 arrived on the facility premises. Review of the OMB's email correspondence showed the OMB emailed the VPO on [DATE] and informed him that R#1 requested to appeal his discharge and wanted to return to the facility until his discharge appeal hearing is completed. The VPO emailed the OMB on [DATE] and informed him that R#1 could not return to the facility during the appeal process and explained the facility community determined R#1 posed an ongoing threat to the health and safety of residents and staff based on repeated verbal threats of violence made toward the ADM and others. Review of R#1's progress notes between [DATE] and [DATE] reflected there were no notes related to the alleged incidents. Review of R#1's progress note created by the MD on [DATE] at 9:59 a.m. reflected, As we discussed, [facility] is issuing an immediate discharge for [R#1] today at 11a r/t his verbal threat to shoot the administrator. He made this threat known to a facility employee. discussed last week regarding previous threat to the corporate leadership and somehow getting hold of their personal contacts and called with threats. Discussed initially with CNO, then I called the administrator back directly -- advised getting the police to the [facility], escort him out directly to an ER, and the ER need to have the psychiatry team evaluate him for admission due to risk of harming others.Review of R#1's progress note created by the DM on [DATE] at 1:35 p.m. reflected, Resident has had behavioral issues and refuses care as noted previously by nursing. He will be D/C r/t increased aggressive behavior and threatening staff members. Recommend to continue diet with med pass r/t poor po intakes and increased needs r/t altered skin status. Recommended to continue high protein supplements such as prostat 30 ml BID for wound healing and to meet needs. Resident remains on hospice care. Weight loss may be unavoidable as the condition continues to decline. Resident's comfort takes priority overweight goals. Weight loss and decreased intake anticipated in end of life process; deceased intake increases endorphins and dynorphins which enhances comfort and can provide individuals with euphoric experiences and prevention of discomfort. Review of R#1's progress note created by the DON on [DATE] at 1:45 p.m. reflected, Resident was served immediate discharge documents from the [VPO]. Resident was served in the presence of two Police Officers and one Police Detective. Resident declined to take the document stating, I don't need a mother fucking thing. The [VPO] offered to pay for a hotel stay for five days for resident and have Hospice continue care. Hospice did speak with resident and explain extended services that will/can be provided while staying at the hotel. Resident received all medications and wound care supplies given in a bag. The list of medications given were: Biktarvy, gabapentin, atorvastatin, hydromorphone, glipizide, metformin, and metoprolol, gauze, collagen with xeroform, calcium alginate, abdominal pads, and kerlix dressing. Resident requested his clothes out of his room and the charge nurse assigned to resident got a clean trash bag and put resident's clothes in a bag and put it where the resident requested. Resident stated he was going to return to the building and no one would stop him. The Police Officers did explain to resident he was also getting served with a no trespassing order and it was explained to resident that failure to comply would result in the resident getting arrested. The Detective offered to take the resident to the hospital and the resident declined. Resident requested to speak with social worker. Social worker provided outside resources for resident to look into for continuity of care.spoke with [VPO] and administrator again. [R#1] no making more active threats. as such it's ok to discharge to self-care BUT still will involve the police this morning to ensure safety measures. [R#1] should not be allowed to return to facility because he made threats to multiple staff/employees/team members of physical violence, and even police had to be involved. This is to ensure the safety ofthe facility and employees.Review of R#1's POC response history for [DATE] showed there staff documented there were no behaviors observed on [DATE], [DATE] and [DATE]. There were also no documented entries on [DATE]. Review of the facility's incident log between [DATE] and [DATE] reflected there were no incidents related to the alleged incidents.An observation of R#1's room on [DATE] at 10:09 a.m. showed R#1's room was locked. The surveyor attempted to knock on R#1's door and introduce themself. There was no response. During an interview with the ADM on [DATE] at 10:11 a.m., the ADM stated R#1 was not at the facility. He stated he believed R#1 was at a friend's home as of [DATE]. He stated he did not have confirmation of R#1 being at a friend's home. He stated he attempted to call R#1 on an unknown date and R#1 did not respond and call him back. He stated R#1 was wheelchair bound and provided his own care. He stated CNA A told him on an unknown date that R#1 told her in his room that he was threatening to shoot the ADM on [DATE]. He stated he and staff did not know if R#1 had any firearms or weapons because R#1 refused an inventory check. He stated RN B and CNA C told him on unknown date that they received threats from R#1 on [DATE]. The ADM did not elaborate on the threats that RN B and CNA C received from R#1 on [DATE]. The ADM stated the HR, VPO, and CNO told him on [DATE] that R#1 made threats to them on [DATE]. He stated R#1 made a threat while on the phone with HR and while on the phone with the VPO and CNO on [DATE]. He did not elaborate on the threats that R#1 made to the HR, VPO, and CNO on [DATE]. He stated he did not know why the HR, VPO, and CNO did not inform him on [DATE] of the threats that R#1 made to them on [DATE]. He stated he was not at the facility on [DATE]. He stated he expected staff to notify him of any alleged threats as soon as possible. He stated the VPO notified the police on [DATE]. He stated the police did not arrive at the facility until [DATE] because the police believed it was not an emergency. He stated R#1 was not on 1:1 and did not have any interventions in place from [DATE] through [DATE] because the OMB told him that it would be ineffective because R#1 often went out on pass. He stated the facility was trying to find another facility to transfer R#1 to on unknown date and he was declined by several other facilities. He stated the police arrived at the facility on [DATE] to ensure the discharge process was properly completed. He stated R#1 received an immediate discharge notice on [DATE]. He stated the OMB was aware of R#1's immediate discharge and received a copy of the immediate discharge notice given to R#1 on [DATE]. He stated the police offered to take R#1 to the hospital and R#1 refused on [DATE]. He stated the IDT team ensured residents had a safe and proper discharge. He stated he knew it was important to ensure residents had a safe and proper discharge and said, So they could continue to get care and services and make sure they were safe. Residents would be at risk of being unsafe if they did not have a safe and proper discharge. He stated he believed R#1 had a safe and proper discharge because the VPO offered him a hotel and he declined and the police offered to take him to the hospital and he declined. During an interview with the DON on [DATE] at 10:37 a.m., the DON stated R#1 required transfer and lower body dressing assistance, took care of his catheter and colostomy bag, demonstrated to her how he changed his colostomy bag, did not receive formal or follow-up training on colostomy care, and could independently shower. the ADM told her on [DATE] that R#1 made threats to RN B on [DATE] and the police were called and arrived at the facility on [DATE]. She stated she could not recall the threats the ADM notified her that R#1 made to RN B on [DATE]. She stated the ADM also told her on [DATE] that the HR was present when R#1 made a threat to harm the ADM by gunshot on [DATE]. She stated the CN was also on duty on [DATE]. She stated RN B had staff check on other residents and R#1 called the police and stepped outside on [DATE]. She stated she did not know when the police arrived at the facility on [DATE]. She stated the OMB was notified on unknown date, but before [DATE], of R#1's alleged threat on [DATE]. She stated the VPO was also notified on [DATE] of R#1's alleged threat on [DATE]. She stated she expected staff to immediately notify her of alleged threats. She stated she was unsure of the process for this similar circumstance, but she believed staff would follow ADM's direction. She stated R#1 was not placed on 1:1 and did not have any other interventions implemented from [DATE] through [DATE] because the OMB told her it would be ineffective because R#1 often went out on pass. She stated R#1 was provided with an immediate discharge notice on [DATE] around 12:00 p.m. She stated R#1 was immediately discharged due to the alleged threat he made on [DATE]. She stated the OMB was notified of the immediate discharge on [DATE]. She stated the VPO offered a hotel room to R#1 and he declined it on [DATE]. She stated R#1 was provided with all his medications before he discharged from the facility and documented it in a progress note. She stated the police provided R#1 with a no trespass order on [DATE]. She stated she did not know where R#1 was currently. She stated she believed the ADM had R#1's contact information and it might be listed in his clinical records. She stated she did not make due diligence to contact R#1 after he was discharged on [DATE]. She stated she did not know if staff attempted to contact R#1 after his discharge on [DATE]. She stated no in-services were initiated after R#1's discharge other than the VPO did an in-service on reporting R#1 to the police if he was observed on the facility property on [DATE]. During an interview with the PO on [DATE] at 11:50 a.m., the PO stated R#1 was served with a no trespass order, R#1 tore it, refused to leave the facility, and would not leave the facility until they told R#1 that he would be arrested if he did not leave the facility. During a telephone interview with R#1 on [DATE] at 12:17 p.m., R#1 stated he was paralyzed from the chest and down his body and required assistance from getting in and out of bed and wound care and foley catheter care. He stated the facility staff and police wanted to speak with him on [DATE] and he stepped outside the facility building. He stated he did not know he was being kicked out of the facility. He explained the VPO, ADM, DON, and police officers informed him that he was being immediately discharged on [DATE] due to an alleged threat that staff reported he made on [DATE]. He stated he was provided with an immediate discharge notice on [DATE]. He stated his discharge notice did not include the address where he would be discharged to. He stated they explained to him that staff reported he threatened that he was going to shoot the ADM on [DATE]. He stated he did not make any threats to shoot the ADM on [DATE] and the allegation was absurd. He stated the police did not arrive at the facility and did not search him for any weapons from [DATE] through [DATE]. He also stated he did not have any weapons. He stated he was trying to get into his wheelchair so he could go out on pass with a friend and get something to eat because he did not receive any snacks or meals on [DATE]. He stated he pressed his call light and no one came for 2-3 hours. He stated he called the HR and told her on [DATE] that he was tired of the ADM picking on him, bullying him and harassing him. He stated he also called the VPO and spoke with him and the CNO on [DATE] and told them that he was not being cared for, not helped out of bed, and felt bullied and picked on by the ADM. He stated the VPO offered to put him in a hotel on [DATE] and he refused because he could not care for himself and needed care and services. He stated no one would help him get into his wheelchair until CNA A, CNA D, and CNA E saw his call light for assistance and responded 2-3 hours after he pressed his call light to get up. He stated he was upset and told CNA A, CNA D, and CNA E to get him into his wheelchair. He stated CNA A, CNA D, and CNA E were trying to transfer him into his wheelchair in his room on [DATE] around 7:00 p.m.-7:30 p.m. He stated CNA A left his room, returned, and told him, CNA D and CNA E that they could not help him get in his wheelchair because RN B told them not to help him in his wheelchair and that the ADM was on his way to the facility. He stated he did not know why RN B told CNA A, CNA D, and CNA E not to help him into his wheelchair. He stated he put himself in his wheelchair, signed himself out on pass, went outside because he was upset, and returned inside the facility on [DATE]. He stated he observed the ADM at the facility on [DATE]. He stated he complained to SW, DOR, DON, ADON and HR on [DATE] about the lack of care that he received on [DATE] and [DATE]. He stated they helped him file a grievance on [DATE]. He stated the staff on duty on [DATE] told them (SW, DOR, DON, ADON and HR) that they did not check on him and did not care for him because they thought he was out on pass on [DATE]. He stated the staff provided him with his medications and did not provide him with wound care supplies on [DATE]. He stated the police offered EMS transport to the hospital and he declined on [DATE]. He also stated the VPO offered a 5-day hotel stay and he declined on [DATE]. He stated no other alternative placement was offered on [DATE]. He stated the police told him that he would be arrested if he did not leave the facility premises on [DATE]. He stated he had nowhere to go, told his hospice he had nowhere to go, and slept in his truck in 37 degree Fahrenheit weather on [DATE]. He stated he did not receive any wound care, colostomy care, ADL care, meals and his wounds smelled. During an interview with the VPO on [DATE] at 1:34 p.m., the VPO stated R#1 relied on his electric wheelchair and was on Medicaid. He stated R#1 often signed in and out of the facility and would take his medication with him. He stated R#1 was at the facility for a little bit, had received very little care, and had the financial means to purchase a firearm. He stated he was not aware if R#1 was in possession of a firearm. He stated he did not know if there were any grievances filed regarding R#1's care. He stated R#1 called him on [DATE] and told him that he was upset and tired of the ADM bullying him and getting rid of people who he got close to. He stated he looped the CNO into the phone conversation. He stated R#1 said, My mind will run and only violence would resolve the issue. He stated he believed R#1 was referring to the ADM. He stated R#1 told him and the CNO that he would make impulsive decisions that he would regret. He stated the police did not arrive at the facility on [DATE]. He stated he did not know why the police did not arrive at the facility on [DATE]. He stated he started investigating the alleged incident on [DATE]. He stated he interviewed CNA A on [DATE] and [DATE]. He stated CNA A told him that she was getting R#1 up when he told her, Put me up in this wheelchair, I'm going shoot up this nursing facility like I did to the other one, on [DATE]. He stated R#1 called the HR, who heard R#1 was upset and arrived at the facility to speak with him. He stated the HR told him on [DATE] that R#1 said, Clear the hallways and put the residents in the dining room. I'm going to shoot [ADM], on [DATE]. He stated R#1 did not threaten to shoot any residents. He stated R#1 was not placed on 1:1 or had any other interventions implemented from [DATE] through [DATE]. He stated he was unsure if the NP and MD gave any special instruction or if psych or behavior services were offered to R#1. He stated he tried to notify the OMB on [DATE], [DATE], and [DATE] about the immediate discharge request. He stated he spoke with the OMB on [DATE] and notified him of the immediate discharge request. He stated he spoke with the OMB again on [DATE] and the OMB told him that he spoke with unknown HHSC staff member and they cleared R#1 immediate discharge due to the threat R#1 made on [DATE] around 4:45pm-5:00pm. He stated he wanted to discharge R#1 on [DATE]. He stated he notified the police on [DATE] that R#1 threatened to shoot the ADM on [DATE], they did not come out to the facility, did not conduct a search and did not explain why they did not come out to the facility. He stated he did not discharge R#1 on [DATE] because he wanted to have something in plan on [DATE]. He stated the CNO called R#1's hospice on [DATE]. He explained he wanted to make sure hospice could visit R#1. He stated he also wanted to make sure R#1 had a place to discharge to. He stated he also had police present when he served the immediate discharge notice to R#1 on [DATE]. He stated R#1 threw the immediate discharge notice back at them and police intervened. He stated Hospice was also present on [DATE]. He stated R#1's friend also showed up to the facility on [DATE]. He stated the police offered EMS transportation to R#1, but he declined. He stated R#1 was provided with his clothes, medications, and an address for where his personal belongings would be sent to. He stated the OMB came to the facility later on in the afternoon of [DATE]. He stated R#1 did not check into the hotel he offered and R#1 declined on [DATE]. He stated he did not know R#1's whereabouts. He stated he knew it was important to ensure residents had a safe and proper discharge and said, The safety of the discharge and ensuring they have a place to go. Residents could be at risk of lack of care if they did not have a safe and proper discharge. He stated residents could stay at the facility during a pending discharge appeal. During an interview with the CNO on [DATE] at 2:23 p.m., the CNO stated she did not know R#1's care or services or if he exhibited any behaviors. She stated R#1 called the VPO on [DATE]. She stated the VPO included her in the phone conversation with R#1. She stated R#1 expressed he was irritated and tired of staff picking on him. She stated the VPO told her that R#1 was referring to the ADM. She stated R#1 said, I can take care of business, the only way things could get settled is through violence. I do things without thinking and then after it's done, I regret it. She stated she offered to put R#1 in hotel on [DATE] and he declined. She stated R#1 wanted to speak with the VPO and the VPO told him that he would speak with R#1 on [DATE]. She stated she was informed by the VPO on [DATE] that the ADM reported R#1 made threats to shoot the ADM on [DATE]. She stated the VPO told her that R#1 told a CNA that he would shoot up the entire facility and to get the residents in the dining room so he could shoot the ADM. She stated she was unsure if R#1 made alleged threats to anyone else. She stated she did not know if R#1 had any weapons in his possession to cause harm. She stated R#1 was not placed on 1:1 because it irritated him and staff were scared of him. She stated R#1 remained at the facility from [DATE] through [DATE]. She stated the VPO called the police on [DATE] and she did not know if the police arrived at the facility. She stated the OMB told the VPO on unknown date that HHSC told him there was grounds to immediately discharge R#1. She stated the MD was notified on unknown date of R#1's immediate discharge and agreed with it. She stated R#1's hospice was also notified on unknown date. She stated the VPO served the immediate discharge notice to R#1 on [DATE]. She stated R#1 was provided with his medications and wound care supplies. She stated the VPO made a hotel reservation for R#1 for five days. She stated she did not know if R#1 accepted or declined the hotel reservation. She stated R#1 left with a friend who was a nurse, but she had no confirmation as to whether or not his friend had a current nurse license. She stated she did not know if R#1's friend was providing care and services to R#1. She stated she did not know R#1's whereabouts. She stated she did not know if R#1 reached out to his hospice. She stated the facility was responsible for residents' safe and proper discharge. She stated she knew it was important to ensure residents had a safe and proper discharge and said, It's important for residents so that their care and services continued. Residents could be at risk of not having their care and services continued if they did not have a safe and proper discharge. During an interview with CNA A on [DATE] at 4:13 p.m., CNA A stated her and CNA D were walking back to the memory care unit, observed R#1's call light and walked into his room to answer it [DATE]. She stated CNA E was already in R#1's room and were arguing back and forth with R#1. She stated that she and CNA D intervened. She stated R#1 was upset and said, I just want y'all motherfuckers to get me up in my chair and out the way. She stated CNA E sarcastically said, Oh don't shoot me. She stated as her and CNA D helped CNA E put R#1 into his wheelchair, R#1 said, Yeah because the previous nursing homes I've been in trouble for shooting them up. She stated her, CNA D and CNA E were not in fear and believed R#1 was upset because he told them that he had been waiting 2-3 hours for staff to answer his call light and put him in his wheelchair because he did not receive any snacks or meals. She stated she stepped out of R#1's room because she was receiving a call and then notified RN B that R#1 did not get any meals or snacks and was upset because he waited for 2-3 hours after pressing his call light for assistance with getting up. She stated RN B questioned why her and CNA D answered R#1's call light. She stated RN B told her that she told the staff not to get R#1 out of his bed, the ADM was on his way to the facility, and to tell CNA D and CNA E to get out of R#1's room and not help him out of bed. She stated she did not understand why her; CNA D and CNA E could not get R#1 out of bed and RN B did not give her a reason. She stated CNA D also questioned how they could not transfer R#1 because he requested to get out of bed. She stated RN B told her to not worry about it and that the ADM was on his way. She stated the ADM arrived and was at the facility on [DATE]. She stated the police came to the facility on [DATE] due to a nonemergency call that was unrelated to the conversation. During an interview with the MD on [DATE] at 5:22 p.m., the MD stated R#1 lied in bed, checked himself out of the facility, was mobile with his wheelchair, required some ADL assistance, received wound care and medications, and was placed on hospice care during his admission for pain management and overall, ADL decline. He stated R#1 had behaviors and the staff notified him and the NP and documented the behaviors since his admission. He stated the CNO notified him on [DATE] that R#1 made threats to the VPO. He stated he could not recall what threats R#1 made to the VPO on [DATE]. He stated the CNO also notified him on [DATE] at 9:36 a.m. that R#1 threatened to shoot the ADM on an unknown date. He stated he expected the staff to notify the police and escort R#1 to the ER for psychiatric evaluation. He stated he notified the ADM on [DATE] to notify the police and have EMS escort R#1 to the ER if it was an active, direct, credible threat. He stated R#1 was not persistently making threats during his admission at the facility. He stated R#1 had a safe discharge because he was on hospice services, which was a critical piece of his care, and was informed that R#1 was offered a hotel stay despite denying the offer. He stated residents had the right to refuse care and services. He stated he could not recall who transported R#1 after his discharge. He stated he would be concerned if R#1 was not on hospice services and did not receive wound care and medications after discharge. During a telephone interview with R#1 on [DATE] at 6:32 p.m., R#1 stated a friend picked him up, did not sign any paperwork and did not indicate he was going to take care of him on [DATE]. He stated he also did not sign any paperwork. He stated he told his hospice on [DATE] that he had nowhere to go when he was immediately discharged from the facility. During an interview with the CNO on [DATE] at 6:38 p.m., the CNO stated the OMB, hospice, and police were present when R#1 was discharged from the facility on [DATE]. During an interview and record review with CNA A on [DATE] at 9:17 a.m., CNA A stated the ADM called and told her on unknown date that he would type up her statement from [DATE]. She stated she refused and told the ADM that she could come to the facility and handwrite her own statement. She stated the ADM told her, That's okay, that's okay, I'll take care of it, and ended the call.

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property of resident property, establish policies and procedures to investigate any such allegations, and ensure reporting of crimes for 2 of 6 residents (R#1 and R#2).1. The facility failed to ensure R#1 was safe after alleging the ADM harassed, bullied, and picked on him on 12/06/25.2. The facility failed to ensure R#2 was safe after alleging R#1 threatened to choke her with his genitals on 12/06/25.3. The facility failed to ensure an AP was removed upon being notified of abuse and neglect allegations on 12/06/25. 4. The facility failed to report and investigate R#1's and R#2's allegations on 12/06/25. An IJ was identified on 12/15/25. The IJ template was provided to the facility on [DATE] at 5:41 p.m. While the IJ was removed on 12/17/25 at 5:30 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of further abuse, neglect, harm, injury, or death. R#1Review of R#1's admission record, dated 12/10/25, showed he was initially admitted to the facility on [DATE]. He had medical diagnoses that included vertebra osteomyelitis (a serious infection and inflammation of the spinal bones), a stage 4 pressure ulcer in his sacral region (a severe, full-thickness wound extending to muscle, bone, or supporting structures, involving tissue loss with potential for dead tissue, deep tunneling, and serious infection risk), neuromuscular bladder dysfunction (nerve damage disrupts signals between the brain and bladder, causing it to not fill or empty properly), paraplegia (paralysis affecting the lower half of the body, including the legs and sometimes the trunk), protein-calorie malnutrition (a serious nutritional disorder from not getting enough protein and/or energy), left lower limb cellulitis (a common bacterial skin infection affecting the skin and tissue of your left leg), and sepsis (life-threatening medical emergency where the body's extreme response to an infection damages its own tissues). He was discharged on 12/10/25 at 3:02 p.m. to other. Review of R#1's annual MDS, dated [DATE], showed he had a 15/15 BIMS, which indicated he was cognitively intact. He required partial/moderate assistance with upper body dressing and bed mobility, substantial/maximal assistance with toileting and showering and dependent on staff for lower body dressing and transfers. He also had one stage 3 pressure ulcer and one stage 4 pressure ulcer. He also had verbal behaviors that occurred 4-6 days but less than daily that did not impact him and others. Review of R#1's care plan report, initiated on 09/25/25, showed he had a stage 3 pressure ulcer on his left heel, stage 4 pressure ulcer to his sacral, right leg amputation and had a suprapubic catheter. He was also at risk for ADL decline and staff were required to provide extensive assistance for bed mobility and upper/lower body dressing, and total assistance with transfers. He also had episodes of exhibiting verbal/physical aggression towards staff and residents who reside in the facility and had a history of manipulative behavior. Nursing staff (CNA, LVN and RN) were required to provide safety, offer alternative time for care, back away, seek assistance if needed, notify the nurse of behaviors, provide medications as ordered, assess reports of behaviors and notify the MD if interventions are not effective if he becomes combative or aggressive. Staff were also required to be direct and firm when approaching him about behavior, clarify from him what he actually was saying or doing, document behavior in clinical record, inform staff on redirect methods for his behaviors when providing care, monitor for mental status changes, and psych services as needed. There were no notes related to R#1 and R#2's allegations. Review of R#1's progress notes between 12/06/25 and 12/09/25 reflected there were no notes related to R#1's and R#2's allegations. Review of R#1's POC response history for December 2025 showed staff documented there were no behaviors observed on 12/06/25, 12/07/25 and 12/09/25. There were also no documented entries on 12/08/25. Review of R#1's assessments from 12/06/25 through 12/10/25 reflected there were none related to R#1's and R#2's allegations. R#2Review of R#2's admission record, dated 12/12/25, showed she was admitted to the facility on [DATE]. She had medical diagnoses including cerebral palsy (a permanent group of neurological disorders affecting movement, posture, and coordination), bipolar disorder, schizophrenia, and generalized muscle weakness. Review of R#2's comprehensive MDS, dated [DATE], showed she had a 15/15 BIMS, which indicated she was cognitively intact. She also took antipsychotic, antianxiety, and antidepressant high risk medications. She required substantial/maximal assistance with dressing, toileting, bed mobility and dressing and was dependent on staff assistance for personal hygiene and transfers. Review of R#2's care plan report, initiated 09/19/25, showed she had manipulative behaviors and exhibited impulsive behaviors and was at risk of further episodes. Staff (CNA, LVN, RN and SW) were required to discuss behaviors with R#2, discuss what more reasonable behaviors would be, distract her with activities, notify MD/NP of behaviors, identify causes of impulsive behaviors, medications as ordered, monitor labs and report abnormalities to MD, psych services as needed, and routine medication as ordered. Review of R#2's progress notes reflected:A behavior note created by LPN H on 12/06/25 at 11:05 p.m., Resident also called non emergent police this evening regarding concerns. Policeman arrived and somewhat deescalated situation. Administrator aware. Will continue to monitor.Review of R#2's progress notes between 12/06/25 and 12/09/25 reflected there were no other notes related to R#2's allegations.Review of R#2's POC response history for December 2025 showed staff documented there were no behaviors observed on 12/06/25 and 12/09/25. Staff documented she cursed at others, expressed frustration/anger at others, screamed at others, and threatened others on 12/07/25. There were also no documented entries on 12/08/25.Review of R#2's assessments from 12/06/25 through 12/10/25 reflected there were none related to R#2's allegations.Review of the facility's incident log between 12/01/25 and 12/11/25 reflected there were no incidents related to R#1's and R#2's allegations.An observation of R#1's room on 12/11/25 at 10:09 a.m. showed R#1's room was locked. The surveyor attempted to knock on R#1's door and introduce themself. There was no response. During an interview with the ADM on 12/11/25 at 10:11 a.m., the ADM stated R#1 was not at the facility. He stated R#1 was wheelchair bound and provided his own care. He stated he was not at the facility on 12/06/25. He stated he expected staff to notify him of any alleged threats as soon as possible. He stated R#1 was not on 1:1 behavior monitoring and did not have any interventions in place from 12/06/25 through 12/10/25 because the OMB told him that it would be ineffective because R#1 often went out on pass. During an interview with the DON on 12/11/25 at 10:37 a.m., the DON stated R#1 required transfer and lower body dressing assistance, took care of his catheter and colostomy bag, demonstrated to her how he changed his colostomy bag, did not receive formal or follow-up training on colostomy care, and could independently shower. She stated she expected staff to immediately notify her of alleged threats. She stated she was unsure of the process for this similar circumstance, but she believed staff would follow ADM's direction if there were any alleged threats reported. She stated R#1 was not placed on 1:1 behavior monitoring and did not have any other interventions implemented from 12/06/25 through 12/10/25 because the OMB told her it would be ineffective because R#1 often went out on pass. During a telephone interview with R#1 on 12/11/25 at 12:17 p.m., R#1 stated he was paralyzed from the chest and down his body and required assistance from getting in and out of bed and wound care and foley catheter care. He stated he was trying to get into his wheelchair so he could go out on pass with a friend and get something to eat because he did not receive any snacks or meals on 12/06/25 . He stated he pressed his call light and no one came for 2-3 hours. He stated he called the HR and told her on 12/06/25 that he was tired of the ADM picking on him, bullying him and harassing him . He stated he also called the VPO and spoke with him and the CNO on 12/06/25 and told them that he was not being cared for, not helped out of bed, and felt bullied and picked on by the ADM. He stated the VPO offered to put him in a hotel on 12/06/25 and he refused because he could not care for himself and needed care and services. He stated no one would help him get into his wheelchair until CNA A, CNA D, and CNA E saw his call light for assistance and responded 2-3 hours after he pressed his call light to get up. He stated he was upset and told CNA A, CNA D, and CNA E to get him into his wheelchair. He stated CNA A, CNA D, and CNA E were trying to transfer him into his wheelchair in his room on 12/06/25 around 7:00 p.m.-7:30 p.m. He stated CNA A left his room, returned, and told him, CNA D and CNA E that they could not help him get in his wheelchair because RN B told them not to help him in his wheelchair and that the ADM was on his way to the facility. He stated he did not know why RN B told CNA A, CNA D, and CNA E not to help him into his wheelchair. He stated he put himself in his wheelchair, signed himself out on pass, went outside because he was upset, and returned inside the facility on 12/06/25. He stated he observed the ADM at the facility on 12/06/25. He stated he complained to SW, DOR, DON, ADON and HR on 12/08/25 about the lack of care that he received on 12/06/25 and 12/07/25. He stated they helped him file a grievance on 12/08/25. He stated the staff on duty on 12/06/25 told them (SW, DOR, DON, ADON and HR) that they did not check on him and did not care for him because they thought he was out on pass on 12/06/25. During an interview with the VPO on 12/11/25 at 1:34 p.m., the VPO stated he did not know if there were any grievances filed regarding R#1's care. He stated R#1 called him on 12/06/25 and told him that he was upset and tired of the ADM bullying him and getting rid of people who he got close to. He stated he looped the CNO into the phone conversation. He stated R#1 was not placed on 1:1 or had any other interventions implemented from 12/06/25 through 12/10/25. He stated he was unsure if the NP and MD gave any special instruction or if psych or behavior services were offered to R#1. During an interview with the CNO on 12/11/25 at 2:23 p.m., the CNO stated she did not know R#1's care or services or if he exhibited any behaviors. She stated R#1 called the VPO on 12/06/25. She stated the VPO included her in the phone conversation with R#1. She stated R#1 expressed he was irritated and tired of staff picking on him. She stated the VPO told her that R#1 was referring to the ADM. She stated R#1 wanted to speak with the VPO and the VPO told him that he would speak with R#1 on 12/09/25. She stated R#1 was not placed on 1:1 because it irritated him and staff were scared of him. She stated R#1 remained at the facility from 12/06/25 through 12/10/25. During an interview with CNA A on 12/11/25 at 4:13 p.m., CNA A stated her and CNA D were walking back to the memory care unit, observed R#1's call light and walked into his room to answer it on 12/06/25. She stated CNA E was already in R#1's room and were arguing back and forth with R#1. She stated that she and CNA D intervened. She stated her and CNA D believed R#1 was upset because he told them that he had been waiting 2-3 hours for staff to answer his call light and put him in his wheelchair because he did not receive any snacks or meals. She stated she stepped out of R#1's room because she was receiving a call and then notified RN B that R#1 did not get any meals or snacks and was upset because he waited for 2-3 hours after pressing his call light for assistance with getting up. She stated RN B questioned why her and CNA D answered R#1's call light. She stated RN B told her that she told the staff not to get R#1 out of his bed, the ADM was on his way to the facility, and to tell CNA D and CNA E to get out of R#1's room and not help him out of bed. She stated she did not understand why her; CNA D and CNA E could not get R#1 out of bed and RN B did not give her a reason. She stated CNA D also questioned how they could not transfer R#1 because he requested to get out of bed. She stated RN B told her to not worry about it and that the ADM was on his way. She stated the ADM arrived and was at the facility on 12/06/25. She stated the police came to the facility the evening of 12/06/25 due to R#2 calling the nonemergency line and said, This nigger was going to choke me with his dick (genitals). She stated the police came to the facility and spoke with R#1 and R#2. She stated R#1 was not taken out of the facility. She stated the police officer told R#1 and R#2 to go to their rooms and stay away from each other. She stated she did not have to perform any 1:1 with R#1 on 12/06/25. She stated she did not work at the facility after 12/06/25. During an interview with the MD on 12/11/25 at 5:22 p.m., the MD stated R#1 lied in bed, checked himself out of the facility, was mobile with his wheelchair, required some ADL assistance, received wound care and medications, and was placed on hospice care during his admission for pain management and overall ADL decline. He stated R#1 had behaviors and the staff notified him and the NP and documented the behaviors since his admission. During an interview with R#2 on 12/11/25 at 6:15 p.m., R#2 stated she called the police nonemergency phone line to report that R#1 said he would choke her with his big, black dick (genitals). She stated the police arrived, told her to go back to her room, and was no help at all. She stated R#1 was not asked to go back to his room and she observed the ADM speak with him after the police left on 12/06/25. She stated staff did not do anything to ensure no further incidents occurred between her and R#1. She stated she was in fear of another incident occurring with R#1 after 12/06/25. She stated staff did not offer a room move and no interventions were put in place to ensure her and R#1 stayed away from each other. She stated her and R#1 continued to reside on the same hallway.During a telephone interview with R#1 on 12/11/25 at 6:32 p.m., R#1 stated R#2 called the police and alleged that he told her that he would choke her with his big, black dick. He stated he spoke with the police, had a video recording of the interaction, and was told to go back to his room and stay away from R#2. He stated he did not speak with the ADM after the police left on 12/06/25. He stated staff did not do anything to ensure no further incidents occurred between him and R#2. He stated staff did not offer a room move and no interventions were put in place to ensure him and R#2 stayed away from each other. He stated him and R#2 continued to reside on the same hallway.During an interview with LVN G on 12/12/25 at 9:18 a.m., LVN G stated she was familiar with R#1 and worked with him during the night shift. She stated R#1 had a stage 4 wound on is back, was paralyzed from the chest down, had a motorized wheelchair, required two-person transfer assistance, and one of his legs was amputated. She stated R#1 was always very respectful to her, always thanked her, never mistreated her, and never said anything threatening to her. She stated R#1 did not exhibit any behaviors on 12/08/25 and 12/09/25. She stated she did not have to conduct 1:1 with R#1. LVN G stated R#2 often yelled and said derogatory remarks. During an interview with the PO on 12/12/25 at 11:17 a.m., the PO stated he did not believe the police were called on 12/06/25. During an interview with the HR on 12/12/25 at 4:02 p.m., the HR stated R#1 called her at home on [DATE] and expressed he was very upset and said, I'm tired of this nigga picking on me, harassing me, and bullying me. He's not allowing the CNAs to get me up. She stated she tried to calm R#1 down and said she would come to the facility and get the CNAs to help him up. She stated she observed the CN was in the room when she arrived at the facility and entered R#1's room. She stated R#1 was wheelchair bound, had a colostomy bag, urine bag and an amputated leg and could only do movement with his hands. She stated she did not call the police on 12/06/25. She stated she notified the ADM at the facility on 12/06/25 and told him to stay out of R#1's way because he was upset with him because he was tired of being bullied and harassed by the ADM. She stated the ADM did not call the police on 12/06/25. She stated she did not know why the police was not called on 12/06/25. She stated R#1 also called the VPO. During an interview with LPN H on 12/12/25 at 5:28 p.m., LPN H stated R#1 was an amputee, had one leg missing, would not get up on his own, could not walk and almost needed total care. She stated R#1 did not make any threats to her or anyone when she worked with him on 12/06/25 and 12/07/25. She stated R#1 had an aggressive personality and attitudes and could at time be verbally abusive, but she believed he could not carry out any threat. During an interview with CNA I on 12/12/25 at 5:53 p.m., CNA I stated R#1 was paralyzed, had a colostomy bag, required assistance with getting into his wheelchair, and never made a threat to shoot or cause bodily harm to anyone at the facility on 12/08/25 and 12/09/25. She stated R#1 made no threats to her and CNA J on 12/08/25. She stated she did not have to conduct 1:1 monitoring for R#1 on 12/08/25 and 12/09/25. During an interview with the DM on 12/13/25 at 9:57 a.m., the DM stated R#1 expressed to her that he felt staff were being petty, did not tell her who the staff were, and he told her that he cannot tell her who because she would confront them on 12/06/25. She stated she would immediately notify the ADM, ADM, and VPO of any allegations of ANE. She stated R#1's statement to her would be a resident abuse allegation. She stated the ADM was responsible for investigating and reporting allegations of ANE. She stated grievances were reviewed daily and ADM notified staff when he would report allegations to HHSC. She stated it was important to report and investigate ANE and said, It was important because resident alleging abuse and need to finish investigation. Resident could be at risk of retaliation if ANE allegations not reported and investigated.During an interview with R#1 on 12/13/25 at 10:14 a.m., R#1 stated the facility did not investigate his allegation of the ADM bullying him. He stated he was not offered psych services, behavior services, 1:1, or move to another room. He stated after he expressed the ADM was bullying him to the staff, from 12/06/25 through 12/10/25, he felt scared for his life. During an interview with the SW on 12/13/25 at 10:23 a.m., the SW stated R#1 told her that he felt the ADM was picking on him on 12/09/25 or 12/10/25. She stated she filed a grievance on 12/09/25 or 12/10/25. She stated there was no one who reviewed and followed up on the grievance while she was out on 12/11/25 and 12/12/25. She stated R#1 did not express any threats to her or anyone at the facility. She stated R#2 and R#1 went back and forth often. She stated she would speak with R#1 and R#2 whenever they argued. She stated R#2 expressed to her that she wanted to transfer to another facility about one week ago. She stated she was working on getting R#2 transferred to another facility. She stated it was resident abuse if a resident expressed a staff member was bullying or picking on them. She stated she would file a grievance for a resident if ANE was alleged. She stated she would review the grievance and assign it. She stated the ADM was the abuse and neglect coordinator and investigated ANE. She stated any staff member could report ANE to the SSA. She stated she was unsure when to report ANE to HHSC. She stated she was not educated on ANE reporting and investigation. During an interview with the ADON on 12/13/25 at 11:23 a.m., the ADON stated R#1 was not able to provide his own wound care. She stated she did not believe R#1 could harm anyone because of his paralysis, weakness, and amputee. She stated she did not receive any threats from residents and staff. She stated there were no reports of threats made by R#1 towards staff. She stated she did not receive any allegations of abuse. She stated she could not recall a resident informing her that they felt they were being bullied or picked on by a staff member. She stated R#1 never expressed that he was being bullied, threatened, or picked on to her. She stated she expected the staff to take the grievance; we reviewed the grievance and give it to the abuse coordinator. She stated ADM was the abuse and neglect coordinator. She stated she knew to immediately notify the ADM. She stated the ADM reports and all staff as a team investigates ANE. She stated resident to resident incidents are still reported and investigated by the ADM and staff intervened and ensured residents were separated and away from each other. She stated she did not know who oversaw and ensured ADM reported and investigated ANE. She stated she knew it was important to report and investigate ANE and said, Because you want to make sure the residents are safe and everyone have the right to report and feel comfortable in their room and to ensure their safety and comfort. Residents could be at risk of feeling unsafe, unheard, needs not being met, and was being followed up on. During an interview and record review with the CN on 12/13/25 at 12:00 p.m., the CN stated R#1 was unable to harm anyone because of his health condition. He stated RN B and the ADM told him to get R#1's medications because he was leaving on 12/06/25. He stated he went into R#1's room to give him pain medication on an unknown date that he believed was 12/06/25 or 12/07/25. He stated R#1 was upset on 12/06/25. He stated R#1 did not make any remarks or threats of wanting to shoot or harm anyone. He stated R#1 did not tell him that the ADM was bullying him. He stated R#1 went outside and then came back inside the facility on 12/06/25. He stated he was expected to immediately notify the ADM, who was the abuse and neglect coordinator. He stated the ADM reported and investigated abuse and neglect. He stated he knew it was important to report and investigate ANE and said, You don't want to accuse someone falsely of anything. You want to make sure your ducks are in a row before HHSC comes out to the facility. Resident could be at risk of harm. During an interview with the DON on 12/13/25 at 12:56 p.m., the DON stated no residents expressed they were being picked on by staff. She stated R#1 did not express being bullied or picked on by the ADM. She stated R#1 told her on 12/08/25 that he asked staff to get him up and staff took a long time to get him up on 12/06/25. She stated R#1 did not file a grievance on 12/08/25. She stated could not recall if she had to provide any counseling to staff after the alleged incident. She stated R#1's care plan was not updated for any new interventions. She stated ADM was the abuse and neglect coordinator. She stated ADM investigated and reported ANE. She stated she expected staff to notify immediately the ADM of any allegations of ANE. She stated she knew it was important to report and investigate ANE and said, To make sure the resident doesn't get harmed. Resident could be at risk of potential harm.During an interview with CNA A on 12/13/25 at 1:23 p.m., CNA A stated R#1 expressed on 12/06/25 that he was tired of the ADM messing with him and he wanted the ADM to leave him alone. She stated she informed the charge nurse and the abuse and neglect coordinator, which is the ADM, immediately of any ANE allegations. She stated the DON and ADM investigate and report ANE. She stated it was important to report and investigate ANE allegations and said, Because it's our job and to make sure the residents are good. Residents could continue to get bullied, abused, or neglected and have a bad turnout and bad situation if not reported. During an interview with the ADM on 12/13/25 at 1:40 p.m., the ADM stated he could not recall if the HR notified him of anything related to R#1 feeling he was bullying, harassing and picking on him. He stated this was the first time he was hearing that R#1 felt he was bullying, harassing and picking on him. He stated he had not investigated the alleged incident. He stated R#2 called the police to report R#1 allegedly said he would choke her with his penis (genitals) and said, I guess it was something that we should've reported. He stated the police notified him on 12/06/25. He stated R#2 told him on 12/08/25 that she was frustrated and refused to talk. He stated R#1 told him on 12/8/25 that the incident did not occur. He stated staff monitored R#1 within eyesight and staff documented in electronic health records every 15 minutes until his discharge on [DATE]. He stated there were no subsequent incidents. He stated he was trying to discharge R#1 as an intervention. He stated he was the abuse and neglect coordinator. He stated he would investigate the alleged incident of suspicions or allegations of ANE. He stated he would expect staff to immediately report ANE to him, separate resident from AP, suspend alleged staff member, and ensure safety. He stated the CNO and VPO oversee to ensure he reported and investigated incident at least twice a week. He stated it was important to report and investigate ANE allegations and said, Because we are dealing with a vulnerable population and it was required to report and investigate by the state and federal government. Resident could be at risk of any form of ANE.During an interview with HR on 12/13/25 at 2:04 p.m., HR stated the ADM was the abuse and neglect coordinator and reported and investigated ANE allegations. She stated it was important to report and investigate ANE allegations and said, It's very important, because we should not let abuse happen and to protect the resident. Resident could be at risk of feeling like nothing is being done in the facility and something could continue to happen if not reported and investigated.During an interview with LPN H on 12/13/25 at 2:34 p.m., LPN H stated the nurse report to the ADM and the ADM handles ANE allegations. She stated it was important to report and investigate ANE allegations and said, To ensure resident was viable or not and to ensure if anything happened or had potential to happen. Resident could be at risk of ANE from the staff member.During staff interviews from 12/14/25 at 12:28 p.m. through 12/14/25 at 1:05 p.m., MA K, CNA L, CNA M, CNA N, CNA O and CNA P stated R#1 never made any threats to harm or hurt anyone from 12/06/25 through 12/10/25 and was not an endangerment to the facility because he was in a wheelchair and a paraplegic. They also stated they knew to report ANE allegations to the ADM, who was the abuse and neglect coordinator. They also stated the ADM reported to SSA and investigated ANE allegations. They knew the importance of reporting and investigating ANE allegations to ensure residents were safe and to prevent further ANE.During an interview with the DOR on 12/14/25 at 1:29 p.m., the DOR stated R#1 was a paraplegic and wheelchair bound, could not get up from his wheelchair, had full range of motion of his arms, was kind to residents, and was not an endangerment to the facility. She stated she received abuse and neglect allegations or suspicions and notified the ADM and filed grievances to the SW. She stated the ADM reported and investigated abuse and neglect. She stated it was important to report and investigate ANE and said, Because it is wrong and no resident should be subjected of any form of harm. Resident could be further harmed, could be seriously injured, and could lead to death and serious consequences. She stated no residents expressed being bullied or picked on. She stated R#1 was direct. She stated she did not engage with R#1 a lot. She stated R#1 was kind to residents. She stated R#1 was not an endangerment to the facility. She stated HR, SW, and her were present in the room, R#1 was requesting to get up, she requested a CNA J get him up, CNA J did not do it, and he filed a grievance that he felt he was being ignored sometime last week. During an interview with RN B on 12/15/25 at 2:26 p.m., RN B stated she was working from 12/06/25 through 12/08/25 and was on duty with the CN and 2-3 other CNAs. She stated the CNAs did not inform her of any alleged statements or threats made by R#1 on 12/06/25. She stated R#1 did not make any alleged statements or threats towards her on 12/06/25. She stated the ADM was at the facility on 12/06/25. She stated she was instructed by the ADM to inform the CNAs to not get R#1 up and did not know why.During an interview with the VPO on 12/15/25 at 2:59 p.m., the VPO stated he did not report R#1's allegation of the ADM harassing, bullying and picking on him to the SSA because he spoke with R#1 on 12/06/25. He explained it was a broad statement made by R#1 and it was not regarding bullying, intimidating and being picking on by the ADM. He stated he did not file a grievance because he talked about it with R#1. He stated he was not informed by the ADM and other staff about ADM bullying and picking on him. He stated he would have a conversation with the ADM and speak with the resident, place the ADM on suspension, conduct safe surveys, and interview staff. He stated he expected the ADM to report to the SSA and investigate any allegations of abuse and neglect. He stated he was responsible for stepping in and investigating and reporting the ANE allegations related to the ADM. He stated he knew it was important to report and investigate ANE and said, Resident safety. Resident could be at risk for harm. During an interview with the CNO on 12/15/25 at 3:08 p.m., the CNO stated she expected staff to report ANE allegations immediately, suspend the alleged employee pending outcome, report to the SSA, collect all information, and said, Always report first and then investigate any allegation. She stated the ADM, who was the abuse and neglect coordinator, was responsible for reporting and investigating ANE allegations. She stated the DON oversaw and ensured if an ANE allegation was made against the ADM. She stated R#1 told her and the VPO that he was tired of the ADM picking on him and watching him all the time on 12/06/25. She stated any resident who alleged someone was picking on them could be self-reported to the SSA. She stated she knew it was important to report and investigate ANE and said, To ensure the safety and protect the residents and to ensure residents are protected from abuse and neglect. Residents could be at risk of continued abuse and neglect. During an interview with CNA D on 12/15/25 at 6:31 p.m., CNA D stated she was working with CNA A on 12/06/25. She stated her and CNA A walked towards the secure memory care unit, saw R#1's call light, and CNA E waved them down. She stated while her, CNA A, and CNA E were in R#1's room, R#1 said, When y'all get me up, y'all stay out the way. She stated CNA A's cellphone rang and she exited the room. She stated CNA A returned to the room and said, Oh someone was on the floor, someone come help me. She stated that she and CNA E exited the room. She stated RN B told her, CNA A and CNA E not to get R#1 up until the ADM came to the facility. She stated she questioned RN B why they could not get R#1 out of bed and RN B stated not to worry about it. She stated R#2 told her that R#1 kept calling her a bitch every time she passed by him. She stated police came out in response to R#2 alleging R#1 was going to choke her with his dick (genitals). She stated police left the facility and did not take anyone to jail on 12/0

Based on observation, interview and record review, the facility failed to provide notice as soon as practicable before discharge and include the location to which the resident is discharged for 1 of 6 residents (R#1). 1. The facility failed to notify R#1 of his discharge before [DATE].2. The facility failed to include the address where R#1 would be discharged to on the discharge notice he was served on [DATE]. R#1 had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:41 p.m. While the IJ was removed on [DATE] at 5:30 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of worsening medical conditions, injury, hospitalization or death. Review of R#1's admission record, dated [DATE], showed he was initially admitted to the facility on [DATE]. He had medical diagnoses that included vertebra osteomyelitis (a serious infection and inflammation of the spinal bones), a stage 4 pressure ulcer in his sacral region (a severe, full-thickness wound extending to muscle, bone, or supporting structures, involving tissue loss with potential for dead tissue, deep tunneling, and serious infection risk), neuromuscular bladder dysfunction (nerve damage disrupts signals between the brain and bladder, causing it to not fill or empty properly), paraplegia (paralysis affecting the lower half of the body, including the legs and sometimes the trunk), protein-calorie malnutrition (a serious nutritional disorder from not getting enough protein and/or energy), left lower limb cellulitis (a common bacterial skin infection affecting the skin and tissue of your left leg), and sepsis (life-threatening medical emergency where the body's extreme response to an infection damages its own tissues). He was discharged on [DATE] at 3:02 p.m. to other.Review of R#1's annual MDS, dated [DATE], showed he had a 15/15 BIMS, which indicated he was cognitively intact. He required partial/moderate assistance with upper body dressing and bed mobility, substantial/maximal assistance with toileting and showering and dependent on staff for lower body dressing and transfers. He also had one stage 3 pressure ulcer and one stage 4 pressure ulcer. He also had verbal behaviors that occurred 4-6 days but less than daily that not impact him and othersReview of R#1's care plan report, initiated on [DATE], showed he had a stage 3 pressure ulcer on his left heel, stage 4 pressure ulcer to his sacral, right leg amputation and had a suprapubic catheter. He was also at risk for ADL decline and staff were required to provide extensive assistance for bed mobility and upper/lower body dressing, and total assistance with transfers. He also had episodes of exhibiting verbal/physical aggression towards staff and residents who reside in the facility and had a history of manipulative behavior. Nursing staff (CNA, LVN and RN) were required to provide safety, offer alternative time for care, back away, seek assistance if needed, notify the nurse of behaviors, provide medications as ordered, assess reports of behaviors and notify the MD if interventions are not effective if he becomes combative or aggressive. Staff were also required to be direct and firm when approaching him about behavior, clarify from him what he actually was saying or doing, document behavior in clinical record, inform staff on redirect methods for his behaviors when providing care, monitor for mental status changes, and psych services as needed. Review of R#1's order summary report, dated [DATE], showed he required hospice care every shift, a catheter change every shift if it was dislodged, his foley catheter bag drained empty every shift, pain assessed every shift, and left heel pressure ulcer cleaned every night shift. Review of R#1's discharge planning review initiated by the CNO on [DATE] showed it was incomplete. Review of the OMB's email correspondence showed the OMB emailed the ADM on [DATE] and asked if he could let R#1 give him a call to discuss his discharge and attached a copy of the inappropriate discharge and provider letter. There was no email response to the OMB's request. Review of R#1's notice of immediate discharge, dated [DATE], showed staff served a formal written notice of his immediate transfer and discharge from the facility on [DATE]. There was no address included that R#1 would discharge to. The reasons for this action reflected, On [DATE], you made a direct and credible threat to shoot the ADM, as reported by staff member. You have stated to staff that you have previously served time in prison and 'would go back,' increasing concern for the seriousness of the threat.You routinely leave the community for extended periods and have access to financial resources, creating a credible risk that you could obtain a weapon and return to the facility. Texas Penal Code - Terroristic Threat (threat of violence causing fear and disrupting a licensed healthcare facility)The right to appeal section reflected, You have the right to appeal this discharge to HHSC. If you wish to appeal, you must contact HHSC immediately upon receipt of this notice. You may request a Fair Hearing by calling the HHSC Appeals Division or sending a written request to HHSC Appeals Division. During the appeal process, you have the right to remain in the facility until a final decision is made, except in cases of immediate jeopardy, which applies in this situation. Review of R#1's criminal trespass notice, dated [DATE], showed the VPO was the owner or had the authority to provide an official notice advising R#1 that his future entry onto the facility property was expressly forbidden and would be subject to arrest for criminal trespassing if he entered or remained on or in the facility property or failed to depart from the facility property. PO signed the notice. Review of the facility's discharge report between [DATE] and [DATE] showed R#1 was discharged to other on [DATE]. Review of the facility's in-service on [DATE] showed the DON taught staff to call the police and notify her, the ADON and ADM in the event R#1 arrived on the facility premises. Review of the OMB's email correspondence showed the OMB emailed the VPO on [DATE] and informed him that R#1 requested to appeal his discharge and wanted to return to the facility until his discharge appeal hearing is completed. The VPO emailed the OMB on [DATE] and informed him that R#1 could not return to the facility during the appeal process and explained the facility community determined R#1 posed an ongoing threat to the health and safety of residents and staff based on repeated verbal threats of violence made toward the ADM and others. Review of R#1's progress notes between [DATE] and [DATE] reflected there were no notes related to the alleged incidents. Review of R#1's progress note created by the MD on [DATE] at 9:59 a.m. reflected, As we discussed, [facility] is issuing an immediate discharge for [R#1] today at 11a r/t his verbal threat to shoot the administrator. He made this threat known to a facility employee. discussed last week regarding previous threat to the corporate leadership and somehow getting hold of their personal contacts and called with threats. Discussed initially with CNO, then I called the administrator back directly -- advised getting the police to the [facility], escort him out directly to an ER, and the ER need to have the psychiatry team evaluate him for admission due to risk of harming others.Review of R#1's progress note created by the DM on [DATE] at 1:35 p.m. reflected, Resident has had behavioral issues and refuses care as noted previously by nursing. He will be D/C r/t increased aggressive behavior and threatening staff members. Recommend to continue diet with med pass r/t poor po intakes and increased needs r/t altered skin status. Recommended to continue high protein supplements such as prostat 30 ml BID for wound healing and to meet needs. Resident remains on hospice care. Weight loss may be unavoidable as the condition continues to decline. Resident's comfort takes priority overweight goals. Weight loss and decreased intake anticipated in end of life process; deceased intake increases endorphins and dynorphins which enhances comfort and can provide individuals with euphoric experiences and prevention of discomfort. Review of R#1's progress note created by the DON on [DATE] at 1:45 p.m. reflected, Resident was served immediate discharge documents from the [VPO]. Resident was served in the presence of two Police Officers and one Police Detective. Resident declined to take the document stating, I don't need a mother fucking thing. The [VPO] offered to pay for a hotel stay for five days for resident and have Hospice continue care. Hospice did speak with resident and explain extended services that will/can be provided while staying at the hotel. Resident received all medications and wound care supplies given in a bag. The list of medications given were: Biktarvy, gabapentin, atorvastatin, hydromorphone, glipizide, metformin, and metoprolol, gauze, collagen with xeroform, calcium alginate, abdominal pads, and kerlix dressing. Resident requested his clothes out of his room and the charge nurse assigned to resident got a clean trash bag and put resident's clothes in a bag and put it where the resident requested. Resident stated he was going to return to the building and no one would stop him. The Police Officers did explain to resident he was also getting served with a no trespassing order and it was explained to resident that failure to comply would result in the resident getting arrested. The Detective offered to take the resident to the hospital and the resident declined. Resident requested to speak with social worker. Social worker provided outside resources for resident to look into for continuity of care.spoke with [VPO] and administrator again. [R#1] no making more active threats. as such it's ok to discharge to self-care BUT still will involve the police this morning to ensure safety measures. [R#1] should not be allowed to return to facility because he made threats to multiple staff/employees/team members of physical violence, and even police had to be involved. This is to ensure the safety ofthe facility and employees.Review of R#1's POC response history for [DATE] showed their staff documented there were no behaviors observed on [DATE], [DATE] and [DATE]. There were also no documented entries on [DATE]. Review of the facility's incident log between [DATE] and [DATE] reflected there were no incidents related to the alleged incidents.An observation of R#1's room on [DATE] at 10:09 a.m. showed R#1's room was locked. The surveyor attempted to knock on R#1's door and introduce themself. There was no response. During an interview with the ADM on [DATE] at 10:11 a.m., the ADM stated R#1 was not at the facility. He stated he believed R#1 was at a friend's home as of [DATE]. He stated he did not have confirmation of R#1 being at a friend's home. He stated he attempted to call R#1 on an unknown date and R#1 did not respond and call him back. He stated R#1 was wheelchair bound and provided his own care. He stated CNA A told him on an unknown date that R#1 told her in his room that he was threatening to shoot the ADM on [DATE]. He stated he and staff did not know if R#1 had any firearms or weapons because R#1 refused an inventory check. He stated RN B and CNA C told him on unknown date that they received threats from R#1 on [DATE]. The ADM did not elaborate on the threats that RN B and CNA C received from R#1 on [DATE]. The ADM stated the HR, VPO, and CNO told him on [DATE] that R#1 made threats to them on [DATE]. He stated R#1 made a threat while on the phone with HR and while on the phone with the VPO and CNO on [DATE]. He did not elaborate on the threats that R#1 made to the HR, VPO, and CNO on [DATE]. He stated he did not know why the HR, VPO, and CNO did not inform him on [DATE] of the threats that R#1 made to them on [DATE]. He stated he was not at the facility on [DATE]. He stated he expected staff to notify him of any alleged threats as soon as possible. He stated the VPO notified the police on [DATE]. He stated the police did not arrive at the facility until [DATE] because the police believed it was not an emergency. He stated R#1 was not on 1:1 and did not have any interventions in place from [DATE] through [DATE] because the OMB told him that it would be ineffective because R#1 often went out on pass. He stated the facility was trying to find another facility to transfer R#1 to on unknown date and he was declined by several other facilities. He stated the police arrived at the facility on [DATE] to ensure the discharge process was properly completed. He stated R#1 received an immediate discharge notice on [DATE]. He stated the OMB was aware of R#1's immediate discharge and received a copy of the immediate discharge notice given to R#1 on [DATE]. He stated the police offered to take R#1 to the hospital and R#1 refused on [DATE]. He stated the IDT team ensured residents had a safe and proper discharge. He stated he knew it was important to ensure residents had a safe and proper discharge and said, So they could continue to get care and services and make sure they were safe. Residents would be at risk of being unsafe if they did not have a safe and proper discharge. He stated he believed R#1 had a safe and proper discharge because the VPO offered him a hotel and he declined and the police offered to take him to the hospital and he declined. During an interview with the DON on [DATE] at 10:37 a.m., the DON stated R#1 required transfer and lower body dressing assistance, took care of his catheter and colostomy bag, demonstrated to her how he changed his colostomy bag, did not receive formal or follow-up training on colostomy care, and could independently shower. the ADM told her on [DATE] that R#1 made threats to RN B on [DATE] and the police were called and arrived at the facility on [DATE]. She stated she could not recall the threats the ADM notified her that R#1 made to RN B on [DATE]. She stated the ADM also told her on [DATE] that the HR was present when R#1 made a threat to harm the ADM by gunshot on [DATE]. She stated the CN was also on duty on [DATE]. She stated RN B had staff check on other residents and R#1 called the police and stepped outside on [DATE]. She stated she did not know when the police arrived at the facility on [DATE]. She stated the OMB was notified on unknown date, but before [DATE], of R#1's alleged threat on [DATE]. She stated the VPO was also notified on [DATE] of R#1's alleged threat on [DATE]. She stated she expected staff to immediately notify her of alleged threats. She stated she was unsure of the process for this similar circumstance, but she believed staff would follow ADM's direction. She stated R#1 was not placed on 1:1 and did not have any other interventions implemented from [DATE] through [DATE] because the OMB told her it would be ineffective because R#1 often went out on pass. She stated R#1 was provided with an immediate discharge notice on [DATE] around 12:00 p.m. She stated R#1 was immediately discharged due to the alleged threat he made on [DATE]. She stated the OMB was notified of the immediate discharge on [DATE]. She stated the VPO offered a hotel room to R#1 and he declined it on [DATE]. She stated R#1 was provided with all his medications before he discharged from the facility and documented it in a progress note. She stated the police provided R#1 with a no trespass order on [DATE]. She stated she did not know where R#1 was currently. She stated she believed the ADM had R#1's contact information and it might be listed in his clinical records. She stated she did not make due diligence to contact R#1 after he was discharged on [DATE]. She stated she did not know if staff attempted to contact R#1 after his discharge on [DATE]. She stated no in-services were initiated after R#1's discharge other than the VPO did an in-service on reporting R#1 to the police if he was observed on the facility property on [DATE]. During an interview with the PO on [DATE] at 11:50 a.m., the PO stated R#1 was served with a no trespass order, R#1 tore it, refused to leave the facility, and would not leave the facility until they told R#1 that he would be arrested if he did not leave the facility. During a telephone interview with R#1 on [DATE] at 12:17 p.m., R#1 stated he was paralyzed from the chest and down his body and required assistance from getting in and out of bed and wound care and foley catheter care. He stated the facility staff and police wanted to speak with him on [DATE] and he stepped outside the facility building. He stated he did not know he was being kicked out of the facility. He explained the VPO, ADM, DON, and police officers informed him that he was being immediately discharged on [DATE] due to an alleged threat that staff reported he made on [DATE]. He stated he was provided with an immediate discharge notice on [DATE]. He stated his discharge notice did not include the address where he would be discharged to. He stated they explained to him that staff reported he threatened that he was going to shoot the ADM on [DATE]. He stated he did not make any threats to shoot the ADM on [DATE] and the allegation was absurd. He stated the police did not arrive at the facility and did not search him for any weapons from [DATE] through [DATE]. He also stated he did not have any weapons. He stated he was trying to get into his wheelchair so he could go out on pass with a friend and get something to eat because he did not receive any snacks or meals on [DATE]. He stated he pressed his call light and no one came for 2-3 hours. He stated he called the HR and told her on [DATE] that he was tired of the ADM picking on him, bullying him and harassing him. He stated he also called the VPO and spoke with him and the CNO on [DATE] and told them that he was not being cared for, not helped out of bed, and felt bullied and picked on by the ADM. He stated the VPO offered to put him in a hotel on [DATE] and he refused because he could not care for himself and needed care and services. He stated no one would help him get into his wheelchair until CNA A, CNA D, and CNA E saw his call light for assistance and responded 2-3 hours after he pressed his call light to get up. He stated he was upset and told CNA A, CNA D, and CNA E to get him into his wheelchair. He stated CNA A, CNA D, and CNA E were trying to transfer him into his wheelchair in his room on [DATE] around 7:00 p.m.-7:30 p.m. He stated CNA A left his room, returned, and told him, CNA D and CNA E that they could not help him get in his wheelchair because RN B told them not to help him in his wheelchair and that the ADM was on his way to the facility. He stated he did not know why RN B told CNA A, CNA D, and CNA E not to help him into his wheelchair. He stated he put himself in his wheelchair, signed himself out on pass, went outside because he was upset, and returned inside the facility on [DATE]. He stated he observed the ADM at the facility on [DATE]. He stated he complained to SW, DOR, DON, ADON and HR on [DATE] about the lack of care that he received on [DATE] and [DATE]. He stated they helped him file a grievance on [DATE]. He stated the staff on duty on [DATE] told them (SW, DOR, DON, ADON and HR) that they did not check on him and did not care for him because they thought he was out on pass on [DATE]. He stated the staff provided him with his medications and did not provide him with wound care supplies on [DATE]. He stated the police offered EMS transport to the hospital and he declined on [DATE]. He also stated the VPO offered a 5-day hotel stay and he declined on [DATE]. He stated no other alternative placement was offered on [DATE]. He stated the police told him that he would be arrested if he did not leave the facility premises on [DATE]. He stated he had nowhere to go, told his hospice he had nowhere to go, and slept in his truck in 37 degree Fahrenheit weather on [DATE]. He stated he did not receive any wound care, colostomy care, ADL care, meals and his wounds smelled. During an interview with the VPO on [DATE] at 1:34 p.m., the VPO stated R#1 relied on his electric wheelchair and was on Medicaid. He stated R#1 often signed in and out of the facility and would take his medication with him. He stated R#1 was at the facility for a little bit, had received very little care, and had the financial means to purchase a firearm. He stated he was not aware if R#1 was in possession of a firearm. He stated he did not know if there were any grievances filed regarding R#1's care. He stated R#1 called him on [DATE] and told him that he was upset and tired of the ADM bullying him and getting rid of people who he got close to. He stated he looped the CNO into the phone conversation. He stated R#1 said, My mind will run and only violence would resolve the issue. He stated he believed R#1 was referring to the ADM. He stated R#1 told him and the CNO that he would make impulsive decisions that he would regret. He stated the police did not arrive at the facility on [DATE]. He stated he did not know why the police did not arrive at the facility on [DATE]. He stated he started investigating the alleged incident on [DATE]. He stated he interviewed CNA A on [DATE] and [DATE]. He stated CNA A told him that she was getting R#1 up when he told her, Put me up in this wheelchair, I'm going shoot up this nursing facility like I did to the other one, on [DATE]. He stated R#1 called the HR, who heard R#1 was upset and arrived at the facility to speak with him. He stated the HR told him on [DATE] that R#1 said, Clear the hallways and put the residents in the dining room. I'm going to shoot [ADM], on [DATE]. He stated R#1 did not threaten to shoot any residents. He stated R#1 was not placed on 1:1 or had any other interventions implemented from [DATE] through [DATE]. He stated he was unsure if the NP and MD gave any special instruction or if psych or behavior services were offered to R#1. He stated he tried to notify the OMB on [DATE], [DATE], and [DATE] about the immediate discharge request. He stated he spoke with the OMB on [DATE] and notified him of the immediate discharge request. He stated he spoke with the OMB again on [DATE] and the OMB told him that he spoke with unknown HHSC staff member and they cleared R#1 immediate discharge due to the threat R#1 made on [DATE] around 4:45pm-5:00pm. He stated he wanted to discharge R#1 on [DATE]. He stated he notified the police on [DATE] that R#1 threatened to shoot the ADM on [DATE], they did not come out to the facility, did not conduct a search and did not explain why they did not come out to the facility. He stated he did not discharge R#1 on [DATE] because he wanted to have something in plan on [DATE]. He stated the CNO called R#1's hospice on [DATE]. He explained he wanted to make sure hospice could visit R#1. He stated he also wanted to make sure R#1 had a place to discharge to. He stated he also had police present when he served the immediate discharge notice to R#1 on [DATE]. He stated R#1 threw the immediate discharge notice back at them and police intervened. He stated Hospice was also present on [DATE]. He stated R#1's friend also showed up to the facility on [DATE]. He stated the police offered EMS transportation to R#1, but he declined. He stated R#1 was provided with his clothes, medications, and an address for where his personal belongings would be sent to. He stated the OMB came to the facility later on in the afternoon of [DATE]. He stated R#1 did not check into the hotel he offered and R#1 declined on [DATE]. He stated he did not know R#1's whereabouts. He stated he knew it was important to ensure residents had a safe and proper discharge and said, The safety of the discharge and ensuring they have a place to go. Residents could be at risk of lack of care if they did not have a safe and proper discharge. He stated residents could stay at the facility during a pending discharge appeal. During an interview with the CNO on [DATE] at 2:23 p.m., the CNO stated she did not know R#1's care or services or if he exhibited any behaviors. She stated R#1 called the VPO on [DATE]. She stated the VPO included her in the phone conversation with R#1. She stated R#1 expressed he was irritated and tired of staff picking on him. She stated the VPO told her that R#1 was referring to the ADM. She stated R#1 said, I can take care of business, the only way things could get settled is through violence. I do things without thinking and then after it's done, I regret it. She stated she offered to put R#1 in hotel on [DATE] and he declined. She stated R#1 wanted to speak with the VPO and the VPO told him that he would speak with R#1 on [DATE]. She stated she was informed by the VPO on [DATE] that the ADM reported R#1 made threats to shoot the ADM on [DATE]. She stated the VPO told her that R#1 told a CNA that he would shoot up the entire facility and to get the residents in the dining room so he could shoot the ADM. She stated she was unsure if R#1 made alleged threats to anyone else. She stated she did not know if R#1 had any weapons in his possession to cause harm. She stated R#1 was not placed on 1:1 because it irritated him and staff were scared of him. She stated R#1 remained at the facility from [DATE] through [DATE]. She stated the VPO called the police on [DATE] and she did not know if the police arrived at the facility. She stated the OMB told the VPO on unknown date that HHSC told him there was grounds to immediately discharge R#1. She stated the MD was notified on unknown date of R#1's immediate discharge and agreed with it. She stated R#1's hospice was also notified on unknown date. She stated the VPO served the immediate discharge notice to R#1 on [DATE]. She stated R#1 was provided with his medications and wound care supplies. She stated the VPO made a hotel reservation for R#1 for five days. She stated she did not know if R#1 accepted or declined the hotel reservation. She stated R#1 left with a friend who was a nurse, but she had no confirmation as to whether or not his friend had a current nurse license. She stated she did not know if R#1's friend was providing care and services to R#1. She stated she did not know R#1's whereabouts. She stated she did not know if R#1 reached out to his hospice. She stated the facility was responsible for residents' safe and proper discharge. She stated she knew it was important to ensure residents had a safe and proper discharge and said, It's important for residents so that their care and services continued. Residents could be at risk of not having their care and services continued if they did not have a safe and proper discharge. During an interview with CNA A on [DATE] at 4:13 p.m., CNA A stated her and CNA D were walking back to the memory care unit, observed R#1's call light and walked into his room to answer it [DATE]. She stated CNA E was already in R#1's room and were arguing back and forth with R#1. She stated that she and CNA D intervened. She stated R#1 was upset and said, I just want y'all motherfuckers to get me up in my chair and out the way. She stated CNA E sarcastically said, Oh don't shoot me. She stated as her and CNA D helped CNA E put R#1 into his wheelchair, R#1 said, Yeah because the previous nursing homes I've been in trouble for shooting them up. She stated her, CNA D and CNA E were not in fear and believed R#1 was upset because he told them that he had been waiting 2-3 hours for staff to answer his call light and put him in his wheelchair because he did not receive any snacks or meals. She stated she stepped out of R#1's room because she was receiving a call and then notified RN B that R#1 did not get any meals or snacks and was upset because he waited for 2-3 hours after pressing his call light for assistance with getting up. She stated RN B questioned why her and CNA D answered R#1's call light. She stated RN B told her that she told the staff not to get R#1 out of his bed, the ADM was on his way to the facility, and to tell CNA D and CNA E to get out of R#1's room and not help him out of bed. She stated she did not understand why her; CNA D and CNA E could not get R#1 out of bed and RN B did not give her a reason. She stated CNA D also questioned how they could not transfer R#1 because he requested to get out of bed. She stated RN B told her to not worry about it and that the ADM was on his way. She stated the ADM arrived and was at the facility on [DATE]. She stated the police came to the facility on [DATE] due to a nonemergency call that was unrelated to the conversation. During an interview with the MD on [DATE] at 5:22 p.m., the MD stated R#1 lied in bed, checked himself out of the facility, was mobile with his wheelchair, required some ADL assistance, received wound care and medications, and was placed on hospice care during his admission for pain management and overall, ADL decline. He stated R#1 had behaviors and the staff notified him and the NP and documented the behaviors since his admission. He stated the CNO notified him on [DATE] that R#1 made threats to the VPO. He stated he could not recall what threats R#1 made to the VPO on [DATE]. He stated the CNO also notified him on [DATE] at 9:36 a.m. that R#1 threatened to shoot the ADM on an unknown date. He stated he expected the staff to notify the police and escort R#1 to the ER for psychiatric evaluation. He stated he notified the ADM on [DATE] to notify the police and have EMS escort R#1 to the ER if it was an active, direct, credible threat. He stated R#1 was not persistently making threats during his admission at the facility. He stated R#1 had a safe discharge because he was on hospice services, which was a critical piece of his care, and was informed that R#1 was offered a hotel stay despite denying the offer. He stated residents had the right to refuse care and services. He stated he could not recall who transported R#1 after his discharge. He stated he would be concerned if R#1 was not on hospice services and did not receive wound care and medications after discharge. During a telephone interview with R#1 on [DATE] at 6:32 p.m., R#1 stated a friend picked him up, did not sign any paperwork and did not indicate he was going to take care of him on [DATE]. He stated he also did not sign any paperwork. He stated he told his hospice on [DATE] that he had nowhere to go when he was immediately discharged from the facility. During an interview with the CNO on [DATE] at 6:38 p.m., the CNO stated the OMB, hospice, and police were present when R#1 was discharged from the facility on [DATE]. During an interview and record review with CNA A on [DATE] at 9:17 a.m., CNA A stated the ADM called and told her on unknown date that he would type up her statement from [DATE]. She stated she refused and told the ADM that she could come to the facility and handwrite her own statement. She stated the ADM told her, That's okay, that's okay, I'll take care of it, and ended the call. She confirmed that she did not type the following statement the ADM provided the surveyor and believed it was falsified by the ADM, While assisting [R#1], I was asked to get him in his motherfucking wheelchair, he then directed all staff and residents to clear the way. He then stated that we must not know who he is because he will shoot up the place and he has shot up another nursing home. This caused me to call my father to help us out in case of emergency. She stated she never called her father on [DATE]. During an interview with LVN G on [DATE] at 9:18 a.m., LVN G stated she was familiar with R#1 and worked with him during the night shift. She stated R#1 was always very respectful to her, always thanked her, never mistreated her, and never said anything threatening to her. She stated R#1 did not exhibit any behaviors on [DATE] and [DATE]. She stated R#1 did not make any comments about shooting up t

Based on interview and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including the category of work for each person on direct care, including, but not limited to, whether the individual was a registered, nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS for one of one facility reviewed for administration. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Record review of the CMS PBJ report for CMS FY Quarter 1 2025 (October 1, 2024 - December 31, 2024) indicated the facility failed to submit data for the quarter. Interview on 07/17/2025 at 7:45 AM the Corporate Nurse stated that she was aware the Payroll Based Journal had not been submitted for the quarter of October 1, 2024 - December 31, 2024, to CMS. She stated she was unsure as to why the data had not been reported and she would reach out to her corporate level staff and attempt to get an answer. She stated she was aware the Payroll Based Journal was required to be submitted. The Corporate Nurse stated the Administrator did quit on 07/01/2025 and she could not answer why he did not ensure the Payroll Based Journal was not submitted. Review of the facility's Reporting Direct Care Staffing Information (Payroll- Based Journal), dated 2001, reflected the following Reporting Direct Care Staffing Information (Payroll-Based Journal)Policy StatementDirect care staffing information is reported electronically to CMS through the Payroll-Based Journal system.Policy Interpretation and Implementation1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS.2. Direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.3. Direct care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees.4. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the facility (for example, housekeeping).5. Providers who are employed by the facility (including physicians) are included in direct care staffing information; providers who bill Medicare directly are not included.6. For auditing purposes, reported staffing information is based on payroll records, invoices, tied back to a contract, or other verifiable information.7. Data is submitted only by designated personnel with training on the PBJ user interface. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to label and date all food items located in the walk-in refrigerator, freezers and in the dry food pantry area on 7/15/2025, and 7/16/2025. 2. The facility failed to clean and sanitize its food storage areas, to include the shelves and 1freezer in storage room. on 7/15/2025, and 7/16/2025.3. The facility failed to clean and sanitize its dining area on 7/15/2025, 7/16/2025, and 7/17/2025. These failures could place residents who receive meals from the kitchen and dine in the facility's dining room at risk for foodborne illnesses.Observation during the initial tour of the kitchen on 7/15/2025 beginning at 09:30 AM, the following was observed:Dry Food Pantry area: 18 cans of diced red peppers, not labeled and dated 6 cans of Thick it, not labeled and dated 2 gallons of Coleslaw Dressings, not labeled and dated 6 cans of chicken noodles, not labeled and dated 4 boxes of Cream of Wheat, not labeled and datedWalk in refrigerator: Ziploc bag of thawed meat, not labeled and dated 3 pitchers of unmarked liquids or drinks, not labeled and dated A plastic pitcher filled about 2/3 full of peaches, not labeled and dated 6 gallons of milk, not labeled and datedUpright Freezer: 4 frozen jugs of orange juice and 4 frozen jugs of cranberry juice, not labeled and dated. Observed the shelf in the [NAME] freezer to be unclean, the shelf noted with sticky brown residue and an unknown dead insect resembling a beetle. The pantry shelves were observed to be unclean. There were mice droppings noted on the bottom shelf of the pantry room.07/15/2025, 12: 30 PM, the dining area was observed with: 5 dirty windowsills with dead bugs and cobwebs Cobwebs on beams Ceiling fans with significant dust and cobwebs07/16/2025 at 9:11AM, kitchen policy and procedure were requested from facility staff. During a follow up tour of kitchen on 7/16/2025 beginning at 11:00 AM, the following was observed: Unlabeled and not dated items remained: 18 cans of diced red peppers, 6 cans of Thick it, 2 gallons of Coleslaw Dressings,6 cans of chicken noodles, and 4 boxes of Cream of WheatNew items noted to be unlabeled and dated: opened frozen omelets and steak friesThe unclean shelves remained with the mouse droppings.The dining area remained with unclean windowsills.In an interview on 07/16/2025 at 3:15 PM Dietary Supervisor, stated the facility's practice is to keep open food for three days and then dispose of it. She also stated that all food products were expected to be labeled and dated upon arrival. She confirmed that her expectation was for all staff to follow this procedure.When asked about cleaning procedures, she stated that she personally trained staff on the cleaning schedule, which included daily cleaning of shelves and sweeping/mopping the storage room. However, when the surveyor asked to review the cleaning schedule book for the week of July 13-19, 2025, it was observed to have no entries. The Dietary Supervisor acknowledged that although staff had cleaned, no one had recorded their work in the log.The surveyor escorted the Dietary Supervisor to the food storage room and pointed out the mouse droppings and visibly soiled shelves. The Dietary Supervisor acknowledged the issue and stated the area would be cleaned that day. She was also shown the unlabeled food items in dry storage, the refrigerator, and freezer, and stated that they would all be marked immediately. She further admitted that she had previously noted a blue bag of food that was not labeled or dated.When asked what potential harm could result from food items not being labeled and dated properly, the Dietary Supervisor stated that items could expire and become contaminated, which could cause residents to become ill. The surveyor escorted the Dietary Supervisor to the windowsills; she stated housekeeping was responsible for cleaning the windowsills in the dining area.In an interview 07/17/2025 at 9:25 AM, Housekeeping Supervisor stated that she was responsible for overseeing the cleaning of the dining room. She reported that housekeeping staff sweep and mop the floors, sanitize all tables, and wipe down countertops. She stated that windows were cleaned once a week, and that dusting, spraying, and wiping of surfaces are part of the routine duties.When asked about who provides training on the cleaning schedule, the Housekeeping Supervisor stated that she was responsible for training staff. She noted that she has not been in her position long and has not yet had time to complete a formal cleaning schedule. She explained that the department has been short-staffed, and she has been assisting in other areas of the facility.She stated that cleaning the ceiling fans was the responsibility of the maintenance department, as housekeeping staff do not have access to ladders. When informed that several dead bugs were observed in the windowsills, the Housekeeping Supervisor stated that they would address the issue that day. She also stated that the three housekeepers currently working have been employed at the facility longer than she has.When asked about potential harm, she stated that dust could trigger resident allergies, and bugs could crawl on residents and bite them, potentially causing illness.In an interview 07/17/2025 at 9:35 AM, Housekeeper E stated that she has been working at the facility for two months. She reported that she has been trained on the facility's cleaning policies. She explained that the expected cleaning process in the dining room included wiping the tables first, sweeping the floors, cleaning the windows and windowsills, and mopping last.She stated that the Housekeeping Supervisor new and was in the process of developing a new cleaning schedule for the staff. When asked about the potential harm of having unclean areas in the dining room, Housekeeper E stated that it could cause health issues for residents or make them sick.In an interview 07/17/2025 at 9:51 AM, Dietary Aide D stated that she has been employed at the facility for six years and has worked in the kitchen for the past four years. She reported that she has been trained on all kitchen policies. Dietary Aide D stated they label and date all items received in the kitchen. She stated opened products were dated with date opened. Dietary Aide D stated they clean the kitchen daily and mark off task in the cleaning book. She stated both dietary and housekeeping clean the dining area, but housekeeping cleans the windowsills.Record Review of facility's Food Storage Policy not dated revealed: Food will be stored in an area that is clean, dry and free from contaminants. Storage areas will be free from rodent and insect infestation; and will be treated for pests and vermin on a regular schedule. Food should be dated as it is placed on the shelves if required by state regulation. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded.Record Review of facility's General Food Preparation and Handling Policy not dated revealed: The kitchen will be kept neat and orderly. a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Leftovers must be labeled, dated, covered, and stored in refrigerator.Record Review of facility's Cleaning and Sanitation of Dining and Food Service Areas revealed: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 7 (Resident #5, Resident #8, Resident #22, Resident #27, Resident #15, Resident #39, and Resident #42 of 11 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure CNA B and Medication Aide A practiced proper hand hygiene while serving and assisting residents #22, #27, and #42 during the lunch meal on [DATE].2. Ensure CNA C changed dirty gloves when handling clean items while providing peri care to Resident #8.3. Ensure Medication Aide A sanitized blood pressure monitors in between Resident #15 and Resident #39 while obtaining blood pressures. 4. Ensure LVN F washed his hands before and after the wound care on Resident #5 and changed dirty gloves when handling clean items while providing wound care. These failures could place residents at risk for healthcare associated cross-contamination and infections. An observation of the lunch meal on [DATE] between 12:08PM and 12:50PM revealed CNA B, and Medication Aide A assisted in the dining room.CNA B, and Medication Aide A were observed passing out trays to 12 residents at 6 tables.CNA B was observed sitting down to provide feeding assistance to Resident #42 immediately after passing lunch trays, without performing hand hygiene (washing or sanitizing hands). Medication Aide A was also observed sitting down to assist Resident #27 with feeding immediately after passing lunch trays, without performing hand hygiene. CNA B was observed later leaving Resident #42 after providing feeding assistance without performing hand hygiene. CNA B then proceeded to Resident #22 to help with her meal, again without washing or sanitizing his hands. Review of Resident #8's face sheet dated [DATE] reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including morbid (severe) obesity due to excess calories, depression, muscle weakness, abnormalities of gait, type 2 diabetes, anxiety disorder and infection following a procedure.Review of Resident #8's quarterly MDS assessment, dated [DATE] reflected a BIMS score of 12, indicating she had moderately impaired cognition.Review of Resident #8's care plan dated [DATE] had not indicated peri care.During an observation on [DATE] at 11:45am CNA C was providing peri care for Resident #8. CNA C put on gloves after washing his hands. After that he opened the brief and cleaned Resident #8's front and back with wet wipes dispensed directly from the wipe's packet. In that process he handled the whole wipe packet with the soiled gloves. He had not changed his gloves in the entire process and touched clean items that included a new brief and Resident #8's clothes and blanket. After the completion of peri care he placed the contaminated wipe packet containing wet wipes in a drawer containing Resident #8's personal belongings.During an interview on [DATE] at 11:55am CNA C stated he received training on peri care when he started working at the facility about 5 months ago. When the investigator walked through the peri care that he had done on Resident #8, CNA C stated he understood he should not have contaminated the wet wipe packet by handling it with soiled gloves, due to the danger of spreading germs. He said, by storing the contaminated packet in the drawer he had contaminated the items inside the drawer as well. He stated he also forgot to change the gloves before picking up the clean items after the completion of the cleaning.Review of Resident #5's face sheet dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including traumatic brain injury without loss of consciousness, injury to L5 level of lumbar spinal cord (5th segment of the lower part of the spinal cord) , severe protein-calorie malnutrition, pressure ulcer of sacral (pelvis) region, stage 4, spinal stenosis of lumbosacral region (narrowing of the spaces within the spine of the lower back region ).Review of Resident #5's initial MDS assessment, dated [DATE] reflected a BIMS score of 0 indicated he had severe impairment with cognition.Review of Resident #5's care plan, dated [DATE], reflected Resident #5 had pressure ulcer at the sacrum (pelvis) area r/t Immobility. The relevant intervention was administering treatments as ordered and monitor for effectiveness.Record review of Resident #5's Physician's order revealed : Sacrum: Cleanse with Wash Cloth, Pat dry, Pack with Silver alginate, Cover with Dry dressing, Change QD/PRN one time a day. Start Date-[DATE].During an observation on [DATE] at 3:00pm LVN F was performing wound care on Resident #5. He put on gown and mask and then went to resident for wound care. LVN F started wound care with putting on gloves, without washing or sanitizing his hands. He opened the brief and cleaned the wound on Resident #5's sacral area. LVN F then applied medication and closed the brief. After the competition of the wound care he adjusted the bed, tidied up bed and sheets, pulled up the blanket for Resident #5. LVN F did not change his gloves in the entire process. Once the process was completed, without sanitizing or washing his hands he left the room and continued work on the computer at the nursing station.During an interview on [DATE] at 3:55pm LVN F stated he worked at the facility for a few years and got experience as an LVN for years. When walked through the wound care that he had done on Resident #5, LVN F stated, as an experienced LVN he was not supposed to forget the fundamentals of wound care. He stated he should have washed his hands thoroughly before and after the wound care. He stated he was supposed to change his gloves when handling clean items during the procedure. LVN F stated he knew all these however forgotten to practice them at that time. LVN F stated proper infection control practices were important while doing nursing care to contain infectious diseases from spreading. He stated he attended infection control and hand hygiene in-services at the facility however could not remember exact dates.Review of Resident #15's face sheet dated [DATE] reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including muscle wasting, Lack of coordination, muscle weakness, abnormalities of gait and mobility, Parkinson's disease and atrial fibrillation (irregular heartbeats).Review of Resident #15's quarterly MDS assessment, dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact.Review of Resident #15's care plan, dated [DATE], reflected Resident #15 had renal insufficiency and relevant intervention was monitoring (increased pulse, increased respirations and increased BP.Record review of Resident #15's Physician's order revealed: Coreg Oral Tablet 12.5 MG (Carvedilol): Give 1 tablet by mouth two times a day for Hold if SBP <110 or HR <70. Start Date: [DATE].Review of Resident #39's face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility initially on [DATE] and readmitted on [DATE] with diagnoses including hypertension, major depressive disorder, pain, atherosclerosis of aorta(main blood vessel leaving the heart has hardened due to build up of fat), Hyperlipidemia(too much fat (lipids) in blood), peripheral vascular disease (poor blood flow to the arms and legs) and generalized anxiety disorder.[VT1]Review of Resident #39's quarterly MDS assessment, dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact.Review of Resident #39's care plan, dated [DATE], reflected Resident #39 had hypertension & Hyperlipidemia. The relevant intervention was obtaining blood pressure readings per MD order/per facility protocol.Record review of Resident #39's Physician's order revealed: Metoprolol Succinate ER [VT3] Tablet Extended Release 24 Hour 50 MG: Give 1 tablet by mouth one time a day related to essential (primary) hypertensionhold for SBP under 110 or HR under 70 and notify Nurse. Start Date-[DATE] During an observation on [DATE] at 10:35am Med Aide A failed to sanitize the wrist blood pressure monitor before using it on Resident #39, in between Resident #15 and Resident #39. Med Aide A took the blood pressure of Resident #15 with a blood pressure monitor without sanitizing it. After administering the medications to Resident #15 she moved on to Resident #39 and used the same blood pressure monitor on her without sanitizing it. Med Aide A did not sanitize the monitor after the use on Resident #15 until the investigator pointed it out. The Assistant Director of Nursing brought some wipes to Med Aide A as there were no wet wipes readily available on the cart.During an interview on [DATE] at 11:15 a.m., Med Aide A stated sanitizing blood pressure cuffs in between the residents was important and, she did not sanitize it because there were no wipes available at the facility. The investigator notified this to the Assistant Director of Nurses and immediately Assistant Director of Nurses brought a few packets of wet wipes to Med Aide A. Med Aide A stated she was under the impression that the wipes were not available at the facility. She stated she was aware of the impact on residents if she did not follow the infection control protocol as it was necessary to minimize spreading diseases from one resident to another. Med Aide A stated she received trainings on infection control occasionally however no in-services received specifically on sanitizing medical equipment. During an interview on [DATE] at 2:20pm the Director of Nurses stated she was the Infection Preventionist at the facility as well. She said CNA C should not have handled the wet wipe packet with soiled gloves. She stated CNA C was supposed to throw away the contaminated wet wipe packet instead of saving for future use, when he realized that the packet was contaminated. The Director of Nurses stated she already completed a one-to-one in- service with CNA C and would be doing an in-service for all the staff members for peri care. The Director of Nurses stated, the deficient practice of LVN F during wound care was a concern as it was violating infection control practices, that opens the avenue for the germs to spread in the facility. She stated Resident #5's pressure ulcer also could get infected if the infection control protocol had not been followed appropriately. The Director of Nurses stated, as per facility's infection control protocol, all the medical equipment in use including blood pressure cuffs should be sanitized immediately after the use on residents. This was one of the ways minimizing contagious diseases and staff were trained for this. The Director of Nurses stated she could not remember exactly when the staff received in- services on infection control as she started working at the facility only few months ago and was in the process of fixing the issues one by one.An interview with CNA B on [DATE] at 1:23 PM revealed he was trained on proper hand hygiene. He stated that he has been working at the facility since [DATE]. He reported that he was currently PRN but was transitioning to a full-time position. When asked if he performed hand hygiene before assisting residents with meals, CNA B stated that he does wash his hands beforehand. He was asked what steps he takes before feeding a resident directly, and he responded that he was supposed to wash his hands or use hand sanitizer. When asked how he ensured proper hand hygiene when delivering meals to multiple residents, he stated that he sanitized his hands in between.The surveyor informed CNA B of the observations made of him failing to use proper hand hygiene before and between assisting residents. CNA B acknowledged the concern and admitted he should have known better, stating that his wife was a registered nurse. He admitted that he did not wash his hands prior to assisting Resident #42 and Resident #22 with their meals. He also stated there were not enough hand sanitizing stations in the facility and that the area was particularly busy that day. CNA B acknowledged that failure to use proper hand hygiene could potentially cause harm to residents by exposing them to germs and increasing the risk of illness.An interview conducted on [DATE] at 1:33 p.m., Medication Aide A stated that she has been working at the facility for one year and five months. When asked if she had received training on hand hygiene and assisting residents during dining, she confirmed that she had been trained on proper handwashing procedures. She stated that after serving every third resident, staff are expected to wash their hands and not use the same gloves or utensils repeatedly.Medication Aide A further stated that she typically washes her hands in the med room or the restroom, as there is no handwashing station in the dining area. When asked what steps should be taken before directly feeding a resident, she replied that staff were supposed to perform hand hygiene.The surveyor informed Medication Aide A of observations where she failed to wash or sanitize her hands-once while passing meal trays and another time when feeding Resident #27. Medication Aide A responded that she did not know why she had not washed her hands in the dining room on that day. She explained that it was a rushed situation, as she was assisting with both meals and medications, and that she had a lot on her mind at the time. She stated a resident can become ill from not performing proper handwashing.In an interview with Director of Nursing, [DATE], 1:30PM, Director of Nursing stated that she has held her position at the facility since February 2025. She reported that she was responsible for conducting hand hygiene training for the staff and confirmed that training sessions were most recently completed in May and [DATE]. She added that she was now involving the Assistant Director of Nursing to assist with ongoing training.The Director of Nursing stated that she has high expectations for staff regarding hand hygiene practices. She emphasized that staff were expected to wash their hands before assisting residents with meals and to sanitize their hands between serving each tray. She further stated that staff should wash their hands before feeding residents and again between assisting different residents. The Director of Nursing reported that necessary supplies for hand hygiene were available and accessible, and that staff were also expected to assist residents with cleaning their hands before meals.She stated that poor hand hygiene could lead to the spread of infections, colds, and other illnesses, which may cause residents to become sick.Record review of facility's policy Handwashing / Hand hygiene revised in [DATE] reflected: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene1. Hand hygiene is indicated:2. immediately before touching a resident.3. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device).4. after contact with blood, body fluids, or contaminated surfaces.5. after touching a resident.6. after touching the resident's environment.7. before moving from work on a soiled body site to a clean body site on the same resident; and8. immediately after glove removal.1. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.2. Wash hands with soap and water:9. when hands are visibly soiled; and10. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.3. Single-use disposable gloves should be used:1. before aseptic procedures.2. when anticipating contact with blood or body fluids; and3. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.4. The use of gloves does not replace hand washing/hand hygiene. Record review of facility policy Wound care revised in [DATE] reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Placeall items to be used during procedure on the clean field. Arrange the supplies so they can be easilyreached.2. Wash and dry your hands thoroughly.4. Put on exam glove. Loosen tape and remove dressing.5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly.10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.21. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart.23.Wash and dry your hands thoroughly.Review of facility's policy Cleaning and Disinfecting Non-Critical Resident-Care Items revised in [DATE] reflected:PurposeThe purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. a. non-critical items are those that come in contact with intact skin but not mucous membranes.(1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers.(2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location).b. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 12 and Resident #16) reviewed for ADL care. The facility failed to ensure Resident #12, and Resident # 16's nails were cleaned, and did not have rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings include: 1. Record review of Resident #12's face sheet, dated 07/17/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Type 2 diabetes mellitus without complications (a disorder where the body either does not produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels), lack of coordination (the inability to smoothly and efficiently combine movements of different body parts. It can manifest as clumsiness, unsteadiness, or difficulty with tasks such as buttoning a shirt), and anxiety disorder (conditions characterized by excessive fear, worry, and apprehension that can interfere with daily activities). Record review of Resident #12's Annual MDS, dated [DATE], reflected the resident had a BIMS score of 15, which indicated his cognition was intact. Resident #12 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and showers. He required supervision/or touching assistance (helper provides verbal cues and/or touching as resident completes activity) with the following: dressing, toileting, and oral hygiene. Record review of Resident #12's Comprehensive Care Plan, with completion date of 06/30/2025, reflected Resident # 12 required one staff assistance with bathing, dressing, grooming and hygiene. Observation and interview on 07/15/2025 at 11:01 AM, revealed Resident #12 was in his room sitting in his wheelchair. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #12's middle fingernail on his right hand was uneven around the edges. Resident #12 stated he requested for his nails to be cleaned and filed a few days ago. He did not recall the date or who he asked to clean his nails. Resident #12 stated the person explained he would receive nail care on Sunday (07/20/2025). He stated he did not recall the ladies name when he requested his nails to be cleaned and filed. 2. Record review of Resident # 16's face sheet, dated 07/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #16 had diagnoses which included paraplegia, unspecified (partial or complete paralysis of both legs and often the lower trunk, with the specific cause or extent of the impairment not being clearly defined), lack of coordination (the inability to smoothly and efficiently combine movements of different body parts. It can manifest as clumsiness, unsteadiness, or difficulty with tasks such as buttoning a shirt), and contracture of left hand (a condition where the tissue under the skin of the palm thickens and tightens, causing one or more fingers to bend towards the palm and making it difficult to straighten them). Record review of Resident #16's Quarterly MDS Assessment, dated 06/09/2025, reflected Resident #16 had a BIMS score of 11, which indicated her cognitive status was moderately impaired. Resident #16 required set up assistance with personal hygiene, oral hygiene, and upper body dressing. She required partial/moderate assistance with showers (helper does less than half the effort). Record review of Resident #16's Comprehensive Care Plan, with completion date of 06/30/2025, reflected Resident #16 had an ADL self-care performance deficit related to disease process and impaired balance. Intervention: Bathing/Showering- check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation and interview on 07/15/2025 at 11:15 AM, revealed Resident #16 was in her room sitting in her wheelchair. She had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #16's ring and middle fingernail on her right hand were uneven around the edges. She stated on Saturday (07/12/2025) she asked a nurse if she would clean her nails. Resident #16 did not recall the nurse's name, and the nurse stated her nails would be cleaned and trimmed on Sunday (07/13/2025). She stated no one cleaned her nails on Sunday (07/13/2025). In an interview on 07/15/2025 at 2:00 PM, LVN F stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. He stated the CNAs were responsible for all other residents' nail care. LVN F stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. LVN F stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. He stated Resident #12 and Resident #16 did not refuse nail care. He stated no one reported to him Resident #16 or Resident #12 refused nail care. LVN F stated he had worked with Resident #12 and Resident #16 for several weeks. He stated he was in- serviced on nail care, however, he did not recall the date. In an interview on 06/19/2025 at 9:20 AM, CNA G stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA G stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA G stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 12 and Resident #16, and they did not refuse nail care. CNA G stated she did not know the last time these residents' nails were trimmed or cleaned. She stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. In an interview on 06/19/25 at 10:30 AM, CNA C stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs' responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. CNA C stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. CNA C stated she was in-serviced on nail care; however, she did not recall the date. She stated she had given care to Resident #12 and Resident #16. She stated she was not aware of Resident #12 or Resident #16 refusing nail care. In an interview on 07/17/25 at 09:36 AM, the Corporate Nurse stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high). She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The Corporate Nurse stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care and the DON was responsible for monitoring the nurse supervisors. Record review of the facility's Policy on Activities of Daily Living, dated 03/2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for one of five residents (Resident #14) reviewed for dignity. The facility failed to speak to Resident #14 in a way that promoted her dignity and self-worth. This failure could place residents at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.Findings include: Record review of Resident #14's face sheet, dated 07/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where a person exhibits symptoms of dementia, but the specific type of dementia was not identified, and the severity had not been specified. Dementia- a loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) , senile degeneration of the brain, not elsewhere classified (a decline in mental abilities like memory, reasoning, and judgement), and anxiety disorder ( excessive, persistent, and uncontrollable feelings of worry, fear, and unease), and Wernicke's encephalopathy (caused by vitamin B1 deficiency, primarily affecting the brain and nervous system). Record review of Resident #14's admission MDS, dated [DATE], reflected the resident had a BIMS score of 9, which indicated her cognition was moderately impaired. Resident #9 did not have any physical or verbal behavior symptoms directed toward others. She had senile degeneration of the brain, Wernicke's encephalopathy, anxiety disorder and non-Alzheimer's dementia (is various types of dementia that are not caused by Alzheimer's disease [(a progressive brain disorder that slowly destroys memory and thinking skills, ultimately interfering with daily life]). Record review of Resident #14's Comprehensive Care Plan, with a revision date of 06/30/2025, reflected Resident #9 had signs and symptoms of anxiety. Interventions: Allow Resident #14 to voice thoughts and feelings. Explore with resident the reason of anxiety. Psych services as ordered. Resident #14 resides in the secure unit. She was at risk for elopement and needed reduced stimuli and a controlled environment. Resident #14's dignity will be maintained and will be safe in the secured unit. Interventions: Monitor frequently to assure residents safety. Explain all procedures, suing terms/ gestures resident can understand. Call by name when given care. Record review of Resident #14's skin assessment and safe survey, on 07/17/2025 at 4:00 PM, dated 07/17/2025, there were no concerns with skin assessments and the resident did not have any psychosocial negative outcomes. She was calm and did not recall the incident. Observation on 07/17/2025 at 12:15 PM, the state surveyor was entering the secured unit and heard someone in a loud tone state you need to sit in your chair. The hallway revealed staff and residents in the dining room. The State Surveyor was approximately 200 feet from the dining room. Upon entering the dining room CNA G and CNA H were passing out trays. Observation on 07/17/2025 at 12: 30 PM to 12:40 PM revealed CNA G remained in the hall when the State Surveyor exited the secure unit and within 3 minutes found the Corporate Nurse and explained what occurred on the secure unit with CNA G. Another DON from a sister facility immediately went to the unit and walked with CNA G to the front office. CNA G wrote a statement, and she was immediately terminated upon further investigation. Interview on 07/17/2025 at 12:20 PM, CNA H stated CNA G did speak in a loud tone when speaking to Resident #14 in the dining room approximately 12:15 PM on 07/17/2025. She stated CNA G stated, you need to sit in your chair. She stated Resident #14 did not respond to CNA G. CNA H stated Resident #14 did not become upset after CNA H spoke to her in a loud tone. Interview on 07/17/2025 at 12:25 PM, CNA G stated she did speak in a loud tone when she stated sit in your chair when she spoke to Resident #14. CNA G stated, I did use a loud tone and was expected to use a softer tone when speaking to a resident. She stated, I can understand this was not the correct tone of voice to use when speaking to residents. CNA G stated she was in-service on abuse and neglect. She did not remember the date. Interview on 07/17/2025 at 2:05 PM, the Corporate Nurse stated CNA G was immediately terminated. She stated anyone using a loud tone when speaking to a resident was not tolerated in the facility. She stated there was a potential a resident may become more anxious and effect a resident's dignity if a staff used a loud tone when speaking to a resident. The Corporate Nurse stated to prevent this from happening again she felt terminating CNA G was in the best interest of the residents in the facility. She stated they wanted to ensure extra precautions were taken to prevent potential neglect or abuse. She stated the physician, ombudsman, family and HHSC were immediately contacted about the incident with Resident #14. The Corporate Nurse stated safety checks and skin assessments were completed on all residents on the secure unit and there were no concerns. She stated an investigation into the incident had begun and the full investigation would be completed within 5 days and submitted to HHSC. The Corporate Nurse stated the facility would not tolerate any rude tone being used when speaking to any of the residents. Interview on 07/17/2025 at 2:30 PM, the DON from the sister facility stated Resident #14 did not have any psychosocial negative outcomes from CNA G speaking to her in a rude tone. She stated Resident #14 was calm and did not display any anxious behavior such as worried expression, wringing her hands or pacing. She stated CNA G was immediately removed from the secure unit and terminated. She stated she instructed nurses to complete skin assessments and safety checks on all residents on the secure unit. The DON stated the skin assessments and safety checks were being completed as a precaution. She stated when staff used a rude tone with a resident this affected a resident's dignity. Interview on 07/17/2025 at 2:45 PM, . Resident #14 stated she did not like for anyone to speak to her very loud. Resident #14 stated no one had spoken to her in a loud tone or yelled at her. She stated no one was rude or mean to her. Resident #14 stated she wanted to see her family. She kept talking about her family. Resident #14 was calm and smiling. She stated, talk to someone else about all of this because I am fine here. Resident #14 stated she felt safe and was not afraid to live in the facility. She stated she did not want to talk anymore and stated come back next week for another visit. Record review of the facility's, undated Resident Rights policy reflected All residents have the right to be treated with dignity and respect, regardless of age, disability, race, ethnicity, religion, sexual orientation, gender identity, or socioeconomic status. Staff will interact with residents in a manner that promotes their self-esteem and self-worth, using preferred names and titles honoring their personal preferences. Record review of the facility's Identifying Types of Abuse Policy, dated June 2023, reflected verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, threatening harm , trying to frighten the resident, racial slurs, etc .

Based on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 4 residents review for catheter care. The facility failed to change Resident #1's foley catheter (a medical device used to drain urine from the bladder.) as ordered monthly on 04/09/2025 and 5/9/2025. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with possible sepsis (is a life-threatening condition that occurs when the body has extreme response to infection). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for hospitalization, coma and death. Findings included: Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels). Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: Urinary retention -multiple trials of foley removal without success -continue foley -continue Flomax -3/10 foley replaced by urology. replace foley monthly. Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter. Review of Resident #1's MAR/TAR reflected: CHANGE F/C 14fr 10cc Q MONTH AND PRN IF DISLOGED. one time a day starting on the 9th and ending on the 9th every month dated 04/03/2025 with start date of 04/09/2025. Provide catheter care Q-shift/PRN every shift. Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for catheter, DM or Hypertension. Review of Resident #1's TAR reflected his Foley was changed on 4/9/25 by MA E. Review of Resident #1's TAR reflected his Foley was changed on 5/9/25 by MA A. Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected: Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure. Review of Resident #1 current hospital records dated 5/17/2025 reflected: He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes (is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis, UTI (his foley was exchanged in ER, had brown urine with some pus in penile area), possible right lung pneumonia, with AKI. During an interview on 05/19/2025 at 10:11 am MA A stated she did not change Resident #1's foley catheter because it was outside her scope of practice. MA A stated Resident #1's foley catheter order to change was on her MAR and she accidentally signed it. MA A also stated she did not tell the nurse who worked on 5/9/2025 about the foley catheter needing to be changed. During an interview on 05/19/2025 at 11:04 am the DON stated, foley catheters were supposed to be changed once a month. The DON stated if foley catheters were not changed as ordered, the resident would get infection. The DON stated Resident #1's foley catheter was supposed to be changed around 5/09/2025 and the nurse was supposed to initial when it was changed. The DON stated staff did not document urine output because Resident #1 did not have orders to document urine output and Resident #1 did not have issues with output. The DON stated MAs cannot change foley catheters because it was not within their scope of practice. The DON reviewed Resident #1's TAR and noted that it was not changed on 4/9 and 5/9 but was initialed by MAs. The DON stated Resident #1's order for catheter change was revised on 5/10/2025 by LVN F to reflect on the nurse's TAR, according to the DON. During an interview on 05/19/2025 at 11:43 am the NP stated Resident #1 had a foley catheter due to urinary retention. The NP stated she usually did not write orders for foley catheters, and she let the urologist deal with foley catheters. The NP stated she expected the facility to keep foley catheters clean and free from infection. The NP asked to step out and call the MD, came back later and stated she would not continue with the interview unless her MD was present. During a phone interview on 05/19/2025 at 2:45 pm the MD stated, there was new evidence that indicated not to change the foley catheter monthly. The MD stated changing foley monthly, really did not make a difference in infection prevention. The MD stated the hospital may have said change the foley catheter monthly, but he disagreed with the urologist (are medical specialists who focus on the diagnosis and treatment of conditions related to the urinary tract and male reproductive system) . The MD stated Resident #1 would have to be scheduled for urology follow-up, maybe his foley catheter was difficult. During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated not changing the foley catheter as ordered can lead to possible infection. The Interim Administrator stated the CNAs were supposed to document urine output. The interim Administrator stated if Resident #1 had the foley catheter due to urinary retentions, it was important to document urine output. Attempts was made to contact MA E on 05/19/2025 at 10:30 am but was unsuccessful. Attempts was made to contact LVN F on 05/19/2025 at 12:21 pm but was unsuccessful . Review of facility's policy titled Catheter Care; Urinary dated August 2022 reflected: Purpose The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/20/25 at 12:51 pm. F690 Immediate Jeopardy Removal Actions Taken 1. Immediate Resident Response o Resident #1 was immediately transferred to the emergency room on 5/17/2025 due to fever, lethargy, and suspected sepsis. o A full head-to-toe assessment was conducted by licensed staff prior to transfer. (No skin breakdown, foley catheter intact) o Foley catheter was replaced in the ER. The resident was diagnosed with UTI, possible sepsis, AKI, and pneumonia. o Family and physician were notified immediately. 2. Resident Safety Review o 100% audit of all residents with Foley catheters completed on [5/19/2025] by the Director of Nursing (audit tool created to monitor foley catheter orders) (DON was in-serviced prior to completing audit on 5/19/2025 by CNO) Reviewed orders for catheter care and replacement schedule. (Review of 1 resident with foley pre- discharged orders in PCC were reviewed by DON as resident #1 is in the hospital. ( No residents other than resident # 1 have a foley catheter. Verified compliance with physician orders, TAR/MAR accuracy, and documented output as needed. Any overdue changes were immediately completed by a licensed nurse. (Currently no residents in the facility with foley catheter orders) None are affected. Any discrepancies in documentation were immediately addressed and corrected. 3. Order Clarification & Physician Review o All current Foley catheter orders reviewed with attending physicians to ensure: By: CNO and DON 5/19/2025. Specific frequency for changes (monthly, prn, etc.) Whether urology follow-up is required. Clear instructions on who is responsible (facility vs. specialist). o Physician orders revised accordingly and entered into EMR (1 resident total) (DON/ designee will monitor upon admission and weekly in Standards of care meeting). 4. Scope of Practice Enforcement o Immediate education and competency check completed on 5/19/2025 for all medication aides (MAs) clarifying: ( DON completed education. Staff that were not present we called by the DON. Staff that could not be reached must be in-serviced prior to next scheduled shift. MAs may not change Foley catheters. MAs must report Foley orders to licensed nurses immediately. MAs may not document, or initial Foley care they did not perform. o The MA involved was removed from the schedule pending retraining and counseling (In-service and posttest). ( Next scheduled shift for MA is 5/21/25 and she will not be allowed to work prior to the in-service and test for acknowledgement. 5. Documentation & Tracking System Improvements o New Foley catheter tracking log implemented for all residents with catheters ( monitored by DON/ Designee. o TARs and MARs updated to reflect accurate task assignments and responsibilities. ( DON completed the task after in-service by CNO on 5/19/2025. o DON or designee to verify completion of catheter change orders date. (This will be reviewed after admission and weekly in Standards of Care meeting) (Continuously). 6. Care Planning & Assessment o Resident #1's care plan updated by DON immediately to reflect catheter management needs. o 100% audit of care plans (foley catheter audit ) for all catheterized residents completed by DON to ensure individualized interventions for infection prevention, hydration, and output monitoring (3 resident's care plans were updated). (This will be tracked in the weekly Standards of care meeting) o Facility policy updated to require catheter care plans within 24 hours of admission. ( DON will be responsible and the CNO will provide oversight weekly X 6 weeks and then monthly. 7. Staff Education o In-service conducted for all licensed nurses and MAs by DON (in-service and posttest) on: ( DON will provide continuous training with new hires, agency, and staff who were not present to ensure compliance is met and sustained. Foley catheter management per HHSC/CMS standards. Identifying early signs of UTI and sepsis. Documentation protocols and scope of practice. o DON and ADON re-trained on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation (in-service by CNO) ( By verbal and written acknowledgement of training. 8. Quality Assurance and Monitoring o Daily (clinical morning meeting) review for 14 days (continuously in weekly Standards of care meeting) of: Catheter care orders. Documentation of changes. Correct scope of task completion. o QA team to review catheter log weekly and monitor compliance during rounds. (Monthly in QAPI meeting indefinitely-as long as there are residents with foley catheters) o Findings reviewed in monthly QAPI meetings. 9. Leadership Accountability o MA involved received documented disciplinary counseling. (DON via phone on 5/20/25) All MAs and nurses have been in-serviced by DON via in person or phone. ( Post test was sent via phone after in-service by DON to the staff who were not present at the time of the in-person training. All staff will be required to acknowledge the education was given by presenting the signed posttest prior to the next scheduled shift. o DON received education on catheter care orders, identifying signs of UTI and sepsis, and documentation protocols and scope of practice. Chief Nursing Officer providing oversight (5/19/25 daily X 10 days in person, then weekly X 4 remotely, and then monthly remotely and prn to ensure continued compliance with the plan. The Surveyor monitored the POR on 05/20/2025 from 1:00 pm to 7:00 pm as follows: During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs (LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO During interviews on 05/20/2025 from 1:00 pm -7:00 pm, two MAs (MA A and B), from all shifts, they both stated they had been in-serviced by the DON and the Interim Administrator/ CNO that MAs and Nurses were responsible for documenting on the MAR. They stated MAs were responsible for documenting in the MAR non-nursing responsibilities. Nurses were responsible for documenting in the MAR nursing responsibilities, such as catheter care. They were trained on MAR documentation. They learned to notify the charge nurse or DON if they observed incorrect entries or nursing responsibilities in the MAR. They stated if they accidentally checked off performing nursing responsibilities, such as ointment, on the MAR, they would strike out and notify nurse on duty. They stated they knew it was important to notify the nurse whenever they observe nursing responsibilities on the MA's MAR. They stated It's important because it could be abuse or neglect. Resident won't get attention they need as ordered from the doctor. Resident needs to get their treatment. Residents won't get what they need, such as wound care or ointment. Residents could not receive a medication or treatment if the MAR was checked off as received but they did not receive. During an interview on 05/20/2025 at 3:40 pm the DON stated she was in-serviced on 05/19/25 by the CNO. She learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, and reviewing and revising care plans. She also reviewed orders for catheter care and replacement schedule on 05/19/25 and found there were no residents other than Resident #1 who had a foley catheter. She reviewed Resident #1's EHR and verified compliance with physician orders, TAR/MAR accuracy, and urinary output documentation on 05/19/25. There were no overdue changes that immediately needed to be completed by a licensed nurse during review and verification. She also did not identify any discrepancies in documentation. Attending physicians, her and the CNO reviewed all current foley catheter orders on 05/19/25 for frequency for changes in output, urology follow-up, and who was responsible for changing. MD became oversight for ensuring urinary output documented, urology follow-ups were made, and foley catheters were changed according to orders. She started and completed the audit of all residents with foley catheters on 05/19/25 and found there were no residents with foley pre-discharged orders in EHR other than Resident #1. Resident #1's physician orders were revised and entered in EHR on 05/19/25 . She provided immediate education and competency checks by phone and in-person to the MAs on 05/19/25 regarding MAs not changing foley catheters, reporting foley orders to licensed nurses immediately, and not documenting or initialing foley care they did not perform. All MAs have been reached by in-person or phone before their next scheduled shift. MA involved was removed from the schedule. She reached out to the MA involved and the MA was scheduled to visit the facility to receive counseling and retraining on 05/21/25. She initiated and was monitoring a new foley catheter tracking log on 05/19/25. No discrepancies and errors observed. She updated Resident #1's TAR/MAR to reflect task assignments and responsibilities after being trained by the CNO on 05/19/25. There were no other residents. She was to start verifying completion of catheter change orders date and review after Resident #1's readmission and weekly. She updated Resident #1's care plan to reflect catheter management needs on 05/20/25. She completed an audit of all catheterized residents' care plans to ensure interventions were included and implemented and was tracking weekly. The DON stated the CNO updated the facility's policy to reflect requiring catheter care plans within 24 hours of admission and overseeing weekly for next 6 weeks and then monthly thereafter. She in-serviced all licensed nurses and MAs and gave post-tests to them regarding foley catheter management, documentation protocols, and identifying early signs of UTI and sepsis. CNO retrained her and had her sign written acknowledgment on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation on 05/19/25. QA was reviewing daily for 14 days and then weekly on catheter care orders, documentation of changes, and correct scope of task completion. QA team also reviewing catheter log weekly to monitor compliance during rounds and findings monthly in QAPI meeting. CNO was overseeing from 05/19/25, daily for the next 10 days in person, weekly for the next four weeks, and then monthly remotely and as needed to ensure compliance. During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on 05/19/25 regarding order reconciliation, ensuring orders were in nurses' MAR, ensuring orders for foley care and monitoring were in place, ensuring MAs notifying nurses of any orders in their MAR, and DON reviewing and tracking any discrepancies and errors and correcting. The Interim Administrator/CNO stated the DON signed an acknowledgement of receiving the in-service before performing the audit of residents with foley catheters. The Interim Administrator/CNO stated she, the DON, and MD reviewed current residents' foley catheter orders on 05/19/25 and found no other discrepancies and errors. The Interim Administrator/CNO stated she and the DON discussed with the MD the IJs as well. The Interim Administrator/CNO stated she in-serviced the DON on updating TARs and MARs to reflect accurate task assignments and responsibilities on 05/19/25 before the DON updated the TARs and MARs. DON signed an acknowledgement of receiving the in-service before updating the TARs and MARs. She was overseeing weekly for the next 6 weeks to ensure facility policy was updated and followed regarding catheter care plans were required within 24 hours of admission. She in-serviced the DON on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. DON signed an acknowledgement of receiving the in-service before initiating oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. She oversaw to ensure processes completed daily for the next 10 days in person, then weekly for four weeks remotely, and then monthly remotely and as needed to ensure continued compliance. Review of facility's in-services dated 05/19/2025 reflected the following: Facility had an ADHOC QAAC for identification of deficient practice. DON: Foley Catheter Review: Foley Catheter Policy presented by the Interim Administrator/CNO and signed by the DON. Nurses: Foley catheter, Foley catheter management/policy and procedure, identify early signs of UTI and sepsis, documentation presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. Medication Aides: Foley Catheter: MAs may not change foley catheter, MAs must report foley catheter orders to nurse, MAs may not document or initial on foley catheter, presented by the Interim Administrator/CNO and the DON; signed by MA A, MA E via phone. Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process and foley catheter orders to be specified if would like catheter changed monthly. Nursing: Scope of Practice/ Medication Administration presented by the DON via phone for MA F. Foley Catheter test completed on 05/19/2025 by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F Review of facility's in-services dated 05/20/2025 reflected the following: Foley Catheter management, notification of change in condition to nurse, where to document output dated 05/20/2025 presented by the DON signed by CNAs . Review of Facility's Indwelling (Foley) Catheter Insertion policy, revised 05/19/25, reflected the policy was updated to required care plan updates with foley catheter within 24 hours of admission, verify resident specific output orders related to diagnosis for foley catheter insertion, and verify resident specific foley change orders with physician monthly or PRN for occlusions and dislodgement. DON audit of all residents with foley catheters, completed on 05/19/25, reflected Resident #1 was the only resident. Orders for catheter care and replacement schedule were reviewed and present. Foley change frequency was ordered. Foley changed as ordered. Care plan reflected foley use. Tracking log was used for foley catheter care residents. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 4 residents review for pharmacy services. The facility failed to carry out Resident #1's orders from the hospital for insulin to control his blood glucose. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with Diabetes Ketone Acidosis (DKA-Diabetes Ketone Acidosis is serious and can be life threatening. DKA is when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy (with a blood serum level of 478. Normal blood serum glucose levels: Fasting blood glucose 70 to 99 mg/dL. Random blood glucose: generally, it should be 125 mg/dL.) . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for high blood glucose, hospitalization, coma and death. Findings included: Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels). Review of Resident #1's hospital discharge orders dated 4/1/2025 reflected: Insulin NPH Hum/Reg 70/30 (Trade name: Novolin 70/30) 15 Units Subcutaneous before Breakfast and Dinner Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: Type 2 diabetes mellitus uncontrolled with hyperglycemia (high blood sugar level), A1c 7.5% - Home regimen; NPH 70/30 15 units b.i.d. - continue at l0u BID due to hypoglycemia - sliding scale insulin, monitor for hypoglycemia Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section I- Active Diagnoses reflected Resident #1 had Diabetes Mellitus. Section N- Medications did not indicate Resident #1 was on insulin. Review of Resident #1's initial physician/NP narrative note written by the MD dated 05/04/2025 reflected: Type 2 Diabetes Mellitus with Foot Ulcer Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing. Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for a catheter, DM. Review of Resident #1's progress notes written by NP dated 05/04/2025 reflected: Type 2 Diabetes Mellitus with Foot Ulcer Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing. Chief Complaint Management of chronic medical conditions including the ones listed above. Review of Resident #1's MAR/TAR reflected no orders for Insulin or blood sugar checks for the months of April and May 2025. Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected: Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure. Review of Resident #1's current hospital records dated 5/17/2025 reflected: He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes ( is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis (is a life threatening condition that occurs when the body has extreme response to infection), UTI (his foley (foley- a medical device that helps drain urine from the bladder when you can't pee on your own) was exchanged in ER), had brown urine with some pus in penile area, possible right lung pneumonia, with AKI. Normal blood serum glucose levels: Fasting blood glucose 70 to 99 mg/dL Random blood glucose: generally, it should be 125 mg/dL. Medlineplus https://medlineplus.gov.ency/article During an interview on 05/19/2025 at 10:01 am LVN B stated he was not aware of Resident #1 needing accu checks (accu check refer to the use of a glucometer to test a patient's blood sugar level) or insulin. During an interview on 05/19/2025 at 11:04 am the DON stated, she knew Resident #1 was diabetic from his referral papers that were faxed over. The DON stated she reviewed Resident #1's admission papers and she didn't see Resident #1 was on Insulin. The DON stated she participated in Resident #1's admission assessments and reviewed his orders from the referral papers sent in February 2025. The DON stated she did not put Resident #1's orders in Point Click Care (PCC- a web based EHR that helps long-term care provider manage the complete lifecycle of a resident care). The DON stated Resident #1 was admitted to the facility with only 2 pieces of paper. The DON stated she called the local hospital for Resident #1's hospital records and was told the records would be faxed over. The DON stated she did not follow up to find out if Resident #1's hospital records were faxed or document that she had called for the hospital records. The DON stated she did not see Resident #1 showing signs or symptoms of Hypo (low) or Hyperglycemia (high blood glucose). The DON stated if a Resident was supposed to get insulin and did not get the insulin, the resident would have hyperglycemia which can lead to DKA and coma. During an interview on 05/19/2025 at 11:43 am the NP stated, Resident #1 was seen once a month because he was non-funded ( no Payal source). The NP stated she had seen Resident #1 twice since he was admitted to the facility. The NP stated she visited with Resident #1 on 5/17/2025. She said he was not responding well, he was unresponsive, and she ordered for him to be sent to the ER for further evaluation. The NP stated she documented on 05/04/2025 that Resident #1 should continue insulin regimen as prescribed, monitor glucose levels and foot ulcer healing based on the MD's previous documentation and Resident #1's hospital records. The NP stated she did not review Resident #1's MAR/TAR for his glucose reading during her visits. The NP stated she did not have access to PCC to put in orders. The NP stated if a resident was ordered insulin and did not get the insulin as ordered, the resident can go into DKA or hyperosmolarity (blood is more concentrated than normal due to dehydration). The NP stated, generally, you want the serum blood glucose around 80 and not more than 200, and 400 plus serum blood glucose can indicate uncontrol diabetes/blood sugar. The NP stated she ordered labs on 5/4/2025 but was not able to get the lab done due to Resident #1's funding. The NP stated she gave the lab ordered sheet to the DON and spoke with the MD regarding that. The NP stated, if the insulin was ordered from the hospital for Resident #1, Resident #1 should have gotten the insulin as ordered. During a phone interview on 05/19/2025 at 12:15 pm RN D stated he worked with Resident #1 but could not remember putting Resident #1's orders in the EMR upon admission. RN D stated he did not recall Resident #1 having orders for accu checks or insulin. RN D stated he had never given Resident #1 insulin or checked his blood glucose level. During an interview on 05/19/2025 at about 12:41 pm, the DON stated the NP gave her a sheet with orders for labs for Resident #1, but the labs were not completed due to Resident's payment source (LOA-Letter of Agreement). The DON stated Resident #1 contract with the hospital only pay for room and boarding only. During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated when a resident is being admitted from the hospital, the admitting nurse was responsible to call the hospital for clarification of orders. She stated, if the Resident was transported to the facility without hospital papers, the admitting nurse is responsible to contact the hospital for discharge papers and follow up on the papers. The Interim Administrator stated the DON was responsible to ensure the nurses were following all orders. The Interim Administrator stated for a resident who was ordered insulin and did not get the insulin, the resident's blood glucose would be high. The Interim Administrator stated the facility missed the insulin order for Resident #1, it was a mistake, and they were working on fixing the problem. The Interim Administrator stated for a Resident with LOA funding, the facility gets paid a flat rate per day through the hospital contract. The Interim Administrator also stated the facility would pay for labs because the Resident had to be taken care of. The Interim Administrator stated that was a misunderstanding. The Interim Administrator stated the MD should be able to see and treat every Resident regardless of their payment source. During a phone interview on 05/19/2025 at 2:45 pm the MD stated he had just reviewed Resident #1's chart and the insulin and accu checks were an error on their part. He stated it was an oversight not looking for the accu check and the insulin administration. The MD stated his office should have realized that Resident #1's insulin was held. The MD stated he was told by the NP that the DON said the insulin was discontinued due to insurance problem/ LOA. The MD stated the facility should have continued with Resident #1's accu checks and stopped the 70/30 insulin when the blood glucose was stable. The MD stated his NP should have asked the facility to monitor Resident #1's blood glucose reading regardless of payment source. The MD stated DKA was considered life threatening, but we can bring the Resident/Patient back from it. He stated DKA can also be triggered by acute infection, but again, the blood glucose should have been monitored before the facility can decide on keeping Resident #1 on the insulin or not. Review of Resident #1's Letter of Agreement dated 04/01/2025 reflected the following: Obligations of Facility a. Facility shall provide quality service to patient without discriminating of the basis of source of payment, gender, nationality, ethnicity, age, or handicap. b. Facility shall invoice Hospital by the 15th of each month for services to patient. An itemized statement will accompany each invoice. c. Facility agrees to provide the following services to the Patient: i. Nursing Care ii. Physical Therapy iii. Speech Therapy iv. Occupation Therapy d. Facility agrees to provide the medications prescribed by transferring physician. A list of the prescribed medications is located in Exhibit A and is included by reference herein. Review of facility's policy titled Reconciliation of Medications on admission dated July 2017 reflected: Purpose The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form. b. Discharge summary from referring facility. c. admission order sheet. d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. 2. Find a quiet place that is free from distractions. General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility. b. Contact the physician from the referring facility. c. Discuss with the resident or family. d. Contact the resident's primary physician in the community. e. Contact the resident's secondary physician(s) in the community. f. Contact the community pharmacy used by the resident; or g. Contact the admitting and/or Attending Physician. The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/20/25 at 12:51 pm. F755 Immediate Jeopardy Removal Actions Taken 1. Immediate Clinical Response o Resident #1 was immediately transferred to the hospital upon identification of altered mental status and signs of sepsis and hyperglycemia on 5/17/2025. o Full head-to-toe nursing assessment completed and documented prior to transfer. o Family and physician were notified promptly. 2. Resident Review & Safety Measures o 100% audit of all current residents with diabetes diagnoses was conducted on [5/19/2025] by Director of Nursing. (Documented on audit tool developed for new admit medication reconciliation) DON was in-serviced before completing audit by Chief Nursing Officer. o Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. o Any missing or incorrect orders were immediately clarified with the physician and implemented. (1 resident) o Any residents found without current diabetic monitoring or medication orders received immediate physician review. (All medications for non-funded residents will be ordered through the pharmacy and charged in the same manner as a skilled resident, facility's responsibility). (All care plans were audited, with 2 updates made to care plans ) 3. Hospital Discharge Order Reconciliation o A new protocol was implemented effective immediately: A licensed nurse and the DON or designee will review all hospital discharge papers at time of admission or return to ensure all orders are entered correctly into the EMR (PCC). (Medication reconciliation form ) The receiving nurse must confirm medication orders, follow-up appointments, and labs on all new and readmitted resident. (This will be tracked daily in the clinical morning meeting by the DON/Designee) Any additional education will be provided to the DON if there are any discrepancies.) Orders will be reviewed by the DON or designee on all admission and noted as reviewed in the EMR. (Within 24 hours after admission) 4. Physician/Nurse Practitioner Notification and Oversight o The facility's Medical Director and NP were re-educated by the Chief Nurse Officer 5/19/25 on the responsibility to review MAR/TAR and hospital discharge notes on every visit. o The facility implemented a process that requires weekly NP review of high-risk residents, including diabetic and non-funded residents. (Medications will be ordered from the pharmacy and cost occurred outside of LOA will be supported by the facility. NP review will be monitored by use of change of condition form) ( Change of condition forms on PCC will be reviewed daily in clinical stand up by DON / Designee to ensure compliance. 5. Education and Training o Emergency in-service conducted on May 19th, 2025, by Director of Nurses to all licensed nursing staff on: ( DON was provided training prior to in-servicing others by CNO. Importance of following hospital discharge orders. Recognizing signs/symptoms of hypo/hyperglycemia. Diabetic care management and documentation requirements. Immediate reporting of missing or unclear orders. (in-service and posttest) o Re-education for DON and ADON on responsibilities during admission/re-admission. (By: CNO) 5/19/25) 6. Monitoring and Quality Assurance o Indefinite Daily audits of all new admissions and re-admissions to ensure: Hospital discharge orders are obtained, reviewed, and implemented timely. Daily review in clinical morning meeting). Medication orders are entered into the EMR correctly. o All audits are reviewed by the Administrator or Regional Nurse Consultant daily. o Ongoing Monthly QA audits will be conducted thereafter and tracked via QAPI. 7. Accountability and Leadership Oversight o DON educated on policy and procedure. ( By: CNO policy reviewed, and DON acknowledged understanding with verbal and written acknowledgment. o Additional coverage and oversight by Chief Nursing Officer ( Weekly X 6 weeks then monthly. The Surveyor monitored the POR on 05/20/2025 from 1:00pm to 7:00 pm as follows: During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs ( LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO and they learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, review residents EHR and verified compliance with physician orders, review MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. They all stated the DON would review orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission. During an interview on 05/20/2025 at 3:40 pm the DON stated she completed a full audit of all current residents with diabetes diagnoses on 05/19/25. Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. The DON stated the CNO in-serviced her before completing the audit on 05/19/25. The DON stated Resident #1 was identified as the only resident with missing or incorrect orders that was immediately clarified with the physician on 05/19/25. The DON stated there were no residents identified as requiring immediate physician review because none were without current diabetic monitoring and medication orders. New protocol immediately implemented by her and licensed nurses on 05/19/25 on reviewing all hospital discharge papers at the time of admission and readmission. The DON stated there were no new admissions nor readmissions since 05/19/25. The DON stated she was conducting daily tracking to ensure receiving nurse confirmed receiving discharge papers and orders at time of admission and readmission. The DON stated she was also reviewing orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission. The DON stated the MD and NP were re-educated by the CNO on 05/19/25 to review MAR/TAR and hospital discharge notes on every visit. The facility also started having NP review weekly high-risk residents on 05/19/25. The DON stated she immediately in-serviced and gave post-tests on all licensed nursing staff on 05/19/25 on importance of following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, and immediate reporting of missing or unclear orders. She was also trained before the in-service by the CNO on 05/19/25. The DON stated the CNO re-educated her on admission/readmission process on 05/19/25. Indefinite daily audits of all new admissions and re-admissions to ensure hospital discharge orders are obtained, reviewed, and implemented timely and medication orders are entered into the EHR correctly. QAPI was conducting monthly reviews thereafter. The DON stated she was educated by the CNO and signed an acknowledgement of the policies and procedures regarding medication administration, physician orders for diabetic's process, and admission/readmission process. CNO would oversee weekly for the next six weeks and then monthly. During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on the importance of admission/readmission process and responsibilities, following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, immediate reporting of missing or unclear orders on 05/19/25. The Interim Administrator/CNO stated the DON also signed an acknowledgement on 05/19/25 before in-servicing the remainder of staff on 05/19/25. The Interim Administrator/CNO stated she reviewed the policy and DON signed acknowledging policy and procedure reviewed on processes. The Interim Administrator/CNO stated she oversaw to ensure processes completed weekly for the next 6 weeks and then monthly. Review of facility's in-services dated 05/19/2025 reflected the following: Facility had an ADHOC QAAC for identification of deficient practice. DON: Review Medication orders on admission: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and signed by the DON. Nurses: Medication Administration: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process, missed dosage of medication due to transcription error presented by the Interim Administrator and the DON signed by Interim Administrator and the DON on behalf of the MD and the NP . Abuse, Neglect and Physician Orders quiz completed by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F Administering Medications policy, revised April 2019, reflected DON was reeducated on policy. Abuse, neglect and physician's orders post-tests were completed by licensed nurses. DON audit of all residents with diabetes diagnoses, conducted 05/19/25, reflected the DON reviewed MAR/TAR reflecting accurate orders, ensured medication reconciliation, diagnosis of diabetes, physician orders, care plans reflect diabetes, glucose monitoring and diabetic care needs, hospital discharge orders reviewed, and insulin ordered and administered as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident# 25) reviewed for elopement and failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 shower rooms reviewed for quality of care. A) The facility failed to ensure Resident #25 was monitored for wandering and elopement. Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away. An immediate Jeopardy (IJ) situation was identified on 05/29/2024 at 1:22 PM. While the IJ was removed on 05/31/2024 at 1:00 PM, the facility remained out of compliance because of the facility's need to evaluate the effectiveness of its corrective systems. This failure places residents at risk for elopement, accidents, and heat exhaustion due to lake of supervision. B) The facility failed to ensure two spray bottles containing a degreaser and a disinfectant were not left in an unlocked shower room. This failure could lead to unintentional ingestion, inhalation or eye contact with chemicals leading to injury and hospitalization . Findings included: A) Review of Resident #25's Face sheet dated 05/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Vertigo (A sense of spinning experienced even when someone is perfectly still.), anxiety disorder, (Fear characterized by behavioral disturbances) and lack of coordination. Review of Resident #25 Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 7 indicating moderate cognitive impairment. Resident #25 was assessed to not have wandering behavior during the assessment period. Resident #25 was assessed to require moderate assist with ADLs. Review of Resident #25's Comprehensive care plan reflected a focus area dated 09/23/22 Resident #25 has impaired cognitive function/dementia or impaired thought processes r/t Dementia, impaired decision making. Further review reflected a focus area dated 01/10/0223 Resident #25 has vertigo related to dizziness. And a focus area dated 07/26/2022 Resident #25 is a wanderer r/t Disoriented to place. He has ideations of wanting to go home and believes he has a vehicle at the community that he can get in and drive. Goals included: The resident's safety will be maintained through the review date and the resident will not leave facility unattended through the review date. Interventions included: Assess for fall risk. Date Initiated: 07/26/2022; Disguise exits; cover door knobs and handles, tape floor. Date Initiated: 07/26/202, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 07/26/2022, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 07/26/2022; Monitor for fatigue and weight loss. Date Initiated: 07/26/2022. Review of Resident #25's nursing progress notes reflected an entry dated 05/13/2024 At approx. 6:25 PM, Resident #25 asked to walk to store, stating they let me do it all the time, I just sign out. This charge nurse verified request with Administrator. This charge nurse was informed that resident cannot leave residence unattended due to being observed breaking the smoking policy and smoking unattended while walking to store on a previous occasion. Resident was mildly argumentative but agreed and verbalized understanding. Further review reflected an entry dated 05/14/2024 at 8:30 PM This resident was observed walking from the facility toward the neighborhood store. Resident stated he went to store to buy candies This charge nurse informed CNA to pick up resident from store due to the fatigue from the walk. The CNA brought resident back to facility. This charge nurse did head to toe assessment. No skin issues noted. Resident denies pain or discomfort at this time. This charge nurse asked resident if he would cooperate with a physical search to make, he doesn't have any unpopular items. Resident refused physical search of himself. Assessed vitals: B/P 124/71, P78, R18, T 98.0. Q 15 min checks initiated. Review of the weather channel website reflected the sunset at the facility on 5/14/2024 was indicated to be at 8:14 PM and the average temperature to be between 82 and 88 degrees Fahrenheit. Review of Google Maps dated 05/14/24 revealed the speed limit on the road Resident #25 walked to be 30 miles per hour and the distance to the store to be 0.4 miles. In an interview on 05/28/2024 at 3:02 PM the Administrator stated the incident with Resident #25 was not reported to the state. She stated he did leave the facility and he did not sign out and the facility did not know where he was. She stated it was not an elopement he just went to the store unattended he likes to get cigarettes. She stated again it was not an elopement, but a behavior and we discourage him from going. Administrator stated she did not know if he was his own responsible party. In an interview on 05/28/2024 at 3:10 PM the DON stated she did not do an investigation of Resident #25's elopement just what was in the nursing notes she stated he had some confusion, but he was pretty much with it. Review of Resident #25's consolidated physician orders reflected an order dated 05/11/2024 Hydrocodone-Acetaminophen 10-325mg by mouth four times daily for low back pain. Further review reflected an order dated 12/05/2022 Meclizine HCL 12.5mg one tablet every 6 hours for vertigo. Review of Resident #25's Behavioral Health care note dated 05/17/2024 This is a follow-up visit and the staff reports that the patient continues to have occasional mood swings and depression. Staff stated that the patient left and went to the store without permission. He started yelling at caregivers and refused to be checked when he came back .Patient stated that he went to the store to buy cigarettes. He denied yelling at staff though and stated that he is a grown man and can do whatever he wants . In an interview on 05/28/2024 at 3:18 PM CNA E she stated that Resident #25 wanders, but she has never seen him leave she stated she was told if he tries to leave, and we caught him that we are to put him on 15 min checks. She stated he was pretty much with it. In an interview on 05/28/2024 at 3:20 PM Resident #25 stated he feels comfortable going out by himself stated he likes to go get M&Ms. He stated, They won't take me, so I just take off, It's only a quarter of mile. Observation on 05/28/2024 at 3:36 PM revealed both the front and back exit doors without locks and an alarm that was barely audible. In an interview on 05/28/2024 at 10:32 AM the DON stated Resident #25 did not elope she stated he was alert. When asked if anyone knew he was gone, she stated no. She further stated he has had an increase in narcotic use due to a fall and complaints of hip pain. She stated she has heard of his behaviors of confusion and wandering but has not seen any. She did not know what the facility's policy was regarding elopement. She stated the nurses could not see the front door from the nurse's station and they could not hear the door alarms from there. Review of Resident #25's EMR reflected an elopement assessment dated [DATE] (no previous elopement assessments were done.) Review of the elopement assessment reflected Resident #25 was assessed to have a 12-elopement risk score indicating he was at risk for elopement. In an interview on 05/29/2024 at 10:38 AM LVN A stated she had been here for about 2 weeks; she stated Resident #25 was alert and knows what is going on. She stated she was told he likes to go to the store, but he was not supposed to go. LVN A stated she cannot see the doors or hear the alarms. She further stated she did not think it was safe for Resident #25 to go to the store alone. In an interview on 05/29/2024 at 11:20 AM Resident #25's facility Physician stated regarding Resident #25's cognitive status It depends she stated she was aware he has left in the past and has had a recent increase in his pain medication. She stated sometimes he is confused and not aware of his safety needs and other times he is aware of his needs. In an interview on 05/29/2024 at 11:42 AM the facility RN C stated an elopement was when someone would leave the facility and does not come back. She stated resident #25 was found at the store and he did not sign out, but he knows where he is going, she stated the facility did not report the incident because they did not feel like it was an elopement because they figured he went to the store. When asked if the facility knew when he left or how long he was gone the RN C stated they did not. In an interview on 05/29/2024 at 11:50 AM Resident #25's RP stated his dad should definitely be supervised and should not walk all the way to the store on his own. He stated Resident #25 did not handle the heat very well. He stated he has episodes of confusion and states he wants to go home sometimes. He stated sometimes he is fine but should definitely be supervised. In an interview on 05/29/2024 at 2:39 PM CNA G stated he was working when Resident #25 left the faciity on [DATE]. He stated he took the residents out on their last smoke break around 6:00 PM or 6:30 PM and he stated Resident #25 stayed outside on the back porch after the break. CNA G stated he was ok to be outside by himself just not to smoke. He stated the RN charge nurse told him she thought Resident #25 had left the facility because a resident told her she saw him leave and to go get him. CNA G stated he left to go get him after he finished the shower he was giving. CNA G stated Resident #25 was at the railroad tracks coming back to the facility. He stated it was still daylight. CNA G stated he was not sure what time it was he stated Resident #25 told him he wanted candy and that was why he left the building. CNA G stated Resident #25 came back without issues. In an interview on 05/30/2024 at 1:53 PM the DON stated regarding Resident #25's elopement and updating his care plan to include his behavior, she stated Well that is questionable when asked why she stated, I did not think he eloped. The DON stated care plans should be updated after changes in condition or behavior and failure to do so could cause staff to overlook something that could affect the resident's care. Attempts to contact RN Charge Nurse on 05/28/2024 at 3:25 PM, 05/29/2024 at 2:00 PM and 5/30/2024 at 10:30 AM were unsuccessful. B) Observation on 05/29/2024 at 1:15 PM in the unlocked shower room revealed two spray bottles hanging from hooks on the wall above the linen cart and approximately 6 feet from the floor. The linen cart was located in a indented area of the wall. One bottle was labeled Non-acid Restroom Cleaner Disinfectant, and the other bottle was labeled a Degreaser. Both bottle labels were from the same chemical company. Both bottles stated Warning: causes eye irritation. Avoid contact with eyes, skin, and clothing. Wash hands and affected area thoroughly after handing. First aid: If in eyes: rinse cautiously with water for several minutes. Continue rinsing for 15 minutes. If eye irritation persists, get medical attention. If on skin: Wash with plenty of water, if skin irritation persists, get medical attention. See label on original container for complete direction for use and additional information. Keep out of reach of children. Review of the product Material Safety Data Sheet for the Non-Acid Restroom Cleaner Disinfectant found online at the manufacturer's website reflected If swallowed, rinse mouth. Do not induce vomiting without medical advice. If conscious, dilute by drinking up to a cupful of milk or water as tolerated. If inhaled, move the person to fresh air and keep comfortable for breathing. Start first aid. Immediately call a poison control center or physician. Classification: eye damage, skin irritation and acute toxicity. Hazard statements: Causes serious eye damage and skin irritation. Harmful if swallowed. In an observation and interview on 05/29/2024 at 3:25 PM in the shower room, the ADM stated the chemicals in the spray bottles were not a brand that the facility used. She opened one bottle, sniffed it, and stated it's just vinegar. Observation in the shower room on 05/29/2024 at 4:40 PM revealed the spray bottles had been removed. In an interview on 05/30/2024 at 3:37 PM the DON stated her expectation was that chemicals should be locked up as the potential risk to the resident could be their skin might break out. She stated she had removed them from the shower room when informed by the ADM that they were in there. In an interview on 05/30/2024 at 4:25 PM the ADM stated chemicals should be locked up and the risk to the resident depends on the chemical. She again stated the chemicals she observed in the shower room were not a brand that the facility used. She had no further comment. Review of an undated facility policy and procedure titled Material Safety Data Sheet reflected Policy Statement: A current Material Safety Data Sheet (MSDS) will be obtained and kept on file for each hazardous chemical stored or used in our facility. The program coordinator is responsible for receiving and reviewing all material safety data sheets (MSDSs) before chemicals are used by employees. Review of the MSDS book for the facility did not include the Material Safety Data Sheets for the two spray bottles found in the shower room. Review of an undated facility policy and procedure titled Location of Hazardous Chemicals reflected Hazardous chemicals and/or materials are maintained in the following locations: housekeeping closet, maintenance closet, maintenance office, kitchen, dietary storage, storage shed. B) Observation on 05/29/2024 at 1:15 PM in the unlocked shower room revealed two spray bottles hanging from hooks on the wall above the linen cart and approximately 6 feet from the floor. The linen cart was located in a indented area of the wall. One bottle was labeled Non-acid Restroom Cleaner Disinfectant, and the other bottle was labeled a Degreaser. Both bottle labels were from the same chemical company. Both bottles stated Warning: causes eye irritation. Avoid contact with eyes, skin, and clothing. Wash hands and affected area thoroughly after handing. First aid: If in eyes: rinse cautiously with water for several minutes. Continue rinsing for 15 minutes. If eye irritation persists, get medical attention. If on skin: Wash with plenty of water, if skin irritation persists, get medical attention. See label on original container for complete direction for use and additional information. Keep out of reach of children. Review of the product Material Safety Data Sheet for the Non-Acid Restroom Cleaner Disinfectant found online at the manufacturer's website reflected If swallowed, rinse mouth. Do not induce vomiting without medical advice. If conscious, dilute by drinking up to a cupful of milk or water as tolerated. If inhaled, move the person to fresh air and keep comfortable for breathing. Start first aid. Immediately call a poison control center or physician. Classification: eye damage, skin irritation and acute toxicity. Hazard statements: Causes serious eye damage and skin irritation. Harmful if swallowed. In an observation and interview on 05/29/2024 at 3:25 PM in the shower room, the ADM stated the chemicals in the spray bottles were not a brand that the facility used. She opened one bottle, sniffed it, and stated it's just vinegar. Observation in the shower room on 05/29/2024 at 4:40 PM revealed the spray bottles had been removed. In an interview on 05/30/2024 at 3:37 PM the DON stated her expectation was that chemicals should be locked up as the potential risk to the resident could be their skin might break out. She stated she had removed them from the shower room when informed by the ADM that they were in there. In an interview on 05/30/2024 at 4:25 PM the ADM stated chemicals should be locked up and the risk to the resident depends on the chemical. She again stated the chemicals she observed in the shower room were not a brand that the facility used. She had no further comment. Review of an undated facility policy and procedure titled Material Safety Data Sheet reflected Policy Statement: A current Material Safety Data Sheet (MSDS) will be obtained and kept on file for each hazardous chemical stored or used in our facility. The program coordinator is responsible for receiving and reviewing all material safety data sheets (MSDSs) before chemicals are used by employees. Review of the MSDS book for the facility did not include the Material Safety Data Sheets for the two spray bottles found in the shower room. Review of an undated facility policy and procedure titled Location of Hazardous Chemicals reflected Hazardous chemicals and/or materials are maintained in the following locations: housekeeping closet, maintenance closet, maintenance office, kitchen, dietary storage, storage shed. Review of the facility's policy Elopements (not dated) reflected Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. The Administrator was notified on 05/29/2024 at 1:22 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/30/2024 at 5:01 PM: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F689 On 05/29/2024 at approximately 1:20 PM, the facility was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Supervision (F689) noncompliance. The surveyor provided an Immediate Jeopardy (IJ) Template notification via email that the Regulatory Services has determined that Immediate action is required to ensure residents are safety. Action: o On 5/29/24 R25 was immediately placed on every 15 min checks Nurse or designee will be assigned to do the monitoring and documentation on paper indicated q 15 min visual checks, Director Of Nursing or Nurse manager will oversee to make sure it's being completed, until the facility can transfer R25 to another facility with secure unit, waiting on approval from facility that has a secure unit, clinicals were sent. o On 5/29/24 Director of Nursing/nurse managers Immediately reviewed residents with Dementia diagnosis or wandering behaviors for elopement risk, all resident's elopement risk assessment was completed to determine risk level, 1 Resident #R25 was only identified to be at risk for elopement at this time. Elopement assessments will be completed on admission and if changes in mental cognition, and yearly. o On 5/29/24 Regional Director of Clinical Operations in-service Administrator/Director of Nursing on Provider Letter for investigation and reporting Elopement to the state. Administrator/ or designee Immediately in-service all staff Full time, Part- Time and PRN, in person and those not present were in-service via phone, 100% completion on elopement policy, exit seeking behaviors per policy, safety and supervision. New employees will be trained as part of their orientation. o On 5/29/24 Maintenance inspected the Alarms at the door entrance and exits for proper functioning, he identified the volume was low and was able to increase volume for staff to hear if someone was exiting. Door locking mechanisms were inspected for both front and dining room doors and were found to be in working order, doors will be locked after visiting hours between 10pm and 6am. o On 5/29/24 MDS nurse reviewed all residents who have diagnosis of Dementia, to make sure interventions and correct supervision were in place for the nursing staff to be able to see in the electronic health record (EHR). Director of Nursing in-service the Nursing staff in person, and the nursing staff not present were in-service via phone on where to find in the information in the care plan and Kardex (nurse to nurse communication form). o Please review and accept this Plan of Removal. All items above have been completed with completion date and time May 30,20024 The Survey Team monitored the POR on 05/29/2024 through 5/31/2024 as followed: Review of nursing notes dated 05/29/2024 reflected an entry at 12:56 PM the DON spoke with resident's RP, notified him that resident will need to be transferred to locked unit and there is a room available at another facility, we will be sending records to them. He expressed understanding. Review of the facility's 24-hour 1:1 Monitoring and Safety check for Resident #25 reflected the monitoring started 05/29/2024 at 11:15 AM and ongoing. In an interview on 05/31/2024 at 10:58 AM the DON stated she was checking the sheet two times per shift to make sure it was done. Review of the 1:1 in-service for Administrator and DON reflected in-services were conducted on 05/29/2024 regarding elopement, and the provider letter safety/ supervision. The in-service was signed by the RNC as the trainer and the Administrator and DON as the recipients of the training. In an interview on 05/31/2024 at 11:10 AM the Administrator stated she was provided a 1:1 in-service from the RNC and was given instruction on elopements, starting to lock the doors at night, activate alarms and replaced broken alarms and purchasing a door bell. Administrator stated was instructed to report elopements as soon as it is reported to her. In an interview on 05/31/2024 at 11:11 AM the DON stated she was instructed on elopement. She stated when an elopement occurs staff should try to stop the resident from leaving and place them on every 15 min checks. She was also instructed that the incident should be reported the State. She stated, I think the confusion came from us not thinking his leaving was an elopement. She stated she was aware now that it was considered an elopement if the resident leaves and the facility was not aware. Review of the in-service training provided to the facility staff by the RNC dated 05/29/2024 through 05/31/2024 reflected the topic was elopement, safety, supervision, and unauthorized departures. The in-service was signed by 31 of the 38 total employees. In an interview on 05/31/2024 at 11:30 AM the DON stated the employees not yet in serviced will be in serviced before they come to work. In an interview on 05/30/2024 at 3:18 PM CNA G stated, We had an in-service about the difference in elopement and leave without signing. Elopement is when they leave with no one knowing and the other is when they tell someone first. Stated they are to monitor for these behaviors and if some is trying to leave, they have to be put on every 15 min checks. In an interview on 05/30/2024 at 4:30 PM LVN Charge nurse LVN A she stated she was trained on elopement, and they are doing q15 min checks on Resident #25. She stated they told her that if they do have a resident that is missing to notify administration right away. She stated she was also told to make sure the front door is locked at 10 pm if she is working the evening shift. In an interview on 05/31/2024 at 11:38 AM LVN B she stated she was trained on elopement, and they are doing q15 min checks on Resident #25. She stated they told her that if they do have a resident that is missing to notify administration and to make sure the door alarms are on and working. In an interview on 05/31/2024 at 11:58 AM CNA Y stated she was in-serviced on elopement and monitoring residents that try to leave and to notify nurses if it occurs. She stated elopement was when a resident leaves and you did not know about it. Also, to keep an eye on Resident #25 every 15 min. In an interview on 05/31/2024 at 12:05 PM CNA J (night) stated she was in-serviced over the phone and was instructed the doors are to be lock at 10:00 PM till 6:00 AM and monitor wandering behaviors. They talked about elopement and to report to nurse if someone is missing. In an interview on 05/31/2024 at 12:20 PM CNA K stated she was in serviced on 05/29/2024 about residents leaving and if a resident is trying to leave tell the nurse and put them every 15 min checks and if they get out to tell charge nurse right away. Also, to keep doors locked at night now. In an interview with the Maintenance supervisor on 05/31/2024 at 11:38 AM checked all door alarms and replaced with louder alarms. Inspected the door locking mechanisms and all were working. Was in-serviced on elopement and monitoring residents for behavior. Observation on 05/31/2024 at 11:45 AM revealed alarms working on all exit doors and alarms are audible. Review of the list of Dementia residents provided by the facility reflected 14 residents. Review of the 14 Resident EMR's reflected elopement assessment done. No high risk for elopement was identified. On 05/31/2024 at 2:00 PM the facility was notified the IJ was lowered to no actual harm with the potential for more than minimal harm. 28689

Based on observation, interview and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility ensured residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care for one of five residents (Resident #1) reviewed for wound assessment and change of condition when: The facility failed to ensure LVN A assessed and reported a change in skin integrity for Resident #1 when CNA D reported to LVN A on 08/19/22 that Resident #1 had new skin breakdown and was identified on 08/25/22 to have an unstageable deep tissue injury to her right buttock, and three Stage III pressure ulcers to her left buttock not previously identified by the facility. These failures resulted in an Immediate Jeopardy (IJ) situation on 08/26/22 at 1:10 PM. While the IJ was removed on 08/30/22, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed facility residents at risk for worsening pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood) severe pain, and loss of limbs. Findings included: Review of Resident #1's face sheet dated 08/25/22 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. Resident #1 was assessed to not have behaviors of rejecting care. Resident #1 was further assessed to require extensive two person assist with bed mobility; to have an indwelling catheter; to be at risk for pressure ulcer development and to not have pressure ulcers during the assessment period. Review of Resident #1's Braden scale for predicting pressure sore risk dated 07/26/22 reflected Resident #1 score was 15 indicating she was at risk for pressure ulcer development. Review of the Resident #1's comprehensive care plan reflected a focus area with the initiated date 08/16/22 The resident has partial thickness non-pressure wounds to left buttock and left thigh related to immobility. Interventions included assess/ record/ monitor wound healing weekly; measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress; report improvements decline to MD. Further review of Resident #1's comprehensive care plan reflected a focus area with the start date 08/16/22 The resident has actual impairment to skin integrity of the heels bilaterally related to unstageable deep tissue injury due to immobility. Further review of Resident #1's comprehensive care plan reflected no plan of care for risk for pressure ulcer development or interventions to prevent pressure ulcer development prior to Resident #1 developing pressure ulcers on 08/16/22. Observation and interview on 08/25/22 at 1:27 PM, reflected Resident #1 in her room in bed alert and oriented. CNA C and CNA D were in the room to provide care to Resident #1. Resident #1 stated she was paralyzed and unable to feel her feet. She stated she had a fall at home and her F4 vertebrae severed her spinal cord. She stated the facility put her on an air mattress after the wounds on her bottom and her heels were discovered. She stated when she first arrived at the facility, she was not getting a bath or shower but has recently been getting showers every other day. She stated she came from the hospital and did not have any wounds. She stated the nurses do not come and check her skin weekly and the nurses do not do treatments to her wounds. Resident #1 stated the nurse aides put cream on her bottom. Resident #1 stated she told the staff for two weeks her bottom was hurting before anyone did anything. CNA C and CNA D using incontinent care wipes began removing the cream to her right buttock. Resident #1's wound was covered in a heavy layer of cream which obscured the wound. During the removal of the cream by the CNAs areas of Resident #1's skin was also removed with the cream. Observation of Resident #1's Right buttock after the removal of the cream revealed a partial thickness open pressure ulcer 4 cm x 6 cm to right buttock with a 3.5 cm x 3 cm area of DTI in the center of the pressure ulcer. The peri wound extended 4 cm around the wound and the skin was dry and peeling off. Further observation revealed three full thickness pressures ulcers (Stage III) to Resident #1's left buttock (no dressings were noted to wounds.) Observation of Resident #1 heels reflected heel protectors on (not EZ boots- EZ boots suspend the heel to prevent pressure which the heel protectors do not) Resident #1 had unstageable pressure ulcers to both heels. In an interview on 08/25/22 at 3:30 PM, CNA C stated herself, CNA D, and CNA E got Resident #1 up to take a shower on 08/19/22. She stated she saw a big sore on Resident #1's right buttocks and between her buttock on the left. She stated she documented the sore on the shower sheet as open sores on the left buttocks, and the right buttocks. She stated she told LVN A about the open sores on 8/19/22, and LVN A told her to put cream on the sores. CNA C stated LVN A did not go and look at the open sores on Resident #1. Review of Resident #1's Shower Sheet dated 08/19/22 reflected CNA C documented open areas to Resident #1's right buttock, left buttock and black spots to her right and left heels. The shower sheet was signed by CNA C and initialed by LVN A. In an interview on 8/25/22 at 2:47 PM, the Wound Care Physician stated he was notified of skin breakdown for Resident #1 on 08/15/2022. He stated he saw Resident #1 on 08/22/22, and he saw her left buttocks. He stated there was a small break down of skin, and he did not see the right buttocks because there was cream on it. He stated he was informed about Resident #1 heels on 08/15/2022 as well, but he did not know about any sore on Resident #1's right buttocks. He stated the facility might have known about the sore on Resident #1's right buttocks, but he was not informed. The Wound Care Physician stated he was informed of the sore on Resident #1's right buttocks on 08/25/22 because he received a picture from a nurse at the facility. He stated from the picture he received it looked more like a pressure wound than a moisture wound due to how deep the wound looks. He stated it would take a lot of moisture to break down skin and penetrate deep and he would need to alter the resident's treatment orders. In an interview on 08/25/22 at 4:16 PM, LVN A stated she was made aware of the open sore on Resident #1's right buttocks and new areas on the left buttock by a CNA. Stated she did not feel the need to go look at the sores on 08/19/22. She stated sometimes CNAs over exaggerate on the shower assessments, and she thought it was just the same skin tears she previously called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Stated she did not call the doctor on 08/24/22 because she did not want to overstep the DON. In an interview on 08/30/22 at 10:30 AM, the Administrator stated he expected the nursing staff to assess residents and to notify the physician if there are any changes. He stated he could not believe LVN A disregarded the CNAs reports of skin changes, and she has been terminated. He stated when he called her, she told him she did not go an assess the resident and the only explanation given was that the CNAs exaggerate. Review of the facility's Policy Skin Integrity (not dated) reflected Ensure the resident does not develop pressure ulcers/ injuries unless clinically unavoidable and that the community provides care and services consistent with professional standards of practice .Review any skin issues from weekly skin assessment. Daily review of shower sheets during morning meeting and follow up during stand down meetings .The residents' physician must be notified/ consulted regarding the status of the PU/PI and prescribe treatment . An Immediate Jeopardy (IJ) was identified on 08/26/22 at 1:10 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 08/28/2022 at 8:37 PM and is as follows: ABATEMENT PLAN: Treatment/Services to Prevent/Heal Pressure Ulcers This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Immediately upon notification Resident #1 was reassessed on 08/26/22 by Medical Director and DON to ensure no change in condition noted. DON reclarified the orders with the Wound Care Physician on 08/26/22 and orders were implemented. All residents at risk for pressure ulcers have the potential to be affected by the alleged deficient practice. A facility-wide skin audit was initiated on 08/26/22 to ensure that all residents have been assessed for any skin alterations. Any new changes in condition related to skin will be identified immediately and appropriate intervention will be implemented. The audits were conducted by the DON and MDS Coordinator. No new skin alterations have been identified at this time. The audit will be completed on 08/26/22. Resident #1's care plan was updated to reflect the resident is at risk for pressure ulcer and noted each wound present. On 08/26/22, the Administrator, and DON, initiated educational in-service training to the licensed nurses regarding communicating with the physician any new skin with alterations, providing detailed description of wound to the physician, obtaining new treatment orders and documenting any new treatment orders received from the physician for the skin alterations. Charge Nurses will document in the 24 hour report any new skin alterations and treatment orders to ensure communication is ongoing and will be monitored by the DON. DON, or designee, will review the 24-hour communication board in Point Click Care daily, including the weekends to ensure new skin alterations have been addressed, Administrator will be responsible to ensure this happens. All in-services will be done by 08/26/22. Licensed staff will not be allowed to work until they receive the training which will be conducted by the DON or MDS Coordinator, this has been completed as of 08/26/22. This is a permanent enhancement to our policy to improve upon our communication and monitoring process. New hire nurses will be provided this training by the DON or MDS Coordinator prior to working the floor and it will be the responsibility of the Administrator to ensure this occurs. On 08/26/22 Charge Nurses were provided training by Administrator and/or DON to communicate that shower sheets are to be reviewed and all new skin areas noted by CNAs are to be addressed immediately and the physician is to be notified and orders implemented. DON will review shower sheets in morning clinical meeting to confirm new skin concerns were addressed by charge nurse and will be responsible for monitoring the process. This is a permanent enhancement to our policy to improve upon our communication and monitoring and ensure processes are carried out timely. Current CNAs will be reeducated on this process as well and education will be completed on 08/27/22. New hire nurses and CNAs will be provided this training by the DON or MDS Coordinator prior to working the floor. Weekly Wound Report will be completed by DON for residents with pressure ulcers and sent to the physician for review each week. This process was put into place on 08/26/22 and discussed with the Medical Director and this will be a permanent process. Educational in-service by the Administrator began on 08/26/22 to the DON and MDS Coordinator regarding this enhancement and will be completed on 08/26/22. The DON will be responsible for monitoring and if absent the MDS Coordinator will be responsible. On 08/26/22 Charge Nurses were provided an in-service by the Administrator and/or DON to ensure that they round with the Wound Care Physician during his visits and follow up and clarify any orders that they put in place during their visit. This process will be in place immediately and monitored by the ADON. Charge Nurses not present were contacted via phone and new hire nurses will be provided this training upon hire prior to working the floor. DON, or MDS Coordinator in the DONs absence, will review the Wound Care Physicians notes after each visit to ensure all orders are implemented correctly. On 08/27/22 CNAs were provided education by the Administrator and DON to report skin concerns to the charge nurse and if not immediately addressed by the charge nurse they are to contact the DON or the Administrator to ensure all new skin alterations are addressed. Ad-Hoc QAPI meeting was held on 08/26/2022 to review the alleged deficiency and the review of the trainings provided to the nurses as listed above. The medical director was involved with the review and the plan of removal. The Administrator will be responsible to ensure the plan is completed by 08/27/2022. The Survey team monitored the plan of removal as follows: Monitoring was conducted from 08/27/22 through 08/30/22. Review of the facility-wide skin audit initiated by the facility on 08/26/22 reflected all residents were assessed and no new skin alterations were identified. Review of Resident #1's care plan reflected her plan of care was updated to include in risk for skin break and interventions to prevent further skin breakdown. Review of in-service training to licensed nurses regarding communicating with the physician new skin alterations and providing detailed descriptions of the wounds reflected all licensed staff were in-serviced. Review of in-service training to licensed nurses regarding follow up on shower sheets reflected all licensed staff were in-serviced. Review of the new weekly wound report to be completed by the DON reflected the process was initiated by the DON. Review of in-services training to CNAs regarding reporting skin concerns and the process for reporting charge nurses if the skin concerns are noted addressed reflected 70 % of staff were in-serviced. In an interview on 08/27/22 at 12:20 PM, CNA D stated she received in services on 8/25/2022 over reporting skin sheets. She stated she received in services on 8/27/2022 regarding shower sheets, and how to describe skin situations. She stated the CNA's have to put red, rash, or open on the skin sheets, and also inform the nurses. In an interview on 08/27/22 at 12:35 PM, LVN H stated she was in serviced on Resident #1. She stated she was told to report any changes, or anything unusual. Stated the CNAs are to report it to the charge nurse first. She stated if the charge nurse is unavailable, they have to report it to the DON. In an interview on 08/27/22 at 1:07 PM, CNA I stated she was in serviced on Resident #1 on 08/25/22, and 08/27/22. She stated she was told that if any skin condition arises, she has to chart it in POC and alert the nurses of the situation. She stated if the nurse is not available they were told to alert the DON, or the administrator. In an interview on 8/27/22 at 1:30 PM, Resident #1 stated she is receiving way better care at this time. She stated she just hopes the care remains the same, and if she need's she knows how to report it. She stated the nurses are paying more attention to her wound and treating it. On 08/3022 at 11:00 AM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of five residents reviewed for pressure ulcers. The facility failed to ensure Resident #1 who was admitted to the facility without pressure ulcers did not develop unstageable pressure ulcers on her bilateral heels, an unstageable deep tissue injury to her right buttock, and three Stage III pressure ulcers to her left buttock. Once developed the facility failed to follow physician orders for treatment, and to notify the physician of the development of new pressure ulcers. These failures resulted in an Immediate Jeopardy (IJ) situation on 08/26/22 at 1:10 PM. While the IJ was removed on 08/30/22, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood), severe pain or death. Finding Include: Review of Resident #1's face sheet dated 08/25/22 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. Resident #1 was assessed to not have behaviors of rejecting care. Resident #1 was further assessed to require extensive two person assist with bed mobility; to have an indwelling catheter; to be at risk for pressure ulcer development and to not have pressure ulcers during the assessment period. Review of Resident #1's Braden scale for predicting pressure sore risk dated 07/26/22 reflected Resident #1 score was 15 indicating she was at risk for pressure ulcer development. Review of the Resident #1's comprehensive care plan reflected a focus area with the initiated date 08/16/22 The resident has partial thickness non-pressure wounds to left buttock and left thigh related to immobility. Interventions included assess/ record/ monitor wound healing weekly; measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress; report improvements decline to MD. Further review of Resident #1's comprehensive care plan reflected a focus area with the start date 08/16/22 The resident has actual impairment to skin integrity of the heels bilaterally related to unstageable deep tissue injury due to immobility. Further review of Resident #1's comprehensive care plan reflected no plan of care for risk for pressure ulcer development or interventions to prevent pressure ulcer development prior to Resident #1 developing pressure ulcers on 08/16/22. Review of Resident #1's Baseline Care Plan dated 07/26/2022 reflected Resident #1 had no skin risk. Review of Resident #1's admission assessment dated [DATE] reflected Resident #1 was assessed to not have pressure ulcers. Review of Resident #1's weekly skin assessments reflected an assessment was done on 07/29/22 and 8/5/22 with no pressure areas noted. Review of Resident #1's weekly skin assessment dated [DATE] reflected Resident #1's bilateral heals were boggy with purple black discoloration. No other assessment or description was documented. The assessment further documented shearing to left buttock with shearing measuring 4.5 cm x 4.5 cm and shearing to left posterior thigh measuring 2.5 cm x 5.5 cm. Review of Resident #1's Wound Physician assessment dated [DATE] reflected Resident #1 had an unstageable DTI (deep Tissue injury) to her left heal measuring 3.2 cm x 2 cm with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's EMR reflected no Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's EMR reflected an entry on Resident #1's TAR to float heels. Heel protectors while in bed. Review of Resident #1 wound MD assessment dated [DATE] reflected a deterioration of the right heel with an order change to apply [MEDICATION(S)] Review of Resident #1's physician orders reflected no update to the orders or TAR to include the change of order. In an interview on 08/25/22 at 11:23 AM, the MDS Coordinator stated Resident #1 was admitted into the facility on [DATE]. She stated Resident #1 was admitted without pressure ulcers. She stated she was informed by the charge nurse on 08/14/2022 about the pressure sores on Resident #1. She stated the wound care doctor was informed on 08/15/2022 about the pressure sore on the left buttock, and the heels of Resident #1's feet. She stated she did not know about the injury on the right buttocks until 08/25/2022. Observation and interview on 08/25/22 at 1:27 PM, reflected Resident #1 in her room in bed alert and oriented. CNA C and CNA D were in the room to provide care to Resident #1. Resident #1 stated she was paralyzed and unable to feel her feet. She stated she had a fall at home and her F4 vertebrae severed her spinal cord. She stated the facility put her on an air mattress after the wounds on her bottom and her heels were discovered. She stated when she first arrived at the facility, she was not getting a bath or shower but has recently been getting showers every other day. She stated she came from the hospital and did not have any wounds. She stated the nurses do not come and check her skin weekly and the nurses do not do treatments to her wounds. Resident #1 stated the nurse aides put cream on her bottom. Resident #1 stated she told the staff for two weeks her bottom was hurting before anyone did anything. CNA C and CNA D using incontinent care wipes began removing the cream to her right buttock. Resident #1's wound was covered in a heavy layer of cream which obscured the wound. During the removal of the cream by the CNAs areas of Resident #1's skin was also removed with the cream. Observation of Resident #1's Right buttock after the removal of the cream revealed a partial thickness open pressure ulcer 4 cm x 6 cm to right buttock with a 3.5 cm x 3 cm area of DTI in the center of the pressure ulcer. The peri wound extended 4 cm around the wound and the skin was dry and peeling off. Further observation revealed three full thickness pressures ulcers (Stage III) to Resident #1's left buttock (no dressings were noted to wounds.) Observation of Resident #1 heels reflected heel protectors on (not EZ boots- EZ boots suspend the heel to prevent pressure which the heel protectors do not) Resident #1 had unstageable pressure ulcers to both heels. In an interview on 08/25/22 at 1:35 PM, CNA D stated Resident #1 has had the area on her left and right buttock for over a week. She stated the area on her right buttock was a big blister before it opened up. In an interview on 08/25/22 at 1:40 PM, LVN G stated Resident #1 did not really have dressing orders for the areas on her buttock. She stated they are just putting the cream on the coccyx and buttock. She stated to her knowledge there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 heels. LVN G stated they were just floating Resident #1 heels. LVN G stated the facility did not have a treatment nurse and the weekly assessments are done by the weekend RN, but the weekend RN has not been at the facility for a while. LVN G stated if the nurses are assigned to do skin checks then they do them in the computer. She stated the facility has been going back and forth from the nursing staff doing them or the weekend nurse doing the skin checks. She stated she was out for 2 weeks with COVID and has seen Resident #1 maybe 3 times over the past 2-3 weeks and was not aware of the pressure ulcers. In an interview on 08/25/22 at 3:30 PM, CNA C stated herself, CNA D, and CNA E got Resident #1 up to take a shower on 08/19/22. She stated she saw a big sore on Resident #1's right buttocks and between her buttock on the left. She stated she documented the sore on the shower sheet as open sores on the left buttocks, and the right buttocks. She stated she told LVN A about the open sores on 8/19/22, and LVN A told her to put cream on the sores. CNA C stated LVN A did not go and look at the open sores on Resident #1. Review of Resident #1's Shower Sheet dated 08/19/22 reflected CNA C documented open areas to Resident #1's right buttock, left buttock and black spots to her right and left heels. The shower sheet was signed by CNA C and initialed by LVN A. In an interview on 8/25/22 at 2:47 PM the Wound Care Physician stated he was notified of skin breakdown for Resident #1 on 08/15/2022. He stated he saw Resident #1 on 08/22/22, and he saw her left buttocks. He stated there was a small break down of skin, and he did not see the right buttocks because there was cream on it. He stated he was informed about Resident #1 heels on 08/15/2022 as well, but he did not know about any sore on Resident #1's right buttocks. He stated the facility might have known about the sore on Resident #1's right buttocks, but he was not informed. The Wound Care Physician stated he was informed of the sore on Resident #1's right buttocks on 08/25/22 because he received a picture from a nurse at the facility. He stated from the picture he received it looked more like a pressure wound than a moisture wound due to how deep the wound looks. He stated it would take a lot of moisture to break down skin and penetrate deep and he would need to alter the resident's treatment orders. In an interview on 08/25/22 at 4:16 PM, LVN A stated she was made aware of the open sore on Resident #1's right buttocks and new areas on the left buttock by a CNA. She stated she did not feel the need to go look at the sores on 08/19/22. She stated sometimes the CNAs over exaggerate on the shower assessments, and she thought it was just the same skin tears she previously called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not call the doctor on 08/24/22 because she did not want to overstep the DON. In an interview on 08/25/22 at 4:31 PM, the DON stated she did not call the doctor on 08/24/22 after the skin assessment. She stated she became swamped on 08/24/22 and just did not make the call to the doctor. In an interview on 08/30/22 at 10:30 AM, the Administrator stated he expected the nursing staff to assess residents and to notify the physician if there are any changes. He stated he could not believe LVN A disregarded the CNAs reports of skin changes, and she has been terminated. He stated when he called her, she told him she did not go an assess the resident and the only explanation given was that the CNAs exaggerate. Review of the facility's Policy Skin Integrity (not dated) reflected Ensure the resident does not develop pressure ulcers/ injuries unless clinically unavoidable and that the community provides care and services consistent with professional standards of practice .Review any skin issues from weekly skin assessment. Daily review of shower sheets during morning meeting and follow up during stand down meetings .CNAs are responsible for reporting any new skin conditions to their nurse on duty .The residents' physician must be notified/ consulted regarding the status of the PU/PI and prescribe treatment . An Immediate Jeopardy (IJ) was identified on 08/26/22 at 1:10 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 08/28/2022 at 8:37 PM and is as follows: ABATEMENT PLAN: Treatment/Services to Prevent/Heal Pressure Ulcers This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Immediately upon notification Resident #1 was reassessed on 08/26/22 by Medical Director and DON to ensure no change in condition noted. DON reclarified the orders with the Wound Care Physician on 08/26/22 and orders were implemented. All residents at risk for pressure ulcers have the potential to be affected by the alleged deficient practice. A facility-wide skin audit was initiated on 08/26/22 to ensure that all residents have been assessed for any skin alterations. Any new changes in condition related to skin will be identified immediately and appropriate intervention will be implemented. The audits were conducted by the DON and MDS Coordinator. No new skin alterations have been identified at this time. The audit will be completed on 08/26/22. Resident #1's care plan was updated to reflect the resident is at risk for pressure ulcer and noted each wound present. On 08/26/22, the Administrator, and DON, initiated educational in-service training to the licensed nurses regarding communicating with the physician any new skin with alterations, providing detailed description of wound to the physician, obtaining new treatment orders and documenting any new treatment orders received from the physician for the skin alterations. Charge Nurses will document in the 24 hour report any new skin alterations and treatment orders to ensure communication is ongoing and will be monitored by the DON. DON, or designee, will review the 24-hour communication board in Point Click Care daily, including the weekends to ensure new skin alterations have been addressed, Administrator will be responsible to ensure this happens. All in-services will be done by 08/26/22. Licensed staff will not be allowed to work until they receive the training which will be conducted by the DON or MDS Coordinator, this has been completed as of 08/26/22. This is a permanent enhancement to our policy to improve upon our communication and monitoring process. New hire nurses will be provided this training by the DON or MDS Coordinator prior to working the floor and it will be the responsibility of the Administrator to ensure this occurs. On 08/26/22 Charge Nurses were provided training by Administrator and/or DON to communicate that shower sheets are to be reviewed and all new skin areas noted by CNAs are to be addressed immediately and the physician is to be notified and orders implemented. DON will review shower sheets in morning clinical meeting to confirm new skin concerns were addressed by charge nurse and will be responsible for monitoring the process. This is a permanent enhancement to our policy to improve upon our communication and monitoring and ensure processes are carried out timely. Current CNAs will be reeducated on this process as well and education will be completed on 08/27/22. New hire nurses and CNAs will be provided this training by the DON or MDS Coordinator prior to working the floor. Weekly Wound Report will be completed by DON for residents with pressure ulcers and sent to the physician for review each week. This process was put into place on 08/26/22 and discussed with the Medical Director and this will be a permanent process. Educational in-service by the Administrator began on 08/26/22 to the DON and MDS Coordinator regarding this enhancement and will be completed on 08/26/22. The DON will be responsible for monitoring and if absent the MDS Coordinator will be responsible. On 08/26/22 Charge Nurses were provided an in-service by the Administrator and/or DON to ensure that they round with the Wound Care Physician during his visits and follow up and clarify any orders that they put in place during their visit. This process will be in place immediately and monitored by the ADON. Charge Nurses not present were contacted via phone and new hire nurses will be provided this training upon hire prior to working the floor. DON, or MDS Coordinator in the DONs absence, will review the Wound Care Physicians notes after each visit to ensure all orders are implemented correctly. On 08/27/22 CNAs were provided education by the Administrator and DON to report skin concerns to the charge nurse and if not immediately addressed by the charge nurse they are to contact the DON or the Administrator to ensure all new skin alterations are addressed. Ad-Hoc QAPI meeting was held on 08/26/2022 to review the alleged deficiency and the review of the trainings provided to the nurses as listed above. The medical director was involved with the review and the plan of removal. The Administrator will be responsible to ensure the plan is completed by 08/27/2022. The Survey team monitored the plan of removal as follows: Monitoring was conducted from 08/27/22 through 08/30/22 Review of the facility-wide skin audit initiated by the facility on 08/26/22 reflected all residents were assessed and no new skin alterations were identified. Review of Resident #1's care plan reflected her plan of care was updated to include in risk for skin break and interventions to prevent further skin breakdown. Review of in-service training to licensed nurses regarding communicating with the physician new skin alterations and providing detailed descriptions of the wounds reflected all licensed staff were in-serviced. Review of in-service training to licensed nurses regarding follow up on shower sheets reflected all licensed staff were in-serviced. Review of the new weekly wound report to be completed by the DON reflected the process was initiated by the DON. Review of in-services training to CNAs regarding reporting skin concerns and the process for reporting charge nurses if the skin concerns are noted addressed reflected 70% of staff were in-serviced. In an interview on 08/27/22 at 12:20 PM, CNA D stated she received in services on 8/25/2022 over reporting skin sheets. She stated she received in services on 8/27/2022 regarding shower sheets, and how to describe skin situations. She stated the CNA's have to put red, rash, or open on the skin sheets, and also inform the nurses. In an interview on 08/27/22 at 12:35 PM, LVN H stated she was in serviced on Resident #1. She stated she was told to report any changes, or anything unusual. Stated the CNAs are to report it to the charge nurse first. She stated if the charge nurse is unavailable, they have to report it to the DON. In an interview on 08/27/22 at 1:07 PM, CNA I stated she was in serviced on Resident #1 on 08/25/22, and 08/27/22. She stated she was told that if any skin condition arises, she has to chart it in POC and alert the nurses of the situation. She stated if the nurse is not available they were told to alert the DON, or the administrator. In an interview on 8/27/22 at 1:30 PM, Resident #1 stated she is receiving way better care at this time. She stated she just hopes the care remains the same, and if she need's she knows how to report it. She stated the nurses are paying more attention to her wound and treating it. On 08/3022 at 11:00 AM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: The facility failed to notify Resident #1's wound care physician when Resident #1 developed an unstageable deep tissue injury to her right buttock, and three Stage III pressure ulcers to her left buttock. These failures resulted in an Immediate Jeopardy (IJ) situation on 08/26/22 at 1:10 PM. While the IJ was removed on 08/30/22, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice could place residents at risk of not having their primary care physician notified of changes, resulting in a delay in medical intervention and decline in health. Findings included: Review of Resident #1's face sheet dated 08/25/22 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. Resident #1 was assessed to not have behaviors of rejecting care. Resident #1 was further assessed to require extensive two person assist with bed mobility; to have an indwelling catheter; to be at risk for pressure ulcer development and to not have pressure ulcers during the assessment period. Review of Resident #1's comprehensive care plan reflected a focus area with the initiated date 08/16/22 The resident has partial thickness non-pressure wounds to left buttock and left thigh related to immobility. Interventions included assess/ record/ monitor wound healing weekly; measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress; report improvements decline to MD. Review of Resident #1's admission assessment dated [DATE] reflected Resident #1 was assessed to not have pressure ulcers. Review of Resident #1's Wound Physician assessment dated [DATE] reflected Resident #1 had an unstageable DTI (deep Tissue injury) to her left heel measuring 3.2 cm x 2 cm with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/25/22 at 1:27 PM, reflected Resident #1 in her room in bed alert and oriented. CNA C and CNA D were in the room to provide care to Resident #1. Resident #1 stated she was paralyzed and unable to feel her feet. She stated she had a fall at home and her F4 vertebrae severed her spinal cord. She stated the facility put her on an air mattress after the wounds on her bottom and her heels were discovered. She stated when she first arrived at the facility, she was not getting a bath or shower but has recently been getting showers every other day. She stated she came from the hospital and did not have any wounds. She stated the nurses do not come and check her skin weekly and the nurses do not do treatments to her wounds. Resident #1 stated the nurse aides put cream on her bottom. Resident #1 stated she told the staff for two weeks her bottom was hurting before anyone did anything. CNA C and CNA D using incontinent care wipes began removing the cream to her right buttock. Resident #1's wound was covered in a heavy layer of cream which obscured the wound. During the removal of the cream by the CNAs areas of Resident #1's skin was also removed with the cream. Observation of Resident #1's Right buttock on 08/25/22 at 1:27 PM after the removal of the cream revealed a partial thickness open pressure ulcer approximately 4 cm x 6 cm to right buttock with a 3.5 cm x 3 cm area of DTI in the center of the pressure ulcer. The peri wound extended 4 cm around the wound and the skin was dry and peeling off. Further observation revealed three full thickness pressures ulcers (Stage III) to Resident #1's left buttock (no dressings were noted to wounds.) In an interview on 08/25/22 at 1:35 PM, CNA D stated Resident #1 had the area on her left and right buttock for over a week. She stated the area on her right buttock was a big blister before it opened. In an interview on 08/25/22 at 1:40 PM LVN G (Resident #1's nurse) stated Resident #1 did not really have dressing orders for the areas on her buttock. She stated they are just putting the cream on the coccyx and buttock. She stated to her knowledge there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 heels. LVN G stated the facility did not have a treatment nurse and the weekly assessments are done by the weekend RN, but the weekend RN has not been at the facility for a while. LVN G stated if the nurses are assigned to do skin checks then they do them in the computer. She stated the facility has been going back and forth from the nursing staff doing them or the weekend nurse doing the skin checks. She stated she was out for 2 weeks with COVID and has seen Resident #1 maybe 3 times over the past 2-3 weeks and was not aware of the pressure ulcers. In an interview on 08/25/22 at 3:30 PM, CNA C stated herself, CNA D, and CNA E got Resident #1 up to take a shower on 08/19/22. She stated she saw a big sore on Resident #1's right buttocks and between her buttock on the left. She stated she documented the sore on the shower sheet as open sores on the left buttocks, and the right buttocks. She stated she told LVN A about the open sores on 8/19/22, and LVN A told her to put cream on the sores. CNA C stated LVN A did not go and look at the open sores on Resident #1. Review of Resident #1's Shower Sheet dated 08/19/22 reflected CNA C documented open areas to Resident #1's right buttock, left buttock and black spots to her right and left heels. The shower sheet was signed by CNA C and initialed by LVN A. In an interview on 8/25/22 at 2:47 PM, the Wound Care Physician stated he was notified of skin breakdown for Resident #1 on 08/15/2022. He stated he saw Resident #1 on 08/22/22, and he saw her left buttocks. He stated there was a small break down of skin, and he did not see the right buttocks because there was cream on it. He stated he was informed about Resident #1's heels on 08/15/2022 as well, but he did not know about any sore on Resident #1's right buttocks. He stated the facility might have known about the sore on Resident #1's right buttocks, but he was not informed. The Wound Care Physician stated he was informed of the sore on Resident #1's right buttocks on 08/25/22 because he received a picture from a nurse at the facility. He stated from the picture he received it looked more like a pressure wound than a moisture wound due to how deep the wound looks. He stated it would take a lot of moisture to break down skin and penetrate deep and he would need to alter the resident's treatment orders. In an interview on 08/25/22 at 4:16 PM, LVN A stated she was made aware of the open sore on Resident #1's right buttocks and new areas on the left buttock by a CNA. Stated she did not feel the need to go look at the sores on 08/19/22. She stated sometimes CNAs exaggerate on the shower assessments, and she thought it was just the same skin tears she previously called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Stated she did not call the doctor on 08/24/22 because she did not want to overstep the DON. In an interview on 08/25/22 at 4:31 PM, the DON stated she did not call the doctor on 08/24/22 after the skin assessment. She stated she became swamped on 08/24/22 and just did not make the call to the doctor. In an interview on 08/30/22 at 10:30 AM, the Administrator stated he expected the nursing staff to assess residents and to notify the physician if there are any changes. He stated he could not believe LVN A disregarded the CNAs reports of skin changes, and she has been terminated. He stated when he called her, she told him she did not go an assess the resident and the only explanation given was that the CNAs exaggerate. Review of the facility's Policy Skin Integrity (not dated) reflected .Review any skin issues from weekly skin assessment. Daily review of shower sheets during morning meeting and follow up during stand down meetings .CNAs are responsible for reporting any new skin conditions to their nurse on duty .The residents' physician must be notified/ consulted regarding the status of the PU/PI and prescribe treatment . An Immediate Jeopardy (IJ) was identified on 08/26/22 at 1:10 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 08/28/2022 at 8:37 PM and is as follows: ABATEMENT PLAN: Treatment/Services to Prevent/Heal Pressure Ulcers This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Immediately upon notification Resident #1 was reassessed on 08/26/22 by Medical Director and DON to ensure no change in condition noted. DON reclarified the orders with the Wound Care Physician on 08/26/22 and orders were implemented. All residents at risk for pressure ulcers have the potential to be affected by the alleged deficient practice. A facility-wide skin audit was initiated on 08/26/22 to ensure that all residents have been assessed for any skin alterations. Any new changes in condition related to skin will be identified immediately and appropriate intervention will be implemented. The audits were conducted by the DON and MDS Coordinator. No new skin alterations have been identified at this time. The audit will be completed on 08/26/22. Resident #1's care plan was updated to reflect the resident is at risk for pressure ulcer and noted each wound present. On 08/26/22, the Administrator, and DON, initiated educational in-service training to the licensed nurses regarding communicating with the physician any new skin with alterations, providing detailed description of wound to the physician, obtaining new treatment orders and documenting any new treatment orders received from the physician for the skin alterations. Charge Nurses will document in the 24 hour report any new skin alterations and treatment orders to ensure communication is ongoing and will be monitored by the DON. DON, or designee, will review the 24-hour communication board in Point Click Care daily, including the weekends to ensure new skin alterations have been addressed, Administrator will be responsible to ensure this happens. All in-services will be done by 08/26/22. Licensed staff will not be allowed to work until they receive the training which will be conducted by the DON or MDS Coordinator, this has been completed as of 08/26/22. This is a permanent enhancement to our policy to improve upon our communication and monitoring process. New hire nurses will be provided this training by the DON or MDS Coordinator prior to working the floor and it will be the responsibility of the Administrator to ensure this occurs. On 08/26/22 Charge Nurses were provided training by Administrator and/or DON to communicate that shower sheets are to be reviewed and all new skin areas noted by CNAs are to be addressed immediately and the physician is to be notified and orders implemented. DON will review shower sheets in morning clinical meeting to confirm new skin concerns were addressed by charge nurse and will be responsible for monitoring the process. This is a permanent enhancement to our policy to improve upon our communication and monitoring and ensure processes are carried out timely. Current CNAs will be reeducated on this process as well and education will be completed on 08/27/22. New hire nurses and CNAs will be provided this training by the DON or MDS Coordinator prior to working the floor. Weekly Wound Report will be completed by DON for residents with pressure ulcers and sent to the physician for review each week. This process was put into place on 08/26/22 and discussed with the Medical Director and this will be a permanent process. Educational in-service by the Administrator began on 08/26/22 to the DON and MDS Coordinator regarding this enhancement and will be completed on 08/26/22. The DON will be responsible for monitoring and if absent the MDS Coordinator will be responsible. On 08/26/22 Charge Nurses were provided an in-service by the Administrator and/or DON to ensure that they round with the Wound Care Physician during his visits and follow up and clarify any orders that they put in place during their visit. This process will be in place immediately and monitored by the ADON. Charge Nurses not present were contacted via phone and new hire nurses will be provided this training upon hire prior to working the floor. DON, or MDS Coordinator in the DONs absence, will review the Wound Care Physicians notes after each visit to ensure all orders are implemented correctly. On 08/27/22 CNAs were provided education by the Administrator and DON to report skin concerns to the charge nurse and if not immediately addressed by the charge nurse they are to contact the DON or the Administrator to ensure all new skin alterations are addressed. Ad-Hoc QAPI meeting was held on 08/26/2022 to review the alleged deficiency and the review of the trainings provided to the nurses as listed above. The medical director was involved with the review and the plan of removal. The Administrator will be responsible to ensure the plan is completed by 08/27/2022. The Survey team monitored the plan of removal as follows: Monitoring was conducted from 08/27/22 through 08/30/22. Review of the facility-wide skin audit initiated by the facility on 08/26/22 reflected all residents were assessed and no new skin alterations were identified. Review of Resident #1's care plan reflected her plan of care was updated to include in risk for skin break and interventions to prevent further skin breakdown. Review of in-service training to licensed nurses regarding communicating with the physician new skin alterations and providing detailed descriptions of the wounds reflected all licensed staff were in-serviced. Review of in-service training to licensed nurses regarding follow up on shower sheets reflected all licensed staff were in-serviced. Review of the new weekly wound report to be completed by the DON reflected the process was initiated by the DON. Review of in-services training to CNAs regarding reporting skin concerns and the process for reporting charge nurses if the skin concerns are noted addressed reflected 70 % of staff were in-serviced. In an interview on 08/27/22 at 12:20 PM, CNA D stated she received in services on 8/25/2022 over reporting skin sheets. She stated she received in services on 8/27/2022 regarding shower sheets, and how to describe skin situations. She stated the CNA's have to put red, rash, or open on the skin sheets, and also inform the nurses. In an interview on 08/27/22 at 12:35 PM, LVN H stated she was in serviced on Resident #1. She stated she was told to report any changes, or anything unusual. Stated the CNAs are to report it to the charge nurse first. She stated if the charge nurse is unavailable, they have to report it to the DON. In an interview on 08/27/22 at 1:07 PM, CNA I stated she was in serviced on Resident #1 on 08/25/22, and 08/27/22. She stated she was told that if any skin condition arises, she has to chart it in POC and alert the nurses of the situation. She stated if the nurse is not available they were told to alert the DON, or the administrator. In an interview on 8/27/22 at 1:30 PM, Resident #1 stated she is receiving way better care at this time. She stated she just hopes the care remains the same, and if she need's she knows how to report it. She stated the nurses are paying more attention to her wound and treating it. On 08/3022 at 11:00 AM the facility was notified that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolation due to the facility requiring time to train all staff and monitor their plan of removal.

Based on interview, observation and record review the facility failed to develop and implement written policies and procedrues that prohibit and prevent abuse of residents for 3 (Resident #1, Resident #2, Resident #3) of 4 Residents reviewed for abuse. 1. CNA A and CNA B verbally abused Resident #1 in the facility's dining room. 2. Resident #3 reported a facility staff member used disturbing language while performing pericare for her roommate (Resident #2) causing Resident # 3 to feel uncomfortable in her room and around staff members. 3. CNA A and CNA B continued to work at the facility after the incident was reported to the ADMIN, and the ADMIN did not report and investigate the indicent. These failures resulted in an Immediate Jeopardy (IJ)-no actual harm situation on 03/18/2022. While the IJ was removed on 03/21/2021, the facility remained out of compliance at a severity level of no actual with the potential for more thatn minimal harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Review of Resident #1's face sheet dated 03/18/2022 reflected a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a Brief Interview of Mental Status score of 4 (severe cognitive impairment) with supervision needed for ADL's requiring one person set-up. Review of Resident #1's Care Plan dated 12/14/2021, reflected that Resident #1 had an ADL self-care deficit and needed one-person assists for most tasks including toileting use in the PM due to urinary incontinence. Review of Resident #2's face sheet dated 03/18/2022 revealed a [AGE] year-old woman admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (Intact cognitive process) with limited or extensive assistance with one-person physical assist for ADL's. Review of Resident #2's Care Plan dated 02/01/2021 revealed the Resident #2 was receiving restorative care with interventions that included monitoring by nursing staff for complaints of pain, weakness or stiffness and informing skilled therapist or nurse if goals are not achievable. Review of Resident #3 face sheet dated 03/18/2022 revealed an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 13 (Intact cognitive) with supervision for ADL's with one-person assistance for ADL's. Record Review of the facility's undated policy named Allegations of Abuse, Neglect, Exploitation or Mistreatment revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of this facility and to other officials (including to the State Survey Agency and adult protective services where state law provide jurisdiction in long-term care facilities) in accordance with State law through established procedures. In an interview on 03/18/2022 at 11:40 AM, Resident #2 revealed sometimes staff aren't kind with words to residents that need extra care. Resident asked if surveyor could come back and talk to her at a different time as she was getting ready for lunch. An interview on 03/18/2022 at 11:45 PM with Visitor D revealed while he was on a visit with a relative at the facility on 03/10/2022, he witnessed the incident with CNA A, CNA B and Visitor D. Visitor D stated he saw CNA A walk up to Resident #1 and used a raised voice to discuss something that he could not hear. He then saw CNA B walk up to Resident #1 and yell at her that Visitor D was not able to make out but caused Resident #1 to begin screaming and crying. He stated another staff member had to come between Resident #1 and CNA B, CNA B walked away. Visitor D stated this was verbal abuse and why he reported it to the State. An interview on 03/18/2022 at 1:00 PM with LVN A revealed she was in the dining room when there was an altercation between the CNAs and Resident #1. LVN A stated CNA A and Resident #1 had a conversation and it could be heard across the dining area. LVN A stated CNA A said did you say, you need to keep my name out of your mouth to the Resident #1. LVN A stated CNA B then came up to Resident #1 and used a high pitch voice while saying something to the Resident. LVN A stated she felt she had to get involved because the Resident was visibly upset and yelling at CNA B. LVN A stated she tried to calm the Resident down by rubbing her back and Resident #1 was crying. LVN A stated the behavior of both CNA's was not appropriate behavior towards Residents. She stated that she reported this incident to the ADON who then told ADIM. An interview on 03/18/2022 at 1:15 PM with RA A revealed she was in the dining room during this incident on 03/10/2022. She revealed CNA A was discussing something with Resident #1 and said, don't repeat. Then CNA B went up to Resident #1 and said something to Resident #1 causing Resident #1 to start to yell and cry. RA A stated LVN A had to come and stop it. RA A stated this interaction was not appropriate between staff and Residents. RA A stated this interaction upset Resident #1 and she was crying. RA A stated this was not normal behavior for the Resident #1 and the Resident was usually very happy. She stated she had seen other interactions between staff and Residents that she didn't feel was appropriate. She stated that her mother used to be in the facility and back then she didn't feel that the staff had enough respect for the residents and that's just they way the staff have always treated residents. She did not reveal specific details as to what was said. She stated that she knew the ADMIN was the abuse coordinator. An observation on 03/18/2022 at 1:20 PM, revealed that both CNA A and CNA B were working in the facility. A record review of the facility grievance log on 03/18/2022 reflected an incident of CNA using inappropriate language regarding resident family members to resident on 03/14/2022. The facility terminated CNA on 03/15/2022. On 03/14/2022, a Resident reported that the CNA being investigated had been rude to Resident when he asked for a bed pan. The facility terminated CNA on 03/16/2022. An interview on 03/18/2022 at 1:32 PM with Resident #3 revealed she doesn't like the way that the staff treat her roommate . Her roommate (Resident #4) was observed to be non-interviewable. Resident #3 revealed she had heard staff say you're nasty while performing incontinent care. Resident #3 stated she does not think staff should talk like that to people, even if they can't respond back. She stated that she didn't feel comfortable reporting this to anyone because she's afraid that she will upset people and she does not want anyone to be mad at her. An interview on 03/18/2022 at 1:37 PM Resident #1 revealed staff yelled at me and this made her upset. Resident #1 became visibly upset during the interview, she was shaking, and surveyor ended the interview. An interview on 03/18/2022 at 1:45 PM with Resident #2 revealed CNA A and CNA B were verbally abusive towards Resident #1 on 03/10/2022 during the lunch service. Resident #2 stated that Resident #1 was in the dining area and was approached by CNA A and said something to the Resident with a forceful voice and then Resident #1 said I'm sorry. Resident #2 stated CNA B then came over to the resident and said something with a raised voice. Resident #2 stated Resident #1 started screaming and became agitated. Resident #2 stated that LVN A came over to calm Resident #1 down as she was visibly upset. Resident #2 stated that she considered the interactions between CNA B and CNA A to be considered verbal abuse towards Resident #1. Resident #2 stated CNA B is rude towards other residents but was not able to recall specific times. An interview on 03/18/2022 at 2:00 PM with CNA A revealed on 03/10/2022 she went up to Resident #1 and had a conversation with the Resident. CNA A stated, I crossed the line and maybe it sounded like I was mad. She stated Resident #1 was crying and stuff, after this conversation Resident #1 acted like she was scared of me. CNA A stated this conversation could be perceived as verbal abuse as Resident was crying and upset. She stated that ADMIN made CNA A, CNA B and Resident #1 all apologize to each other after ADMIN had verbally counseled both CNAs. CNA A stated Resident #1 was acting differently towards her after this incident and CNA A told the Resident she didn't need to be scared of her, she wasn't going to hurt Resident #1. An interview on 03/18/2022 at 2:15 PM with CNA B revealed on 03/10/2022 she had a conversation with Resident #1 but didn't feel like it was verbally aggressive. She stated the conversation was in regard to having heard that Resident #1 was making disparaging comments about CNA #2's daughter CNA #1. She stated that both CNA B and CNA A had been verbally counseled by ADMIN, DON and ADON. She stated she had a meeting with the ADMIN and afterward apologized to Resident #1. She stated that she had previously had training on Abuse and Neglect. An interview on 03/18/2022 at 2:30 PM with the ADMIN he stated that he is responsible for investigation and reporting allegations of Abuse and Neglect. He stated that he is responsible for ensuring the Abuse and Neglect policy is enforced. The Admin did not report the incident on 03/10/2022 as he had spoken to both CNAs and given them a verbal warning regarding being verbally aggressive with Residents. He stated he was not in the dining room when this happened but was told about the incident and didn't feel it needed to be reported. He stated that both CNA A and CNA B were both still working at the facility because he didn't think the incident was that big of a deal. ADMIN stated his investigation only included speaking with CNA A, CNA B, Resident #1 and LVN A. He stated in the future, he will report incidents like this. ADMIN stated he had done an investigation which only included Resident #1, the two CNA's and LVN A. There was no documentation of ADMIN's investigation. This failure places all Residents at risk of potential Abuse and Neglect as the ADMIN failed to recognize the incident on 03/10/2022 as Abuse. A record review of training logs on 03/18/2022, revealed the last Abuse and Neglect inservice for all staff was conducted in June of 2021. An interview on 03/18/2022 at 2:45 PM with the DON revealed during the incident between the CNA's and Resident #1, she was in her office and didn't hear what was said between the CNA's and the Resident. She stated that she went into the dining room after the incident was coming to an end and saw LVN A comforting Resident #1. The DON stated she heard Resident #1 screaming. She went on to state she didn't feel it needed to be reported as she wasn't aware the CNAs had any inappropriate behaviors towards the Resident. Record Review of CNA #1, CNA #2 and RA A personnel files for revealed CNA B's received Verbal Coaching on 12/07/2009 for staying behind the nurses' station with the nurse at the time of a Resident fall who was ambulating in the unit unsupervised. She received a written warning on 04/07/2010 for excessive tardiness. She received a verbal warning on 12/12/2012 for smoking during an unauthorized smoke break and Disciplinary Action Form on 07/02/2019 for a verbal altercation with ADON in front of other staff and used inappropriate language. The ADMIN and DON were notified of the Immediate Jeopardy on 03/18/2022 at 5:05 PM and the IJ template was provided. A Plan of Removal was requested. The Plan of Removal was accepted on 03/21/2022 at 3:10 PM and included the following: Problem: Abuse/Neglect CNA A and CNA B were both informed of the investigation and left the building immediately on 3/18/22. On 3/18/22 all facility staff, to include those that are PRN and on leave, were contacted by MDS Coordinator, BOM and/or Human Resources and provided education regarding the facilities policy and procedures regarding recognizing signs of abuse and neglect, reporting abuse and neglect and preventing abuse and neglect. On 3/18/22 all facility staff were informed that they are to report allegations of abuse and neglect to the Abuse Coordinator immediately and in servicing was conducted by MDS Coordinator, BOM and/or Human Resources. If the Abuse Coordinator is not available, the Director of Nursing is to be contacted immediately. On 3/18/22 the Administrator and Director of Nursing were provided education regarding thorough investigations for abuse and neglect by the Director of Operations. On 3/18/22 the Administrator and Director of Nursing were provided education regarding reporting allegations of abuse and neglect to the state by the Director of Operations. All residents have the potential to be affected by this alleged deficient practice. On 3/18/22 Administrator, Director of Nursing and/or LVN on duty immediately communicated the process for reporting abuse and neglect to all interviewable residents, those that are not interviewable contact was made to their families, contact to these families were made on 3/18/22 by BOM and Human Resources. During these contacts to residents and family's residents and families were provided assurance that if they report allegations of abuse and neglect, they would be safe of retaliation by staff members and a thorough investigation would be completed. No other concerns identified that needed to be addressed during conversations with residents or family members. Immediately upon notification on 3/18/22 Resident #1 was interviewed by Administrator to ensure she felt safe in which she responded that she did, Resident #1 expressed the same during several meetings with Administrator on 3/19/22. Administrator consistently meets with Resident #1 and will continue to do so each day he is at the facility as the resident comes into his office to visit several times each day. Administrator will ensure she always feels safe and will ask her during their visits at least once a day when Administrator is at the facility, he will do this daily for a minimum of one month. Resident #1 was referred for counseling with facilities contracted psychological services, Senior Psych Care on 3/19/22, Administrator followed up on 3/21/22 to confirm referral was received and resident will be on services going forward indefinitely until Senior Psych Care determines the need is no longer there. The facility will provide education regarding abuse and neglect to all employees up on hire as well as ongoing on a monthly basis effective 3/18/22. Ad hoc QAPI meeting was held on 3/18/22 to include, Administrator, Director of Nursing, BOM, Medical Director, Human Resources to review the alleged deficiency and the review of education provided to staff as listed above. The medical director was involved with the review and the plan of removal. All staff will be required to have training on preventing abuse and neglect, recognizing signs of abuse and neglect and reporting abuse and neglect prior to assuming resident care responsibilities, this was completed on 3/18/22. The Administrator will be responsible for monitoring the above actions for compliance for a minimum of 6 months. The Administrator will ensure the plan is completed in full by 3/19/22. Monitoring for the Plan of Removal was completed 03/21/2022 and consisted of: Staff interviews conducted on 03/21/2022 and record review of staff and training logs revealed staff were re-educated on the centers Abuse and Neglect policy by ADMIN and DON on 03/18/2022. Staff indicated they knew to report any future incidents of Abuse and Neglect to ADMIN. Educational Counseling for Preventing Resident Abuse and Neglect and Reporting Resident Abuse and Neglect were completed by ADMIN by DO on 03/18/2022. Record Review of in-service documents demonstrated 17 interviewable residents were informed of the process of reporting abuse and neglect on 03/18/2022 DON. Record Review of in-service documents demonstrated that 12 non-interviewable residents' families were contacted and informed of the process of reporting abuse and neglect on 03/18/2022 by BOM. Record Review of facility's documents revealed an Ad Hoc QAPI Meeting held on 03/18/2022. Record Review of facility's documents revealed that Resident #1 was referred for Psychiatric Therapy Care on 03/19/2022 by ADMIN. The ADMIN and DON were notified of an Immediate Jeopardy situation on 03/18/2022, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness.

Based on Observation, Interview and Record Review the facility failed to prevent a Stage 1 Pressure sore for 1 resident (Resident #133) from progressing to a Stage IV (Stage 1 reddened skin, stage IV full thickness wound down to the bone). This deficient practice affected one Resident in the facility (one Resident of the facility had a pressure sore) admitted with a Stage 1 pressure sore (reddened skin which does not return to normal color) which deteriorated to a Stage IV (full thickness wound down to bone) potentially putting the resident's life in jeopardy from infection and wound complications and was cited at the IJ level. The facility failed to provide care necessary treatment and services to promote healing and prevent the ulcer from deteriorating. On 1/07/22 at 7:08 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1/11/22, the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. Findings include: Review of the Face Page for Resident #133 reflected he was admitted to the facility on [DATE] from acute care in hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #133 reflected interventions were in place for: A Pureed diet, [CONDITION(S)], Shortness of Breath, Skin Impairment to Coccyx (moisture associated skin deterioration or MASD), and a history of Stroke or Cerebral infarction. Review of Resident #133's hospital records, dated 12/22/21, reflected he was admitted after complaints of weakness and falls at home. He was described as having left sided [CONDITION(S)] or weakness following a stroke. Review of Resident #133's hospital records, dated 12/27/21, reflected Resident #133 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #133's hospital records, dated 12/29/21, reflected Resident #133 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #133's Admit/Readmit Screener, dated 12/30/21, reflected Resident #133 had a scratch to the left side of his head, a skin tear to his right wrist, and an open wound to his buttock. Review of the Braden Scale skin assessment for Resident #133, dated 1/01/22, reflected the risk of pressure sores was high at 12.0. The Braden Scale assessed sensory perception, moisture, activity, nutrition and friction and shear to predict the risk of skin breakdown and pressure sores. Review of the Daily Skilled Nurses Notes for Resident #133, dated 12/30/21, reflected the skin assessment noted a Stage 1 pressure sore wound to the sacrum/coccyx. Review of the Daily Skilled Nurses Notes for Resident #133, dated 1/01/22, reflected Resident #133 had open skin to his coccyx and buttocks x2 with scabs to his legs. Review of the Weekly Skin Assessment for Resident #133, dated 1/02/22, reflected resident had scabs to various parts of his extremities and was admitted with excoriation to his sacrum measuring approximately 6.0 x 13.0 cm. The assessment reflected discoloration with dark and pink areas and a small center area at the tailbone 1.5 x 1.0 cm with lighter color/whitish. The skin was intact, fragile, and tender to both buttocks. The area was cleaned with wound cleanser, dried, and applied a [MEDICATION(S)]/antimicrobial gel, foam pad and waterproof dressing. Review of the Daily Skilled Nurses Notes for Resident #133, dated 1/04/22, reflected he was incontinent of bowel and bladder and received peri care. The skin assessment portion of the note reflected an open wound to the sacrum/coccyx, but no size or scale. Observation of wound care for Resident #133 on 1/05/22 at 2:28 p.m. revealed care was performed by LVN H with the assistance of CNA P. Resident #133 stated some discomfort during repositioning. He stated his backside was painful. LVN H removed the dressing to Resident #133's sacrum and buttocks to reveal a large stage IV wound. The open area was approximately 14.0 cm x 6.5 cm x 1.0 cm. The skin was open from the right to left buttock, pink and red in color with scant serous (red) drainage. A large area of scabbed or necrotic skin to the right buttock was seen; it was separated from the edge of the wound by 2.0 cm and was approximately 5.0 cm x 4.5 cm in diameter. The area to the coccyx was open to the bone or cartilage; white area seen. LVN H cleansed the area with wound cleanser, applied [MEDICATION(S)] (antimicrobial/wound gel) gel and foam padding. The area was covered with clear [MEDICATION(S)] dressing. Resident #133 was observed to have a large scabbed over area to the outside of his right knee, approximately 3.0 cm in diameter. Scabs were also observed to his left knee, left wrist, and right elbow. In an interview on 1/06/22 at 2:19 p.m. the Medical Director (and Resident #133's PCP) stated she was contacted when he was admitted to the facility on [DATE]. She stated she was advised of his hospital medications and approved them. She stated she was informed of skin breakdown to his coccyx and stated the facility could use her standard orders for skin breakdown (such things as clean with normal saline, pat dry, apply skin protective cream). She stated she approved consultation for wound care. In an interview on 1/06/22 at 2:29 p.m. LVN H stated no standing orders were received for Resident #133. She stated other physicians had standing orders for skin breakdown at the facility and provided a copy of an example . In an interview on 1/06/22 at 2:44 p.m. RN J stated she worked with Resident #133 on the weekend of 12/31/21 and 1/01/22. She stated she completed a skin assessment and looked at his whole body. She stated the skin to Resident #133's coccyx was excoriated but the skin was not open. She stated she requested the doctor order an air mattress as Resident #133 was not good at repositioning himself. RN J stated if Resident #133 had a large skin opening to his coccyx, she would have requested appropriate wound care orders. Note review of orders reflected barrier cream order was started 12/30/21 (not 12/31/21 when RN J was working with Resident). In an interview on 1/07/22 at 11:25 a.m. RN J stated she did perform an assessment on Resident #133 and his skin was intact. The Surveyor informed her there was no documentation in the computer. RN J stated she may have been waiting for a second opinion on what she saw, as Resident #133 appeared fragile and was pooping a lot. She stated she did get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #133's physician's orders in his electronic health recorded reflected the order was entered on 1/02/22. No other wound care orders were entered from 12/30/21 to 1/02/22. RN J stated she did put a dressing over the area on 1/02/22, even though the order reflected it started on 1/03/22. RN J stated LVNs who followed her may have assumed a treatment was in place when they saw the dressing. RN J stated Resident #133's skin was still intact on 1/02/22 when she last worked with him and did not know how it had progressed to a Stage 4 on 1/06/22. In an interview on 1/07/22 at 11:40 AM the Medical Director stated she was informed about Resident #133's health when he was admitted on [DATE]. She stated she was told he had excoriation and a stage 1 pressure sore to his coccyx. The Medical Director stated she did not recall exact details but could check her records. She stated she did not recall any callbacks for changes in condition or skin changes. She stated the facility had a good record of notifying her about changes. The Medical Director stated she saw Resident #133 this morning and he appeared to be a frail elderly man with a history of health problems which could leave him with fragile skin. She stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 1/07/22 at 11:50 a.m. Resident #133's family member, Family Member Z stated he was told by the hospital his father had a bedsore. He stated the hospital did not tell him how bad it was or how it was being treated. Family Member Z stated Resident #133 had fallen recently and it was possible he had multiple injuries;, he was aware his father had scrapped to his knees, arms, and hands. Family Member Z stated Resident #133 had left the faciity on a pass for a couple of hours (on 1/07/22 from 9:00am to 1:00 pm) to go pay his bills. He stated Resident #133 did not walk and got around by scooting along on his bottom on the floor or dragging himself along the floor. In an interview on 1/07/22 at 12:50 MA N stated she worked with Resident #133 on the weekend of 1/01/22 and 1/02/22. She stated he was able to communicate well and make his needs known. She stated Resident #133 did not appear to be in any discomfort on 1/01/22. In an interview on 1/07/22 at 12:56 p.m. CNA M stated she did work with Resident #133 on 1/02/22. She stated she helped to provide incontinence care as needed. She stated she saw a dressing was in place to his Coccyx area. She stated she did not see any nursing care performed or dressing change while she was in the room. In an interview on 1/07/22 at 1:17 p.m. the Administrator provided a list of all nurses who had worked with Resident #133 since his admission on 12/30/22. 1. LVN H 2. RN J 3. LVN I 4. LVN K 5. LVN G In an interview on 1/07/22 at 1:40 p.m. LVN H stated she had helped care for Resident #133 on the weekend of 1/01/22 and 1/02/22. She stated the Weekend RN (RN J) did the treatments for Resident #133 and was to stage the wound. LVN H stated she had put a protective dressing over the site to keep the skin from being soiled with BM. She stated when she saw Resident #133's coccyx on 12/31/21 the skin looked excoriated and was worse than a stage I. She stated treatment was started on Tuesday 1/04/22. LVN H stated when she performed the dressing change on 1/05/22 the wound looked much worse and was down to the white of the coccyx. She stated she did not see the wound on Monday or Tuesday (1/03/22 or 1/04/22). In an interview on 1/07/22 at 2:25 p.m. LVN I stated she had provided care for Resident #133 on Monday and Tuesday (1/03/22 and 1/04/22). She stated she did not change his dressing on the night shift as he was scheduled for a shower and treatment on Monday (1/03/22). LVN I stated she saw Resident #133's coccyx on 12/30/21 when he was admitted , and the area looked reddened and had dry sheared skin but no open areas. In an interview on 1/07/22 at 2:45 p.m. CNA Q stated she had worked with Resident #133 every day since he was admitted on [DATE]. She stated he came in on LVN I's shift 6 p.m. to 6 a.m. CNA Q stated he came in with a wound to his bottom. She stated RN J asked the aides to clean him up and she would come in to look at the wound and stage it. She stated the RN sprayed it, cleaned it, and applied a clear dressing with foam padding. CNA Q stated when removing the old dressing, blackened skin came off on the tape. She stated the middle part between the buttocks was open and RN J measured it. CNA Q stated that was how Resident #133's skin appeared when he arrived at the facility. CNA Q stated when Resident #133 returned from his pass with family on Tuesday, he stated he had pain to his right leg. In an interview on 1/07/22 at 2:57 p.m. LVN K stated she had worked with Resident #133 on Tuesday, Wednesday, and Thursday night shifts. She stated on Tuesday 1/04/22 she changed the dressing to his coccyx when it became soiled by BM. She stated the wound had a slight smell and had open skin. She stated the color of the wound was 50 percent pink and 50 percent dark red. She stated Resident #133 had not stated any pain during dressing changes. She stated the skin over the coccyx area was also patchy pink and dark red. Review of Inservice Education reflected on 10/01/21 Staff received education on ways to prevent Pressure Injures and Care of Hospice Residents. Review of the facility policy Skin Integrity , undated, reflected the facility must provide care and services consistent with professional standards to prevent pressure ulcer injuries. The policy reflected on admission the staff must identify if the resident had the risk for developing or already had a pressure ulcer. If present the staff must provide treatment to heal it or prevent development of additional pressure ulcers. Each dressing change should include assessment and documentation of the pressure ulcer staging, size,drainage, pain, color of wound bed and description of edges. The facility clinician would decide if the wound was avoidable or unavoidable. The Administrator was notified of the Immediate Jeopardy on 01/07/2022 at 7:08 PM. The Plan of Removal was accepted on 01/10/2022 and included the following: Facility: [NAME] Nursing & Rehabilitation Center[Facility name] Survey Type: Full Book Survey Survey Date: 1/4/2022 Abatement Plan: Quality of Care This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the actual allegations of the survey or the department's theories of violation. Plan to remove immediate jeopardy The resident is not currently in the community. The LVN, who took care of the resident on admission was identified and was provided one to one educational in service training on the following areas: communication to the physician for a new admission identified to have skin alteration in order to obtain the appropriate orders for wound treatment. This information will be documented in the resident's medical record under the nurses note section. The LVN was also trained to consult with the RN DON if there is any question related to alterations in skin, assessment and carrying out physician orders. The training was provided by the Assistant Director of Nursing, LVN, on 1/7/2022. All residents have the potential to be affected by the alleged deficient practice. A facility wide audit was initiated on 1/7/22 to ensure that all residents have been assessed for any skin alterations. Any new changes in condition related to skin will be identified promptly and appropriate intervention will be mplemented. The audits were conducted by the RN Weekend Supervisor. No skin alternations have been identified at this time. The audit was completed on 1/7/2022. On 1/7/2022, the Administrator and ADON (Assistant Director of Nursing), Initiated on one educational inservice training to the licensed nurses regarding communicating with the physician any new admission with alterations in skin, providing detailed description of wound to the physician, obtaining new treatment orders, documenting any new treatment orders received from the physician for the skin alterations, recognizing the change of condition in skin/wound color and size and signs of infection, LVNs will be provided with training to consult RN in if they have any questions on their assessments. All in services will be done by 1/7/2022. Licensed staff will not be allowed to work until they receive the training All resident change of condition related to skin alteration is discussed and reviewed during morning Clinical meetings and during all shifts change clinical reporting, including the weekends. The Clinical team makes daily rounds and will identify resident changes in condition through nursing observation, staff resident interview and review of 24 hour reports. The nursing supervisors during the weekend will conduct the clinical meetings. This is a permanent enhancement to our policy to improve upon our communication and ensure processes are carried out timely. Educational inservice retraining will begin on 1/7/22 regarding this enhancement and was completed on 1/8/22. The Administrator and ADON LVN conducted this one on one educational in servicing. Ad Hoc QAPI meeting was held on 1/7/2022 to review the alleged deficiency and the review of the trainings provided to the nurses as listed above. The medical director was involved with the review and the plan of removal. All licensed staff will be required to have training before assuming patient care responsibilities. The Administrator will be responsible to ensure the plan is completed by 1/7/2022. All Licensed nurses were in serviced with signatures. The plan was monitored as follows: Record Review of facility's in service, dated 1/8/22, reflected Daily Communication of Proving Clinical Updates: This process occurs routinely seven days a week. 1. All Resident change of condition related to skin alteration is discussed and reviewed during morning Clinical meetings and during all shift change clinical reporting, including the weekends. 2. The Clinical team makes daily rounds and will identify resident changes in condition through nursing observation, staff slash resident interview and review of 24 hour reports. 3. Any changes in condition are addressed timely with physician notification. Documentation of physician notification along with orders received are noted in your PCC documentation along with entering any order received into PCC. 4. The nursing supervisors during the weekend will conduct the clinical meetings. They will gather the information from these staff working, resident rounding, and reading of the shift report. If there are any questions throughout the shift the doctor is to be contacted for consultation and provide the necessary guidance as needed. This is an enhancement to our policy to improve upon our communication and ensure processes are carried out timely. For all new admissions: 1. communicate to the physician any new admission identified to have skin alteration to obtain the appropriate orders for wound treatment. 2. Provide detailed description of wound to the physician, obtain new treatment orders, document any new treatment orders received from the physician for the skin alteration 3. consult with the RN DON if there is any question related to alterations in skin, assessment and carrying out physician orders. Additional information included regarding recognizing changes in skin condition for skin/wound and signs of wound infection. In an interview on 1/11/22 at 11:01 a.m. LVN H stated she had attended in services on 1/7/22 and 1/8/22 regarding notifying nurses of any skin concerns. She stated the RN, the physician and the oncoming shift would be notified regarding any skin alteration. She stated any orders received by the physician would be entered into the electronic health record by the nurse receiving the orders. She stated new admissions, no matter the day of the week admitted , would receive a thorough assessment and any skin alternations noted would be described in detail to include any signs or symptoms of infection. She stated there was a physician on call 24 hours per day to accept notifications regarding skin concerns. In an interview on 1/11/22 at 11:05 a.m. RN J stated she was the weekend nurse at the facility. She stated she had received in services on the enhanced policies regarding wounds and also assisted in providing in services to other staff. She stated she, as well as all other nurses in the building, were re educated on responding to skin alternations and reporting to the physician, DON and ADON. She stated this included ensuring any verbal reports were followed up with a written report. She stated any identification of a skin alternation would need to be shared with the next shift and documented on the 24 hour report. She stated this process would be the same on weekends as during the week to include physician notification. She stated any nurse who received orders from the physician had the ability to and was responsible to enter the orders into the electronic health record. She stated orders were to be implemented right away. In an interview on 1/11/22 at 11:15 a.m. MDS Nurse C stated she assisted in providing in services to all nurses regarding providing full skin assessments, documenting descriptively and ensuring an order was in place to provide care as needed for any skin alteration. She stated the CNAs were educated as well regarding alerting their charge nurse of any skin issues, signs of infection or anything that might be identified as a change. She stated the inservices included preventing skin breakdown, signs and symptoms of skin breakdown, changes to skin and nutritional assistance with skin breakdown. She stated any order received from a physician was to be implemented immediately. She stated the nurse receiving the order, LVN or RN had the ability and was expected to enter the order into the electronic health record. She stated once entered into the record, the order would be on the nurse's treatment record and would be carried out. She stated 100% of the nurses had been in serviced and approximately 70% of the CNAs. The remainder of the CNAs would be educated prior to their next shift. In an interview on 1/11/2022 at:11:20 a.m. CNA R stated she had been in serviced to ensure any change in skin condition was reported to the charge nurse immediately and that a written record of the change was placed in the POC. She stated changes would include any new red area, or any drainage or odor to a current wound. She stated anything that was different from the last time the resident was showered or toileted would need to be reported. In an interview on 1/11/2022 at 11:38 a.m. HR stated she had sent emails to all of the nurses with the training information on 1/8/2022. She stated in person in services were held over the weekend. She stated 100% of the buildings nurses were notified of the enhancements to the wound care policy. She stated the CNAs were brought in over the weekend for in person in services. In an interview on 1/11/2022 at 11:50 a.m. the DON stated she was new to her position and not present for the IJ. She stated all nurses were in serviced regarding acute changes to skin, notifying the physician of any changes, documenting assessments, and ensuring all orders were entered into the electronic health record to ensure treatment would start immediately. She stated the nurse who was provided the order would be responsible for entering the order into the electronic health record. She stated any change in condition would be placed on the 24 hour report and passed from current shift to oncoming shift. In an interview on 1/11/2022 at 12:04 p.m. the RDR stated she attended the recent in services regarding wound care. She stated for her part, she would assist staff with signs and symptoms of pressure injuries and positioning techniques to offload, steps for care and reporting of changes to nurses. She stated the CNAs were in serviced regarding providing verbal as well as written reports of any changes. She stated if she noted any changes during treatment, she would notify the nurse verbally and changes would be included in her treatment notes. In an interview on 1/11/2022 at 12:09 p.m. CNA A stated she was in serviced on wounds prior to starting her shift. She stated the in service included notifications to the charge nurse of any change in skin conditions of the resident. She stated the changes were also documented in the POC. She stated a change would be anything different but included a reddened area and if there was already a wound would include redness, drainage or odor. In an interview on 1/11/2022 at 1:36 p.m. the ADM stated all nurses and CNAs were in serviced regarding the enhancements to the current policy regarding skin assessments and wound care. He stated 100% of the nurses as approximately 70% of the CNAs had been in serviced. He stated all staff were to communicate any changes in skin via a verbal report, documentation in the electronic chart and addition to the 24 hour report so the next shift would be aware. He stated they physician was to be notified immediately of any skin concerns. He stated all new admits were to receive a skin assessment and it was to be documented in the electronic health record. He stated there was a physician on call 24 hours per day, 7 days per week.

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for: A) One of two Licensed Vocational Nurses (LVN) C when the LVN provided improper wound care, omission of incontinent care, and omission of foley catheter care to Resident #2; and B) The DON failed to ensure nursing staff responsible for providing quality care for 3 of 6 residents (Resident # 2, #8 and #1) reviewed for pressure sores were monitored and supervised in the procedures of developing accurate comprehensive care plans, providing sanitary wound care, identifying, assessing and notifying the physician of pressure sores, initiating preventative measures and reviewing physician orders to ensure the correct protein supplement was administered. This resulted in an Immediate Jeopardy (IJ) on 03/26/2013. While the IJ was removed on 03/28/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice affected Resident #2 by causing the pressure sore to become infected which could [MEDICAL CONDITION] and death and had the potential to affect an additional 21 residents at risk for pressure sores. Findings include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions; (B) Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions. A) Observation on 3/25/2013 at 5:25 pm revealed LVN C and Certified Nurse Aide (CNA) J provided wound care to Resident #2's sacral and heel wounds. CNA J assisted Resident #2 to her right side. LVN C observed and pointed at a brown, firm, feces at Resident #2 ' s rectum, approximately 1 inch from the resident's coccyx/sacral wound. LVN C stated " will clean that later " . CNA J also did not perform incontinent care on Resident #2 prior to the wound care. LVN C removed the dirty, purulent, saturated dressing from Resident #2 ' s coccyx/sacrum area that had a strong odor. She then had to remove kerlix gauze packing and silver calcium alginate packing. This kerlix gauze packing was not in the physician ' s orders. She used gauze to cleanse the wound that was soaked in a wound cleanser. She placed the gauze in the wound bed and scrubbed up and down instead of starting in the middle of the wound bed to cleanse in a circular, outward motion. (Describing the wound using a clock face, with the top of the wound at 12:00 towards head of resident and 6:00 towards the feet, 9:00 is left side and 3:00 is the right side) Resident # 2's large pressure sore had noted undermining at ten o ' clock to two o ' clock and four o ' clock to eight o ' clock. The pressure sore also had a beefy red wound bed at five o ' clock to seven o ' clock. The pressure sore had wet, black eschar connecting at nine o ' clock to three o ' clock down the middle. Under the eschar and in the middle of the wound was yellow slough. LVN C placed the ordered dressing on Resident #2 ' s coccyx/sacrum pressure sore. She used tape to secure the dressing, but did not secure the area directly above the rectum where the firm stool was located. LVN C and CNA J did not provide incontinent care after the wound care. Resident #2 also had a Foley catheter, and LVN C and CNA J also did not provide Foley catheter care at this time. LVN C removed heel protectors from Resident #2 feet. Resident # 2 had a SDTI with dry eschar to the left heel. Heel protectors were placed back on Resident # 2's feet. Resident # 2 was repositioned and placed on her back and a sheet placed over her. In an interview on 03/25/2013 at 5:45 PM, LVN C stated she does not measure pressure wounds and that the Director of Nurses (DON) measures wounds on Wednesdays. LVN C stated Resident #2's wound to her coccyx/sacral area was unstageable. LVN C stated she would come back later to perform incontinent care and clean the feces off of Resident # 2's rectum, which was approximately 1 inch from the wound. In an interview on 3/25/2013 at 6:00 PM, the DON stated it was her expectation incontinent care be provided prior to wound treatment for [REDACTED]. Observation on 3/26/2013 at 11:45 AM revealed LVN C, the DON, and CNA K to provide wound care for Resident #2. LVN C removed a purulent, oversaturated dressing dated 03/25/2013. The dressing had a strong pervasive odor. LVN C cleansed Resident # 2's coccyx/sacral wound with gauze saturated in wound cleanser in an up and down motion instead of a circular and outward motion. The DON measured Resident # 2's coccyx/sacral pressure sore: at 10.25 cm x 15.0 cm x 7.0 cm. The DON measured tunnels at two o ' clock to equal 7.0 cm and four o ' clock to equal 6.0 cm. The DON measured undermining at three o ' clock to equal 3.0 cm, five to six o ' clock to equal 3.5 cm, six to seven o ' clock to equal 3.0 cm, and seven to eight o ' clock to equal 1.0 cm. The DON noted black, wet eschar attached at nine o ' clock and to the bottom of the wound bed at three to four o ' clock going across the middle of the wound. LVN C then applied the ordered dressing, but did not tape the dressing down above the rectum. The DON also measured the pressure sore to the left heel 3.0 cm x 6.5 cm SDTI dry eschar, unstageable. In an interview on 3/26/2013 at 1:45 PM, the DON stated LVN C should have taped the dressing all the way around the wound. Observation on 3/27/2013 at 9:23 AM revealed an extremely pervasive foul odor at the nurses ' station. The nurses' station is located four (4) rooms from Resident # 2's room. In an interview on 3/27/2013 at 9:23 AM, LVN C stated the pervasive odor was coming from the pressure ulcer of Resident #2, located 4 rooms from the nurse's station. In a telephone interview on 03/26/2013 at 4:00 PM, Resident # 2's Hospice Nurse stated cleansing the wound thoroughly and providing incontinent care prior to wound care would be essential in the healing of this wound. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician, stated he would expect staff to fully cleanse a resident prior to performing wound care and not perform wound care while a resident's bowel movement remained one inch above the site. Physician # 2 stated leaving feces close to the wound could cause worsening of the wound and infection. B) 1) Review of the History and Physical (H&P) from the hospital dated 01/12/2013 reflected Resident # 2 was admitted to the Intensive Care Unit from home on 01/07/2013 and had suffered a Right Middle Cerebral Artery [MEDICAL CONDITIONS] with left facial droop and [MEDICAL CONDITION]. The H&P reflected Resident # 2 could not use her walker to get out of bed the morning of 01/07/2013. The H&P did not reflect Resident # 2 had pressure sores. Review of Resident # 2's Face Sheet reflected a [AGE] year old female who entered the facility on 02/04/2013. Review of Resident # 2's record of Comprehensive Care Plan Team Meeting dated 02/19/2013 reflected the resident's [DIAGNOSES REDACTED]. Review of Resident # 2's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected staff assessed cognitive level and the Resident scored two out of three which indicated moderate cognitive impairment. Resident # 2 had poor decision making ability and required cueing/supervision. The assessment reflected Resident # 2 was at risk for pressure sores, but had no current pressure sores. Review of Resident # 2's Admission Evaluation, Nurses Notes and Weekly Skin Report/Body Assessment Sheets dated 02/04/2013 reflected Resident # 2 entered the facility without pressure sores. Resident # 2 had bruising, a gastrointestinal-tube site, old surgery scars to knees and discoloration to bilateral shins, but no pressure sores Review of Resident # 2's Braden Scale for Predicting Pressure Sore Risk dated 02/12/2013 reflected a score of 14 and reflected the Resident was at moderate risk for developing pressure sores. The Braden Scale reflected Resident # 2's skin was very moist, she was chair fast with very limited mobility and friction and shear was a potential problem. In an interview on 03/26/2013 at 11:56 AM, the MDS Coordinator stated, in regards to the Braden Scale, a score of 19 or below indicated a resident is at "high" risk for pressure sores, not moderate risk as indicated on the facility computerized form. In addition, although the initial assessment did not reflect this, Resident # 2 was now on hospice and bedbound. Review of Resident # 2's Nurse's Notes dated 02/14/2013 reflected "OOB (out of bed) earlier to have shower and CNA noticed discoloration to L (left) heel. Pressure area noted to site. Area blanchable. Heel protectors put on when put to bed." The Nurse's Note reflected no notification to the physician regarding the pressure sore to Resident # 2's heel and there was no physician order for [REDACTED]. Review of Resident # 2's Weekly Skin Report/Body assessment dated [DATE] (11 days between Weekly Skin Report/Body Assessments) reflected Resident # 2 had blanchable redness/eschar to her coccyx with no measurements. The document reflected no area to Resident # 2's heel and no notification to the resident's physician regarding redness/eschar to Resident # 2's coccyx nor the pressure area to the resident's left heel. Review of Resident # 2's Comprehensive Care Plan dated 02/18/2013 reflected the Resident was at risk for skin breakdown due to poor bed mobility and recent [MEDICAL CONDITION]. Goals reflected Resident #2 would remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions reflected: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. (Initiated 02/18/2013) Monitor for incontinence every 2 hours and as needed, incontinent care after each episode. (Initiated 02/19/2013) Monitor skin weekly and notify MD/RP (Medical Doctor/Responsible Party) of any new areas. (Initiated 02/18/2013) Provide pressure relieving and positioning devices on resident's bed, wheelchair as appropriate. (Initiated 02/18/2013) There were no preventative measures of turning and repositioning Resident # 2 every two hours to prevent the development of pressure sores. In an interview on 03/26/2013 at 12:01 AM the MDS Coordinator stated she did not add preventative measures of turning and repositioning Resident # 2 every two hours to the Resident's care plan dated 02/18/13, and stated it should have been on the care plan and she "must have missed it." Review of Resident # 2's Nurse's Notes dated 02/23/2013 reflected the Resident "has dark purple/black area to coccyx, sacral area surrounded by Stage II redness. Also thin line of small blisters vertical on R (right) buttocks." There was no notification made to Resident # 2's physician. Further review of Nurses Notes dated 02/23/2013 at 11:00 PM reflected Resident # 2 was "yelling out frequently at this time. Has thrown covers off multiple times". At 1:00 AM on 02/24/2013 Resident # 2 "con't (continued) to yell out." Review of Resident # 2's Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 (8 days between Weekly Skin Report/Body Assessments) reflected the resident had pressure sores to her coccyx and left outer heel. The report reflected conflicting measurements and staging documented for Resident # 2's pressure sore to her coccyx as follows: 02/23/2013 - 15.0 centimeters (cm) x 12.0 cm and reflected Stage I Again on 02/23/2013 - 10.0 cm by 0.5 cm and reflected Stage II Again on 02/23/2013 - 5.0 cm circular and reflected Stage III The Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 reflected Resident # 2's pressure sore to her left outer/posterior heel measured 5.0 cm x 3.0 cm with reddish brown color and reflected Stage I. In an interview on 03/25/2013 at 3:30 PM the DON stated she did not know why Resident # 2's coccyx wound had conflicting measurements on 02/23/2013. The DON stated there was a change in staff during February and March of 2013 and that is the only explanation she had regarding Weekly Skin Assessments not being completed weekly or every 7 days. The Weekly Pressure Sore Record reflected Resident # 2's wound to her coccyx was not reported to the physician until 02/24/2013. The wound to Resident # 2's left outer posterior heel had not been reported to the physician as of survey review date of 03/25/2013. Review of the Physician Order dated 02/24/2013 reflected clean coccyx pressure ulcer with DWC (disinfectant wound cleanser) , apply Santyl Ointment and dry dressing every day and as needed for soiling. Have wound consultant advise further treatment. The order also [MEDICATION NAME] milligrams (mg) twice per day for 14 days was ordered for increased temperature and wounds (2). There was no physician order to treat Resident # 2's left outer heel pressure sore. Review of the Medication Chart Record for February, 2013 reflected the new order for Resident # 2's coccyx wound treatment began on 02/24/2013. There was no wound treatment performed the date the coccyx wound was identified on 02/23/2013. Review of Resident # 2's Nurse's Notes dated 02/24/2013 at 9:10 PM reflected the initial dose [MEDICATION NAME] given at 8:00 PM. Resident # 2 was lying in bed propped off buttock with pillows, heel protectors on both feet. Dressing applied to coccyx area per order. Review of Resident # 2's Resident Infection Report reflected the Resident had an elevated temperature on 02/24/2013 on the 10:00 AM - 6:00 PM shift. " ....Also noted was "breakdown on coccyx with odor." Review of Resident # 2's Nurse's Notes dated 02/25/2013 at 9:00 AM reflected "On ABT -[MEDICATION NAME] area to coccyx. At 4:30 PM the "dressing to buttock changed. Area is large dark purple in color with some skin sloughing off. Foul odor and bloody looking drainage. DON present during change. Area cleansed with DWC, pat dry, Santyl with dry dressing applied." There was no notification to the physician that the pressure sore to Resident # 2's coccyx had changed with skin sloughing off and foul odor and bloody looking drainage. Review of Resident # 2's Nurse's Notes dated 02/26/ reflected "wound specialist here to assess resident's coccyx wound. Measurements done by wound specialist: 12.0 cm x 14 cm x undermined depth. Recommended some type of silver to help with the odor. Stated wound is going to get worse before it gets better because of resident's altered tissue perfusion. Also stated wounds may appear rapidly. Resident is being turned from side to side not on back. Has low air loss mattress." "Resident continued [MEDICATION NAME] wound to coccyx." Review of Resident # 1's Weekly Skin Report/Body Assessment Sheet dated 02/26/2013 reflected the Resident's coccyx pressure sore measured 12.0 cm x 14.0 cm with undetermined depth and reflected unstageable. There was a note documented by the DON on 02/26/2013 that reflected resident was seen by a wound care specialist on 02/26/2013 and this is the correct measurement and stage. Review of Resident # 2's clinical record reflected no report from the wound care specialist except the documentation made by the DON on 02/26/2013 on the Weekly Pressure Sore Record. In an interview on 03/28/2013 at 3:45 PM the DON stated the wound care specialist did see Resident #2's wound to her coccyx on 02/26/2013. The DON stated the wound care specialist examined the wound and suggested some type of silver product but that information was not relayed to the physician and the physician order was not changed to reflect the wound care specialist's recommendation made on 02/26/2013. The DON stated she thought the silver product was for odor of the wound. The DON stated the wound care specialist did not give a written report of her findings and recommendations due to a payer source issue. (Silver products are used for the antibacterial properties and odor per website: http://www.[MEDICATION NAME].com/products/restore_silver.aspx which reflected: Restore Calcium Alginate Dressing - Silver This advanced wound dressing features a complex of calcium and ionic silver for effective antimicrobial action and odor reduction. Effective antimicrobial agent against a broad spectrum of micro-organisms frequently associated with bacterial colonization and infection in wounds - including fungi,[MEDICAL CONDITION] and VRE.) Review of Resident # 2's Comprehensive Care Plan dated 02/26/2013 reflected new pressure areas to the Resident's coccyx and left heel. The goal was updated to reflect both pressure sore areas will improve/reduce in size over next 90 days. There was no addition of measures to promote healing or wound treatment ordered by the physician. In an interview on 03/26/2013 at 12:05 PM, the MDS Coordinator stated the first Comprehensive Care Plan dated 02/18/2013 was based on the Initial assessment dated [DATE] when Resident # 2 had no pressure sores. The MDS Coordinator stated the preventative measures of turning/repositioning Resident # 2 every 2 hours should have been added to the care plan. The MDS Coordinator stated "I must have missed it." The MDS Coordinator stated Resident # 2 had developed pressure areas prior to the completion of the Comprehensive Care Plan dated 02/26/2013. The MDS Coordinator stated interventions of turning and repositioning the Resident and the addition of Resident # 2's physician ordered treatments should have been added to the care plan for preventative measures and promote healing of current wounds. Review of Resident # 2's Nurses Notes dated 02/27/2013 reflected "DON notified this nurse that resident was going to be sent to E.R........[DIAGNOSES REDACTED]. Resident has not been voiding every shift and coccyx area getting worse.". Review of Resident # 2's Admission Evaluation dated 03/11/2013 reflected the resident returned to the facility on that date with a wound (unstageable) to the coccyx. There was no note regarding Resident # 2's left heel pressure area. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected a Pressure Sore to the resident's coccyx measuring 15.0 cm x 13.0 cm with undetermined depth, unstageable. The area was foul purulent with moderate exudate (fluid such as pus or clear fluid that leaks out of blood vessels into nearby tissues) amount and 100% black in color. Also, a pressure sore to Resident # 2's left heel measuring 7.0 cm x 4.0 cm, 100% red in color, Stage I. No notification to the physician. Review of Resident # 2's Hospice Physician Orders/Plan of Care reflected the Resident was admitted to Hospice on 03/11/2013. There was no documentation of Resident # 2's coccyx/sacral or left heel wound. Review of Resident # 2's Hospice Team Care Plan dated 03/13/2013 reflected an Admission Summary, 3/11/2013, at 1:00 PM. The Admission Summary reflected Resident #2 had a history of Gastrointestinal-tube infection, [MEDICAL CONDITIONS], Sacral decub, Hypertension, and functional [MEDICAL CONDITION]. Resident # 2 had a stroke in January resulting in Dysphagia and left sided Paralysis....Resident # 2 was lying supine in bed at the time of the assessment.....Resident # 2 had a large unstageable wound to sacral area with serosanguinous drainage and foul odor noted. Left outer foot with brown/purple discoloration.... Interventions for Skin/Wound included: Use antiseptic as needed for redness or closed wound as needed. 03/12/2013 - Clean Sacral Wound with wound cleanser, pat dry with 4 x 4. Apply silver alginate and cover with ABD every other day and as needed. There was no treatment reflected for Resident # 2's left heel pressure sore. In a telephone interview on 03/26/2013 at 4:00 PM the Hospice Nurse stated she had admitted Resident # 2 to Hospice on 03/11/2013 and at that time the resident had a large unstageable, necrotic wound to her sacral. The Hospice Nurse stated she did not know the wound developed at the facility. The Hospice Nurse stated she had talked to the DON regarding wound treatment, turning Resident # 2 every hour and she felt the wound could make progress to heal. Review of Resident # 2's telephone Physician Orders dated 03/12/2013 reflected an order to clean wound on the sacrum with wound cleanser. Pat dry with 4 x 4. Apply Silver alginate. Cover with ABD every other day and as needed. There was no physician order for [REDACTED]. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx measured 12.0 cm x 12.0 cm with undetermined depth. The pressure sore had moderate exudate amount, was 90% black in color with bright red peri-wound skin. No notification made to the physician. Resident # 2's pressure sore to her right heel was documented as drying up, no drainage, dark red scaly dry. No notification to the physician. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx had no measurements, "much underlying tunneling" was written in the measurement section of this report. Resident # 2's coccyx pressure sore had foul odor with copious amount of exudate and was mixed in colors. The peri-wound was bright red. No notification to the physician made. Resident # 2's left heel pressure sore had no measurement with "drying up, no drainage, continue heel protectors" written in the measurement section. No notification to the physician and no care plan or physician order for [REDACTED]. In an interview on 03/26/2013 at 5:45 PM, RN A stated she was responsible for measuring wounds on the weekend. RN A stated she started work at the facility on 03/09/2013 with the expectation of having four (4) days of orientation however after one (1) day of orientation the wounds were turned over to her. RN A stated she had been familiar with assessing and staging wounds however Resident # 2's wound was so complicated and since the resident was a Hospice patient, the treatment was not aggressive. RN A stated the wound appeared to be getting worse. RN A stated she could not assess the size, depth, or stage of the pressure sore, but it had a quarter moon size opening this past weekend, 3/23/2013, and she noted tunneling and undermining. RN A stated she had contacted the DON by phone and advised the DON due to Resident # 2's coccyx wound tunneling and undermining, she could not measure it anymore. RN A stated the DON advised her Resident # 2 was on Hospice and when somebody's actively dying they don't heal. RN A stated she did not notify the physician either weekend because she could not get a clear measurement and was not really sure about the size . RN A stated she had not seen a wound that bad in a long time. In an interview on 03/28/2013 at 3:45 PM, the DON stated RN A had contacted her sometime this past weekend with information regarding opening, tunneling and undermining of Resident # 2's wound. The DON stated RN A asked her if the foul odor had been present prior to this weekend. The DON stated what RN A described to her over the phone was different than what she had been aware of regarding Resident # 2's wound but she did not look at Resident # 2's wound during the weekend nor upon returning to work on Monday, 3/25/2013. The DON stated she was not aware of when wound treatment was being performed on Monday, 3/25/2013 but did not request the nurse on duty to notify her of the time of wound care for Resident # 2. The DON stated she did not look at the wound until the survey team requested current assessment and measurements of the wound on 03/26/2013. The DON stated she did not tell RN A that Resident # 2 is on Hospice and her wound will not heal. The DON stated Resident # 2 was not actively dying at this time. The DON stated Resident # 2's physician was not notified of the wound to her heel nor given the specific information regarding the pressure sore to her coccyx. The DON stated the physician was not notified of the progression of Resident # 2's wounds that included foul odor, tunneling and undermining. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 being fed by CNA M. Resident # was alert and able to made eye contact, there was no respiratory distress and the resident was responding to being fed. In an interview on 03/25/2013 at 12:11 PM, CNA M stated that Resident # 2 was eating pretty good. CNA M stated she had fed Resident # 2 her breakfast and she had eaten very well, almost 100%. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician (PCP), stated he had not been notified of the Resident's pressure wound to her left heel. Physician # 2 stated he was notified of a pressure area to Resident # 2's coccyx on 02/26/2013, although the physician order was dated 02/24/2013, and again on 03/26/2013 (today, after the survey team had examined the wound) but had not been notified of foul odor and drainage of the wound. Physician # 2 stated he depends upon the facility staff to notify him of all changes of condition and had he known of the Resident's condition he possibly would have changed the course of treatment. Observation made on 03/25/2013 at 8:00 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 9:30 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the Resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 laying on her back, with her head of the bed raised. Resident # 2 was being fed by an aide. Observation on 3/26/2013 at 8:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:02 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 03/26/2013 at 9:30 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 11:30 am revealed Resident #2 in the same position-with a pillow under her left side and she was facing the door. In an interview on 03/26/2013 at 9:45 AM, Resident # 2's family member stated a family member for the Resident was at the facility daily. This family member stated prior to the Resident acquiring a pressure sore to her coccyx the family had noticed each time they visited, daily and at different times during the day, Resident # 2 would be in the same position, laying on her back. The family member stated somewhere around the end of February, 2013, the family had a meeting with the MDS Coordinator who had assured the family the facility could initiate Resident # 2 to be turned and repositioned each hour. The family member stated Resident # 2 was ambulatory with a walker prior to her stroke on 01/07/2013. In an interview on 03/26/2013 at 10:00 AM a another family member, who was visiting, stated the family had made a complaint to the facility regarding Resident # 2 not being turned and repositioned often enough. The family member stated each time someone in the family came to the facility, daily and at different times during the day, Resident # 2 was in the same position. The family member stated the MDS Coordinator stated a physician order could be written to turn and reposition Resident # 2 hourly. In an interview on 03/26/2013 at 11:45 AM, the MDS Coordinator stated she had a Care Plan meeting for Resident # 2 on 02/26/2013 when the family reported finding the Resident in the same position daily, at different times, when they would visit. The MDS Coordinator stated she did discuss an order to t

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment, that residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 3 of 6 residents (Residents # 2, #8 and #1) when: A) Resident # 2 entered the facility on 02/04/2013 without pressure sores. On 02/15/2013 a blanchable red area was found on Resident # 2's coccyx that progressed to encompass the Resident's sacral and coccyx to an unstageable pressure sore (Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) measuring 10.25 centimeters (cm) x 15.0 cm x 7.0 cm, with undermining, tunneling and pervasive odor. The Physician was not notified of the accurate progression of Resident # 2's coccyx/sacral pressure sore. On 02/14/2013 a blanchable red area was found on Resident # 2's left heel that progressed to a Suspected Deep Tissue Injury (SDTI) that measured 3.0 cm x 6.5 cm that was unstageable on 02/23/2013 with no notification to the physician. The facility failed to 1) provide timely and accurate assessments and notify the physician of the Resident # 2's pressure sores and failed to complete an accurate and individualized care plan; 2) provide sanitary wound care to promote healing and prevent infection; 3) place interventions of turning and repositioning Resident # 2 to prevent and promote healing to the resident's coccyx/sacral wound; and 4) ensure physician ordered nutritional supplement was provided to Resident # 2. B) Resident # 8 entered the facility on 10/12/2012 without pressure sores. A pressure sore was identified to Resident # 8's right heel on 03/09/2013. The facility failed to accurately assess, notify the physician, treat and update the comprehensive care plan to reflect measures to promote healing. C) On 03/27/2013 CNA H identified a Stage I pressure sore located on Resident # 1's right heel by CNA H. CNA H failed to notify the Charge Nurse for assessment and treatment on 03/27/2013. This resulted in an Immediate Jeopardy (IJ) on 03/26/2013. While the IJ was removed on 03/28/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 22 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: A) Review of the History and Physical (H&P) from the hospital dated 01/12/2013 reflected Resident # 2 was admitted to the Intensive Care Unit from home on 01/07/2013 and had suffered a Right Middle Cerebral Artery [MEDICAL CONDITIONS] with left facial droop and [MEDICAL CONDITION]. The H&P reflected Resident # 2 could not use her walker to get out of bed the morning of 01/07/2013. The H&P did not reflect Resident # 2 had pressure sores. Review of Resident # 2's Face Sheet reflected a [AGE] year old female who entered the facility on 02/04/2013. Review of Resident # 2's record of Comprehensive Care Plan Team Meeting dated 02/19/2013 reflected the resident's [DIAGNOSES REDACTED]. 1) Review of Resident # 2's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected staff assessed cognitive level and the Resident scored two out of three which indicated moderate cognitive impairment. Resident # 2 had poor decision making ability and required cueing/supervision. The assessment reflected Resident # 2 was at risk for pressure sores, but had no current pressure sores. Review of Resident # 2's Admission Evaluation, Nurses Notes and Weekly Skin Report/Body Assessment Sheets dated 02/04/2013 reflected Resident # 2 entered the facility without pressure sores. Resident # 2 had bruising, a gastrointestinal-tube site, old surgery scars to knees and discoloration to bilateral shins, but no pressure sores Review of Resident # 2's Braden Scale for Predicting Pressure Sore Risk dated 02/12/2013 reflected a score of 14 and reflected the Resident was at moderate risk for developing pressure sores. The Braden Scale reflected Resident # 2's skin was very moist, she was chair fast with very limited mobility and friction and shear was a potential problem. In an interview on 03/26/2013 at 11:56 AM, the MDS Coordinator stated, in regards to the Braden Scale, a score of 19 or below indicated a resident is at "high" risk for pressure sores, not moderate risk as indicated on the facility computerized form. In addition, although the initial assessment did not reflect this, Resident # 2 was now on hospice and bedbound. Review of Resident # 2's Nurse's Notes dated 02/14/2013 reflected "OOB (out of bed) earlier to have shower and CNA noticed discoloration to L (left) heel. Pressure area noted to site. Area blanchable. Heel protectors put on when put to bed." The Nurse's Note reflected no notification to the physician regarding the pressure sore to Resident # 2's heel and there was no physician order for [REDACTED]. Review of Resident # 2's Weekly Skin Report/Body assessment dated [DATE] (11 days between Weekly Skin Report/Body Assessments) reflected Resident # 2 had blanchable redness/eschar to her coccyx with no measurements. The document reflected no area to Resident # 2's heel and no notification to the resident's physician regarding redness/eschar to Resident # 2's coccyx nor the pressure area to the resident's left heel. Review of Resident # 2's Comprehensive Care Plan dated 02/18/2013 reflected the Resident was at risk for skin breakdown due to poor bed mobility and recent [MEDICAL CONDITION]. Goals reflected Resident #2 would remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions reflected: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. (Initiated 02/18/2013) Monitor for incontinence every 2 hours and as needed, incontinent care after each episode. (Initiated 02/19/2013) Monitor skin weekly and notify MD/RP (Medical Doctor/Responsible Party) of any new areas. (Initiated 02/18/2013) Provide pressure relieving and positioning devices on resident's bed, wheelchair as appropriate. (Initiated 02/18/2013) There were no preventative measures of turning and repositioning Resident # 2 every two hours to prevent the development of pressure sores. In an interview on 03/26/2013 at 12:01 AM the MDS Coordinator stated she did not add preventative measures of turning and repositioning Resident # 2 every two hours to the Resident's care plan dated 02/18/13, and stated it should have been on the care plan and she "must have missed it." Review of Resident # 2's Nurse's Notes dated 02/23/2013 reflected the Resident "has dark purple/black area to coccyx, sacral area surrounded by Stage II redness. Also thin line of small blisters vertical on R (right) buttocks." There was no notification made to Resident # 2's physician. Further review of Nurses Notes dated 02/23/2013 at 11:00 PM reflected Resident # 2 was "yelling out frequently at this time. Has thrown covers off multiple times". At 1:00 AM on 02/24/2013 Resident # 2 "con't (continued) to yell out." Review of Resident # 2's Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 (8 days between Weekly Skin Report/Body Assessments) reflected the resident had pressure sores to her coccyx and left outer heel. The report reflected conflicting measurements and staging documented for Resident # 2's pressure sore to her coccyx as follows: 02/23/2013 - 15.0 centimeters (cm) x 12.0 cm and reflected Stage I Again on 02/23/2013 - 10.0 cm by 0.5 cm and reflected Stage II Again on 02/23/2013 - 5.0 cm circular and reflected Stage III The Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 reflected Resident # 2's pressure sore to her left outer/posterior heel measured 5.0 cm x 3.0 cm with reddish brown color and reflected Stage I. In an interview on 03/25/2013 at 3:30 PM the DON stated she did not know why Resident # 2's coccyx wound had conflicting measurements on 02/23/2013. The DON stated there was a change in staff during February and March of 2013 and that is the only explanation she had regarding Weekly Skin Assessments not being completed weekly or every 7 days. The Weekly Pressure Sore Record reflected Resident # 2's wound to her coccyx was not reported to the physician until 02/24/2013. The wound to Resident # 2's left outer posterior heel had not been reported to the physician as of survey review date of 03/25/2013. Review of the Physician Order dated 02/24/2013 reflected clean coccyx pressure ulcer with DWC (disinfectant wound cleanser) , apply Santyl Ointment and dry dressing every day and as needed for soiling. Have wound consultant advise further treatment. The order also [MEDICATION NAME] milligrams (mg) twice per day for 14 days was ordered for increased temperature and wounds (2). There was no physician order to treat Resident # 2's left outer heel pressure sore. Review of the Medication Chart Record for February, 2013 reflected the new order for Resident # 2's coccyx wound treatment began on 02/24/2013. There was no wound treatment performed the date the coccyx wound was identified on 02/23/2013. Review of Resident # 2's Nurse's Notes dated 02/24/2013 at 9:10 PM reflected the initial dose [MEDICATION NAME] given at 8:00 PM. Resident # 2 was lying in bed propped off buttock with pillows, heel protectors on both feet. Dressing applied to coccyx area per order. Review of Resident # 2's Resident Infection Report reflected the Resident had an elevated temperature on 02/24/2013 on the 10:00 AM - 6:00 PM shift. " ....Also noted was "breakdown on coccyx with odor." Review of Resident # 2's Nurse's Notes dated 02/25/2013 at 9:00 AM reflected "On ABT -[MEDICATION NAME] area to coccyx. At 4:30 PM the "dressing to buttock changed. Area is large dark purple in color with some skin sloughing off. Foul odor and bloody looking drainage. DON present during change. Area cleansed with DWC, pat dry, Santyl with dry dressing applied." There was no notification to the physician that the pressure sore to Resident # 2's coccyx had changed with skin sloughing off and foul odor and bloody looking drainage. Review of Resident # 2's Nurse's Notes dated 02/26/ reflected "wound specialist here to assess resident's coccyx wound. Measurements done by wound specialist: 12.0 cm x 14 cm x undermined depth. Recommended some type of silver to help with the odor. Stated wound is going to get worse before it gets better because of resident's altered tissue perfusion. Also stated wounds may appear rapidly. Resident is being turned from side to side not on back. Has low air loss mattress." "Resident continued [MEDICATION NAME] wound to coccyx." Review of Resident # 1's Weekly Skin Report/Body Assessment Sheet dated 02/26/2013 reflected the Resident's coccyx pressure sore measured 12.0 cm x 14.0 cm with undetermined depth and reflected unstageable. There was a note documented by the DON on 02/26/2013 that reflected resident was seen by a wound care specialist on 02/26/2013 and this is the correct measurement and stage. Review of Resident # 2's clinical record reflected no report from the wound care specialist except the documentation made by the DON on 02/26/2013 on the Weekly Pressure Sore Record. In an interview on 03/28/2013 at 3:45 PM the DON stated the wound care specialist did see Resident #2's wound to her coccyx on 02/26/2013. The DON stated the wound care specialist examined the wound and suggested some type of silver product but that information was not relayed to the physician and the physician order was not changed to reflect the wound care specialist's recommendation made on 02/26/2013. The DON stated the wound care specialist did not give a written report of her findings and recommendations due to a payer source issue. Review of Resident # 2's Comprehensive Care Plan dated 02/26/2013 reflected new pressure areas to the Resident's coccyx and left heel. The goal was updated to reflect both pressure sore areas will improve/reduce in size over next 90 days. There was no addition of measures to promote healing or wound treatment ordered by the physician. In an interview on 03/26/2013 at 12:05 PM, the MDS Coordinator stated the first Comprehensive Care Plan dated 02/18/2013 was based on the Initial assessment dated [DATE] when Resident # 2 had no pressure sores. The MDS Coordinator stated the preventative measures of turning/repositioning Resident # 2 every 2 hours should have been added to the care plan. The MDS Coordinator stated "I must have missed it." The MDS Coordinator stated Resident # 2 had developed pressure areas prior to the completion of the Comprehensive Care Plan dated 02/26/2013. The MDS Coordinator stated interventions of turning and repositioning the Resident and the addition of Resident # 2's physician ordered treatments should have been added to the care plan for preventative measures and promote healing of current wounds. Review of Resident # 2's Nurses Notes dated 02/27/2013 reflected "DON notified this nurse that resident was going to be sent to E.R........[DIAGNOSES REDACTED]. Resident has not been voiding every shift and coccyx area getting worse.". Review of Resident # 2's Admission Evaluation dated 03/11/2013 reflected the resident returned to the facility on that date with a wound (unstageable) to the coccyx. There was no note regarding Resident # 2's left heel pressure area. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected a Pressure Sore to the resident's coccyx measuring 15.0 cm x 13.0 cm with undetermined depth, unstageable. The area was foul purulent with moderate exudate (fluid such as pus or clear fluid that leaks out of blood vessels into nearby tissues) amount and 100% black in color. Also, a pressure sore to Resident # 2's left heel measuring 7.0 cm x 4.0 cm, 100% red in color, Stage I. No notification to the physician. Review of Resident # 2's Hospice Physician Orders/Plan of Care reflected the Resident was admitted to Hospice on 03/11/2013. There was no documentation of Resident # 2's coccyx/sacral or left heel wound. Review of Resident # 2's Hospice Team Care Plan dated 03/13/2013 reflected an Admission Summary, 3/11/2013, at 1:00 PM. The Admission Summary reflected Resident #2 had a history of Gastrointestinal-tube infection, [MEDICAL CONDITIONS], Sacral decub, Hypertension, and functional [MEDICAL CONDITION]. Resident # 2 had a stroke in January resulting in Dysphagia and left sided Paralysis....Resident # 2 was lying supine in bed at the time of the assessment.....Resident # 2 had a large unstageable wound to sacral area with serosanguinous drainage and foul odor noted. Left outer foot with brown/purple discoloration.... Interventions for Skin/Wound included: Use antiseptic as needed for redness or closed wound as needed. 03/12/2013 - Clean Sacral Wound with wound cleanser, pat dry with 4 x 4. Apply silver alginate and cover with ABD every other day and as needed. There was no treatment reflected for Resident # 2's left heel pressure sore. In a telephone interview on 03/26/2013 at 4:00 PM the Hospice Nurse stated she had admitted Resident # 2 to Hospice on 03/11/2013 and at that time the resident had a large unstageable, necrotic wound to her sacral. The Hospice Nurse stated she did not know the wound developed at the facility. The Hospice Nurse stated she had talked to the DON regarding wound treatment, turning Resident # 2 every hour and she felt the wound could make progress to heal. Review of Resident # 2's telephone Physician Orders dated 03/12/2013 reflected an order to clean wound on the sacrum with wound cleanser. Pat dry with 4 x 4. Apply Silver alginate. Cover with ABD every other day and as needed. There was no physician order for [REDACTED]. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx measured 12.0 cm x 12.0 cm with undetermined depth. The pressure sore had moderate exudate amount, was 90% black in color with bright red peri-wound skin. No notification made to the physician. Resident # 2's pressure sore to her right heel was documented as drying up, no drainage, dark red scaly dry. No notification to the physician. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx had no measurements, "much underlying tunneling" was written in the measurement section of this report. Resident # 2's coccyx pressure sore had foul odor with copious amount of exudate and was mixed in colors. The peri-wound was bright red. No notification to the physician made. Resident # 2's left heel pressure sore had no measurement with "drying up, no drainage, continue heel protectors" written in the measurement section. No notification to the physician and no care plan or physician order for [REDACTED]. In an interview on 03/26/2013 at 5:45 PM, RN A stated she was responsible for measuring wounds on the weekend. RN A stated she started work at the facility on 03/09/2013 with the expectation of having four (4) days of orientation however after one (1) day of orientation the wounds were turned over to her. RN A stated she had been familiar with assessing and staging wounds however Resident # 2's wound was so complicated and since the resident was a Hospice patient, the treatment was not aggressive. RN A stated the wound appeared to be getting worse. RN A stated she could not assess the size, depth, or stage of the pressure sore, but it had a quarter moon size opening this past weekend, 3/23/2013, and she noted tunneling and undermining. RN A stated she had contacted the DON by phone and advised the DON due to Resident # 2's coccyx wound tunneling and undermining, she could not measure it anymore. RN A stated the DON advised her Resident # 2 was on Hospice and when somebody's actively dying they don't heal. RN A stated she did not notify the physician either weekend because she could not get a clear measurement and was not really sure about the size . RN A stated she had not seen a wound that bad in a long time. In an interview on 03/28/2013 at 3:45 PM, the DON stated RN A had contacted her sometime this past weekend with information regarding opening, tunneling and undermining of Resident # 2's wound. The DON stated RN A asked her if the foul odor had been present prior to this weekend. The DON stated what RN A described to her over the phone was different than what she had been aware of regarding Resident # 2's wound but she did not look at Resident # 2's wound during the weekend nor upon returning to work on Monday, 3/25/2013. The DON stated she was not aware of when wound treatment was being performed on Monday, 3/25/2013 but did not request the nurse on duty to notify her of the time of wound care for Resident # 2. The DON stated she did not look at the wound until the survey team requested current assessment and measurements of the wound on 03/26/2013. The DON stated she did not tell RN A that Resident # 2 is on Hospice and her wound will not heal. The DON stated Resident # 2 was not actively dying at this time. The DON stated Resident # 2's physician was not notified of the wound to her heel nor given the specific information regarding the pressure sore to her coccyx. The DON stated the physician was not notified of the progression of Resident # 2's wounds that included foul odor, tunneling and undermining. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 being fed by CNA M. Resident # was alert and able to made eye contact, there was no respiratory distress and the resident was responding to being fed. In an interview on 03/25/2013 at 12:11 PM, CNA M stated that Resident # 2 was eating pretty good. CNA M stated she had fed Resident # 2 her breakfast and she had eaten very well, almost 100%. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician (PCP), stated he had not been notified of the Resident's pressure wound to her left heel. Physician # 2 stated he was notified of a pressure area to Resident # 2's coccyx on 02/26/2013, although the physician order was dated 02/24/2013, and again on 03/26/2013 (today, after the survey team had examined the wound) but had not been notified of foul odor and drainage of the wound. Physician # 2 stated he depends upon the facility staff to notify him of all changes of condition and had he known of the Resident's condition he possibly would have changed the course of treatment. 2) Observation on 3/25/2013 at 5:25 pm revealed Licensed Vocational Nurse (LVN) C and Certified Nurse Aide (CNA) J provided wound care to Resident #2's sacral and heel wounds. CNA J assisted Resident #2 to her right side. LVN C observed and pointed at a brown, firm, feces at Resident #2 ' s rectum, approximately 1 inch from the resident's coccyx/sacral wound. LVN C stated " will clean that later " . CNA J also did not perform incontinent care on Resident #2 prior to the wound care. LVN C removed the dirty, purulent, saturated dressing from Resident #2 ' s coccyx/sacrum area that had a strong odor. She then had to remove kerlix gauze packing and silver calcium alginate packing. This kerlix gauze packing was not in the physician ' s orders. She used gauze to cleanse the wound that was soaked in a wound cleanser. She placed the gauze in the wound bed and scrubbed up and down instead of starting in the middle of the wound bed to cleanse in a circular, outward motion. (Describing the wound using a clock face, with the top of the wound at 12:00 towards head of resident and 6:00 towards the feet, 9:00 is left side and 3:00 is the right side) Resident # 2's large pressure sore had noted undermining at ten o ' clock to two o ' clock and four o ' clock to eight o ' clock. The pressure sore also had a beefy red wound bed at five o ' clock to seven o ' clock. The pressure sore had wet, black eschar connecting at nine o ' clock to three o ' clock down the middle. Under the eschar and in the middle of the wound was yellow slough. LVN C placed the ordered dressing on Resident #2 ' s coccyx/sacrum pressure sore. She used tape to secure the dressing, but did not secure the area directly above the rectum where the firm stool was located. LVN C and CNA J did not provide incontinent care after the wound care. Resident #2 also had a Foley catheter, and LVN C and CNA J also did not provide Foley catheter care at this time. LVN C removed heel protectors from Resident #2 feet. Resident # 2 had a SDTI with dry eschar to the left heel. Heel protectors were placed back on Resident # 2's feet. Resident # 2 was repositioned and placed on her back and a sheet placed over her. In an interview on 03/25/2013 at 5:45 PM, LVN C stated she does not measure pressure wounds and that the Director of Nurses (DON) measures wounds on Wednesdays. LVN C stated Resident #2's wound to her coccyx/sacral area was unstageable. LVN C stated she would come back later to perform incontinent care and clean the feces off of Resident # 2's rectum, which was approximately 1 inch from the wound. In an interview on 3/25/2013 at 6:00 PM, the DON stated she does not measure wounds on Wednesdays but the weekend Registered Nurse (RN) Supervisor measures the wounds on the weekends. The DON stated it was her expectation incontinent care be provided prior to wound treatment for [REDACTED]. Observation on 3/26/2013 at 11:45 AM revealed LVN C, the DON, and CNA K to provide wound care for Resident #2. LVN C removed a purulent, oversaturated dressing dated 03/25/2013. The dressing had a strong pervasive odor. LVN C cleansed Resident # 2's coccyx/sacral wound with gauze saturated in wound cleanser in an up and down motion instead of a circular and outward motion. The DON measured Resident # 2's coccyx/sacral pressure sore: at 10.25 cm x 15.0 cm x 7.0 cm. The DON measured tunnels at two o ' clock to equal 7.0 cm and four o ' clock to equal 6.0 cm. The DON measured undermining at three o ' clock to equal 3.0 cm, five to six o ' clock to equal 3.5 cm, six to seven o ' clock to equal 3.0 cm, and seven to eight o ' clock to equal 1.0 cm. The DON noted black, wet eschar attached at nine o ' clock and to the bottom of the wound bed at three to four o ' clock going across the middle of the wound. LVN C then applied the ordered dressing, but did not tape the dressing down above the rectum. The DON also measured the pressure sore to the left heel 3.0 cm x 6.5 cm SDTI dry eschar, unstageable. In an interview on 3/26/2013 at 1:45 PM, the DON stated LVN C should have taped the dressing all the way around the wound. The DON stated the physician had not been notified of the increased drainage to the wound nor of the pervasive odor coming from the wound, nor the wound specialist's recommendation for a silver product. Therefore there was no order to culture the wound and no order to pack the undermining and tunneling of the wound from the physician. The DON also stated the physician had not been notified of the depth and need for a dressing change to include packing. The DON stated the silver calcium alginate (recommended by the wound care specialist) was only for the odor. (Silver products are used for the antibacterial properties and odor per website: http://www.[MEDICATION NAME].com/products/restore_silver.aspx which reflected: Restore Calcium Alginate Dressing - Silver This advanced wound dressing features a complex of calcium and ionic silver for effective antimicrobial action and odor reduction. Effective antimicrobial agent against a broad spectrum of micro-organisms frequently associated with bacterial colonization and infection in wounds - including fungi,[MEDICAL CONDITION] and VRE.) Observation on 3/27/2013 at 9:23 AM revealed an extremely pervasive foul odor at the nurses ' station. The nurses' station is located four (4) rooms from Resident # 2's room. In an interview on 3/27/2013 at 9:23 AM, LVN C stated the pervasive odor was coming from the pressure ulcer of Resident #2, located 4 rooms from the nurse's station. In a telephone interview on 03/26/2013 at 4:00 PM, Resident # 2's Hospice Nurse stated cleansing the wound thoroughly and providing incontinent care prior to wound care would be essential in the healing of this wound. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician, stated he would expect staff to fully cleanse a resident prior to performing wound care and not perform wound care while a resident's bowel movement remained one inch above the site. Physician # 2 stated leaving feces close to the wound could cause worsening of the wound and infection. 3) Observation made on 03/25/2013 at 8:00 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 9:30 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the Resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 laying on her back, with her head of the bed raised. Resident # 2 was being fed by an aide. Observation on 3/26/2013 at 8:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:02 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 03/26/2013 at 9:30 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 11:30 am revealed Resident #2 in the same position-with a pillow under her left side and she was facing the door. In an interview on 03/26/2013 at 9:45 AM, Resident # 2's family member stated a family member for the Resident was at the facility daily. This family member stated prior to the Resident acquiring a pressure sore to her coccyx the family had noticed each time they visited, daily and at different times during the day, Resident # 2 would be in the same position, laying on her back. The family member stated somewhere around the end of February, 2013, the family had a meeting with the MDS Coordinator who had assured the family the facility could initiate Resident # 2 to be turned and repositioned each hour. The family member stated Resident # 2 was ambulatory with a walker prior to her stroke on 01/07/2013. In an interview on 03/26/2013 at 10:00 AM a another family member, who was visiting, stated the family had made a complaint to the facility regarding Resident # 2 not being turned and repositioned often enough. The family member stated each time someone in the family came to the facility, daily and at different times during the day, Resident # 2 was in the same position. The family member stated the MDS Coordinator stated a physician order could be written to turn and reposition Resident # 2 hourly. In an interview on 03/26/2013 at 11:45 AM, the MDS Coordinator stated she had a Care Plan meeting for Resident # 2 on 02/26/2013 when the family reported finding the Resident in the same position daily, at different times, when they would visit. The MDS Coordinator stated she did discuss an order to turn and reposition Resident # 2 every one hour. The MDS Coordinator stated she had relayed the information to the DON that day but did not follow up with the DON to ensure the plan was put into place. The MDS Coordinator stated she did not add turning and repositioning each hour or every 2 hours at that time to Resident # 2's care plan, and further stated "I must have missed it." In an interview on 03/26/2013 at 2:30 PM, CNA M stated she and the other aides turn Resident # 2 every two hours. CNA M stated she had not been advised to turn Resident # 2 every hour. In an interview on 03/26/2013 at 4:40 PM, the DON stated the MDS Coordinator had advised her of the family's complaint regarding Resident # 2 not being turned and repositioned. The DON stated the MDS Coordinator had stated the family requested Resident # 2 be turned and repositioned each hour but the facility had not had any trouble with turning and repositioning so she did not initiate the plan. The DON stated she did tell staff, that included aides and nurses, to turn and reposition Resident # 2 every two hours, not hourly, prior to the Resident acquiring the pressure sore on her coccyx/sacral area. Review of Resident # 2's Physician Orders reflected an order dated 03/26/2013 to "turn resident every 1 hour while in bed per hospice....." 4) Review of Resident # 2's Comprehensive Nutritional assessment dated [DATE] reflected the Resident had an unstageable wound to her sacrum. Recommendations and Plan reflected Magic cup three times per day between meals at 10:00 AM, 2:00 PM and HS (Hour of Sleep) for increased k-cal and protein. Review of Resident # 2's Diet Requisition dated 03/18/2013 reflected "upon availability, send magic cup at 10:00 AM, 2:00 PM and HS for increased k-cal and protein." Review of Resident # 2's Physician Orders dated 03/18/2013 reflected "upon availability, send magic cup three times per day at 10:00 AM, 2:00 PM and HS fo

Based on observation, interview and record review, the Administrator and Director of Nurses (DON) failed to administer the facility in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident when: The Administrator failed to supervise, monitor and consult with the DON to ensure the 22 residents residing in the facility received the care and services to meet their individual needs with regards to pressure sores. The Administrator failed to ensure Quality Assessment and Assurance (QA&A) Committee Meetings were conducted quarterly and communicate information regarding wounds in order for the committee to address and put interventions in place; and The DON failed to ensure nursing staff responsible for providing quality care for 3 of 6 residents (Resident # 2, #8 and #1) reviewed for pressure sores were monitored and supervised in the procedures of developing accurate comprehensive care plans, providing sanitary wound care, identifying, assessing and notifying the physician of pressure sores, initiating preventative measures and reviewing physician orders to ensure the correct protein supplement was administered. A) Resident # 2 entered the facility on 02/04/2013 without pressure sores. On 02/15/2013 a blanchable red area was found on Resident # 2's coccyx that progressed to encompass the Resident's sacral and coccyx to an unstageable pressure sore (Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) measuring 10.25 centimeters (cm) x 15.0 cm x 7.0 cm, with undermining, tunneling and pervasive odor. The Physician was not notified of the accurate progression of Resident # 2's coccyx/sacral pressure sore. On 02/14/2013 a blanchable red area was found on Resident # 2's left heel that progressed to a Suspected Deep Tissue Injury (SDTI) that measured 3.0 cm x 6.5 cm that was unstageable on 02/23/2013 with no notification to the physician. The facility failed to 1) provide timely and accurate assessments and notify the physician of the Resident # 2's pressure sores and failed to complete an accurate and individualized care plan; 2) provide sanitary wound care to promote healing and prevent infection; 3) place interventions of turning and repositioning Resident # 2 to prevent and promote healing to the resident's coccyx/sacral wound; and 4) ensure physician ordered nutritional supplement was provided to Resident # 2. B) Resident # 8 entered the facility on 10/12/2012 without pressure sores. A pressure sore was identified to Resident # 8's right heel on 03/09/2013. The facility failed to accurately assess, notify the physician, treat and update the comprehensive care plan to reflect measures to promote healing. C) On 03/27/2013 CNA H identified a Stage I pressure sore located on Resident # 1's right heel by CNA H. CNA H failed to notify the Charge Nurse for assessment and treatment on 03/27/2013. This resulted in an Immediate Jeopardy (IJ) on 03/26/2013. While the IJ was removed on 03/28/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 22 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: A) Review of the History and Physical (H&P) from the hospital dated 01/12/2013 reflected Resident # 2 was admitted to the Intensive Care Unit from home on 01/07/2013 and had suffered a Right Middle Cerebral Artery [MEDICAL CONDITIONS] with left facial droop and [MEDICAL CONDITION]. The H&P reflected Resident # 2 could not use her walker to get out of bed the morning of 01/07/2013. The H&P did not reflect Resident # 2 had pressure sores. Review of Resident # 2's Face Sheet reflected a [AGE] year old female who entered the facility on 02/04/2013. Review of Resident # 2's record of Comprehensive Care Plan Team Meeting dated 02/19/2013 reflected the resident's [DIAGNOSES REDACTED]. 1) Review of Resident # 2's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected staff assessed cognitive level and the Resident scored two out of three which indicated moderate cognitive impairment. Resident # 2 had poor decision making ability and required cueing/supervision. The assessment reflected Resident # 2 was at risk for pressure sores, but had no current pressure sores. Review of Resident # 2's Admission Evaluation, Nurses Notes and Weekly Skin Report/Body Assessment Sheets dated 02/04/2013 reflected Resident # 2 entered the facility without pressure sores. Resident # 2 had bruising, a gastrointestinal-tube site, old surgery scars to knees and discoloration to bilateral shins, but no pressure sores Review of Resident # 2's Braden Scale for Predicting Pressure Sore Risk dated 02/12/2013 reflected a score of 14 and reflected the Resident was at moderate risk for developing pressure sores. The Braden Scale reflected Resident # 2's skin was very moist, she was chair fast with very limited mobility and friction and shear was a potential problem. In an interview on 03/26/2013 at 11:56 AM, the MDS Coordinator stated, in regards to the Braden Scale, a score of 19 or below indicated a resident is at "high" risk for pressure sores, not moderate risk as indicated on the facility computerized form. In addition, although the initial assessment did not reflect this, Resident # 2 was now on hospice and bedbound. Review of Resident # 2's Nurse's Notes dated 02/14/2013 reflected "OOB (out of bed) earlier to have shower and CNA noticed discoloration to L (left) heel. Pressure area noted to site. Area blanchable. Heel protectors put on when put to bed." The Nurse's Note reflected no notification to the physician regarding the pressure sore to Resident # 2's heel and there was no physician order for [REDACTED]. Review of Resident # 2's Weekly Skin Report/Body assessment dated [DATE] (11 days between Weekly Skin Report/Body Assessments) reflected Resident # 2 had blanchable redness/eschar to her coccyx with no measurements. The document reflected no area to Resident # 2's heel and no notification to the resident's physician regarding redness/eschar to Resident # 2's coccyx nor the pressure area to the resident's left heel. Review of Resident # 2's Comprehensive Care Plan dated 02/18/2013 reflected the Resident was at risk for skin breakdown due to poor bed mobility and recent [MEDICAL CONDITION]. Goals reflected Resident #2 would remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions reflected: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. (Initiated 02/18/2013) Monitor for incontinence every 2 hours and as needed, incontinent care after each episode. (Initiated 02/19/2013) Monitor skin weekly and notify MD/RP (Medical Doctor/Responsible Party) of any new areas. (Initiated 02/18/2013) Provide pressure relieving and positioning devices on resident's bed, wheelchair as appropriate. (Initiated 02/18/2013) There were no preventative measures of turning and repositioning Resident # 2 every two hours to prevent the development of pressure sores. In an interview on 03/26/2013 at 12:01 AM the MDS Coordinator stated she did not add preventative measures of turning and repositioning Resident # 2 every two hours to the Resident's care plan dated 02/18/13, and stated it should have been on the care plan and she "must have missed it." Review of Resident # 2's Nurse's Notes dated 02/23/2013 reflected the Resident "has dark purple/black area to coccyx, sacral area surrounded by Stage II redness. Also thin line of small blisters vertical on R (right) buttocks." There was no notification made to Resident # 2's physician. Further review of Nurses Notes dated 02/23/2013 at 11:00 PM reflected Resident # 2 was "yelling out frequently at this time. Has thrown covers off multiple times". At 1:00 AM on 02/24/2013 Resident # 2 "con't (continued) to yell out." Review of Resident # 2's Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 (8 days between Weekly Skin Report/Body Assessments) reflected the resident had pressure sores to her coccyx and left outer heel. The report reflected conflicting measurements and staging documented for Resident # 2's pressure sore to her coccyx as follows: 02/23/2013 - 15.0 centimeters (cm) x 12.0 cm and reflected Stage I Again on 02/23/2013 - 10.0 cm by 0.5 cm and reflected Stage II Again on 02/23/2013 - 5.0 cm circular and reflected Stage III The Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 reflected Resident # 2's pressure sore to her left outer/posterior heel measured 5.0 cm x 3.0 cm with reddish brown color and reflected Stage I. In an interview on 03/25/2013 at 3:30 PM the DON stated she did not know why Resident # 2's coccyx wound had conflicting measurements on 02/23/2013. The DON stated there was a change in staff during February and March of 2013 and that is the only explanation she had regarding Weekly Skin Assessments not being completed weekly or every 7 days. The Weekly Pressure Sore Record reflected Resident # 2's wound to her coccyx was not reported to the physician until 02/24/2013. The wound to Resident # 2's left outer posterior heel had not been reported to the physician as of survey review date of 03/25/2013. Review of the Physician Order dated 02/24/2013 reflected clean coccyx pressure ulcer with DWC (disinfectant wound cleanser) , apply Santyl Ointment and dry dressing every day and as needed for soiling. Have wound consultant advise further treatment. The order also [MEDICATION NAME] milligrams (mg) twice per day for 14 days was ordered for increased temperature and wounds (2). There was no physician order to treat Resident # 2's left outer heel pressure sore. Review of the Medication Chart Record for February, 2013 reflected the new order for Resident # 2's coccyx wound treatment began on 02/24/2013. There was no wound treatment performed the date the coccyx wound was identified on 02/23/2013. Review of Resident # 2's Nurse's Notes dated 02/24/2013 at 9:10 PM reflected the initial dose [MEDICATION NAME] given at 8:00 PM. Resident # 2 was lying in bed propped off buttock with pillows, heel protectors on both feet. Dressing applied to coccyx area per order. Review of Resident # 2's Resident Infection Report reflected the Resident had an elevated temperature on 02/24/2013 on the 10:00 AM - 6:00 PM shift. " ....Also noted was "breakdown on coccyx with odor." Review of Resident # 2's Nurse's Notes dated 02/25/2013 at 9:00 AM reflected "On ABT -[MEDICATION NAME] area to coccyx. At 4:30 PM the "dressing to buttock changed. Area is large dark purple in color with some skin sloughing off. Foul odor and bloody looking drainage. DON present during change. Area cleansed with DWC, pat dry, Santyl with dry dressing applied." There was no notification to the physician that the pressure sore to Resident # 2's coccyx had changed with skin sloughing off and foul odor and bloody looking drainage. Review of Resident # 2's Nurse's Notes dated 02/26/ reflected "wound specialist here to assess resident's coccyx wound. Measurements done by wound specialist: 12.0 cm x 14 cm x undermined depth. Recommended some type of silver to help with the odor. Stated wound is going to get worse before it gets better because of resident's altered tissue perfusion. Also stated wounds may appear rapidly. Resident is being turned from side to side not on back. Has low air loss mattress." "Resident continued [MEDICATION NAME] wound to coccyx." Review of Resident # 1's Weekly Skin Report/Body Assessment Sheet dated 02/26/2013 reflected the Resident's coccyx pressure sore measured 12.0 cm x 14.0 cm with undetermined depth and reflected unstageable. There was a note documented by the DON on 02/26/2013 that reflected resident was seen by a wound care specialist on 02/26/2013 and this is the correct measurement and stage. Review of Resident # 2's clinical record reflected no report from the wound care specialist except the documentation made by the DON on 02/26/2013 on the Weekly Pressure Sore Record. In an interview on 03/28/2013 at 3:45 PM the DON stated the wound care specialist did see Resident #2's wound to her coccyx on 02/26/2013. The DON stated the wound care specialist examined the wound and suggested some type of silver product but that information was not relayed to the physician and the physician order was not changed to reflect the wound care specialist's recommendation made on 02/26/2013. The DON stated the wound care specialist did not give a written report of her findings and recommendations due to a payer source issue. Review of Resident # 2's Comprehensive Care Plan dated 02/26/2013 reflected new pressure areas to the Resident's coccyx and left heel. The goal was updated to reflect both pressure sore areas will improve/reduce in size over next 90 days. There was no addition of measures to promote healing or wound treatment ordered by the physician. In an interview on 03/26/2013 at 12:05 PM, the MDS Coordinator stated the first Comprehensive Care Plan dated 02/18/2013 was based on the Initial assessment dated [DATE] when Resident # 2 had no pressure sores. The MDS Coordinator stated the preventative measures of turning/repositioning Resident # 2 every 2 hours should have been added to the care plan. The MDS Coordinator stated "I must have missed it." The MDS Coordinator stated Resident # 2 had developed pressure areas prior to the completion of the Comprehensive Care Plan dated 02/26/2013. The MDS Coordinator stated interventions of turning and repositioning the Resident and the addition of Resident # 2's physician ordered treatments should have been added to the care plan for preventative measures and promote healing of current wounds. Review of Resident # 2's Nurses Notes dated 02/27/2013 reflected "DON notified this nurse that resident was going to be sent to E.R........[DIAGNOSES REDACTED]. Resident has not been voiding every shift and coccyx area getting worse.". Review of Resident # 2's Admission Evaluation dated 03/11/2013 reflected the resident returned to the facility on that date with a wound (unstageable) to the coccyx. There was no note regarding Resident # 2's left heel pressure area. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected a Pressure Sore to the resident's coccyx measuring 15.0 cm x 13.0 cm with undetermined depth, unstageable. The area was foul purulent with moderate exudate (fluid such as pus or clear fluid that leaks out of blood vessels into nearby tissues) amount and 100% black in color. Also, a pressure sore to Resident # 2's left heel measuring 7.0 cm x 4.0 cm, 100% red in color, Stage I. No notification to the physician. Review of Resident # 2's Hospice Physician Orders/Plan of Care reflected the Resident was admitted to Hospice on 03/11/2013. There was no documentation of Resident # 2's coccyx/sacral or left heel wound. Review of Resident # 2's Hospice Team Care Plan dated 03/13/2013 reflected an Admission Summary, 3/11/2013, at 1:00 PM. The Admission Summary reflected Resident #2 had a history of Gastrointestinal-tube infection, [MEDICAL CONDITIONS], Sacral decub, Hypertension, and functional [MEDICAL CONDITION]. Resident # 2 had a stroke in January resulting in Dysphagia and left sided Paralysis....Resident # 2 was lying supine in bed at the time of the assessment.....Resident # 2 had a large unstageable wound to sacral area with serosanguinous drainage and foul odor noted. Left outer foot with brown/purple discoloration.... Interventions for Skin/Wound included: Use antiseptic as needed for redness or closed wound as needed. 03/12/2013 - Clean Sacral Wound with wound cleanser, pat dry with 4 x 4. Apply silver alginate and cover with ABD every other day and as needed. There was no treatment reflected for Resident # 2's left heel pressure sore. In a telephone interview on 03/26/2013 at 4:00 PM the Hospice Nurse stated she had admitted Resident # 2 to Hospice on 03/11/2013 and at that time the resident had a large unstageable, necrotic wound to her sacral. The Hospice Nurse stated she did not know the wound developed at the facility. The Hospice Nurse stated she had talked to the DON regarding wound treatment, turning Resident # 2 every hour and she felt the wound could make progress to heal. Review of Resident # 2's telephone Physician Orders dated 03/12/2013 reflected an order to clean wound on the sacrum with wound cleanser. Pat dry with 4 x 4. Apply Silver alginate. Cover with ABD every other day and as needed. There was no physician order for [REDACTED]. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx measured 12.0 cm x 12.0 cm with undetermined depth. The pressure sore had moderate exudate amount, was 90% black in color with bright red peri-wound skin. No notification made to the physician. Resident # 2's pressure sore to her right heel was documented as drying up, no drainage, dark red scaly dry. No notification to the physician. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx had no measurements, "much underlying tunneling" was written in the measurement section of this report. Resident # 2's coccyx pressure sore had foul odor with copious amount of exudate and was mixed in colors. The peri-wound was bright red. No notification to the physician made. Resident # 2's left heel pressure sore had no measurement with "drying up, no drainage, continue heel protectors" written in the measurement section. No notification to the physician and no care plan or physician order for [REDACTED]. In an interview on 03/26/2013 at 5:45 PM, RN A stated she was responsible for measuring wounds on the weekend. RN A stated she started work at the facility on 03/09/2013 with the expectation of having four (4) days of orientation however after one (1) day of orientation the wounds were turned over to her. RN A stated she had been familiar with assessing and staging wounds however Resident # 2's wound was so complicated and since the resident was a Hospice patient, the treatment was not aggressive. RN A stated the wound appeared to be getting worse. RN A stated she could not assess the size, depth, or stage of the pressure sore, but it had a quarter moon size opening this past weekend, 3/23/2013, and she noted tunneling and undermining. RN A stated she had contacted the DON by phone and advised the DON due to Resident # 2's coccyx wound tunneling and undermining, she could not measure it anymore. RN A stated the DON advised her Resident # 2 was on Hospice and when somebody's actively dying they don't heal. RN A stated she did not notify the physician either weekend because she could not get a clear measurement and was not really sure about the size . RN A stated she had not seen a wound that bad in a long time. In an interview on 03/28/2013 at 3:45 PM, the DON stated RN A had contacted her sometime this past weekend with information regarding opening, tunneling and undermining of Resident # 2's wound. The DON stated RN A asked her if the foul odor had been present prior to this weekend. The DON stated what RN A described to her over the phone was different than what she had been aware of regarding Resident # 2's wound but she did not look at Resident # 2's wound during the weekend nor upon returning to work on Monday, 3/25/2013. The DON stated she was not aware of when wound treatment was being performed on Monday, 3/25/2013 but did not request the nurse on duty to notify her of the time of wound care for Resident # 2. The DON stated she did not look at the wound until the survey team requested current assessment and measurements of the wound on 03/26/2013. The DON stated she did not tell RN A that Resident # 2 is on Hospice and her wound will not heal. The DON stated Resident # 2 was not actively dying at this time. The DON stated Resident # 2's physician was not notified of the wound to her heel nor given the specific information regarding the pressure sore to her coccyx. The DON stated the physician was not notified of the progression of Resident # 2's wounds that included foul odor, tunneling and undermining. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 being fed by CNA M. Resident # was alert and able to made eye contact, there was no respiratory distress and the resident was responding to being fed. In an interview on 03/25/2013 at 12:11 PM, CNA M stated that Resident # 2 was eating pretty good. CNA M stated she had fed Resident # 2 her breakfast and she had eaten very well, almost 100%. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician (PCP), stated he had not been notified of the Resident's pressure wound to her left heel. Physician # 2 stated he was notified of a pressure area to Resident # 2's coccyx on 02/26/2013, although the physician order was dated 02/24/2013, and again on 03/26/2013 (today, after the survey team had examined the wound) but had not been notified of foul odor and drainage of the wound. Physician # 2 stated he depends upon the facility staff to notify him of all changes of condition and had he known of the Resident's condition he possibly would have changed the course of treatment. 2) Observation on 3/25/2013 at 5:25 pm revealed Licensed Vocational Nurse (LVN) C and Certified Nurse Aide (CNA) J provided wound care to Resident #2's sacral and heel wounds. CNA J assisted Resident #2 to her right side. LVN C observed and pointed at a brown, firm, feces at Resident #2 ' s rectum, approximately 1 inch from the resident's coccyx/sacral wound. LVN C stated " will clean that later " . CNA J also did not perform incontinent care on Resident #2 prior to the wound care. LVN C removed the dirty, purulent, saturated dressing from Resident #2 ' s coccyx/sacrum area that had a strong odor. She then had to remove kerlix gauze packing and silver calcium alginate packing. This kerlix gauze packing was not in the physician ' s orders. She used gauze to cleanse the wound that was soaked in a wound cleanser. She placed the gauze in the wound bed and scrubbed up and down instead of starting in the middle of the wound bed to cleanse in a circular, outward motion. (Describing the wound using a clock face, with the top of the wound at 12:00 towards head of resident and 6:00 towards the feet, 9:00 is left side and 3:00 is the right side) Resident # 2's large pressure sore had noted undermining at ten o ' clock to two o ' clock and four o ' clock to eight o ' clock. The pressure sore also had a beefy red wound bed at five o ' clock to seven o ' clock. The pressure sore had wet, black eschar connecting at nine o ' clock to three o ' clock down the middle. Under the eschar and in the middle of the wound was yellow slough. LVN C placed the ordered dressing on Resident #2 ' s coccyx/sacrum pressure sore. She used tape to secure the dressing, but did not secure the area directly above the rectum where the firm stool was located. LVN C and CNA J did not provide incontinent care after the wound care. Resident #2 also had a Foley catheter, and LVN C and CNA J also did not provide Foley catheter care at this time. LVN C removed heel protectors from Resident #2 feet. Resident # 2 had a SDTI with dry eschar to the left heel. Heel protectors were placed back on Resident # 2's feet. Resident # 2 was repositioned and placed on her back and a sheet placed over her. In an interview on 03/25/2013 at 5:45 PM, LVN C stated she does not measure pressure wounds and that the Director of Nurses (DON) measures wounds on Wednesdays. LVN C stated Resident #2's wound to her coccyx/sacral area was unstageable. LVN C stated she would come back later to perform incontinent care and clean the feces off of Resident # 2's rectum, which was approximately 1 inch from the wound. In an interview on 3/25/2013 at 6:00 PM, the DON stated she does not measure wounds on Wednesdays but the weekend Registered Nurse (RN) Supervisor measures the wounds on the weekends. The DON stated it was her expectation incontinent care be provided prior to wound treatment for [REDACTED]. Observation on 3/26/2013 at 11:45 AM revealed LVN C, the DON, and CNA K to provide wound care for Resident #2. LVN C removed a purulent, oversaturated dressing dated 03/25/2013. The dressing had a strong pervasive odor. LVN C cleansed Resident # 2's coccyx/sacral wound with gauze saturated in wound cleanser in an up and down motion instead of a circular and outward motion. The DON measured Resident # 2's coccyx/sacral pressure sore: at 10.25 cm x 15.0 cm x 7.0 cm. The DON measured tunnels at two o ' clock to equal 7.0 cm and four o ' clock to equal 6.0 cm. The DON measured undermining at three o ' clock to equal 3.0 cm, five to six o ' clock to equal 3.5 cm, six to seven o ' clock to equal 3.0 cm, and seven to eight o ' clock to equal 1.0 cm. The DON noted black, wet eschar attached at nine o ' clock and to the bottom of the wound bed at three to four o ' clock going across the middle of the wound. LVN C then applied the ordered dressing, but did not tape the dressing down above the rectum. The DON also measured the pressure sore to the left heel 3.0 cm x 6.5 cm SDTI dry eschar, unstageable. In an interview on 3/26/2013 at 1:45 PM, the DON stated LVN C should have taped the dressing all the way around the wound. The DON stated the physician had not been notified of the increased drainage to the wound nor of the pervasive odor coming from the wound, nor the wound specialist's recommendation for a silver product. Therefore there was no order to culture the wound and no order to pack the undermining and tunneling of the wound from the physician. The DON also stated the physician had not been notified of the depth and need for a dressing change to include packing. The DON stated the silver calcium alginate (recommended by the wound care specialist) was only for the odor. (Silver products are used for the antibacterial properties and odor per website: http://www.[MEDICATION NAME].com/products/restore_silver.aspx which reflected: Restore Calcium Alginate Dressing - Silver This advanced wound dressing features a complex of calcium and ionic silver for effective antimicrobial action and odor reduction. Effective antimicrobial agent against a broad spectrum of micro-organisms frequently associated with bacterial colonization and infection in wounds - including fungi,[MEDICAL CONDITION] and VRE.) Observation on 3/27/2013 at 9:23 AM revealed an extremely pervasive foul odor at the nurses ' station. The nurses' station is located four (4) rooms from Resident # 2's room. In an interview on 3/27/2013 at 9:23 AM, LVN C stated the pervasive odor was coming from the pressure ulcer of Resident #2, located 4 rooms from the nurse's station. In a telephone interview on 03/26/2013 at 4:00 PM, Resident # 2's Hospice Nurse stated cleansing the wound thoroughly and providing incontinent care prior to wound care would be essential in the healing of this wound. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician, stated he would expect staff to fully cleanse a resident prior to performing wound care and not perform wound care while a resident's bowel movement remained one inch above the site. Physician # 2 stated leaving feces close to the wound could cause worsening of the wound and infection. 3) Observation made on 03/25/2013 at 8:00 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 9:30 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the Resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 laying on her back, with her head of the bed raised. Resident # 2 was being fed by an aide. Observation on 3/26/2013 at 8:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:02 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 03/26/2013 at 9:30 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 11:30 am revealed Resident #2 in the same position-with a pillow under her left side and she was facing the door. In an interview on 03/26/2013 at 9:45 AM, Resident # 2's family member stated a family member for the Resident was at the facility daily. This family member stated prior to the Resident acquiring a pressure sore to her coccyx the family had noticed each time they visited, daily and at different times during the day, Resident # 2 would be in the same position, laying on her back. The family member stated somewhere around the end of February, 2013, the family had a meeting with the MDS Coordinator who had assured the family the facility could initiate Resident # 2 to be turned and repositioned each hour. The family member stated Resident # 2 was ambulatory with a walker prior to her stroke on 01/07/2013. In an interview on 03/26/2013 at 10:00 AM a another family member, who was visiting, stated the family had made a complaint to the facility regarding Resident # 2 not being turned and repositioned often enough. The family member stated each time someone in the family came to the facility, daily and at different times during the day, Resident # 2 was in the same position. The family member stated the MDS Coordinator stated a physician order could be written to turn and reposition Resident # 2 hourly. In an interview on 03/26/2013 at 11:45 AM, the MDS Coordinator stated she had a Care Plan meeting for Resident # 2 on 02/26/2013 when the family reported finding the Resident in the same position daily, at different times, when they would visit. The MDS Coordinator stated she did discuss an order to turn and reposition Resident # 2 every one hour. The MDS Coordinator stated she had relayed the information to the DON that day but did not follow up with the DON to ensure the plan was put into place. The MDS Coordinator stated she did not add turning and repositioning each hour or every 2 hours at that time to Resident # 2's care plan, and further stated "I must have missed it." In an interview on 03/26/2013 at 2:30 PM, CNA M stated she and the other aides turn Resident # 2 every two hours. CNA M stated she had not been advised to turn Resident # 2 every hour. In an interview on 03/26/2013 at 4:40 PM, the DON stated the MDS Coordinator had advised her of the family's complaint regarding Resident # 2 not being turned and repositioned. The DON stated the MDS Coordinator had stated the family requested Resident # 2 be turned and repositioned each hour but the facility had not had any trouble with turning and repositioning so she did not initiate the plan. The DON stated she did tell staff, that included aides and nurses, to turn and reposition Resident # 2 every two hours, not hourly, prior to the Resident acquiring the pressure sore on her coccyx/sacral area.

Based on observation, interview and record review, the facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) met at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and develop and implement appropriate plans of action to correct identified quality deficiencies. The facility did not meet quarterly for the past year (03/2012 through 02/2013) and failed to identify quality deficiencies in the area of pressure ulcers including failure to identify, notify the physician, implement care and services to prevent and promote healing for 3 of 6 residents (Resident # 2, #8 and #1) reviewed for pressure sores when: A) Resident # 2 entered the facility on 02/04/2013 without pressure sores. On 02/15/2013 a blanchable red area was found on Resident # 2's coccyx that progressed to encompass the Resident's sacral and coccyx to an unstageable pressure sore (Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) measuring 10.25 centimeters (cm) x 15.0 cm x 7.0 cm, with undermining, tunneling and pervasive odor. The Physician was not notified of the accurate progression of Resident # 2's coccyx/sacral pressure sore. On 02/14/2013 a blanchable red area was found on Resident # 2's left heel that progressed to a Suspected Deep Tissue Injury (SDTI) that measured 3.0 cm x 6.5 cm that was unstageable on 02/23/2013 with no notification to the physician. The facility failed to 1) provide timely and accurate assessments and notify the physician of the Resident # 2's pressure sores and failed to complete an accurate and individualized care plan; 2) provide sanitary wound care to promote healing and prevent infection; 3) place interventions of turning and repositioning Resident # 2 to prevent and promote healing to the resident's coccyx/sacral wound; and 4) ensure physician ordered nutritional supplement was provided to Resident # 2. B) Resident # 8 entered the facility on 10/12/2012 without pressure sores. A pressure sore was identified to Resident # 8's right heel on 03/09/2013. The facility failed to accurately assess, notify the physician, treat and update the comprehensive care plan to reflect measures to promote healing. C) On 03/27/2013 CNA H identified a Stage I pressure sore located on Resident # 1's right heel by CNA H. CNA H failed to notify the Charge Nurse for assessment and treatment on 03/27/2013. This resulted in an Immediate Jeopardy (IJ) on 03/26/2013. While the IJ was removed on 03/28/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 22 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: A) Review of the History and Physical (H&P) from the hospital dated 01/12/2013 reflected Resident # 2 was admitted to the Intensive Care Unit from home on 01/07/2013 and had suffered a Right Middle Cerebral Artery [MEDICAL CONDITIONS] with left facial droop and [MEDICAL CONDITION]. The H&P reflected Resident # 2 could not use her walker to get out of bed the morning of 01/07/2013. The H&P did not reflect Resident # 2 had pressure sores. Review of Resident # 2's Face Sheet reflected a [AGE] year old female who entered the facility on 02/04/2013. Review of Resident # 2's record of Comprehensive Care Plan Team Meeting dated 02/19/2013 reflected the resident's [DIAGNOSES REDACTED]. 1) Review of Resident # 2's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected staff assessed cognitive level and the Resident scored two out of three which indicated moderate cognitive impairment. Resident # 2 had poor decision making ability and required cueing/supervision. The assessment reflected Resident # 2 was at risk for pressure sores, but had no current pressure sores. Review of Resident # 2's Admission Evaluation, Nurses Notes and Weekly Skin Report/Body Assessment Sheets dated 02/04/2013 reflected Resident # 2 entered the facility without pressure sores. Resident # 2 had bruising, a gastrointestinal-tube site, old surgery scars to knees and discoloration to bilateral shins, but no pressure sores Review of Resident # 2's Braden Scale for Predicting Pressure Sore Risk dated 02/12/2013 reflected a score of 14 and reflected the Resident was at moderate risk for developing pressure sores. The Braden Scale reflected Resident # 2's skin was very moist, she was chair fast with very limited mobility and friction and shear was a potential problem. In an interview on 03/26/2013 at 11:56 AM, the MDS Coordinator stated, in regards to the Braden Scale, a score of 19 or below indicated a resident is at "high" risk for pressure sores, not moderate risk as indicated on the facility computerized form. In addition, although the initial assessment did not reflect this, Resident # 2 was now on hospice and bedbound. Review of Resident # 2's Nurse's Notes dated 02/14/2013 reflected "OOB (out of bed) earlier to have shower and CNA noticed discoloration to L (left) heel. Pressure area noted to site. Area blanchable. Heel protectors put on when put to bed." The Nurse's Note reflected no notification to the physician regarding the pressure sore to Resident # 2's heel and there was no physician order for [REDACTED]. Review of Resident # 2's Weekly Skin Report/Body assessment dated [DATE] (11 days between Weekly Skin Report/Body Assessments) reflected Resident # 2 had blanchable redness/eschar to her coccyx with no measurements. The document reflected no area to Resident # 2's heel and no notification to the resident's physician regarding redness/eschar to Resident # 2's coccyx nor the pressure area to the resident's left heel. Review of Resident # 2's Comprehensive Care Plan dated 02/18/2013 reflected the Resident was at risk for skin breakdown due to poor bed mobility and recent [MEDICAL CONDITION]. Goals reflected Resident #2 would remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions reflected: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. (Initiated 02/18/2013) Monitor for incontinence every 2 hours and as needed, incontinent care after each episode. (Initiated 02/19/2013) Monitor skin weekly and notify MD/RP (Medical Doctor/Responsible Party) of any new areas. (Initiated 02/18/2013) Provide pressure relieving and positioning devices on resident's bed, wheelchair as appropriate. (Initiated 02/18/2013) There were no preventative measures of turning and repositioning Resident # 2 every two hours to prevent the development of pressure sores. In an interview on 03/26/2013 at 12:01 AM the MDS Coordinator stated she did not add preventative measures of turning and repositioning Resident # 2 every two hours to the Resident's care plan dated 02/18/13, and stated it should have been on the care plan and she "must have missed it." Review of Resident # 2's Nurse's Notes dated 02/23/2013 reflected the Resident "has dark purple/black area to coccyx, sacral area surrounded by Stage II redness. Also thin line of small blisters vertical on R (right) buttocks." There was no notification made to Resident # 2's physician. Further review of Nurses Notes dated 02/23/2013 at 11:00 PM reflected Resident # 2 was "yelling out frequently at this time. Has thrown covers off multiple times". At 1:00 AM on 02/24/2013 Resident # 2 "con't (continued) to yell out." Review of Resident # 2's Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 (8 days between Weekly Skin Report/Body Assessments) reflected the resident had pressure sores to her coccyx and left outer heel. The report reflected conflicting measurements and staging documented for Resident # 2's pressure sore to her coccyx as follows: 02/23/2013 - 15.0 centimeters (cm) x 12.0 cm and reflected Stage I Again on 02/23/2013 - 10.0 cm by 0.5 cm and reflected Stage II Again on 02/23/2013 - 5.0 cm circular and reflected Stage III The Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 reflected Resident # 2's pressure sore to her left outer/posterior heel measured 5.0 cm x 3.0 cm with reddish brown color and reflected Stage I. In an interview on 03/25/2013 at 3:30 PM the DON stated she did not know why Resident # 2's coccyx wound had conflicting measurements on 02/23/2013. The DON stated there was a change in staff during February and March of 2013 and that is the only explanation she had regarding Weekly Skin Assessments not being completed weekly or every 7 days. The Weekly Pressure Sore Record reflected Resident # 2's wound to her coccyx was not reported to the physician until 02/24/2013. The wound to Resident # 2's left outer posterior heel had not been reported to the physician as of survey review date of 03/25/2013. Review of the Physician Order dated 02/24/2013 reflected clean coccyx pressure ulcer with DWC (disinfectant wound cleanser) , apply Santyl Ointment and dry dressing every day and as needed for soiling. Have wound consultant advise further treatment. The order also [MEDICATION NAME] milligrams (mg) twice per day for 14 days was ordered for increased temperature and wounds (2). There was no physician order to treat Resident # 2's left outer heel pressure sore. Review of the Medication Chart Record for February, 2013 reflected the new order for Resident # 2's coccyx wound treatment began on 02/24/2013. There was no wound treatment performed the date the coccyx wound was identified on 02/23/2013. Review of Resident # 2's Nurse's Notes dated 02/24/2013 at 9:10 PM reflected the initial dose [MEDICATION NAME] given at 8:00 PM. Resident # 2 was lying in bed propped off buttock with pillows, heel protectors on both feet. Dressing applied to coccyx area per order. Review of Resident # 2's Resident Infection Report reflected the Resident had an elevated temperature on 02/24/2013 on the 10:00 AM - 6:00 PM shift. " ....Also noted was "breakdown on coccyx with odor." Review of Resident # 2's Nurse's Notes dated 02/25/2013 at 9:00 AM reflected "On ABT -[MEDICATION NAME] area to coccyx. At 4:30 PM the "dressing to buttock changed. Area is large dark purple in color with some skin sloughing off. Foul odor and bloody looking drainage. DON present during change. Area cleansed with DWC, pat dry, Santyl with dry dressing applied." There was no notification to the physician that the pressure sore to Resident # 2's coccyx had changed with skin sloughing off and foul odor and bloody looking drainage. Review of Resident # 2's Nurse's Notes dated 02/26/ reflected "wound specialist here to assess resident's coccyx wound. Measurements done by wound specialist: 12.0 cm x 14 cm x undermined depth. Recommended some type of silver to help with the odor. Stated wound is going to get worse before it gets better because of resident's altered tissue perfusion. Also stated wounds may appear rapidly. Resident is being turned from side to side not on back. Has low air loss mattress." "Resident continued [MEDICATION NAME] wound to coccyx." Review of Resident # 1's Weekly Skin Report/Body Assessment Sheet dated 02/26/2013 reflected the Resident's coccyx pressure sore measured 12.0 cm x 14.0 cm with undetermined depth and reflected unstageable. There was a note documented by the DON on 02/26/2013 that reflected resident was seen by a wound care specialist on 02/26/2013 and this is the correct measurement and stage. Review of Resident # 2's clinical record reflected no report from the wound care specialist except the documentation made by the DON on 02/26/2013 on the Weekly Pressure Sore Record. In an interview on 03/28/2013 at 3:45 PM the DON stated the wound care specialist did see Resident #2's wound to her coccyx on 02/26/2013. The DON stated the wound care specialist examined the wound and suggested some type of silver product but that information was not relayed to the physician and the physician order was not changed to reflect the wound care specialist's recommendation made on 02/26/2013. The DON stated the wound care specialist did not give a written report of her findings and recommendations due to a payer source issue. Review of Resident # 2's Comprehensive Care Plan dated 02/26/2013 reflected new pressure areas to the Resident's coccyx and left heel. The goal was updated to reflect both pressure sore areas will improve/reduce in size over next 90 days. There was no addition of measures to promote healing or wound treatment ordered by the physician. In an interview on 03/26/2013 at 12:05 PM, the MDS Coordinator stated the first Comprehensive Care Plan dated 02/18/2013 was based on the Initial assessment dated [DATE] when Resident # 2 had no pressure sores. The MDS Coordinator stated the preventative measures of turning/repositioning Resident # 2 every 2 hours should have been added to the care plan. The MDS Coordinator stated "I must have missed it." The MDS Coordinator stated Resident # 2 had developed pressure areas prior to the completion of the Comprehensive Care Plan dated 02/26/2013. The MDS Coordinator stated interventions of turning and repositioning the Resident and the addition of Resident # 2's physician ordered treatments should have been added to the care plan for preventative measures and promote healing of current wounds. Review of Resident # 2's Nurses Notes dated 02/27/2013 reflected "DON notified this nurse that resident was going to be sent to E.R........[DIAGNOSES REDACTED]. Resident has not been voiding every shift and coccyx area getting worse.". Review of Resident # 2's Admission Evaluation dated 03/11/2013 reflected the resident returned to the facility on that date with a wound (unstageable) to the coccyx. There was no note regarding Resident # 2's left heel pressure area. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected a Pressure Sore to the resident's coccyx measuring 15.0 cm x 13.0 cm with undetermined depth, unstageable. The area was foul purulent with moderate exudate (fluid such as pus or clear fluid that leaks out of blood vessels into nearby tissues) amount and 100% black in color. Also, a pressure sore to Resident # 2's left heel measuring 7.0 cm x 4.0 cm, 100% red in color, Stage I. No notification to the physician. Review of Resident # 2's Hospice Physician Orders/Plan of Care reflected the Resident was admitted to Hospice on 03/11/2013. There was no documentation of Resident # 2's coccyx/sacral or left heel wound. Review of Resident # 2's Hospice Team Care Plan dated 03/13/2013 reflected an Admission Summary, 3/11/2013, at 1:00 PM. The Admission Summary reflected Resident #2 had a history of Gastrointestinal-tube infection, [MEDICAL CONDITIONS], Sacral decub, Hypertension, and functional [MEDICAL CONDITION]. Resident # 2 had a stroke in January resulting in Dysphagia and left sided Paralysis....Resident # 2 was lying supine in bed at the time of the assessment.....Resident # 2 had a large unstageable wound to sacral area with serosanguinous drainage and foul odor noted. Left outer foot with brown/purple discoloration.... Interventions for Skin/Wound included: Use antiseptic as needed for redness or closed wound as needed. 03/12/2013 - Clean Sacral Wound with wound cleanser, pat dry with 4 x 4. Apply silver alginate and cover with ABD every other day and as needed. There was no treatment reflected for Resident # 2's left heel pressure sore. In a telephone interview on 03/26/2013 at 4:00 PM the Hospice Nurse stated she had admitted Resident # 2 to Hospice on 03/11/2013 and at that time the resident had a large unstageable, necrotic wound to her sacral. The Hospice Nurse stated she did not know the wound developed at the facility. The Hospice Nurse stated she had talked to the DON regarding wound treatment, turning Resident # 2 every hour and she felt the wound could make progress to heal. Review of Resident # 2's telephone Physician Orders dated 03/12/2013 reflected an order to clean wound on the sacrum with wound cleanser. Pat dry with 4 x 4. Apply Silver alginate. Cover with ABD every other day and as needed. There was no physician order for [REDACTED]. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx measured 12.0 cm x 12.0 cm with undetermined depth. The pressure sore had moderate exudate amount, was 90% black in color with bright red peri-wound skin. No notification made to the physician. Resident # 2's pressure sore to her right heel was documented as drying up, no drainage, dark red scaly dry. No notification to the physician. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx had no measurements, "much underlying tunneling" was written in the measurement section of this report. Resident # 2's coccyx pressure sore had foul odor with copious amount of exudate and was mixed in colors. The peri-wound was bright red. No notification to the physician made. Resident # 2's left heel pressure sore had no measurement with "drying up, no drainage, continue heel protectors" written in the measurement section. No notification to the physician and no care plan or physician order for [REDACTED]. In an interview on 03/26/2013 at 5:45 PM, RN A stated she was responsible for measuring wounds on the weekend. RN A stated she started work at the facility on 03/09/2013 with the expectation of having four (4) days of orientation however after one (1) day of orientation the wounds were turned over to her. RN A stated she had been familiar with assessing and staging wounds however Resident # 2's wound was so complicated and since the resident was a Hospice patient, the treatment was not aggressive. RN A stated the wound appeared to be getting worse. RN A stated she could not assess the size, depth, or stage of the pressure sore, but it had a quarter moon size opening this past weekend, 3/23/2013, and she noted tunneling and undermining. RN A stated she had contacted the DON by phone and advised the DON due to Resident # 2's coccyx wound tunneling and undermining, she could not measure it anymore. RN A stated the DON advised her Resident # 2 was on Hospice and when somebody's actively dying they don't heal. RN A stated she did not notify the physician either weekend because she could not get a clear measurement and was not really sure about the size . RN A stated she had not seen a wound that bad in a long time. In an interview on 03/28/2013 at 3:45 PM, the DON stated RN A had contacted her sometime this past weekend with information regarding opening, tunneling and undermining of Resident # 2's wound. The DON stated RN A asked her if the foul odor had been present prior to this weekend. The DON stated what RN A described to her over the phone was different than what she had been aware of regarding Resident # 2's wound but she did not look at Resident # 2's wound during the weekend nor upon returning to work on Monday, 3/25/2013. The DON stated she was not aware of when wound treatment was being performed on Monday, 3/25/2013 but did not request the nurse on duty to notify her of the time of wound care for Resident # 2. The DON stated she did not look at the wound until the survey team requested current assessment and measurements of the wound on 03/26/2013. The DON stated she did not tell RN A that Resident # 2 is on Hospice and her wound will not heal. The DON stated Resident # 2 was not actively dying at this time. The DON stated Resident # 2's physician was not notified of the wound to her heel nor given the specific information regarding the pressure sore to her coccyx. The DON stated the physician was not notified of the progression of Resident # 2's wounds that included foul odor, tunneling and undermining. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 being fed by CNA M. Resident # was alert and able to made eye contact, there was no respiratory distress and the resident was responding to being fed. In an interview on 03/25/2013 at 12:11 PM, CNA M stated that Resident # 2 was eating pretty good. CNA M stated she had fed Resident # 2 her breakfast and she had eaten very well, almost 100%. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician (PCP), stated he had not been notified of the Resident's pressure wound to her left heel. Physician # 2 stated he was notified of a pressure area to Resident # 2's coccyx on 02/26/2013, although the physician order was dated 02/24/2013, and again on 03/26/2013 (today, after the survey team had examined the wound) but had not been notified of foul odor and drainage of the wound. Physician # 2 stated he depends upon the facility staff to notify him of all changes of condition and had he known of the Resident's condition he possibly would have changed the course of treatment. 2) Observation on 3/25/2013 at 5:25 pm revealed Licensed Vocational Nurse (LVN) C and Certified Nurse Aide (CNA) J provided wound care to Resident #2's sacral and heel wounds. CNA J assisted Resident #2 to her right side. LVN C observed and pointed at a brown, firm, feces at Resident #2 ' s rectum, approximately 1 inch from the resident's coccyx/sacral wound. LVN C stated " will clean that later " . CNA J also did not perform incontinent care on Resident #2 prior to the wound care. LVN C removed the dirty, purulent, saturated dressing from Resident #2 ' s coccyx/sacrum area that had a strong odor. She then had to remove kerlix gauze packing and silver calcium alginate packing. This kerlix gauze packing was not in the physician ' s orders. She used gauze to cleanse the wound that was soaked in a wound cleanser. She placed the gauze in the wound bed and scrubbed up and down instead of starting in the middle of the wound bed to cleanse in a circular, outward motion. (Describing the wound using a clock face, with the top of the wound at 12:00 towards head of resident and 6:00 towards the feet, 9:00 is left side and 3:00 is the right side) Resident # 2's large pressure sore had noted undermining at ten o ' clock to two o ' clock and four o ' clock to eight o ' clock. The pressure sore also had a beefy red wound bed at five o ' clock to seven o ' clock. The pressure sore had wet, black eschar connecting at nine o ' clock to three o ' clock down the middle. Under the eschar and in the middle of the wound was yellow slough. LVN C placed the ordered dressing on Resident #2 ' s coccyx/sacrum pressure sore. She used tape to secure the dressing, but did not secure the area directly above the rectum where the firm stool was located. LVN C and CNA J did not provide incontinent care after the wound care. Resident #2 also had a Foley catheter, and LVN C and CNA J also did not provide Foley catheter care at this time. LVN C removed heel protectors from Resident #2 feet. Resident # 2 had a SDTI with dry eschar to the left heel. Heel protectors were placed back on Resident # 2's feet. Resident # 2 was repositioned and placed on her back and a sheet placed over her. In an interview on 03/25/2013 at 5:45 PM, LVN C stated she does not measure pressure wounds and that the Director of Nurses (DON) measures wounds on Wednesdays. LVN C stated Resident #2's wound to her coccyx/sacral area was unstageable. LVN C stated she would come back later to perform incontinent care and clean the feces off of Resident # 2's rectum, which was approximately 1 inch from the wound. In an interview on 3/25/2013 at 6:00 PM, the DON stated she does not measure wounds on Wednesdays but the weekend Registered Nurse (RN) Supervisor measures the wounds on the weekends. The DON stated it was her expectation incontinent care be provided prior to wound treatment for [REDACTED]. Observation on 3/26/2013 at 11:45 AM revealed LVN C, the DON, and CNA K to provide wound care for Resident #2. LVN C removed a purulent, oversaturated dressing dated 03/25/2013. The dressing had a strong pervasive odor. LVN C cleansed Resident # 2's coccyx/sacral wound with gauze saturated in wound cleanser in an up and down motion instead of a circular and outward motion. The DON measured Resident # 2's coccyx/sacral pressure sore: at 10.25 cm x 15.0 cm x 7.0 cm. The DON measured tunnels at two o ' clock to equal 7.0 cm and four o ' clock to equal 6.0 cm. The DON measured undermining at three o ' clock to equal 3.0 cm, five to six o ' clock to equal 3.5 cm, six to seven o ' clock to equal 3.0 cm, and seven to eight o ' clock to equal 1.0 cm. The DON noted black, wet eschar attached at nine o ' clock and to the bottom of the wound bed at three to four o ' clock going across the middle of the wound. LVN C then applied the ordered dressing, but did not tape the dressing down above the rectum. The DON also measured the pressure sore to the left heel 3.0 cm x 6.5 cm SDTI dry eschar, unstageable. In an interview on 3/26/2013 at 1:45 PM, the DON stated LVN C should have taped the dressing all the way around the wound. The DON stated the physician had not been notified of the increased drainage to the wound nor of the pervasive odor coming from the wound, nor the wound specialist's recommendation for a silver product. Therefore there was no order to culture the wound and no order to pack the undermining and tunneling of the wound from the physician. The DON also stated the physician had not been notified of the depth and need for a dressing change to include packing. The DON stated the silver calcium alginate (recommended by the wound care specialist) was only for the odor. (Silver products are used for the antibacterial properties and odor per website: http://www.[MEDICATION NAME].com/products/restore_silver.aspx which reflected: Restore Calcium Alginate Dressing - Silver This advanced wound dressing features a complex of calcium and ionic silver for effective antimicrobial action and odor reduction. Effective antimicrobial agent against a broad spectrum of micro-organisms frequently associated with bacterial colonization and infection in wounds - including fungi,[MEDICAL CONDITION] and VRE.) Observation on 3/27/2013 at 9:23 AM revealed an extremely pervasive foul odor at the nurses ' station. The nurses' station is located four (4) rooms from Resident # 2's room. In an interview on 3/27/2013 at 9:23 AM, LVN C stated the pervasive odor was coming from the pressure ulcer of Resident #2, located 4 rooms from the nurse's station. In a telephone interview on 03/26/2013 at 4:00 PM, Resident # 2's Hospice Nurse stated cleansing the wound thoroughly and providing incontinent care prior to wound care would be essential in the healing of this wound. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician, stated he would expect staff to fully cleanse a resident prior to performing wound care and not perform wound care while a resident's bowel movement remained one inch above the site. Physician # 2 stated leaving feces close to the wound could cause worsening of the wound and infection. 3) Observation made on 03/25/2013 at 8:00 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 9:30 AM revealed Resident # 2 laying on her back, no pillow was observed under either side of the Resident. Resident # 2's feet were out from under the sheet and there were no heel protectors on her feet. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 laying on her back, with her head of the bed raised. Resident # 2 was being fed by an aide. Observation on 3/26/2013 at 8:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:02 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 9:15 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 03/26/2013 at 9:30 AM revealed Resident #2 with a pillow under her left side and she was facing the door. Observation on 3/26/2013 at 11:30 am revealed Resident #2 in the same position-with a pillow under her left side and she was facing the door. In an interview on 03/26/2013 at 9:45 AM, Resident # 2's family member stated a family member for the Resident was at the facility daily. This family member stated prior to the Resident acquiring a pressure sore to her coccyx the family had noticed each time they visited, daily and at different times during the day, Resident # 2 would be in the same position, laying on her back. The family member stated somewhere around the end of February, 2013, the family had a meeting with the MDS Coordinator who had assured the family the facility could initiate Resident # 2 to be turned and repositioned each hour. The family member stated Resident # 2 was ambulatory with a walker prior to her stroke on 01/07/2013. In an interview on 03/26/2013 at 10:00 AM a another family member, who was visiting, stated the family had made a complaint to the facility regarding Resident # 2 not being turned and repositioned often enough. The family member stated each time someone in the family came to the facility, daily and at different times during the day, Resident # 2 was in the same position. The family member stated the MDS Coordinator stated a physician order could be written to turn and reposition Resident # 2 hourly. In an interview on 03/26/2013 at 11:45 AM, the MDS Coordinator stated she had a Care Plan meeting for Resident # 2 on 02/26/2013 when the family reported finding the Resident in the same position daily, at different times, when they would visit. The MDS Coordinator stated she did discuss an order to turn and reposition Resident # 2 every one hour. The MDS Coordinator stated she had relayed the information to the DON that day but did not follow up with the DON to ensure the plan was put into place. The MDS Coordinator stated she did not add turning and repositioning each hour or every 2 hours at that time to Resident # 2's care plan, and further stated "I must have missed it." In an interview on 03/26/2013 at 2:30 PM, CNA M stated she and the other aides turn Resident # 2 every two hours. CNA M stated she had not been advised to turn Resident # 2 every hour. In an interview on 03/26/2013 at 4:40 PM, the DON stated the MDS Coordinator had advised her of the family's complaint regarding Resident # 2 not being turned and repositioned. The DON stated the MDS Coordinator had stated the family requested Resident # 2 be turned and repositioned each hour but the facility had not had any trouble with turning and repositioning so she did not initiate the plan. The DON stated she did tell staff, that included aides and nurses, to turn and reposition Resident # 2 every two hours, not hourly, prior to the Resident acquiring the pressure sore on her coccyx/sacral area. Review of Resident # 2's Physician Orders reflected an order dated 03/26/2013 to "turn resident every 1 hour while in bed per hospice....." 4) Review of Resident # 2's Comprehensive Nutritional assessment dated [DATE] reflected the Resident had an unstageable wound to her sacrum. Recommendations and Plan reflected Magic cup three times per day between meals at 10:00 AM, 2:00 PM and HS (Hour of Sleep) for increased k-cal and protein. Review of Resident # 2's Diet Requisition dated 03/18/2013 reflected "upon availability, send magic cup

Based on observation, interview and record review, the facility failed to promptly notify the physician when there was a significant change in the Resident's physical, mental or psychosocial status and of a need to alter treatment significantly for 3 of 6 residents (Residents # 2, #8 and #1) reviewed for pressure sores when: A) Resident # 2 entered the facility on 02/04/2013 without pressure sores. On 02/15/2013 a blanchable red area was found on Resident # 2's coccyx that progressed to encompass the Resident's sacral and coccyx to an unstageable pressure sore measuring 10.25 centimeters (cm) x 15.0 cm x 7.0 cm, with undermining, tunneling and pervasive odor. The Physician was not notified of the accurate progression of Resident # 2's coccyx/sacral pressure sore. On 02/14/2013 a blanchable red area was found on Resident # 2's left heel that progressed to a Suspected Deep Tissue Injury (SDTI) that measured 3.0 cm x 6.5 cm that was unstageable on 02/23/2013 with no notification to the physician. B) Resident # 8 entered the facility on 10/12/2012 without pressure sores. A pressure sore was identified to Resident # 8's right heel on 03/09/2013. The facility failed to accurately assess, notify the physician, treat and update the comprehensive care plan to reflect measures to promote healing. C) On 03/27/2013 CNA H identified a Stage I pressure sore located on Resident # 1's right heel by CNA H. CNA H failed to notify the Charge Nurse for assessment and treatment on 03/27/2013. This resulted in an Immediate Jeopardy (IJ) on 03/26/2013. While the IJ was removed on 03/28/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 22 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: A) Review of the History and Physical (H&P) from the hospital dated 01/12/2013 reflected Resident # 2 was admitted to the Intensive Care Unit from home on 01/07/2013 and had suffered a Right Middle Cerebral Artery [MEDICAL CONDITIONS] with left facial droop and [MEDICAL CONDITION]. The H&P reflected Resident # 2 could not use her walker to get out of bed the morning of 01/07/2013. The H&P did not reflect Resident # 2 had pressure sores. Review of Resident # 2's Face Sheet reflected a [AGE] year old female who entered the facility on 02/04/2013. Review of Resident # 2's record of Comprehensive Care Plan Team Meeting dated 02/19/2013 reflected the resident's [DIAGNOSES REDACTED]. 1) Review of Resident # 2's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected staff assessed cognitive level and the Resident scored two out of three which indicated moderate cognitive impairment. Resident # 2 had poor decision making ability and required cueing/supervision. The assessment reflected Resident # 2 was at risk for pressure sores, but had no current pressure sores. Review of Resident # 2's Admission Evaluation, Nurses Notes and Weekly Skin Report/Body Assessment Sheets dated 02/04/2013 reflected Resident # 2 entered the facility without pressure sores. Resident # 2 had bruising, a gastrointestinal-tube site, old surgery scars to knees and discoloration to bilateral shins, but no pressure sores Review of Resident # 2's Braden Scale for Predicting Pressure Sore Risk dated 02/12/2013 reflected a score of 14 and reflected the Resident was at moderate risk for developing pressure sores. The Braden Scale reflected Resident # 2's skin was very moist, she was chair fast with very limited mobility and friction and shear was a potential problem. In an interview on 03/26/2013 at 11:56 AM, the MDS Coordinator stated, in regards to the Braden Scale, a score of 19 or below indicated a resident is at "high" risk for pressure sores, not moderate risk as indicated on the facility computerized form. In addition, although the initial assessment did not reflect this, Resident # 2 was now on hospice and bedbound. Review of Resident # 2's Nurse's Notes dated 02/14/2013 reflected "OOB (out of bed) earlier to have shower and CNA noticed discoloration to L (left) heel. Pressure area noted to site. Area blanchable. Heel protectors put on when put to bed." The Nurse's Note reflected no notification to the physician regarding the pressure sore to Resident # 2's heel and there was no physician order for [REDACTED]. Review of Resident # 2's Weekly Skin Report/Body assessment dated [DATE] (11 days between Weekly Skin Report/Body Assessments) reflected Resident # 2 had blanchable redness/eschar to her coccyx with no measurements. The document reflected no area to Resident # 2's heel and no notification to the resident's physician regarding redness/eschar to Resident # 2's coccyx nor the pressure area to the resident's left heel. Review of Resident # 2's Comprehensive Care Plan dated 02/18/2013 reflected the Resident was at risk for skin breakdown due to poor bed mobility and recent [MEDICAL CONDITION]. Goals reflected Resident #2 would remain clean, dry and intact without evidence of breakdown over the next 90 days. Interventions reflected: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. (Initiated 02/18/2013) Monitor for incontinence every 2 hours and as needed, incontinent care after each episode. (Initiated 02/19/2013) Monitor skin weekly and notify MD/RP (Medical Doctor/Responsible Party) of any new areas. (Initiated 02/18/2013) Provide pressure relieving and positioning devices on resident's bed, wheelchair as appropriate. (Initiated 02/18/2013) There were no preventative measures of turning and repositioning Resident # 2 every two hours to prevent the development of pressure sores. In an interview on 03/26/2013 at 12:01 AM the MDS Coordinator stated she did not add preventative measures of turning and repositioning Resident # 2 every two hours to the Resident's care plan dated 02/18/13, and stated it should have been on the care plan and she "must have missed it." Review of Resident # 2's Nurse's Notes dated 02/23/2013 reflected the Resident "has dark purple/black area to coccyx, sacral area surrounded by Stage II redness. Also thin line of small blisters vertical on R (right) buttocks." There was no notification made to Resident # 2's physician. Further review of Nurses Notes dated 02/23/2013 at 11:00 PM reflected Resident # 2 was "yelling out frequently at this time. Has thrown covers off multiple times". At 1:00 AM on 02/24/2013 Resident # 2 "con't (continued) to yell out." Review of Resident # 2's Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 (8 days between Weekly Skin Report/Body Assessments) reflected the resident had pressure sores to her coccyx and left outer heel. The report reflected conflicting measurements and staging documented for Resident # 2's pressure sore to her coccyx as follows: 02/23/2013 - 15.0 centimeters (cm) x 12.0 cm and reflected Stage I Again on 02/23/2013 - 10.0 cm by 0.5 cm and reflected Stage II Again on 02/23/2013 - 5.0 cm circular and reflected Stage III The Weekly Skin Report/Body Assessment Sheet dated 02/23/2013 reflected Resident # 2's pressure sore to her left outer/posterior heel measured 5.0 cm x 3.0 cm with reddish brown color and reflected Stage I. In an interview on 03/25/2013 at 3:30 PM the DON stated she did not know why Resident # 2's coccyx wound had conflicting measurements on 02/23/2013. The DON stated there was a change in staff during February and March of 2013 and that is the only explanation she had regarding Weekly Skin Assessments not being completed weekly or every 7 days. The Weekly Pressure Sore Record reflected Resident # 2's wound to her coccyx was not reported to the physician until 02/24/2013. The wound to Resident # 2's left outer posterior heel had not been reported to the physician as of survey review date of 03/25/2013. Review of the Physician Order dated 02/24/2013 reflected clean coccyx pressure ulcer with DWC (disinfectant wound cleanser) , apply Santyl Ointment and dry dressing every day and as needed for soiling. Have wound consultant advise further treatment. The order also [MEDICATION NAME] milligrams (mg) twice per day for 14 days was ordered for increased temperature and wounds (2). There was no physician order to treat Resident # 2's left outer heel pressure sore. Review of the Medication Chart Record for February, 2013 reflected the new order for Resident # 2's coccyx wound treatment began on 02/24/2013. There was no wound treatment performed the date the coccyx wound was identified on 02/23/2013. Review of Resident # 2's Nurse's Notes dated 02/24/2013 at 9:10 PM reflected the initial dose [MEDICATION NAME] given at 8:00 PM. Resident # 2 was lying in bed propped off buttock with pillows, heel protectors on both feet. Dressing applied to coccyx area per order. Review of Resident # 2's Resident Infection Report reflected the Resident had an elevated temperature on 02/24/2013 on the 10:00 AM - 6:00 PM shift. " ....Also noted was "breakdown on coccyx with odor." Review of Resident # 2's Nurse's Notes dated 02/25/2013 at 9:00 AM reflected "On ABT -[MEDICATION NAME] area to coccyx. At 4:30 PM the "dressing to buttock changed. Area is large dark purple in color with some skin sloughing off. Foul odor and bloody looking drainage. DON present during change. Area cleansed with DWC, pat dry, Santyl with dry dressing applied." There was no notification to the physician that the pressure sore to Resident # 2's coccyx had changed with skin sloughing off and foul odor and bloody looking drainage. Review of Resident # 2's Nurse's Notes dated 02/26/ reflected "wound specialist here to assess resident's coccyx wound. Measurements done by wound specialist: 12.0 cm x 14 cm x undermined depth. Recommended some type of silver to help with the odor. Stated wound is going to get worse before it gets better because of resident's altered tissue perfusion. Also stated wounds may appear rapidly. Resident is being turned from side to side not on back. Has low air loss mattress." "Resident continued [MEDICATION NAME] wound to coccyx." Review of Resident # 1's Weekly Skin Report/Body Assessment Sheet dated 02/26/2013 reflected the Resident's coccyx pressure sore measured 12.0 cm x 14.0 cm with undetermined depth and reflected unstageable. There was a note documented by the DON on 02/26/2013 that reflected resident was seen by a wound care specialist on 02/26/2013 and this is the correct measurement and stage. Review of Resident # 2's clinical record reflected no report from the wound care specialist except the documentation made by the DON on 02/26/2013 on the Weekly Pressure Sore Record. In an interview on 03/28/2013 at 3:45 PM the DON stated the wound care specialist did see Resident #2's wound to her coccyx on 02/26/2013. The DON stated the wound care specialist examined the wound and suggested some type of silver product but that information was not relayed to the physician and the physician order was not changed to reflect the wound care specialist's recommendation made on 02/26/2013. The DON stated the wound care specialist did not give a written report of her findings and recommendations due to a payer source issue. Review of Resident # 2's Comprehensive Care Plan dated 02/26/2013 reflected new pressure areas to the Resident's coccyx and left heel. The goal was updated to reflect both pressure sore areas will improve/reduce in size over next 90 days. There was no addition of measures to promote healing or wound treatment ordered by the physician. In an interview on 03/26/2013 at 12:05 PM, the MDS Coordinator stated the first Comprehensive Care Plan dated 02/18/2013 was based on the Initial assessment dated [DATE] when Resident # 2 had no pressure sores. The MDS Coordinator stated the preventative measures of turning/repositioning Resident # 2 every 2 hours should have been added to the care plan. The MDS Coordinator stated "I must have missed it." The MDS Coordinator stated Resident # 2 had developed pressure areas prior to the completion of the Comprehensive Care Plan dated 02/26/2013. The MDS Coordinator stated interventions of turning and repositioning the Resident and the addition of Resident # 2's physician ordered treatments should have been added to the care plan for preventative measures and promote healing of current wounds. Review of Resident # 2's Nurses Notes dated 02/27/2013 reflected "DON notified this nurse that resident was going to be sent to E.R........[DIAGNOSES REDACTED]. Resident has not been voiding every shift and coccyx area getting worse.". Review of Resident # 2's Admission Evaluation dated 03/11/2013 reflected the resident returned to the facility on that date with a wound (unstageable) to the coccyx. There was no note regarding Resident # 2's left heel pressure area. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected a Pressure Sore to the resident's coccyx measuring 15.0 cm x 13.0 cm with undetermined depth, unstageable. The area was foul purulent with moderate exudate (fluid such as pus or clear fluid that leaks out of blood vessels into nearby tissues) amount and 100% black in color. Also, a pressure sore to Resident # 2's left heel measuring 7.0 cm x 4.0 cm, 100% red in color, Stage I. No notification to the physician. Review of Resident # 2's Hospice Physician Orders/Plan of Care reflected the Resident was admitted to Hospice on 03/11/2013. There was no documentation of Resident # 2's coccyx/sacral or left heel wound. Review of Resident # 2's Hospice Team Care Plan dated 03/13/2013 reflected an Admission Summary, 3/11/2013, at 1:00 PM. The Admission Summary reflected Resident #2 had a history of Gastrointestinal-tube infection, [MEDICAL CONDITIONS], Sacral decub, Hypertension, and functional [MEDICAL CONDITION]. Resident # 2 had a stroke in January resulting in Dysphagia and left sided Paralysis....Resident # 2 was lying supine in bed at the time of the assessment.....Resident # 2 had a large unstageable wound to sacral area with serosanguinous drainage and foul odor noted. Left outer foot with brown/purple discoloration.... Interventions for Skin/Wound included: Use antiseptic as needed for redness or closed wound as needed. 03/12/2013 - Clean Sacral Wound with wound cleanser, pat dry with 4 x 4. Apply silver alginate and cover with ABD every other day and as needed. There was no treatment reflected for Resident # 2's left heel pressure sore. In a telephone interview on 03/26/2013 at 4:00 PM the Hospice Nurse stated she had admitted Resident # 2 to Hospice on 03/11/2013 and at that time the resident had a large unstageable, necrotic wound to her sacral. The Hospice Nurse stated she did not know the wound developed at the facility. The Hospice Nurse stated she had talked to the DON regarding wound treatment, turning Resident # 2 every hour and she felt the wound could make progress to heal. Review of Resident # 2's telephone Physician Orders dated 03/12/2013 reflected an order to clean wound on the sacrum with wound cleanser. Pat dry with 4 x 4. Apply Silver alginate. Cover with ABD every other day and as needed. There was no physician order for [REDACTED]. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx measured 12.0 cm x 12.0 cm with undetermined depth. The pressure sore had moderate exudate amount, was 90% black in color with bright red peri-wound skin. No notification made to the physician. Resident # 2's pressure sore to her right heel was documented as drying up, no drainage, dark red scaly dry. No notification to the physician. Review of Resident # 2's Weekly Body assessment dated [DATE] reflected Resident # 2's pressure sore to her coccyx had no measurements, "much underlying tunneling" was written in the measurement section of this report. Resident # 2's coccyx pressure sore had foul odor with copious amount of exudate and was mixed in colors. The peri-wound was bright red. No notification to the physician made. Resident # 2's left heel pressure sore had no measurement with "drying up, no drainage, continue heel protectors" written in the measurement section. No notification to the physician and no care plan or physician order for [REDACTED]. In an interview on 03/26/2013 at 5:45 PM, RN A stated she was responsible for measuring wounds on the weekend. RN A stated she started work at the facility on 03/09/2013 with the expectation of having four (4) days of orientation however after one (1) day of orientation the wounds were turned over to her. RN A stated she had been familiar with assessing and staging wounds however Resident # 2's wound was so complicated and since the resident was a Hospice patient, the treatment was not aggressive. RN A stated the wound appeared to be getting worse. RN A stated she could not assess the size, depth, or stage of the pressure sore, but it had a quarter moon size opening this past weekend, 3/23/2013, and she noted tunneling and undermining. RN A stated she had contacted the DON by phone and advised the DON due to Resident # 2's coccyx wound tunneling and undermining, she could not measure it anymore. RN A stated the DON advised her Resident # 2 was on Hospice and when somebody's actively dying they don't heal. RN A stated she did not notify the physician either weekend because she could not get a clear measurement and was not really sure about the size . RN A stated she had not seen a wound that bad in a long time. In an interview on 03/28/2013 at 3:45 PM, the DON stated RN A had contacted her sometime this past weekend with information regarding opening, tunneling and undermining of Resident # 2's wound. The DON stated RN A asked her if the foul odor had been present prior to this weekend. The DON stated what RN A described to her over the phone was different than what she had been aware of regarding Resident # 2's wound but she did not look at Resident # 2's wound during the weekend nor upon returning to work on Monday, 3/25/2013. The DON stated she was not aware of when wound treatment was being performed on Monday, 3/25/2013 but did not request the nurse on duty to notify her of the time of wound care for Resident # 2. The DON stated she did not look at the wound until the survey team requested current assessment and measurements of the wound on 03/26/2013. The DON stated she did not tell RN A that Resident # 2 is on Hospice and her wound will not heal. The DON stated Resident # 2 was not actively dying at this time. The DON stated Resident # 2's physician was not notified of the wound to her heel nor given the specific information regarding the pressure sore to her coccyx. The DON stated the physician was not notified of the progression of Resident # 2's wounds that included foul odor, tunneling and undermining. Observation made on 03/25/2013 at 12:10 PM revealed Resident # 2 being fed by CNA M. Resident # was alert and able to made eye contact, there was no respiratory distress and the resident was responding to being fed. In an interview on 03/25/2013 at 12:11 PM, CNA M stated that Resident # 2 was eating pretty good. CNA M stated she had fed Resident # 2 her breakfast and she had eaten very well, almost 100%. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician (PCP), stated he had not been notified of the Resident's pressure wound to her left heel. Physician # 2 stated he was notified of a pressure area to Resident # 2's coccyx on 02/26/2013, although the physician order was dated 02/24/2013, and again on 03/26/2013 (today, after the survey team had examined the wound) but had not been notified of foul odor and drainage of the wound. Physician # 2 stated he depends upon the facility staff to notify him of all changes of condition and had he known of the Resident's condition he possibly would have changed the course of treatment. 2) Observation on 3/25/2013 at 5:25 pm revealed Licensed Vocational Nurse (LVN) C and Certified Nurse Aide (CNA) J provided wound care to Resident #2's sacral and heel wounds. CNA J assisted Resident #2 to her right side. LVN C observed and pointed at a brown, firm, feces at Resident #2 ' s rectum, approximately 1 inch from the resident's coccyx/sacral wound. LVN C stated " will clean that later " . CNA J also did not perform incontinent care on Resident #2 prior to the wound care. LVN C removed the dirty, purulent, saturated dressing from Resident #2 ' s coccyx/sacrum area that had a strong odor. She then had to remove kerlix gauze packing and silver calcium alginate packing. This kerlix gauze packing was not in the physician ' s orders. She used gauze to cleanse the wound that was soaked in a wound cleanser. She placed the gauze in the wound bed and scrubbed up and down instead of starting in the middle of the wound bed to cleanse in a circular, outward motion. (Describing the wound using a clock face, with the top of the wound at 12:00 towards head of resident and 6:00 towards the feet, 9:00 is left side and 3:00 is the right side) Resident # 2's large pressure sore had noted undermining at ten o ' clock to two o ' clock and four o ' clock to eight o ' clock. The pressure sore also had a beefy red wound bed at five o ' clock to seven o ' clock. The pressure sore had wet, black eschar connecting at nine o ' clock to three o ' clock down the middle. Under the eschar and in the middle of the wound was yellow slough. LVN C placed the ordered dressing on Resident #2 ' s coccyx/sacrum pressure sore. She used tape to secure the dressing, but did not secure the area directly above the rectum where the firm stool was located. LVN C and CNA J did not provide incontinent care after the wound care. Resident #2 also had a Foley catheter, and LVN C and CNA J also did not provide Foley catheter care at this time. LVN C removed heel protectors from Resident #2 feet. Resident # 2 had a SDTI with dry eschar to the left heel. Heel protectors were placed back on Resident # 2's feet. Resident # 2 was repositioned and placed on her back and a sheet placed over her. In an interview on 03/25/2013 at 5:45 PM, LVN C stated she does not measure pressure wounds and that the Director of Nurses (DON) measures wounds on Wednesdays. LVN C stated Resident #2's wound to her coccyx/sacral area was unstageable. LVN C stated she would come back later to perform incontinent care and clean the feces off of Resident # 2's rectum, which was approximately 1 inch from the wound. In an interview on 3/25/2013 at 6:00 PM, the DON stated she does not measure wounds on Wednesdays but the weekend Registered Nurse (RN) Supervisor measures the wounds on the weekends. The DON stated it was her expectation incontinent care be provided prior to wound treatment for [REDACTED]. Observation on 3/26/2013 at 11:45 AM revealed LVN C, the DON, and CNA K to provide wound care for Resident #2. LVN C removed a purulent, oversaturated dressing dated 03/25/2013. The dressing had a strong pervasive odor. LVN C cleansed Resident # 2's coccyx/sacral wound with gauze saturated in wound cleanser in an up and down motion instead of a circular and outward motion. The DON measured Resident # 2's coccyx/sacral pressure sore: at 10.25 cm x 15.0 cm x 7.0 cm. The DON measured tunnels at two o ' clock to equal 7.0 cm and four o ' clock to equal 6.0 cm. The DON measured undermining at three o ' clock to equal 3.0 cm, five to six o ' clock to equal 3.5 cm, six to seven o ' clock to equal 3.0 cm, and seven to eight o ' clock to equal 1.0 cm. The DON noted black, wet eschar attached at nine o ' clock and to the bottom of the wound bed at three to four o ' clock going across the middle of the wound. LVN C then applied the ordered dressing, but did not tape the dressing down above the rectum. The DON also measured the pressure sore to the left heel 3.0 cm x 6.5 cm SDTI dry eschar, unstageable. In an interview on 3/26/2013 at 1:45 PM, the DON stated LVN C should have taped the dressing all the way around the wound. The DON stated the physician had not been notified of the increased drainage to the wound nor of the pervasive odor coming from the wound, nor the wound specialist's recommendation for a silver product. Therefore there was no order to culture the wound and no order to pack the undermining and tunneling of the wound from the physician. The DON also stated the physician had not been notified of the depth and need for a dressing change to include packing. The DON stated the silver calcium alginate (recommended by the wound care specialist) was only for the odor. (Silver products are used for the antibacterial properties and odor per website: http://www.[MEDICATION NAME].com/products/restore_silver.aspx which reflected: Restore Calcium Alginate Dressing - Silver This advanced wound dressing features a complex of calcium and ionic silver for effective antimicrobial action and odor reduction. Effective antimicrobial agent against a broad spectrum of micro-organisms frequently associated with bacterial colonization and infection in wounds - including fungi,[MEDICAL CONDITION] and VRE.) Observation on 3/27/2013 at 9:23 AM revealed an extremely pervasive foul odor at the nurses ' station. The nurses' station is located four (4) rooms from Resident # 2's room. In an interview on 3/27/2013 at 9:23 AM, LVN C stated the pervasive odor was coming from the pressure ulcer of Resident #2, located 4 rooms from the nurse's station. In a telephone interview on 03/26/2013 at 4:00 PM, Resident # 2's Hospice Nurse stated cleansing the wound thoroughly and providing incontinent care prior to wound care would be essential in the healing of this wound. In a telephone interview on 03/26/2013 at 6:15 PM, Physician # 2, Resident # 2's Primary Care Physician, stated he would expect staff to fully cleanse a resident prior to performing wound care and not perform wound care while a resident's bowel movement remained one inch above the site. Physician # 2 stated leaving feces close to the wound could cause worsening of the wound and infection. B) Review of Resident # 8's Face Sheet reflected an [AGE] year old female who entered the facility on 10/19/2012. Review of Resident # 8's Monthly Physician Orders reflected [DIAGNOSES REDACTED]. Review of Resident # 8's Quarterly MDS assessment dated [DATE] reflected the resident scored 03 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was had severe cognitive impairment. The assessment reflected Resident # 2 was at risk for pressure sores and had one (1) Stage II pressure sore that developed on 01/04/2013. Review of Resident # 8's Physician Orders reflected an order dated 03/01/2013 to discontinue treatment to Resident # 2's pressure sore, the area was healed. Review of Resident # 8's Comprehensive Care Plan dated 01/09/2013 reflected the resident was at risk for UTI (Urinary Tract Infection) and Skin breakdown due to being incontinent of bowel and bladder. The goals included Resident # 8's dignity will be maintained and will not have any signs/symptoms of UTI or skin breakdown over the next 90 days. Interventions in place for the plan of care were as follows: Encourage dietary/fluid within dietary limits. Monitor every 2 hours and change promptly. Provide appropriate pericare after each episode. Use incontinent pads/briefs as appropriate. There was no plan in place for treatment of [REDACTED].# 8's heels. Review of Resident # 8's Weekly Body Assessment Sheet dated 03/09/2013 reflected a pressure sore to the Resident's right heel. There was no staging of the pressure sore nor description of the wound including measurements. Review of Resident # 8's Weekly Body Assessment Sheet dated 03/17/2013 (8 days later) the assessment reflected the Resident had a pressure sore but no area of the wound was documented and no description of the wound including staging or measurements. Review of Resident # 8's Weekly Body Assessment Sheet dated 03/24/2013 reflected no pressure sores. Review of the facility Weekly Skin Problem Log dated 03/12/2013 and 03/23/2013 reflected Resident # 8 was not listed on the log as having a pressure sore to her right heel. Observation on 3/27/3012 at 6:20 PM revealed Resident #8 had an area of black eschar to her right heel. The eschar area appeared to be approximately 4.0 cm x 3.0 cm and was a burgundy color with a black spot at the top of the wound. In an interview on 3/27/2013 at 6:22 PM CNA I stated she was not sure how long Resident #8 had had the black area to her right heel but it had been there a week or two. Review of Resident # 8's Nurse's Notes reflected no notification to the physician or new order to promote healing of the Resident's pressure sore to her right heel until 03/27/2013. Review of Resident # 8's Physician Orders on 03/27/2013 reflected no notification to the physician or no physician order for [REDACTED]. Review of Resident # 8's Physician Orders reflected a fax to the Resident's Primary Care Physician on 03/27/2013 at 11:32 AM and reflected "Resident noted to have a hard dark eschar that is unstageable to (R) (right) heel area measures 4.0 x 3.0 cm. We are offloading BL (bilateral) heels and using heel protectors while in bed. Area has 0 drainage. Resident does not c/o (complain of) any pain." Interview on 3/27/2013 at 7:20 PM the DON stated she was made aware of the eschar to Resident # 8's right heel on 3/27/2013 at 11:00 AM and she had informed the physician at 11:32 AM on the same day. The DON stated the weekend RN who noted the pressure sore to Resident #8 right heel should have notified the MD and started treatment. The DON further stated she was not made aware of the right heel pressure sore and the treatment of [REDACTED]. The DON also stated the communication from the nurses to DON was part of the system failure. C) Review of Resident #1 ' s face sheet reflected she was a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident # 1 ' s Significant Change Minimum Data Set ((MDS) dated [DATE] reflected that Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated Resident #1 had some confusion or forgetfulness. Resident #1 had received extensive assistance with mobility related activities of daily living (ADL) and limited assistance with functional ADL. The MDS did not reflect any pressure related skin issues. Review of Resident #1 ' s Comprehensive Care Plan dated 3/13/2013 reflected that Resident #1 was " at risk for infection or the resident has an infection as evidenced by UTI (Urinary Tract Infection) " . Also reflected was " Resident has been diagnosed with [REDACTED]. The resident is at risk for possible adverse reactions/side effects as evidence by UTI (in past 30 days) " . The care plan reflected the resident had a history of [REDACTED].