Every finding on record at Grace Pointe Wellness Center

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services. The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 02/09/2026. This failure could place residents at risk of not having their psychosocial or discharge planning needs met. Record Review on 06/16/2026 at 02:27 PM, of an email sent to SW on May 27, 2026, from The Association of Social Work Boards (ASWB) revealed a passing score on the ASWB master's examination. Received preliminary requirements for licensure in the state of Texas and how to obtain forms and instructions on ways to complete the licensing process in the state of Texas,In an interview on 06/16/2026 at 02:35 PM SW stated she had been employed with the facility since February 2026. She stated she had been informed upon hire that she was required to obtain her license within six months of employment. The SW was unable to provide documentation or an employment agreement verifying the six-month licensing requirement. The SW stated she had worked independently after completing a 30 day orientation and reported no individual had routinely supervised or reviewed her work. She stated the facility did not have a regional department on site and that she contacted corporate via email if she had questions. The SW stated no one routinely oversaw her at the facility. In an interview on 06/16/2026 at 02:40 PM with HR Manager stated she had been employed with the facility for about a year in July. HR Manager stated the SW had received an offer letter indicating Licensure was required within six months of hire; however, the facility did not yet have documentation verifying the letter or completion of license. HR manager confirmed the SW did not possess a current license and stated she was not permitted to practice independently. HR Manager stated no one had routinely overseen the SW work and reported that corporate personnel did not physically visit the facility. In an interview on 06/16/2026 at 02:45 PM, Administrator stated that the risk of SW not having a license were residents safety risk, behaviors, and emotional concerns not being assessed. He stated that he was aware of SW not having a license, but the SW had already registered to take the licensing examination after being hired. In an interview on 06/17/2026 at 11:14 am with HR manager stated the facility did not have a written policy regarding the hiring process for anyone at the facility including the SW.Record review of job offer letter for SW dated 02/09/2026 with official start date of 02/23/2026.Record review of Criminal History verification revealed SW hire date of 02/05/2026, with date of first day of service on 02/23/2026.Record review of an employee roster provided by the DON on 06/16/2026 reveled the SW was identified as Unlicensed.Record review of facilities HR-Personnel handbook 2019, revised 09/20/2019, revealed Registered, Licensed, and certified employees; all professionally registered, licensed and certified staff was required to maintain current licensure, registration and/or certification. A Copy of the current documentation must be submitted to your department head for inclusion in your personnel file. Failure to provide the documentation or failure to maintain status may result in suspension and/or termination.Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who was licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

Based on interview and record review, the facility failed to appropriately discharge for 1 (Resident #3) of 1 resident reviewed for transfer/discharge. The facility failed to ensure Resident #3 was provided a proper 30-day discharge letter from the facility after an incident with LVN R. This failure could place residents at risk of being discharged inappropriately causing a disruption in their care and services and potential decline in health.Record review of Resident #3's face sheet dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and still currently a resident at the facility. Resident #3's diagnoses included Depressive Disorders (feelings of sadness, tearfulness, emptiness or hopelessness), Post Traumatic Stress Disorder (Mental Health Condition that triggered by experiencing or witnessing a terrifying event), and Schizophrenia (brain disorder that makes it hard to tell the difference between what was real and what was imaginary),Record review of Resident #3's Quarterly MDS dated [DATE], reflected a BIMS score of 15, which indicated cognition was intact. Resident #3 had no impairment to of upper extremity (shoulder, elbow, wrist, hand), and no impairment on both sides to lower extremities (hip, knee, ankle, foot). Resident #3 had not exhibit behavior for physical, verbal to others. Resident #3 does reject care, 4 to 6 days but less than daily.Record review of Resident #3's Care Plan dated 06/16/2026, stated focus The Resident has potential to demonstrate verbally abusive behaviors, with a goal; The resident will demonstrate effective coping skills through the review date, interventions/task; Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, notify the charge nurse of any abusive behaviors. Focus Behavior; verbal threats with a goal; episodes of verbal threats will decrease to less than daily in the next 90 days, with interventions/task; be nonjudgmental but firm that inappropriate behavior was not acceptable, intervene if residents shows signs of hostility or anger report to charge nurse ASAP of any incident of behaviorRecord review of Resident #3's Order Summary Report dated 06/16/2026, stated behavioral services to eval and treat as warrantedRecord Review of Resident #3's Progress note dated 05/21/2026 at 06:40 am reveled incident documented by LVN R.Record Review of Resident #3's Progress note dated 06/04/2026 at 13:47 PM reveled a note IDT meeting with meeting with Resident #3. Per admin MD is recommending for resident to discharge to an assisted living facility, where he can have more independent due to nursing home having more rules and regulations. Per administrator 30 day discharge notice will be issued on 6/04/25 social services to find a safe discharge place. Resident requesting to have Ombudsman present care plan schedule for 6/15/26. resident requesting to speak to the doctor as well. Resident #3 refused to sign 30 day notice follow up care plan on 6/15/26 at 1:30pm with IDT team. Last day for 30 day notice will be 7/04/26.Record Review of Resident #3's Provider Note dated 05/19/2026, reveled The patient was seen and examined in hall, patient is freee distress remains AOx3, we are recommending patient to go to another facility due to him being independent and non-compliant. he is leaving the facility daily on the sun metro and is usually gone all day. the staff does report behavioral issues deer oaks has been consulted when he was first admitted but patient refused care. we are consulting dear oaks again patient voices no needs is ambulatory with cane, appetite is good.In an interview on 06/16/2026 at 11:03 am, Resident #3 was alert and oriented and demonstrated the ability to recall dates, names, and prior events with good recollection. Resident #3 stated he had a verbal altercation with LVN R, during which LVN R had called the police. The resident stated he had informed facility staff of the incident and was able to recall the detective's last name. The resident reported he had apologized to LVN R and observed that she appeared frightened and did not shake his hand when he offered it. The resident stated he became emotional and cried because he felt embarrassed by the situation. Resident #3 stated there had been a prior incident with LVN R while entering an elevator. LVN R immediately became upset and instructed him that he should not enter the elevator with her. Resident #3 stated the Social Worker (SW) had not followed up with him regarding how he felt after the altercation with LVN R. The resident stated he had received a letter of discharge that made him feel sad and frightened after the incident, and reported the SW had never explained the reason for his discharge from the facility. Resident #3 stated he understood the SW did not possess a license; therefore, he had contacted the local ombudsman for assistance.In an interview on 06/16/2026 at 01:41 PM, DON stated resident had never been alone with detective during discussions related to the incident. The DON stated the resident had not expressed fear of the detective until the day of the care plan meeting on 06/15/2026. The DON stated she completed a trauma assessment following the care plan meeting to ensure [behavioral services] was informed of the resident's emotional status. The DON stated the detective had last been at the facility in May 2026, and the resident had continued leaving the facility on pass without exhibiting signs of distress or other concerns. The DON further stated the resident had been leaving the facility more frequently than before. DON stated that during the care plan meeting, Resident #3 was explained the discharge notice that was given to him on 06/04/2026, and agreed to tour assisted living facilities contracted through his insurance. The Ombudsman was present during the care plan meeting, and the resident agreed to explore alternative placement options. In an interview on 06/17/2026 at 10:19 AM, Business Manager V stated she had been employed at the facility since 01/08/2026. Business Manager stated the Administrator had informed her that a 30-day notice needed to be issued because the provider had changed the medical necessity care needs for Resident #3. She reported a copy of the letter had also been sent to the Ombudsman. Business Manager V stated that her understanding was the administration had met with Resident #3 on 06/04/2026, and explained the purpose of the letter and its implications regarding his continued residency at the facility. Business Manager V stated she had informed the administrator that the 30-day notice had been issued for nonpayment rather than a transition of care. Business manager V, stated I did my job, if he asked me for the letter, I did it and provided the letter the Administrator to give to Resident #3. She stated she had informed the administrator on 06/04/2026 that the requested letter was not appropriate notice for the residents discharge from the facility.In an interview on 06/17/2026 at 11:30 AM, with Social Worker stated she was the one responsible for generating a 30-day notice of discharge plan for change of treatment plan. She stated she was off the day the wrongful discharge letter was issued to Resident #3 by the Administrator and did not do any assessment or follow up with the letter until his care plan meeting on 06/15/2026. SW stated she coordinated the care plan meeting for Resident #3 and stated she had provided the resident with a letter informing him of the meeting six days prior to the scheduled care plan meeting, but did not follow up with the nonpayment letter that was provided to him on 06/04/2026 she had no reasoning on why she did not follow up. SW stated she was absent for the meeting because she had taken time off to complete licensing testing. The SW stated residents were at risk for emotional distress if their concerns were not properly assessed. She stated her trauma assessment process consisted of asking residents how they were feeling. She stated Resident #3 had verbalized his concerns regarding the altercation between LVN R but he had been referred to behavioral services, mental health services and had obtained assistance through those services. The SW stated she assessed residents if they only expressed concerns during morning meetings or if nursing staff notified her of behavioral concerns the social worker further stated the facility did not have a formal process for conducting trauma assessments and she confirmed that she did not conduct an assessment for Resident #3 in regard to his feelings towards the wrongful discharge letter for nonpayment.In an interview on 06/17/2026 at 12:00 pm, ombudsman, stated he was unaware if facility staff had explained the purpose of the discharge notice to Resident #3 he reported the notice identified as nonpayment as the reason for discharge although the resident had stated he had not experienced payment issues. The ombudsman stated he had not voiced concerns during the meeting because the resident intended to appeal the discharge notice of nonpayment which will be revoked due to that not being the reason of discharge from facility. The ombudsman further stated that the facility had not provided an appropriate discharge notice identifying the resident of his actual discharge status he reported the residence level care had improved however because the resident had permanent Medicaid coverage the facility could not discharge him solely for that reason. The ombudsman stated he had discussed assisted living options with the residents and explained that Medicaid funding would follow the resident he reported the resident did not wish to leave the facility but had only agreed to visit assisted living facilities to consider transfer options. The ombudsman stated he had spoken with the resident multiple times by telephone and text messages he reported the resident initially appeared frightened following the incident involving LVN R and later demonstrated improvement in his emotional status after receiving services through the behavioral services . The ombudsman stated the resident had initially declined counseling and medication but had since accepted therapy and appeared to be doing well.Record review of grievances dated January 2026 through June 2026, revealed the SW had signed grievance documentation since February 2026, none of the grievances were related to the altercation between Resident #3 and LVN R.Record Review of 30 day discharge letter to Resident #3 dated 06/04/2026, revealed notice of discharge, This discharge is based on your failure, after reasonable and appropriate notice, to pay to provide services and your stay at this facility

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 dryers reviewed.The facility failed to ensure the furthest right dryer was operational.This failure placed residents at risk for delay in having their clothes and bedding returned without delay.During an observation on 3/11/2026 at 3:09 PM of the laundry room revealed Laundry Aide I was utilizing 2 of 3 dryers in the laundromat. The furthest right Dryer was rusted, had dust, and was missing its operational panel that covered the top portion of the dryer. The dryer was non-responsive despite moving the knobs and checking for power to the machine. Laundry Aide I confirmed the 3rd dryer was non-operationalDuring an interview on 3/11/2026 at 3:10 PM with Laundry Aide I, she stated she had worked at the facility for 2 years and the 3rd dryer has not been operational for approximately a year. She stated she was not the individual who reported it the dryer was non-operational but suspected it was the day shift laundry aides who reported it to the previous laundry supervisor. She stated that the previous supervisors were informed the dryer did not work because they entered the laundry room approximately 4 times a day. She stated not having the 3rd dryer unit did not affect her ability to complete tasks in a timely manner. She stated if the laundry equipment stopped working, she would report it to her supervisor immediately. She stated this needed to be done so that the process for repairs could be initiated. She stated not having operational dryer affected residents by potentially creating a delay in cleaning sheets, towels, Hoyer nets, personal clothing, etc. She stated residents could be left without clean supplies or clothing. She identified the maintenance director and laundry supervisor were responsible for reviewing the equipment and ensuring it was operational. She stated she had not received training or in-service on reporting broken equipment.During an interview on 3/11/2026 at 3:24 PM with the Laundry Supervisor, he stated t he had been in his position for 2 months. He stated he oversaw the operations for laundry and housekeeping throughout the facility. He stated he had a total of 7 employees to handle housekeeping tasks and laundry. He stated he had not found any documentation from his predecessors about the dryer's dysfunction. He stated the Maintenance Director had notified him that the dryer had not been operational for a year and added that the tumbling drum inside was rusty. He stated he had been aware the dryer was not operational since he began in January. He stated that him nor the facility had no intention on fixing or replacing the dryer because the current census did not require more than 2 dryers. He stated if there was an increase in the census he would partner with sister facilities to meet the new laundry demands. He stated he had no concern for having inoperable equipment in the laundry room. He stated it did not pose a risk for infestations of pests, mice, or infection. He stated if the dryer was removed, it would create more hazard. He stated the maintenance team cleaned the dryer area and behind it weekly. He stated staff was trained to notify him whenever equipment was faulty and to stop use until it was repaired. He clarified this training was provided by word of mouth, and he did not capture in signatures or have a formal in-service log for documentation. He stated the inoperable dryer did not affect residents and added that there had not been a delay in laundry being returned to residents.During an interview on 3/12/2026 at 8:30 AM with the Maintenance Supervisor, he stated he had been in his position for 2 months and had one employee in his department. He stated the facility had 1 dryer in the laundry room and identified it was the 3rd unit (from left to right). He stated he had reviewed the records from his predecessor and discovered the dryer was not fixable and would require a replacement. He stated the facility will be removing the dryer soon and anticipated it being removed in the next 1-2 months. He stated that he had to contact a company to remove it because it could not just be left in the parking lot near the dumpster. He stated the dryer was not obstructing operations and did not affect the facility. He stated residents were not affected because there was still 2 operational dryers and no report of delays. He stated that if a staff member had a work order for him, he was made aware by word of mouth. He identified himself as the individual responsible for contacting vendors to complete repairs beyond his knowledge.During an interview on 3/12/2026 at 12:41 PM the Administrator stated she was aware the dryer was broken down. She stated there had not been interruption of services for returning laundry to the residents. She stated that the census did not require an extra dryer. She stated that it was going to be removed upon the surveyors' exit. She identified herself and all staff members down the chain of command to report the defective equipment to the Maintenance Supervisor. She stated she had known for 3 months about the dryer's inoperable condition. She stated she was not aware if it was a state or federal requirement for all electrical and mechanical equipment to be fully operational. She stated she had not provided in-training and services and stated it was within the job description of staff to report faulty equipment. She stated the dryer not being operational had not affected the residents and if it did affect them then the facility would prioritize a resolution.A policy pertaining to reporting faulty equipment or maintaining equipment was requested at end of day on 3/11/2026; the facility did not provide such policy.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 8 residents (Residents #2 and Resident #15) reviewed for dignity. -The facility failed on 03/10/2026 to assist Resident #2 to shave her facial hair.-The facility failed on 03/10/2026 and 03/11/2026 to cover Resident #15's genitals and anus. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues and diminished quality of life.The findings included:Record review of Resident #2's face sheet revealed Resident #2 was a 69 year old female who was admitted to the facility on [DATE]. Record review of Resident #2's history and physical revealed diagnoses including morbid obesity (severely elevated body weight that increases health risks), schizoaffective disorder (mental illness involving mood symptoms and psychosis), unspecified psychosis (loss of contact with reality), bipolar disorder with manic episode and psychotic features (severe mood disorder with elevated mood and psychosis), major depressive disorder (persistent depressed mood), Parkinson's disease (neurological condition affecting movement), generalized muscle weakness (reduced muscle strength), anxiety disorder (excessive worry), delusional disorder (fixed false beliefs) and personality disorder (persistent pattern of behavior affecting functioning). Record review of Resident #2's MDS admission assessment dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident was cognitively intact and able to communicate needs and preferences. The MDS revealed the resident was able to make decisions regarding daily activities. Review of section GG for functional abilities revealed Resident #2 required substantial to maximal assistance (meaning that staff made more than half the effort by helping to lift and hold trunk or limbs of the resident) with showering and was dependent (meaning the staff made all the effort and the resident does none of the effort to complete the activity) for toileting hygiene, lower body dressing and putting on and taking off footwear. Record review of Resident #2's care plan revealed care plan interventions addressing ADLs and self care deficits. The care plan revealed the resident required staff assistance with bathing, shaving and personal hygiene tasks. Interventions included staff assistance with grooming and hygiene needs and monitoring the resident's ability to perform personal care tasks. Record review of Resident #15's face sheet revealed the resident had an initial admission on [DATE] and readmission on [DATE]. Record review of Resident #15's history and physical dated 12/16/2025 revealed diagnoses of left and right leg amputation at knee level, dementia (a condition that effects an individual's cognition, memory, mood, and behavior) without behavioral disturbance, insomnia (a sleep disorder that effects and individuals ability to fall asleep and stay asleep). Record review of Resident #15's comprehensive MDS dated [DATE] revealed the resident had a BIMS of 07 (meaning the resident had severe cognitive impairment). Review of section I for active diagnosis revealed the resident had an active diagnosis of need for assistance with personal care, attention and concentration deficits, and cognitive communication deficits. Record review of Resident #15's significant change MDS dated [DATE] Review of section C for cognitive patterns revealed the resident had behavior present with fluctuations for inattention, disorganized thinking, and altered level of consciousness. Review of section GG for functional abilities revealed the resident required partial/moderate assistance from staff for lower body dressing. Record review of Resident #15's care plan dated 01/08/2026 revealed care plan interventions addressing resistive to care related to Dementia. The care plan revealed the resident had episodes of inappropriate behavior: wants to keep urinal on the bed side table or siderail without plastic bag, with interventions of ensure staff is aware of resident's behaviors and successful interventions and monitor behaviors to identify any patterns to assist with decreasing number of episodes. During observation and Interview on 03/10/2026 at 9:05 AM with Resident #15, it was observed he was not wearing bottoms as evident by his genitalia being out for the duration of his interview. He stated he did have bottoms on and proceeded to sit restlessly by opening and closing his legs. Follow up observations completed on 03/10/2026 at 12:41 PM, 1:28 PM, and 2:00 PM revealed no change and his partition curtain that divided the room was open for neighbor to view. In a follow-up observation on 03/11/2026 at 2:10 PM, the resident's anus and genitals were visible from the entrance of his fully open doorway and privacy curtain was not in use; Resident #15 was asleep at this time. During an interview on 03/11/2026 at 2:15 PM with LVN G, he stated Resident #15 was resistant to care due to dementia diagnosis as it was his right to refuse care and staff would continue prompting in case he changed his mind. He stated if Resident #15 declined care it would be documented within the facility's resident care portal. He stated the Hospice maintained records of services provided to Resident #15 and he was only responsible for signing off on the Hospice's tablet. He stated Resident #15 had refused to participate in activities, to smoke, baths, grooming, and to wear bottoms or covers. He stated if Resident #15 was within his room, staff would not intervene on his decision to remain bottomless. He stated the curtains needed to be drawn close when Resident #15 wanted to be bottomless. He stated the facility monitored the effectiveness of interventions by asking the resident on preferences and trying to keep his curtain closed. He stated it was difficult to keep the curtains closed because Resident #15 could draw them open himself and required frequent prompting and redirecting. He stated the last in service for dignity was a week prior. During an interview on 3/12/2026 at 10:54 a.m. with CNA F, she stated Resident #15 used to utilize a blanket cover for his lower body as he preferred to not use briefs, underwear, or bottoms. She stated when Resident #15 returned from the hospital in January 2026 he stopped actively covering his lower body. She stated she assisted to cover Resident #15 with a blue blanket on 03/11/2026 at 2:15 PM and closed his door to a small opening. She stated Resident #15 was usually modest and covered himself and clarified a reasonable person would not want to have their genitals exposed and visible from the entrance of their room. She stated Resident #41 who had wandering behaviors would sometimes enter Resident #15's room and could result in exposure for both Resident #41 and Resident #15. She stated that staff would prompt Resident #15 during care if he wanted to apply bottoms and when he would enter the hallway they would provide coverage. She stated that other residents should not be exposed to a fellow resident's genitals as this was a dignity issue for both residents. She stated the last time she received training regarding dignity and residents rights was two weeks prior. During an interview on 3/12/2026 at 12:54 PM with the Administrator, she stated it was not acceptable for residents to be exposed because it was a dignity issue. She stated if a resident felt uncomfortable seeing another resident's genitals, they could notify the charge nurse to address. She stated that a reasonable person would want to have their bottom covered to prevent genital and anus exposure. She stated that a resident without bottoms needed to be reported to the nurse because it was an uncommon behavior. She stated if it was a resident's preference, it needed to be care planned and have interventions documented to address it. She stated it affected residents because it was an unaddressed behavior and was a dignity concern. She stated it was a collaborative responsibility between staff, supervisors, and IDT to address a resident's uncovered bottom preferences. During an interview on 3/12/2026 at 2:09 PM with the DON she stated the staff facilitated the preferences of residents to meet their needs, care plans, and attempt to put interventions in place for abnormal behavior. She provided examples of abnormal behavior was yelling out, refusal of care, refusal of hygiene care, verbal and physical aggression. She added those behaviors required a care plan addressment and ongoing progress notes and included the same applied to a resident who preferred to be bottomless. She stated that she needed to speak to Resident #15 and review his preferences to be bottomless and update his care plan and enter progress notes for monitoring. She stated that a reasonable person would not want to have their genitals and anus exposed. She stated interventions staff could do to uphold Resident #15's dignity would include frequent rounding and prompting Resident #15 if he would like a cover for his bottom. She stated the last in-service staff received for resident rights was 2 weeks prior. She completed a brief review of Resident #15's progress notes and care plan revealed there was no documentation that pertained to his preferences to be bottomless. She stated it effected Resident #15 and other residents by exposing them to intimate areas that a reasonable person would not want to see. During an observation and Interview on 03/10/2026 at 10:12 a.m. with Resident #2, she stated she had been at the facility for a month. It was observed that Resident #2 had long facial hair on her shin. Resident #2 stated she would have liked to be shaved, but that staff had not offered her assistance to shave her. Resident #2 stated she did not like to have facial hair. The resident stated she had not asked for assistance because she felt she was bothering them by asking them to be shaved. During an interview on 03/11/2026 at 9:19 a.m. with LVN A, stated that all staff who worked directly with residents were responsible for checking their hygiene. LVN A stated CNAs should have asked Resident #2 during showers or while visiting her room, if she needed help with shaving. LVN A stated it was not acceptable for a female resident to have unwanted facial hair. LVN A stated the possible negative outcome was that Resident #2 could feel embarrassed for having long facial hair, which could affect her self esteem and make her feel like staff did not pay attention to her. During an interview on 03/11/2026 at 9:24 a.m. with LVN B, stated that CNAs were responsible for checking the resident's hygiene while assisting with showers and helping with shaving if the resident desired to be shaved. LVN stated if a resident refused to shave, whoever was providing shower assistance or helping with ADLs, needed to document it in the resident's progress notes or notify a charge nurse. LVN B stated the potential negative outcome for not shaving facial hair on a female resident who did not wish to have hair, could result in the resident feeling she was not well taken care of and make her feel like the staff did not care about her wellbeing. During an interview on 03/11/2026 at 9:32 a.m. CNA C stated all staff who assisted residents with ADLs were responsible for checking the resident's facial hair and assisting with shaving if the resident wished to be shaved. CNA C stated the potential negative outcome for a female resident not being assisted with shaving could result in the resident feeling embarrassed and ignored by staff. During an interview on 03/11/2026 at 9:41 a.m. the SW stated that all staff needed to be vigilant and pay attention to the residents' grooming and hygiene. SW stated that if a resident wished to be shaved, especially a female resident, staff needed to ask if they needed assistance. SW stated that by not aiding with grooming and shaving a female resident, it could result in the resident feeling ashamed or embarrassed and feeling ignored by the facility staff, which could negatively impact their self esteem. During an interview on 03/12/2026 at 9:40 a.m. with the DON, she stated she did not see harm with Resident #2 having long facial hair. She stated Resident #2 had been refusing ADLs, showers, and medications. Record review of the facility's progress notes did not show refusals of ADLs for shaving Resident#2's facial hair. During an interview on 03/12/2026 at 11:28 a.m. with CNA D stated the possible negative outcome of leaving a female resident unshaven when she did not wish to have long facial hair could make the resident feel ashamed which could potentially make the resident self-isolate, and as if the facility staff were not paying attention to her. During an interview on 03/12/2026 at 1:11 p.m. with the Administrator, stated it was the responsibility of every team member to assist the residents with ADLs and hygiene. The Administrator stated that any staff member who had contact with Resident #2 should have asked if she wanted to be assisted with shaving her facial hair and stated failure to help her with shaving could negatively impact Resident #2's self esteem and confidence. Record review of the facility's policy title Resident Rights dated 11/28/2016 read in part, The resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy (planning and implementing care section) the right to participate in the development and implementation of his or her person centered place of care, including but not limited to (Respect and Dignity section) the resident has a right to be treated with respect and dignity, including: .the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endager the health or safety of the resident or other residents Record review of the facility's policies and procedures titled Shaving, Electric/Safety Razors, not dated, stated in part: Shaving of the male resident can be performed with an electric or safety razor depending on the preference and availability of equipment. It is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. It is done to promote cleanliness and a positive body image. Usually, the resident or a staff member performs the procedure, but the nurse can shave the resident if illness or disability prevents independence. Goals 1. The resident will experience cleanliness and comfort. 2. The resident will be free from infection. 3. The resident will maintain intact skin integrity. 1. Assemble the necessary equipment: a basin of warm water (115 degrees F.), shaving cream, the safety razor, a towel, a wash cloth, and aftershave. 2. Wash your hands and put on gloves. 3. Explain what you are going to do. 4. Place a towel under the resident's chin. 5. If the resident wears dentures, be sure they are in his mouth. 6. Put the washcloth in warm water, wring it out, and place it on the face to soften the beard. 7. Apply shaving cream to the face. 8. With the fingers of one hand, hold his skin taut. With the other hand shave in the direction the hair grows. Using short, firm strokes, shave under the sideburns, downward over the cheeks, over the chin, and upward on the neck. 9. Rinse the razor often. 10. Wash the remaining shaving cream off his face. 11. Apply aftershave, if the resident desires it. 12. Store all articles in the appropriate place. 13. When finished, dispose of the gloves and wash your hands.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed to ensure dietary staff followed proper food safety practices for cooling and storing prepared food on 03/10/2026. This failure had the potential to place all residents who received meals from the main kitchen at risk for foodborne illness due to, improper food storage practices.Findings included: During an observation on 3/10/2026 at 8:37 a.m. in the facility's kitchen, inside refrigerator #1 revealed: a steam table pan containing oatmeal was observed stored on the bottom rack of the refrigerator, covered with plastic food wrap. Upon assessment, the pan containing oatmeal was noted to be hot to the touch at the time of storage. During an interview on 03/10/2026 at 10:40 a.m., the [NAME] stated hot oatmeal should not have been placed directly into the refrigerator and explained that food must be allowed to cool prior to storage. The [NAME] acknowledged that placing hot food into the refrigerator could promote bacterial growth if proper cooling procedures were not followed, which could result in contaminated food and pose a risk of illness to residents. During an interview on 03/10/2026 at 10:32 a.m., the DS stated oatmeal should have been cooled appropriately by placing it over ice, before being stored in the refrigerator. The DS explained placing hot oatmeal into the refrigerator could raise the internal temperature of the unit, potentially affecting other stored food items. The DS stated this practice could have led to food spoilage, bacterial growth, and increase the risk of residents becoming ill if contaminated food were consumed. During an interview on 03/12/2026 at 9:36 a.m., the DON stated storing hot oatmeal in the refrigerator could have contributed to bacterial growth if proper cooling processes were not followed. The DON stated failure to cool food appropriately prior to refrigeration could have resulted in unsafe food conditions and place residents at risk of illness. During an interview on 03/12/2026 at 1:11 p.m., the Administrator stated food should have been cooled to safe temperatures prior to being placed in the refrigerator. The Administrator stated placing hot food into the refrigerator could increase the internal temperature of the unit, potentially damage the equipment, and compromise its function. The Administrator stated this could have led to spoilage of other food items stored in the refrigerator and increase the risk of bacterial growth. The Administrator stated consumption of improperly stored or contaminated food could place residents at risk of foodborne illness. Record review of the Dietary Services Policy and Procedure Manual, titled Left-Over Foods, dated 2012, stated in part: Left- Over FoodsLeft-over foods shall be handled in a manner to ensure the safe use of these foods at a later date. Procedure:Left-over foods shall be refrigerated, dated, labeled and properly covered promptly after meal service. When cooling large quantities of food, divide into shallow pans and place on ice in the refrigerator. It must reach 70 degrees within 2 hours, and 41 degrees or below within 4 additional hours. Foods are not to be stored at room temperature. Food is to be kept at 41 degrees F or below to prevent bacterial growth.Was he asked who placed it in the fridge? Was this to serve residents? If so, when?These were leftovers from breakfast and he placed it in the refrigerator

Based on observation, interview, and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional for 1 of 1 (activities staff) reviewed for staff qualifications.The facility failed to ensure the activities staff had completed State approved training to direct facility activities.This failure could place residents who participated in facility activities at risk of physiological, psychological, social, and spiritual harm by receiving services from unlicensed personnel.Findings include:During an interview on 3/11/2026 at 8:47 AM the Receptionist stated that the Activities Assistant was the only individual in the Activities department.During an observation on 3/11/2026 at 10:14 AM, the Activities Assistant lead an activity independently with 14 residents present and engaged in physical stretching, meditation, and prayer.During an interview on 3/12/2026 at 10:03 AM the HR Coordinator stated the activities department consisted of one Activities Assistant and a part-time assistant and there was a vacancy for the Activities Director position since 2/20/2026. She stated the Activities Assistant would be transitioning into the Activities Director position once she passed her certification course. She stated the Activities Assistant was leading activities while the Administrator oversaw the operation and helped with the monthly calendar and acquiring supplies. She stated she was unaware if there was a policy that required the Activities Assistant to possess a certificate. She stated it was state/federal requirement for the facility to have an activities director and added the Activities Assistant had a lot of experience. She stated she would not accept an application for a position from someone who was unlicensed when the position required it. She added this was per facility policy and state/federal requirement that employees possess a license/certificate when the position required it. She stated it did not affect residents if the Activities Assistant was not certified. She identified herself as the individual who was responsible for reviewing licenses and certifications for employees. She stated she reviewed employee licenses and certificates on a daily basis. She stated the Activities Director was responsible for organizing resident outings, activities, birthdays, holiday celebrations, events, documenting residents who participated, and transporting residents from their rooms to the gathering. She clarified that all the tasks mentioned were completed by the Activity Assistant since 2/20/2026.During an interview on 3/12/2026 at 11:40 AM the Activities Assistant stated she did not have her certification to be an Activity Director. She stated her responsibilities were to conduct activities, conduct morning rounds, transport residents to activities, provide activities in residents rooms, distribute coffee and utensils before meals, ensured that residents did not fall during activities, prompt residents to participate, and transport residents back to their room. She stated her previous Activities Director had resigned 2 weeks ago and there was a part-time assistant who would help her 2-3 times a week. She added the HR Coordinator and Administrator would follow up with her to help when needed. She stated the Administrator completed the activity calendar for March but that she would be completing the activity calendar going forward. She stated it was a requirement for her to possess a certificate to be conducting the tasks she was actively completing. She stated it effected residents because she could not have ample information or knowledge to complete her responsibilities as an Activities Director.During an interview on 3/12/2026 at 12:30 PM the Administrator stated the Activities Assistant was the department head and had a conditional offer for the Activities Director position. She stated the Activities Assistant did not currently possess a certificate needed to the Activities Director position. She stated the Activities Assistant was given 1 month to complete her training for the certification Activities Director position. She stated she was not aware if it was a state/federal requirement for the Activities Director to possess a certificate or license. She stated that HR oversaw the credentialing and qualifications of staff. She stated that license and certifications provided credentials to prove that someone had the qualifications to complete their job. She added that someone could possess the knowledge even without the pass acknowledgement on an exam. She stated that the Activities Director being uncertified did not affect residents because there were course resources available through the facility and additional staff assistance. During an interview on 3/12/2026 at 1:59 PM the DON stated the purpose of a license and certification as used to prove that someone was eligible to provide care or service within their scope of practice. She stated the facility had a regional Activities Director who oversaw the Activities Department at the facility and simultaneously oversaw the Activities department at a sister facility. She stated the Regional Activity Director had not been in the facility for the 3 days of the annual survey. She stated the Activities Assistant had been facilitating the activities because they had been planned, purchased supplies, and provided her with instruction. She stated there was no effect on residents because they were still receiving services and activities. She identified the HR Coordinator and Administrator were responsible for reviewing licensures and credentialing of staff in positions that required a license/certification.Record review of the facility's Job Description for the Activity Assistant dated 2014 read in part, This position reports directly to the Activity Director Record review of the facility's Job Description for the Activity Director dated 2014 read in part, These are legitimate measures of the qualifications for a Activity Director, and are related to the functions that are essential to the job of a Activity Director. Knowledge Base Must be certified Activity Director .

Based on observations, 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 one of eight residents ( Resident #2) reviewed for ADL care. The facility failed on 03/10/2026 to ensure Resident #2's fingernails were clean and trimmed. This failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings included: Record review of Resident #2's face sheet revealed Resident #2 was a 69 year old female who was admitted to the facility on [DATE]. Record review of Resident #2's history and physical revealed diagnoses including morbid obesity (severely elevated body weight that increases health risks), schizoaffective disorder (mental illness involving mood symptoms and psychosis), unspecified psychosis (loss of contact with reality), bipolar disorder with manic episode and psychotic features (severe mood disorder with elevated mood and psychosis), major depressive disorder (persistent depressed mood), Parkinson's disease (neurological condition affecting movement), generalized muscle weakness (reduced muscle strength), anxiety disorder (excessive worry), delusional disorder (fixed false beliefs) and personality disorder (persistent pattern of behavior affecting functioning). Record review of Resident #2's MDS admission assessment dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident was cognitively intact and able to communicate needs and preferences. The MDS revealed the resident was able to make decisions regarding daily activities. Review of section GG for functional abilities revealed Resident #2 required substantial to maximal assistance (meaning that staff made more than half the effort by helping to lift and hold trunk or limbs of the resident) with showering and was dependent (meaning the staff made all the effort and the resident does none of the effort to complete the activity) for toileting hygiene, lower body dressing and putting on and taking off footwear. Record review of Resident #2's care plan revealed interventions related to activities of daily living and personal hygiene care. The care plan indicated the resident required assistance with bathing, and personal hygiene. Interventions included staff monitoring and assisting with grooming tasks and maintaining the resident's hygiene needs, including routine care related to nail length and hygiene as part of regular personal care. During an observation and Interview on 03/10/2026 at 10:12 a.m. with Resident #2, she stated she had been at the facility for a month. It was observed that Resident #2 had long fingernails measuring about one inch in length; Resident #2's nails looked yellowish in color and dark particles, and debris were observed underneath her fingernails. Resident #2 stated she would like her fingernails trimmed, but that staff had not offered her assistance. Resident #2 stated she did not like to have long fingernails because she scratched herself and had cut herself in the past. During an interview on 03/11/2026 at 9:20 a.m. with LVN A stated all staff who worked with residents were responsible for checking on the resident's fingernails. LVN A stated during showers or while helping with hygiene, CNAs, LVNs and RNs needed to ask the residents if they wished to have their fingernails trimmed. LVN A stated the potential negative outcome for not trimming a resident's fingernails could result in the resident cutting or scratching themselves and soil their fingernails which could lead to infection and sickness. During an interview on 03/11/2026 at 9:26 a.m. LVN B stated CNAs were responsible for checking the resident's fingernails and trimming them while assisting with showers. LVN B stated if a resident refused to have their fingernails trimmed, whoever was providing shower assistance needed to document it in the resident's progress notes. LVN B stated the potential negative outcome for not trimming the resident's fingernails could have resulted in them scratching themselves, which could lead to infection and potentially make the residents sick if they were to eat, and their fingernails were dirty. During an interview on 03/11/2026 at 9:34 a.m. CNA C stated CNAs and whichever staff assisted a resident with showers were responsible for checking the residents' fingernails and trim them if necessary. CNA C stated that not trimming a resident's fingernails could result in them scratching and cutting themselves which could result in infection. She stated that if a resident had long and dirty fingernails and they ate food, it could lead to the resident getting sick or an infection. During an interview on 03/11/2026 at 9:43 a.m. the SW stated all staff from the facility who provided assistance with hygiene to the residents were responsible for asking if they needed their nails trimmed. The SW stated the negative outcome for not trimming a resident's fingernails could result in them scratching themselves, which would lead to bleeding and infections. The SW stated if the resident's nails were not clean and they ate their meals, they could potentially get sick from their stomachs. During an interview on 03/12/2026 at 9:44 a.m. the DON stated she did not see harm with Resident #2 having long fingernails. She stated Resident #2 had been refusing ADLs, showers, and medications. Record review of the facility's progress notes did not show refusals of ADLs for nail trimming. During an interview on 03/12/2026 at 11:30 a.m. CNA D stated any staff who provided assistance with ADLs for Resident #2 were responsible for asking the resident if she needed assistance with trimming her fingernails. CNA D stated the potential negative outcome of leaving Resident #2's fingernails long could have resulted in the resident harming herself if she was to scratch her skin, which could result in skin infections. CNA D stated if Resident #2's fingernails were dirty and she was to eat her meals; she could potentially get sick due to bacteria growth transmitted to her. During an interview on 03/12/2026 at 1:15 p.m. the Administrator stated it was not acceptable that Resident #2 was not assisted with trimming her nails and the potential outcome could be that she scratched herself and she could bleed and it could lead to infection. The Administrator stated if Resident #2 did not wash her hands and had dirty fingernails, she could potentially get sick from her stomach and could lead to vomiting or diarrhea.Record review of the facility's policies and procedures titled Nail Care, not dated, stated in part: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions The resident will be free from infection.ProcedureShould be performed according to the resident centered plan of care. 1. Explain the procedure to the resident.2. Wash hands.3. Immerse hands or feet in a basin of warm soapy water to cleanse and soften the nails for ease in cleansing and trimming. Use a soft brush if necessary to cleanse under and around the nails.4. Remove debris from under the nails with an orange stick while soaking.5. Remove the hands or feet from the basin and pat dry.6. Apply lotion and massage into the cuticles and push back with a towel. Avoid cutting any cuticle.7. Trim the nails with a clipper, straight across for the toenails and rounded for the fingernails.8. Smooth the nails with an emery board.9. Apply hose and shoes or slippers as appropriate.10. Discard removed nails, cleanse basin and articles used and store for future use.14. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 dining rooms reviewed.- 1 living cockroach was in the dining room.-The facility failed to dispose of 1 dead cockroach in the dining room.-The facility failed to dispose of 5 dead cockroaches in the Air Conditioning unit room.This failure placed residents at risk for a facility wide infestation of cockroaches. Findings include:During an observation on 3/11/2026 at 11:05 AM, a live cockroach was discovered in the dining room and was acknowledged by the Activities Assistant. A dead cockroach was found between the wall and the furniture table in the dining room near the air conditioning unit. Inside the air conditioning unit room, 5 additional dead cockroaches were found to the right of the doorway. Activities Assistant proceeded to pass out coffee and stepped over the cockroach at 11:28 AM. Residents sitting in the dining room exterminated the cockroach at 11:37 AM and was left at the table side by the Activities Assistant.During an interview on 3/12/2026 at 8:06 AM with LVN J, she stated she would kill a cockroach immediately, apply gloves, discard of the remains, and wash hands afterward. She stated this needed to be done immediately to prevent the cockroach from escaping and contacting residents. She stated she would notify maintenance immediately after the incident to contact pest control. She stated she had only 1 previous interaction with a cockroach on her floor. She stated she had not received any complaints about cockroaches in residents' rooms.During an interview on 3/12/2026 at 8:39 AM with the Maintenance Supervisor, he stated the facility had a contract with a company that was self-automated to spray poison in the facility once a month. He stated the contracted pest control treated the whole facility and all floors. He stated he was not aware of any complaints from staff or residents regarding cockroaches. He stated if he was aware about a live cockroach he would contact the pest control immediately. He stated he was not notified about the cockroach in the dining room on 3/11/2026 by staff or residents. He stated the facility did not have a policy for staff to exterminate a live cockroach and suggested it would be instinct to kill and dispose of a cockroach. He stated it affected residents because it could potentially cross contaminate food.During an interview on 3/12/2026 at 11:27 AM with the Activities Assistant she stated she advised the HR Coordinator to notify housekeeping to pick up the dead cockroach and disinfect the floor. She identified the residents had killed the cockroach. She stated she notified the HR Coordinator to notify housekeeping so that the area could be disinfected. She stated the cockroach was not a little one associated with cleanliness but the big dark ones associated with water and plumbing. She stated she had a phobia of cockroaches and therefore did not exterminate it herself for the 32-minute observation. She stated pest control came every 3 months to apply poison around the entire facility to deter pests. She stated she suspected the cockroaches were coming from the air-conditioning room. She denied notifying the Maintenance Supervisor of this suspicion. She stated it affected residents because it was an infection control issue, residents could be scared of cockroaches, and that cockroaches could potentially look for food and water throughout the facility. She stated it was housekeeping's responsibility to contact and schedule pest control services. She stated she had never received training on pest control.During an interview on 3/12/2026 at 12:23 PM with the administrator, she stated she was notified about the live cockroach in the dining room by the HR coordinator via group chat. She stated that pest control services came monthly to apply poison as this was an automatic scheduled routine the facility had in place. She stated it was her expectation for staff to kill the cockroach immediately, dispose of it, and document in the pest control book near the receptionist desk. She stated staff could notify any other department head or immediate supervisor about pest problems. She identified herself, the Maintenance Supervisor, and the Receptionist were staff members who could contact pest control to schedule an urgent service apart from their monthly visit. She stated it affected residents because cockroaches carried diseases, presented a health concern, and could potentially create an infestation. She stated there was not a policy in place that pertained to staff handling live pests.During an interview on 3/12/2026 at 1:40 PM with the DON, she stated she had not been notified by residents or staff about an increased number of cockroaches. She stated pest control came monthly on an automated scheduling system, and pest control binders were located at the receptionist and nurses' stations. She stated any staff member could notify pest control to visit the facility and apply poison and added that it was usually the Maintenance supervisor who organized this service. She stated the steps staff should take when dealing with a cockroach was to remove it from the area immediately, practice hand hygiene after, and document it in the pest control binder. She stated staff needed to report it to their immediate supervisor or the Maintenance supervisor. She stated it affected residents by making them feel bothered at the site of a cockroach. She stated she had not provided an in-service or training to staff on pest control.Record review of the facility's invoices from the pest control company read in part for service date on: 6/18/2025, 7/15/2025, 8/19/2025, 9/5/2025, 10/9/2025, 10/24/2025, 11/7/2025, 12/11/2025, 12/31/2025, 1/8/2026, 2/2/2026, and 3/12/2026 target pest: American cockroach and German cockroach .Record review of the facility's policy titled Insect and Rodent Control dated 2012 read in part, The facility will maintain an effective pest control program in order to provide an insect free and vermin free food service department.ProcedureArrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes structurally maintained walls, baseboard, etc. To prevent entrance access of insects and rodents.Sanitation of facility will be maintained per other stated policies to prevent food sources, breeding places, etc. for insects or rodents.

Based on observation, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #18) of 5 residents observed for oxygen management.The facility failed to ensure Resident #18's nasal canula was properly stored while oxygen was not in use. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.The findings include:Record review of Resident #18's admission Record dated 03/10/2026 revealed a [AGE] year-old male with an admission date of 06/06/2025. Record review of Resident #18's History and Physical dated 09/09/2025 revealed a diagnosis of chronic obstructive pulmonary disorder(Long term lung condition caused by damage to the airways and lungs leading to reduced air flow and difficulty breathing). Record review of Resident #18's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 09 indicating moderate cognitive impairment. Special treatment section revealed the use of oxygen therapy. Record review of Resident #18's orders dated 12/03/2025 revealed an order for oxygen at 3 liters per minute via nasal cannula related to chronic obstructive pulmonary disorder. Record review of Resident #18's care plan revised 01/27/2026, revealed Acute respiratory failure with hypoxia chronic obstructive pulmonary disease with acute exacerbation interventions included to give oxygen therapy as ordered by the physician. In an observation in Resident # 18's room on 03/10/2026 at 11:05 am the residents' nasal canula was left exposed on the bed. The resident was not in the room. During an interview on 03/12/2026 at 9:55 a.m., with the DON she stated the oxygen tubing was to be stored in a plastic bag when not in use. She stated she did not see an issue with the nasal canula left exposed on the bed. She stated since it was on the residents' bed, it was not contaminated because it was on his belongings. She stated if nasal cannulas were on the floor then she would expect staff to discard it and replace it. She stated that all staff were responsible to ensure it was stored properly when not in use. She stated the risk of not changing tubing was the risk of infection. She stated the last Inservice was about 1 month ago. During an interview on 03/12/2026 at 10:24 a.m., RN E stated that oxygen tubing and nasal cannulas were to be kept in a plastic bag with a date and the tubing had to be dated as well. She stated the purpose of keeping it in a plastic bag was to keep it from becoming contaminated. She stated if it were left exposed on the bed it needed to be changed because it was contaminated because it could have been dropped on the floor prior. She stated the risk to the resident would be potential infection. She stated the last Inservice was done last month. During an interview on 03/12/2026 at 11:24 a.m. CNA D revealed the nasal cannulas were to be stored in a plastic bag while not in use. She stated the purpose of the plastic bag was to keep the tubbing clean. She stated it was the responsibility of all staff to ensure nasal cannulas were stored properly when not in use. She stated a risk to the resident would be potential infection. She stated the last Inservice was in February. Review of facility policy titled Oxygen Administration not dated read in part under goals section The resident will be free from infection .

Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 5 residents (Resident #10) reviewed for call lights. The facility failed to ensure Resident #10's call light was within reach on 03/10/2026.This failure placed residents at risk of having their needs unmet when they were unable to contact staff.Findings included:Record review of Resident # 10's admission Record revealed an [AGE] year-old male with an initial admission date of 04/07/2023 and a readmission date of 12/12/2024. Record review of Resident #10's History and Physical dated 10/07/2025 revealed a diagnosis of Dementia (decline in brain function including memory, thinking, and reasoning). Record review of Resident #10's Quarterly MDS assessment revealed a BIMS score of 02 indicating severe cognitive impairment. Section GG revealed resident needed supervision or touching assistance for toileting meaning that the helper provides verbal cues and/or touching/steadying and/ or contact guard assistance as resident completes activity. Record review of Resident # 10's care plan revised on 02/16/2026 revealed Resident #10 had an ADL self-care performance deficit related to clinical illness myopathy (weakness in skeletal muscles), weakness and sarcopenia (age related muscle loss). Interventions included x 1 staff for bed mobility and toilet use. An observation on 03/10/2026 at 10:04am revealed Resident #10 asleep in his bed, and the call light was looped around another call light that was hanging from the wall. During an interview on 03/12/2026 at 9:55 a.m., the DON stated the purpose of a call light was for the resident to be able to make needs known. She stated that the call light should have been within the residents' reach for residents to call for help. She stated that all staff members were responsible for making sure that the call lights were within reach. She stated that this was done by the department heads, during morning rounds, and should have been done during the nurses and CNAs 2-hour rounds. She stated that the risk of the call light not being within reach would have been residents receiving delayed care. She stated the last training was done was last year. During an interview on 03/12/2026 at 10:24 AM RN E stated the purpose of a call light was for the resident to ask for help. She stated that call lights should have been in reach of the resident so they can ask for help. She stated all employees were responsible for ensuring that the call lights were within reach. She stated nurses and CNAs should have also ensured they were properly placed, when doing their rounds. She stated the risk of residents not being able to reach their call light was delay in their care and needs not being met. She stated she could not recall the last Inservice, but they were done frequently. During an interview on 03/12/2026 at 11:24 AM, CNA D stated the purpose of the call light was for the resident to call for help. She stated call lights should have been within reach of the resident. She stated all staff were responsible for ensuring call lights were within reach. She stated as a CNA she ensures call lights were within reach every time she rounded. She stated a risk to the resident was receiving delayed care. She stated she could not recall the last Inservice done over call lights. On 03/12/2026 at 2:30 pm, The DON stated the facility did not have a policy regarding call lights.

Based on observation and interview the facility failed to ensure the residents had the right to examine the results of the most recent survey of the facility and the facility failed to post the results of the most recent survey in a place that is readily accessible to residents, family members, legal representatives of residents, and the public for 1 of 1 survey results binder reviewed.The facility failed to ensure the annual survey results binder was accessible for residents, family members, and staff on 03/11/2026This failure placed residents, family members, and legal representatives of the residents at risk of not being informed the facility's survey and investigation results.Findings included:During an observation conducted on 03/11/2026 from 11:27 AM to 11:55 AM the annual survey results binder was not locatable in an easily accessible area on the ground floor, 2nd floor, and 3rd floor. At 11:56 AM it was observed The Administrator was placing the annual survey results binder in the receptionist desk area.During an interview on 03/11/2026 at 11:57 AM with the Administrator, she stated the annual survey results binder was on her bookshelf inside the administrator's office before she placed it in the receptionist desk area. She stated the binder needed to be placed in an easy access area without the need to ask for it. She stated the bookshelf inside The Administrator's office was not an easily accessible placement for the binder. She stated Resident #51 had wandering behaviors and was known for reorganizing office supplies around the reception desk and added she did not want to potentially lose pages from the annual survey results binder. She added that she will have to review the binder everyday and print out new pages to compensate those misplaced by Resident #51. She stated the binder could be provided upon request and noted there was a print out posting on the cork board across from the ground floor restrooms. She stated residents and visitors should not have to ask for it. She stated it put residents and visitors at risk of not having access to it and added it could be requested and it would be provided. She stated residents and visitors would not have readily access to see past survey results and corrections made by the facility. She stated staff was trained upon orientation from hire on locating the annual survey results binder.During an interview on 3/11/2026 at 12:13 PM with the Receptionist, she stated she had been working at the facility for a month and did not receive training or knowledge about the annual survey results binder. She stated she did not know where it needed to be placed in the facility. She stated if a resident or visitor asked for the survey results binder, she would look in her general area or ask for help from the HR coordinator and the Administrator. She stated she was not sure if it was a resident's right to have access to it. She stated no staff member, resident, or visitor had asked her for the survey results binder before. She stated she did not know how it affected residents and visitors if they did not have access to the survey results binder. She identified the Administrator as the individual responsible for updating the contents of the binder and placing it in an accessible location.During an interview on 03/11/2026 at 12:21 PM with LVN G, he stated the annual survey results binder was in the receptionist desk area. He stated if it was in the Administrator's office it would be a problem for accessibility because it would require assistance from staff to locate the survey results binder. He stated it should always be accessible for residents and visitors. He identified the administrator would be responsible for maintaining the contents of the binder and placing it in an accessible location. He stated the binder contained important information on the building, findings from State investigators, and provided facility corrections taken. He stated it affected residents by limiting access to the information inside the binder. He stated it was a resident's right to have access to it. He stated the last in service was in October or November 2025 on locating the survey results binder.During an interview on 03/12/2026 at 8:15 AM with CNA H, he stated the results to the annual survey could be in the office of the DON or the Administrator. He stated no residents or family members had asked him where to find the survey results binder. He stated it was a resident's right to obtain the information, but the facility had to be sure they were not providing confidential information. He stated he received training on locating the binder but cannot recall when. He stated he did not know the exact location of the binder, but he could ask supervisors where it was and they could assist him with locating it. During a confidential group interview on 3/12/2026 at 10:15 AM 10 out of 10 residents denied knowing where to locate the annual survey results binder and denied know the significance of the contents of the survey results binder.A policy pertaining to survey binder results was requested from the DON at end of day on 3/11/2026; the facility did not provide such policy.

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 of 6 residents (Resident #1) reviewed for pharmacy services.The facility failed to document accurately on Resident #1's EMAR for Acetaminophen with Codeine 300-30 MG tablet, 1 tablet. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.Findings included:Record review of Resident #1's face sheet dated 12/29/25 noted she was a [AGE] year-old female with admission date 08/28/25.Record review of Resident #1's health and physical dated 12/23/25 revealed a medical history of Lupus Erythematosus (an autoimmune disease where the immune system mistakenly attacks the body's own tissues, causing inflammation and tissue damage).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact.Record review of Resident #1's care plan, last revised 12/29/25, revealed resident had a potential for uncontrolled pain secondary to Systemic Lupus Erythematosus. Staff intervention included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Nursing staff were to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability.Record review of Resident #1's physician order dated 10/22/25 noted medication Acetaminophen with Codeine 300-30 MG tablet Give 1 tablet by mouth every 6 hours as needed for pain.Record review of Resident #1's physician order dated 11/05/25 noted medication Acetaminophen with Codeine 300-30 MG tablet Give 2 tablets by mouth every 6 hours as needed for pain.Record review of Resident #1's Electronic Medication Administration Record (EMAR) revealed resident was administered Acetaminophen-Codeine Oral tablet 300-30 MG Take 2 tablets by mouth as needed for pain as notated by nursing staff on the following dates: 11/08/25 at 08:01 AM, 02:02 PM, 08:00 PM; 11/15/25 at 07:01 AM, and 12:59 PM.Record review of Resident #1's Narcotic Count Sheet revealed nursing staff pulled 1 tablet of Acetaminophen-Codeine Oral tablet 300-30 MG on the following dates: 11/08/25 at 08:00 AM, 02:00 PM, and 08:00 PM; 11/15/25 07:00 AM, and 1:00 PM.Interview on 12/29/25 at 10:50 AM with Resident #1, she stated she was provided 1-2 tablets during the month of November and was only aware of her medication order Acetaminophen-Codeine Oral tablet 300-30 MG take 2 tablets by mouth and was unsure why she would only receive 1 tablet at times.Interview on 12/31/25 at 1:32 PM with MA A revealed only nurses were to administer narcotic medication as needed to residents. She stated nursing staff were trained to perform the 3 checks, confirming the medication label matches the physician order when pulling medications. They stated 3 checks including confirming the name of resident, medication, dosage, time, and how many tablets, before, when, and after pulling medication. She stated nursing staff were trained to document on the EMAR and Narcotic Count Sheet when pulling the medication. MA A stated the nurse pulling the medication was responsible for documenting and administering medication per physician order. She stated the potential risks of not documenting on the correct EMAR order for residents included harming the resident's health by over or underdosing. She stated the ADON and DON were responsible for monitoring Narcotic Count Sheets. MA A stated the facility did provide an in-service regarding the 5 rights for medication but was unable to recall the date.Interview on 12/31/25 at 2:34 PM with LVN B revealed only nurses were to administer narcotic medications. He stated nurses were to document on the EMAR and Narcotic Count Sheet immediately after pulling medication and confirming it was the correct medication. He stated it included name of resident, medication, dosage, and time. He stated nurses monitor Narcotic Count during shift change, 2 nurses count and confirm there were no discrepancies. LVN B stated the DON monitored the Narcotic Count Sheets but was unsure how often. LVN B stated the risk for the resident included double dosing the resident.Interview on 12/31/25 at 3:14 PM with the DON revealed nursing staff were responsible for documenting on the EMAR and Narcotic Count sheet as they pull medications. She stated the purpose of accurately documenting the correct EMAR was to ensure the resident was being treated accurately, according to the physician's orders. She stated the narcotic count would trigger during shift change, which was completed by 2 nurses. She stated as the DON, she monitored monthly, or if notified by nursing staff of discrepancies.Record review of the facility's policy Controlled Medications-Administration dated 2025, read in part: when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 154 beds, failed to employ a qualified social worker on a full-time basis since 08/14/2025. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Record review of the facility census dated 09/24/2025 revealed that the facility had a capacity of 154 beds and had a census of fifty-four. During an interview and record review on 09/25/25 at 12:49 PM with the Administrator revealed, the Social Worker had resigned a month ago. He said they hired a social worker on 08/29/25, and she only worked for about a week and resigned for personal reasons. He said they just hired a social worker to start on 10/07/25. He said their company had multiple facilities in town and he had not reached out for help with social services at his facility. He said the potential risk of not having a social worker could result in resident's psychosocial needs, grievances and coordination of resident discharges not being addressed. Record review of the facility's undated policy Social Services revealed, the following is a non-exhaustive criterion that related to the job of a Social Worker, and it is consistent with the business needs of the facility. Knowledge Base: A bachelor's degree in social work or secondary education in social services and certification as a social worker may be substituted as appropriate. Social Worker Responsibilities: Purpose: To outline the role of the social worker in discharge planning to ensure safe transitions of care, regulatory compliance, and adequate coordination with residents, families, and the interdisciplinary team. Scope: This procedure applies to social workers managing the psychosocial and coordination aspects of resident discharges. Other duties as assigned.

Based on interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for one (Resident #1) of four resident reviewed for grievance resolution. The facility did not issue a written decision to Resident #2 who filed a grievance on 09/05/25 and 09/09/25. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included:Review of the admission Record dated 09/24/25, revealed Resident #2 was admitted on [DATE] from home. Review of History & Physical dated 08/08/25 revealed Resident #2 was a [AGE] year-old female GAD (severe, ongoing anxiety that interferes with daily activities), bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), DM2 (a chronic metabolic disorder characterized by high blood sugar levels due to insulin deficiency), HTN (is a condition where the force of blood flowing through the arteries is consistently too high), CHF (a condition where the heart muscle weakens and cannot pump blood effectively), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs). Alert and oriented to person and place. Review of admission Minimum Date Set (MDS) dated [DATE] for Resident #2, revealed the resident was admitted from home, BIMS Summary Score 15 (cognitively intact). Active Diagnoses - Diabetes Mellitus, Anxiety Disorder, Lupus, Heart Failure, Hypertension; Medications - insulin injections, antipsychotic, antianxiety, opioid, anticonvulsant; oxygen. The resident participated in the assessment. The resident's overall goal during the assessment process - remain in the facility. Is active discharge planning already occurring for the resident to return to the community? No. Review of Care Plan initiated 08/29/25 revealed: The resident had a history of making false accusations. Interventions: Social Services/Administrator to interview resident after each accusation. Date Initiated: 09/22/2025.The resident has potential to demonstrate verbally abusive behaviors Ineffective coping skills, Mental /Emotional illness Date Initiated: 09/22/2025 Interventions: Notify the charge nurse of any abusive behaviors. Psychiatric/Psychogeriatric consult as indicated.Record review of the facility's Grievance Binder revealed, July 2025, 7 of 16 Grievances/Concerns reported by residents did not have documentation of resolutions; August 2025, 5 of 9 Grievances/Concerns reported by residents did not have documentation of resolutions. September 2025, 5 of 9 Grievances/Concerns reported by residents did not have documentation of resolutions. Review of an undated Grievance/Complaint Report revealed, This form shall be utilized to provide written documentation of a grievance or concern expressed by a resident and/or resident representative and to record the facility follow-up action taken and resolution. Receipt of Grievance/Complaint. Concern From: [Resident #2] Date received: Was left blank. The Form initiated by [LVN B] Charge Nurse. Documentation of Grievance/Complaint related to: Maintenance. Description: Waiting since 09/05/25, Friday, for TV to be reprogrammed/fixed. Can only watch Spanish channels, she is upset, due to maintenance giving his word would be done by time Football game is on. Person (s)/Departments Contacted: Maintenance 09/05/25 and ADON 09/09/25. Summary/Findings was left blank. Recommendations/Actions Taken: TV is not compatible to any remotes. Pt. had talked to Admin about getting a new TV and need to call cable service. Pt. says TV is not the issue. Identify the method (s) used to notify the resident and/or resident representative of the resolution: The resolution was left blank. The Grievance/Concern form was signed by the Maintenance Director on 09/10/25. Review of an undated Grievance/Complaint Report for Resident #2 written by LVN ADON C revealed, Documentation of Grievance/Complaint related to: Activities Department. Description: Resident would like to participate in activities. However, they only speak Spanish language. Person (s)/Departments Contacted: Activities Director 09/09/25. Summary/Findings was left blank. Recommendations/Actions Taken: Was left blank. Resolution of Grievance/Complaint: Was left blank. Identify the method (s) used to notify the resident and/or resident representative of the resolution: Was left blank. Date of notification: 09/09/25. The Activities Director signed the form on 09/10/25. During an interview and record review on 09/25/25 at 9:56 AM, with Activities Director revealed she wrote a Grievance Report for Resident #2, regarding the resident's concern that activities were done in Spanish. She said she had a communication barrier, because she could only speak little English and the resident did not speak Spanish. She said she had explained to the resident, there were three other residents at the facility who only spoke English, and they attended activities. She said the resident wanted to know why all activities were done in Spanish. She said the nurse on the fourth floor had assisted her in translating and explaining to Resident #2 that the monthly activities are scheduled according to the special holidays celebrated on a particular month and in September they celebrated the independence of Mexico. She said Resident #2 showed no interest to associate with other English-speaking residents because they were not Jewish. She said they offered activities, and she refused. The Activities Director stated she had documented a note on the back of the grievance form. The note reflected resident is a little confused by their requests, she assumes that the problem is that the activities are mostly done in Spanish, it was explained to her that this is because almost all the residents speak Spanish but the group can still be included and it will be explained in English to her and to three other residents who only speak English and who do participate in activities but she doesn't want to. She doesn't want to do in-room activities because she wants to be private in her room, but she also doesn't want to go to the dining room with other residents. She says she likes chess and was offered to socialize with the people who speak English. She said yes, but she didn't want to be bothered. And she started talking about financial matters to be here in the building. I think she can't adapt and wants things done that are difficult to understand, not because of the language, but because of her needs. During an interview on 09/25/25 at 10:42 AM, with Maintenance Assistant revealed the televisions were not programmed to only see Spanish channels. He said they provided cable services to all the residents, and they had access to sixty-five channels. He said that he was not aware of any residents having issues with the TV channels. He said he had not assisted in resolving any concerns related to televisions. During an interview on 09/25/25 at 10:44 AM the Maintenance Director revealed he had been employed at the facility for five months. He said they did not have compatible remotes for Resident #2's TV, and she was only able to use subscription entertainment. He said he did not know the name of the contracted cable company and was waiting for the Administrator to provide him with the information for the cable company to come and check Resident #2's cable connection. He said, the Administrator gave a universal remote to Resident #2 that was when I found out there was no cable service in that room. He said Resident #2's television worked but only accessed Spanish channels. He said the resident informed him, she did not like to see Spanish channels, because she only speaks English. He said he had not documented a resolution on the Grievance form that he had signed on 09/10/25 because the Administrator was going to order new televisions and did not know if that had been done. He said he had not forgotten her, and the issue was the TV remotes were not working, and she could only get Spanish channels in the TV. He said the Administrator had said he was going to call the cable company to install cable in that room. During an interview on 09/25/25 at 12:20 PM, with the Administrator revealed he was aware Resident #2 did not have TV cable services and that her TV was only showing Spanish channels. He said he had placed an order for new televisions and was pending corporate approval. The state surveyor requested a copy of the invoice to purchase new televisions.During an interview on 09/25/25 at 1:00 PM with the DON revealed, the Administrator was managing the Grievances until they hired a new social worker. During an interview on 09/25/25 at 4:00 PM with the Administrator, he said he did not have an invoice for purchasing multiple televisions. He said the process they used to buy things such as televisions was to notify the Area director of Operations and they would forward the request to the corporate office. Review of the facility's policies and procedures on Grievances revised 11/02/2016, revealed the resident had the right to voice grievance to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievance the resident may have. Procedure: The grievance official of this facility is the administrator or their designee. The grievance official will: Oversee the grievance process; Receive and track grievances to their conclusion; Lead any necessary investigations by the facility; Issue written grievance decisions to the resident; Coordinate with state and federal agencies, as necessary. All written grievances decisions will include: The date the grievance was received. A summary statement of the resident's grievance. The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the residents' concerns. A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued.

Based on interview and record review the facility failed to provide to send a copy of notice to the Office of the State Long-Term Care Ombudsman at least 30 days prior to the discharge or as soon as possible for 1 (Resident #2) of two residents reviewed for facility-initiated discharges, in that: The facility failed to send a copy of the Discharge Notice at the same time notice was provided to Resident #2 on 09/03/25 to the Local Office of the State-Long Term Care Ombudsman. This failure could place residents at risk of not providing added protection to residents from being inappropriately transferred or discharged and provide residents with access to an advocate who can inform them of their options and rights. Findings included:Review of the admission Record dated 09/24/25, revealed Resident #2 was admitted on [DATE] from home. Review of History & Physical dated 08/08/25 revealed Resident #2 was a [AGE] year-old female GAD (Severe, ongoing anxiety that interferes with daily activities), bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), DM2 (a chronic metabolic disorder characterized by high blood sugar levels due to insulin deficiency), HTN (is a condition where the force of blood flowing through the arteries is consistently too high), CHF (a condition where the heart muscle weakens and cannot pump blood effectively), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs). Alert and oriented x 1-2. Review of admission Minimum Date Set (MDS) dated [DATE] for Resident #2 revealed the resident admitted from home, BIMS Summary Score 15 (cognitively intact). Active Diagnoses - Diabetes Mellitus, Anxiety Disorder, Lupus, Heart Failure, Hypertension; Medications - insulin injections, antipsychotic, antianxiety, opioid, anticonvulsant; oxygen. The resident participated in the assessment. The resident's overall goal during the assessment process - remain in the facility. Is active discharge planning already occurring for the resident to return to the community? No. Review of Care Plan initiated 08/29/25 revealed: Resident had a history of making false accusations. Interventions: Social Services/Administrator to interview the resident after each accusation. Date Initiated: 09/22/2025.The resident has potential to demonstrate verbally abusive behaviors Ineffective coping skills, Mental /Emotional illness Date Initiated: 09/22/2025 Interventions: Notify the charge nurse of any abusive behaviors. Psychiatric/Psychogeriatric consult as indicated.Resident to remain in facility long term as he/she requires 24-hour licensed nursing care Date Initiated: 09/22/2025. Review of a Notification of discharge date d 09/03/25 for Resident #2 revealed, This letter is written notification that the above resident, [Resident #2], will be discharged from the nursing facility effective thirty-one days from the receipt of this letter. This discharge is based on your failure, after reasonable and appropriate notice, to pay for services provided and your stay at the facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 09/09/25. [Resident #2] will be discharged to the following address. The choosing of resident with assistance from discharge team. You have the right to appeal this decision as outlined in the Health and Human Services Commission's Fair Hearings, Fraud and Civil Rights Handbook. You may also contact the regional representative of the Office of the State Long Term Care Ombudsman, HHSC. A copy of this letter has been sent to the local Ombudsman. You may also contact the Texas Long Term Care Ombudsman toll-free at (800) [PHONE NUMBER]. Resident #2 and the facility's Administrator signed the document on 09/03/25. During a telephone interview on 09/24/25 at 10:38 PM, the Local Ombudsman revealed he had visited Resident #2 09/23/25 and she had not mentioned anything about being given discharge notice. He said she had called him two weeks ago to discuss room rates. He said that as far as he knew the resident had not been given 30-day notice. He said the resident did not want to be discharged . During an interview on 09/24/25 at 11:42 AM with the Administrator, he said he had issued Resident #2 a Discharge Notice on 09/03/25, because she had not qualified financially for Medicaid and did not have sufficient resources to pay the rate for a private room. He said that he had informed the resident that if she chose to have a private room, she had to pay the monthly rate for a private room or she would be given a discharge notice, according to facility's policy on discharges for non-payment.During an interview on 09/24/25 at 1:59 PM, the Administrator revealed he had explained to Resident #2 why she had not qualified financially for Medicaid. He said the resident paid for a semi-private room and did not want to have a roommate because she had PTSD. He said he had explained to the resident, she would have to pay the monthly rate for a private room, since she did not want to have a roommate. He said the resident could not afford to pay the monthly rate for a private room. He said he had given her a discharge notice on 09/03.25. He said he had emailed a copy of the Discharge Notice to the Ombudsman. The state surveyor requested a copy of the email sent to the Ombudsman notifying him of the Resident #2's discharge notice. During an interview on 09/25/25 at 6:06 PM with the Administrator revealed, he had not sent the local Ombudsman a copy of Resident #2's Notification of Discharge Notice given to the Resident #2 on 09/03/25.Review of facility's Policy on Discharge or Transfer revised 02/12/2025 revealed, Facility Initiated Discharge - The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiative transfer or discharges: The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicate or Medicaid, for his or her stay at the facility. Notification of Discharges: For a facility-initiated non-emergent transfer or discharge of a resident, the facility will notify the resident and resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand with at least 30 days' notice prior to discharge. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 10 employees (LVN A) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete the annual employee misconduct registry and annual nurse aide registry screenings for LVN A. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included:Record review of facility's policy undated on Abuse/Neglect revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Procedure A. Screening: Criminal History and Background Checks All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined the applicable requirement of 483.13 (c) (1) (ii) (A) and (B). Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry by calling the Texas Department of Aging and Disability at [PHONE NUMBER]. The hiring authority will follow the automated response prompts to screen the employee for abuse, neglect, exploitation of a resident or misappropriation of a resident's or consumer's property. The hiring authority is responsible for training an individual to complete misconduct registry checks on every employee. The facility is required to provide a written statement to the employee upon hire about the Employee Misconduct Registry including a statement indicating that a person may not be employed if listed on the registry. During an interview and record review 09/25/25 at 5:15 PM with the HR Coordinator revealed the annual last EMR and NAR screening on LVN A was completed on 08/12/24. She said, This one was over-looked and was not completed until 9/10/2025. We will be changing the process of completing the annual EMR and NAR on each employee's anniversary date to ensure the annual EMR and NAR screenings are completed annually according to company policy and state requirements.

Based on interview and record review the facility failed to ensure that information is comprehensive, timely and properly signed for 1 of 9 residents (Resident #3) reviewed for accuracy and completeness. The facility failed to document when Resident #3 complained of pain to the right lower extremity. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in treatment, or a potential decline in the resident's health. Findings included: Record review of closed admission Record dated 07/31/25 for Resident #3, revealed Original admission Date: 03/07/25; re-admission date 03/21/25. Date of discharge: [DATE] at 12:30 PM to hospital. Review of Hospital Operative Record dated 04/17/25 for Resident #3 revealed, Date of Surgery: 04/17/25. Preoperative diagnosis: Right reverse obliquity intertrochanteric femur fracture (is a break in the upper part of the right thigh bone femur, specifically in the area between the two bony bumps) due to osteoporosis (is a condition where bones become weak and brittle, making them more likely to break). Procedure: Right femur cephalomedullary nail (is a specific surgical procedure to fix a broken thigh bone (femur) particularly fractures near the hip joint). Indication for procedure: this is a [AGE] year-old female with multiple comorbidities (when someone has two or more illnesses or diseases at the same time) including quite severe renal osteodystrophy (is a serious bone disease that develops as a complication of advanced, long-standing kidney disease), sustained a fall from standing 4 weeks ago. She was seen in my clinic 2 days ago where I diagnosed a right reverse obliquity intertrochanteric femur fracture. Review of Hospital X-ray report dated 02/23/25 for Resident #3 revealed, X-ray Right knee, Impression: No acute osseous (joint appears normal, no fracture or infection seen in x-ray) or joint centered abnormality. Review of Hospital X-ray report dated 02/23/25 for Resident #3 revealed, X-ray Right lower Leg, Impression: No acute osseous (joint appears normal, no fracture or infection seen in x-ray) or joint centered abnormality. Record review of Nursing Facility History & Physical dated 03/07/25 for Resident #3, revealed [AGE] year-old recently had a fall and injured her right leg and currently in brace. Patient was admitted due to worsening pain and swelling of right lower extremity. Plan: Admit to SNF, PT and OT to evaluate, Multimodal Pain and Fall precautions.Record review of admission MDS dated [DATE] for Resident #3, functional limitation in range of motion-impairment on one side to lower extremity, mobility device-wheelchair, partial/moderate assistance to roll left and right; sit to lying; lying to sitting on side of bed; dependent - with sit to stand, transfer from bed to chair; substantial/maximum assistance with toilet transfer/shower transfer; received PRN pain medication; pain presence - none; History of Falls in the last month prior to admission; no falls since admission. Record review of Care Plan for Resident #3, revealed uncontrolled pain. Date Initiated: 03/10/2025 Revision on 04/04/2025 revealed:- Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.- Monitor/document for probable cause of each pain episode. Remove/limit causes where possible.- Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain.- Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician.- Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.- Monitor/record/report to Nurse any sign/symptoms of non-verbal pain: Changes in breathing(noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out,silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy,constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face(sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Record review of Physician Order Summary dated 07/31/25 for Resident #3, revealed Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non pharmaceutical interventions prior to medicating if appropriate. Document and the progress note every shift for pain management. Ortho consult status post femur fracture. Portable x-ray of right knee for diagnosis of knee pain. PT to eval and treat as warranted. Orthopedic appointment on 04/15/25 at 9:00 AM. Acetaminophen-Codeine 300-30 mg give 1 tablet by mouth every 6 hours as needed for pain. Gabapentin 300 mg at bedtime for right thigh pain. Tylenol 325 mg give 650 mg by mouth every 4 hours as needed for pain. Record review of Nurse Practitioner Progress Note dated 03/07/25 for Resident #3, revealed encounter at 11:00 PM. History of Present Illness: Patient recently had a fall and injured her right leg and currently in brace. Patient was admitted due to worsening pain and swelling of right lower extremity. Plan: Admit to SNF, PT and OT to evaluate.Record review of Physical Therapy Evaluation dated 03/24/25 for Resident #3, revealed Diagnoses: Unsteadiness on feet, Muscle weakness, other abnormalities of gait and mobility, other lack of coordination. Current Past Medical History: [AGE] year-old female transferred to hospital from SNF on 03/18/25. Previous hospitalization due to progressive LE edema x 6 months and fall 2 days prior to admission. X-ray RLE negative for fracture per medical chart. R knee immobilizer for comfort. Pain Assessment at rest: Intensity = 0/10. She continued to report pain to right lower extremity from knee to ankle level. For nurse, X-rays have been done at this facility which were negative. Patient is very guarded to right lower extremity. Record review of Physical Therapy Treatment Note dated 04/01/25 written by, PTA for Resident #3 revealed, Right quad tightness (the muscles on the front of your right thigh feel stiff, tense, or shortened) noted. C/O pain with Right hip flexion (lifting your right thigh or knee towards your chest). Record review of Nurse Practitioner Progress Note dated 04/01/25 at 11:00 PM, for Resident #3, History of Present Illness: Patient recently had a fall and injured right leg and currently in brace. Patient was admitted due to worsening pain and swelling of right lower extremity. Plan: PT and OT, Multimodal Pain control strategies (using a combination of different methods to manage pain, rather than just one), Fall precautions. Record review of Nursing Progress Note dated 04/02/25 written by LVN A for Resident #3, revealed New Order after x-ray results. Reported to NP, continue Tramadol 50 mg po Q6H PRN pain. New order for Tylenol 650 mg po Q4H PRN pain. New order Gabapentin 300 mg po Q HS. Record review of Nurse Practitioner Progress Note dated 04/03/25 for Resident #3, revealed Interval History of Present Illness: Physical Therapy was reporting patient was having increased swelling to her lower extremities. X-ray does show femur fracture. No reports of falls or traumatic injuries while at SNF. Medical chart review performed to review acuity of her fracture given remote history of acute traumatic injuries. She will need to follow up with Ortho clinic. I requested nursing staff to assist patient with that follow up appointment. Physical examination: No acute distress. Assessment: RLE fracture. Plan: Follow up with Ortho clinic, requested nursing staff to assist patient with that follow up appointment. The case was discussed with attending physician, and he provided medical decision in this case. Physician documented on the progress note, I have reviewed the patient's information as well as discussed all the events and plans with NP, and agree with the findings, assessment, and recommendations. Record review of Nurse Practitioner Progress Note dated 04/10/25 at 11:00 PM, for Resident #3, revealed Interval History of Present Illness: No reports of falls or traumatic injuries as per nursing management this SNF admission. Pain is well controlled. Medical chart reviewed to investigate the acuity of RLE fracture. Pt. is pending follow up with Ortho clinic. Physical examination: No acute distress. Assessment: RLE fracture. Record review of Discharge summary dated [DATE] written by NP for Resident #3, revealed Date of admission: [DATE]. Date and time the encounter: 04/15/25 at 6:00 PM. Discharge Diagnosis: RLE fracture. History of Present Illness: Patient recently had a fall and injured her right leg and currently in brace. Patient was admitted due to worsening pain and swelling of right lower extremity. Discharge Disposition: She was sent to ER as per ortho for ongoing medical management. During an interview and record review on 08/04/25 at 2:00 PM, with LVN B on the 6-2 shift nurse assigned to Resident #3 revealed, he did not remember if the PTA had reported to him that Resident #3 was having pain to her right lower extremity with flexion. He said, I checked my notes, and I did not write a note on 04/01/25 for Resident #3. He said licensed staff had been trained to document in their nurse's notes when therapy staff reported to them if residents were having pain while receiving therapy services. During an interview and record review on 08/04/25 at 2:03 PM, with LVN A on the 2-10 pm shift assigned to Resident #3 revealed, resident had complained of pain to the right leg since admission to the nursing facility, and was administered Tylenol and Tramadol for pain and the pain medication was effective. He said he was not aware if resident had a history of fractures to the right leg. He said the resident had not sustained any falls in the nursing facility and did not know if resident had a history of falls at home. He said that he did not remember if the therapy staff had reported to him that the resident had complained of pain to the right leg when she was receiving physical therapy. He said that he did not remember if it was reported during the change of shift that the PTA had reported that resident was having pain to the right lower extremity. He said, I would have documented that in resident's nursing progress notes. During an interview on 08/04/25 at 2:41 PM, with PTA, revealed Resident #3 complained of Quad pain to the right leg. She said, Quad pain was pain in the large muscle at the front of the leg and thigh, extending from the hip and pelvis down to kneecap and below. She said, I reported this to one of the nurses, but I did not document that in my notes. She said that she had been trained to document in the therapy notes when she reported to the nurses when the residents were having pain. Telephone interview on 08/04/25 at 2:47 PM, with Physical Therapist revealed, Resident #3 was evaluated for Physical Therapy services on 03/24/25. She said the resident had sustained a fall at home prior to admission to the nursing facility. She said Resident #3 did not consistently complained of pain to the right lower leg. She said the resident had complained of pain on 04/01/25 with attempted movement to the right leg when therapy was provided. She said that she did not remember the pain level to the right leg. She said the PTA had not documented in her notes that she had notified the nurses that resident complained of pain to the right lower leg with flexion. She said they had been trained to document in their therapy notes when residents complained of pain and when they notified the nurses to ensure that this was communicated to the attending physician. During a second interview on 08/04/25 at 2:58 PM, with PTA, revealed that she had remembered reporting to one of the nurses, but could not remember who she had notified Resident #3 was having pain to the right leg with flexion. She said she had been trained to document the notification of pain to the nurses in her therapy notes. She said, I remember that I went upstairs to notify the nurse, I remember that it was a Friday, but I did not document the notification to the nurse in the therapy notes. During an interview and record review on 08/04/25 at 3:12 PM, with DON revealed, Resident #3 was having pain to the right hip with flexion. She said that therapy staff had been trained to document in their notes when the resident complained of pain and to immediately report the complain of pain to the nurses. She said that the resident was sent to an Orthopedic appointment on 04/15/25 and had been sent from the doctor's office to the ER at UMC. She said the resident had sustained a pathological fracture due to osteoporosis prior to admission to the nursing facility and it was a chronic and not an acute fracture. She said that LVN B had documented resident's level pain was at 4 out of 10, on 04/02/25. The DON confirmed that the facility did not have any documentation in the nurse's notes progress notes that the therapy staff had reported to the nurse that the resident was having pain with flexion to the right leg. She confirmed that the therapy staff, had not documented in their therapy notes that PTA had notified the nurse on 04/01/25 when the resident complained of pain with flexion to the right leg. She said that LVN B and LVN A had not documented in the nursing progress notes that the PTA had reported to them on 04/01/25 that Resident #3 was complaining of pain to the right lower extremity. She said licensed staff and therapy staff had been trained to document notification of pain in the progress notes. During an interview and record review on 08/04/25 at 2:53 PM, with LVN ADON, revealed he had completed the Weekly-Nursing Summary dated 04/01/25 and had documented Resident #3 had pain level of 4.4, and pain intensity was mild. He said that he had been trained to immediately notify the nurse when the resident's complained of pain. He said, I did not document in the progress notes, when I notified the nurse that Resident #3 was having pain to the right leg when I completed the Weekly Nursing Summary on 04/01/25. He said failure to notify the nurse, when a resident complained of pain could result in the pain getting worse. Record review of the facility provided Documentation policy, revised May 2015, read in part Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets . Goal .the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #2) reviewed for abuse. -The Facility Administrator failed to report a suspected crime to local law enforcement and the State Survey Agency, resulting in failure to protect residents from further potential criminal activity by an alleged perpetrator when Resident #1 reported sexual abuse by CNA O to staff in January 2025. An Immediate Jeopardy (IJ) situation was identified on 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse, and emotional distress. Findings include: Record review of Resident #1's Admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers, and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E learned Resident #1 reported the allegation to CMA M, and she then reported it to LVN F. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. ADON E said the Administrator told him she was out of the building, but when she came back, she would follow-up on the allegation. ADON E said he had been trained to report allegations of abuse/neglect/exploitation to the Administrator immediately. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said an incident occurred 2 to 3 days before. CMA M said Resident #1 said while CNA O was assisting him to shower, CNA O touched Resident #1 inappropriately on his backside. CMA M said Resident #1 did not complain of any pain at the time. CMA M said she told Resident #1 she would report it to the nurse, and the nurse would talk with him. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. CMA M said she heard no other complaints from any other residents regarding CNA O. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for [AGE] years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Appropriate notification to state and home office will be the responsibility of the administrator and per policy .Reporting: Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19; a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. - The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. - The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact number s for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made. Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Residents #1) reviewed for abuse. The facility failed to ensure residents right to be free from abuse when Resident #1 reported sexual abuse by CNA O to staff in January 2025 and the alleged perpetrator was not suspended, the allegation was not investigated, and the facility did not report the suspected crime to local law enforcement and the State Agency, resulting in failure to protect residents from further potential criminal activity by an alleged perpetrator. An Immediate Jeopardy (IJ) situation was identified on 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for further abuse, physical harm, psychosocial harm, trauma, unrecognized abuse, and emotional distress. Findings include: Record review of Resident #1's Admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said Resident #1 did not say which staff at the time. LVN F said Resident #1 said he did not want any males working with him. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said ADON E told him to make sure no males went into the room with Resident #1. LVN F said he then informed the staff on the floor about the instructions ADON E told him regarding no males in Resident #1's room. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said Resident #1 did not complain about any discomfort or injury. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E learned Resident #1 reported the allegation to CMA M, and she then reported it to LVN F. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. ADON E said the Administrator told him she was out of the building, but when she came back, she would follow-up on the allegation. ADON E said he did not speak with Resident #1 and figured the Administrator would do what needed to be done such as report and investigate. ADON E said he had been trained to report allegations of abuse/neglect/exploitation to the Administrator immediately. The ADON E said he instructed LVN F no males were allowed in Resident #1's room. ADON E said Resident #1 was informed and he did not have a problem with any other male CNAs, and only CNA O. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said nothing was brought up in the morning meeting the following day. ADON E said he did not document any of the events anywhere . ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said an incident occurred 2 to 3 days before. CMA M said Resident #1 said while CNA O was assisting him to shower, CNA O touched Resident #1 inappropriately on his backside. CMA M said Resident #1 did not complain of any pain at the time. CMA M said she told Resident #1 she would report it to the nurse, and the nurse would talk with him. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. CMA M said she heard no other complaints from any other residents regarding CNA O. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for [AGE] years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff . Prevention ., The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy .Reporting, Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19; a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist.the employee(s) will immediately be suspended pending an investigation .Protection .The facility will take necessary measures to protect residents This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO , and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. - The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. - The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made . Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 7 residents (Residents #1) reviewed for abuse/neglect. 1. The facility failed to investigate an allegation of sexual abuse of Resident #1. 2. The facility failed to prevent further potential abuse and mistreatment by allowing the alleged perpetrator to remain in the facility and to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress. The findings include: Record review of Resident #1's Admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said Resident #1 did not say which staff at the time. LVN F said Resident #1 said he did not want any males working with him. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said ADON E told him to make sure no males went into the room with Resident #1. LVN F said he then informed the staff on the floor about the instructions ADON E told him regarding no males in Resident #1's room. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said Resident #1 did not complain about any discomfort or injury. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers, and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. The ADON E said he instructed LVN F no males were allowed in Resident #1's room. ADON E said Resident #1 was informed and he did not have a problem with any other male CNAs, and only CNA O. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said CNA O touched him inappropriately on his backside. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for [AGE] years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. - The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. - The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made. Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. The IJ was removed on [DATE], but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. This failure could place residents at risk for diminished quality of care, untreated medical issues, and death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of dementia and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive was severely impaired. Record review of Resident #1's SBAR note dated [DATE] revealed a respiratory change with oxygen saturations of ,d+[DATE]% on room air. Respiratory change was shortness of breath on exertion only and upper lung fields with wheezing when auscultated, diminished to bilateral bases. Chest x-ray results on [DATE] were right lower lobe infiltrate seen with possible right pleural effusion, bilateral pulmonary vascular congestion with mild cardiomegaly. Medication history of Lasix daily by mouth. Primary diagnoses were COPD and dementia. NP was notified at [DATE] at 4:50 pm. New orders provided by NP were to increase Lasix to 60 mg by mouth for 5 days then resume current dosing, ipratropium nebulizer 0.5 mg inhaler as needed every 4 hours, and robitussin mucus and chest as needed by mouth for cough. Record review of Resident #1's chest x-ray results dated [DATE] revealed findings of right lower lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen ,d+[DATE]% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of ,d+[DATE] /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on ,d+[DATE] /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday ,d+[DATE] shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday ,d+[DATE] shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday ,d+[DATE] pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works ,d+[DATE] shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions.

Based on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) residents reviewed for change in condition. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. The IJ was removed on [DATE], but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. This failure placed Residents at risk of serious decrease in health related to delayed treatment. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of dementia and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive was severely impaired. Record review of Resident #1's SBAR note dated [DATE] revealed a respiratory change with oxygen saturations of ,d+[DATE]% on room air. Respiratory change was shortness of breath on exertion only and upper lung fields with wheezing when auscultated, diminished to bilateral bases. Chest x-ray results on [DATE] were right lower lobe infiltrate seen with possible right pleural effusion, bilateral pulmonary vascular congestion with mild cardiomegaly. Medication history of Lasix daily by mouth. Primary diagnoses were COPD and dementia. NP was notified at [DATE] at 4:50 pm. New orders provided by NP were to increase Lasix to 60 mg by mouth for 5 days then resume current dosing, ipratropium nebulizer 0.5 mg inhaler as needed every 4 hours, and robitussin mucus and chest as needed by mouth for cough. Record review of Resident #1's chest x-ray results dated [DATE] revealed findings of right lower lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen ,d+[DATE]% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of ,d+[DATE] /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on ,d+[DATE] /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday ,d+[DATE] shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday ,d+[DATE] shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday ,d+[DATE] pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works ,d+[DATE] shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accident and supervision. Resident # 1 had a history of [REDACTED]. Resident #1 was exhibiting on-going behavioral symptoms and frequently removed or turn off the bed/tab alarms which resulted in a fall with injuries. This failure could place 8 residents who had bed/tab alarms on the third floor at risk of falls and serious injury. Findings include: Closed record review of the Resident Face Sheet dated 04/26/17 documented resident #1 was a [AGE] year old male initially admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented in part: Resident understood and understand others, adequate vision, Brief Review of Mental Status (BIMS) summary score 3 (severely impaired), required extensive assistance of one person with transfers, dressing, toileting and grooming, limited assistance of one person with bed mobility, and locomotion in room and off the unit, total assistance of one person with bathing, no history of falls, and no behaviors. Review of the care plan initiated on 12/09/16 for resident #1 documented in part: The resident has the potential for falls related to imbalance. Goal-The resident will have less falls during the next 90 days. Interventions-Alarm in bed due to safety awareness. Alarm when in chair due to poor safety awareness. Fall 12/12/16. Anticipate and meet the resident's needs. Fall Risk Screening upon admission and quarterly to identify risk factors. Low bed. Review of the Fall Risk assessment dated [DATE] for resident #1 documented in part: Type-Reentry. Reason for assessment recent falls. Intermittent confusion, chair bound-requires assistance with elimination, 1-2 falls in past 3 months, balance problem and standing; balance problem while walking. Review of the Fall Risk Evaluation dated 12/13/16 for resident #1 documented in part: Score 15 Moderate Risk for falls. Incontinent of bowel & bladder, no behaviors in the last 7 days, unable to independently come to a standing position, exhibits loss of balance while standing, requires hands-on assistance to move from place to place. Interventions-low bed and therapy for strengthening, anticipate needs, and alarm when in bed or up in chair due to poor safety awareness. Review of Fall Risk Evaluation dated 12/09/16 for resident #1 documented in part: Score 13 Moderate Risk for falls. New Admission. No history of falls. Frequently incontinent of bowel and bladder. No behaviors exhibited in last 7 days. Confined to a chair and oriented. Interventions: low bed, therapy for strengthening. Anticipate and meet needs. Review of the Behavior/Mood Charting dated 2/22/17 for resident #1 documented in part: Behavior/Mood noted at all times. Behavior-Wandered. Mood-Crying/tearfulness noted. Interventions: conversation, offered snacks, reassured, and reoriented. Response-accepted. Outcome-improved. Review of the Progress Nurses Notes dated 12/25/16 through 04/07/17 documented in part: 12/11/17 Removes clothing and brief. 12/12/16 Removes clothing and brief. Attempts to get out of bed without assist. At 3:25 PM, resident was in his wheelchair in the dining room when he stood up unassisted and fell landing on his left side. 12/13/16 Refused night medications. 12/24/16 Resident was propelling himself in wheelchair. Resident was getting up from wheelchair and fell on left side. Doctor notified of incident. 12/25/16 Resident takes his clothes and throws on the floor. 2/03/17 Resident was transferred from the 4th floor to the 3rd floor. Resident to have chair alarm and bed alarm with floor mat. 2/15/17 Resident was aggressive today towards staff, he was re-directed, did not feel like participating in any table games. 3/02/17 Resident was observed walking in the hallway and was re-directed back to bed. After resident was returned to bed he attempted to get back up and when CNA E instructed him not to, he swung at her with a closed fist. Resident was informed that type of behavior was unacceptable and reportable to facility administrator. 3/08/17 Aggressive at times. Review of the Incident Report dated 3/31/17 at 11:30 PM, for resident #1 documented in part: Certified Nurse Aide (CNA) was walking down the hall and noted resident #1 was lying on the floor in the dining room. Denies pain. Oriented x1. No injuries noted. Tab alarm was not sounding. Resident has a history of removing alarm from clothing. Resident stated that he wanted to walk. Review of the Incident Report dated 4/7/17 at 1:54 AM, for resident #1 documented in part: Incident Description: Resident was found on the floor conscious but bleeding to right side of his head on the temporal area. Mobility: Wheelchair bound. Predisposing Physiological Factors: Confuse, Incontinent, and Gait Imbalance. Predisposing Situation Factors: Ambulating without assistance. Notes: 4/07/17 On-call Physician gave order to send the resident to the ER (emergency room ) for CT (computerize tomography) scan of the head. Review of the Progress Nurses Notes dated 04/07/17 documented resident #1 was found on the floor in his room at 12:15 PM. Resident was responsive and complained of pain to right side of head. Noted laceration to the right temporal area which was bleeding. Neuro-check done and right eye was sluggish to respond. Physician on call gave orders to send resident to the hospital for a CT of the head. Resident transferred by ambulance at 1:45 AM. Review of the Hospital History & Physical dated 4/07/17 documented in part: Chief complaint: Same level fall. admitted for isolated traumatic brain injury, not on blood thinners after same level fall at nursing home without change in mental status. The fall was not witnessed. He was found lying on the floor with a small bruise and some blood. He had no known loss of consciousness. His baseline is Dementia. CT of head and CT of spine was performed and this showed a subdural hematoma and cortical contusion. He is disoriented to place and times and stated he remembers falling but tells something about a fence and, clearly, is unable to give details. Review of the Hospital Consultation Report dated 04/07/17 for resident #1 documented in part: A [AGE] year old gentleman brought to the emergency room from the Nursing Home status [REDACTED]. Despite being on fall precautions in the nursing home, he got up, walked and fell . Patient sustain superficial injuries to right periorbital. Head CT with evidence of right hemispheric contusion and very small subdural bleed. Assessment: Right small subdural hematoma. Cognitive Function: Impaired Cognition. Central Nervous System Agents: Lorazepam 2 mg (milligrams) IV (intravenous) every four hours as needed, Haldol 10 mg IV x one time and Haldol 5 mg every 6 hours as needed. Review of the Hospital Operative Report dated 04/09/17 for resident #1 documented in part: The patient is a pleasant [AGE] year old male who presented after head trauma and imaging demonstrated increasing subdural hematoma. Patient had mental status changes, disorientation and weakness. Patient had a Right Craniotomy for subdural hematoma. Telephone interview on 4/26/17 at 10:01 PM, Certified Nurse Aide (CNA) G said, I remember that on that night on 4/07/17 the roommate for resident #1 pulled the call light for help in room 322-A. When I entered the room, I found resident #1 lying on the floor by the bathroom bleeding from the right eyebrow. He would not answer questions when I talked to him. I also noted that the bed/tab alarms were not ringing when I got to the room. I yelled out for CNA E to come to help me. She was next door in room 320 caring for another resident. When CNA E came to resident #1's room and saw the resident on the floor she immediately went to get the nurse on duty to come and check the resident. CNA G reported resident #1 was confused, and required moderate to extensive assistance with activities of daily living. CNA G said, Resident #1 would turn off the bed/tab alarms or would remove the tab alarm. On the day of the incident on 4/07/17 resident #1 was very restless that night. When we put him back to bed on that day I noted that resident #1 had turned the bed alarm off and the tab alarm was on top of the bed attached to the hospital gown. On 4/07/17 there were only two CNAs on the unit instead of 3 CNAs. When we only have 2 CNAS, we cannot make rounds every two hours. We have multiple resident that have bed/tab alarms on the unit and if the residents are restless and removing alarms they need to be checked more often. That night we had four residents that were very restless, constantly removing the bed alarms, and attempting to get out of bed so we were rushing from room to room doing the best that we could to care for the residents. CNA G reported that on 4/07/17 initial rounds were started at 10:00 PM. CNA G said, I remember helping CNA E change resident #1 on the initial rounds because he was wet. I do not recall the time. I do remember seeing that the bed and tab alarms were in place and were turned on. No one reported if resident #1 had been restless on the evening shift on 4/07/17. CNA G reported that they have been trained to immediately report to the nurse on duty when the residents have behaviors or are removing the alarms. Telephone interview on 4/26/17 at 9:12 PM, with CNA E reported that she had been assigned to resident #1 on 4/07/17. CNA E said, On the initial round at 10:00 PM, we check all of the residents that have bed alarm to ensure that alarms are in place and provide incontinent care as needed. At approximately 12 midnight on 4/07/17 we changed resident #1 because he was wet. CNA E reported that resident #1 frequently turned off the bed alarm, removed or turned off the tab alarm. CNA E said, We had been trained to report to the nurse on duty ever time that residents removed or turned off the alarms. So the nurses were aware that Resident #1 would frequently turned off the bed alarm or would remove the tab alarm when he took off the gown and got out of bed. He had wounds on both heels and had unsteady gait. CNA E reported that they usually had 3 CNAs on the night shift and one nurse. On the day of the incident on 4/07/17 we only had 2 CNAs and the nurse. That night we had 4 residents on the unit that were very restless, removing bed/tab alarms and attempting to get out of bed. The nurse was helping us as much as she could with these residents. We were rushing and trying to check the residents as fast as we could. I was in the room next door to resident's #1 rooms providing care to another resident when I heard CNA G call out my name. I rushed to finish caring for the other resident and went to see what was going on. When I went to resident #1's room, I noted that he was lying on the floor close to the bathroom and immediately went to get the nurse. The resident's eyes were closed and did not respond. When the nurse checked the resident he was able to answer simple questions. He had a cut on one of the eye brows. After the nurse assessed the resident the three of us picked him up and put him in bed. At that time we noted that resident #1 had turned off the bed alarm and the Tab alarm was on top of the bed attached to the hospital gown. CNA E reported that resident #1 was confused, transferred with moderate assistance of one person, able to stand and bear weight, incontinent of bowel and bladder, used disposable briefs and occasionally would be awake at night. CNA E reported that they had been trained to immediately report behaviors or if the resident remove or turn off alarms to the nurse on duty. Telephone interview on 4/26/17 at 9:10 PM, Licensed Vocational Nurse (LVN) F reported one of the CNAs had found resident #1 lying on the floor on 4/07/17 by the bathroom close to his roommate's bed. LVN F said, Resident #1 said he went to the bathroom. He was alert, oriented x 2, and answered simple questions. LVN F reported that resident #1 frequently removed the bed/tab alarms. LVN F said, CNA E reported that she had just left the room when they finished changing the resident because he was wet. I saw him last at approximately 11:00 or 11:15 PM, he was lying in bed, and he was restless and attempting to get up. He is very impulsive and is constantly moving in bed. He frequently often removes the bed/tab alarms. I can't say for certain if anyone had notified the physician about the resident being impulsive or that he frequently removed or turned off the bed/tab alarms. I called the on-call physician on 4/07/17 to report the fall and he gave orders to send the resident to the hospital for a CT of the head. I don't know why, but on that day we only had 2 CNAs instead of three. Two CNAs and one nurse cannot care for the residents especially when we have 4 residents with the same behaviors as resident #1. The CNAs do not have time to make rounds every two hours when we only have two CNAs, so they prioritize to get things done the best they can. I remember reporting to Assistant Director of Nurses (ADON) D that we only had two CNAs on duty on 4/07/17. LVN E reported that they have been trained to report behavioral symptoms to the physician and to document behaviors in the Progress Nurses Notes. In an interview on 5/08/17 at 2:55 PM, Licensed Vocational Nurse (LVN) A reported that he had been assigned to resident #1 on 3/31/17 on the evening shift when he was found on the floor in the dining room. LVN A said, I notified the physician of the fall. I did not report to the physician that the resident was impulsive, frequently stood up and walked without assistance, or that the resident was able to turn off the bed alarm or remove the tab alarm when sitting in the wheelchair. We would try to keep him within visual range and we would re-attach the tab alarms and turn the alarms back on as needed when resident # 1 turned the alarms off. LVN A reported that they had been trained to report behavioral symptoms to the physician and to document behaviors in the resident's clinical record. In an interview on 4/26/17 at 2:56 PM, LVN C reported she had worked on the morning and evening shift on 4/06/17 and had been assigned to resident #1. LVN C reported that resident #1 was confused, chair bound, was able to stand up and take a few steps without assistance. LVN C said, I don't know if resident #1 had a history of [REDACTED]. At times he would stand up without assistance and had unsteady gait. We find out if a resident is at risk for falls when we get report upon admission or during report at the change of shift. I do not remember if resident #1 had an order for [REDACTED]. We tried to keep resident #1 within visual range as we did our work. LVN C reported that they had been trained to report behavioral symptoms to the physician and to document behaviors in the resident's clinical record. In an interview on 4/26/17 at 3:15 PM, with LVN B reported that she had been assigned to resident #1 on the morning and evening shift on 4/05/17. It was reported that resident #1 was confused, required moderate to extensive assistance with activities of daily living and was incontinent of bowel and bladder. LVN B said, He had just lost his wife and had exit seeking behavior. He would cry and say that he wanted to go home or to the casino. He could propel the wheelchair with his feet down the hall and into other resident rooms. He was impulsive, restless, kept standing up from the wheelchair or got out of bed and walked without assistance. He had unsteady gait and required frequent re-direction and supervision. He would also remove the tab alarm when sitting in the wheelchair or turn off the tab alarm when it went off. He also knew how to turn off the bed alarm. The nurses check the alarms to ensure they are working properly. We tried to keep him within visual range by the nurses station as much as we could. LVN B said, I don't remember if I reported the behaviors to the physician. He was sent to the hospital after he fell on [DATE] and did not come back. LVN B reported that they had been trained to report behavioral symptoms to the physician and to document behaviors in the resident's clinical record. In an interview and record review on 4/26/17 at 3:53 PM, with the Director of Nurses (DON) reported resident #1 was confuse, very impulsive, stood up from the wheelchair whenever he wanted to go to the bathroom. The DON said, It was reported that on the day of the incident on 4/07/17 on the night shift, the resident got out of bed to go to the bathroom and fell down when he was walking back to his bed. It was reported that the bed alarm was in place and was ringing. I do not know if the care plan documents that resident #1 would remove the tab alarm when sitting in his wheelchair or that he would turn off the bed alarm. Fall assessments are done on admission and on a Quarterly basis. I do not know if the nurses have documented resident #1 was impulsive and had behaviors. I do know that resident #1 had a history of [REDACTED]. Review of the care plan dated 12/09/16 for resident #1 did not document resident was impulsive or that he removed the tab alarm or turned off the bed/chair alarms. The DON said, That would be something, the nurses would have to care plan. The DON reported the nurses checked that alarms are used as ordered by the physician and should also check for placement. In an interview on 4/26/17 at 4:49 PM, Assistant Director of Nurses (ADON) D said, There were times when resident #1 constantly stood up from the bed or the wheelchair and walked without assistance. He had unsteady gait and had sores on the heels. He would hit the staff on the hands when they attempted to assist him and provide re-direction. I don't know if the behaviors were reported to the physician. We document the behavioral symptoms in the Progress Nurses Notes unless the resident is taking medications such as psychotropic medications then we document behaviors on the Behavior Tracking Sheets. I do not know if the nurses documented the behaviors in their progress nurses notes. ADON D reported that they had been trained to report behavioral symptoms to the physician and to document behaviors in the resident's clinical record. In an interview on 5/05/17 at 2:18 PM, CNA H reported resident #1 had exit seeking behavior, swearing/cussing at staff, and had episodes of impulsive behavior. CNA H said, He constantly stood up and walked without assistance, he had unsteady gait, removed the bed/chair alarms and he would push us away or hit us with his hands when we attempted to re-direct him or assist him to sit down. He would also frequently cry for no reason. He would do this at least 2 x a week. I reported this to the nurses on several occasions. CNA H reported they had been trained to report behaviors and/or when alarms are turned off or removed by the residents to the nurses. In an interview on 5/05/17 at 2:25 PM, CNA I reported resident #1 was impulsive and constantly stood up and ambulated without assistance, wandered into other resident rooms, swearing/cussing at staff when they attempted to re-direct, strike staff when care was provided, removed or turned off the bed/tab alarms, and cried for no apparent reason. CNA I said, I reported these behaviors to the nurse and I also reported to the nurses that resident #1 would turn off or removed the bed/tab alarms. Resident #1 had been having these behaviors since February when he was transferred from the fourth floor to the third floor. We have many residents with behaviors that have bed/chair alarms that require close supervision and re-direction. Review of the physician progress notes [REDACTED].#1 did not document physician was aware of behavioral symptoms. Review of the Physician order [REDACTED].#1 documented in part: Verify function and placement of bed and chair alarm every shift for fall prevention. Review of the facility's policy & procedure on Behavioral Assessment, Intervention and Monitoring revised March 2015 provided by the DON on 4/26/17 documented in part: Policy Statement - Behavioral symptoms will be managed appropriately. Resident will have minimal complications associated with the management of altered or impaired behavior. Assessment - The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity and frequency of behavioral symptoms. Any precipitating or relevant factors, or environmental triggers. Cause Identification - The interdisciplinary team will thoroughly evaluate new of changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: Emotional, psychiatric and/or psychological stressors, Functional, social or environment factors. Management - The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risks to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Review of the facility's policy & procedure on Falls and Fall Risk, Managing revised December 2007 provided by ADON J on 5/08/17 documented in part: Policy Statement - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation - The staff, with the input of the Attending Physician will identify appropriate interventions to reduce the risk for falls. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A list of residents dated 04/26/17 provided by the Assistant Director of Nurses (ADON) J documented 8 residents had bed/tab alarms on the third floor.

Based on the comprehensive assessment of a resident, the facility failed to ensure that 5 (Residents #4, #11, #15, #14 and #23) of 27 residents reviewed for measures to maintain skin integrity received care consistent with professional standards of practice to prevent and/or treat pressure injuries as evidenced by: A. Resident #4 developed an unstageable pressure injury to her right foot. B. Resident #15 had a stage 2 pressure injury on her right thigh, surgical wound on her right leg and a deep tissue injury on her right foot for which treatments were not performed at the facility until 2 weeks after she had been admitted . C. Resident #11 did not have weekly skin assessments for 6 weeks prior to the development of a deep tissue injury on her left heel and an unstageable pressure injury on her right heel. D. Residents #14 and #15 did not receive physician ordered weekly skin assessments. This failure placed 8 residents identified by the facility as having pressure injuries at risk of developing new pressure injuries, worsening pressure injuries and/or infections. The findings included: A. Resident #4 Review of undated face sheet documented Resident #4 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] documented: Section M - M0300 Current Number of Unhealed Pressure Ulcers = 1 Unstageable Pressure Ulcer Unstageable due to coverage of wound bed by slough and/or eschar M0700 Most Severe Tissue Type for any Pressure Ulcer = Eschar - black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Review of Care Plan Dated [DATE] documented Resident has a pressure area, continue antibiotic - Bactrim DS for 10 days, Cleanse open wounds with normal saline apply Santyl (a [MEDICATION NAME] agent) ointment cover with 4 X 4 and wrap with gauze roll ever. Bunny boots at all times. Observation at multiple times [DATE] until [DATE] revealed Resident #4 never had Bunny Boots on her feet or on her bed. Review of Braden Risk Assessment Scale dated [DATE] revealed a score of 15. At Risk Score 14 - 18 = Moderate Risk. In an interview on [DATE] at 1:40 PM Resident #4's son said Resident #4 came to the facility after wound surgery and the wound healed prior to moving to 2nd floor. Resident #4's son said he saw a small wound a couple of months ago and told nurses but no one took action and a few days ago it was larger so now they are trying to do something about it. He said it is a big problem that the staff never make assessments in advance they wait until something is big and then try to do something about it. He said the facility wants to send his mother to the wound care clinic (WCC) but he wants his mother evaluated by the physician who knows her and her history and not to start at a new physician. In an interview on [DATE] at 4:43 PM the Director of Nursing (DON) said she had only been working at the facility for 2 months and did not know about any issues with Resident #4. Review of Weekly Skin assessment dated [DATE], [DATE], [DATE], [DATE] and [DATE], completed by floor nurses, all documented skin intact. Review of the Weekly Pressure Ulcer Logs from [DATE] through [DATE] revealed Resident #4 had an initial entry on [DATE] for an unstageable pressure wound on the right foot measuring 2.0 cm by 3.0 cm covered with eschar. Review of Progress Notes documented: [DATE] - Certified Nursing Assistant (CNA) reported a new unstageable pressure ulcer on residents foot, cover wound with a [MEDICATION NAME] and will pass report to next nurse. [DATE] - Wound Care Nurse requested to evaluate. Upon wound evaluation noted: Right foot inner lateral aspect black dry eschar approximately. 2.0 X 3.0, mushy, painful, redness, warm to touch, skin closed. Right bunion lateral aspect of foot 1.0 X 1.0 dry scab. Son refused Wound Care Center. [DATE] - New order from physician for Wound Care Consult, Bactrim DS 1 by mouth twice a day for 10 days and X-Ray right foot. [DATE] - 2nd Wound Care Evaluation Open wound to right lateral inner site approximately 2.0 X 3.6 X 0.8. During wound bed evaluation felt a hard protrusion apparently a bone exposure. Wound bed was completely covered with a white powder substance from an unidentified source. New orders received from physician as follows : Cleanse open wound to right foot with normal saline, pat dry, apply Santyl ointment, [MEDICATION NAME], 4X4 and wrap with kerlix. Change daily. Son refused to send Resident to WCC. Also noted a hard white eschar approximately. 1.0 X 0.8. Review of Progress Notes dated [DATE] through [DATE] revealed no documentation of notification to physician who had treated and performed surgery on Resident #4's previous wound. B. Resident #15 Review of electronic medical records revealed Resident #15 was a [AGE] year old woman admitted on [DATE]. Review of the History and Physical dated [DATE], provided from the managed care provider (MCP), documented Resident #15 had [DIAGNOSES REDACTED]. Resident #15 was a participant in a Managed Care Program (MCP). Review of Resident #15's admission comprehensive assessment ((MDS) dated [DATE] revealed she had a BIMS score of 15 out of 15 (cognitively intact), was totally dependent on staff for most activities of daily living), had no pressure injuries or deep tissue injuries, had a surgical wound and was getting surgical wound care and triggered for the need for a care plan for pressure injuries. Review of the Care Plan dated [DATE] revealed Resident #15 had a potential for pressure injury development, but did not address a current pressure injury. The care plan did not include an intervention of weekly skin assessments. The care plan prepared by the Wound Care Nurse dated [DATE] for Resident #15's skin revealed the current skin concern was the surgical wound of the right thigh. The right foot pressure injury was not included in the care plan until [DATE]. Review of the Admit/Readmit Evaluation dated [DATE] documented C. Skin Integrity - Wound types present on admission, skin wound or ulcer, checked bruising/discoloration, skin tears/shearing and surgical incision/wound. The sites indicated were the right iliac crest (bruising), right thigh (blister) and right lateral (pressure) stage 1 (no site documented). Resident has abrasions to right side of her back. Review of the Braden Risk Assessment Scale dated [DATE] documented a score of 16 for Resident #15. According to the Scale a score of 14 - 18 represents a moderate risk of pressure injury. Review of Order Summary Report for date range [DATE] - [DATE] revealed orders to: a. ([DATE]) Weekly Skin Evaluation every day shift every Wed. b. ([DATE]) Weekly Skin Evaluation every evening shift every Wed. c. ([DATE]) treatment for [REDACTED]. Wound care on right lateral foot area deep tissue lesion: wash with soap and water and cover with protective dry dressing, change daily call if draining or progression of [MEDICAL CONDITION] appear. Review of Orders Note for Resident #15 dated [DATE] (faxed date was [DATE]) documented an order for [REDACTED]. (This was an order faxed by the Managed Care Provider but never received by the facility until [DATE] for the facility to provide wound care) Review of Skilled Documentation dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] through [DATE] documented Resident #15 has treatable wounds, Left leg surgical incision CDI (clean, dry, intact) (surgical wound on right leg). There was no mention of the deep tissue injury. Review of Weekly Skin Assessment documented assessments on [DATE]. There were no documented skin assessments for [DATE] and [DATE]. Review of Progress Notes from [DATE] through [DATE] documented: a. [DATE] - Admission Notes 7:42 PM - bruising noted to upper extremities, pressure dressing to coccyx to prevent pressure wound, blister to back of right thigh, dressing dry and intact. Pressure wound to right lateral side of foot. Wound care to evaluate sites. b. [DATE] - Resident was transported to the MCP (Managed Care Provider) this morning. Prior to leaving this facility a head to toe skin assessment was performed. No new skin impairments were noted. c. [DATE] - Spoke to treatment nurse (at the MCP) regarding wound to right lateral foot. Treatment nurse voices, The Dr. did not leave any new orders for right foot and will not be back until Monday and for the facility WCN (wound care nurse) to treat. WCN notified at 4:30 PM, will pass on report to charge nurse. d. [DATE] - Skin assessment from WCN with descriptions of wounds and measurements. (Resident had been in facility since [DATE]) Review of Skin Grid - Other Skin Problems, provided by the WCN on [DATE] documented the surgical wound on the right thigh was identified on [DATE]. There was no Skin Grid provided for the right foot. Review of the Weekly Pressure Ulcer Logs from [DATE] through [DATE] revealed Resident #15 was initially listed on the log dated [DATE]. Only the surgical wound was listed. The DTI (unstageable) wound was not listed. Observation on [DATE] at 11:09 AM, with the WCN, Resident #15 was seated in bed. She had a long leg immobilizer on her right leg. The WCN opened the immobilizer revealing a long surgical incision extending down her right leg from her lower thigh to mid-calf. The edges were well-approximated and there were still some steri-strips attached to her skin. On the resident's outside right foot was an area of eschar about 2 by 1 cm. Resident #15 denied pain. She said she went to the MCC as needed and thinks sometimes they did wound care. In an interview on [DATE] at 10:39 AM, the Wound Care Nurse (WCN) said the admitting nurse does the initial skin assessment on the residents and then call the WCN if there are any skin issues. The WCN said she was first informed of skin issues for Resident #15 on [DATE] (2 weeks after admission). The WCN assessed Resident #15 on [DATE] and the resident had a surgical wound on her right leg, an immobilizer on the right leg and a DTI (deep tissue injury) on the outside of her right foot. It had eschar measuring 4 cm by 1 cm by 0.1 cm. ( According to the National Pressure Ulcer Advisory Panel, www.npuap.org on [DATE], the presence of eschar makes this wound an unstageable pressure injury). When asked why Resident #15 was not listed on the weekly skin report dated [DATE], she said because the staff does not treat pressure injuries on the Managed Care Company's participants; their wounds are not tracked. The WCN said she only treats the participants wounds if an order is written for her to do so and she did not get an order to treat Resident #15's wounds until [DATE]. The WCN said she was only checking the surgical incision, although she was putting a dry dressing over the unstageable pressure injury on the right foot. The WCN said the nurse from the MCC said to just check the surgical incision and when the WCN asked about the unstageable pressure injury on the right foot the MCP nurse said to wait until the doctor orders the treatment. The WCN said she has been waiting since [DATE]. In an interview on [DATE] at 10:54 AM, LVN E said she called the MCP for orders for Resident #15's surgical wound. Both she and the Unit Manager called several times. She said she was not aware of the unstageable pressure injury. LVN E said she only received orders for the surgical wound on [DATE]. In an interview on [DATE] at 11:01 AM, Unit Manager (UM) F said she tried several times to get orders for Resident #15's wounds. No orders were sent until [DATE]. The WCN is supposed to see all new admissions. UM F said she did not tell the DON she was having problems getting orders from the MCP In an interview on [DATE] at 11:39 AM, the DON said the admitting nurse performs a complete skin assessment on admission. The WCN should see all new admissions. She can be informed of new admissions in the morning meeting or she can ask on each floor. The WCN should assess all new residents. The DON said there should be an order on the chart of the MCP residents that either they will go to the MCP for wound care or the facility will do the wound care. The nurse in charge needs to call for orders. Resident #11 Review of electronic medical records documented Resident #11 was an [AGE] year old woman admitted on [DATE]. Resident #11 was discharged to the hospital on [DATE] for a [MEDICAL CONDITION] (blood clot) and readmitted on [DATE]. The facility History and Physical dated [DATE] documented Resident #11's [DIAGNOSES REDACTED]. Review of Resident #11's quarterly MDS dated [DATE] documented she had severe cognitive impairment, was total dependent on 1 person for most of her activities of daily living such as transfer, dressing and hygiene and did not have any pressure injuries. Review of Resident #11's care plan dated since [DATE] stated she had potential for impairment of skin integrity related to diabetes mellitus. There were no interventions listed for weekly skin assessments or bunny boots to be worn at all times. There was no further care plan addressing Resident #11's skin until [DATE] when the deep tissue injury on the left heel and the unstageable pressure injury was found on her right heel. Review of Resident #11's Medication Review Report documented orders for weekly skin evaluations every evening shift every Thursday (dated [DATE]). Review of a Telephone Order dated [DATE] documented wound treatment to the left heel - protective dressing, skin prep, ABD (abdominal) pad, and wrap with Kerlix every Tuesday, Thursday and Saturday. Review of a Telephone Order dated [DATE] documented to discontinue treatment to the left heel as it had healed. Telephone Order dated [DATE] documented an order to apply skin prep to bilateral heels and cover with a 4X4, ABD pad and wrap with Kerlix Tuesday, Thursday and Saturday until healed. Review of Resident #11's Progress Notes from [DATE] through [DATE] revealed the following entries regarding skin assessments: a. [DATE] - Skin assessment performed, redness to inguinal area. b. [DATE] - Redness to left heel, notified incoming nurse to follow-up for wound care evaluation c. [DATE] - Noted left heel dry area, possible to open, Protective dressing applied. Pass on to wound care. d. [DATE] - CNA requested this nurse (WCN) to evaluate left foot. Description and measurements done. e. [DATE] - wound to left heel resolved. f. [DATE] - Charge nurse requested wound evaluation. Outer aspect of right heel purple discoloration 3.0 x 1.5 cm, painful to touch. Left outer aspect of foot reddish discoloration approximately 1.5 x ,[DATE], painful to touch. Apply skin prep to bilateral heels ad cover with 4x4s, ABD pad and wrap with Kerlix Tuesday, Thursday, Saturdays. g. [DATE] - Returned from hospital. Resident with DTI to right heel, left heel dry scab Review of the electronic weekly skin assessments provided by the facility revealed there were no skin assessments conducted on Resident #11 [DATE] through [DATE] (3 weeks), [DATE], [DATE] through [DATE] (6 weeks) (New pressure injuries identified on [DATE]) . Review of Resident #11's November MARs (Medication Administration Record) revealed there was no documentation weekly skin assessments were completed on [DATE], [DATE], [DATE] and [DATE]. Review of the Weekly Pressure Ulcer Logs from [DATE] through [DATE] revealed Resident #11's initial entry on the tracking device of [DATE] with deep tissue injury of the left and right heels. The right heel has eschar (which makes this an unstageable pressure injury) measuring 2.0 cm by 1.5 cm and the left heel measured 1.5 cm by 1.5 cm. Observation on [DATE] at 7:55 AM, with the WCN, revealed a ,[DATE] cm circular eschar on Resident #11's right outer heel. There was a 2 cm circular maroon area on her outer left heel that was mushy around the deep tissue injury. The WCN nurse said these wounds were acquired in the facility. Observation on [DATE] at 12:25 revealed Resident #11 was seated in her wheelchair with her bunny boots off of her feet. Licensed Vocational Nurse (LVN) K said she will not keep her boots on and continued to place then on her feet. LVN K said Resident #1 has Prevalon boots but refuses to wear them. The resident says the boots are bigger than her. In an interview on [DATE] at 3:20 PM, LVN K said the floor nurse is responsible to perform weekly skin assessments on residents. The skin assessment schedule is on the MAR (Medication Administration Record). The assessments are recorded in the computer on the weekly skin assessment. If a skin issue is found, the nurse tells the WCN and both nurses evaluate the resident. The WCN then documents the site, calls the doctor and provides treatment. Interview on [DATE] at 11:12 AM, Unit Manager (UM) F said the unit managers review the Medication Administration Records monthly. She said residents' schedules for weekly skin assessments was placed on the MAR showing the shift responsible and the day the assessment was to be done. After the skin assessment is completed, the nurse signs the MAR and documents the assessment on the computer on the weekly skin assessment. UM K said there was no steady 2 PM - 10 PM nurse and nurses from other floors help out. In a telephone interview on [DATE] at 1:58 PM, LVN M said skin assessments are performed on each resident once a week. The resident's skin assessment day is on the Medication Administration Record. LVN M said he was not aware of any place to document skin assessments. LVN M said he did not remember performing a skin assessment in November for Resident #11. LVN M worked on scheduled skin assessment days [DATE] and [DATE]. In an interview on [DATE] at 4:30 PM, the WCN said the floor nurses are responsible to complete the first skin assessment and the WCN reassess with 24 hours. Skin assessments are documented in the computer under weekly skin assessment. The WCN said LVN P called her to assess Resident #11's legs when they were found red and swollen. ([DATE]). That's when she saw the bilateral heel wounds. The WCN said Resident #11 spends most of her time in bed and refuses to wear bunny boots. The WCN said Resident #11 had a deep tissue injury to her left heel about 2 months ago but it healed. D. Resident #14 Review of the electronic medical records documented Resident #14 was a [AGE] year old man admitted on [DATE] and readmitted on [DATE]. Review of the History and Physical dated [DATE] documented Resident #14 had [DIAGNOSES REDACTED]. Review of the MARs documented Resident #14 had no documented weekly skin assessments in October or [DATE] (except for [DATE]). E. Resident #23 Review of closed medical records revealed Resident #23 was a [AGE] year old man who was admitted on [DATE] and died in the facility on [DATE]. Closed review of Resident #23's admission MDS dated [DATE] revealed he was severely cognitively impaired, was total dependent on staff for activities of daily living, did not have a pressure injury but was at risk, and triggered for the need for a care plan addressing pressure ulcers. Closed review of Resident #23's undated Clinical Physician Orders documented an order for [REDACTED]. Closed Review of Resident #23's Weekly Skin Assessments, Provided by the facility, revealed he did not have weekly skin assessments on [DATE] and [DATE] through [DATE]. Closed review of Resident #23's Progress Notes from [DATE] through [DATE] revealed on [DATE] his right heel had discoloration, was not open, area cleansed with NS (normal saline), pat dry, gauze and wrap with Kerlix In an interview on [DATE] at 11:40 AM, the Director of Nurses (DON) said the Wound Care Nurse and the unit managers are responsible to make sure each resident has a weekly skin assessment. The first head to toe assessment of a resident ' s skin is accomplished by the admitting nurse at the time of admission. Then the CNAs (Certified Nurse Aides) see the residents skin every other day when the resident is given a shower. If a patient complains of something hurting, the nurse will do a skin assessment and also weekly. The charge nurse is responsible for doing the weekly skin assessments with the unit managers following-up. The DON said she knows the assessments are being done on admission and if the resident complains, but she cannot guarantee 100% the weekly assessments are being performed. The DON said there was no process for monitoring that the nurses were doing their assessments but they have all received the policy and procedure and it is available to them on the floor. The Wound Care Nurse is responsible for tracking all wounds. She has a book, which the DON said she can go look at any time. In an interview on [DATE] at 9:02 AM, the Director of Education and Quality (DEQ) said the unit managers were responsible for monitoring that the nurses were completing the weekly skin assessments. The skin assessments are on the MARs and will pop-up on the computer if they are late being done. The nurses document their findings on the computer weekly skin assessment or on the progress notes. Even if a resident has a wound being treated by the Wound Care Nurse, the charge nurses are responsible for performing the weekly skin assessments on each resident. The Unit Managers need to audit the nurses to be sure the assessments were completed. Review of the facility policy Pressure Ulcer Risk Assessment revised [DATE] revealed Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Monitoring. If a new skin alteration is noted, initial a (pressure or non-pressure) form related to the type of alteration in skin. Proceed to care planning and interventions for the resident and their particular risk factors. Document the procedure. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The 8 residents identified with pressure injuries was obtained from the CMS 672 dated [DATE].

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for risk of elopement. Resident #1 who was at risk for elopement and had a wander guard, eloped from the facility without staff being aware. He was found by the local university Police Department 1.2 miles away from the facility. While Resident #1 was out of the facility he suffered a fall which caused a laceration that required stiches on his forehead and skin tears. An Immediate Jeopardy (IJ) was identified on 3/1/16. While the IJ was removed on 3/4/16 the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, isolated because the facility had not monitored for effectiveness. These facility failure could affect the 15 other residents who were identified as wanderers and place them at risk of leaving the facility without being seen by staff which could result in serious injury or death. Findings Included: Review of Resident #1 ' s face sheet dated 3/2/16 revealed he was an [AGE] year old male admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Review of the Elopement Evaluation dated 12/16/15 and 12/23/15 revealed Resident #1 was at risk to elope and should be placed on the Elopement risk protocol. Review of Elopments policy statement (12/2007) revealed the facility elopement protocol consisted of the following: If an employee discovers that a resident is missing front he facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass. if the resident was not authorized to leave, initiate a search of the building(s) and premises. If the resident is not located, notify the Administrator and the Director of Nursing Services, the residents legal representative (sponsor) the Attending physician, law enforcement officials, and (as necessary volunteer agencies d. Provide search teams with residents identification information e. Initiate an extensive search of the surrounding area. Review of the Wander guard Risk assessment dated [DATE] revealed Resident #1 was at moderate risk for wandering. Review of Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 3 (severely impaired). MDS document revelaed, Resident #1 required set up help only for locomotion on and off the unit, walking in room and in the corridor. Review of Resident #1 ' s Care Plan (undated) revealed the following: · The resident has high risk for wandering, (2/4/16) Interventions: educate resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage socialization, redirect resident as needed when resident is exhibiting exit seeking behaviors · Wander guard in place at all times (1/8/16) · Resident has potential impairment to skin integrity (12/29/15) Interventions: avoid scratching , follow facility protocols for treatment of [REDACTED].>· Resident has impaired cognitive function of impaired thought processes related to dementia (12/29/15) Interventions: monitor report to physician an changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others and mental status changes, face resident when speaking an make eye contact, resume any distractions-turn off TV, radio, close door etc. ensure the resident understands, use consistent sentences. Repeat information as needed., engage in simple, structured activities, provide instruction to resident using clear voice and simple sentences, repeat as needed, keep routine consistent and try to provide consistent care givers as much as possible. Review of Medication Administration Record (MAR) dated 2/2016 revealed patient to wear wander guard at all times, every shift for risk for elopement (1/11/2016). Review of MAR revealed wander guard was checked for placement by nursing staff from 2/1/16 to 2/24/16 at 6 am-2pm, 2-10pm, and 10-6 pm shifts. Review of the Nurses Notes dated 2/4/16 at 3:00 AM, documented by Licensed Vocational Nurse (LVN) A who worked on 2/4/16 10 pm to 6 am shift revealed: Resident was observed to be pacing the halls during beginning of shift and getting kind of aggressive towards other. He was observed attempting to leave from facility in elevators when Emergency Medical Services (EMS) took another other resident out approx. 11:30pm. LVN A then observed and redirected resident to room. At 11:45pm there was another resident transferring via EMS. However, Resident 1 was still in his room sitting in bed. After attending another resident, Resident #1 was no longer observed in room. LVN A was then told by staff that the local university police called @ 1230 am, they had found resident and that resident was sent out to the hospital due to fall. Emergency Medical Services (EMS) arrived and identified patient to be from this facility after previously seeing him on an EMS call and wander guard. Resident came back to facility around 0300 (3:00AM) with 3x1 gash to forehead which was sutured, skin tears to right elbow normal saline cleansed and covered, and another on right knee which was also cleansed with normal saline and covered. In an interview on 2/24/16 at 3:00 PM, LVN A stated He was saying he wanted to go home. He had tried to leave with EMS once, I had another EMS transport they left, and I saw Resident #1 sitting in his bed after they left. I went to answer the call bell and came back and he was gone. I should have told someone, an aide, to keep an eye on him at all times. I should have kept him within eye sight since he had already tried to leave once. I started looking for him when we did not find him I initiated the code green. LVN A stated staff got a call from the 2nd floor saying the University police had found him on the university campus. LVN A stated When EMS leaves they have to open both doors in the front entrance. They stay open a few minutes. We did not hear any alarms from the wander guard go off. LVN A stated EMS has the codes to get in and out of the building. No one goes down with them when they transport residents out. I don ' t know if the alarms will ring when EMS opens the doors. It was my mistake; I guess I should have been more vigilant with Resident #1. No one escorted EMS out; I guess they would not be noticing if a resident is behind them. LVN stated after this incident she was trained to escort any EMS personnel out of the building to ensure resident safety. Review of the local university Police Incident/Investigation Report dated 2/4/16, time 00:30 hrs. (12:30am) Revealed resident was found on 350 W. University Ave. El Paso TX. , parking lot/garage. On 3/1/16, MapQuest was utilized to calculate distance from the facility address to the address provided on the police report. The distance was 1.2 miles. Review of local weather report (http://www.accuweather.com/en/us/el-Paso-tx/ /February-weather/ 5) revealed the temperature for 2/4/16 was: High 49 degrees, and an overnight temperature of 24 degrees Fahrenheit. According to https://www.wunderground.com/history/airport/KELP/2016/2/3/DailyHistory.html?req_city=&req_state=&req_statename=&reqdb.zip=&reqdb.magic=&reqdb.wmo= the temperature on 2/3/16 at 11:51 p.m. was 25 degrees Fahrenheit, and on 2/4/16 at 12:51 a.m., 28.9 degrees Fahrenheit. Review of hospital records dated 2/4/16 revealed: patient present to the ED (Emergency Department) with head laceration wound evaluation status [REDACTED]. Head/Eyes 3 centimeter laceration to the right frontal area. Objective assessment: 3x1 laceration noted to frontal open to air. Do not touch the stitches or staples. In an interview on 2/23/16 at 4:10 PM, Resident #1 stated I don ' t remember leaving, let me think, can you tell me if I left? In an interview on 2/24/16 at 3:30 PM, Assistant Administrator of Nursing (ADON) B stated Resident #1 had been trying to get out. LVN A said that EMS had come to take a resident out. We don ' t know how he got out. He had the wander guard on the whole time, he came back from the hospital and he had it on. ADON A stated I did not ask if any staff went down with EMS when they left. I did not ask (during facility investigation) if anyone on the 2nd floor opened the door for EMS. EMS have the codes to get in and out of the facility. ADON B stated someone should have gone down with EMS and let them out of the facility. ADON was asked who was responsible for ensuring residents did not leave the facility when EMS transports residents at night; his response was we (facility) are responsible I guess they (EMS) should not have the codes. In an interview on 2/24/16 at 3:45 PM, Director of Nursing (DON) stated EMS have the codes to open the doors. The DON stated We have no idea how he got out of the facility, we don ' t know how it happened he might of used brute force, he cheated the system. We don ' t know how he did it. The DON stated EMS is not responsible for assuring residents do not leave the building, we should have been sending someone down, they (EMS) should have never had the code. In an interview on 3/1/16 at 9:30 AM, the Nursing Home Administrator (NHA) stated I can't assure how Resident #1 left the building or assure that staff was doing what they were supposed to. The NHA stated staff should have been escorting residents out of the building after hours. Review of the facility policy Wandering, Unsafe Resident dated (8/2014), revealed the following: -staff will assess at risk individuals for potentially correctable risk factors related to unsafe wandering. -If a resident is missing, the elopement/missing resident emergency procedure will be initiated: a. determine if resident is out on an authorized leave or pass b.if the resident was not on pass initiated a search of the bulling) and premises c. if the resident is not located, notify the administrator and director of nursing services, legal representative, attending physician, law enforcement officials and the necessary volunteer agencies -provide search teams with resident identification information -initiate extensive search of surrounding area An IJ was identified on 3/1/16 at 2:10 PM and the Nursing Facility Administrator was informed. In an observation on 3/1/16 at 4:00 PM, Resident #1 was observed to have 1:1 supervision. In an interview on 3/2/16 at 9:45 AM, Resident #1 ' s son stated, we placed Dad there because we needed help taking care of him. I don ' t feel comfortable knowing he left on their watch. I do think it ' s their fault, they told me the wander guard was going to be fool proof. My goal to place him there was to have people watching him because he can ' t take care of himself. I expected them to keep him safe; I thank God that he went towards the University, instead of the opposite direction towards Mesa St. If he would of walked just half a street to the left he would been in the University bar district, with lots of cars, its a main artery for the city, he could have gotten run over. It was cold that night too, there are all kinds of people in that area, someone could of hurt him. I am thankful that he only needed stiches. I stop and think, he could have broken his head open. The Plan of Removal was accepted on 3/4/16 at 12:19 PM and it included the following: · On 3/1/16 Resident #1 was placed on 1:1 supervision pending evaluation from the Medical director. · Elopement assessment for a total of 15 residents identified as elopement risk have been updated to determine if 1:1 supervision is needed · All nurses will be in-serviced to assure that all residents who are at risk for elopement will be accounted for after dinner with the use of daily check off list. · To provide additional supervision of the exit doors, the receptionist hours have been extended to 8 pm. · When transferring resident to the hospital via EMS, the receptionist on duty, nursing staff member or designee will greet EMS at entrance doors and will escort them to the designated floor. Afterwards nursing staff member of designee will escort EMS back to the exit doors and assure there are not resident on the first floor after hours. · Before going upstairs to get report, the 10pm-6 am nursing staff will round the entire first floor to assure there are no residents. · After 8 pm, rounds will be conducted every 2 hours and documented on the 24 hr. shift report by nursing staff to include the dining room, patio, and lobby area. On 3/4/16 the surveyor confirmed by observations and interviews with nursing and administrative staff and by record review that nursing staff were in-serviced on the above and were knowledgeable about changes in procedures. On 3/4/16 at 12:19 PM the NHA was informed the IJ was removed. The facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy, isolated, because the facility had not in-serviced all staff and had not monitored their plan for effectiveness. In an interview on 3/1/16 at 1: 45 PM, ADON B stated there were 15 residents identified at risk for elopement.

Based on observation, interview, and record review the facility failed to ensure 1 of 14 residents (Resident #1) reviewed for elopement risk received adequate supervision to prevent accidents. Resident #1, who was at high risk for elopement, left the faciity on [DATE] without staff being aware. Facility staff noticed the resident with a police officer who found the resident 5 or 6 miles away from the facility and the staff brought him back to the facility.Resident #1 was sunburnt and developed blisters the day he returned to the facility on [DATE]. An IJ was identified on 7/9/13. While the IJ was removed on 7/12/13 the facility remained out of compliance at a pattern of potential harm for more than minimal harm due to the facility ' s need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 14 other residents identified as wanderers at risk of leaving the facility without being seen by staff in situations that might lead to serious injury or death. Findings include: Review of Resident #1's Incident Report and Face sheet revealed the [AGE] year-old resident was admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1 ' s Care Plan dated 4/10/13 identified resident at risk for wandering. The Care Plan also documented resident would be observed and documented on every 2 hours. Review of the entire closed medical record revealed no documentation Resident #1 was being observed and documented on every 2 hours. Review of Nurses Notes dated 4/10/2013 documented resident was admitted that day around 5:00 PM, was alert x1, follows simple commands and wander guard placed as per order due to high risk for elopement. Review of Nurses Notes dated 4/14/13 at 2:45 AM documented patient wanders into other patients rooms at night, reoriented and follows simple commands. Patient sleeps fully dressed and horizontally on bed. Review of the Resident Incident Report revealed on 4/17/13 around 11:00 AM Resident #1 eloped from the facility. Resident #1 was later found around 1:23 PM by police officers who escorted Resident #1 to the bank and then released him to facility staff who brought him back to the facility around 1:40 PM. Review of the Provider Investigation Report dated 4/17/13 completed by the Director of Nursing (DON) C, documented Resident #1 was last seen by staff members at approximately 11:00 AM on 4/17/13. At 12 noon Certified Nurse Aide (CNA) D reported she could not find Resident #1 and the facility began their search inside of the facility, the ground and immediate vicinity. The police were notified. Staff members later found Resident #1 accompanied by two police officers. Resident # 1 was returned to the facility at 1:40 PM. Resident #1 received a head to toe assessment and no injuries were noted. Resident #1's wander guard was still in place. The facility concludes that Resident #1 self-ambulated on the elevator from the 4th floor and got off on the 5th floor and exited through the 5th floor exit belonging to the hospital. The resident was placed on 1 to 1 supervision until he was discharged to another facility on 5/13/13. In an interview on 6/21/13 at 12:17 PM CNA D, she stated that she was the CNA for Resident # 1 the day he eloped from the facility. CNA D stated Resident #1 was up since 6:30 AM and he told Nurse E that he wanted to leave. CNA D was instructed to keep a close eye on Resident #1 and remembers last seeing Resident # 1 around 11:30 AM in his room watching television. In a telephone interview on 6/21/13 at 8:27 AM Officer A said that Resident # 1 was found 5 or 6 miles away from the nursing home. In an interview on 6/21/13 at 12:34 PM Nurse B (wound care nurse) said Resident #1 was sunburnt and developed blisters the day he returned to the facility after he eloped. The facility treated the blisters with Silvadene (SILVADENE Cream 1% (silver sulfadiazine) is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED]. Nurse B stated the day of the elopement, 4/17/13, she and two other employees went out looking for Resident #1 after they noticed he was not in the facility. They drove to the address that was in the resident's chart and on the way back noticed Resident #1 was on the side of the road with 2 police officers. The police officer told her they noticed Resident #1 was having a difficult time walking so they stopped and assisted. The police officer took Resident #1 to the bank to take out $700 and then was going to an address the resident had given, that was not the facility's address. Resident #1 agreed to go back to the facility with Nurse B and the two other employees. Review of the Wound Assessment Report written by Nurse B (wound care nurse) revealed on 4/17/13 Resident#1 was assessed to have thermal burn to his upper head-rear. They were noted to be blisters intact and broken. Physician was contacted and ordered Silvadene to the affected areas. Wound Assessment Report on 4/18/13 revealed Resident #1 had multiple blisters to bridge of nose and to the top of his head. Scant amount of serous drainage was noted. In a telephone interview on 6/24/13 with an employee that works at the hospital on the 5th floor above the facility, she stated she remembers seeing Resident #1 on the 5th floor. He was going in the stairwell following a staff member she recalled. Review of facility policy Elopement Prevention and Management date 5/1/2011 stated in part: Elopement- Facility Practices Protocol: The facility team will assess the environment to identify potential risks associated with elopement. Facility interventions will be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement. Procedure: 1. Assess the security of potential internal environmental risk factors including, but not limited to the following: ? Elevators ? Exit doors ? Screens ? Stairwells ? Windows An IJ was identified on 7/9/13 and the facility Administrator was informed at 2:23 PM. Plan of Removal: Resident ' A ' was assessed on 4/17/2013 for injuries. The resident ' s responsible party and physician were notified of the event and the findings. Resident ' A ' was placed on 1:1 monitoring. An elopement assessment was completed on Resident ' A ' and his/her care plan updated to reflect current plan of care. A staff member was immediately placed at 2:55PM on 7/9/13 at the 5th floor LTACH (Long Term Acute Care Hospital) elevator to prevent attempted resident elopements, through the 5th floor elevator. The staff member will remain in place 24 hours/ day until another method/ device of resident elopement prevention is installed, that will be acceptable, within the guidelines of Life Safety Code, local Fire Marshall, LTACH hospital licensure and Skilled Nursing Facility guidelines. The facility has solicited a bid to install a keypad on the 5th floor elevator, to prevent wandering residents from entering the elevator. An audit was completed on 7/9/13 of residents at risk for elopement. The 14 residents were assessed for risk via the ' Elopement Risk Assessment ' . The identified residents have had interventions implemented to prevent elopement. The care plan have been updated, to reflect current care needs. The facility ' s elopement risk binder, identifying " at risk " residents, contain each residents face sheet and a current picture, has been updated. A binder will be kept at each nurses station, receptionist and with the 5th floor staff member, posted near the LTACH elevator. Residents, upon admission and re-admission, will be assessed for elopement risk, utilizing the Elopement Risk Assessment. Residents identified at risk will be added to the Elopement Risk binder. On 7-9-13 at 4:30PM immediate elopement education was initiated for all facility staff members. Education was completed by the Director of Education and Quality and will continue until all facility staff have been educated on the facility ' s elopement policy and procedure and on the Elopement Risk binder, located at each nursing station and the 5th floor elevator entrance. No staff member will be allowed to work until they have completed the in-service training on elopement policy and procedure. Elopement policy and procedure guidelines have been added to the new employee orientation agenda. The Elopement Risk binder, listing residents with the possibility for elopement, will be updated by the medical records director, at time of admission on identified at risk residents. On weekends and holidays, the RN supervisor will update the binder. The stairwell exits, for each floor, have an existing keypad, to prevent elopement. There is no access to the roof by residents. The Medical Director was notified of the Immediate Jeopardy and the above plan on 7-10-13. Through random audits, the Director of Nursing/ designee will monitor this plan, weekly for 30 days and/ or until substantial compliance is sustained. The Director of Nursing/ designee will report audit results to the Monthly QAPI(Quality Assurance Committee) committee for review, until substantial compliance is sustained. Date of Alleged Compliance: 7/10/13 Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 7/12/13 at 1:21PM. The facility remained out of compliance at a scope and severity of pattern of potential for more than minimal harm. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. There were 14 residents identified as wanderers in an interview with LVN H on 6/25/13 at 11:07 AM.

Based on observation, record review and interview, the facility failed to implement written policies and procedures that prohibit neglect when they failed to assess and obtain treatment in a timely manner for two residents (ID#1 and ID#2) out of 8 residents reviewed for significant changes as evidenced by: A) On 01/31/13 Resident #1sustained a fall and resident's buttocks were noted to be resting on the wheelchair footrests with both legs straight forward. B) On 02/14/13 at 11:30 PM, Resident #2, who was identified as being a two-person transfer, had been transferred from her wheelchair to her bed by Certified Nurse Aide (CNA) #D. Resident complained of pain and CNA #D immediately informed LVN #E. There was no documentation that Resident #2 had been assessed by LVN #E. The failure could potentially affect all residents requiring assistance with transfers and that were reviewed for a change of condition by not receiving timely treatment. The findings were: 1) RESIDENT #1 Review of Resident #1's Facesheet revealed resident had been admitted to the nursing facility on 07/11/08 and readmitted on [DATE]. Review of History and Physical dated 02/16/13 revealed Resident #1 was a [AGE] year-old male who was sent in from the skilled nursing facility for lower extremity leg pain. The resident had advanced dementia and is severely hard of hearing, so all the history is provided from the documents in the chart, the nursing staff and the resident's daughter at bedside. Resident apparently has been complaining of pain to his legs bilaterally for approximately 1 week. The family does not know what happened as the resident is bedbound. He does sit in the chair with max assist. The nursing facility was aware his legs hurt because he would not let anyone touch him. He was getting Tylenol, but it was no relieving his pain. Once the family questioned the nursing home about the resident's pain, they said he fell 2 weeks ago, but the family had never been told this 2 weeks ago. His past medical history included Insulin-dependent diabetes mellitus, Vitamin B12 deficiency, [MEDICAL CONDITION] of chronic disease, CKD stage III, [MEDICAL CONDITION], History [MEDICAL CONDITION] 2003 with ambulatory deficitis, Hearing loss, Constipation, Incontinence, [MEDICAL CONDITION], History of hip replacement in 2009, Bedbound status, [MEDICAL CONDITION] ulcer disease, GERD, Hiatal hernia and possibly [MEDICAL CONDITION]. Review of Consultation Report from the hospital dated 02/17/13 revealed Resident #1 was transferred to the hospital for further evaluation for concerns of bilateral lower extremity pain. X-rays taken at the time of initial evaluation demonstrated a nondisplaced proximal tibia fracture on the left side at the metadiaphysis region. The daughter reports she is concerned about abuse. The resident is quite anxious with any attempt at examination of his bilateral lower extremities. The resident is demented and he cannot verbalize whether or not he sustained a traumatic injury. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed resident had clear speech, was usually understood and could usually understand. He was moderately impaired in his daily decision making. The MDS documented Resident #1 required two plus persons or extensive assistance of staff for all Activities of Daily Living (ADLs), such as transferring, bathing and toileting. Review of Comprehensive Plan of Care for Resident #1 dated 02/07/13 revealed resident was at risk for falls due to his cognitive impairment, unsteady gait, visual deficits and attempts to stand unassisted. Review of Provider Investigation Report revealed that on 01/31/13 Resident #1sustained a fall and resident's buttocks were noted to be resting on the wheelchair footrests with both legs straight forward. Resident was assessed by LVN #A and LVN #B and no injuries were noted. No incident report or documentation on Resident #1's medical record was completed. Neither the physician or responsible party were notified of the incident on 01/31/13. On 02/05/13 Resident #1 complained to LVN #G of pain to bilateral lower extremities. Resident was noted to have swelling to his left knee and a light purple bruise on his left shin. Prior to going to the Managed Care Center/Clinic, LVN #H had applied cream to resident #1's bilateral lower extremities on 02/07/13 and did not notice any abnormalities, bruising nor did resident complain of pain. Resident #1 was seen at the Clinic on 02/07/13 regarding pain to bilateral lower extremities. While at the clinic, RN#C from the Managed Care Center/Clinic informed the nursing facility approximately at 2:00 PM that Resident #1 had a bruise to his left leg. Resident returned back to the nursing facility with orders to treat resident for Acute [MEDICAL CONDITION]. Resident #1 was assessed by LVN #H at the nursing facility and was observed to have a bruise to his left lower extremity measuring 18 cm x 3 cm. On 02/08/13 LVN #G reported to the Managed Care Clinic Nurse RN#C that Resident #1 was still complaining of pain to left lower extremity and had a bruise and swelling to his left knee. RN #C stated to monitor and continue to provide [MEDICATION NAME] and to notify her if the leg got worse. On 02/10/13 LVN #H reported same as 02/08/13. Resident #1 was to be seen at the Clinic on 02/11/13 but refused to go to the appointment. On 02/14/13, prior to Resident #1 going to the Managed Care Clinic, LVN #H applied cream to resident's legs in the morning and documented a hematoma to resident's left lower extremety lateral aspect of his leg. The Clinic was called by LVN #H and asked if it was the same bruise that was reported on 02/07/13. Resident #1 returned with new orders to hold Aspirin for 7 days, discontinue [MEDICATION NAME] and give [MEDICATION NAME] 5/500 mg po TID and x-rays were conducted. On 02/19/13 x-ray results for 02/14/13 were received and revealed: Bones are osteoporotic. The left proximal tibial diametaphyseal fracture is present without displacement. Bilateral knee joint moderate degerative disease is present. Review of nurses' notes revealed that on 02/15/13 at 2:12 PM LVN #H noted LATE ENTRY: 1/31/13 approximately around 10:00 AM LVN #B and LVN #A notified this nurse about resident that was found sitting on footrest. An assessment was done by LVN #A and LVN #B. Resident denied any pain, no bruises, no skin tears, no cuts, no bumps noted at the time resident was placed in his wheelchair and brought back to the dining room area. Review of nurses' notes revealed that on 02/15/13 at 3:11 PM LVN #B noted LATE ENTRY: 1/31/13 around 10:00 AM she was giving medication to a resident in the middle side cart when CNA #K screamed from outside Resident #1's room. LVN #B and LVN #A ran to resident's room. Resident was found sitting on footrest of his wheelchair with legs relaxed, hands relaxed on his sides. Resident denied any pain or distress and active range of motion was done on upper and lower extremities with no apparent S/S(signs/symptoms). A head to toe assessment was done with no cuts, no bumps, no skin tears, no bruises noted at this time. Resident #1 was placed in his wheelchair and brought back to the dining room area and reported to nurse in charge of resident LVN#H. Resident at eye sight from nurses station. Review of nurses' notes revealed that on 01/31/13 at 9:55 PM revealed Resident #1 did not eat today and had refused all 3 meals and drank "sisco shacks and milk" during breakfast, lunch and dinner and stated he was not hungry. Resident #1 denied pain, no distress noted at this time. The Registered Nurse (RN #C at the Managed Care Center/Clinic was notified and stated that she would pass the report to the oncoming nurse. Review of nurses' notes revealed that on 02/03/13 at 9:30 PM revealed Resident #1 ate 50% of breakfast with fluids, refused lunch and had fluids and had boost only for dinner. Doctor #L from the Managed Care Center/Clinic was notified and orders were given to check BS (blood sugar) at twice at night, risk of [DIAGNOSES REDACTED] due to not eating throughout the day. Contact Managed Care Clinic in the AM per MD and to contact patient manager to do Labs at the Clinic. Passed 24 hour report. Resident vitals were 100/65, 80, 98.1 97.5 at room air, no pain, abdomen no distention or pain, active BS present. Review of nurses' notes revealed that on 02/05/13 at 2:01 PM revealed LVN #G had spoken with RN#C at the Managed Care Center/Clinic in regards to Resident #1 stating he was in too much pain to attend visit. PM Tylenol was given but when changing his brief, resident stated he still hurt. Resident was left in bed, family came in to see him and situation was explained. RN #C at the Managed Care Center/Clinic called back and faxed an order for [REDACTED]. Meanwhile Resident #1 was medicated with Tylenol. Resident had an appointment at the Managed Care Clinic on 02/07/13. Review of nurses' notes revealed that on 02/07/13 at 8:42 PM revealed LVN #H received new orders from the Managed Care Center/Clinic for [MEDICATION NAME] 500 mg 2 tabs po everyday x 7 days, [DIAGNOSES REDACTED]. Resident was noted with an old bruise to his LLE (lower left extremity) (external area) measuring 18 cm x 3 cm. Will monitor x 72 hours. Responsible party was aware. Review of nurses' notes revealed that on 02/08/13 at 7:45 PM LVN #G noted that Resident #1 had pain to his left LLE leg and had a bruise and swelling to left knee. All meds were provided including PRN [MEDICATION NAME]. RN #C at the Managed Care Center/Clinic was notified and stated to monitor and continue to provide [MEDICATION NAME] and to notify her if the leg gets worse. Review of nurses' notes revealed that on 02/09/13 at 3:41 PM LVN #M documented that staff reported a bruise to Resident #1's LLE, purple, green bruise noted to the left lower extremity area by knee, minimal swelling, resident verbalized pain to BLE (bilateral lower extremity). Resident currently taking Tramador for pain scheduled, no redness or open areas noted. Review of nurses' notes revealed that on 02/10/13 at 9:52 PM Resident noted with pain to BLE, bruise to the LLE with no changes, no redness or open area noted. Doctor #N was notified about continued with pain and refusing meals and only boost given. Telephone order to continue with [MEDICATION NAME] 5 mg tab 1 to 2 tabs po tid prn for pain. Give only 15 units of [MEDICATION NAME] due to refusing meals and only intake of boost for today. F/U (follow-up) in AM with Managed Care Center/Clinic. Review of nurses' notes revealed that on 02/13/13 at 1:07 PM continued with pain to BLE (bilateral lower extremeity) controlled with scheduled pain meds no distress noted at this time. At 9:02 PM no complaints. Review of nurses' notes revealed that on 02/14/13 at 6:53 AM no complaints. At 5:02 PM Managed Care Center/Clinic called regarding LLE hematoma lateral aspect, patient had that bruise as charted on 02/07/13, new orders given by Managed Care Center/Clinic to hold Aspirin for 7 days, D/C (discontinue) Tramodol, [MEDICATION NAME] 5/500 mg tab 1 tab po tid. At 9:42 PM patient continued with pain to BLE controlled with pain meds no distress noted at this time. In an interview on 03/04/13 at 11:58 AM LVN #H stated that he had been informed on 01/31/13 around 10:00 AM when he had returned back to the third floor, LVN #A and LVN #B informed him that Resident #1 was found sitting on the wheelchair footrests. They reported they had assessed resident and did not find anything wrong with him. He denied completing an incident report. On 02/07/13 Resident #1 was scheduled to go to the Managed Care Center/Clinic for an appointment due to not eating. Prior to the resident leaving, he raised residents pants, lifted both legs and rubbed cream on both legs, cleaned toes and resident did not complain of any pain. He did not note any bruises at that time. He stated that a female nurse from the Clinic had called him that afternoon to inform him of Resident #1 was noted to have a bruise on his left lateral leg and that the doctor had seen it at the Clinic. When resident returned from the Clinic he saw a maroon bruise and asked the resident what had happened. Resident stated that both fo his knees were hurting. He documented the bruise on the Echart (computer) which did not look like a fresh bruise but like if it had been there for a few days. Neither his CNAs nor Resident #1 reported any falls. He stated that no x-rays were done at the Clinic or the nursing home on 02/07/13. Several days later xrays were done and Resident #1 was found to have a small fracture and was taken to the hospital. In an interview on 03/05/13 at 12:22 PM LVN #B stated that she had completed a Resident Incident Report on 02/15/13, notified the responsible party and the physician on 02/15/13 regarding the fall that occured on 01/31/13 for Resident #1. She could not recall if the incident occurred either during the last week of January 2013 or the first week of February 2013 after breakfast. She was told by DON #O to just put a date on the Incident Report. On the day of the incident, CNA #R screamed from outside Resident #1's room. She and LVN #A ran to resident's room and found Resident #1 sitting on the footrest of his wheelchair in his room. She and LVN #A both conducted a head to toe assessment, vital signs, full range of motion which was fine and resident had no complaints of pain. She thought resident was trying to get something and slipped. She reported the incident to LVN #H who was out to lunch and who was the nurse assigned to Resident #1. LVN #H stated okay and said that he would document. Facility's protocol is that the nurse in charge of the resident completes the incident report, conducts neurochecks for 72 hours, documents in the Echart for 3 days, notifies the physician and responsible party, the DON and ADON (Assistant Director of Nursing). She thought that LVN #H had notified the physician and the responsible party and had completed an Incident Report. In an interview on 03/14/13 at 10:30 AM CNA #R reported several weeks ago, unable to recall the date, after breakfast, she observed Resident #1 sitting on the footrests of his wheelchair in his room. She immediately yelled for help and LVN #A and LVN #B arrived to assess resident. In a telephone interview on 03/13/13 at 9:36 AM with Resident #1's daughter stated that she and her son had visited her father on 01/31/13 in the morning after breakfast and he did not complain of any pain. She did not receive any reports of her father having a fall. Her father knows his age, is unable to bear any weight, looked happy and had no complaints of pain. She and her son visited her father again on 02/05/13 or 02/06/13 around 10:00 AM and her father was in bed asleep on his left side. She woke him up and he did not recognize her. He told her to please don't move his legs because they hurt. She immediately notified LVN #H at which time gave him Tylenol and told her he could not give him anything the Clinic had not ordered. On 02/07/13 her father was taken to the Managed Care Center/Clinic. She stated that no one from the nursing had called her to inform her if her father had fallen. Review of Physician Summary Report from the Managed Care Center/Clinic revealed that on 02/07/13 at 1:32 PM -- Resident #1 brought from Nursing Home because he was reported with bilateral leg pain, anorexia and decrease movements. He is reporting pain to the left leg since unknown date, also the right leg or wherever he is touched. Presenting productive cough with lots of phlegm that he is unable to expel. No fever reported or found today. No sore throat or nasal problems. Today he ate better than days before. No voiding problems. Alert, awake, no apparent distress, not cooperative, limited speech due to profound hearing loss. Skin is dry, no [MEDICAL CONDITION] except for big bruise vanishing to the middle third of the left leg, no swelling, tenderness, no deformity. Resident #1 with left leg trauma not reported by nursing home staff, they do not have reports either of that, no fall documented. He is hoyer lift, could have the trauma during daily manage of indirect trauma, he is unable to explain due to memory problems. Will be treated with [MEDICATION NAME] tabs besides tylenol. Close observation. Acute bronchities will be treated with [MEDICATION NAME] tabs, duo neb treatment and [MEDICATION NAME]. Re val in a week. He is eating better now, continue monitor and DM treatment as usual. Monitor BS. Review of Managed Care Center/Clinic Notes revealed that on 02/07/13 at 3:28 PM -- Resident #1 seen in Clinic to F/U on pain to BLE. Resident denied having a fall and stated did not know reason of pain. LVN #H from the nursing home reported and denied resident having any fall or injuries. Upon skin check resident present with yellowish discoloration to left lower leg from left knee to shin, tender to touch, skin intact. Resident able to move BLE while voicing discomfort. Doctor #L informed and after assessment ordered to start DUO NEB TX 1 treatment TID x 1 week for [MEDICAL CONDITION], [MEDICATION NAME] 500 mg 2 tabs PO daily x 7 days for bronchtis and [MEDICATION NAME] DM syp #300 ml 10 ml PO QID for [MEDICAL CONDITION], one DUO neb TX given here at clinic. Review of Managed Care Center/Clinic Notes revealed that on 02/11/13 at 4:28 PM -- Resident #1 was seen in Clinic today. Left lower leg noted with yellowish/green and some reddned bruises, no swelling noted. No open areas noted. Review of Managed Care Center/Clinic Notes revealed that on 02/14/13 at 2:07 PM -- Head to toe skin check. Resident #1 presents with long linear fading hematoma that runs from mid aspect of left thigh down to left malleolous with surrounding fading yellow discoloration to left lower leg, no swelling noted, skin integrity intact, no other skin issues to report. Resident complained of discomfort to lateral aspect of left leg when palpated. Continue to observe. Doctor #L and RN #C present. Review of Physician Summary Report from the Managed Care Center/Clinic revealed that on 02/14/13 at 2:46 PM -- Nursing Home resident monthly visit. Resident #1 complaining of left leg pain from the thigh to the leg that increases with any leg movement, he is unable to provide a clinical history due to dementia. The nursing home staff do not report any trauma or fall during the last week but they are reporting the pain. We found an old big bruise to the left leg lateral aspect comprising from the knee to the distal third, no other [MEDICAL CONDITION]. Today again the resident is presenting a big hematoma located to the distal thigh, in purple discoloration, also involves the lateral aspect and runs down to the meddle leg third, it is hot and tender with limited ROM (range of motion). No swelling, no [MEDICAL CONDITION], no signs of infection. Possible trauma during daily management with hoyer lift but needs to have an investigation to r/o (rule out) trauma or abuse. Review of Clinic Notes from the Managed Care Center/Clinic revealed that on 02/15/13 at 11:14 AM -- X-ray results were received and reviewed by PCP (primary care physician). Per PCP resident presents with Complete Left Proximal Tibial Diametaphyseal FX. Clinic staff attempted to speak with the DON #O (Director of Nursing) at the nursing facility and were informed that she was currently in a meeting and was unable to answer the call. Return phone number and extension number were left to return the call ASAP (as soon as possible) . At 1:08 PM -- Facility received call from DON #O at the nursing facility and denied Resident #1 having a fall. DON was informed Resident #1 present with Complete Left proximal Tibial Diametaphyseal FX. At 1:24 PM Doctor #L generated consult for Orthodonic care to measure and provide left knee and tibial immobilizer STAT (urgent) at nursing home for left tibial FX. MD also generated consult to see Orthopedic doctor to evaluate treatment for [REDACTED]. Resident to be evaluated for left knee/tibial FX later this evening approximately at 5 PM. At 2:07 PM (Note for 02/14/13) -- Head to toe skin check done. Resident #1 presents with long linear fading hematoma that runs from mid aspect to left thigh down to left malleolous with surrounding fading yellow discoloration to left lower leg, no swelling noted, skin integrity intact. . In a telephone interview on 03/05/13 at 3:32 PM RN #C, Managed Care Center/Clinic stated that she had seen Resident #1 today at the Clinic and resident stated he had fallen a while back and was not able to give any details. Resident is hoyer net lift, nonambulatory, no pain voiced, answered simple questions, has pain on and off on his left leg and was wearing the immobilizer under his clothing. Resident #1 is alert and oriented to self and is very hard of hearing. On 02/11/13 she received a call from LVN #G from the nursing facility and reported that Resident #1 had pain to bilateral lower extremities was slightly high and vitals signs were normal. Doctor #L was informed and ordered one time injection of [MEDICATION NAME] 3 times a day PRN. She stated that Resident #1 was seen at the Clinic on 02/07/13 for follow-up on pain. Resident denied having fallen. She had spoken with LVN #H from the nursing facility and he denied Resident #1 having a previous fall, any swelling, any discoloration or bruising. On 02/07/13 Resident #1 was noted to have yellowish discoloration to left lower leg. The physician did not order any x-rays at that time. On 02/14/13 Resident #1 was seen at the Clinic and was noted to have a large hematoma to his left lower leg, dark purple and reddened and tender to touch. He was also noted to have a faded yellow discoloration to left lower medial upper shin area. Resident #1 continued with pain to left lower extremity. X-rays were ordered in the afternoon and were done that afternoon with a portable x-ray from the Center. On 02/15/13 x-ray results were received in the morning, Complete left proximal tibial diametathyseal fracture. The doctor ordered a left knee brace immobilizer at which time they were suppose to go to the nursing facility after 5 PM to measure Resident #1 and issue the immobilizer. Later that day she received a telephone call from LVN #F stating that DON #O had sent Resident #1 to the ER (emergency room ) because they didn't want to wait. On 02/19/13 she received a telephone call from LVN #F from the nursing facility informing her that on 01/31/13 Resident #1 had sustained a fall and was found on the floor. I'm sure the doctor would of ordered an x-ray had he known resident had a fall or an injury. In an interview on 03/08/13 at 10:31 AM Doctor #L, Managed Care Center/Clinic reported that all nursing home participants are seen every month. Resident #1 was seen on 01/23/13 and everyting was fine. He stated that he had seen Resident #1 on 02/07/13 to assess him because the nursing home had called days before stating that he was complaining of bilateral leg pain. At that time resident was complaining of pain to his left leg, whatever we touched, resident hurt. He stated that resident had a history of [REDACTED]. His new pain was to the left leg. He identified Resident #1 as being oriented to name and resident could not tell him if he had fallen or injured his leg. The nursing home stated that they had no record of him falling. The leg was not swollen and was not bruised when he saw resident on 02/07/13 and had ordered [MEDICATION NAME] for pain. When Resident #1 came for his monthly visit on 02/14/13, he had a big bruise to the left leg, purple in color. Resident could not remember how he got the bruise and the nursing facility did not know if resident had fallen or injured himself. Resident was congested and nebulizer treatments were ordered for him. I ordered an x-ray to his left leg and the results were tibial fracture at which time I ordered a brace for him. Resident #1 was not a candidate for surgery because of his age and the fracture only required a brace. I did not decide to send resident to the ER. There was no deviation, the treatment was enough with the brace and the brace was delivered to the nursing home prior to Resident #1 being sent to the hospital by the nursing home. The fracture should heal within 8 weeks. He was seen later and he is doing better with the brace in place. Observation on 03/08/13 at 11:03 AM revealed Resident #1 to be up in a wheelchair with left leg immobilizer, at the Managed Care Center/Clinic and was being seen by LVN #P. When asked by surveyor why he was wearing the immobilizer on his leg, resident stated "me calli" (I fell ). He stated they had gotten him up and then put him down. Resident #1 stated his leg was burning and he had pain. In a telephone interview on 03/05/13 at 9:53 PM RN #Q from the hospital reported that on 02/15/13 Resident #1 had arrived to the ER at which time he was seen. RN stated that Resident #1 had told him he had fallen out of his bed two weeks ago. Resident told him that he had pain at the time of the fall and nothing was done to treat the pain. 2) RESIDENT #2 Review of Resident #2's Facesheet revealed resident had been admitted to the nursing facility on 05/29/09. Resident is [AGE] years of age. Review of Resident #2's Quarterly MDS assessment dated [DATE] identified resident as having [MEDICAL CONDITIONS], Anxiety disorder, Depression and [MEDICAL CONDITION]. She was identified as having unclear speech-slurred or mumbled words, was usually understood-difficulty communicating some words or finishing thought but is able if prompted or given time, usually understands-misses some part/intent of message but comprehends most conversation. Resident#2 required extensive assistance, 2+ persons physical assist with transfers and other ADLs, such as bathing and toileting. Review of Comprehensive Plan of Care dated 07/16/12 and updated on 02/06/13 revealed Resident #2 required assistance of staff for transfers and bed mobility. Review of X-ray report dated 02/15/13 revealed a Distal fibular [MEDICAL CONDITION] ankle. [MEDICAL CONDITION] and [MEDICAL CONDITION] chagnes. Review of Provider's Investigation Report revealed that on 02/15/13 at 7:00 AM Resident #2 noted with redness, selling to the right ankle and complaining of pain. The physician and responsible party were notified. Upon knowledge, the facility immediately addressed pain and swelling to the right ankle. Pain meds were administered and resident was taken to the ER for x-ray and treatment. Resident returned back to the facility at about 5:00 PM. On 02/15/13 day shift LVN #F was made aware by CNA at 7:00 AM that Resident #2's right ankle was swollen. Assessment of the ankle was conducted and the physician at the Managed Care Center/Clinic was notified of findings. Xray of right ankle was ordered STAT and along with [MEDICATION NAME] 5/500 mg for pain. Her scheduled Tylenol was given for pain. There were no reports on 02/14/13 day shift through 02/15/13 of resident complaining of any pain. On 02/14/13 at 2200 Resident #2 was assisted to bed by nursing assistant whom at that time changed resident and noticed a pressure area to RLE (right lower extremity) pink in color. During that night NCA checked on resident during rounds and observed resident asleep and dry. On 02/15/13 day shift CNA did rounds at 0600 and resident was observed asleep. At 0700 resident was observed holding her right leg and crying. Conclusion: Review of Resident #2's medical record concluded history of [MEDICAL CONDITION]. Resident self propels in wheelchair and is often observed with body alignment in windswept position. Resident last fall was on 02/05/13 in dining area with a hematoma noted to her left forehead. No other injuries were noted. Resident was seen on 02/11/13 at the Clinic and there were no reports from that visit of any falls or changes in condition. Nurses notes on 02/13/14 revealed no reports of change in resident's condition at that time. Resident was not observed by any staff members on floor or hitting right lower extremity against anything. Review of statement written by CNA #D dated 02/18/13 documented that she had worked the 10 PM - 6 AM shift on 02/14/13. At 11:30 PM resident was falling asleep and was taken to her room and transferred to her bed. When she was doing a brief change, resident complained of pain to her lower leg. Resident had a red ara o her leg due to the pressure of the padding of the wheelchair. The charge nurse was informed of Resident #2 complaining of pain to her lower leg. Review of statement written by LVN #E dated 02/15/13 documented that he had worked the 10 PM - 6 AM shift on 02/14/13 to 02/15/13. Documentation revealed that he was unaware of any abnormalitieis or incident that pertained to Resident #2 and denied being notified of any resident having any acute distress. Review of statement written by CNA #K dated 02/15/13 documented that on 02/15/13 she had gone to change Resident #2 and resident started complaining of pain. Resident was noted to have her right leg swollen and red and had a skin tear on her left arm. She immediately notified LVN #F. Review of statement written by LVN #F stated that on 02/15/13 at approximately 6:45 AM CNA #K had notified her of Resident #2 resting on her bed crying and complaining of pain to her right lower extremity. Resident's right ankle was noted to be swollen and warm to touch. Attempted to elevate leg without success. Resident kept taking her ice pack off. A call was placed to the physician and orders were received for [MEDICATION NAME] 5/500 mg PO every 6 hours and an x-ray of resident's right lower extremity STAT. Review of nurses notes revealed that on 02/14/13 at 11:30 PM, Resident #2, who was identified as being a two-person transfer, had been transferred from her wheelchair to her bed by Certified Nurse Aide (CNA) #D. Resident complained of pain and CNA #D immediately informed LVN #E. There was no documentation that Resident #2 had been assessed by LVN #E. Review of nurses notes revealed that on 02/15/13 at approximately 7:00 AM, LVN #F noted resident in bed crying, grabbing her right ankle, was in pain and was noted to be swollen and bruised. The Managed Care Center/Clinic was notified and ordered for x-rays. Results of the x-rays revealed a distal fibula fracture. Resident #2 was observed on 03/04/13 at 11:50 AM to be wheeling self out on hall, disoriented and with immobilizer on her right leg. In an interview on 03/04/13 at 5:00 AM CNA #D identified Resident #2 as requiring 2 staff for transfers. She stated that on 02/14/13 Resident #2 was up in her chair in the dining room asleep. She stated that she wheeled resident to her room and transferred resident to her bed without anyone assisting her. She stated that resident was not able to assist at all during the transfer. She did not go look for CNA #S or the nurse that was working on the floor because she thought they were busy. Resident #2 complined of pain and was moaning loud. She immediately notified LVN #E and he told her that he would go and check on resident. In an interview on 03/04/13 at 4:30 AM CNA #S reported that on 02/14/13 at 11:30 PM CNA #D told her that she was putting Resident #2 to bed. CNA #S identified resident as requiring two staff for transfers. She stated that on that evening she had done rounds at 1:30 AM and at 4:30 AM and resident was noted to be dry. She stated that she did not want to wake up resident so she lifted resident's blanket "a little" to check on resident's diaper. In an interview on 03/14/13 at 1030 AM CNA #R identified Resident #2 as requiring two staff for transfers because resident gets hard, stiff and heavy during transfers. Resident is not able to bear any weight. She stated that on 02/15/13 at 6:00 AM resident was asleep in her bed on her left side. At 7:00 AM she woke resident up and resident started crying and stating "hay me duele, hay me duele" (it hurts) as she guarded her leg. She starting checking her le

Based on observation, interview, and record review, the facility failed to promptly notify the physician and family after a fall occurred for 1 (ID#1) of 8 residents reviewed for falls. A) On 01/31/13 Resident #1sustained a fall and resident's buttocks were noted to be resting on the wheelchair footrests with both legs straight forward. The failure could potentially affect all residents requiring assistance with transfers and that were reviewed for a change of condition by not receiving timely treatment. The findings were: 1) RESIDENT #1 Review of Resident #1's Facesheet revealed resident had been admitted to the nursing facility on 07/11/08 and readmitted on [DATE]. Review of History and Physical dated 02/16/13 revealed Resident #1 was a [AGE] year-old male who was sent in from the skilled nursing facility for lower extremity leg pain. The resident had advanced dementia and is severely hard of hearing, so all the history is provided from the documents in the chart, the nursing staff and the resident's daughter at bedside. Resident apparently has been complaining of pain to his legs bilaterally for approximately 1 week. The family does not know what happened as the resident is bedbound. He does sit in the chair with max assist. The nursing facility was aware his legs hurt because he would not let anyone touch him. He was getting Tylenol, but it was no relieving his pain. Once the family questioned the nursing home about the resident's pain, they said he fell 2 weeks ago, but the family had never been told this 2 weeks ago. His past medical history included Insulin-dependent diabetes mellitus, Vitamin B12 deficiency, [MEDICAL CONDITION] of chronic disease, CKD stage III, [MEDICAL CONDITION], History [MEDICAL CONDITION] 2003 with ambulatory deficitis, Hearing loss, Constipation, Incontinence, [MEDICAL CONDITION], History of hip replacement in 2009, Bedbound status, [MEDICAL CONDITION] ulcer disease, GERD, Hiatal hernia and possibly [MEDICAL CONDITION]. Review of Consultation Report from the hospital dated 02/17/13 revealed Resident #1 was transferred to the hospital for further evaluation for concerns of bilateral lower extremity pain. X-rays taken at the time of initial evaluation demonstrated a nondisplaced proximal tibia fracture on the left side at the metadiaphysis region. The daughter reports she is concerned about abuse. The resident is quite anxious with any attempt at examination of his bilateral lower extremities. The resident is demented and he cannot verbalize whether or not he sustained a traumatic injury. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed resident had clear speech, was usually understood and could usually understand. He was moderately impaired in his daily decision making. The MDS documented Resident #1 required two plus persons or extensive assistance of staff for all Activities of Daily Living (ADLs), such as transferring, bathing and toileting. Review of Comprehensive Plan of Care for Resident #1 dated 02/07/13 revealed resident was at risk for falls due to his cognitive impairment, unsteady gait, visual deficits and attempts to stand unassisted. Review of Provider Investigation Report revealed that on 01/31/13 Resident #1sustained a fall and resident's buttocks were noted to be resting on the wheelchair footrests with both legs straight forward. Resident was assessed by LVN #A and LVN #B and no injuries were noted. No incident report or documentation on Resident #1's medical record was completed. Neither the physician or responsible party were notified of the incident on 01/31/13. On 02/05/13 Resident #1 complained to LVN #G of pain to bilateral lower extremities. Resident was noted to have swelling to his left knee and a light purple bruise on his left shin. Prior to going to the Managed Care Center/Clinic, LVN #H had applied cream to resident #1's bilateral lower extremities on 02/07/13 and did not notice any abnormalities, bruising nor did resident complain of pain. Resident #1 was seen at the Clinic on 02/07/13 regarding pain to bilateral lower extremities. While at the clinic, RN#C from the Managed Care Center/Clinic informed the nursing facility approximately at 2:00 PM that Resident #1 had a bruise to his left leg. Resident returned back to the nursing facility with orders to treat resident for Acute [MEDICAL CONDITION]. Resident #1 was assessed by LVN #H at the nursing facility and was observed to have a bruise to his left lower extremity measuring 18 cm x 3 cm. On 02/08/13 LVN #G reported to the Managed Care Clinic Nurse RN#C that Resident #1 was still complaining of pain to left lower extremity and had a bruise and swelling to his left knee. RN #C stated to monitor and continue to provide [MEDICATION NAME] and to notify her if the leg got worse. On 02/10/13 LVN #H reported same as 02/08/13. Resident #1 was to be seen at the Clinic on 02/11/13 but refused to go to the appointment. On 02/14/13, prior to Resident #1 going to the Managed Care Clinic, LVN #H applied cream to resident's legs in the morning and documented a hematoma to resident's left lower extremety lateral aspect of his leg. The Clinic was called by LVN #H and asked if it was the same bruise that was reported on 02/07/13. Resident #1 returned with new orders to hold Aspirin for 7 days, discontinue [MEDICATION NAME] and give [MEDICATION NAME] 5/500 mg po TID and x-rays were conducted. On 02/19/13 x-ray results for 02/14/13 were received and revealed: Bones are osteoporotic. The left proximal tibial diametaphyseal fracture is present without displacement. Bilateral knee joint moderate degerative disease is present. Review of nurses' notes revealed that on 02/15/13 at 2:12 PM LVN #H noted LATE ENTRY: 1/31/13 approximately around 10:00 AM LVN #B and LVN #A notified this nurse about resident that was found sitting on footrest. An assessment was done by LVN #A and LVN #B. Resident denied any pain, no bruises, no skin tears, no cuts, no bumps noted at the time resident was placed in his wheelchair and brought back to the dining room area. Review of nurses' notes revealed that on 02/15/13 at 3:11 PM LVN #B noted LATE ENTRY: 1/31/13 around 10:00 AM she was giving medication to a resident in the middle side cart when CNA #K screamed from outside Resident #1's room. LVN #B and LVN #A ran to resident's room. Resident was found sitting on footrest of his wheelchair with legs relaxed, hands relaxed on his sides. Resident denied any pain or distress and active range of motion was done on upper and lower extremities with no apparent S/S(signs/symptoms). A head to toe assessment was done with no cuts, no bumps, no skin tears, no bruises noted at this time. Resident #1 was placed in his wheelchair and brought back to the dining room area and reported to nurse in charge of resident LVN#H. Resident at eye sight from nurses station. In an interview on 03/05/13 at 12:22 PM LVN #B stated that she had completed a Resident Incident Report on 02/15/13, notified the responsible party and the physician on 02/15/13, involving a fall on 01/31/13 for Resident #1. Facility's protocol is that the nurse in charge of the resident completes the incident report, conducts neurochecks for 72 hours, documents in the Echart for 3 days, notifies the physician and responsible party, the DON and ADON (Assistant Director of Nursing). She thought that LVN #H had notified the physician and the responsible party and had completed an Incident Report. In a telephone interview on 03/13/13 at 9:36 AM with Resident #1's daughter stated that she and her son had visited her father on 01/31/13 in the morning after breakfast and he did not complain of any pain. She did not receive any reports of her father having a fall. Her father knows his age, is unable to bear any weight, looked happy and had no complaints of pain. She and her son visited her father again on 02/05/13 or 02/06/13 around 10:00 AM and her father was in bed asleep on his left side. She woke him up and he did not recognize her. He told her to please don't move his legs because they hurt. She immediately notified LVN #H at which time gave him Tylenol and told her he could not give him anything the Clinic had not ordered. On 02/07/13 her father was taken to the Managed Care Center/Clinic. She stated that no one from the nursing had called her to inform her if her father had fallen. In an interview on 03/08/13 at 10:31 AM Doctor #L, Managed Care Center/Clinic reported that all nursing home participants are seen every month. Resident #1 was seen on 01/23/13 and everyting was fine. He stated that he had seen Resident #1 on 02/07/13 to assess him because the nursing home had called days before stating that he was complaining of bilateral leg pain. At that time resident was complaining of pain to his left leg, whatever we touched, resident hurt. He stated that resident had a history of [REDACTED]. His new pain was to the left leg. He identified Resident #1 as being oriented to name and resident could not tell him if he had fallen or injured his leg. The nursing home stated that they had no record of him falling. The leg was not swollen and was not bruised when he saw resident on 02/07/13 and had ordered [MEDICATION NAME] for pain. When Resident #1 came for his monthly visit on 02/14/13, he had a big bruise to the left leg, purple in color. Resident could not remember how he got the bruise and the nursing facility did not know if resident had fallen or injured himself. Resident was congested and nebulizer treatments were ordered for him. I ordered an x-ray to his left leg and the results were tibial fracture at which time I ordered a brace for him. Resident #1 was not a candidate for surgery because of his age and the fracture only required a brace. I did not decide to send resident to the ER. There was no deviation, the treatment was enough with the brace and the brace was delivered to the nursing home prior to Resident #1 being sent to the hospital by the nursing home. The fracture should heal within 8 weeks. He was seen later and he is doing better with the brace in place. Observation on 03/08/13 at 11:03 AM revealed Resident #1 to be up in a wheelchair with left leg immobilizer, at the Managed Care Center/Clinic and was being seen by LVN #P. When asked by surveyor why he was wearing the immobilizer on his leg, resident stated "me calli" (I fell ). He stated they had gotten him up and then put him down. Resident #1 stated his leg was burning and he had pain. In a telephone interview on 03/05/13 at 9:53 PM RN #Q from the hospital reported that on 02/15/13 Resident #1 had arrived to the ER at which time he was seen. RN stated that Resident #1 had told him he had fallen out of his bed two weeks ago. Resident told him that he had pain at the time of the fall and nothing was done to treat the pain. Review of the facility's policy entitled Notification of Resident/Patient Change in Condition dated 05/01/2011 provided by DON #O on 03/13/13 at 4:10 PM revealed, in part: The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. Notify the Physician and family or legal representative at the earliest possible time, during waking hours, if there is a change in condition (unless requested to do otherwise). Notify the Physician and family or legal representative immediately if there is a significant change in condition, regardless of the time. The facility's census on 03/04/13 was reported to be 125.

Based on interview and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for 1 (ID #1) of 7 sampled residents with a change in condition. Facility Wound Care Manager (WCM) #A failed to consult with the Attending Physician, Surgeon or Responsible Party (RP) when she observed that resident #1's surgical flap incision on the sacrum was separated 1 centimeter (cm) upon admission. A surgical flap is a piece of tissue that is still attached to the body and is pulled over an area that has suffered tissue loss. Prior to admission, resident #1 had a pressure sore covered by the flap. WCM #A failed to consult with the Attending Physician, Surgeon or RP on 4/07/11, when resident #1's surgical flap incision line on the sacrum separated another 1 cm a week later. The Surgeon was not consulted until 4/11/11 that the surgical flap incision line was separated, 12 days after admission to the facility. The wound measured 3 cm wide. Because of this deficient practice, resident #1 was readmitted to the hospital on [DATE] where a 2nd surgical flap procedure was performed to cover an opening over the sacrum measuring 8-10 cm long by 6 cm wide. This deficient practice resulted in an immediate jeopardy identified on 5/05/11. While the immediate jeopardy was removed on 5/06/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure placed 6 other residents with surgical incisions at risk of infection from incision lines opening and exposing underlying tissues to bacteria. The findings are: Review of closed medical records [REDACTED]. The Medical History and Physical dated 4/02/11 and hospital Progress Note dated 3/29/11 documented [DIAGNOSES REDACTED]. Record review of admission Minimum Data Set ((MDS) dated [DATE] (assessment reference date was 4/06/11) documented resident #1 had severely impaired cognitive skills for daily decision-making, was 2 person total dependence for bed mobility and transfer, 1 person total dependence for dressing and bathing, was 1 person extensive assistance for eating and personal hygiene, had functional limitation in range of motion in upper and lower extremities-both sides, was incontinent of bowel and bladder, was at risk of developing pressure ulcers, had 2 unstageable pressure ulcers and had (2) surgical wounds. Record review of the Operative Note dated 3/24/11 documented a sacral flap procedure was performed on resident #1 and was closed with multiple layers of sutures below the skin surface and at the skin surface. Record review of hospital Progress Notes for resident #1 signed by the Surgeon dated 3/30/11 documented, by photograph, that the sacral surgical flap incision line was intact. The note documented "L (left) trochanter (hip) and sacral flap intact with staples (on trochanter) intact/scant serosanguinous drainage, no odor." In the photograph, the surgical incision edges appeared to be well approximated (together). In a telephone interview on 5/02/11 at 3:30 PM, the Surgeon stated when resident #1 left the hospital on [DATE] "the surgical flap incision line was not separated and there were no openings. The wound was intact. In an interview on 5/02/11 at 8:45 AM, WCM #A stated resident #1 was admitted with a surgical flap to the sacrum on 3/30/11 and it was already opened when she assessed it on 3/31/11. WCM #A drew a picture of what she saw - 2 vertical, parallel lines with zig-zagged lines from one of the vertical lines to the other side down the length of the drawing. " I could see the sutures in the opening of the incision line. I did not call the doctor. I assumed the doctor already knew because she (resident #1) was admitted from the hospital. The next week when the wound had increased in size to 2 cm wide, I told Licensed Vocational Nurse (LVN) #B that the wound on the sacrum was opened and she said she would call the doctor. I entered a late entry on 4/19/11 (5 days after resident #1 left the facility) in the Departmental Notes documenting the physician had been informed of the wound opening and of the follow-up appointment because LVN #B told me she had done that." In record review of Nursing Comprehensive Admission Data dated 3/30/11, there in no written documentation of surgical wounds for resident #1 and no documentation that the physician was notified of any abnormalities in the resident's wounds. Record review of Skin Grid - Other Skin Problems dated: a. 3/31/11 documented the surgical wound on the coccyx (sacral flap) was 6 cm long and was opened 1 cm wide. b. 4/07/11 documented the surgical wound on the coccyx was 6 cm long by 2 cm wide and 0.5 cm deep. In record review of Skilled Nursing Documentation Record dated 4/07/11 and entered at 9:51 PM by Licensed Vocational Nurse (LVN) #B, there was no written documentation that the Wound Care Center or the Surgeon had been informed of the opened sacral flap incision on resident #1. In a telephone interview on 5/02/11 at 9:19 AM, LVN #B stated she did not remember calling the Surgeon or the Wound Care Center to inform them of a problem with resident #1's surgical flap. LVN #B stated, "Since October, the wound care nurse calls the doctors." Record review of Skilled Nursing Documentation Record dated 4/11/11 documented a follow-up appointment was made with the Wound Care Center. Record review of the 24 Hour Report documented in an entry on 3/31/11 that resident #1 "needs appt w/ Surgeon at Wound Care Center". There was no other entry concerning an appointment until 4/11/11 that stated "4/14 @ (at) 8 AM." Resident #1 had an appointment at the Wound Care Center on 4/14/11 at 8:00 AM. In a telephone interview on 4/28/11 at 8:53 AM, Responsible Party (RP) for resident #1 stated she visited resident #1 on Saturday 4/09/11 and asked when the follow-up appointment with the Surgeon was scheduled. The RP stated she was told there was no follow-up appointment scheduled. RP stated when she visited resident #1 on Tuesday 4/12/11 she was informed the follow-up appointment was scheduled for 4/14/11. RP stated she asked to see the flap on resident #1's back and when the diaper was removed it was bloody. RP stated WCM #A said the blood was drippage from the sacral dressing. RP stated she asked WCM #A how the blood could be from the dressing when there was no blood on the dressing. RP stated the dressing was removed. "I fell to my knees shaking and crying. Where the surgical flap used to be was a 3 inch by 3 inch hole. The nurses never told me the flap on my mother's tailbone was opened and not healing. " In a telephone interview on 5/02/11 at 1:16 PM, Wound Care Center RN stated "The Surgeon sees resident #1 at the Wound Care Center. When there is a problem with a wound, usually the facility nurses will call the Wound Care Center and we will contact the doctor. If we are closed, they will call the doctor directly. We keep a log of all calls to the center. If the doctor is called directly, his office will notify us the next day for our records. There is no documentation that anyone called to report any problems with resident #1's wounds until she was seen at the Center on 4/14/11." In a telephone interview on 5/02/11 at 3:30 PM, the Surgeon stated, "I do not remember being informed of a problem with the sacral flap incision, but if they called it was only 3-4 days before I saw her at the Wound Care Center. We take pictures of wounds when a patient is admitted to the hospital and when they are discharged . Look at the pictures taken when resident #1 was discharged on [DATE] and you will see the condition of the wound." In an interview on 5/03/11 at 1:55 PM, Assistant Director of Nurses (ADON) #D stated, "The admission nurse is supposed to do a complete skin assessment and call the doctor if there is anything that is abnormal." Record review of Protocol: Notification of Resident/Patient Change in Condition revised October 2010 and provided by Director of Nurses (DON) #Q on 5/03/11 documented in part: The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. If the change in the resident/patient's condition is not crucial or significant, according to the Guidelines, the resident/patient's Physician and family or legal representative will be notified at the earliest convenient time. Document in the Nurse's Notes the time notification was made and the names of the person(s) to whom you spoke. Sign entry. An immediate jeopardy was identified on 5/05/11 and the Nursing Facility Administrator, DON #Q and Human Resources Director were informed at 12:45 PM on 5/05/11. PLAN OF ACTION: A. Flap deteriorating/MD not notified timely about the flap deterioration Resident #1 was discharged from the facility on 4/14/11 to the hospital. All surgical wounds were assessed on 5/5/11 and 5/6/11 there were no abnormal findings. Admission nurse will inspect skin including removing all bandages/dressings. The Admission nurse will measure and document location, size, color, odor and drainage, if applicable, of surgical site and document findings. Resident Admission and Re-Admission documentation will be monitored by the ADONs and reported to the DON using the ADON Daily Worksheet. Surgical site changes will be reported immediately to the physician and family member and documented. Document what you reported, who you spoke to, what time and date. All abnormal findings in surgical sites will be reported to the DON via the ADON daily worksheet. B. On Admission MD not notified about condition of flap. Admission nurse will inspect skin including removing all bandages/dressings. The Admission nurse will measure and document location, size, color, odor, and drainage, if applicable, of surgical site and document findings. All surgical site abnormal findings will be reported immediately to the admitting physician, surgeon and documented. Document what you reported, who you spoke to, what time and date. Resident Admission and Re-Admission documentation will be monitored by the ADONs and reported to the DON using the ADON Daily Worksheet. C. Education: On May 5 and 6, 2011, all scheduled nurses were in-serviced in person or via telephone in-service by ADONs, Wound Care Manager, and DON on the following: 1) CNA's a) Skin - all changes must be reported immediately to the nurse. b) Bandages and dressings if soiled or wet must be reported immediately to the nurse. 2) Nurses - Resident Admission and Re-Admission Surgical Site Assessment and Physician Notification Admission nurse will inspect skin including removing bandages/dressings. The Admission nurse will measure and document location, size, color, odor and drainage, if applicable, of surgical site and document findings. All abnormal findings will be reported immediately to the admitting physician, surgeon and documented. Document what you reported, who you spoke to, what time and date. The Plan of Action was accepted on 5/6/11 at 1:00 PM. Through observations, interviews, and record reviews the surveyor determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 5/06/11 at 11:00 AM. The facility remained out of compliance at a scope and severity of pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The universe of 6 residents with surgical incisions was obtained from DON #Q on 5/06/11..

Based on interview and record review the facility failed to immediately consult with the Attending Physician or Surgeon and notify the resident's legal representative for 1 (ID #1) of 7 sampled residents that had a significant change. Facility Wound Care Manager (WCM) #A failed to consult with the Attending Physician, Surgeon or Responsible Party (RP) when she observed that resident #1's surgical flap incision on the sacrum was separated 1 centimeter (cm) upon admission. A surgical flap is a piece of tissue that is still attached to the body and is pulled over an area that has suffered tissue loss. Prior to admission, resident #1 had a pressure sore covered by the flap. WCM #A failed to consult with the Attending Physician, Surgeon or RP on 4/07/11, when resident #1's surgical flap incision line on the sacrum separated another 1 cm a week later. The Surgeon was not consulted until 4/11/11 that the surgical flap incision line was separated, 12 days after admission to the facility. The wound measured 3 cm wide. Because of this deficient practice, resident #1 was readmitted to the hospital on [DATE] where a 2nd surgical flap procedure was performed to cover an opening over the sacrum measuring 8-10 cm long by 6 cm wide. This deficient practice resulted in an immediate jeopardy identified on 5/05/11. While the immediate jeopardy was removed on 5/06/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure placed 6 other residents with surgical incisions at risk of infection from incision lines opening and exposing underlying tissues to bacteria. Deficient Practice Not at an Immediate Jeopardy Level Licensed nursing staff failed to notify the Attending Physician, Infectious Disease Physician or RP when the ordered intravenous (IV) [MEDICATION NAME] (antibiotic) was not administered to resident #1 on 3/31/11, 4/02/11, 4/03/11 and 4/04/11. Resident #1 was being treated for [REDACTED].) This failure had the potential to place 10 residents who had physician orders for intravenous medications at risk of not having medications administered according to physician order, altering the effectiveness of the medications. The findings include: A. Immediate Jeopardy Review of closed medical records [REDACTED]. The Medical History and Physical dated 4/02/11 and hospital Progress Note dated 3/29/11 documented [DIAGNOSES REDACTED]. Record review of admission Minimum Data Set ((MDS) dated [DATE] (assessment reference date was 4/06/11) documented resident #1 had severely impaired cognitive skills for daily decision-making, was 2 person total dependence for bed mobility and transfer, 1 person total dependence for dressing and bathing, was 1 person extensive assistance for eating and personal hygiene, had functional limitation in range of motion in upper and lower extremities-both sides, was incontinent of bowel and bladder, was at risk of developing pressure ulcers, had 2 unstageable pressure ulcers and had (2) surgical wounds. Record review of the Operative Note dated 3/24/11 documented a sacral flap procedure was performed on resident #1 and was closed with multiple layers of sutures below the skin surface and at the skin surface. Record review of hospital Progress Notes for resident #1 signed by the Surgeon dated 3/30/11 documented, by photograph, that the sacral surgical flap incision line was intact. The note documented "L (left) trochanter (hip) and sacral flap intact with staples (on trochanter) intact/scant serosanguinous drainage, no odor." In the photograph, the surgical incision edges appeared to be well approximated (together). In a telephone interview on 5/02/11 at 3:30 PM, the Surgeon stated when resident #1 left the hospital on [DATE] "the surgical flap incision line was not separated and there were no openings. The wound was intact. In an interview on 5/02/11 at 8:45 AM, WCM #A stated resident #1 was admitted with a surgical flap to the sacrum on 3/30/11 and it was already opened when she assessed it on 3/31/11. WCM #A drew a picture of what she saw - 2 vertical, parallel lines with zig-zagged lines from one of the vertical lines to the other side down the length of the drawing. " I could see the sutures in the opening of the incision line. I did not call the doctor. I assumed the doctor already knew because she (resident #1) was admitted from the hospital. The next week when the wound had increased in size to 2 cm wide, I told Licensed Vocational Nurse (LVN) #B that the wound on the sacrum was opened and she said she would call the doctor. I entered a late entry on 4/19/11 (5 days after resident #1 left the facility) in the Departmental Notes documenting the physician had been informed of the wound opening and of the follow-up appointment because LVN #B told me she had done that." In record review of Nursing Comprehensive Admission Data dated 3/30/11, there was no written documentation of surgical wounds for resident #1 and no documentation that the physician was notified of any abnormalities in the resident's wounds. Record review of Skin Grid - Other Skin Problems dated: a. 3/31/11 documented the surgical wound on the coccyx (sacral flap) was 6 cm long and was opened 1 cm wide. b. 4/07/11 documented the surgical wound on the coccyx was 6 cm long by 2 cm wide and 0.5 cm deep. In record review of Skilled Nursing Documentation Record dated 4/07/11 and entered at 9:51 PM by Licensed Vocational Nurse (LVN) #B, there was no written documentation that the Wound Care Center or the Surgeon had been informed of the opened sacral flap incision. In a telephone interview on 5/02/11 at 9:19 AM, LVN #B stated she did not remember calling the Surgeon or the Wound Care Center to inform them of a problem with resident #1's surgical flap. LVN #B stated, "Since October the wound care nurse calls the doctors." Record review of Skilled Nursing Documentation Record dated 4/11/11 documented a follow-up appointment was made with the Wound Care Center. In a telephone interview on 4/28/11 at 8:53 AM, Responsible Party (RP) for resident #1 stated she visited resident #1 on Saturday 4/09/11 and asked when the follow-up appointment with the Surgeon was scheduled. The RP stated she was told there was no follow-up appointment scheduled. RP stated when she visited resident #1 on Tuesday 4/12/11 she was informed the follow-up appointment was scheduled for 4/14/11. RP stated she asked to see the flap on resident #1's back and when the diaper was removed it was bloody. RP stated WCM #A said the blood was drippage from the sacral dressing. RP stated she asked WCM #A how the blood could be from the dressing when there was no blood on the dressing. RP stated the dressing was removed. "I fell to my knees shaking and crying. Where the surgical flap used to be was a 3 inch by 3 inch hole. The nurses never told me the flap on my mother's tailbone was opened and not healing. " In a telephone interview on 5/02/11 at 1:16 PM, Wound Care Center RN stated "The Surgeon sees resident #1 at the Wound Care Center. When there is a problem with a wound, usually the facility nurses will call the Wound Care Center and we will contact the doctor. If we are closed, they will call the doctor directly. We keep a log of all calls to the center. If the doctor is called directly, his office will notify us the next day for our records. There is no documentation that anyone called to report any problems with resident #1's wounds until she was seen at the Center on 4/14/11." In a telephone interview on 5/02/11 at 3:30 PM, the Surgeon stated, "I do not remember being informed of a problem with the sacral flap incision, but if they called it was only until 3-4 days before I saw her at the Wound Care Center. We take pictures of wounds when a patient is admitted to the hospital and when they are discharged . Look at the pictures taken when resident #1 was discharged on [DATE] and you will see the condition of the wound." In an interview on 5/03/11 at 1:55 PM, Assistant Director of Nurses (ADON) #D stated, "The admission nurse is supposed to do a complete skin assessment and call the doctor if there is anything that is abnormal." Record review of Protocol: Notification of Resident/Patient Change in Condition revised October 2010 and provided by DON on 5/03/11 documented in part: The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. If the change in the resident/patient's condition is not crucial or significant, according to the Guidelines, the resident/patient's Physician and family or legal representative will be notified at the earliest convenient time. Document in the Nurse's Notes the time notification was made and the names of the person(s) to whom you spoke. Sign entry. An immediate jeopardy was identified on 5/05/11 and the Nursing Facility Administrator, DON #Q and Human Resources Director were informed at 12:45 PM on 5/05/11. PLAN OF ACTION: A. Flap deteriorating/MD not notified timely about the flap deterioration Resident #1 was discharged from the facility on 4/14/11 to the hospital. All surgical wounds were assessed on 5/5/11 and 5/6/11 there were no abnormal findings. Admission nurse will inspect skin including removing all bandages/dressings. The Admission nurse will measure and document location, size, color, odor and drainage, if applicable, of surgical site and document findings. Resident Admission and Re-Admission documentation will be monitored by the ADONs and reported to the DON using the ADON Daily Worksheet. Surgical site changes will be reported immediately to the physician and family member and documented. Document what you reported, who you spoke to, what time and date. All abnormal findings in surgical sites will be reported to the DON via the ADON daily worksheet. B. On Admission MD not notified about condition of flap. Admission nurse will inspect skin including removing all bandages/dressings. The Admission nurse will measure and document location, size, color, odor, and drainage, if applicable, of surgical site and document findings. All surgical site abnormal findings will be reported immediately to the admitting physician, surgeon and documented. Document what you reported, who you spoke to, what time and date. Resident Admission and Re-Admission documentation will be monitored by the ADONs and reported to the DON using the ADON Daily Worksheet. C. Education: On May 5 and 6, 2011, all scheduled nurses were in-serviced in person or via telephone in-service by ADONs, Wound Care Manager, and DON on the following: 1) CNA's a) Skin - all changes must be reported immediately to the nurse. b) Bandages and dressings if soiled or wet must be reported immediately to the nurse. 2) Nurses - Resident Admission and Re-Admission Surgical Site Assessment and Physician Notification Admission nurse will inspect skin including removing bandages/dressings. The Admission nurse will measure and document location, size, color, odor and drainage, if applicable, of surgical site and document findings. All abnormal findings will be reported immediately to the admitting physician, surgeon and documented. Document what you reported, who you spoke to, what time and date. The Plan of Action was accepted on 5/6/11 at 1:00 PM. Through observations, interviews, and record reviews the surveyor determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 5/06/11 at 11:00 AM. The facility remained out of compliance at a scope and severity of pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. B. Deficiency Not Immediate Jeopardy Record review of hospital Progress Note dated 3/29/11 written by Infectious Disease Physician documented: - ASSESSMENT AND PLAN: 1. Left hip osteo[DIAGNOSES REDACTED] (bone infection) 2. status [REDACTED]. - The patient will be transferred to a long-term acute care facility in the near future. I will make arrangements for her to have a PICC line put in place. I will also make arrangements for her to receive the intravenous antibiotic therapy to finish treatment course for the osteo[DIAGNOSES REDACTED]. She will be on [MEDICATION NAME] 1 gram IV every 24 hours until May 3, 2011. She will be monitored closely while on treatment. Record review of Admission/Readmission/Physician Orders dated 3/30/11 documented [MEDICATION NAME] 1 gm (gram) PICC line (peripherally inserted central catheter for giving intravenous medications in a large vein) Q 24 H (every 24 hours) D5W (IV fluid to mix in) Stop date 5/03/11. Record review of resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Stop date 5/3/11. The medication was timed for 8:00 PM. The dates of 3/31/11, 4/02/11, 4/03/11 and 4/04/11 were circled. (A circled medication time on a MAR indicated [REDACTED]. In record review of Department Notes from dates 3/30/11 through 4/9/11 there is no written documentation that resident #1 refused [MEDICATION NAME] 3/31/11, 4/02/11, 4/03/11 and 4/04/11 or that a Physician was notified. In record review of Skilled Nursing Documentation Record dated 3/31/11, 4/02/11, 4/03/11 and 4/04/11 there was no documentation that resident #1 refused the administration of the [MEDICATION NAME] 1 Gm or that a Physician was notified. Record review of 24 Hour Reports from 3/30/11 through 4/14/11 documented the following for resident #1: - 4/03/11 "refusing meds. Told Attending Physician on 4/02/11." There was no written documentation what medications were refused or that the Attending Physician was notified that resident #1 was not administered [MEDICATION NAME] on 4/03/11 and 4/04/11. In a telephone interview on 5/05/11 at 3:39 PM, LVN #E, when asked what she meant when she documented in the Departmental Notes dated 4/03/11 at 11:55 AM and 6:34 PM that resident #1 "refusing medications at this time", stated she meant resident #1 "refused oral meds." LVN #E stated, "I worked 6 AM to 6 PM on 4/03/11 and was not working when resident #1's [MEDICATION NAME] was due." In a telephone interview on 5/6/11 at 9:56 AM, Infectious Disease Physician, who followed resident #1's case due to the treatment for [REDACTED]. The Infectious Disease Physician stated, "If the order is written it should be given." In an interview on 5/9/11 at 8:10 AM, DON #Q stated she spoke with LVN #E on 5/08/11 and the LVN stated she did work over on 4/02/11 and 4/03/11 and called the Attending Physician on 4/02/11 when resident #1 would not let her administer the [MEDICATION NAME]. The resident would bend her arms at the elbow preventing access to the PICC line. DON #Q reported that LVN #E stated she did not notify the Attending Physician on 4/03/11 when resident #1 again refused to let the [MEDICATION NAME] be administered. DON #Q stated she did not know which nurse worked on 4/04/11. Record review of Medication Administration revised May 2010 provided by DON #Q on 5/03/11 documented in part: Notify physician of changes in resident/patient or with refusal of medication. The universe of 6 resident with surgical incisions was provided by DON #Q on 5/06/11 and the 10 residents with physician orders for IV medications was obtained from the CMS 672 dated 4/28/11 provided by DON #Q.

Based on observation, interview and record review the facility failed to ensure 4 (ID #1, #2, #4 and #8) of 6 residents reviewed for pressure sores received the necessary care and treatment to prevent new pressure sores from developing and to promote the healing of current pressure sores as evidenced by: A. Resident #1 was admitted to the facility on [DATE] with 2 documented pressure sores on the right upper back and the right hip. There were no other pressure sores identified by the nursing staff during resident #1's stay at the facility. Resident #1 was discharged to the hospital on [DATE]. On admission to the hospital the hospital nursing staff identified additional pressure sores - a Stage II on the outer right side of the foot, right outer ankle and lower leg stages II & III and multiple pressure sores mid back stages I and III. B. Resident #4 was admitted to the facility on [DATE] with pressure ulcers on her coccyx and left and right buttocks. Resident #4 was unable to independently change position. Facility staff failed to change resident #4's position every 15 minutes as ordered by the attending physician. C. Resident #8 had a stage III pressure ulcer on the coccyx and a history of an unstageable pressure ulcer on the right heel. There was no care plan addressing pressure ulcers or skin integrity. Resident #8 had an order for [REDACTED]. D. Resident #2 did not have weekly skin checks done from 2/02/11 to 3/20/11. There was no documentation that the resident wore Prevalon boots after a pressure ulcer to the right ankle resolved prior to 3/01/11. These failures could affect the facility's 13 residents currently identified with pressure ulcers and placed them at risk for the development of more pressure ulcers and deterioration and delayed healing of existing pressure ulcers The findings are: A. Resident #1 Review of closed medical records [REDACTED]. The Medical History and Physical dated 4/02/11 and hospital Progress Note dated 3/29/11 documented [DIAGNOSES REDACTED]. Record review of admission Minimum Data Set ((MDS) dated [DATE] documented resident #1 had severely impaired cognitive skills for daily decision-making, was 2 person total dependence for bed mobility and transfer, 1 person total dependence for dressing and bathing, was 1 person extensive assistance for eating and personal hygiene, had functional limitation in range of motion in upper and lower extremities-both sides, was incontinent of bowel and bladder, was at risk of developing pressure ulcers, had 2 unstageable pressure ulcers and had (2) surgical wounds. Record review of the Nursing Comprehensive Admission Data and Departmental Notes dated 3/30/11 revealed there was no written documentation of the type, location, size or condition of the surgical wounds and pressure sores at the time of admission. Record review of Weekly Skin Assessment documented skin assessments were performed on resident #1 on Wednesday 3/30/11 and again 4 days later on Sunday 4/03/11. There were no documented measurements or descriptions of the wounds. There was not another documented skin assessment prior to resident #1 being discharged to the hospital 10 days later on 4/14/11. Record review of resident #1's closed record and electronic charting revealed a Braden Pressure Ulcer Risk Scale dated 3/30/11. There was no other documented Braden Scales performed on resident #1 during her time at the facility. Record review of the facility's Wound Prevention and Treatment Protocol documented in part Braden Scale to completed on admission and weekly for 4 weeks. Record review of MDS ADLS (Smart Charting) Roster (electronic charting by the CNAs) for the month of April 2011 documented resident #1's Bed Mobility (change in position while in bed) was documented as "Activity did not occur" on 6 out of 40 shifts (nights on 4/01/11, 4/03/11, 4/09/11, 4/10/11 and on evenings 4/03/11 and 4/09/11). Record review of Skin Grids dated 3/31/11 documented resident #1 had a surgical wound on the coccyx measured 6 cm long by 1 cm wide, surgical wound with 57 staples on the left hip, an unstageable pressure sore on the right hip and an unstageable pressure sore on the right upper back. Review of the Skin Grids dated 3/07/11 documented 1) sacral flap surgical incision had increased in width from 1 cm to 2 cm, 2) Right upper Back pressure ulcer had progressed from a stage II with no odor or drainage on admission to unstageable with an odor and purulent drainage. There was no documentation on the Departmental Notes or Skilled Nursing Documentation Record dated 4/07/11 that the physician was notified. Record review of the 24 Hour Report documented in an entry on 3/31/11 that resident #1 "needs appt w/ Surgeon at Wound Care Center". There was no other entry concerning an appointment until 4/11/11 that stated "4/14 @ (at) 8 AM." Resident #1 had an appointment at the Wound Care Center on 4/14/11 at 8:00 AM. Record review of inpatient Hospital Progress Note dated 4/14/11 revealed photographic documentation of resident #1's admitting wounds. The Progress notes of 4/15/11 again documented resident #1's wounds with accompanying measurements and staging. The documented wounds are as follows with the writing on the pictures in quotations: a. Full view of resident #1 lying on left side with back to feet exposed. Right upper back, coccyx, right hip pressure sores visible and the right foot is wrapped in gauze. No close-up views in this picture. b. "R (right) lateral foot - Stage II." There is no measurement documented but there is a legible tape measure adjacent to the wound. The wound measured 4.5 cm across the top of the wound. c. "L (left) trochanter (hip) - intact myocutaneous flap." d. "R trochanter - unstageable PU (pressure ulcer) 25 mm W (millimeters wide) X (by) 50 mm L (long) X 2 mm D (deep). e. "Sacrum 40 mm W X 50 mm L X 13 mm D, unstageable. (Most of the area was covered with slough which is dead tissue that is in the process of separating from the viable, or live, portions of the body.) f. "R lateral back unstageable PU, eschar, deep, slough" g. "Mid back, multiple stages, stage 1 & 2 PU" h. "R lateral ankle and lower leg stage 2 & 3" i. "R foot 3rd toe, partial thickness abrasion" Closed record review revealed electronic charting, did not have any documentation that documented resident #1 had a skin assessment that identified the sacral flap with an unstageable pressure sore, the right ankle and lower leg with stage 2 and 3 pressure sores and the right foot with a stage 2 pressure sore. In a telephone interview on 4/28/11 at 8:53 AM, Responsible Party (RP) for resident #1 stated she visited resident #1 on Saturday 4/09/11 and asked when the follow-up appointment with the Surgeon was scheduled. The RP stated she was told there was no follow-up appointment scheduled. RP stated when she visited resident #1 on Tuesday 4/12/11 she was informed the follow-up appointment was scheduled for 4/14/11. RP requested to see the sacral flap. RP stated the dressing was removed. "I fell to my knees shaking and crying. Where the surgical flap used to be was a 3 inch by 3 inch hole. The nurses never told me the flap on my mother's tailbone was opened and not healing. " In a telephone interview on 5/02/11 at 3:30 PM, the Surgeon who had performed flap procedures on resident #1 and saw her at the Wound Care Center stated, "When I saw her at the Wound Care Center on 4/14/11 she had come back with more pressure sores than when we sent her to the facility. She has a new wound on her hip (right) and on her sacrum and lots of little ulcers all over." In an interview on 5/03/11 at 1:30 PM, Certified Nurse Assistant (CNA) #I stated resident #1 required a 2 person transfer and needed to be fed. CNA #I stated resident #1 was too contracted to stay on her back so she had to be turned side to side. CNA #I stated resident #1 was too contracted to sit in a wheelchair so when she was out of bed she was placed in a Geri-chair. In an interview on 5/03/11 at 1:55 PM, Assistant Director of Nurses (ADON) #D stated skin assessments are done weekly by the week-end nursing staff. ADON #D reported that Braden Scale Risk Assessment are completed on admission, and weekly for 4 weeks. ADON #D stated the Braden Risk Assessments are performed weekly on her hallway because they have such a big turnaround in residents. In an interview on 5/03/11 at 3:30 PM, MDS Nurse #G stated resident #1 may not have had a comprehensive care plan yet but there should be an interim care plan for the resident's main issues. After searching through resident #1's chart MDS Nurse #G confirmed she did not find any interim care plan in resident #1's chart. "About 2 months ago, corporate sent a list of care plans that were to be started prior to the comprehensive care plan being written. I don't know what is on the list and the nurses were doing it, but between vacations and illnesses I guess it's not being done." In an interview on 5/04/11 at 3:05 PM, Facility Wound Care Manager (WCM) #A stated resident #1 developed small blisters on her lower legs 2 days after admission. WCM #A stated resident #1 wore Prevalon boots, and due to the location of the blisters felt they were heat related from the boots and not due to pressure. "I wrapped resident #1's lower legs in gauze, following protocol, and checked on them every other day until the blisters dried up - about 5 days. I never saw any breakdown on her ankles or feet." B. Resident #4 Record review of medical records documented resident #4 was an [AGE] year old woman admitted to the facility on [DATE]. Admission/Transfer Notice dated 4/13/11 documented [DIAGNOSES REDACTED]. Record review of Skin Grid sheets dated 4/14/11 documented resident #4 was admitted with pressure sores on her right heel, right dorsal foot, right upper posterior thigh, right buttock and left buttock. Record review of faxed physician orders [REDACTED]. Wound care to sacrum/buttocks: Cleanse with SNS (sterile normal saline), pat dry. Apply [MEDICATION NAME] and cover with dry dressings daily until healed then D/C. Turn patient to her sides Q 2 hrs (every 2 hours) while in bed, change position Q 15 minutes while on chair. Record review of E-charting on 4/28/11 documented an admission Braden Pressure Ulcer Risk Scale dated 4/13/11 for resident #4. There were no other documented Braden Scales. Record review of the care plan Alteration in Skin Integrity: Pressure Ulcers dated 4/19/11 did not document resident #4 needed to have her position changed every 15 minutes while she sat in a chair. Record review of the care plan Alteration in Mobility dated 4/19/11 did not document resident #4 needed assistance to change her position every 15 minutes while she sat in a chair. Observations on 4/28/11 from 10:55 AM through 11:58 AM, revealed resident #4 was seated in her wheelchair and being wheeled from the 1st floor to the dining area in the 4 th floor where she sat in her wheelchair. Resident #4 did not attempt to reposition herself while seated in the wheelchair. No staff member was observed assisting resident #4 to change her position while seated in the wheelchair during the time period observed. Observation on 4/28/11 at 1:20 PM, revealed resident #4 seated in her wheelchair in her room. Resident #4's son was with her. Resident #4's son stated the resident cannot move herself and the nursing staff do not reposition her when she is sitting in her wheelchair. Observation on 4/28/11 at 1:31 PM revealed CNAs #I and #J transferred resident #4 from her wheelchair into the bed. When the incontinent brief was removed, and resident #6 was turned onto her left side, the skin over the right ischial tuberosity (lower right buttock just above the thigh) area was red. A scar from what appears to be a healed pressure sore was also seen to the right of the reddened area. CNA #I stated the redness was from sitting in the wheelchair. CNA #I stated resident #4 cannot change her position by herself; she requires assistance. In an interview on 4/29/11 at 8:20 AM, Licensed Vocational Nurse (LVN) #K stated he works PRN (as needed). LVN #K stated he was not aware resident #4 had orders to change her position every 15 minutes while she was sitting in her wheelchair. LVN #K stated even if a resident has a Roho cushion in the wheelchair like resident #4 (a Roho cushion is a pressure relief cushion that constantly adjusts in response to a person's body movement), they still need to be repositioned, especially if they do not move on their own. In a telephone interview on 5/04/11 at 11:27 AM, Managed Care Provider Registered Nurse (RN) #M stated LVN #N had called about changing the physician order [REDACTED].#4. "The doctor will review it and might change the order, but at this point it is still an order and the physician expects it to be followed by the facility. In a telephone interview on 5/05/11 at 1:24 PM, LVN #L stated on 5/01/11 she performed a skin assessment on resident #4 after the resident was put to bed and saw a red, unblanchable area to the right ischial area. LVN #L did not remember how long the resident had been sitting up but stated, "When resident #4 is in the wheelchair we try to change her position several times an hour." Review of facility policy Protocol, Wound Prevention and Treatment, no date, provided by DON, documented in part: Stage II Treatment, Procedure: Communicate interventions to staff Educate resident/patient/family on the importance of the following: Repositioning and pressure relief C. Resident #8 Record review of medical records documented resident #8 was a [AGE] year old woman admitted to the facility on [DATE] and readmitted on [DATE]. The History and Physical dated 4/06/11 documented [DIAGNOSES REDACTED]. Record review on Physician's Telephone Orders dated 2/01/11 documented resident #8 had a history of [REDACTED]. Record review of Physician's Telephone Order dated 11/15/10 and 4/14/11 documented physician order [REDACTED]. Record review of the Care Area Assessment (CAA) on the annual MDS dated [DATE] documented that the triggered area of pressure ulcers had been addressed in a care plan. Record review of the comprehensive care plan revealed there was no care plan that addressed resident #8's skin integrity/pressure sores or that she was to have Prevalon boots on at all times. Observation on 4/28/11 at 3:27 PM, revealed resident #8 lying in bed. Prevalon boots were not on the resident. Observation on 5/02/11 at 9:31 AM, revealed resident #8 lying in bed. There were no Prevalon boots on her feet. The Prevalon boots wee laying on a chair at the foot of the bed. Observation on 5/03/11 at 1:25 PM, revealed resident #8 was not wearing the Prevalon boots. CNA #O stated resident #8 is supposed to wear the Prevalon boots at all times. "If the boots are put on, she will not remove them." Observation on 5/05/11 at 12:38 PM, revealed MDS Nurse #G and Medical Records #H looked through resident #8's closed/thinned records and confirmed there was no care plan to address the problems of maintaining skin integrity or treatment of [REDACTED]. In an interview on 5/05/11 at 12:30 PM, ADON #F confirmed there was no care plan in the resident #8's chart. D. Resident #2 Closed record review of medical records documented resident #2 was an [AGE] year old woman admitted to the facility on [DATE] and readmitted on [DATE]. The annual History and Physical dated 9/22/10 documented [DIAGNOSES REDACTED]. Resident #2 was discharged to the hospital on [DATE]. Record review of resident #2's MAR for March 2011 documented the stage II pressure sore on the right outer ankle had resolved prior to 3/01/11. Record review of Skin Grid documented on 3/24/11 an unstageable pressure sore 0.5 cm wide by 0.5 cm long on resident #2's right outer ankle was identified. Record review of Weekly Skin Assessments documented there were no documented weekly skin assessments from 2/02/11 to 3/20/11. The Assessment documented a skin tear to resident #2's left forearm, but no other skin issue was documented. E. Resident #3 Record review of medical records documented resident #3 was a [AGE] year old man admitted to the facility on [DATE]. Medical History and Physical dated 8/18/10 documented [DIAGNOSES REDACTED]. Record review of Braden Risk Assessment Scale documented only 3 assessments between May 2010 and May 2011 (8/3/10, 12/09/10 and 4/9/11). F. Resident #5 Record review of medical records documented resident #5 was an [AGE] year old woman admitted to the facility on [DATE]. Hospital History and Physical dated 7/31/10 documented [DIAGNOSES REDACTED]. Record review of the care plan Alteration in Skin Integrity: Pressure Ulcers documented resident #5 had a history of [REDACTED]. Record review of paper medical records and E-charting documented 1 Braden Skin Risk Assessment between August 2010 when E-charting began and 4/28/11 (12/10/10). Review of facility policy Protocol Wound Prevention and Treatment; Braden Scale Risk Assessment, not dated, provided by DON documented, in part: Purpose: To identify residents/patients who are at risk for skin breakdown. To identify the factors which place those residents/patients at risk. Assessment: The Braden Scale Assessment is completed in blue or black ink. It is to be completed: - On admission - Weekly: 4 weeks - Monthly: 3 months - With significant change - Quarterly Reviewed at the initial interdisciplinary Plan of Care (IPOC) meeting/Standards of Care meetings. Population: All residents/patients The universe of 13 residents identified with pressure sores was obtained from the CMS 672 dated 4/28/11 provided by DON.