Every finding on record at Harker Heights Nursing & Rehabilitation

Based on interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #2) of 5 residents reviewed for pain. The facility failed to administer Resident #2's Methadone HCI oral tablet 10MG ordered 4 times a day, each evening (6PM dose) on 08/03/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/08/26, 09/09/26, 08/10/26, and 08/11/26. This resulted in Resident #2 not receiving the therapeutic effects of her combined pain medication which caused uncontrolled pain. This failure placed the resident at risk of ongoing uncontrolled pain.Findings included Record review of Resident #2's face sheet dated 08/26/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included centrilobular emphysema (common form of COPD or chronic obstructive pulmonary disease that damages the central portions of the lung lobules), major depressive disorder (mental health disorder characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), long term current use of opiate analgesic, and low back pain. Record review of Resident #2's significant change MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Record review of Resident #2's care plan last revised 08/19/26 reflected a focus I may be at risk for self-care deficit, falls, skin concerns, pain, infection, nutritional/ hydration concerns and emotional distress with intervention medication/ treatment/ care services: administer and provide medications, treatments, diet, care, and services prescribed/ recommended and pain risk: monitoring ongoing for pain or discomfort such as repositioning, provide nonpharmacological interventions to relieve pain/discomfort such as repositioning, back rub, relaxation, etc. Administer pain medications as indicated. Another focus included I am at risk for experiencing discomfort or pain r/t comorbid medical conditions with interventions risk for pain: monitor for s/s of substance abuse such as changes in resident behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and/or loss of consciousness- administer my medication to relieve my pain as recommended by my doctor. An additional focus was seen targeted behaviors: I have been noted to exhibit wandering behaviors, including entering other residents rooms, fixated on using a wc when I can ambulate safely, ambulating in wc that do not belong to me, I have been observed wearing a cervical neck brace and arm sling without current medical indication, I have been noted to exhibit drug seeking behaviors asking other residents for medications, inquiring to the charge nurse about narcotic medications. I have been noted to exhibit episodes of unprovoked crying with intervention to administer medications as ordered. Record review of Resident #2's orders reflected the following pain medications:Hydropmorphone HCI Tablet 2MG, start date 07/31/26, give 3 tablets by mouth as needed for pain.Gabapentin Capsule 300 MG, start date 06/29/26 (d/c 08/19/26), 1 capsule by mouth 3 times a day for neuro pain.Methadone HCI Oral Tablet 10MG, start date 06/18/26 (d/c 08/14/26), give 1 tablet by mouth 4 times a day (07:00 AM, 11:00 AM, 02:00PM, and 06:00PM) for chronic pain. Record review of Resident #2's MAR for the month of August reflected the following:Hydropmorphone HCI Tablet 2MG, start date 07/31/26, give 3 tablets by mouth as needed for pain.Reflected administration as ordered. Gabapentin Capsule 300 MG, start date 06/29/26 (d/c 08/19/26), 1 capsule by mouth 3 times a day for neuro pain.Reflected administration as ordered.Methadone HCI Oral Tablet 10MG, start date 06/18/26 (d/c 08/14/26), give 1 tablet by mouth 4 times a day (7AM, 11AM, 2PM, and 6PM) for chronic pain.Reflected was NOT administered as ordered during the evening (ordered at 1800 or 6PM) from 08/03/26 through 08/11/26.**record reflected Hydromorphone WAS still being administered after 6pm. This was a narcotic medication that was ordered and administered for pain management to work alongside other pain medications prescribed. Record review of Resident #2's controlled substance administration record sheets for Methadone 10MG tablet ordered 1 tablet by mouth 4 times a day, reflected that the medication was not documented as provided for the 6pm dose on 08/03/26 through 08/11/26. During an interview on 08/26/26 at 02:52 PM., the ADM stated his expectation as it pertains to pain management is that it is managed for those residents in pain. He stated if there is scheduled pain medication there is no reason for it to not be given, if it were only a PRN medication then its provided at the residents request. The ADM stated if pain medication that was scheduled was missed, there was the potential that pain would not be managed for the resident. During an interview on 08/26/26 at 03:35 PM., MT D stated she worked evening shifts and worked with Resident #2 between 08/03/26 and 08/11/26. She stated she was responsible for giving scheduled medications to the resident and PRN pain medication a nurse would have provided. She stated the Methadone HCI 10MG tablet was her responsibility to provide because it was scheduled. MT D stated that she did not provide the medication because Resident #2 had been complaining about getting her medications too early or on other occasions she would be asleep and she hated to be woke up for medications. MT D stated Resident #2 has chronic pain even if you give her the medications she will claim she is in pain. MT D stated that she took responsibility for this error because if the resident was refusing the medication, it should have been documented, or she should have reported it to the nurse and spoken to the provider about changing the time on the medication. if possible, to better accommodate when the resident wanted it. She stated if residents were not provided their pain medication. they could be in a lot of pain. During an interview and observation 08/26/26 at 03:59 PM., Resident #2 stated she was on a lot of strong medication to address her chronic pain that she had since she was [AGE] years of age. She stated she knew the facility was trying hard to address and manage her pain and the providers were good about listening to her concerns. She stated however that there was a few days in early August that her pain medication was not provided, and that did not help because she was in more pain than she normally was. She stated some days she cried as a result of the pain. Resident was observed self-propelling to her room, once in her room she was observed placing on a cervical neck brace (with no medical indication), her mood appeared well, no crying or distress, and she stated she wanted to cut the interview short to go outside and smoke. Resident #2 stated the ADM was a lifesaver when it came to her pain, but she wanted to avoid pain medication being missed again for multiple days. Resident #2 stated she did not completely go without pain medication as other scheduled medications were still provided. She stated she did not feel they reached a therapeutic effect since she missed the Methadone. She stated if she had scheduled pain medication and she was asleep she would have wanted staff to wake her up. During an interview on 08/26/26 at 04:11 PM., the DON stated the Methadone was not administered at 6pm as ordered between 08/03/26 and 08/11/26. She stated the expectation was that residents were medicated per physicians orders. She stated if there is a scheduled pain medication and the resident is sleep it was her expectation for the staff to attempt to wake them up, if they refuse it needed to be documented and if they needed to make adjustments to the schedule the provider needed to be notified. The DON stated that if pain medication is not provided there would be continued complaints of pain due to unmanaged pain. She stated if medication is not being documented or refusals are not being documented there would not be a clear picture of whether or not pain was being managed for a resident. Record review of the facility policy titled Medication Administration dated March 2019 reflected: Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner.Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community. Time Sensitive Medications and Non-Time Sensitive Medications/TreatmentsTime-sensitive medications: Medications/treatments that are time sensitive should be ordered by the prescriber as such. The prescriber's order should indicate the specified time that the medication should be administered, i.e., administer daily at 9 am or administer daily before breakfast.Scheduled opioids for chronic pain or palliative careTime Sensitive Medications/Treatments should be administered according to the prescribed time which includes a one hour before and one hour after the specified administration time as per standard of practice.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was implemented on 08/22/26, which required non spill cup with hot liquids which resulted in the resident spilling coffee on herself. This failure could place residents at risk of not having their individual medical and nursing needs being met, which could result in preventable accidents.Findings included: Record review of Resident #1's facesheet dated 08/26/26 reflected an [AGE] year-old female initially admitted to the facility on [DATE] with diagnosis that included normal pressure hydrocephalus (neurological condition characterized by accumulation of cerebrospinal fluid in the brains ventricles leading to symptoms such as cognitive decline, gait disturbances, and urinary incontinence), essential hypertension (high blood pressure), Alzheimer's disease (neurodegenerative disorder that affects memory, thinking and behavior) with late onset, and adult failure to thrive (syndrome of progressive decline in weight, nutrition, physical function, and cognitive or emotional health, most commonly seen in older adults) Record review of Resident #1' quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #1's care plan last revised 08/10/26 reflected a special focus area initiated 02/14/26, I am at risk for nutritional deficits and/or dehydration risk r/t chronic comorbidity medical diagnosis with intervention that included non spill cup with hot liquids. Record review of Resident #1's Kardex report dated 08/26/26 reflected section z-diet which indicated non spill cup with hot liquids. Record review of Resident #1's hot liquid assessment dated [DATE] reflected cognitive impairment applied to Resident #1 which impacted the resident's ability to safely handle hot liquids. A focus included I have the potential for injury r/t hot liquid spill; may benefit utilizing a lid on a hot liquid cup. Record review of Resident #1's skin assessment on the MAR/TAR for 08/25/26 reflected no skin issues. Record review of Resident #1's kitchen slip dated 08/26/26, notes for all meals reflected hot lid. Record review of FM submitted image of Resident #1 timestamped 08/22/26 at 11:14 AM reflected Resident #1 sitting in her wc with dark fluid stain that covered Resident #1's left torso on outer clothing, abdomen, and lap/ both upper pant legs. During an interview on 08/26/26 at 10:45 AM with Resident #1's FM, she stated she arrived at the facility the morning of Saturday 08/22/26 to find Resident #1 in the dining room covered in coffee, had a strong coffee smell coming off of her and did not see any staff members provided assistance. She stated that when she asked Resident #1 at the time what happened the resident indicated hot liquid spilled on her. FM stated that she has provided the facility with cups with lids to use for hot liquids but that she has not seen them use it and did not see it in use that morning for Resident #1's coffee. She stated she immediately went to notify LVN A that Resident #1 had s spill on her, and LVN A said she would find a CNA to assist. During an interview on 08/26/26 at 12:22 PM., LVN A stated she worked the morning of 08/22/26 and worked with Resident #1. She stated Resident #1's FM approached her saying Resident #1 was wet, she stated the FM did not mention it was coffee, so she was not aware the resident had a coffee spill. She stated the FM only said she is wet and this is unacceptable. LVN A stated Resident #1 was not cognitive enough to indicate what could have happened or to verbalize if she was in pain. LVN A stated when she had seen her after the CNAs had already changed her clothing and Resident #1 did not appear to be in any pain or showing any signs of discomfort from the spill. LVN A stated RN B was the nurse assigned the dining room that day, and she was not sure what cup Resident #1 was provided because she was not in the dining room. During an interview on 08/26/26 at 12:37 PM., RN B stated she worked the morning of 08/22/26 and was working the breakfast shift. She stated when she works in the dining room her duties and responsibilities included passing meal trays and checking the meal tickets to ensure everyone gets their food per their diet, and any assistive devices as indicated on the tickets. RN B stated that Resident #1 regularly has coffee for her meal. She stated Resident #1 was provided a cup with 2 handles that makes it easier to hold, but that she is not provided a lid. She stated during all meals she had only seen Resident #1 being provided a coffee cup with an open top. RN B stated the purpose of the care plan was to ensure that care was provided based on what the resident needs which is individualized. RN B stated she was not aware of what the residents needs were based on the care plan for hot coffee. After reviewing the care plan with she stated Resident #1 was supposed to have a non-spill cup with a lid based on the care plan. She stated she did not consider the cup that had been provided for Resident #1's meals a non-spill cup, but instead an open top cup. She stated a negative outcome of not following the plan of care, which required a non-spill cup with lid, had the potential to result in burns if the coffee was hot enough and there is also other concerns of affecting the residents self-esteem and dignity with spilled fluids. RN B stated Resident #1 was not cognitively intact and therefore could not indicate to staff if she needed help or was in any pain. She stated CNAs were supposed to report if they saw or knew of a hot liquid spill which they did not after learning of the incident and changing Resident #1. She stated if not reported it could have resulted in an injury they did not know about getting worse. During an interview on 08/26/26 at 12:56 PM, CNA C stated she worked Saturday 08/22/26 and was the CNA that changed Resident #1 from her soiled clothing following the spill after she was informed by LVN A that she needed assistance. CNA C stated Resident #1 did not appear to be in any pain or distress from the spill. When the clothing was removed, CNA C stated she did not see any redness or burns on Resident #1. CNA C stated she was not aware of the resident needing a cup with a lid, but she had recommended that to the facility nurses in the past because she noticed Resident #1s hands shake a lot. CNA C stated when she sees Resident #1 in the dining room with coffee for meals its always in a regular mug with an open top and would not consider it a non-spill cup with lid per the care plan/ Kardex. CNA C stated that if the care plan was not being followed it had the potential to result in hot liquid spills and burns. She stated that Resident #1 did not have the cognitive ability to request help so she could have sat for an extended period of time with the spill before getting the assistance she required. During an interview on 08/26/26 at 02:29 PM., the DON stated she was new to the facility and had only worked there 3 days so was not familiar with the incident and was not alerted to any hot liquid spill. She stated that the purpose of the care plan is to communicate with the care team how to provide patient specific care. She stated it was her expectation that the care plan was updated as needed with anything identified that a resident needed. She stated it was the expectation that all direct care staff look at the care plan, so they would know what the residents needed. She stated if the care plan was not being followed the resident had the potential of not be receiving the specific care they required. She stated the hot liquid spill could have resulted in skin injury. During an interview on 08/26/26 at 02:52 PM., the ADM stated the purpose of the care plan was to be able to meet the needs of the resident. He stated the expectation was that the care plan was implemented by anyone that cared for the residents. He stated the potential negative outcome of not following the care plan depended on the section not followed, the potential negative impact to not using a non-spill cup with lid had the potential to result in hot liquid on the residents skin and potential physical harm. Record review of the facility policy titled Care Plan Development, Review, and Update Policy last revised January 2026 reflected: I. PurposeTo ensure that each resident receives an individualized, person centered care plan that reflects their assessed needs, goals, preferences, risks, and strengths, and that the care plan is developed, implemented, and updated in accordance with federal regulations and RAI Manual guidance.II. Policy StatementThe community will develop and maintain a comprehensive, interdisciplinary, person centered care plan for each resident. The care plan will include measurable objectives, appropriate interventions, and resident directed goals designed to support the resident's highest practicable physical, mental, and psychosocial well being.Care PlansThe community develops a comprehensive care plan for each resident that includes measurable objectives designed to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The care plan should reflect the identified problem or risk, the measurable outcome objective, and the appropriate interventions based on the resident's abilities, needs, medical condition, and preventative measures. The care plan may also include the resident's expressed preferences.The care plan should be written in a manner that is understandable, and actionable for staff, ensuring that the interventions can be implemented as intended. The care plan should also allow for appropriate variability in care approaches when the resident's needs fluctuate, and within the scope of the resident's assessed needs and abilities.The care plan, in conjunction with the broader plan of care documented throughout the medical record, is developed to help the resident attain or maintain their highest practicable physical, mental, and psychosocial well being, in accordance with federal regulations and RAI guidance.

Based on observation, interview, and record review, the facility failed to ensure that residents receive the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish for 5 of 7 residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for quality of life. The facility failed to ensure nursing staff provided scheduled showers for Resident #2 according to his ADL care plan goal. The facility failed to ensure Resident #3, Resident #4, Resident #5, and Resident #6 were provided with perineal care and showers according to their ADL care plan goals. These failures could place residents at risk of decline in physical, mental, and psychosocial well-being. The findings included: 1.Record review of Resident #2's face sheet, dated 07/15/2026, reflected a [AGE] year-old-male initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures), and history of falling. Record review of Resident #2's quarterly MDS Assessment, dated 06/24/2026, reflected a BIMS score of 11 indicating moderate cognitive impairment and Resident #2's frequent incontinence of bladder and bowels status. Record review of Resident #2's Comprehensive Care Plan, dated 06/24/2026, reflected Resident #2's focus: Self-care deficit related to cognitive impairment and weakness and debility with interventions: Bathing/shower schedule: prefer to be showered 2-3 times weekly and as needed. Bathing: Tuesday, Thursday and Saturday: 6-2. Record review of Resident #2's nursing progress notes, dated 07/09/2026, reflected a head-to-toe skin assessment completed with no skin abnormalities documented and no notes regarding Resident #2's missed showers were identified. Record review of bathing POC for 30 days (6/16-7/14) identified the facility did not follow the shower schedule of 3 days a week with showers provided and documented on 6/27/26, 7/2/26, 7/09/2026, 7/11/26 and 7/14/26 with Resident #2's refusals on 6/18/26, 6/20/26 and 6/23/26. No showers were provided and documented on 06/16/2026, 06/25/2026, 06/30/2026, 7/04/26, 07/07/2026 indicating Resident #2 was offered 8 showers in last 30 days. Record review of nursing notes, dated 07/09/2026, revealed Resident #2's head-to-toe assessment: Resident assessed. Comprehensive head-to-toe skin assessment completed by this nurse in conjunction with the Wound Care Nurse. [Resident #2] observed alert and in no acute distress. [Resident #2] denied pain and stated pain level was 0/10. No bruising,redness, skin tears, pressure injuries, or other abnormal skin markings noted. Skin observed to be dry and intact throughout assessment. [Resident #2's] family member was present at the bedside during the assessment. Per [family member's] request, resident was provided with shower, which was completed without incident. [Resident #2] tolerated assessment and care well. No additional concerns identified at this time. Plan of care ongoing. During an interview with Resident #2 on 07/16/2026 at 11:16 a.m., he stated that he received showers sometimes and he did not refuse showers. Resident #2 did could not clearly express his opinion about not receiving his showers on a regular basis. During an interview with Resident #2's family member on 07/16/2026 at 1:08 p.m., she stated that she reported her concerns to ADM regarding Resident #2's showers on his scheduled days. The family member stated, For several months, he has not been receiving showers as expected. The situation has continued and recently worsened. She stated that she communicated to nurses and they were unsure why Resident #2 was not provided with showers. She stated that when she called the facility on 07/04/2026 and asked to assist Resident #2 with getting up and showering him before she takes him out for a family visit, staff got Resident #2 out of bed but did not provide him with a shower. She stated that because he was not showered by staff, she did not take him out for a family visit that day and she gives him showers herself because staff do not shower him. During an interview with CNA F on 07/16/2026 at 11:32 a.m., she stated that CNAs were responsible for providing showers and they did not have shower aides in the facility available for assistance with showers. She stated that she attempted to assist with Resident #2's showers but she did not always have time to do the task as she had 18-20 residents, she was taking care of. She stated that not providing regular showers could affect the skin condition and lead to infection. 2.Record review of Resident #3's face sheet, dated 07/15/2026, reflected a [AGE] year-old-female initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough of it, leading to high blood sugar), and anxiety disorder (cause intense, excessive, and persistent worry about everyday situations that do not go away and often worsen over time). Record review of Resident #3's quarterly MDS Assessment, dated 06/04/2026, reflected her BIMS score of 12 indicating moderate cognitive impairment and always incontinent of urine and frequently incontinent of bowel status. Record review of Resident #3's comprehensive Care Plan, dated 06/23/2025, reflected Resident #3's focus: self-care deficit and skin concerns with interventions: provide ADL care as indicated. Focus: incontinent with interventions: ask and assist resident to toilet during waking hours and check/change on rounds and as needed. During an interview with Resident #3 on 07/16/2026 at 9: 25 a.m., she stated she was not provided with perineal care when she asked she called to be assisted with changing for about two hours and did not receive needed showers on the regular basis. She stated that it made her feel sad when she had to wait for 1-2 hours to be changed or not getting her showers. 3.Record review of Resident #4's face sheet, dated 07/15/2026, reflected a [AGE] year-old-female initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, type 2 diabetes mellitus, epilepsy. Record review of Resident #4's quarterly MDS Assessment, dated 06/15/2026 reflected Resident #4 had a BIMS score of 0 indicating severe cognitive impairment. Resident #4's bladder and bowel assessment reflected: always incontinent. Record review of Resident #4's Comprehensive Care Plan, dated 03/24/2024, reflected Resident #4's focus self-care deficit and skin concern with interventions bathing/showering x2 person assistance with documented family prefer to give a shower-on-shower days. Toileting/Incontinent Care x 2 person assistance. 4.Record review of Resident #5's face sheet, dated 07/15/2026, reflected a [AGE] year-old-female initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included unspecified Alzheimer's disease (a progressive brain disorder characterized by memory loss, cognitive decline, and personality changes.), major depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy), and aphasia (a language disorder caused by brain damage that impairs speaking, understanding, reading, and writing). Record review of Resident #5's quarterly MDS Assessment, dated 06/24/2026 reflected Resident #5 had a BIMS score of 0 indicating severe cognitive impairment. Resident #5's bladder and bowel assessment indicated: always incontinent. Record review of Resident #5's Comprehensive Care Plan, dated 02/23/2026, reflected Resident #5's focus: self care deficit related to cognitive impairment. My family has been noted to be involved in shower days and has been noted to prefer to give a shower on shower days. with interventions indicated: Bathing 3 days a week. Focus: Risk for skin impairment with intervention: keep clean and dry and apply skin barrier cream. Focus incontinence related to dementia, impaired mobility, and inability to communicate needs with intervention check and change on rounds and as needed. Resident #4 and Resident #5 were observed 07/16/2026 at 10:39 a.m. sitting in their room in wheelchairs and were not able to respond to questions comprehensively. During an interview with Resident # 4 and Resident #5's family members on 07/16/2026 at 10:41a.m., they statedthey come to help with showers as not enough staff are available to provide showers and CNAs do not have enough time to do it. They stated that they put a camera in the room and were able to monitor the care and frequently see that only one CNA works on the 200 hall in the afternoon. They stated that they bring their own wipes and briefs as supplies were not always available and perineal care is not always provided to their family members, so they call the facility to come to change their family members. They stated there were no concerns and issues with skin at this time only because they are very involved and monitor the perineal care themselves. Record review of Resident #6's face sheet, dated 07/15/2026, reflected a [AGE] year-old-male admitted [DATE] with diagnoses which included discitis (a rare condition involving inflammation of the cushion-like discs between the bones of the spine), lumbosacral region (the lower part of the back where the lumbar spine meets the sacrum), type 2 diabetes (a chronic condition where the body resists insulin or does not make enough insulin, leading to high blood sugar), and major depressive disorder (a common mood disorder defined by persistent sadness, low energy, and loss of interest in activities). Record review of Resident #6's quarterly MDS Assessment, dated 06/01/2026 reflected Resident #6 had a BIMS score of 14 indicating his cognition was intact. Resident #6's bladder and bowel assessment indicated: occasionally incontinent of bladder and bowel. Record review of Resident #6's Comprehensive Care Plan, dated 07/15/2026, reflected Resident #6's focus: risk for complications associated with incontinence of bowel and bladder with interventions assist with toileting as indicated. Skin risk: monitor skin during care and report to nurse if any signs of skin breakdown as needed. During an interview with Resident #6 on 07/16/2026 at 2:31 p.m., he stated that he had to wait on CNA G to change him for 45 minutes and he had to lay in his feces for 45 minutes and he called and asked multiple times and was not assisted for 45mins to an hour. It made him feel frustrated and angry. He stated that this facility is short staffed and sometimes he does not get his showers as scheduled. He stated that he complained to charge nurses and did not get responses. During an interview with CNA B on 07/16/2026 at 10:12 a.m., she stated she was responsible for providing peri care for residents including Resident #3 and there is always a shortage of staff in this facility, especially on weekends when only 3-4 CNAs work on weekends with about 25 residents per one CNA. She stated that sometimes she was not able to assist residents with showers or get them out of bed or answer call lights promptly due to lack of assistance from other nursing staff including charge nurses and administration. She stated that she reported it to ADM and he did not get back to her. During an interview with CNA C on 07/16/2026 at 11:06 a.m., she stated she was responsible for bathing and providing perineal (the region of the body between the thighs, encompassing the area from the pubic bone to the tailbone) care to residents on a timely basis in the facility according to their shower schedules. She stated that there was a schedule for residents' showers: three times a week and morning/evening showers. She stated that CNAs were responsible for documenting showers in POC or shower sheets. She stated that they were responsible for reporting to charge nurse any skin abnormalities and shower refusals. She stated that she was responsible for about 12-15 residents and her hallway was very busy with residents needing two people assistance for transfers and showers and they did not have enough CNAs to assist, so sometimes they did not provide showers to residents as scheduled. She stated that she did not feel it was safe for residents with staff to resident ratios, but they need a shower aide to assist with showers and facility does not provide a shower aide. She asked for help from other CNAs or nurses, but they are busy too. She stated that not providing showers or changing residents timely could affect their skin condition and cause infection. During an interview with CNA D on 07/16/2026 at 1:40 p.m., she stated that she takes care of 20 residents sometimes and tries to do everything including rounding every two hours, providing perineal care and showering them according to the shower schedule. She stated that sometimes she did not have time to provide showers and complete perineal care to residents due to being very busy. She stated that not providing perineal care and leaving residents to stay in wet clothes could affect them mentally and cause skin issues like infection.During an interview with ADM on 07/16/2026 at 4:56 p.m., he stated that CNAs and charge nurses were responsible for providing showers and proper/timely perineal care to residents. He stated that according to the facility's policy the resident quality of life is safe environment and all their needs are met. He stated that residents receive showers and perineal care as often as possible. He stated that if nursing staff were notified about residents' request for care, they should come as soon as they were available. He stated that aides know shower schedules and they need to report and document in POC. He stated that charge nurses were responsible for checking POC documentation and DON was responsible for overseeing the whole system. He stated if perineal care and showers were not provided promptly, it could affect residents' health outcome. During an interview with DON on 07/16/2026 at 4:29 p.m., she stated she in-serviced all staff including quality-of-Care training sometime in the last quarter. The training included: residents being changed and checked frequently. The policy does not specify exact time of rounding and changing. She stated that the facility's policy indicated providing the most basic care to the best of their ability. She stated that all team members could answer the call and nursing staff could provide showers and provide perineal care with routine rounding: every couple of hours. If resident notified nursing staff and requested to be changed and were not provided with changing for 45 minutes-1 hour that was not acceptable. She stated that it was not neglectful if it was not deliberate and depended on the situation. She stated that potential risk of not providing perineal care and scheduled showers could be skin breakdown. She stated that they were fully staffed with 2 CNAs and one nurse per hall. In case of emergencies and short staff situations, they used agency staff to fill in. She stated that nobody complained to her about short staff and not being able to provide showers for residents. Record review of the facility's policy on Quality of Care, dated January 2023, reflected Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records. The facility failed to ensure RN A documented oxygen saturation assessment on 6/13/2026 according to the physician order in Resident #1's medical records. This deficient practice could place residents at risk of not receiving proper care due to incomplete and inaccurate records. The findings included: Record review of Resident #1's face sheet, dated 07/15/2026, revealed a [AGE] year-old-female admitted on [DATE]. Her diagnoses included acute kidney failure (a sudden loss of kidney function that happens over hours or days), chronic obstructive pulmonary disease (a progressive lung disease that makes breathing difficult), and pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus). Record review of Resident #1's initial care plan, dated 06/13/2026, revealed a focus: risk for self-care deficit, falls, skin concerns, pain, infection and nutrition/hydration concerns. with intervention indicated: Monitor vital signs and health condition as indicated; with another focus: risk for experiencing shortness of breath with interventions indicated monitor oxygen saturation (measures the percentage of hemoglobin in your blood carrying oxygen) as ordered by a doctor and as clinically indicated. Record review of Resident #1's order summary report, dated 06/12/2026, revealed an order for monitoring oxygen saturation every shift with start date 07/13/2026. Record review of Resident #1's vital signs including oxygen saturation and nursing progress notes did not reveal vital signs and oxygen saturation results documented for Resident #1 between 07/12/2026 at 6:00p.m. and 07/13/2026 at 6:00 a.m. (night shift). During an interview with RN A on 07/15/2026 at 2:23 p.m., she stated she worked as a nurse for 35 years and was trained to assess and document assessment results in residents' medical charts. She stated when she started working at this facility, she was trained for two days and did not have training in documentation policies. RN A stated she knows that she was supposed to document results of her assessment of vital signs and oxygen saturation for all residents including Resident #1 in medical charts as soon as possible before the end of her shift on 06/13/2026. RN A stated that she did not chart Resident #1's oxygen saturation because she got busy and forgot to do it. She stated she checked on Resident #1 every 2 hours and as needed. She stated that Resident #1 was on 5L of oxygen supplement through nasal canula and such a high concentration of oxygen worried her in the beginning of her shift on 06/12/2026, but Resident #1 was not in distress and seemed to be ok. She stated she did an assessment constantly, every two hours and sometimes more often- twice every hour. She stated she did not see any signs of distress in Resident #1 all night. She stated that if the physician order was to check oxygen saturations every shift, she did it but did not document the results in Resident #1's chart as she was responsible for doing it to maintain accurate clinical documentation. She stated that she looked at Resident #1's skin colors, listened to her breathing sounds, and did not notice any shortness of breath or decline in oxygen saturation. RN A stated that she did not chart Resident #1's oxygen saturation , but she checked her oxygen saturation through her shift and it was: 94-95%. During an interview with MD on 07/15/2026 at 4:24 p.m., she stated that if the physician order stated to check Resident #1's oxygen saturation, nurses were responsible to follow the order and document results in Resident #1's medical chart. She stated that documenting accurately in medical charts was important to provide the proper and accurate documentation of Resident #1's assessment and prevent worsening of her health condition. During an interview with NP on 07/15/2026 at 11:10 a.m., he stated that checking vital signs and oxygen saturation for Resident #1 every shift was important with proper documentation of nursing assessment per physician order. He stated that he saw Resident #1 on 06/12/2026 in the afternoon after she arrived at the facility and she was stable and not in distress. He stated that if nursing assessment was not documented, it could potentially compromise care and put residents at risk of receiving incorrect treatment. During an interview with PA on 07/15/2026 at 4:10 p.m., she stated RN A notified her that Resident #1 was not in distress during her shift from 6:00 p.m. on 06/12/2026 to 6:00 a.m. on 06/13/2026. She stated perhaps RN A could see that Resident #1 was not hypertensive (high blood pressure) and hyperventilating (breathing faster or deeper than normal). She stated vital signs should be checked and documented more often than just on residents' admission. During an interview with ADM on 07/16/2026 at 4:56 p.m., he stated that charge nurses were responsible for documenting residents' assessment and care provided during their shifts. He stated if there was an order to check the oxygen saturation, it should be followed and documented. He stated that if it was not followed or documented, it could interfere with residents' care and affect the health outcome. During an interview with DON on 07/16/2026 at 4:29 p.m., she stated charge nurses were responsible for residents' assessments and documentation of assessment results. She stated if not documented properly, it could prevent monitoring the change of condition. She stated Resident #1 had an order for assessing oxygen saturation once a shift and she was not sure why RN A did not document her assessment in Resident #1's medical records. Record review of the facility's policy on Oxygen Administration in the Facility, dated January 2023, reflected Obtain physician orders for oxygen administration. Orders should include the following: d. oxygen saturation monitoring parameters, if indicated. Monitor the resident's response to oxygen therapy. Check pulse oximetry as indicated by physician's orders. 6. Monitor the resident for signs of hypoxemia (a lower-than-normal level of oxygen in your blood, primarily affecting arteries. Normal oxygen saturation is 95% or higher) as appropriate, such as: pulse oximetry (fast, painless test that measures the oxygen level of blood and pulse rate by shining light through a fingertip, earlobe, or toe), vital signs (respiratory rate). Documentation: place documentation in the treatment administration record and medication administration records, and resident progress notes: resident's vital signs, respiratory effort. Record review of the facility's policy on Professional Standard of Care, dated January 2023, reflected Nurses should conduct assessments or evaluations and document nurses' notes in the following instances:Routine charting for residents should reflect the recipient's ability as assessed upon admission, re-admission and as clinically indicated.

Based on, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 18 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 was provided incontinent care from 11:30 p.m. until 5:50 a.m. on 06/11/2026. This failure could place residents at risk of infection, skin breakdown and diminished quality of life.Findings include: Record review of Resident #1's face sheet, dated 06/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental function), dementia (memory, thinking, difficulty), bipolar (extreme mood swings), history of malignant neoplasm of bladder (cancer of the bladder), hypertension (high blood pressure), and protein-calorie malnutrition (inadequate intake of both protein and calories).Record review of Resident #1's quarterly MDS assessment, dated 03/15/2026, reflected a BIMS score of 0, which indicated severe cognitive impairment. [Resident #1] was dependent on staff for toileting hygiene (helper does all of the effort. Resident does none of the effort to complete the activity). [Resident #1] was always incontinent of bowel and urine.Record review of Resident #1's care plan, dated 05/12/2026, reflected the following: Focus: Baseline / Initial Care Plan: [Resident #1] may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress. Cognition Impairment, Resident has difficulty communicating her needs/wants, Weakness and debility.Goals: [Resident #1] condition will be stable and his/her needs will be anticipated and met as indicated. Resident will not experience a health decline.Interventions: Provide ADL care as indicated. See nurse for any care related questions or concerns. *Interview Patient/Resident/Representative regarding: ADL & care needs/preferences.During an interview with Resident #1's FM on 06/11/2026 at 11:35 a.m., she said Resident #1 did not get incontinent care from 11:00 p.m. when she changed Resident #1 until 5:00a.m. on 06/11/2026 by CNA A. She said she had other days Resident #1 did not get changed on camera. She said she talked to the facility about Resident #1 not getting changed at night and nothing had been done about it. She said she would provide the camera footage.During an interview with CNA B on 06/11/2026 at 2:05 p.m., she said she had been trained on incontinent care. She said the policy for changing the residents was to change them every two hours. She said the CNAs were responsible for changing the residents. She said if staff did not change the resident regularly the resident could have skin breakdown. She said the CNAs monitored to ensure the residents were changed. She said the CNAs monitored by checking the residents. She said she did not know why Resident #1 was not changed all night. During an interview with CNA C on 06/11/2026 at 2:19 p.m., she said she was trained on incontinent care. She said the policy was that staff must round on the resident every two to three hours and change the resident. She said the CNAs were responsible for changing the residents. She said if the resident did not have brief changes the resident could have skin break down. She said the DON monitored to ensure staff were changing the residents. She said the DON monitored by checking on the residents. She said she did not know why CNA A did not provide Resident #1 was not changed all night.Interview attempted with CNA A on 06/11/2026 at 02:49p.m., was unsuccessful. Interview attempted with DON on 06/11/2026 at 3:56 p.m., revealed she had to leave the facility. During an interview with the ADON on 06/11/2026 at 4:01p.m., she said she was trained on incontinent care. She said the policy for changing the residents was to check and change the resident every two hours. She said the licensed nursing staff and direct care staff were responsible for changing the residents. She said if a resident was not changed regularly it could cause skin breakdown and could also lead to other issues. She said the Nurses, DON and ADON monitored to ensure staff were changing the residents. She said the nurses, DON and ADON monitored by doing rounds on the residents. She said she had one complaint recently about Resident #1 not being changed. She said she had not done anything yet. She said she did not know why Resident #1 did not get changed. During an interview with the ADM on 06/11/2026 at 4:12 p.m.,. He said his expectation was to change the residents if the resident needed to be changed. He said the CNAs, nurses, and medication aides were responsible for changing the residents. He said if the resident was not being changed regularly it could affect their skin integrity. He said the nurse monitored to ensure staff were changing the residents. He said the nurse monitored through rounds. He said he did not know why the staff did not change Resident #1. Record review of video footage dated 06/11/2026 from midnight to 5:58am revealed no staff entered the room to change Resident #1.Record review of the Activities of Daily Living Policy, dated 1/2023, revealed Each resident's abilities to perform activities of daily living will not diminish unless the individual's clinical condition demonstrates that diminution was unavoidable. Activities of daily living include personal hygiene, and toileting.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling.The facility failed to ensure MC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings include:During an observation of the nurses station on 06/11/2026 at 12:35 p.m., revealed LVN D was down one of the halls and the medication cart was up against the nurses station unattended and unlocked. MC #1 contained residents prescription medications, narcotics, antibiotic ointment, and over the counter medications. Staff and residents were observed walking past the unlocked medication cart.During an interview with LVN D on 06/11/2026 at 12:37 p.m., she said she was trained on medication storage. She said the policy was staff must lock the medication carts any time the nurse/medication aide walked away from the cart. She said the nurse or whoever was working on the cart was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident or someone else could get into the medication cart and take medications. She said management monitored to ensure the medication carts were locked. She said management monitored the medication carts through observation. She said she had two residents who wanted their nails cut and she was looking for her nail stuff and she forgot to lock the medication cart.During an interview with the ADON on 06/11/2026 at 04:05 p.m., she said she was trained on medication storage. She said the policy was the medication cart was to be locked at all times. She said whoever was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended someone could get into the medication cart and take medications. She said the ADON and RNs monitored to ensure staff locked the medication cart. She said the ADON and RNs monitored through observations. She said she did not know why LVN D left the medication carts unlocked.During an interview with the ADM on 06/11/2026 at 04:16 p.m., revealed his expectation for the medication cart was the nurses locked the medication carts when they were not in them. He said the person who was using the medication cart was responsible for ensuring the medication cart was locked. He said if the medication cart was left unlocked and unattended someone could get into the cart and take medication. He said everyone monitored to ensure the staff were locking the medication cart. He said everyone monitored by doing rounds. He said he did not know why LVN D left the medication cart unlocked.Record review of the Medication Cart Use and Storage Policy, dated January 2023, reflected The nursing Team Members (Nurses & CMA's) use the medication cart to systematically distribute physician ordered medications to residents. he medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. If an emergency occurs during a medication pass, the nurse/medication aide should be closed, secured and/or in the line of sight before attending to the emergency.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) for medical records.The facility failed to ensure Resident #1's skin tear cleaning was documented completed in the electronic medical record for 04/07/2026, 04/08/2026, and 04/13/2026.These failures could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.Findings included:A record review of Resident #1's face sheet, dated 05/16/2026, reflected a [AGE] year-old male, admitted [DATE]. Resident #1's diagnoses included unspecified dementia (cognitive decline), Alzheimer's disease (progressive irreversible brain disorder that slowly destroys memory and cognitive skills), and hypertension (high blood pressure).A record review of Resident #1's care plan, dated 03/10/2026, reflected Resident #1 was at risk for skin impairment (diminished, weakened, or damaged).A record review of Resident #1's Quarterly MDS assessment, dated 04/16/2026, reflected Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment. Resident #1 was at risk of developing pressure ulcers/injuries and had one unhealed pressure ulcers/injuries.A record review of Resident #1's physician's order, dated 04/06/2026, reflected cleanse skin tear to LLE (lower left extremity) with wound cleanser, pat dry with 4x4 gauze, apply hydrogel (advanced water based dressing that mimics the body's natural moisture), cover with Xeroform (sterile, non-adhering petrolatum dressing), cover with dry dressing qd (everyday) until resolved, once daily, starting 04/06/2026.A record review of Resident #1's TAR, dated 04/07/2026, 04/08/2026, and 04/13/2026, reflected to cleanse skin tear to LLE (lower left extremity) with wound cleanser, pat dry with 4x4 gauze, apply hydrogel (advanced water based dressing that mimics the body's natural moisture), cover with Xeroform (sterile, non-adhering petrolatum dressing), cover with dry dressing qd (everyday) until resolved, once daily,was not signed off completed in the electronic medical record by LVN A.Attempted an interview and observation with Resident #1 on 05/15/2026 but Resident #1 had transferred out of the facility on 04/28/2026.During an interview with Resident #1's RP on 05/15/2026 at 12:37 PM, stated Resident #1 was transferred to another nursing facility in another town. Resident #1's RP stated the facility did not meet her expectations of what they had agreed to and she transferred Resident #1 out because she wanted what was best for Resident #1 and she was the only family that Resident # 1 had.During an interview on 05/17/2026 at 1:33 PM, LVN A stated she was responsible for signing off in the electronic medical record when she completed Resident #1's skin tear cleansing treatment on the leg. LVN A stated that she failed to sign off in the electronic medical recorc after she had completed the treatment on 04/04/2026, 04/08/2026, and 04/13/2026. LVN A stated she was assisting with other job duties and did not sign off in the electronic medical record that the treatment was completed. LVN A stated if treatment was not signed off on in the electronic medical record it would look like the skin tear treatment did not happen.During an attempted telephone interview on 05/17/2026 at 2:00 PM, 2:35 PM, and 2:55 PM, the Wound Care Nurse did not answer. Voice messages were left and no return calls were received by exit 05/17/2026 at 4:30 PM or after.During an interview on 05/17/2026 at 3:25 PM, the DON stated it was LVN A's responsibility to have documented in electronic medical record on 04/07/2026, 04/08/2026, and 04/13/2026 that the skin tear treatment to leg of Resident #1 was completed. The DON stated that she would have been responsible for double checking to make sure the documentation was in the electronic medical record. The DON stated she failed to double check. The DON stated if documentation was not signed off on, it would indicate the treatment did not happen.During an interview on 05/17/2026 at 3:40 PM, the ADM stated LVN A was responsible to have signed off in the electronic medical record that Resident #1's treatment was completed for 04/07/2026, 04/08/2026, and 04/13/2026. The ADM stated it was expected for LVN A to have documented in the electronic medical record once the treatment was completed. The ADM stated that without documentation in the electronic medical record it would not show the treatment was completed.Record review of the facility's, revised 01/2024 , policy titled, Professional Standard of Care, reflected, Nurses should conduct assessments or evaluations and document within the medical record in the following instances:admission, re-admission and as clinically indicated.at the time of accidents, incidents or change in conditionswhen exceptions are identifiedas otherwise directed.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure the dumpsters were free from debris on 4/14/26 and on 4/15/26. The facility failed to ensure that 2 dumpsters were closed/covered on 4/14/26, 4/15/26 and 4/26/26.CK H failed to close/cover the dumpster after using it on 4/15/26. These failures placed residents at risk of being exposed to rodents and pests.Findings included: During an observation of the facility's dumpsters on 4/14/26 at 11:45 AM, three plastic gloves and one metal can were observed between the two dumpsters and the dumpster on the left was open. During an observation interview on 4/14/26, a rodent trap was observed outside of the kitchen's back door. The Dietary Supervisor stated no the facility had not had any problems with rodents. During an observation on 4/15/26 at 10:16 AM, CK H put a bag of trash in the dumpster and walked away without closing it. An observation of the dumpster area on 4/15/26 at 10:18 PM revealed the three gloves and tin can from the previous day (4/14/26) were gone, and a resident's walker was observed behind the dumpster on the left. Both sliding doors on the left dumpster were open and the left-hand door on the dumpster on the right was open. An observation on 4/16/26 at 9:16 AM revealed the dumpster on the left had its left-hand door open and the dumpster on the right had both doors open. The resident's walker observed the previous day (4/15/26) was still sitting behind the dumpster on the left. During an interview on 4/16/26 at 4:55 PM, the ADM stated that everybody was responsible for keeping the dumpsters clean and covered. The ADM stated if they were not maintained that way, it could attract pests and odors. A record review of the facility's policy titled Garbage Receptacles titled 10/1/2018 reflected the following: Outdoor receptacles: Outdoor storage surfaces for refuse shall be constructed of nonabsorbent material such as concrete or asphalt and shall be smooth, durable, and sloped to drain. It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle.

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 need of each resident for 2 of 6 medication carts (*the medication cart designated for use on the 100 Hall and the medication cart designated for use on the 200 Hall) reviewed for pharmacy services.The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change for the medication cart designated for use on the 100 Hall and the medication cart designated for use on the 200 Hall. This failure could place residents at risk of drug diversions and could result in diminished health and well-being.Findings Included: Record review of the Change of Shift Narcotic Count Sheets revealed missing signatures for the following: 100 Hall Medication Cart04/03/2026 1st Shift Nurse Oncoming04/03/2026 2nd Shift Nurse Off going04/04/2026 2nd Shift Nurse Off going04/04/2026 2nd Shift Nurse Oncoming04/05/2026 1st Shift Nurse Off going04/05/2026 1st Shift Nurse Oncoming04/05/2026 2nd Shift Nurse Off going 200 Hall Medication Cart04/03/2026 1st Shift Nurse Oncoming04/03/2026 2nd Shift Nurse Off going04/04/2026 2nd Shift Nurse Off going04/04/2026 2nd Shift Nurse Oncoming04/05/2026 1st Shift Nurse Off going04/052026 1st Shift Nurse Oncoming04/05/2026 2nd Shift Nurse Off going04/11/2026 2nd Shift Nurse Off going04/14/2026 1st Shift Nurse Oncoming04/14/2026 2nd Shift Nurse Off going During an interview with LVN C on 04/15/2026 at 2:46PM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. She stated they received training on the process for change of shift narcotic count and documentation at new hire and then every year. She stated a possible negative outcome for failure to do the count would be drug diversion or a possible delay in care. During an interview with MA A, on 04/15/2026 at 3:00PM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. She stated they received training on the process for change of shift narcotic count and documentation at new hire and then every year. There are also in-services at different times, the last one being about 2 weeks ago. During an interview on 04/15/2026 at 3:05PM during an interview with MA B, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. She stated she was trained on this process at new hire. During an interview on 04/16/2026 at 10:50AM with the DON she stated it was her expectation that the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. The DON stated a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion. The DON stated the staff are trained at New Hire and annually thereafter. She stated there are also in-services throughout the year on this topic, the last one being two weeks ago. During an interview on 04/16/2026 at 3:20PM with the Administrator, he stated it was his expectation that the oncoming and off going shift count the narcotics together and then document the inventory on the Change of Shift Narcotic Count Sheet. A possible negative outcome of not performing the count would be a possible drug diversion. Record review of the Medication: Controlled Drugs Policy dated January of 2023 was performed. The Policy stated, Reconcile the narcotic count inventory at least at the beginning and end of each shift. Reconciliation should be performed by a visual count of the remaining narcotic medications comparing the actual count to the narcotic drug count sheet. This should be conducted by two persons who are legally authorized to administer medications.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately after the allegation was made for 1 of 5 (Resident #131) reviewed for resident abuse in that: RN E failed to report an allegation of verbal abuse made by Resident #131 on 4/03/2026. This failure could place residents at risk for on-going abuse.Findings included: A record review of Resident #131's face sheet dated 4/16/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of diabetes mellitus (uncontrolled blood sugar), intervertebral disc degeneration (gradual breakdown of spinal discs), end stage renal (kidney) disease, obesity class 3, paraplegia (paralysis of lower half of the body), heart failure, and hypertension (high blood pressure). A record review of Resident #131's MDS assessment dated [DATE] reflected a BIMs score of 15, which indicated no cognitive impairment. A record review of Resident #131's care plan last revised on 3/04/2026 reflected that she had cognitive communication deficit and self-care deficit. Interventions included a one-person assist with most ADLs and referral to the SW as needed. A record review of Resident #131's progress note dated 4/03/2026 authored by RN E reflected the following: Resident said to this nurse that she was threatened by her roommate saying she will kill her. Social worker [name] and administrator was made aware. 2.A record review of Resident #31's face sheet dated 4/16/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes (uncontrolled blood sugar), dementia (neurocognitive disorder), unstable angina (chest pain), schizoaffective disorder, bipolar type (mental disorder including mania), major depressive disorder (depression), cognitive communication deficit, difficulty in walking, and anemia. A record review of Resident #31's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #31's care plan last reviewed on 4/15/2026 reflected that she was at risk for psycho-social issues and required psychotropic medications. Interventions included to administer medications as ordered and attempt non-pharmacological interventions to promote calming. During an interview and observation on 4/16/2026 at 1:25 PM, Resident #131 was observed lying in bed. Resident #131 stated that her roommate threatened her a few weeks ago but she was not sure exactly when. Resident #131 called her family member and placed her on speaker phone. Resident #131's family member stated that the incident was on 4/02/2026. Resident #131 stated she told a nurse who told the DON, but the DON did not do anything about it. During an observation on 4/16/2026 at 1:27 PM, Resident #31 was observed walking towards the sink in her room. Resident #31 was non-interviewable. During an interview on 4/16/2026 at 2:15 PM, the DON stated she had not been notified about an allegation of verbal abuse. During an attempted interview on 4/16/2026 at 2:28 PM, RN E was contacted and a voicemail was left but she did not return the call. During an interview on 4/16/2026 at 2:56 PM, the SW stated that RN E had not reported an allegation of abuse to her. The SW stated, the roommate doesn't even talk. The SW stated that Resident #131 had never brought it up with her. The SW stated that she would have moved Resident #131 if she had known. During an interview on 4/16/2026 at 3:40 PM, the DON stated that if an allegation of abuse were reported to a person, that person needed to make a report to the ADM within two hours. The DON stated that staff were trained on reporting allegations of abuse with in-services and that they would start one that day (4/16/2026). The DON stated she would have to check if RN E was trained on reporting allegations of abuse. The DON stated that if allegations of abuse were not reported timely, the situation could escalate. During an interview on 4/16/2026 at 4:17 PM, the ADM stated that the allegations of abuse were reported to him and he reported them to the State. The ADM stated that many things could happen if allegations were not reported and investigated including someone else being abused. A record review of RN E's training record dated 2/10/2026 reflected that she had been trained on reporting abuse. A record review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/02/2025 reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/ResponseA. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 of 5 (Resident #131) residents reviewed for resident abuse. The facility failed to investigate an allegation of abuse made by Resident #131 on 4/03/2026. This failure could place residents at risk for on-going abuse.Findings included: A record review of Resident #131's face sheet dated 4/16/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of diabetes mellitus (uncontrolled blood sugar), intervertebral disc degeneration (gradual breakdown of spinal discs), end stage renal (kidney) disease, obesity class 3, paraplegia (paralysis of lower half of the body), heart failure, and hypertension (high blood pressure). A record review of Resident #131's MDS assessment dated [DATE] reflected a BIMs score of 15, which indicated no cognitive impairment. A record review of Resident #131's care plan last revised on 3/04/2026 reflected that she had cognitive communication deficit and self-care deficit. A record review of Resident #131's progress note dated 4/03/2026 authored by RN E reflected the following: Resident said to this nurse that she was threatened by her roommate saying she will kill her. Social worker [name] and administrator was made aware. During an interview and observation on 4/16/2026 at 1:25 PM, Resident #131 was observed lying in bed. Resident #131 stated that her roommate threatened her a few weeks ago but she was not sure exactly when. Observed Resident #131 call her family member and place her on speaker phone. Resident #131's family member stated that the incident was on 4/02/2026. Resident #131 stated she told a nurse who told the DON, but the DON did not do anything about it. During an interview on 4/16/2025 at 2:15 PM, the ADM stated that he would report the allegation of verbal abuse that Resident #131 made to HHSC and he would start investigating. During an interview on 4/16/2026 at 3:40 PM, the DON stated that the allegation of verbal abuse made by Resident #131 was not investigational because we were not aware. The DON stated that since she became aware, Resident #131 was moved. The DON stated she would suspend RN E pending their investigation. During an interview on 4/16/2026 at 4:17 PM, the ADM stated that he had not started an investigation because he just found out. The ADM stated no RN E had not been notified him about the allegation that Resident #131 made. The ADM stated that RN E would be suspended pending his investigation. The ADM stated that many things could happen if allegations were not reported and investigated including someone else being abused. A record review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/02/2025 reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, ,and cause; and6. Providing complete and thorough documentation of the investigation.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's psychosocial needs for 1 of 5 (Resident #130) reviewed for care plans.The facility failed to ensure that Resident #130's care plan included interventions to address her psychosocial behaviors.This failure placed residents at risk of dwelling in a disruptive environment.The findings include: A record review of Resident #130's face sheet dated 4/16/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anxiety disorder, cerebral vascular disease (condition affecting blood vessels), and altered mental status. A record review of Resident #130's MDS assessment dated [DATE] reflected that she had a BIMS score of 13, which indicated minimally impaired cognition. A record review of Resident #130's care plan last reviewed on 3/09/2026 reflected that she had anxiety, required anti-depressant medication, and chose not to follow recommendations made by the physician and/or clinical team related to care, services, and medications. Interventions included to administer medications as ordered and provide education on options for care and reassure resident that choices will be respected. A record review of Resident #130's POC Response History report with a 30-day lookback period dated 4/16/2026 reflected the following behavioral symptoms: Yelling/Screaming: 3/18/2026, 3/25/2026, 3/27/2026, 3/28/2026, 3/29/2026, 3/30/2026, 3/31/2026, 4/01/2026, 4/02/2026, 4/03/2026, 4/04/2026, 4/05/2026, 4/06/2026, 4/07/2026, 4/08/2026, 4/09/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/14/2026, and 4/15/2026. During an interview on 4/14/2026 at 3:05 PM, Resident #130 stated she came from the hospital and she was not sure why she was there. During an observation on 4/15/2026 at 11:00 AM, Resident #130 was observed in the hallway yelling you never push me. Observed the DON assist the resident in the hall. During an interview on 4/15/2026 at 11:17 AM, CNA F stated that Resident #130 was always yelling and if staff did not do what she wanted, she yelled and screamed. CNA F stated that residents complained that they could not sleep because they could hear Resident #130. CNA F stated that Resident #130 yelled in the morning, afternoon, and night. CNA F stated that Resident #130 was at the end of the hall and when she screamed, she could be heard at the front of the hall. CNA F stated that staff tried to anticipate her needs and redirect her. CNA F stated I don't know if the interventions were working. During an interview on 4/16/2026 at 1:42 PM, CNA G stated that Resident #130 had been there for a few months and she did a lot of attention-seeking behavior. CNA G stated, she hoops and hollers all the time and a lot of residents complained about the noise. CNA G stated that Resident #130's behavior of yelling should be in her care plan. During an interview on 4/16/2026 at 3:40 PM, the DON stated that MDS Nurse A and MDS Nurse B were responsible for updating care plans and yes she would expect to see a history of yelling in a resident's care plan. The DON stated she was not familiar with Resident #130's behavior of yelling and did not know if it was care planned. The DON stated she did not know which interventions were in place for Resident #130's behavior without looking into her chart. The DON stated she would go to the care plan first to look. The DON stated that residents could be disturbed and their behaviors could be exacerbated by Resident #130's yelling. During an interview on 4/16/2026 at 4:55 PM, the ADM stated that MDS Nurse A, MDS Nurse B, the SW, and the IDT were responsible for revising care plans. The ADM stated yes he would expect to see a history of yelling behaviors to be care planned. The ADM stated he was familiar with Resident #130 and said that she yelled for help and wanted things right away. When asked what could happen if behaviors were not care planned, the ADM stated, it could get worse. A record review of the facility's policy dated February 2017 reflected the following: Care Plans The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 7 residents (Resident #26 and Resident #107) reviewed for grooming. The facility failed to provide showers to Resident #26 in compliance with his shower schedule.The facility failed to provide ADL facial hair care to Resident #107. This deficient practice could place residents at risk of decline in skin integrity and psychological well-being. Findings included: 1.Record review of Resident #26's admission record, dated 04/16/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included: osteomyelitis (infection in a bone), diabetes (condition where the body has trouble controlling blood sugar, morbid obesity(having very high amount of body fat that significantly increases health risk), end stage renal disease ( the final stage of chronic kidney disease), hypertension ( high blood pressure), anemia in chronic kidney disease (your body doesn't have enough healthy red blood cells because your kidneys aren't working properly. Record review of Resident #26's care plan, dated 03/30/2026, reflected Resident #26 was care planned for ADL self-care performance deficit and had an intervention of bathing/shower: to be showered 2-3 times weekly and as needed on 2-10 shift and requires staff x1 for assistance. Review of Resident #26's task sheet Bathing dated 04/16/2026, reflected Resident #26 was scheduled for a bath on Tuesday, Thursday, and Saturdays during the evening shift. There was no documentation reflecting Resident #26 received a bath on the following dates: 03/27/2026, 03/28/2026, 03/29/2026, 03/30/2026, 04/01/2026, 04/04/2026, 04/07/2026, 04/09/2026, 04/11/2026. Reviewed shower sheet dated 04/14/2026 reflected at 2:20 pm, 5:00 pm, and 6:30 pm Resident #26 did not have clothes and did not want a shower. During an interview on 04/14/2026 at 2:43 pm, Resident #26 stated he had not received a bath in two weeks from the facility staff. He stated he was supposed to receive a bath today. He stated he does not like or want to smell bad. He did not report refusing a shower or bath on his scheduled days. During an interview on 04/16/2026 at 10:30 am, CNA D stated she was not aware that Resident #26 had not been receiving showers as scheduled. CNA D stated that resident's bath/shower schedule was located on the EMR. CNA D stated that if a resident did not receive scheduled a bath/shower they would smell bad and cause the resident not to feel well. 2.Record review of Resident #107's admission record indicated an [AGE] year-old male resident who admitted to the facility on [DATE]. Resident #107 had diagnoses of other cerebral infarction (specific types of ischemic strokes caused by blocked blood flow to the brain that do not fit into common categories like thrombosis or embolism), unspecified dementia (cognitive decline that prevents a definitive diagnosis of a specific type), and hyperlipidemia (a common, often inherited or lifestyle-driven condition characterized by excess fat in the blood). Record review of Resident #107's care plan record dated 06/21/2024, indicated Resident #107 had a self-care deficit related to a diagnosis of cognitive impairment, weakness and debility. Resident #107 required 2 person assist with ADL self care. During an observation on 04/14/2026 at 11:45AM, Resident #107 was observed to have long facial hair, which appeared to not be maintained. During an interview on 04/16/2026 at 10:15AM, Resident #107 stated that the facility had not offered to shave his face. Resident #107 stated he would like his face shaved. He stated that because the facility had not offered to shave his face, it made him feel bad about himself. During an interview with the DON on 04/16/2026 at 10:44 am, the DON stated CNAs were responsible for giving the residents a bath/shower. The DON stated if a resident did not receive their scheduled bath/shower they could develop an odor or a skin issue. The DON stated her expectation was for all residents to receive a bath/shower as scheduled. During an interview with the ADM on 04/16/2026 at 10:58 am, the ADM stated the CNAs were responsible for giving the residents a bath/shower. The ADM stated that residents would develop an odor if they were not receiving a bath/shower per the residents' bath/shower schedule. ADM stated that he expected all residents to receive a bath/shower as scheduled. The ADM stated that residents should be offered to be shaved every time they have a shower, which should be 3 times a week. He stated that a resident could not feel good if the residents are not offered to be shaved. A record review of the facility's Routine resident care policy, dated, 3/14/19, revised date 01/2024 reflected Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene and safety. Steps are taken to provide that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to maintain resident safety at all times. Responsible Disciplines:License nurses and non-licensed direct care team membersGuidelines.2. Showers, tub baths, and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preference. Shower schedules should be geared to resident preference and scheduled as such.3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands and combing their hair.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with the comprehensive person-centered care plan and the residents' choices for 5 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of care. The facility failed to implement interventions, according to the comprehensive plan of care, to check and change on rounds and as needed to keep Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5's skin clean and dry. The failure placed residents with self-care deficit, falls, and skin concerns at risk of decline or decrease in their quality of life and quality of care. Findings included: Record review of Resident #2's face sheet, dated 1/26/2026, revealed an 81-years-old female, admitted on [DATE] and readmitted [DATE] with diagnosis hemiplegia (severe paralysis affecting one side of the body, often caused by brain injury) and hemiparesis (weakness or partial paralysis affecting one side of the body, commonly caused brain injuries) following cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain resulting in brain tissue death) affecting left non-dominant side, dementia (a progressive syndrome, not a normal part of aging, characterized by cognitive decline), type 2 diabetes mellitus (a chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar) and anxiety disorder. Record Review of Resident #2's quarterly MDS, dated [DATE], revealed BIMS score of 3, severe cognitive impairment. The MDS indicated occasional incontinence and occasional bowel incontinence with need for assistance with personal care. Record review of Resident #2's care plan, dated 10/27/2025, revealed the risk for self-care deficit, falls, skin concerns, pain, infection, nutrition/hydration concerns and emotional distress. Personal hygiene x1 person assist, turning and repositioning: on rounds and as needed, transfer and toilet transfer x2 person assistance. Fall risk was identified with interventions: routine rounds to help with safety checks by all team members. She has incontinence related to dementia diagnosis with interventions in place to check and change on rounds and as needed. Record review of nursing notes for Resident #2, dated 3/23/26, revealed that resident family call for resident perineal (around genitals and bottom region) care. The note reflected, Resident's family proceeded to make a complaint that resident was not changed for hours and was soaking wet with urine. CNA went into resident room to perform perineal care on resident. Resident brief is noted to be dry and free from urine and BM by this nurse, CNA and DON.Observation on 3/26/2026 at 10:15 a.m. revealed Resident #2 was lying in bed and crying for help. When the call light button was pushed, nobody answered Resident #2's call light for 14 minutes and 9 seconds until a surveyor went to the nursing station and brought it to the nursing staff's attention. No nursing staff was visible in the 500 hall. The housekeeper was cleaning a room across the hall and did not attempt to answer the light. The sound of the call light system was heard through the hallway, but nobody came to Resident #2's room to assist her. The DON was walking by the nursing station and was informed about the call light going on for 14 minutes and 9 seconds. The DON found CNA C who was in another resident's room to answer the call light. Attempted to interview Resident #2 on 3/26/2026 at 10:21 a.m. and Resident #2 could not provide the comprehensive information about help she needed. She stated she had pain pointing to her stomach and needed her family member. During interview on 3/26/2026 at 2:27 p.m. with RP E for Resident #2, she stated the care for Resident #2 was not too good. The RP E said nursing staff left Resident #2 wet and soiled when she was sleeping. The RP E said there was a brown stain on her brief a few days ago. Th RP said it was not all the time and it's just with some nurses. The RP E said they say they've already changed her and it's brown, it happens about once a week. During interview on 3/26/26 at 11:05 a.m. with CNA C, she stated she was occupied in a different room with another resident. She stated that answering call lights was everybody's responsibility and if not answered promptly that could lead to residents' falls and skin breakdown. She stated that she had training on answering call lights in the last two months. CNA C stated that there were two CNAs per hallway, but she was the only one during lunch time. She stated that they supposed to round on residents every two hours and change briefs at that time if it was wet or soiled. She did not remember specifically when she changed Resident #2 last time during her shift. CNA C stated she tried to answer the call lights promptly when she was not busy with other residents. She stated with 28 residents on 500 hall, she was responsible for 14 residents. Record review of Resident #1's face sheet, dated 3/26/2026, revealed a 78-years-old male, originally admitted [DATE] and readmitted [DATE], with diagnosis of type 2 diabetes mellitus (a chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), and chronic obstructive pulmonary disease (a progressive, treatable lung disease, commonly caused by smoking, that makes breathing difficult due to airflow blockage). Record Review of Resident #1's quarterly MDS, dated [DATE], revealed BIMS score of 14, intact cognition. The MDS indicated Resident #1's had incontinence of bowel and bladder with need for assistance with personal care. Record review of Resident #1's care plan, dated 10/03/2025, revealed Resident #1 has bowel incontinence and interventions to check and change on regular rounds and as needed. Incontinence care assistance should be provided every shift and as needed. No current skin issues were identified. Interview and observation of Resident #1 on 3/26/2026 at 10:48 a.m. revealed resident lying in bed stating he had concerns that staff did not check on him every two hours as they needed to. He said sometimes nobody checked on him all night. He stated that he wanted to be checked on more often. Resident #1 stated that he needed to be changed and repositioned in bed. He stated that he told nursing staff regarding his concerns before, but nothing changed. Record review of Resident #3's face sheet, dated 3/26/2026, revealed a 78-years-old female, originally admitted [DATE] and readmitted [DATE], with diagnosis of type 2 diabetes mellitus (a chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen), hypertension (high blood pressure), and depression. Record Review of Resident #3's quarterly MDS, dated [DATE], revealed BIMS score of 8, moderate cognitive impairment. The MDS indicated the resident had frequent bladder incontinence and occasionally bowel incontinence with a need for assistance with personal care. Record review of Resident #3's care plan, dated 09/21/22, indicated Resident #3 was incontinent of bowel and bladder, required assistance with toileting with interventions to monitor for incontinence every 2-3 hours and as needed, apply skin protective barrier. Record Review of Resident #3's progress notes indicated maximum assistance with ADLs. No skin issues were identified. Interview and observation of Resident #3 on 3/26/2026 at 11:07 a.m., revealed Resident #3 was sitting in a wheelchair and stated that she had been in the facility for three years. She stated that it took staff 30-45minurs on different shifts to answer call lights to assist her with being changedInterview on 3/26/2026 at 1:25 p.m. with RP D for Resident #3 revealed it took too long for staff to respond to requests like warming the food or changing her. She stated that Resident #3 felt uncomfortable asking for help because most of the time staff said they would be right back and then don't end up coming back. The RP D said one hour was nothing, but every time she was the facility she witnessed staff not answering call lights or not coming back. She stated typically Resident #3 waited 45 minutes to an hour for the call light to be answered. She said it was not always an hour, but it happened multiple times when she was visiting. She stated Resident #3 complained to her that they take a while when she was not at the facility as well. Interview and observation of Resident #3 on 3/26/2026 at 11:07 a.m., revealed Resident #3 was sitting in wheelchair and stated that she has been in the facility for three years. She stated that it takes staff a while on different shifts to answer call lights. Record review of Resident #4's face sheet, dated 3/26/2026, revealed an 81-years-old female, originally admitted [DATE] with diagnosis of acute respiratory failure with hypercapnia (excessive buildup of carbon dioxide with symptoms range from headaches and dizziness to confusion and severe breathing difficulties), hemiplegia (severe paralysis affecting one side of the body, often caused by brain injury) and hemiparesis (weakness or partial paralysis affecting one side of the body, commonly caused brain injuries) following cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain resulting in brain tissue death) affecting left non-dominant side, and need for assistance with personal care. Record Review of Resident #4's none above MDS, dated [DATE], revealed no BIMS level indicated. The MDS reflected the resident was frequently incontinent of bladder and occasionally had bowel incontinence with need for assistance with personal care. Record Review of Resident #4's care plan, dated 8/15/2024, revealed Resident #4 has self-care deficit related to hemiparesis affecting left non-dominant side with interventions in place: Incontinent Care: check and change upon rounds and as indicated. Toileting/incontinent Care x1 person assistance. She is at risk for a decline in physical functions: chronic poor health and medical conditions. She is at risk for falls related to weakness, unsteady gait and poor balance. With interventions: encourage resident to use call light for assistance. Actual or at risk for skin impairment. With interventions: Keep clean and dry and apply skin barrier cream as indicated. She has incontinence related to impaired mobility with intervention to ask and assist resident to toilet during waking hours as indicated. Check and change on rounds and as needed. Incontinent Care assistance every shift and as needed. Interview and observation of Resident #4 on 3/26/2026 at 12:21 p.m. revealed she was sitting up in bed, and she stated that her call light was not answered promptly. She said a few days ago, she was wet and called to get changed and the CNA did not come for one hour and 26 minutes as she timed her. She felt mad at herself that she had to urinate again and could not control her bladder. She stated that she had to wait for nursing staff to assist her to get up from the commode for 15-30 minutes sometimes as she needs assistance due to her left hamstring pain and left leg gave up sometimes, so she was afraid to slip and fall. She stated she did not fall recently. Record review of Resident #5's face sheet, dated 3/26/2026, revealed a 61-years-old female, admitted [DATE], with diagnosis of type 2 diabetes mellitus (a chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar), end stage renal disease (the final, permanent stage of kidney failure where kidneys can no longer function independently), dependence on renal dialysis, and heart failure. Record Review of Resident #5's admission MDS, dated [DATE], revealed BIMS score of 15, intact cognition. The MDS indicated the resident had bowel and bladder incontinence and was maximum x2 assistance with personal care. Record Review of Resident #5's care plan, dated 2/03/2026, revealed Resident #5 has self-care deficit related to actual or at risk for skin impairment with interventions to keep clean and dry and apply skin barrier cream as indicated. She is incontinent related to complete paraplegia (impairment or loss of motor and sensory function in the lower half of the body) with interventions to check and change on rounds and as needed with incontinent care assistance every shift and as needed. Record Review of Resident #5's skin assessment dated [DATE], revealed history of skin issues: Sacrum. Moisture Associated with Skin Damage (MASD). Incontinence Associated Dermatitis. Resolved: Wound healed and/or closed. During interview on 3/26/2026 at 1:00 p.m. with Resident #5, she stated she got bed sores on her bottom from not being changed in a timely manner. She stated that she had the sore for 2-3 months, it was healing well and looked dry and once they didn't change her it broke out again. She stated that she wasn't changed overnight last week when one CNA had the whole hall to himself and she was waiting until the next shift to be changed. She stated that she waited sometimes for 7-8 hours during night shifts sitting in her own filth before getting changed. She pressed the call light and nobody ever showed up. She stated staff came in and turned the call light off and say they'll be back when they have time. She stated that she was usually waiting 30 minutes to an hour after pressing the light to be helped. During interview on 3/26/25 at 2:25 p.m. with CNA A, she stated that she had been working here for almost 1 year. She stated that she had call light in-services sometimes this year. She stated that call lights needed to be answered immediately, and anyone could answer a call light as it was everyone's responsibility. She stated that call lights should be answered within a minute or two. She stated that call light beeped when call light lit up. She stated that there was a panel near the nursing station where they could see who's call light was on. She stated the potential risks for residents if call lights were not answered promptly, someone could be on the floor, dying, having a heart attack, ready to fall, or skin breakdown. CNA A stated that it was a neglect to not answer a call light for a long period of time. CNA A stated nursing staff should be doing rounds on residents every two hours and with 10-14 residents per CNA it could be hard to do sometimes. During interview on 3/26/26 at 3:00 p.m. with CNA B, she stated that call lights were supposed to be answered right away, may take a minute or 5 if nursing staff were busy. She stated it was everyone's responsibility to answer call lights. She stated that nursing staff should frequently check on residents who were unable to press their call lights. She stated that potential risks of unanswered call lights was that anything could happen, someone could be choking, almost falling out of bed, and skin could become red if they stay wet for a long time. She stated it was neglect given a call light isn't answered in over an hour. CNA B stated nursing staff should be rounding on each resident every two hours and depending on residents' needs it hard to attend each call light and completed all duties timely. During interview on 3/26/26 at 3:12 p.m. with the LVN, she stated she had in-service on call lights a few months ago. She stated call lights should be answered in a timely manner. She stated that call light should not be turned off until the problem was resolved. The LVN stated it was everybody's responsibility to answer call lights. She stated that potential risks associated with unanswered call lights could be falls and skin breakdown. She stated that it could be a form of neglect if a call light was not answered for an hour and 26 minutes. During interview on 3/26/26 at 3:29 p.m. with the RN, she stated she had worked for 6 months at the facility. She stated that she received an in-service on call lights within 2-3 months. She stated that call lights should be answered immediately after the call light turned on and even when not pressed there should be timely checks on residents. The RN stated that it was everyone's responsibility to answer call lights. She stated the potential risks for residents were falls and skin breakdown if not changed timely. She stated that it could be considered resident neglect not to answer a call light for over an hour. Observation of Resident #5's peri care, and interview, on 3/26/2026 at 4:00 p.m., revealed that Resident #5 had skin breakdown around sacrum (a triangular bone in the lower back) and medial (being situated in the middle or center) thighs. The skin breakdown appeared pink in color and appeared dry. No drainage or odor was noted. During interview on 3/26/2026 at 4:15p.m. with the DON, she stated she had training on the call light policy sometimes last year. She stated that there was no specific time for answering call lights per the facility's policy. She stated call lights should be answered in a timely manner or if nursing staff were in the middle of doing some tasks, they needed to let the residents know. She stated that an hour and 26 minutes for answering call lights was not acceptable. She stated that timing for answering call lights depended on a specific resident's situation. She stated that the potential risk for residents if call lights were not answered promptly could be falls or skin breakdown or cause anxiety if the resident needed to be changed or assisted to get up from the commode. She stated that she started a call light in-service today for all team members. She stated that all team members were responsible for answering call lights and not just direct care staff. She stated that when a call light was on, the sound of the call light was loud for everybody to hear and answer the call light. She stated that the call light panel was located near the nursing station indicating room numbers that call lights were on. DON stated that round should be conducted every two hours on each resident or as needed. She stated that each hallway staffed with two CNAs and one charge nurse. She stated she was not aware of those complaints regarding staff not conducting rounds. During interview on 3/26/2026 at 4:31 p.m. with the ADM, he stated he had a call light in-service sometime last year. He stated that per the policy when somebody saw a call light on, they needed to answer it in a timely manner. He said when a call light was on, it showed outside of the residents' rooms and at the nursing station on the wall panel. He stated that during residents' mealtime one CNA stayed in each hall and nurses should answer the call light. He stated that everybody was responsible for answering call lights, including housekeepers, and report to appropriate staff the residents' needs. He stated that the potential risk for residents if call lights were unanswered could be skin issues and falls. ADM stated he was not aware of rounds not being done or care was not provided to residents timely. Record review of Routine Resident Care Policy, implemented 3/14/2019 and revised January 2024, revealed Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene and safety. 9. Resident call lights should be answered timely and resident requests are addressed, if permitted. Record review of in-services Staff Responsiveness and Timely Care, dated 1/5/26, revealed The purpose: to reinforce expectations for timely, respectful and appropriate responses to resident needs in order to ensure safety, dignity, and quality care. What is responsiveness? Prompt acknowledgement and action taken when a resident, family member, or situation requires assistance, attention, or intervention. Staff expectations: All staff are expected to: Respond promptly to call lights and residents requests. Acknowledge residents even if assistance is delayed. Immediate response required for: Call lights and toileting needs. Safety concerns. family or responsible party concerns. Why responsiveness matters: Delayed or poor responsiveness can lead to falls or injuries, increased agitation or behaviors, resident and family dissatisfaction, survey deficiencies, disciplinary action. This in-service was signed by 27 nursing staff members including CNA C.

Based on observation, interview and record review, the facility failed to ensure drugs were stored properly and only authorized persons had access for 1 (MC #1) of 3 med carts reviewed for drug storage and labeling. The facility failed when MC #1 was in an unsecured location, unlocked, and was accessible to staff, residents and passers-by. This failure could place residents at risk of ingesting medications that was not prescribed to them leading to sickness.During an observation of MC #1 on 2/28/26 at 10:00 AM, revealed it was unattended, unlocked and accessible to staff, residents, and passers-by in the main lobby area. The locking mechanism was protruding outward on the medication cart. Neither the RN, nor the LVN saw the surveyor open the drawers and take pictures. During an interview with the RN on 02/28/26 at 10:23 AM, she stated the cart belonged to the LVN who was working the 300 hall. The RN stated staff were trained a couple of weeks ago on med cart storage. She stated residents could get into the cart and take medications that were not intended for them, leading to harm or sickness. She stated as the charge nurse and supervisor on duty, she was responsible for ensuring med carts remained locked. During an interview with the DON on 02/28/26 at 03:00 PM, she stated med carts were supposed to be locked at all times with no exception. She stated all nurses should have known that practice. She stated she was sure there was a facility policy related to med cart security. The DON stated an in-service was started 02/28/26. During an interview with the LVN on 02/28/26 at 03:32 PM, she stated she worked with the facility 15 or 16 years. She stated she was responsible for the 300-nurse cart. When asked about it being left unlocked, she stated she could not say about that. The LVN stated the policy said carts were to remain locked at all times because there was a possibility someone could go into it. The LVN stated residents were at risk of taking medication that was not prescribed to them and could cause sickness. The LVN stated the facility held regularly scheduled in-services about the med carts., The LVN stated the most recent was a couple of weeks ago. She stated she could not recall the date. During an interview with the ADM on 02/28/26 at 05:45 PM, he stated med carts were to be locked at all times when not in use. He stated whichever nurse was assigned to the specific cart was responsible for ensuring security. He stated any staff member, or member of management, who saw it unlocked was also responsible for ensuring security. He stated the facility policy was for med carts to be locked at all times. Record review of facility policy titled, Medication Cart Use & Storage, dated 01/2023, reflected, Responsible Disciplines: Licensed nurses, C.M.A.'s Guidelines: 1. Security: The medication and its storage bins should be kept closed, secured and/or in the line of sight when not in use. If an emergency occurs during a medication pass, the nurse/medication cart should be closed, secured and/or in the line of sight before attending to the emergency. During administration of medications, the cart may be positioned in the doorway of the resident's room with drawers unlocked and facing inward, and within sight. Record review of in-service dated 02/28/26 reflected:02/28/26 Medication Cart: Purpose: To reinforce the importance of keeping medication carts locked at all times when not in direct attendance to prevent medication errors, diversion, theft, resident harm, and regulatory violations; Regulatory & Policy Basis; Medication carts must remain locked when unattended per: Facility Policy & Procedure, State Regulations (including Texas HHSC standards), CMS F-Tag Requirements (Tag #: Labeling, Storage, and Security of Drugs), Medication Safety Best Practices. Failure to comply may result in: (blank) (the LVN's signature included).

Based on observation, interview and record review the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 1 of 3 residents (Resident #1) reviewed for room or roommate changes.The facility failed to ensure Resident #1, and her RP received written notice prior to moving Resident #1 to another room. This failure could place residents at risk of having their resident rights violated and being moved into another room without notice.Findings include:Observation on 10/15/25 at 10:45 AM revealed Resident #1 was sitting up in her wheelchair in her room. She was clean and well-groomed, and dressed appropriately for the day. Resident #1's RP was also in her room placing items in her closet. Review of an undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included idiopathic normal pressure hydrocephalus (a neurological disorder primarily affecting older adults, characterized by gait disturbances, cognitive impairment, and urinary incontinence, often treatable through shunt surgery), repeated falls, Alzheimer's disease, adult failure to thrive (a condition characterized by significant decline in physical and emotional well-being, often leading to weight loss, decreased appetite, and inactivity), hyperlipidemia (high levels of fat in the blood), hypertension (high blood pressure), hyperglycemia (low blood sugar) and depression.Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/25, reflected a BIMS Score of 3, which indicated a severe impairment in cognition. The assessment further reflected Resident #1 required partial to substantial/maximal assistance for her activities of daily living. Record review of Resident #1's Care Plan Report, dated 02/14/25, reflected she had a self-care deficit related to generalized weakness and right lower extremity weakness. The goal reflected Resident #1 would maintain or improve her ability to participate in her care with ADLs and experience safe transfers through the next review date by staff assisting with her activities of daily living with one person assisting.Record review of Resident #1's progress notes in the electronic health record, dated 09/22/25, reflected the DON communicated with the RP regarding the room change for Resident #1, and the RP gave verbal approval. The DON requested the RP camera removal to come to the facility to move the camera to the new room on Tuesday, 09/23/25 around 3:30 PM. No other concerns were discussed at that time.Record review of Resident #1's electronic nursing note, dated 09/24/2025 at 4:51 PM, reflected the RP was contacted by the DON and ADM regarding Resident #1's room change. An interview on 10/15/25 at 10:45 AM with the RP revealed on 09/24/25 the RP had a conversation with the ADM that Resident #1 had already been moved. The RP stated the change of rooms was communicated to her, but she was not notified in writing regarding the move and did not see the room before Resident #1 moved there. She further stated on 09/25/25 the camera had been moved along with Resident #1's belongings to the new room. An interview by phone on 10/15/25 at 11:18 AM with the RP revealed the DON informed her they could not move Resident #1's belongings to the new room along with the camera themselves and told her she would need to come and do it. The RP stated the next day when she went to the facility, Resident #1's belongings were moved into the new room, and the ADM stated, I had to move [Resident #1] to prove to the state that we did it. Interview on 10/15/25 at 1:43 PM with the SW, who stated she worked in the facility for 4 months. She stated for a room change they had a team meeting, obtained room numbers of rooms available, then they would reach out to the family, and show the room to the resident. The SW stated she did not remember being involved in a move room/change for Resident #1. The SW stated room changes were communicated to residents and families by verbal consent but not in writing per facility policy. The SW further stated verbal consent from residents and family was written into a progress note in the electronic health record. She stated Housekeepers moved the residents' belongings, and social workers were in charge. An interview on 10/15/25 at 2:05 PM with the AD, who stated they discussed room changes with residents and their families, if residents needed to change rooms. The AD stated they discussed room changes during IDT meetings and saw the availability of rooms in the facility. The AD stated they notified the family and residents verbally, and they asked if families wanted to be in the facility during the move. The AD stated the camera should be removed by the family in person per her understanding to make sure it's not broken and re-installed correctly. She stated the SW was in charge of room changes, but other staff members could be involved in the family notifications. An interview on 10/15/25 at 2:19 PM with LVN A, stated the family must be notified and present during the Residents' move from the other room. An interview on 10/15/25 at 3:30 PM with the ADM, stated the bathroom was not working in Resident #1's previous room, and they moved Resident #1 into another room. He stated the DON had verbally notified the RP of the room move. He further stated the RP became upset about the facility already moving Resident #1, and the RP became aggressive towards staff members, and threatening if they were to come near Resident #1. The ADM stated the room change for Resident #1 was discussed at the IDT meeting, and there were many reasons for changing rooms, such as the room was not appropriate. He further stated the families were notified verbally, and they were not required to notify the residents or family in writing, according to the facility policy. An interview on 10/15/25 at 3:55 PM with the DON, stated she worked in facility since August of 2025. The DON stated she talked to the RP on multiple occasions. She further stated she called the RP regarding moving Resident #1 on Monday, 09/23/25, and had spoken with her regarding the upcoming move. The DON stated the ADM notified her, and stated the RP did not come on 09/23/25. She further stated a state surveyor told the facility to have Resident #1 moved to a different room with a working toilet, so they were under pressure to complete Resident #1's room move. She stated they were trying to do the right thing by completing the room move and to be in compliance with the state. The DON stated she discussed the urgency to be in compliance with the RP, and she was not sure if the facility was supposed to remove the camera from Resident #1's previous room.Attempted a review on 10/15/25 at 4:20 PM from the ADM and did not obtain a Policy & Procedure of Resident Room Changes and whether the resident and/or RP should be notified in writing and/or verbally.Record review of the facility's Policy & Procedure for Statement of Resident Rights, dated January 2023, reflected, Compliance Guidelines.15. To not be relocated within the community, except in accordance with nursing community regulations.Refusals of Certain TransfersThe community will document reasons for room transfers and refusals.

Based on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 (Resident #1) of 25 residents reviewed for smoking.The facility failed to implement their policy that smoking for team members was permitted only in approved designated areas. This failure could place residents at risk of an unsafe smoking environment, accidents, harm and long-lasting health concerns centered around secondhand smoke. Findings include:Record review of Resident #1's face sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following diagnoses which included normal pressure hydrocephalus (cerebrospinal fluid builds up in the ventricles), Alzheimer's(a progressive disease that destroys memory and other important mental functions), adult failure to thrive (when a person's dependence declines) , hyperlipidemia ( a condition in which there are high levels of fat particles) , hypertension(condition in which the force of blood against the artery) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). Record review of Resident's #1's cognitive intact GG functional section of the quarterly MDS, dated [DATE], reflected a BIMS score 03, which indicated cognitive impaired cognition. Record review of Resident #1's care plan, dated 01/21/2025, reflected Resident # 1 had a self-care deficit of generalized weakness & R lower extremity weakness. Resident #1 was a gait belt x2 transfer, toileting x2, and was at risk of falls due to unsteady gait & poor balance. The care plan reflected the following interventions: Keep call light within reach and encourage use for assistance. Respond promptly to all requests for assistance.An observation of an, undated, video recording provided by FM, revealed CNA A and CNA B provided care for Resident #1, CNA B was observed providing care for the resident in the restroom. CNA A stood by the bathroom door, she removed something from her pocket, put it to her mouth and put it back in her pocket.During an interview on 09/16/2025 at 11:15 AM with the Admin, he revealed the FM of Resident #1 told him she saw CNA A on camera smoking what appeared to be a vape while she and another caregiver cared for Resident #1. He informed her he would look into the situation and follow up with her. He reveled he reviewed the camera footage and did in fact see CNA A with what appeared to be a vape to her mouth and then put it in her pocket. The admin stated he and the DON both provided CNA A with in-services as well as a verbal warning. During an interview on 09/16/2025 at 12:37 PM with the DON revealed she was made aware of the situation when the admin made her aware of the incident involving CNA A vaping. She said when she was made aware she interviewed CNA A who admitted she abruptly took her vape pen from her pocket, quickly inhaled it and returned it to her pocket. The DON revealed CNA A was very apologetic and she had only did it one time. She said CNA A was a good worker, and she felt as if this was a one-time mistake. The DON revealed she coached CNA A on her behavior. She said she also reminded CNA A there was a designated smoking area outside of the facility. During an interview on 09/16/2025 at 05:09 PM with Resident #1 revealed she had only been at the facility since January of 2025. She stated she felt safe at the facility and felt the staff treated her with respect. She revealed she was not aware CNA A was smoking a vape while in her presence. She said she was made aware when her FM, came to visit her one day and she told her she saw CNA A on camera bring what appeared to be a vape to her mouth, then put it back in her pocket. Resident #1 revealed she was surprised when her family member told her because she had never seen CNA A do anything like that before. During a phone interview on 09/16/2025 at 5:45 PM with CNA A, she revealed on 09/09/2025 while she was caring for Resident #1, she was told she was seen on camera smoking a vape. She said she was unsure if it was a vape, she said she had several pens that she kept in her pocket that had lights on them. CNA A stated it could have been mistaken for a vape. CNA A revealed she did smoke vapes when she took residents out to smoke in the designated smoking area. CNA A revealed she was coached on her behavior and how it could have a harmful outcome on the residents. A record review of the facility's grievance log reflected CNA A had never had a grievance filed on her before. A record review of CNA A's employee file reflected she only had this one write up. A conduct and workplace expectation notice dated 09/12/2025 was signed by CNA A. A record review of the facilities seniority date/rehire date reflected Team members smoking is permitted only in approved designed areas. Smoking will be prohibited in all other areas including but not limited to any areas where oxygen, flammable liquids, and/or combustible gases are being used or stored, in any area that would create hazardous or unsafe condition. Smoking will also be prohibited in public areas or where groups of people frequently gather. Smoking is permitted only during authorized breaks. Smoking includes both tobacco products as well as electronic devices.

Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained safe, clean, comfortable, and homelike including keeping the facility comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 F; for 1 of 1 memory care unit.The facility failed to maintain comfortable and safe temperature levels in the memory care unit when the local temperatures were at 97 Degrees Fahrenheit (F) and the temperature inside the memory care unit was 93 degrees (F) on 08/09/2025. An IJ was identified on 08/09/2025. The IJ template was provided to the facility on [DATE] at 8:47pm. While the IJ was removed on 08/11/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because (e.g.) all staff had not been trained on temperatures and hydration.This failure could affect residents result in discomfort, hyperthermia, a decline in health and/or death.Findings Included: Resident #1 Record review of Resident #1's face sheet dated 08/09/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis included cerebrovascular disease (a range of conditions that affect the blood flow to the brain), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), vascular dementia (lack of blood that carries oxygen and nutrients to a part of the brain), Seizures, hypertension (high blood pressure), and history of falling. Resident #2 Record review of Resident #2's face sheet dated 08/09/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis included hyperlipidemia (high cholesterol), dementia (memory, thinking, difficulty), need for assistance with personal care, unsteadiness on feet, muscle weakness and hypertension (high blood pressure). Observation of memory care 600 hall dining room on 08/09/2025 at 4:51pm revealed there were 16 residents sitting in the dining room eating dinner. Some residents appeared to be hot (skin flushed and sweating). The residents were eating their dinner none were complaining at the time of being hot. The temperature in the room was 93 degrees according to the thermostat. Observation of the 700-hall memory care dining room on 08/09/2025 at 4:53pm revealed there were 10 residents sitting in the dining room and Resident #1 was in the hall with no pants on sitting in his wheelchair. The residents appeared to be warm (skin flushed and sweating) staff were providing the residents drinks. Staff said they were not giving residents coffee since it was hot. The temperature in the dining room was 87 degrees according to the thermostat. An interview with the LVN G on 08/09/2025 at 4:50pm revealed the air conditioner had been out since this morning. She said that none of the resident have become sick due to the heat. She said they were giving the residents fluids. She said that she did notify MAIN but was not sure when she notified him. She said MAIN brought fans and was in the process of getting portable AC's. She said it had been hot in the facility since the morning time. An interview with CNA A on 08/09/2025 at 4:54pm revealed that the air conditioner had been out since 5:00 am. He said Resident #2 had said his room was hot and wanted the air conditioner turned on. He said as far as he knows none of the resident have gotten sick. He said MAIN was aware and that the DON also was aware. He said that the residents were complaining that it was hot in the facility. He said it was hot. An interview with the MAIN on 08/09/2025 at 4:56pm revealed that he got the call that the air conditioner was out at 2:17pm. He said that the air conditioner company was on their way. He said he was going to get four more emergency air conditioners. He said he did not have a log of the temperature. An interview with the DON at 08/09/2025 at 5:26pm revealed that the facility has a plan in place, and they were going to move residents. She said the staff moved the resident to the common area in the main building. She said that staff were positioned all around them so they could not leave the facility. She said that the MAIN should be there soon with the other air conditioners.An interview with the On-Call Doctor on 08/09/2025 at 7:58pm revealed that with the temperatures 93 degrees it could cause the residents dehydration if the staff were not monitoring the residents' fluids. She said the most that could happen that would be concerning was the residents getting dehydrated. Record review of the Weather Channel App on 08/09/2025 revealed the local temperature in [NAME] Heights was 97 degrees Fahrenheit. Record Review of the Extreme or Dangerous Temperature Levels Policy dated 11/2021 revealed Federal and Texas state standards for nursing centers require heating systems to be capable of maintain a minimum temperature of 71 F degrees and cooling systems to maintain a maximum temperature of not greater than 81 degrees F. Record Review of form 671 Long Term Care Facility Application for Medicare and Medicaid dated 8/9/2025 revealed a census of 24 residents in memory care area.This was determined to be an Immediate Jeopardy (IJ) on 08/09/2025 at 8:45pm. The DON was notified. The DON was given the IJ template on 08/09/2025 at 8:47pm.The facility's plan of removal was accepted on 8/11/2025 at 08:11am and reflected the following:Date Plan Implemented: 8/9/2025.Issue/Concern: AC unit required repair. Date occurred: 8/9/2025.Date of ADHOC: 8/9/2025 AdHoc Attendees: Administrator, Director of Nursing, and Medical Director Risk: All Residents who reside in the affected area (Memory Care Unit) may be affected. 1.On 8/9/2025 the Maintenance Director checked the HVAC system and found it in need of repair and contacted Oncor to make all necessary repairs. The Maintenance Director is responsible for maintaining the HVAC system.Date initiated: 8/9/2025Date completed: 8/9/20252.On 8/9 2025 the Maintenance Director received an estimate from Oncor for repair of HVAC system within one business day. The Administrator signed the proposal authorizing immediate repair. The Maintenance Director is responsible for maintaining the HVAC system.Date initiated: 8/9/2025.Date completed: 8/9/20253.The Maintenance Director established a direct line of communication with Oncor and requested status updates every two hours.Date initiated: 8/9/2025.Date completed: 8/9/20254.The Maintenance Director/Director of Nursing/Charge Nurses/ Nursing staff began taking the air temperature of resident rooms/resident care areas upon notice of the air conditioner not working properly and every 30 minutes for 2 hours. The Director of Nursing/Charge Nurses/Nursing Staff initiated plan to move residents from the affected area to other units. The Maintenance Director/Director of Nursing/Charge Nurses/ Nursing staff will continue to take air temperatures twice daily for the next 48 hours to ensure that the AC unit is functioning properly post being repaired on 8/9/2025 @ 1731. The Maintenance Director/Director of Nursing/Charge Nurses/ Nursing staff will document air temperatures on monitoring audit tool. The Maintenance Director ensured all wall thermostats were functioning properly on 8/10/2025 and will check wall thermometers twice daily for 2 days, then randomly weekly and ongoing and document compliance using a monitoring audit tool. Any issues will be addressed immediately.Date Initiated: 8/9/2025.Date Completed: 8/9/2025 and ongoing5.The Director of Nursing/Charge Nurses immediately began assessing/evaluating residents in the affected areas for s/s of hyperthermia, signs and symptoms of dehydration, safe, clean, comfortable, homelike environment.Date initiated: 8/9/2025.Date Completed: 8/9/2025 and ongoing6.The Administrator and Director of Nursing was educated on 8/9/2025 on what to do when the AC unit is not functioning properly by the vice president of operations and director of clinical operations. The Director of Nursing/Director of Clinical Education/Designee educated nursing staff on all shifts regarding what to do if the AC unit is not functioning properly, s/s of hyperthermia and how to recognize signs in the older adults.Date Initiated: 8/9/2025.Date Completed: 8/10/2025 and ongoing7.The Director of Nursing/Charge Nurses/designee began providing cold/cool beverages upon care encounters, every two - four hours and more often as needed.Date Initiated: 8/9/2025.Date Completed: 8/9/2025 and ongoing8.The Director of Nursing/Charge Nurses/Nurse Aides evaluated all residents in the affected area to ensure residents were comfortable and offered/assisted with removing bed linens for those who desired less bed linens as needed.Date Initiated: 8/9/2025.Date Completed: 8/9/20259.The Director of Nursing / Charge Nurses /Nurse Aides ensured residents were dressed in appropriate clothing to ensure their comfort.Date Initiated: 8/9/2025.Date Completed: 8/9/2025 and ongoing10.Portable AC units were promptly delivered on-site by maintenance director and placed in resident care area affected in efforts to ensure a safe and comfortable temperature. The Maintenance Director was responsible for delivering the Portable AC Units.Date Initiated: 8/9/2025.Date Completed: 8/9/202512.In an abundance of caution the Administrator purchased portable air conditioning/heating units to have as needed for back up. The Administrator and Maintenance Director is responsible for approving the purchasing and renting equipment and purchasing of equipment. The portable air conditioning units are not in use due to the AC Units are back in service as of 8/9/2025 @1731 and properly functioning as evidenced by monitoring of temperatures using a temperature log audit tool.Date Initiated: 8/9/2025.Date Completed: 8/9/202513.After the HVAC repair was made, the Director of Nursing or designee will monitor resident room temperatures twice per day at random times/shifts for two days to ensure acceptable temperature ranges.Date Initiated: 8/9/2025.Date Completed: 8/9/2025 and ongoingQAPI Monitoring: Director of Nurses/Assistant Director of Nurses will review the 24-hour report, progress notes, SBARS/COCs and risk management reports to identify safety risks / concerns related to direct care staff providing care and/or any care related issues or concerns documented. This will take place daily up to 7 days a week for the next 2 months. Findings will be documented on a monitoring tool and retained in the designated survey binder. The [NAME] President of Operations and Director of Clinical Operations will be responsible for training management team members prior to them training non-management team members. This plan and all education and auditing tools will be placed in binder and kept with the Administrator or Director of Nursing Services. This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training or updates to policies. Monitoring included: During an interview with MAIN on 08/09/2025 at 6:48pm revealed that he had come to the facility after getting the call for the AC on memory care. He stated that he checked everything on the AC, and it was working correctly. He said he then called [company name] which was the electric company to come out. He said they came out and checked the main building. He said [company name] did not find an issue. He said he checked all his system again and called [company name] back out and found that the transformer to the memory care had blown. The electric company fixed the transformer and AC started working. Observation of Residents in Memory care on 08/10/2025 at 10:00 am and at 3:15pm revealed that residents were dressed appropriately. Observation of memory care temperatures on 08/10/2025 at 3:15pm revealed that temperatures were 77, 77, 76, 77, 80 and 78 according to the MAIN temperature gun and thermostat. Observation of Residents in memory care on 08/11/2025 at 3:40pm revealed residents were dressed appropriately.Observation of Memory care temperatures on 08/11/2025 at 3:40pm revealed the temperatures in memory care 600 hall were 77, 76, 75, 76. 600 hall dining room was 78. 700 hall dining room temperatures were 75 and 700 hall were 76, 75, and 76 according to the thermostat and the MAIN temperature gun.During an interview with CNA A on 08/11/2025 at 2:48pm revealed she worked the two to ten shift she had been trained on resident rights. She said that the policy for temperatures was that the temperatures needed to be between 71 and 81 degrees. She said that if the temperature were not within the range it was supposed to be reported to the administrator. She said some signs of dehydration were dry/cracked lips, constantly wanting water and white stuff in the corners of their mouths. She said if a resident got dehydrated, they could pass out or end up in the hospital. She said if she noticed the air conditioner not working, she would report it to the administrator and the DON. She said she would also encourage residents to drink water and have fans on the residents. During an interview with CNA B on 08/11/2025 at 2:53pm revealed she had been trained on resident rights and homelike environment. She said that the policy for temperatures was if the AC was not working staff were to let the Administrator and DON know immediately. She said staff were also to check the residents for dehydration, she said some signs of dehydration was extremely thirsty, dry mouth and chapped lips. She said if a resident gets dehydrated the resident could get ill and pass out. She said to prevent dehydration she would offer the resident water throughout the day. She said that the temperatures should be between 71-81 degrees Fahrenheit. During an interview with LVN H on 08/11/2025 at 3:03pm revealed she had been trained on resident rights and homelike environment. She said the policy for temperatures was if the AC was higher than 81 or lower than 71 it needed to be reported to the DON, MAIN and ADM immediately. She said some signs of dehydration was fatigue, dry mouth, light headedness, and decreased urination. She said if a resident became dehydrated the resident could become dizzy, confused, and have a fall. She said if the AC were not functioning correctly, she would provide the resident with fluids and keep them cool. She also said if it became intolerable then she would move the residents. During an interview with CNA C on 08/11/2025 at 3:07pm revealed she had been trained on resident rights and homelike environment. She said the policy for temperatures was if the AC was not working to report it to the ADM and the DON. She said the temperatures should be between 71- 81 degrees Fahrenheit. She said if the AC was not working staff were to watch the residents for signs of dehydration. She said some signs of dehydration were dry mouth and thirsty. She said if a resident got dehydrated, they could get sick or irritated. She also said if the AC was not working staff were to give the residents water. During an interview with CNA D on 08/11/2025 at 3:12pm revealed she had been trained on resident rights and homelike environment. She said the policy for temperatures was the temperature should be 71-81 degrees Fahrenheit, if not at those temperatures staff should immediately report to the admin. She also said if not at the correct temperature staff were to relocate the residents. She said signs of dehydration were dry mouth, waxy skin, and dry lips. She said if a resident did get dehydrated, they could become sick. She said staff should be ensuring the resident was getting enough fluids. During an interview with LVN I on 08/11/2025 at 3:21pm revealed she had been trained on resident rights and homelike environment. She said the policy for temperatures was if the AC was out staff were to report it to the DON and ADM. She said the temperatures should be between 71 degrees and 81 degrees Fahrenheit. She said staff were supposed to make sure the residents did not become dehydrated. She said that staff were to give residents adequate liquid and help residents with drinking. She said signs of dehydration were dry mouth and clammy skin. She said if a resident became dehydrated, they could have a poor health outcome. During an interview with LVN J on 08/11/2025 at 3:29pm revealed she had been trained on resident rights and homelike environment. She said the policy for temperatures was to call MAIN, ADM, and DON if the AC was not working. She said staff were to also watch the residents to ensure the heat was not affecting them. She said signs of dehydration were lethargic, sweating, dry mucus, and dry mouth. She said if a resident became dehydrated, they could get hyperthermia (elevated body temperature). She said if the AC was not working staff were to move the residents to a cool area and provide fluids to them. She also said staff were to monitor the resident's intake and output. She said the temperatures were to be between 71 degrees and 81 degrees Fahrenheit. Record review of the POR Documents revealed that the MAIN Director checked the system, called [company name] for repairs and did status checks every two hours on 08/09/2025. Record review of the Hardware Store Receipt revealed that the portable AC were purchased at 4:18pm on 08/09/2025 from the hardware store. Record review of the receipt from the Hardware Store dated 08/09/2025 revealed the facility purchased 4 portable AC units from the hardware store. Record review of the Temperature Log dated 08/09/2025, 08/10/2025 and 08/11/2025 revealed temperatures have remained within regulation since being fixed. Record review of resident medical records revealed 36/36 Residents in memory care were assessed on 8/9/2025 with no signs or symptoms noted. Record review of In-Services dated 08/09/2025 revealed the DON and Administrator were educated on 08/09/2025 on what to do when the AC unit is not functioning properly by the VP of Operations. Record review of In-services dated 08/09/2025 revealed all staff on all shifts had been educated on what to do when the AC is not functioning correctly, and how to spot and prevent dehydration. Record review of the Temperature monitoring log revealed that the DON had monitored the temperatures and no issues were noted. Record review of the QAPI revealed that QAPI meeting was held on 08/09/2025. The DON was informed the Immediate Jeopardy was removed on 08/11/2025 at 8:45pm. The facility remained out of compliance at a severity level of isolated and a scope of no actual harm with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry-out activities of daily living received necessary services to maintain personal hygiene for three of four (Resident #1, Resident #2, and Resident #3) residents reviewed for ADL care. 1. The facility failed to shave the underside of Resident #1's chin hair that was approximately 1 cm in length.2. The facility failed to shave the underside of Resident #2's chin hair that was approximately 1 cm in length.3. The facility failed to shave the underside of Resident #3's chin hair that was approximately 1 cm in length.This deficient practice could place residents at risk of a decline in self-confidence, isolation, low self-esteem, general happiness, and satisfaction, and feeling undignified. 1.Review of Resident #1's face sheet dated 7/1/2025, reflected a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including cerebrovascular disease (disrupted blood flow to brain), Type 2 Diabetes (body does not produce enough insulin) Bed Confinement Status (unable to leave bed without assistance), Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (progressive lung disease making it hard to breathe). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of ten (10) which indicated cognition was moderately impaired. Section G reflected the resident required total assistance with ADL care. takeReview of Resident #1's care plan reflected she had an ADL Self Care Deficit with goals to maintain or improve her ability to participate in her care with ADLs. An intervention dated 2/7/2025 included, Resident prefers to keep her facial hair at times.Review of Resident #1's Task Profile dated 6/2/2025 thru 7/1/2025 for Personal Daily Hygiene - nail care, oral care, brushing/combing hair, shaving, washing face and hands, reflected the resident had not refused personal hygiene during that period. Observation and interview on 7/1/2025 at 11:31 AM with Resident #1 sitting in her wheelchair in dining room. The resident had facial hair along her chin that was approximately 1cm in length. When asked about her chin hair, the resident stated she wanted it trimmed, but she had not asked staff to assist her, and they had not offered. She was unable to recall the last time she was shaved and unable to explain why she wanted chin hair shaved.2.Review of Resident #2's face sheet dated 7/1/2025, reflected an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a progressive neurodegenerative disorder that gradually destroys memory and thinking skills), Dementia (decline in mental ability), and Cerebral Infarction (brain tissue dies from lack of blood supply). Review of Resident #2's quarterly MDS assessment dated [DATE], reflected a BIMS score of three (3) which indicated cognition was severely impaired. Section GG reflected the resident was dependent for assistance with personal hygiene. Review of Resident #2's care plan dated 6/10/2025 reflected she had an ADL Self Care Deficit related to cognitive impairment, weakness, and debility with goals to maintain or improve her ability to participate in her care with ADLs. An intervention dated 6/21/2024 included, Hygiene - 1 (one) person assist. The care plan did not specifically address shaving. Review of Resident #2's Task Profile dated 6/2/2025 thru 7/1/2025 for Personal Daily Hygiene - nail care, oral care, brushing/combing hair, shaving, washing face and hands, reflected the resident had not refused personal hygiene during that period. Observation and interview on 7/1/2025 at 11:42 AM with Resident #2 sitting in her wheelchair in dining room. The resident had facial hair along her chin that was approximately 1cm in length. When asked about her chin hair, she said, I want these whiskers trimmed. They do not do it and I do not ask. She was unable to recall the last time she was shaved.3.Review of Resident #3's face sheet dated 7/1/2025, reflected a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes (body does not produce enough insulin), Vascular Dementia (decline in thinking skills caused by damaged blood vessels and reduced blood flow to the brain), Atherosclerotic Heart Disease of Native Coronary Artery (plaque build-up narrows the coronary arteries). Review of Resident #3's quarterly MDS assessment dated [DATE], reflected a BIMS score of twelve (12) which indicated moderately impaired cognition. Section GG reflected the resident was dependent for assistance with personal hygiene. Review of Resident #3's care plan dated 6/20/2025 reflected she had an ADL Self Care Deficit related to CVA with goals to maintain or improve her ability to participate in her care with ADLs. An intervention dated 6/21/2024 included, Dressing and Grooming - 1 (one) person assist. The care plan did not specifically address shaving. Review of Resident #3's Task Profile dated 6/2/2025 thru 7/1/2025 for Personal Daily Hygiene - nail care, oral care, brushing/combing hair, shaving, washing face and hands, reflected the resident had not refused personal hygiene during that period. Observation and interview on 7/1/2025 at 12:30 PM with Resident #3 sitting at dining table. The resident had facial hair along her chin that was approximately 1cm in length. When asked about her chin hair, she said she could not remember when she was last shaved and These whiskers are driving me crazy and I want them shaved. During an interview on 7/3/2025 at 11:15 AM CNA-C employed by the facility for three-years, said treating residents with dignity meant honoring their wishes, dressing, and grooming them in a way that made them feel like themselves. She said residents were shaved on their assigned shower days or more often if they had noticed hair growth. She said it was important for female residents to have their chin hair shaved because they wanted smooth skin. She said the effects on residents were that they might feel less beautiful, not like themselves and it may bother them.During an interview on 7/3/2025 at 11:27 AM CNA-D employed by the facility for one-month, said treating residents with dignity meant showing respect, treating them as she would want to have been treated, like a person. She said it was not okay for female residents to have whiskers. She said it was important to shave female residents because it was a dignity issue. She said it could have made the residents feel less confident, more depressed, and not wanted to be seen by others.During an interview on 7/3/2025 at 11:39 AM LVN-E employed at the facility for four-years, said if a female resident did not want to be shaved, it should have been on the resident's care plan. She said shaving female residents was a dignity issue and it would have given them their faces back and made them feel more like themselves. She said female residents might have been ashamed if they had whiskers. During an interview on 7/3/2025 at 12:10 PM the DON employed by the facility for four-months, said it was okay for female residents to have whiskers only if they wanted it. She said this could have caused body image issues for female residents with whiskers and her expectation was that staff should have asked the residents if they wanted their facial hair removed during care.During an interview on 7/3/2025 at 12:18 PM interim ADM-B, said his expectation was for staff to follow the ADL policy as it could have led to dignity issues for female residents who had chin whiskers.Record Review of the facility's policy titled, Respect and Dignity, dated February 2017 reflected the following: Compliance Guidelines:The community promotes care for residents in a manner and environment that enhances each residents' dignity and respect in full recognition of his or her individuality.Dignity means that the team members carry-out activities that assist the resident to maintain and enhance self-esteem and self-worth. To achieve this goal, the community strives to achieve the following:Hygiene and appearance:- Residents are groomed as they wish (e.g., hair combed and styled, beards shaved/trimmed, nails clean and clipped).

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food labeling and storage in that: The facility failed to ensure the foods were labeled and dated in the kitchen refrigerator. This deficient practice could place residents at risk of foodborne illness. An observation on 7/02/2025 at 9:17 AM of the facility's only refrigerator revealed the following: - Salad greens in a metal container covered with clear, plastic wrap did not have a label containing the opened on and discard by dates. - Pasta noodles in a metal container covered with tinfoil did not have a label containing the opened on and discard by dates. - A yellow, non-opaque liquid, with chunks (like creamed corn) in a metal container covered with tinfoil did not have a label containing the opened on and discard by dates. During an interview on 7/02/2025 at 9:18 AM the DM stated, Those containers should have been labeled and dated and everyone was responsible for labeling and storage. During an interview on 7/3/2025 at 12:18 PM interim ADM-B, said his expectation was for staff to follow the policy and everything should have been labeled and dated. He said if items were not labeled the kitchen staff would not have known when food went bad, and they could have served spoiled food to the residents. Review of the U.S. Public Health Service Food Code, dated 2022, revealed:3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A)A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or PACKAGE that does not bear a date or day;

Based on observation, interviews, and record reviews, the facility failed to ensure a resident's environment remained free of accident hazards and a received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for assistance devices in that: NAIT T did not provide Resident #1 with an assistive device (modified cup with lid) when serving coffee to prevent an avoidable accident from occurring. NAIT T served Resident #1 coffee in a standard mug which resulted in Resident #1 spilling the coffee onto her left hand and the table due to her tremors and spastic movements in both arms. The facility failed to ensure NAIT T was knowledgeable on how to locate the Kardex to determine what assistive devices were required during meal services to prevent accidents. An IJ was identified on 02/04/25. The IJ Template was provided to the facility on [DATE] at 06:09 PM. While the IJ was removed on 02/7/25 , the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings included: Review of Resident #1's face sheet dated 02/04/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included unspecified psychosis not due to a substance or known physiological condition (mental health condition characterized by a disconnection from reality), personal history of traumatic brain injury, seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), convulsions, epilepsy, muscle weakness, unspecified mental disorder due to known physiological condition, and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 09 indicating moderate cognitive impairment. Review of Resident #1's care plan last revised 01/06/25 revealed a focus on risk for nutritional deficit and/ or dehydration risks related to diagnosis heart disease and dysphagia with intervention that included modified cup with lid and encourage/offer/assist me to drink fluids during care time opportunities, ask my nurse if you have any questions. The care plan also identified the resident as being PASARR positive for IDD (intellectual and developmental disabilities). Interventions included coordinate plan of care with service coordinator as indicated, report any need to reevaluate specialized services and/ or plan of care to service coordinator and responsible party, and specialized services: Durable medical equipment approved mattress, wheelchair, and pad. Review of Resident #1's IDT: care plan conference and advanced care planning review dated 10/16/24 reflected PASARR meeting/ care plan meeting held with notes that included diet regular with cup with lid. Review of Resident #1's Dietary Nutritional Risk assessment dated [DATE] reflected diet/Tube Feed order: regular, cup with lid. Review of Resident #1's physician orders reflected a dietary order with a start date of 12/28/17 regular texture, thin/regular consistency, **NON-SPILL CUP WITH MEALS**. Review of Resident #1's hot liquid evaluation dated 02/04/25 reflected this evaluation identifies if the resident is at risk for injury while handling and drinking hot liquids. Resident #1 was marked for Difficulty holding onto a cup or glass due to weakness or tremors, altered voluntary movement and/or sensation of feeling, such as neuropathy, hemiplegia, or hemiparesis to dominant side. The document showed a focus for I have the potential for injury related to hot liquid spill; may benefit utilizing a lid on hot liquid cup and interventions refer to therapy to screen and/ or eval as indicated and team members will apply/encourage use of a lid to the hot liquid cup when served. In an observation on 02/04/25 at 12:02 PM in the dining room, Resident #1 was observed sitting at a table with 4 other residents. Resident #1 had a plastic reusable cup with a screw on lid filled with cranberry juice, meal trays had not yet been brought out. An observation was made of Resident #1's need for the modified cup with a lid, as Resident #1 was seen to have tremors/ altered movement, she was seen at times shaking her plastic cup around and banging the cup on the table. NAIT T was observed passing out coffee from the coffee cart, Resident #1 saw her and was heard saying coffee. NAIT T was then heard saying oh you want some coffee, I will get you some and then handed Resident #1 hot coffee in a standard mug, no lid. At 12:15 PM Resident #1 was then observed grabbing the coffee mug and due to the altered movements and tremors of her arms and hands she swung the mug around causing the hot coffee to spill on her left hand and all over the table. 2 staff members observed the spill approximately 2-3 minutes later and cleaned the coffee and removed the tablecloth. No assessment was observed completed on Resident #1. In an interview on 02/04/25 at 01:04 PM with NAIT T she stated she will review the meal tickets to determine if a resident requires an assistive device. She stated she had not previously worked with Resident #1 and stated it was only her 3rd day of work and she was still in training. NAIT T stated she has not previously read Resident #1's meal ticket or gotten to know her. She stated she did not know where else to look aside from the meal tickets to determine a residents' needs with assistive devices. She stated she did not know where to look for the Kardex. After discussing Resident #1's requirement for a modified cup with a lid NAIT T stated she should not have given Resident #1 hot coffee in a standard mug and said, she could have burned herself. In an interview on 02/04/25 at 12:57 PM with DCE, she stated Resident #1 does require an assistive device for all fluids. The DCE stated that if Resident #1 wants coffee, she was allowed to have it as long as it is in a sealed container with a lid or modified cup with lid. DCE stated that a negative outcome of not providing Resident #1 with a cup with a lid was the resident could burn herself. Upon discussing the observations, DCE stated that Resident #1 could have burned herself and should not have been provided hot coffee in a regular cup. The DCE stated that the meal tickets will contain information about a residents' assistive device needs, however, she stated it was also her expectation that staff look on the Kardex to determine a residents' needs with assistive devices as well if they do not know. An observation on 02/04/25 at 01:23 PM of Resident #1's meal ticket on her table reflected Diet order regular, thin/regular liquids. Notes: ADAPTIVE CUP WITH COVER/LIDS. An observation on 02/04/25 at 01:25 PM by nurse surveyor observation made of Resident #1's hands, no burns, redness, or blistering noted. No signs of pain indicated. An observation on 02/04/25 at 01:37 PM the temperature of the coffee pulled from the coffee carafe into a mug and checked registered at 128.8 degrees Fahrenheit. In an interview and observation on 02/04/24 at 01:46 PM with the DON, she was observed reviewing Resident #1's EMR and she stated Resident #1 does require a cup with a lid for all fluids. She stated it was her expectation that staff ensured they look on the meal tickets to verify assistive devices needed and to ensure those devices are available. The DON stated a negative outcome of not providing Resident #1 her assistive device (modified cup with lid) was that she would spill it which could result in a burn, and she would not be able to drink her drinks. The DON stated that if staff do not know whether a resident required an assistive device, she expected them to ask questions. She stated her expectation with all staff and with trainees was for them to also be looking at the Kardex if the meal ticket was not yet available. In an interview on 02/05/25 at 08:42 AM with the DOR she stated that based on her knowledge Resident #1 has always required a modified cup with a lid since her admission in 2014. She stated Resident #1's condition has only progressively gotten worse and therapy was provided to her as maintenance. She stated based on her condition she should be provided hot liquids in a cup with a lid due to her tremors. In an interview and observation on 02/05/25 at 03:40 PM the DM was observed taking temperatures of coffee in different containers. The readings were as followed: (followed by interview) *Temperature in the carafe 145.2 degrees Fahrenheit. *Temperature in a cup poured from the carafe 136.8 degrees Fahrenheit. *Cup of coffee from the coffee brewing for residents' dinner registered at 150.6 degrees Fahrenheit. An observation of a coffee log dated 02/2025 on the side of the coffee machine with dates 1-3 for the month of February were blank for AM and PM temperatures and 02/04 for AM was left blank and PM was marked 145 degrees Fahrenheit. The DM stated that she began to log coffee temperatures 02/04/25 beginning with dinner and that there were no temperatures logged prior for the month of February. The DM stated it was her expectation that coffee was served between 125-130 degrees Fahrenheit. In an interview on 02/07/25 at 05:00 PM with the ADM she stated it was her expectation that NAIT's always worked with a certified nurse aide and were supervised by nursing staff during meal services. She stated failure to provide the required assistance to residents or necessary devices could result in injury. Review of the Accident Prevention policy last revised 01/2023 reflected: The community ensures that the resident environment remains as free of accident hazards as possible. Accident hazards are defined as physical features in the environment that can endanger a resident's safety. Adequate supervision and assistance devices to prevent accidents: The community identifies residents who may be at risk for accidents and or falls. An accident is an unexpected, unintended, event that can cause a resident bodily injury. It does not include adverse outcomes associated with consequences of treatment or care. Assessments and care plans are used to develop and implement procedures to prevent accidents. Review of the facility Hot liquid/ Food spills policy last revised 01/2023 reflected: Residents are at risk of having any hot liquid /food spilled on their person. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal, or any other dietary substance that could cause injury. - Should the IDT deem the resident unsafe to handle hot liquids, educate, encourage, assist, and provide lidded cups as resident tolerates or allows and may apply other appropriate interventions necessary to promote safety. - If a staff member observes a resident spill a hot liquid or food on themselves or another resident the staff member may attempt to dissipate the heat of the item spilled with at least a liquid that is at temperature of room or below by pouring the room temperature or cooler liquid directly on the affected area. - The charge nurse/designee should be immediately notified so that the skin assessment of the area can be completed. - The charge nurse should notify the attending physician and responsible party of any injury and initiate any further physician orders. - An incident report and investigation should then be completed and determine if the resident needs further interventions such as screening by therapy department to prevent future occurrences. - Update the plan of care as indicated. Review of the Nurse Aide non-certified position agreement dated 07/01/20 reflected: To support the community by providing premier care to each resident through direct care to residents in accordance with community policies and procedures. - Completes resident feeding training and assists with meal service when directed. - Address concerns immediately and reports them to supervisor. - All issues are reported to a licensed nurse immediately- under the supervision of a licensed nurse. - No violations of community procedures for delivering care and elevation protocol. - No safety infractions of residents under your supervision. The ADM and DON were notified on 02/04/25 at 06:09 PM that an IJ was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 02/05/25 and included: Plan of Removal Problem: F689 Free from Accident Hazards/ Supervision/ Devices The facility failed to provide assistance devices necessary to prevent an avoidable accident from occurring. Immediate Response: Licensed nurse assessed Resident #1 No injury noted at this time. Risk management/Incident Report completed. Date completed: 2/4/2025. Physician notification by licensed nurse Date completed: 2/4/2025. Responsible party notified by licensed nurse. Date completed: 2/4/2025. Occupational Therapist will evaluate Resident #1 for safety on 2/4/2025. Date completed: 2/4/2025. Director of Clinical Operations /Director of Nursing Services/Assistant Director of Nursing Services, and administrative nurses conducted a 100% Audit of all residents who reside in the community to re-evaluate the need for Hot Liquid Assessments. Resident involved in the incident care plan was reviewed and updated. All residents identified had assessments completed.\ Date completed: 2/4/2025. Resident #1 care plan was reviewed and updated by Licensed Nurse Date completed: 2/5/2025. Director of Clinical Operations /Director of Nursing Services, and administrative nurses provided immediate education to the nurse aide in training involved in the incident and all other nurse aides in training and certified nurse assistants on Abuse Neglect, Residents Rights, Kardex Use prior to providing care to the residents. All nurse aide in training and certified nurse aides will be monitored by Director of Clinical Operations/Designee during meal service to ensure they are following appropriate protocol for residents needing assistance devices. Date completed: 2/4/2025 and ongoing. The Director of Clinical Operations/Director of Nursing/Administrative Nursing is responsible for ensuring compliance and oversight of monitoring and education to ensure compliance. All Nursing Team Members to include Agency/Prn/[NAME] Hires were educated on providing care to residents and were re-educated/re-trained by the Director of Clinical Operations /Director of Nursing Services/administrative nurses. o Direct care educated on review of the Kardex before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. Nurse aides are not limited. There may be incidents where a resident not assigned to them will need assistance. The expectation for the nurse aide and all direct care staff is the review the Kardex prior to providing care. o Licensed nurse will review tray card accuracy to validate dining information to include diet, adaptive devices and use of a lid for hot liquids as indicated prior to resident receiving a meal or beverage. o Education provided to all Nursing Department including PRN/Agency/New Hires in Preventing Accidents/Hot Liquids/Promoting a Safe Environment: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by the o All nursing staff will receive the in-service prior to working next shift. o All newly hired nursing staff will receive in-service training prior to assuming shift responsibility during orientation process. o All agency nursing staff will receive in-service training prior to assuming shift responsibility. o Director of Clinical Operations /Director of Nursing Services/administrative nurses conducted 100% skills validation all nurse aides in training and certified nurse assistants of accessing the Kardex by the Director of Clinical Operations /Director of Nursing Services/administrative nurses. Date completed: 2/4/2025. Community will ensure all staff on leave/agency staff /PRN/new hires staff are in serviced prior to working their shift. No licensed nurse, nurse aides in training and certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. To include licensed nurses, nurse aide in trainings and certified nurse aides. Risk Response: All residents who currently reside in community potentially can be affected by the deficient practice. Systemic Response: Director of Clinical Operations /Director of Nursing Services/administrative nurses conducted a 100% Audit of all residents who reside in the community to re-evaluate for the need for Hot Liquid Assessments. Date completed: 2/4/2025. Director of Clinical Operations /Director of Nursing Services/administrative nurses provided immediate education was provided to the nurse aide in training on: Abuse Neglect/Residents Rights, Kardex Use prior to providing care to the residents. Date completed: 2/4/2025. o The Director of Clinical Education/Director of Nursing Services/Administrative Nurses is responsible for ensuring compliance and oversight of monitoring and education to ensure compliance of education. All Nursing Team Members including PRN/Agency/New Hires were educated on providing care to residents and were re-educated/re-trained by the Director of Clinical Operations/Director of Nursing/administrative nurses on the following: o Review of the Kardex before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. o Licensed nurse will review tray card accuracy to validate dining information to include diet, adaptive devices and use of a lid for hot liquids as indicated prior to resident receiving meal or beverage. o Education provided to all Nursing Department Preventing including PRN/Agency/New Hires on: Accidents/Hot Liquids/Promoting a Safe Environment: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by Director of Nursing Services/Designee. o Temperature for coffee/hot beverages will be taken twice daily prior to serving residents by dietary/designee. This will be recorded on the document in the kitchen and kept in a monitoring binder to be kept by the Director of Clinical Operations/Administrator. The Administrator/Dietary Manager will review 3 days a week for 2 months to ensure compliance of the temperature checks. o 100% skills validation of accessing the Kardex. Date completed: 2/4/2025 and ongoing. Community will ensure all staff on leave/agency/PRN staff /new hires are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Monitoring Response: o The ADM/ DON/ designee will conduct weekly rounds to validate interventions related to Hot Liquid/Accident and Supervision are in place 1-7 days a week for 2 months. o The DON/Designee will conduct random skills validations regarding Kardex use 3-7 days a week for 2 months to ensure direct staff is compliant with the use of the Kardex. o Temperature for coffee/hot beverages will be taken twice daily prior to serving residents by dietary/designee. This will be recorded on the document in the kitchen and kept in a monitoring binder to be kept by the Director of Clinical Operations/Administrator. The Administrator/Dietary Manager will review the temperature checks 3 days a week for 2 months to ensure compliance of the temperature checks. o Policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations. On 02/06/25 and 06/07/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by the following: 02/06/25: Review of Resident #1's total body skin assessment dated [DATE] reflected good elasticity, normal skin color, warm temperature, normal moisture, normal condition, and no new wounds observed. Review of Resident #1's nursing progress notes reflected a late entry nursing progress note dated 02/04/25 writer notified MD and MDR of incident. Review of Resident #1's Occupational therapy (OT) evaluation 02/05/25 reflected new goals that included assess safety and management of self-feeding adaptive equipment to ensure of self-feeding independence and OT to provide education to caregiver staff in management of self-feeding adaptive equipment to ensure of good carryover/ competence in caregiving skills for patient. OT Evaluation and Plan of Treatment 02/05/25 dx include muscle wasting and atrophy, muscle weakness, lack of coordination, and need for personal assistance with personal care. Review of Resident #1's updated care plan revised 02/04/25 reflected I have the potential for injury related to hot liquid spill, may benefit from lid on hot liquid cup with intervention team members will apply/ encourage use of lid to hot liquid cup when served. Review of QAPI dated 02/04/25 reflected meeting was held, document shows Purpose of the meeting is to discuss the following concerns- F689 the facility must ensure that residents are provided assistive devices necessary to prevent an avoidable accident from occurring. The document stated meeting was attended by ADM, MD, MDR, DON, ADON B, and other key leadership. Review of Adaptive Equipment Tally Report dated 02/05/25 revealed 6 residents who had adaptive equipment updated on their Kardex to include Resident #1 - 1 cup with lid for all liquids. Review of the coffee temperature log reflected coffee temperatures being taken with the following dates and temperatures observed in new process beginning 02/05/25: 02/04/25: 145 PM (no location specification) (in degrees Fahrenheit) 02/05/25: Back Hall 130, Front 125 AM/ Back Hall 130, Front 127 (in degrees Fahrenheit) 02/06/25: Back Hall 130, Front 130 AM/ Back Hall 130, Front 130 (in degrees Fahrenheit) Review of 22 resident hot liquid evaluations reflected each had identified concern related to individual diagnosis, focus to include potential for injury related to hot liquid spill and interventions that included referral to therapy for screening and apply/encourage use of lid to hot liquid cup. Review of in-service dated 02/04/24 titled Kardex contained 6 signatures. Review of in-service dated 02/04/25 titled Feeding- all staff need to have training before feeding anyone including non-clinical management. The document contained 21 staff signatures which included CMAs, CNAs, and Admin staff. Review of in-service dated 02/04/25 titled adaptive tools- any resident who has an adaptive tool for meals (ex. Spoon, fork, plate, cup) must be at every meal. Signed by 25 staff members. Review of in-service dated 02/04/25 titled resident rights contained 16 signatures. ANE, resident rights, Kardex, respect and dignity, accidents, hot liquids, tray card accuracies text status 02/04/25 Review of in-service sheet dated 02/04/25 contained 12 signatures from kitchen/ dietary staff that reviewed tray card accuracy. Review of in-service specific to NAIT on Kardex and adaptive tools signed off on 02/04/25. Review of 34 Kardex locating competency checks completed by facility and signed off by direct care staff dated 02/05/25. Review of 3 additional Kardex locating competency checks completed by facility and signed off by staff dated 02/06/25. An observation on 02/06/25 between 12:00 PM and 01:00 PM of lunch services, 2 nurses were observed in the dining room checking all meal tray tickets and supervising CNA's and NAIT's. Staff that required assistive devices were observed provided with their assistive device. NAIT T observed, and knowledge check completed. In an interview on 02/06/25 at 01:43 PM with RN CC, she stated she works PRN (as needed) and stated she also helps to check meal trays before delivery to the residents' rooms. She stated she has been trained on Kardex and safe environment. She stated she would verify diet is correct and check for allergies on the meal trays and would determine if a resident required an assistive device by looking at the Kardex. She stated that if she found a concern related to an inaccurate meal ticket or question about the assistive device, she would report it to ADON A. She stated it was important to provide an assistive device and failure to do so could result in harm to the resident. In an interview on 02/06/25 at 01:59 PM with CNA S, she stated she received training and inservices that included abuse and neglect, resident rights, locating the Kardex, preventing accidents/ hot liquids, and promoting a safe environment before the start of her shift by ADON A. CNA S was asked to locate the Kardex on a resident and surveyor observed competency. CNA S stated it was important to provide the required assistive devices to resident or it could result in spillage and injury such as burns. 02/07/25: A binder of in-services and training was provided: it contained a log documenting the following training: On 02/04/25 and 02/05/25 training was completed on Resident Rights, Kardex, Respect and Dignity, Accidents and Prevention, Hot Liquids, Tray Card Accuracy, and Abuse and neglect. The trainers involved in completing the training of staff included RDBD, DON, ADM, DCE, CR, and ADON A. Of 131 staff members 105 were marked as educated which accounted for 80 percent of the staff, and the remained is ongoing. In an interview on 02/07/25 at 09:10 AM with VPO She stated a care feed system (a system that communicated with all staff via text) in-services facility wide to all staff related to Resident Rights, Kardex, Respect and Dignity, Accidents and Prevention, Hot Liquids, Tray Card Accuracy, and Abuse and neglect was sent to all staff. She stated the staffing list was then divided and each of the leadership trainees was in charge of educating staff either in person or via phone. Staff was asked questions in regard to the topics listed above and after they successfully verbalized understanding and competence in the subject they were marked as completing the training. Sign in sheets were also provided and reviewed with staff signatures for training that was completed in person. On 02/07/25 from 12:00 PM through 04:00 PM surveyor reached out to care staff with a focus on CNAs and NAITs, to include PRN staff and a mixture of different shifts. Of the 15 staff members contacted, 8 responded and confirmed competency on the trained subjects and knowledge checks were completed over the phone- 2 of which were also observed in person accessing the Kardex and being able to identify and locate assistive devices. During these interviews staff stated they received various inservices which included Kardex and meal tickets, accidents, hot beverages, abuse and neglect, and assistive devices. Staff stated that knowledge was assessed by leadership staff through the employees verbal understanding and competency checks as well as in person verifications with locating the Kardex. Staff provided the surveyor verbal understanding of locating the Kardex, described where to locate information regarding assistive devices, and gave examples of negative outcomes that could occur when assistive devices are not provided. Staff verified for this competency included: - NAIT U (day shift) - CNA V (night shift) - CNA W (night shift and PRN) - CNA X (day shift) - CNA Y (works both day and night shifts) in person competency verification also completed. - CNA Z (PRN) in person competency verification also completed. - CNA AA (new hire) - CNA BB (new hire) **NAIT T was interviewed to confirm understanding during a meal services observation prior to these interviews. In an interview on 02/07/25 at 04:31 PM with DON, she stated the training completed by leadership and knowledge verifications with 80% of staff, stating education began immediately on 02/04/25 after notification of the incident. She stated that staff are required to check meal tray tickets and Kardex for the use of assistive devices and encouraged to ask questions if they do know something to prevent an injury from occurring. She stated retraining was immediately completed for NAIT T on 02/04/25 and said that through this experience they have modified their practices and licensed nurses are to supervise all CNAs and NAIT's during meal services. She said all residents who require assistive devices should and will be provided them to include modified cup with lid, weighted spoons, special plates etc. she stated training and implementation of corrective processes are also ongoing. In an interview on 02/07/25 at 05:00 PM with the ADM she stated it was her expectation that NAIT's always worked with a certified nurse aide and were supervised by nursing staff during meal services. She stated failure to provide the required assistance to residents or necessary devices could result in injury. The administrator was notified the IJ was removed on 02/07/25 at 04:30 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors. The facility failed to: -Ensure Resident #1's order for insulin was instated upon admission from the hospital on 10/18/24. -Ensure Resident #1's medication orders were accurate as she was being administered two anti-seizure medications in which she did not have a diagnosis for which resulted in a sudden change in consciousness/responsiveness and she had to be sent to the hospital. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/03/24 at 5:19 PM and an IJ template was given. While the IJ was removed on 12/05/24 at 5:29 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke, type II diabetes, and end-stage renal disease. Review of Resident #1's admission MDS assessment, dated 10/22/24, reflected a BIMS score of 5, indicating a severe cognitive impairment. Section I (Active Diagnoses reflected she did not have a seizure disorder, epilepsy, or a psychiatric/mood disorder. Section N (Medications) reflected she was not on insulin or antipsychotics. Section O (Special Treatments, Procedures, and Programs) reflected she required dialysis. Review of Resident #1's admission care plan, dated 10/24/24, reflected she had diabetes and was at risk for complications associated with diabetes with an intervention of administering her medications as recommended by her doctor. It further reflected she ESRD (End Stage Kidney Disease) and required dialysis treatments with an intervention of giving medications as ordered by her physician. Review of Resident #1's Admission/Readmission Assessment, dated 10/18/24 and documented by LVN A, reflected she did not have a diagnosis of diabetes. Review of Resident #1's hospital discharge paperwork, dated 10/18/24, reflected an order for Novolin 70/30 FlexPen - 100 Unit/ML injection - Inject 8 units under the skin before breakfast and before evening meal and an order to check blood sugar four times a day. There was not an order for an anti-seizure medication. Review of Resident #1's physician order, dated 10/19/24, reflected Lacosamide Oral Tablet - Give 1 tablet by mouth one time a day for seizures. Review of Resident #1's October MAR, on 12/03/24, reflected she was administered four doses of Lacosamide - on 10/20/24, 10/21/24, 10/23/24, and 10/24/24. Review of Resident #1's physician order, dated 10/19/24, reflected Divalproex Sodium Oral Tablet Delayed Release - 500 MG - Give 1 tablet by mouth one time a day for seizures. Review of Resident #1's October MAR, on 12/03/24, reflected she was administered five doses of Divalproex - from 10/20/24 - 10/24/24. Review of Resident #1's physician order, dated 10/24/24 at 1:50 PM (after Resident #1 had been discharged to the hospital), reflected Novolin 70/30 FlexPen - 100 UNIT/ML - Inject 10 units subcutaneously two times a day for DM. Review of Resident #1's blood sugar readings in her EMR, on 12/03/24, reflected the following: 10/19/24 7:45 AM - 114.0 mg/dL 10/19/24 4:52 PM - 125.0 mg/dL 10/23/24 6:58 AM - 562.0 mg/dL 10/23/24 8:37 PM - 397.0 mg/dL 10/24/24 7:40 AM - 186.0 mg/dL 10/24/24 10:34 AM - 485.0 mg/dL 10/24/24 11:26 AM - 485.0 mg/dL Review of Resident #1's Change in Condition Assessment, dated 10/24/24 and documented by LVN B, reflected the following: [Resident #1] barely talking but verbally responsive with [NP] after this nurse notified [NP] of s/s of lethargy. [NP] came to [Resident #1] and talked to [Resident #1]. N/o to send to (hospital). Mental Status Evaluation: Altered level of consciousness - Sudden change in level of consciousness or responsiveness. Describe functional status changes: Needs more assistance with ADLs, general weakness, decreased mobility, and other. Describe the functional status signs or symptoms: weak and barely eating only sips of fluids and s/s of lethargy. . Specify neurological changes: Weakness or hemiparesis (weakness of one side of entire body). Review of Resident #1's progress note, dated 10/24/24 at 9:15 AM and documented by LVN B, reflected the following: [Resident #1] with bs of 186 called [NP] and this nurse also notified [NP] of all bs since admit at this time r/t high and out of normal range . Review of Resident #1's progress note, dated 10/24/24 at 9:22 AM and documented by LVN B, reflected the following: .[NP] notified that [Resident #1] is not talking and very weak and not as responsive . Review of Resident #1's progress note, dated 10/24/24 at 9:35 AM and documented by LVN B, reflected the following: DON speaking with [NP] about changes. [NP] notified this nurse to send resident to (hospital) with dx of lethargy . Review of Resident #1's progress note, dated 10/24/24 at 4:11 PM and documented by LVN B, reflected the following: Call out to (hospital) for 3rd update on resident and this time this nurse spoke with resident [sic] being admitted with dx of sepsis, ams, and hypotension . Review of Resident #1's hospital records, dated 10/24/24, reflected the following: .presented to ED on 10/24/24 presentation concerning for sepsis with subsequent blood cultures showing Gram-positive organisms . However [Resident #1] is unable to have oral intake because of weakness at this point as well as change in mental status and we will reassess. A1C - 14.7 (Reference Range: 3.0 - 5.6) Received 6 units of Insulin Lispro on 10/24/24 at 9:15 PM. During an interview on 12/03/24 at 10:46 AM, the IDON stated if a resident was prescribed Divalproex and Lacosamide they should have a diagnosis or history of seizures. During an interview on 12/03/24 at 10:54 AM, the WCN stated if a resident was being administered seizure medications with no seizure diagnosis, it could cause a resident to have an anticholinergic effect (symptoms include delirium, confusion, restlessness, it suppressed the central nervous system in different ways for different people) or to become sedated. During an interview on 12/03/24 at 12:04 PM, Resident #1's NP stated she reviewed resident vitals such as blood sugars and blood pressures every month. She stated if a resident was on a sliding scale insulin, there were parameters on how much insulin was to be administered. She stated if a resident's blood sugar was consistently elevated, even if not over 400, then most of the time the nurses would notify her. She stated if a resident was not on insulin and their blood sugar was over 200, she would expect to be notified. She stated if a resident was admitted from the hospital with insulin orders, they would not all the time immediately keep those orders in place. She stated if they had a normal A1c they would just monitor their sugar levels. She stated but if they did come with orders for insulin, they would follow the orders and adjust as needed. She stated it was just a case-by-case basis. She stated Lacosamide was medication utilized strictly for seizure disorders, but Divalproex could be used for behavioral issues. She stated if a resident did not have a history of seizures and was administered seizure medication, they could have an allergic reaction to the medication, but as for other symptoms, it would just depend on the possible side effects of the medication. She stated every body's chemical makeup was different and it just depended. She stated she was the one that gave the orders to send Resident #1 to the hospital on 10/24/24. She stated lethargy was her baseline since admission but that morning she could not be aroused and could barely open her eyes. She stated she was aware her blood sugars had been elevated but she (Resident #1) had not been at the facility long and they had not gotten there yet (when it came to prescribing insulin). During a telephone interview on 12/03/24 at 1:23 PM, Resident #1's MD stated it was not uncommon for a resident to not have orders for insulin even after they were on insulin in the hospital because they were going from the hospital to a post-acute world. He stated it was also very difficult with a dialysis patient because there were so many variables such as the dynamic fluid shift due to dialysis. He stated if Resident #1's blood sugars were in the 300 - 500 range, that would be way higher than it should be. He stated he would not have agreed at that at all (to not instate insulin at that point). He stated a resident would not be started on anti-seizure medication in a post-acute setting unless they were on them in the hospital. He stated if a resident was on these medications without a diagnosis of epilepsy/seizures it would typically cause sedation as they alter brain waves. He stated that could have 100% caused Resident #1's hospitalization and he wondered if the orders got transcribed in error. During an interview on 12/03/24 at 4:58 PM, the IDON stated the nurse admitting a resident was responsible for inputting medication orders after reconciling with the NP or MD. She stated the admitting nurse would only add or take away orders if the NP/MD told them to. She stated it depended on what the medication was when asked what a negative outcome of inputting inaccurate orders could be. She stated she would have to ask a doctor what a negative outcome could be for a resident to be administered anti-seizure medication without a diagnosis of seizures. She stated all medications had a potential for side effects. On 12/04/24 and 12/05/24, multiple attempts were made to contact LVN A. A returned phone call was not received prior to exiting. Review of the facility's Medication Administration Policy, revised January 2024, reflected the following: Resident medications are administered in an accurate, safe, timely, and sanitary manner. The ADM and IDON were notified on 12/03/24 at 5:19 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 12/05/24 at 10:50 AM: F760 - The facility must ensure that residents are free from significant medication errors. Immediate Response: Resident # 1 was discharged to the hospital on 10/24/24. Director of Clinical Operations reviewed with the clinical leadership- Assistant Director of Nursing regarding the proper process for: o Licensed nurse should conduct appropriate medication reconciliation as well as blood glucose monitoring orders in relation to the hospital discharge orders and the nurse should ensure that all hospital discharge orders to include medications, treatments and blood glucose monitoring orders are reviewed and confirmed with the accepting attending physician upon admission. o Post reconciliation of the medication/treatment/blood glucose monitoring order the licensed nurse should review each medication and/or treatment and blood glucose monitoring orders as well as insulin orders, to ensure that they are accurately transcribed as per the hospital discharge orders as well as any new orders provided by the attending physician / medical provider are accurately transcribed into the electronic health record. o Clinical leadership/assigned licensed nurse will conduct a post admission review all new admission/re-admission orders to include but not limited to insulin orders, blood glucose monitoring orders, correct medication orders and treatment orders against the hospital discharge order to validate the accuracy of medication reconciliation and proper transcription of physician orders. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy, clarify with the attending physician/medical provider and complete a medication error report as indicated. o Abuse & Neglect and Medication Administration, Accurate transcribing of physician orders. Date commenced: 12/3/2024. Date completed: 12/4/2024. The Director of Clinical Operations/ Assistant Director of Nursing initiated in-service training for licensed nurses regarding the process for: o Licensed nurse should conduct appropriate medication reconciliation as well as blood glucose monitoring orders in relation to the hospital discharge orders and the nurse should ensure that all hospital discharge orders to include medications, treatments and blood glucose monitoring orders are reviewed and confirmed with the accepting attending physician upon admission. o Post reconciliation of the medication/treatment/blood glucose monitoring order the licensed nurse should review each medication and/or treatment and blood glucose monitoring orders as well as insulin orders, to ensure that they are accurately transcribed as per the hospital discharge orders as well as any new orders provided by the attending physician / medical provider are accurately transcribed into the electronic health record. o Clinical leadership/assigned licensed nurse will conduct a post admission review all new admission/re-admission orders to include but not limited to insulin orders, blood glucose monitoring orders, correct medication orders and treatment orders against the hospital discharge order to validate the accuracy of medication reconciliation and proper transcription of physician orders. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy, clarify with the attending physician/medical provider and complete a medication error report as indicated. o Abuse & Neglect and Medication Administration, Accurate transcribing of physician orders. Date commenced: 12/3/2024. Date completed: 12/4/2024. Licensed nurses will complete a test to validate the process for proper process for medication reconciliation, confirming orders upon admission/re-admission and transcribing orders into the electronic health record in order to validate competency of the facility's expected practices. Date Commenced: 12/4/2024 and ongoing. Director of Clinical Operations / Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions / re-admissions' medication and treatment orders reconciliations to validate accuracy of the admission / re-admission orders entered into the electronic medical record. Outcome: Date Completed: 12/4/2024. Director of Clinical Operations / Administrator suspended the licensed nurse pending investigation who was responsible for completing an accurate medication reconciliation and accurately entering the correct hospital discharge orders after confirming the medication and treatment orders with the accepting medical provider upon admission. Date completed: 12/3/2024. Director of Clinical Operations / Assistant Director of Nursing will provide the same in-service trainings with all newly hired licensed nurses going forward as a part of the on-boarding process for nurses. Date commenced: 12/3/2024. Date completed: 12/4/2024 and ongoing. Director of Clinical Operations / Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior the licensed nurses working their next assigned shift. Risk Response: All residents who are newly admitted or readmitted have the potential to be affected by the deficient practice. Systemic Response: Director of Clinical Operations / Assistant Director of Nursing initiated in-service training for licensed nurses regarding the process for: o Licensed nurse should conduct appropriate medication reconciliation as well as blood glucose monitoring orders in relation to the hospital discharge orders and the nurse should ensure that all hospital discharge orders to include medications, treatments and blood glucose monitoring orders are reviewed and confirmed with the accepting attending physician upon admission. o Post reconciliation of the medication/treatment/blood glucose monitoring order the licensed nurse should review each medication and/or treatment and blood glucose monitoring orders as well as insulin orders, to ensure that they are accurately transcribed as per the hospital discharge orders as well as any new orders provided by the attending physician / medical provider are accurately transcribed into the electronic health record. o Clinical leadership/assigned licensed nurse will conduct a post admission review all new admission/re-admission orders to include but not limited to insulin orders, blood glucose monitoring orders, correct medication orders and treatment orders against the hospital discharge order to validate the accuracy of medication reconciliation and proper transcription of physician orders. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy, clarify with the attending physician/medical provider, and complete a medication error report as indicated. o Abuse & Neglect and Medication Administration, Accurate transcribing of physician orders. Date commenced: 12/3/2024. Date completed: 12/4/2024. Director of Clinical Operations / Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions / re-admissions' medication and treatment orders reconciliations to validate accuracy of the admission / re-admission orders entered into the electronic medical record. Outcome: Date Completed: 12/4/2024. Director of Clinical Operations / Assistant Director of Nursing will provide the same in-service trainings with all newly hired licensed nurses going forward as a part of the on-boarding process for nurses. Date commenced: 12/3/2024. Date completed: 12/4/2024 and ongoing. Director of Clinical Operations / Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior the licensed nurses working their next assigned shift. Monitoring: Director of Clinical Operations /Assistant Director of Nursing will conduct random weekly (1-7 days per week for 2 weeks) audit of new admission / re-admission physician orders to validate the accuracy of the medication reconciliation and transcription process of the physician/medical provider confirmed orders within the E.H.R against the hospital discharge orders to validate medication, insulin and treatment accuracy. The Director of Clinical Operations / Assistant Director of Nursing will maintain a monitoring log of the audits conducted identifying compliance throughout the monitoring period. Director of Nursing/Assistant Director of Nursing will conduct daily reviews during clinical start-up meeting (1-7 days per week for 2 weeks) review of new / re-admission orders, progress notes, and the 24-hour report to ensure that appropriate interventions and/or all needed follow up has been assigned. The Director of Clinical Operations / Assistant Director of Nursing will maintain a monitoring log to validate that the daily (1-7 days per week) monitoring has taken place and the outcome of the review, identifying any related compliance issue. This monitoring plan will remain in place for the next 2-3 months to ensure compliance or to identify additional training needs. All findings will be reported to the QAPI committee during monthly meeting for the next 2-3 months. Administrator, Director of Clinical Operations, and the Medical Director conducted an Ad Hoc QAPI meeting to review the identified deficient practice and plan of removal (corrective action plan) implemented. Date of completion: 12/4/2024. The Surveyor Monitored the POR on 12/05/24 as followed: During interviews on 12/05/24 from 2:03 PM - 4:46 PM, six LVNs and eight CNAs from multiple shifts stated they were in-serviced on multiple topics prior to their shifts. They all stated they were in-serviced by the DCO on abuse and neglect and the ADM was their Abuse and Neglect Coordinator. They gave examples of abuse such as physical, sexual, financial, or verbal. The LVNs all stated they were in-serviced on medications upon admissions and readmissions. They stated they needed to get the provider to verify all orders that would be sent to the pharmacy. They stated the most important thing was to ensure the residents had the correct orders for medications. They stated now they would have a second nurse look at the orders while verifying/reconciling with the provider. Review of the facility's Ad Hoc QAPI meeting Agenda, dated 12/03/24, reflected the ADM, the DNS, key nursing leadership, and the MD were in attendance. Review of the audit of all current in-patient new admissions/re-admissions' medication and treatment orders to validate accuracy of orders, dated 12/04/24, reflected no concerns. Review of an in-service entitled Abuse and Neglect, from 12/03/24 - 12/04/24 and conducted by the DCO (IDON), reflected nursing staff from all shifts were educated on the facility's Abuse and Neglect policy. Review of an in-service entitled Medication Administration, from 12/03/24 - 12/04/24 and conducted by the DCO, reflected nursing staff from all shifts were educated on the facility's Medication Administration policy. Review of an in-service entitled Medication Administration, from 12/03/24 - 12/04/24 and conducted by the DCO, reflected nursing staff from all shifts were educated on accurately transcribing physician orders upon admissions and readmissions. Review of Charge Nurse Admit/Readmit Competency Checks, from 12/03/24 - 12/04/24, reflected all nurses passed the competency checks regarding physician orders and reconciling medication orders. Review of an e-mail sent by the ADM, dated 12/05/24 at 4:11 PM, reflected at that time 81% of their CNAs and 90% of their nurses had been in-serviced and the rest would be in-serviced before working the floor. The ADM and DON were notified on 12/05/24 at 5:29 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to instate wound treatment orders for Resident #1 after she was admitted from the hospital after a hip fracture requiring surgery on 10/18/24 until 10/22/24. When she was admitted there was shearing to her sacrum and after not receiving treatment the wound was a stage III. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/03/24 at 5:19 PM and an IJ template was given. While the IJ was removed on 12/05/24 at 5:29 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke, type II diabetes, end-stage renal disease, and need for assistance with personal care after a hip fracture requiring surgery. Review of Resident #1's admission MDS assessment, dated 10/22/24, reflected a BIMS score of 5, indicating a severe cognitive impairment. Section M (Skin Conditions) reflected she had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device and was at risk of developing pressure ulcers/injuries. Review of Resident #1's admission care plan, dated 10/19/24, reflected she was at risk for skin impairment due to frail and fragile skin and decreased mobility with an intervention of handling fragile skin with caution and reporting to a nurse if any skin concerns were to arise. Review of Resident #1's discharge hospital paperwork, dated 10/18/24 reflected a skin assessment - L hip - ORIF, L fistula, R dialysis cath, R knee scab, and redness to sacrum. Review of Resident #1's Admission/Readmission Assessment, dated 10/19/24 and completed by LVN A , reflected an open/significant skin issue with an open area to buttock and shearing, redness to right knee, scab on knee. Review of Resident #1's Skin and Wound Evaluation, dated 10/23/24 and completed by the TN, reflected a stage III pressure injury (full-thickness skin loss) to her left gluteus measuring 9.0 cm x 5.9 cm. Observation of the picture of Resident #1's wound, taken on 10/23/24 by the TN, revealed a large wound with multiple pink areas where the top layer of skin was missing, a yellow area in the center reaching into the tissue under the skin layers, and some black scab-like tissue covering part of the wound. Review of Resident #1's physician order, dated 10/23/24, reflected TX - left buttocks, cleanse w/wc, pat dry, apply Santyl to areas of slough, apply triad to macerated skin, and cover with foam dressing one time a day every Mon, Wed, Fri for wound care and as needed for soiled or dislodged dressing. Review of Resident #1's hospital records, dated 10/24/24, reflected the following: .presented to ED on 10/24/24 presentation concerning for sepsis with subsequent blood cultures showing Gram-positive organisms . However [Resident #1] is unable to have oral intake because of weakness at this point as well as change in mental status and we will reassess. During an interview on 12/03/24 at 10:54 AM, the WCN stated he was at the facility once a week to do wound assessment rounds with the TN. He stated if a resident was admitted with wounds, the TN wound text/call to inform him and the next time he was at the facility he would evaluate wound and write orders. He stated until he assessed the wound, there should be their standing wound treatments put into place. He stated he expected to be notified if a resident was admitted with a wound or developed one at the facility. He stated he did not remember being notified of Resident #1's wound or assessing her. During an interview on 12/03/24 at 12:04 PM, the NP stated if a resident was admitted with a wound or skin issues, the TN needed to assess right away. She stated they did have a few standing orders for skin tears and excoriation but then the TN/WCN would need to assess to see if there was anything else that needed to be implemented. She stated as soon as a skin issue was identified, interventions needed to be put in place immediately. During a telephone interview on 12/03/24 at 1:23 PM, the MD stated typically, if a resident had any skin integrity issues, it would cause nurses to call attention to that. He stated TN would then assess and would contact the WCN if needed. He stated his expectations were that treatment orders be put in place immediately and the WCN to assess the skin issues weekly upon his rounds. During an interview on 12/03/24 at 4:58 PM, the IDON stated all nurses were responsible for wound care orders and to initiate standing treatment orders until assessed by the WCN. She stated this was important to prevent deterioration of a wound. She stated wound care was part of a resident's plan of care and should be addressed upon admission. During an interview on 12/04/24 at 12:43 PM, the TN stated she could not remember how she was informed of Resident #1's wound - if the nurse told her directly (on 10/22/24) or if she was running report. She stated how it usually went was a nurse would tell her about a resident's skin integrity issues or she would run a report based on the nurses' skin assess or admission assessment. She stated she remembered Resident #1 and provided wound care on 10/22/24. She stated Resident #1 was admitted on a Friday after she had had already left for the day and the admitting nurse (LVN A) did not do her follow-through. She stated LVN A should have assessed her skin and put standing wound care orders in place. She stated after the skin assessments, nurses did not feel obligated to take action to care for the resident. She stated she had problems with nurses seeing skin issues on residents and then not following up with resident care. She stated she had conducted multiple in-services about that. She stated the problem with the incident with Resident #1 was the lack of follow-through because LVN A did not obtain orders for wound care. She stated she marked, documented, and described the wound and then did not do anything about it. On 12/04/24 and 12/05/24, multiple attempts were made to contact LVN A. A returned phone call was not received prior to exiting. Review of in-services entitled Skin Assessment and Wound Care at Time of Admission, dated 06/12/24 and 11/05/24 and conducted by the TN, reflected nursing staff were educated on the following: New admissions who arrived with skin impairments have to have treatment orders initiated at time of admissions this cannot be delayed and is the responsibility of the admitting charge nurse. Charge nurses taking new admissions are required to complete the (EMR) admission assessment this requires a head-to-toe assessment to enter accurate information. During this time charge nurses should document any skin impairments in the admission assessment. If the discharge orders the pt arrives with does not include treatment orders, the admitting nurse is responsible for entering the appropriate standing wound care order. A list of standing wound care orders can be found in 24hr nursing binder, pink wound care nurse binder, and in the physician's communication binder. Review of an undated document entitled Standing Wound Care Treatment Orders reflected standing orders for the following: reddened rashes to sacral/buttocks MASD (moisture associated skin damage), skin tears, nonruptured [sic] blisters, DTI and ruptured blisters, and abrasions and superficial trauma injuries. Review of the facility's Skin and Wound Prevention Management Policy, revised January 2023, reflected the following: An individual's skin is the largest organ of the body . Each resident will receive the care and services necessary to retain or regain optimal skin integrity. . Guideline: . 4. The licensed nurse should document the wound presentation or description of skin issue identified within the electronic health record. 5. The licensed nurse should communicate all newly identified wounds or skin concerns as well as the status of current wounds or skin concerns to the attending medical provider (MD/NP/PA) and resident's representative. The licensed nurse should then document the notifications and any orders provided with the electronic health record. The ADM and IDON were notified on 12/03/24 at 5:19 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 12/05/24 at 10:50 AM: F686 - The facility must ensure residents receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers. Immediate Response: Resident # 1 was discharged to the hospital on 10/24/24. Director of Clinical Operations reviewed with the clinical leadership- Assistant Director of Nursing regarding the proper process for: o Licensed nurse should conduct appropriate medication/treatment reconciliation of the hospital discharge orders and should confirm all hospital discharge orders with the accepting attending physician upon admission. o Licensed nurse should conduct a complete skin assessment and validate that any identified skin issue has an appropriate treatment order in place. o Post medication/treatment orders reconciliation, the licensed nurse should validate that the appropriate wound care / treatment order is in place as per the hospital discharge orders or an alternate wound care/treatment order has been provided upon admission and validate that the wound care / treatment order is accurately transcribed into the electronic health record physician orders once confirmed by the assigned medical provider and that the prescribed wound care has been administered as ordered . o Clinical leadership licensed nurse should review all new admission/re-admission wound care / treatment orders, validate that the wound care / treatment orders have been correctly transcribed into the electronic health record (physician orders) in comparison to the hospital discharge order to validate the accuracy and proper transcription of as well as to ensure that the appropriate wound care / treatment order is being administered as prescribed. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy to the medical provider and clarify with the attending physician/medical provider any new orders and will complete a medication error report as indicated. o Abuse & Neglect and Medication Administration, Accurate transcribing of physician orders and ensuring that any skin issue has an appropriate wound care / treatment order in place and that the wound care is being provided as prescribed. Date Completed: 12/4/2024. Director of Clinical Operations / Assistant Director of Nursing completed 100% of skin sweep was conducted on all residents who currently reside in the community was completed. No newly identified pressure areas. Date Completed on 12/4/2024. Director of Clinical Operations / Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions / re-admissions wound care/treatment orders reconciliation to validate accuracy of the admission / re-admission orders transcribed into the electronic medical record. Outcome: No negative outcome noted Date Initiated: 12/3/2024. Date Completed: 12/4/2024. Director of Clinical Operations / Administrator removed from schedule the agency nurse who was responsible for the admission in question, nurse was permanently removed and reported to the staffing agency as no longer allowed to work at facility. Date completed: 12/3/2024. Director of Clinical Operations / Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior the licensed nurses working. Risk: All admissions/readmissions with a potential for skin breakdown are at risk for being affected by the deficient practice. Systemic Response: Director of Clinical Operations / Assistant Director of Nursing initiated in-service training for licensed nurses regarding the process for: o Licensed nurse should conduct appropriate medication/treatment reconciliation of the hospital discharge orders and should confirm all hospital discharge orders with the accepting attending physician upon admission. o Licensed nurse should conduct a complete skin assessment and validate that any identified skin issue has an appropriate treatment order in place. o Post medication/treatment orders reconciliation, the licensed nurse should validate that the appropriate wound care / treatment order is in place as per the hospital discharge orders or an alternate wound care/treatment order has been provided upon admission and validate that the wound care / treatment order is accurately transcribed into the electronic health record physician orders once confirmed by the assigned medical provider and that the prescribed wound care has been administered as ordered . o Clinical leadership licensed nurse should review all new admission/re-admission wound care / treatment orders, validate that the wound care / treatment orders have been correctly transcribed into the electronic health record (physician orders) in comparison to the hospital discharge order to validate the accuracy and proper transcription of as well as to ensure that the appropriate wound care / treatment order is being administered as prescribed. Should any discrepancies be identified, the licensed nurse should immediately report the discrepancy to the medical provider and clarify with the attending physician/medical provider any new orders and will complete a medication error report as indicated. o Abuse & Neglect and Medication Administration, Accurate transcribing of physician orders and ensuring that any skin issue has an appropriate wound care / treatment order in place and that the wound care is being provided as prescribed. Date commenced: 12/3/2024. Date completed: 12/4/24. Licensed nurses will complete a competency test in order to validate competency regarding the process for medication/treatment orders reconciliation, confirming that the resident has appropriate wound care orders upon admission/re-admission and the process for transcribing wound care orders into the electronic health record in order to validate competency of the facility's expected practices. Date Initiated: 12/4/2024 and ongoing. Director of Clinical Operations / Assistant Director of Nursing will conduct 100% audit of all current in-patient new admissions / re-admissions wound care/treatment orders reconciliation to validate accuracy of the admission / re-admission orders transcribed into the electronic medical record. Outcome: No negative outcome noted Date Initiated: 12/3/2024. Date Completed: 12/4/2024. Director of Clinical Operations / Assistant Director of Nursing will ensure all licensed nursing staff will be re-educated to include any licensed nurse on leave/agency/PRN staff. All licensed nurses will be in-serviced prior to assuming next shift. Director of Clinical Operations/Administrator will ensure administrative nursing staff is available to provide in-service/education prior the licensed nurses working. Monitoring: Director of Clinical Operations /Assistant Director of Nursing will conduct random weekly (1-7 days per week for 2 weeks) audit of new admission / re-admission physician orders to include but not limited to validate the accuracy of the wound care / treatment orders reconciliation and accurate transcription of the wound care orders provided by the physician/medical provider upon admission as well as to validate that the wound care orders were properly confirmed and accurately transcribed within the E.H.R. The Director of Clinical Operations / Assistant Director of Nursing will maintain a monitoring log of the audits conducted identifying compliance throughout the monitoring period. Director of Nursing/Assistant Director of Nursing will conduct daily reviews during clinical start-up meeting (1-7days per week for 2 weeks) review of new / re-admission orders, admission assessment, progress notes, and the 24-hour report to ensure that appropriate interventions and/or all needed follow up has been assigned. The Director of Clinical Operations / Assistant Director of Nursing will maintain a monitoring log to validate that the daily (1-7 days per week) monitoring has taken place and the outcome of the review, identifying any related compliance issue. This monitoring plan will remain in place for the next 2-3 months to ensure compliance or to identify additional training needs. All findings will be reported to the QAPI committee during monthly meeting for the next 2-3 months. Administrator, Director of Clinical Operations, and the Medical Director conducted an Ad Hoc QAPI meeting to review the identified alleged deficient practice and plan of removal (corrective action plan) implemented. Date of completion: 12/4/2024. The Surveyor monitored the POR on 12/05/24 as followed: During interviews on 12/05/24 from 2:03 PM - 4:46 PM, six LVNs and eight CNAs from multiple shifts stated they were in-serviced on multiple topics prior to their shifts. They all stated they were in-serviced by the DCO on abuse and neglect and the ADM was their Abuse and Neglect Coordinator. They gave examples of abuse such as physical, sexual, financial, or verbal. The CNAs all stated if they noticed any skin impairments to residents' skin during personal care or showers, they would report it to the nurse immediately. They all stated it was important for their shower sheets to reflect any skin impairments such as a rash, redness, lacerations, or bruising. The LVNs all stated the importance of detailed skin assessments was to reflect exactly what was going on with the residents' skin. They stated if a resident was admitted from the hospital, they would initiate treatment immediately and not wait for the TN. They all stated there were standing wound care orders, but they would also contact the NP and describe the wound to see if they wanted to add anything additional to the order(s). They all stated they would ensure they notified the TN so she could follow up and assess the resident. Review of the facility's Ad Hoc QAPI meeting Agenda, dated 12/03/24, reflected the ADM, the DNS, key nursing leadership, and the MD were in attendance. Review of an audit conducted by the DCO and ADON, on 12/04/24, reflected a 100% skin sweep was conducted on all residents in the facility with no findings of newly identified pressure areas. Review of an audit conducted by the DCO and ADON, from 12/03/24 - 12/04/24, reflected 100% accuracy of all residents' wound care treatment orders. Review of an in-service entitled Abuse and Neglect, from 12/03/24 - 12/04/24 and conducted by the DCO (IDON), reflected nursing staff from all shifts were educated on the facility's Abuse and Neglect policy. Review of an in-serviced entitled Wound Care/Treatment Orders, from 12/03/24 - 12/04/24 and conducted by the DCO, reflected nursing staff from all shifts were educated on ensuring that all skin issues had appropriate wound/treatment orders in place and that wound care was being provided as prescribed. Review of Charge Nurse Admit/Readmit Competency Checks, from 12/03/24 - 12/04/24, reflected all nurses passed the competency checks regarding wound treatment orders. Review of an e-mail sent by the ADM, dated 12/05/24 at 4:11 PM, reflected at that time 81% of their CNAs and 90% of their nurses had been in-serviced and the rest would be in-serviced before working the floor. The ADM and DON were notified on 12/05/24 at 5:29 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, record review and interviews, the facility failed to ensure that each resident was provided an environment that was as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for one (1) of one (1) residents (Resident #1) reviewed for wandering/elopement leading to fall with major injury. The facility failed to supervise and prevent Resident #1 from exiting the MCU of the building on 04/26/23. As a result, Resident #1 scaled the MCU courtyard fence and fell from a retaining wall to the asphalt parking lot. The resident sustained compression fractures of L1 and L3 vertebra (two bones of the lower spine which protect the nerves allowing sensation, control, and movement to the lower half of the body), requiring surgical repair. This failure could place residents at risk for accidents which could lead to injury, harm, or death; failure led to the injury of one resident and had the potential to harm 35 residents in the MCU that relied on supervision and assistive devices to prevent injury from accidents caused by unsupervised elopement/wandering. An Immediate Jeopardy (IJ) was identified on 05/06/23. The IJ template was provided to the facility on [DATE] at 4:27 pm. While the IJ was removed on 05/10/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility continued to monitor to ensure assessments for wandering/elopement were accurate for all residents, that all facility staff working in the MCU were in-serviced on wandering/elopement update procedure to residents' Kardexes (a component of the EMR in which nursing staff can view/update/identify relevant information specific to an individual resident's care needs) identifying changes made to the Kardex, reviewing Kardex of each resident prior to assuming care of a resident at shift change, and seeking alternate placement for resident in MCU of another facility with enclosed courtyard. The findings were: Review of Resident #1's face sheet from facility readmission on 05/03/23 in the EMR indicated a [AGE] year-old man who was originally admitted to the facility on [DATE] and was readmitted to the facility after hospitalization from [DATE] until discharge from hospital on 05/03/23. Resident #1 health history included on face sheet reflected Metabolic Disorder (a disorder that alters the body's processing and distribution of nutrients which can result in obesity, coronary heart disease, diabetes, and stroke), type II Diabetes Mellitus (a disorder involving an abnormal response by cells to release of insulin by the pancreas resulting in too much sugar in the blood), Hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, resulting in slow metabolism), Epilepsy (a disorder involving [NAME] of electoral activity in the brain causing seizures), and Hypertension (high blood pressure). Resident #1 face sheet dated 05/03/23 also listed unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with unspecified severity, without behavioral disturbance (not having symptoms of sleep disturbance, aggression, emotional distress, restlessness, or pacing), psychotic disturbance (a mental health term indicating hallucinations and delusions), mood disturbance (feelings of distress), and anxiety (persistent worry). Review of Resident #1's MDS (part of the U.S. federally mandated process for clinical assessment of all residents in facilities who accept Medicare or Medicaid) dated 05/04/23 was reviewed and indicated: -BIMS score (a score which indicates severity of cognitive impairment) of 4 out of possible 15 points (0-7: severe impairment; 8-12: moderate impairment; 13-15 cognitively intact). -Section G0110 relating to Activities of Daily Living Assistance indicated a transfer (how resident moves between surfaces) level for Resident #1 of Supervision, walk in room and corridor at Supervision level, locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor) at Supervision level, locomotion off unit (how resident moves to and from off-unit locations) at Supervision level. Section G0110 Section J1900 relating to Number of Falls Since Admission/Entry or Re-entry or Prior assessment indicated Resident #1 had one fall with major injury since admission or prior assessment. -Section E0900 Wandering - Presence and Frequency indicated that this behavior occurred 4 to 6 days in the 7-day period reviewed. -Section E0100 Potential Indicators of Psychosis indicates that Resident #1 was having delusions. A review of Wandering/Elopement Risk Evaluation dated 03/25/23 in the EMR indicated that Resident #1 mobility status was Independent with no assistance and no aid (assistive device such as cane or walker) and indicated a moderate risk for Wandering/Elopement. Readmission Wandering/Elopement Risk with date of 05/03/23 indicated that Resident #1 was high risk for wandering/elopement. Wandering/Elopement Risk Evaluations dated 05/06/23 and 05/07/23 indicated a high risk for wandering/elopement. A review of Fall Risk Evaluation dated 03/25/23 for Resident #1 indicated a low fall risk. Review of Resident #1's Progress Notes/Nurses' Notes in his EMR for the dates of 03/24/23 through 04/26/23 reflected the following: - 03/25/23 at 2:31 PM Admission Nurse A noted that Resident #1 stated he would bust out the windows and get out of here if you leave me' and that he would give the facility three days to see if he will like it here to his family member as translated to Admission Nurse. - 03/26/23 at 06:31 AM Night Nurse A noted that resident is independent with transfers, ambulating, and toileting. Resident walking on unit. - 04/07/23 at 5:10 AM Night Nurse A noted that Resident #1 was exit seeking throughout night shift; note described Resident #1 as gathering his belongings in to a bag, wandering to exit doors and pushing them/setting off door alarms, and looking for his car so that he could leave. Intervention documented as encouraging resident to return to room. - 04/24/23 at 05:26 AM Night Nurse A noted that resident was wandering and exit seeking. Resident was entering other residents' rooms. Intervention documented was redirecting resident. - 04/26/23 at 00:18 AM Night Nurse noted that resident was lying on floor in another resident room with pillow and blanket. No fall noted. - 04/26/23 at 4:10 PM noted that LVN B noted that resident attempted to jump fence and fell . Noted that resident was brought to nurse's station in a wheelchair, sent to hospital; DON, ADON, Director, NP, and POA were notified. No documentation was found to indicate that medical provider was notified of insomnia or behaviors during the time period of 3/25/23 through 04/26/23 when Resident #1 fell . Record review of Clinical Physician Order in EMR dated 03/27/23 reflected [Psychological Services Provider A] may provide psychological services. [Medication Management Provider] may provide psychiatric services and [Psychological Services Provider A] to eval (evaluate) and treat, may provide Psychological and Psychiatric services. Review of EMR did not reflect that Resident #1 had received evaluation and/or treatment from Provider referenced in order prior to incident. Review of provider investigation file regarding Resident #1 incident reflected the following: Review of Incident Report written by LVN A on 04/26/23 at 4:00 pm and contained within provider investigation file indicated that resident was an Active Exit Seeker, confused, a wanderer, and had impaired memory. Provider investigation file statement from Floor Tech A, witness to incident, indicated that Resident #1 passed Floor Tech A, opened the exit door causing alarm to sound, and exited to courtyard. Witness statement indicated that NA A came out of a resident room and Floor Tech A informed her that a resident had exited. NA A and Floor Tech A ran outside and Resident #1 was on top of the courtyard fence, straddling it. NA A tried to assist Resident #1 off of the fence. Resident #1 resisted assistance and went down the other side of the fence. Resident #1 landed upright on rock and cement retaining wall that supported the rod-iron fence that he had just gotten over. NA A and Floor Tech A held on to Resident #1's arms as he stood on the rock and cement retaining wall. As Resident #1 resisted efforts to hold on to him, he fell from the retaining wall onto his back on the ground. Resident #1 then got up from the ground. At this time NA A went back into the building and outside and around to where Resident #1 was. NA A assisted resident into a wheelchair and took him inside. Review of provider investigation file statement from NA A indicated that she heard the door alarm when she was in another resident room. When NA A entered the hall she could see through the glass in the door that resident was almost completely over the fence. NA A stated that she ran out of the door and could see that the left side of Resident #1's body was over the fence. NA A stated that she grabbed the resident's right foot/ankle area. Resident #1 began kicking at NA A and in the process kicked his right leg over the fence. Resident #1 landed in a standing position on the retaining wall. As NA A held on to Resident #1 through the fence bars to prevent a fall, the resident tried to hit NA A and fell backwards landing on his back. NA A stated that Floor Tech A stayed in enclosed courtyard area where Resident #1 was on the ground below and NA A ran through the building to outside area where Resident #1 was, followed by LVN B. Resident #1 was up and walking and NA A and LVN B assisted Resident #1 to sit down into a wheelchair. NA A statement was typewritten, unsigned, and undated. Review of provider investigation file indicated that LVN A, primary nurse responsible for Resident #1, was taking another resident outside to smoke at the time of incident. She did not hear door alarm sound at time of exit by Resident #1. LVN A was unaware of incident as it evolved and was informed when LVN B went out to resident smoking area to provide the information. LVN A statement indicated that after she received notification of incident she assessed Resident #1, notified the ADM, DON/ADON, and attempted to notify the NP prior to calling 911. After calling 911, LVN A checked Resident #1's vital signs and sent Resident #1 to hospital. LVN A statement is typewritten, unsigned, and undated. Provider investigation file included undated interview of Floor Tech A, by ADM. Statement of interview findings were handwritten and signed by ADM and Floor Tech A and were consistent with statement of NA A. Interview with LVN B was included in provider investigation file and was typewritten, undated, and unsigned. LVN B statement relayed going outside to site of Resident #1, who was up walking, and assisting NA A with getting Resident #1 into wheelchair. Provider Investigation file also included summary of events dated 05/03/23 and signed by ADM. Review of Provider Investigation File included undated and unsigned Timeline of Events. Review of provider investigation file included printed copy of EMR Incident Report documented by LVN A on 04/26/23 at 16:00 (4:00 pm). Incident report written by LVN A from EMR indicated that following the incident, resident #1 had pain level of 7/10, was grimacing, difficult to console, alert and sitting in a wheelchair, oriented to person, place, and situation, and was sent out to hospital by EMT at unknown time. Incident report by LVN A stated that APRN A and Resident #1 wife were notified of incident. Review of provider investigation file indicated that door opening delay mechanism and alarms on MCU doors were working properly at time of incident as maintenance door and alarm check log for day of incident and weeks prior to and after incident were included. Review of provider investigation file did not reflect an intake number or completion of forms to indicate a facility-reported incident intake had been initiated or completed with Texas Health and Human Services. Review of provider investigation file did not include interventions to prevent reoccurrence of incident. In an interview with NA A on 05/05/23 at 11:20 am NA A described incident involving Resident #1. Facts verbalized were consistent with NA A typewritten statement in Provider Investigation file. NA A stated that Resident #1 often wandered and tried to exit; NA A stated that wandering and exit-seeking had occurred both prior to and after Resident #1's fall on 04/26/23. In an interview with the ADON on 05/05/23 at 11:33 am, the ADON stated that she was at the facility on the day of Resident #1 fall. She stated that she did not witness incident of 04/26/23 but she saw Resident #1 after he was brought back into the building. The ADON stated that interventions in place for Resident #1 include keeping him busy and distracting him so that he will not try to exit-seek. The ADON stated that resident continues to actively exit-seek at the current time. In an interview on 05/06/23 at 09:15 am with LVN B, LVN B stated she did not witness incident but assisted NA A in getting Resident #1 back into the building after Resident #1 fell . LVN B stated that she notified Resident #1's primary nurse, LVN A, that Resident #1 had fallen outside. LVN B stated that she had observed Resident #1 ambulating in the hallway that she was working on in the MCU prior to accident. LVN B stated that she warned staff to keep an eye on Resident #1 as he appeared restless and had tried to open the exit door in her hall of the memory care unit. LVN B reported that Resident #1 often wandered and tried to exit. Complainant A who reported incident to State intake line was interviewed and stated that a facility staff member had made her aware of the incident which prompted reporting to State intake. Record review of provider-uploaded hospital records indicate the following: [Hospital Name] History and Physical Report dated 04/27/23 at 04:50 am for Resident #1 and signed by APRN B states a diagnosis of closed compression fracture of L1 and L3 vertebra was made. Review of provider-uploaded hospital record from [Hospital Name] dated 04/27/23 indicated that APRN C used an interpreter service to explain to Resident #1 wife the risks associated with surgery. Review of provider-uploaded hospital record from [Hospital Name] dated 04/27/23 indicated that Resident#1's wife wished to proceed with surgical procedure for Resident #1. Review of provider-uploaded hospital record from [Hospital Name] Operative Report dated 05/01/23 at 11:52 a.m. written by MD A for Resident #1 reflected that a L1 and L3 kyphoplasty (a procedure to restore the vertebra's height and relieve pain) was performed. EMR Progress note dated 05/04/23 at 00:00 by APRN A indicated that resident is seen today for a readmission visit. Pt presented to [Hospital Name] on 04/26/2023 following a mechanical fall (a fall related to extrinsic factors in the environment and not a fall related to fainting) at [facility name]. Review of Resident #1 Care Plan with admitted reflected as 05/03/2023 was reviewed on 05/05/23 and contained the following: - Focus area of Resident Care/Safety, Interventions for Resident #1 Care/Safety column was reviewed and interventions were not documented. - Focus area of Elopement Risk was reviewed and interventions included: assess Resident #1 for risk of elopement, place Resident #1 in secure unit if needed, seek alternate placement (for Resident #1) of a secured memory unit that has an enclosed courtyard within the center of the facility where the courtyard is surrounded by the building. - Focus area of Risk for Fall related to history of Falls was reviewed for Resident #1. Interventions included adequate lighting (in Resident #1's environment), assess for possible contributing factors (in Resident #1 environment), assist (Resident #1) with transfers, encourage (Resident #1) use of call light, evaluate for safety devices (needed for Resident #1), keep call light within reach (of Resident #1) at all times when in room, keep floors clean and free of spills and/or debris (in Resident #1 environment), provide wheelchair (for Resident #1), walker (for Resident #1), geri-chair (large, padded reclinable chair with wheels which helps with limited mobility, most often used with bedridden residents who have difficulty sitting upright in a conventional wheelchair) as indicated (for Resident #1), and reinforce to Resident #1 the need to call for assistance. - Focus area of Resident Social Services needs due to Mood/Behaviors/Cognition Issues reviewed and indicated interventions: if behaviors (non-specified) exist, the root cause will be identified and addressed accordingly; resident mood will be addressed by keeping the resident engaged in activities that the resident likes; resident short and long term memory problems will be identified and addressed through engaging activities. In an interview with the ADM on 05/05/23 at 10:00 a.m., the ADM stated that Resident #1 fell to the ground from a retaining wall that was approximately 9' on 04/26/23. The ADM stated staff witnessed incident. The ADM stated that staff acted appropriately (responded quickly) in addressing the situation. The ADM stated emergency services were called after Resident #1 stated that he had hurt his back. The ADM stated Resident #1 was taken to the hospital and then transferred from there to another hospital for surgery. The ADM stated that Resident #1 was currently in the MCU having returned on 05/03/23 from the hospital. The ADM stated Resident #1 is ambulatory after his surgery. The ADM stated that Resident #1 had been placed in the MCU on his original admitted [DATE] and is in the MCU at this time. The ADM stated that Elopement and Wandering Assessments are documented and are done at time of admission, quarterly, and when there is a change in condition. The ADM stated that the facility had confused residents who may try on occasion to follow a visitor outside. Those residents have been easy to redirect back into the building without incident. The ADM stated they have never had an incident such as the event with Resident #1. The ADM stated that Resident #1 had been wandering and exit seeking in the facility during his stay but Resident #1 had not gotten outside prior to April 26, 2023. The ADM stated events leading up to Resident #1's fall on 04/26/23 progressed very rapidly. The ADM stated that Resident #1 is [AGE] years old and 115 pounds, quick, and strong. The ADM states Resident #1's family made the decision to place him in the facility after he had been wandering frequently from the family home and they could not find him. The ADM stated that Resident #1 was once the subject of a Silver Alert (missing older adult). Resident #1 was observed in the MCU on 05/05/23 at 11:10 am. Resident #1 was observed sitting alone in a day room which was next door to his room. Resident #1 was sitting on a loveseat which has an exit door next to it in the day room. Resident #1's room was noted to be approximately 2/3 distance of the hall away from the nurse's station toward the hallway exit door. Staff were observed sitting at the nurses station. In an interview with the DON on 05/05/23 at 3:00 pm., the DON stated that MCU exit doors to the outside of building had a delay in opening which had always been in place and continue to be. The DON stated an alarm will sound when someone tries to open the door and after 15 seconds the door will open. The DON stated that she did not believe that there were other residents were capable of scaling MCU fence. The DON stated she had been at facility approximately two years and had never seen this type incident before. The DON stated that Resident #1 had been wandering and exit-seeking since he was originally admitted but staff were surprised at the strength of the resident when he scaled the fence and how quickly the event unfolded. The DON was asked about residents eloping and stated that residents have gotten outside by following someone out of the doors. The DON stated that residents who have gotten outside of building have been easy to get back inside with staff assistance. The DON stated that facility does not use wander-guards or other technology (sensor device that a resident could wear or could be put in their shoe which causes an alarm to go off or a door to lock when resident is within 10-15 feet) to assist in preventing elopements. The DON stated that Resident #1 cannot be moved closer to nurse's station as there are currently no available closer rooms to move him to. The DON stated that sleep aides had not been given to Resident #1 for not sleeping well at night. The DON stated that she would notify APRN of Resident #1 not sleeping well/wandering at night and request a sleep aide for Resident #1. The DON stated that Resident #1 had not been seen by psychology and/or psychiatry services but she would put in a referral to have Resident #1 seen on Monday 05/08/23, as the PMHNP visits the facility on Mondays. The DON did not offer reason for the omission of follow-through for physician order to have Resident #1 evaluated and treated by psychology/psychiatry services. The DON stated that Resident #1 is with his family member at current time but when he is not with a family member, he has been supervised one on one. When it was mentioned that Resident #1 had been observed alone in the day room earlier in the day, the DON added that Resident #1 is not directly supervised but is kept within eyesight of an assigned staff member as someone too close to him may increase his behaviors. The DON was asked for a copy of the facility policy for one-on-one monitoring but the DON was unable to find one. The DON stated that staff began observing resident one-one-one, when his family is not in the facility, after Resident #1 returned from the hospital on 05/03/23. The DON stated she would like to hire an ADON responsible solely for the MCU. The DON stated that she was going to get MCU nurses enrolled in a dementia training class to increase their knowledge of managing their resident population. In an interview with Resident #1's family member on 05/05/23 at 11:55 a.m., using translator, it was revealed by Resident #1's family member that he had a history of wandering when he was living at home. Resident #1's family member stated that police would recognize him and bring him home because it happened so often. Resident #1's family member stated that Resident #1 had a history at home of leaving during the night and family members did not know where he went. She stated that Resident #1 is safer at facility than he was at home because there is not a busy road right outside the door. Resident #1's family member stated that facility staff had been informed at time of initial admission that Resident #1 had a history of eloping from the family home on multiple occasions and requiring law enforcement intervention; she stated that she informed the facility this was the reason for placing him in the facility. In an interview on 05/05/23 at 12:00 p.m. with Resident #1, using translator, Resident #1 I haven't had any pain for 7 days and now my back hurts. Resident #1 stated he did not remember before he had the fall or after he had the fall, but he remembers the fall itself. Resident #1 was unable to provide additional information. Record review of the facility in-services with nursing staff during the weeks before and after the incident included Incident and Accident Reporting Process and Falls Notifications dated 05/02/23, Nurse Aide Rounding/Incontinent Care dated 05/03/23, Resident Rights dated 04/10/23, Reporting Abuse and Neglect dated 04/04/23. Facility in-services were in written form with a staff sign-in sheet. Facility in-services were reviewed for content. Wandering/Elopement in-service during this time frame was not found. The facility ADM and facility DON were notified on 05/06/23 at 4:27 PM that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal was requested at this time. The following Plan of Removal was accepted on 05/10/23: Plan of Removal Immediate Jeopardy On 05/05/23 an abbreviated survey was initiated at [facility name]. On 05/06/23 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. Resident A and the other 4 high risk residents identified residing in the MCU have the potential to be affected by the deficient practice called on 5/6/23. These patients will remain on the MCU and continue to be monitored by the staff on the MCU. The facility has added resident centered activity interventions to their care plan. Action: Resident A is currently within secured unit has had a new exit seeking/wandering assessment completed by the Director of Nursing on 5/7/23 and remains a score of 16 which is a high risk for wandering/elopement. The DON/designee will monitor and ensure completeness. An exit seeking assessment will be completed on admission, readmission, and at least quarterly on any MCU resident that is attempting to leave the premises of the MCU. Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: Charge Nurse to initiate, the DON/designee to monitor the completeness of each assessment. Action: The DON/designee will complete weekly audits in Point Click Care (electronic medical record software system specifically designed for use in long term care facilities) for 4 weeks as our monitoring component for continued weekly compliance on new admits/re-admits/anyone exhibiting exit seeking behavior which is identified by the completion of the At-Risk Elopement Assessment. Any assessments completed during the 4-week monitoring period of review will be checked by the DON/designee to initiate and Admin/designee to monitor. Weekly checks x 4 weeks and monthly thereafter for continued compliance which is our monitoring aspect. All residents residing on MCU had elopement risk assessments completed by nurses on duty on 5/7/23. 5 residents in total were identified at high risk and care plans were updated to reflect current assessment data. Resident B's care plan was added with calling the [family member] for agitation. Resident C's care plan was updated with snacks and activity mat. Resident D had no changes made. Resident E's care plan was updated that staff and visitors would be mindful to ensure exit doors closed behind them. Changes have been updated on the patient's Kardex (a component of the EMR in which nursing staff can view/update/identify relevant information specific to an individual resident's care needs), that is available to nursing staff. The DON/designee interviewed memory care nursing staff to ensure complete understanding on the process of identifying changes to the Kardex by completing a return demonstration. 28 memory care nursing staff have completed the return Kardex demonstration on 6 a.m.-2 p.m., 2 p.m.-10 p.m., and 10 p.m.-6 a.m. shifts to reflect all residents, not just Resident A. Anytime an update is made to any patient's care plan, the system automatically updates their specific Kardex. Start Date: 5/7/23 Completion Date: 5/7/23 Responsible: The DON/designee to initiate and ADM/designee to monitor weekly completed assessments for continued compliance for 4 weeks. Action: Only Resident A to remain in MCU on 1:1 with assigned staff member for each shift until alternate placement is found. Resident A's care plan has been updated to reflect additional interventions put in to place to include [Psychological Services Provider A] for medication management, psychological and psychiatric needs and continuous 1:1. These interventions are automatically updated into the Kardex found in Point Click Care that is available to the nursing staff. Resident A care plan will be updated within any changes of condition, quarterly, and annually by the IDT (team of healthcare professionals which may include a nurse, physical therapist, occupational therapist, speech therapist, social worker, medical doctor and/or nurse practitioner) to reflect current status. 5 residents identified as high-risk care plans have been reviewed by members of the IDT. No new physician's orders on the medical chart or changes made to the other 4 identified residents' physicians orders; only changes made were to the intervention section of the care plan for wandering/elopement. Resident B's care plan was added with calling the [family member] for agitation. Resident C's care plan was updated with snacks and an activity mat. Resident D had no changes made. Resident E's care plan was updated that staff and visitors would be mindful to ensure exit doors close behind them. All changes are added to the Kardex that is available to all nursing staff. The DON/designee interviewed memory care staff to ensure complete understanding on the process of identifying changes to the Kardex. Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: Care plans will be reviewed by the IDT at a minimum of quarterly and/or significant change which will be ongoing per regulatory requirement. Action: In-service all memory care team members to include agency and PRN staff on elopement procedure prior to their next scheduled shift on the memory care unit. Only new hires and current team members will be educated by the start of their next shift on the memory care unit and any MCU team member not present will be educated on process via phone prior to the start of their next shift on the memory care unit which includes agency and PRN staff [staff who work on an as-needed basis) as well as our policy on wandering and elopement for the facility. Documentation Log for 5-minute documentation of what a resident is doing and signed by staff member that was assigned by the DON/designee to 1:1 for that specified shift. All changes in care plans are reflected on the Kardex located in Point Click Care and available to all memory care nursing staff. The DON/designee interviewed memory care staff to ensure complete understanding on the process of identifying changes to the Kardex. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: The DON to initiate and ADM/designee to monitor until Resident #1 is discharged to alternate placement. Annual re-education on wandering/elopement will be provided as well as training upon any identified issue or concern of elopement by the DON/ADM/designee. Action: Resident A was referred to [Psychological Services Provider A] for medication management, psychological and psychiatric services. Patient was seen on 5/8/23. Medication changes were made effective 5/9/23 for an anti-depressant and agitation. Start Date: 5/6/23 Completion Date: Referral sent 5/6/23. Patient seen on 5/8/23 Responsible: The SW to initiate and the DON/designee to ensure [Psychological Services Provider A] sees patient on their visit. Action: Meeting with Resident A's family was completed on 5/7/23 to discuss possible alternate placement to another locked facility that has a more centralized courtyard to go outside and enjoy. Family involvement with the placement is occurring. If no acceptance to another facility, Resident A will remain on MCU under 1:1 care until alternate placement can be found. Start Date: 5/7/23 Completion Date: 5/7/23 Responsible: The SW submitted referral to 5 facilities on May 6 and 1 referral on May 7. The DON/designee to monitor placement process. Action: Emergency meeting (Adhoc) held with clinical team on 5/6/23. The MD was notified and the meeting was in reference to Resident A continuing to be a risk for elopement. No formal additional meetings were held. Group meetings were held to discuss the plan of removal. Start Date: 5/6/23<br [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents were free from neglect, when it failed to provide required structures and processes in order to meet the needs of residents. The facility failed to provide the necessary care and services and ensure staff knowledge of their skin management system for four (4) of eight (8) residents reviewed for quality of care and four (4) of thirteen (13) residents reviewed for pharmaceutical services in that: A) The facility failed to ensure residents (Resident #1, #2, #3 and #4) with diabetic stasis ulcers and pressure ulcers were routinely assessed, monitored for decline, and treated per physician instruction and orders. The facility failed to ensure staff were trained and knowledgeable about wound care and the facility's wound care system. The facility further failed to monitor compliance of staff regarding the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] B) The facility failed to have a system in place for Resident's medication and treatment including insulin administration in the event there is a power outage, disasters or computer system failure, thereby causing Residents (Resident #1, #3, #5 and #6) to not receive scheduled medications and treatments on 04/09/2021 from 12:30 PM to 9:55 PM. These failures resulted in an Immediate Jeopardy situation on 04/10/2021. While the IJ was removed on 04/13/2021, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. These failures placed facility residents at risk for worsening stasis, venous and pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood) severe pain, and loss of limbs and placed residents in the facility at risk for not receiving a therapeutic effect from medications and treatments ordered, potential effect of hyperglycermia, change in condition and hospitalization . Findings Include: A.) Review of Resident #2's Face Sheet dated 04/10/2021 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to require extensive to dependent assist with ADLs. Resident #2 was assessed to have diabetic foot ulcers with application of dressings to feet. Review of Resident #2's Comprehensive Care Plan reviewed on 04/10/2021 reflected a focus area not dated Altered skin integrity related to wound to left heel. Interventions included assess skin on admit and weekly thereafter .Follow treatment per MD orders, keep responsible party updated on plan of care, notify physician of concerns . Further review of Resident #2's Comprehensive Care Plan reflected a focus area not dated The resident is on antibiotic therapy ([MEDICATION(S)] DS 800-160mg) related to infection (MRSA) left heel wound. The plan of care did not address any other wounds or ulcers. In an interview on 04/10/2021 at 1:33 PM Resident #2's FM stated the facility is ignoring doctor's orders and not treating Resident #2's foot per doctor orders and this was not the first time it has happened. She stated one person at the facility several weeks ago wrapped Resident #2's foot too tight (was not able to give date) and it caused a lot of damage to her foot by cutting off what little blood flow she had and it caused her toes to turn black and her foot develop more wounds. She stated last week the wounds to Resident #2's left foot got worse and the wound care clinic cultured them. She stated on Monday 04/05/2021 she called the wound care clinic to get the culture reports and they showed she had MRSA and E. coli in her wounds. She stated the wound care clinic told her they called in orders to the pharmacy for antibiotics for Resident #2 and had sent the information back to the facility with the resident. Resident #2's FM stated on Tuesday 04/06/2021 after her sister complained of not getting any antibiotics, she called the pharmacy and they stated the facility had not been picked up the medication. Resident #2's FM stated she called the facility and a facility nurse (she was not sure who) told her they could not pay attention to an order from wound care clinic they would have to call her primary doctor. Resident #2's FM stated on 04/08/2021 Resident #2 still did not have her antibiotics even after she called the facility to complain. Review of Resident #2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation and interview on 04/10/2021 at 2:42 PM Resident #2 was in her room in bed alert. A [NAME] Boot (used for offloading- pressure relief) was observed to her left foot and a dressing could be seen to the left foot. Resident #2 stated she went to the wound care doctor yesterday. Resident #2 stated that the nursing care at the facility is poor and further stated she is not sure the nursing staff know what they are doing. When asked if she was on antibiotics, she stated she was not sure and stated, that's a problem too. Resident #2 was not able to elaborate on that and did not present as fully orientated. Review of Resident #2's EMR reflected no weekly wound progress notes or wound assessments. An overdue alert was noted at the top of the assessments tab in the EMR indicating the weekly wound progress note was overdue and had not been done. Review of Resident #2's Nursing Admission assessment dated [DATE] reflected Resident #2 had a wound to her left heel; no description or measurements of the left heel wound were noted. Review of the facility's Weekly pressure injury QI Reports dated 03/02/2021 through 04/01/2021 which listed pressure and non-pressure areas reflected Resident #2 was not listed on the weekly tracking form. Review of the facility's Weekly pressure injury QI Report dated 04/08/2021 reflected Resident #2 was listed on form. The document indicated Resident #2 had a wound to the left heel. No measurements or assessment information to describe the wound was listed on the form. No other wound locations were listed on the form. Review of Resident #2's Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Left anterior & lateral ankle dated 03/11/2021 Clean with normal saline and 4x4 gauze. Paint area with [MEDICATION(S)], protect with foam. Change daily one a day for non-pressure chronic ulcer of left ankle. - Left Calcaneus (heel) dated 03/11/2021 Clean with normal saline and 4x4 gauze. Apply Barrier cream to macerated area, Iodoscorb (antimicrobial), cover bone with [MEDICATION(S)], cover wound with foam once daily three times week M-W-F. Do not wrap extremity tightly for chronic ulcer of left heel, midfoot with bone involvement. - Left Distal Foot dated 03/11/2021 Apply Iodoscorb, gauze and gauze wrap one daily 3 x week. Do not wrap extremity tightly. - Left Dorsal Foot dated 03/11/2021 clean wound with normal saline and 4x4 gauze. Paint area with [MEDICATION(S)], protect wound with foam. Change daily for acute [CONDITION(S)] left ankle and foot. In an interview on 04/10/2021 at 3:00 PM the DON stated after reviewing Resident #2's EMR that no wound assessments were done for Resident #2. When Surveyor asked about the Wound care Clinic notes from 04/09/2021 the DON stated she would have to ask medical records where they were. When the DON was asked why Resident #2 had no wound care assessments and has orders for four (4) wounds she stated she did not know. The DON after further review of Resident #2's EMR stated there were no wound care clinic assessments in her EMR. The DON stated Resident #2 was seen by a different wound care physician and was pretty sure she went to the wound care clinic on 04/09/2021. The DON stated Resident #2 should have weekly wound assessments in her record as well as the wound care clinic notes. Observation and interview on 04/10/2021 at 3:05 PM revealed RN A in Resident #2's room to perform wound care to Resident #2's left foot. RN A stated Resident #2 went to the wound care clinic on 04/09/2021. RN A removed the kerlix wrap from Resident #2's left foot to reveal Resident #2's fourth and fifth toes to be black and gangrenous. RN A then removed a foam dressing from Resident #2's left medial dorsal foot to reveal an area of eschar (dead tissue that sheds or falls off) (approximately 2 cm x 2.5 cm). Another foam dressing was removed to reveal two more areas of eschar one to the left lateral foot (approximately 4 cm x 1.5 cm) and another one to the left lateral foot (approximately 1 cm x 1 cm). Another foam dressing was removed by RN A to reveal another area of eschar to the left ankle (approximately 1cm x 1cm). RN A cleaned each area of eschar with [MEDICATION(S)]. RN A then removed a foam dressing from Resident #1's heel to reveal a heel ulcer with areas of eschar, bone exposed and areas of slough (a white or yellow covering on the base of the wound can prevent a wound from healing properly), the skin to the peri wound was macerated (the whiteness and loss of intact skin around wound margins as a result of dressing not able to pull or control excess fluid, skin damage caused by moisture) (Surveyor unable to approximate size related to resident's inability to have foot raised to the level necessary for full view). RN A then removed a large foam dressing from Resident #2's Left lateral lower leg to reveal a large full thickness stasis ulcer with areas of eschar and slough. The ulcers edges were red and epibole (rolled or curled-under closed wound edges) the wound measured approximately 12 cm x 4 cm. RN A applied [MEDICATION(S)] and a foam dressing to all ulcers expect the left heel and the fourth and fifth toes. RN A did not cover Resident #2's fourth or fifth toes or place gauze between the toes. RN A applied [MEDICATION(S)] to the heel and applied a [MEDICATION(S)] and foam dressing to the heel ulcer. In an interview on 04/10/2021 at 4:15 PM RN A was asked if Resident #2 had an order to treat her Left fourth and fifth toes in her EMR. RN A look at Resident #2's TAR and stated no. When asked about the treatment she performed on Resident #2's wounds she stated she just did what was ordered for the other areas. RN A then pulled out Resident #2's assessment from the wound care clinic dated 04/09/2021 from a folder on her medication cart and presented it to the Surveyor. Review of Resident #2's Wound care and hyperbaric medicine assessment dated [DATE] reflected orders for Resident #2's wound care that included orders for all six of Resident #2's wounds with changes in orders to her other wounds. Review of the orders reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Left distal foot Apply Iodosorb, gauze woven loosely between third, fourth and fifth toes, and secure with foam, change three times a week. Left Calcaneus Barrier cream to macerated peri wound, paint with [MEDICATION(S)], cover bone with [MEDICATION(S)], cover wound with border foam, change daily. All other wound orders were to apply [MEDICATION(S)] and bordered foam. In an interview on 04/10/2021 at 4:30 PM RN A was asked why the orders from Resident #2's NP A were not transcribed she stated the wound care nurse carries out the orders when the resident returns from the wound care clinic. When asked who the wound care nurse was, RN A stated it was LVN A. When asked if LVN A was not at the facility, what would happen, she stated LVN A would put the orders in when she got back. When asked if she gave LVN A the new orders for Resident #2, she shook her head no. When asked why all other nursing staff interviewed stated there was not a wound care nurse why did she think there was one. RN A stated she has seen LVN A making rounds with the Wound Doctor. When asked if she knew what the facility's policy was for carrying out physician orders, assessing wounds and the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/10/2021 at 6:30 PM the DON stated the facility did not have a wound care nurse. The DON stated LVN A made rounds with the Wound Care Doctor weekly, but the floor nurses were responsible for their own treatments, making sure orders were carried out and for weekly wound assessments for their residents. In an interview on 04/12/2021 at 10:00 AM NP A stated she had concerns and she was going to send it in regarding the care her patient is receiving at the facility. She stated last Monday on 04/05/2021 she sent orders for Resident #2 to have antibiotics when her cultures came back positive for MRSA and E. coli. NP A stated the orders were not carried out until 04/08/2021 she stated there are times when the wound dressings are not applied correctly causing restriction of blood flow and residents come to the clinic with more wounds than when they left. Review of NP A's Written statement dated 04/09/2021 reflected I am a wound care provider, providing wound care to patients with acute and chronic wounds .Many of my patients are residents of nursing homes and assisted living facilities and are transported to the wound care clinic weekly for routine wound care. When the patient is here in clinic with us, their wounds are assessed, dressed with appropriate wound dressings and orders for the continuation of their wound care, during the days they are not in our clinic, are sent back to their living facility where the expectation is the nursing staff there will execute the appropriate wound care as ordered. However, my experience with this facility has repeatedly been poor, placing my patients at risk for infection, injury, and in worst case, loss of limbs. There have been instances where the patient (Resident #2) presents to our wound care center with more wounds than they left with due to inappropriately placed wound dressings and bandages, causing restriction of blood flow. In this situation, the wrap was applied so tightly, it caused blood restriction in the limb of a patient with already poor perfusion. This led to the development of wounds on (Resident #2') feet, ankle, and lower leg, which have turned necrotic, and have led to the impending loss of two toes and likely loss of her leg in the future. In addition, when one of these new wounds became infected and an antibiotic was prescribed for the patient, the facility did not provide the medication to the patient even after the staff was contacted and notified a Rx had been electronically sent to their pharmacy and a hard copy of the order was faxed to them. The patient repeatedly tells wound care clinic staff, the facility did not provide wound care at the intervals listed on her orders, and that she feels she is at the mercy of the facility to ensure her safety and health, and she does not feel confident in their ability to provide care for her .The patient's family is equally concerned and frustrated and have tried to have the patient moved to another facility but due to insurance and lack of available facilities in the area, it has not been possible for this to occur. I fear my patient's health is in jeopardy at this location and I am not confident they can provide skilled wound care and execution of orders essential to their resident's medical needs. I feel it would be in the best interest of my patient and the other residents residing at the facility to have this facility thoroughly reviewed to ensure the safety, health, and well-being for the residents who live there. Review of Resident #4's Face Sheet reflected a [AGE] year-old female admitted to the facility n 08/16/2019 and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Annual MDS dated [DATE] reflected Resident #4 had a BIMS score of 15 indicating she was cognitively intact. Resident #4 was assessed to require extensive assist with ADLs. Resident #4 was assessed to have diabetic foot ulcers and application of dressing to feet. Review of Resident #4' s Comprehensive Care Plan (not dated) reflected The resident has (Stage 2) pressure ulcer L-heel or potential for pressure ulcer development related to immobility. Interventions included Administer treatments as ordered and monitor for effectiveness, Assess/ record/ and monitor wound healing (weekly) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . Further review reflected another focus area Resident has diabetic ulcer of the right heel related to diabetes . Review of Resident #4's Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Weekly Wound Progress noted dated 04/08/2021 reflected resident had two wounds one to right and left heel. With the right heel measuring 1 cm x 3cm x 0.1 cm and the left measuring 1.2 cm x 3.5 com x 0.3 cm with the right heel wound bed described as epithelial tissue and the left described as 50 percent slough and 50 percent granulation tissue. Observation/ and interview on 04/11/2021 at 12:08 PM revealed Resident #4 in her room alert and orientated. Resident #4 had a dressing to left and right heels. Resident #4's dressings were dated 04/08/2021. Resident #4 stated that getting her wounds treated could be a problem sometimes. Resident #4 further stated she had not had her dressing's changed in days. In an interview on 04/11/2021 at 12:15 PM RN A stated she was on Resident #4's hall and she was responsible for doing her wound care. When asked if she had done Resident #4's wound care since 04/08/2021, she stated no. When asked how many days she had been assigned down the hall she stated three. When RN A was asked why Resident #4's wound care had not been done she stated, I don't know what to say, I guess I missed it. In an observation on 04/11/2021 at 12:20 PM revealed RN A in Resident #4's room to do wound care. RN A attempted to remove the dressing from Resident #4's right heel and the dressing was stuck to the wound. Resident #4 verbalized pain and RN A stopped wound care to notify the physician. Review of Resident #1's face sheet revealed an [AGE] year-old male DOB 05/29/1929 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 000, staff interview indicated memory problems. Review of Resident #1's Care Plan which was undated revealed has ADLs self-care deficits, has stasis ulcer to my Left anterior leg and a trauma area to my Left med calf, stage 4 pressure ulcer on my sacrum. Review of Resident #1's wound care Physician notes dated 04/08/2021 revealed Resident #1 has the following wounds: left anterior leg venous ulcer, right lateral leg stage 4 pressure ulcer, left heel pressure/deep tissue injury, right lateral malleolus stage 4 pressure ulcer, left posterior leg venous ulcer, right lateral heel unstageable pressure ulcer, right medial heel arterial ulcer, left lateral malleolus unstageable pressure ulcer, left distal medial leg venous ulcer. Resident #1 was seen by wound doctor on 03/25/2021 and the orders was not initiated until 3/29/2021. It was also noted, Resident #1's wound care was not done every day as ordered but was done three times a week. RN A failed to perform wound care on Resident #1 even though his wound dressing was saturated. See orders below from wound doctor Clean left anterior leg venous ulcer with normal saline, apply collagen and calcium alginate three times a week. Clean right lateral leg stage 4 pressure ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean left heel pressure/deep tissue injury with normal saline, pat dry, apply skin prep Clean right lateral malleolus stage 4 pressure ulcer with normal saline, apply silver alginate every day. Clean left posterior leg venous ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean right lateral heel unstageable pressure ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean right medial heel arterial ulcer with normal saline, pat dry, apply [MEDICATION(S)] every day Clean left distal medial leg venous ulcer with normal saline, pat dry, apply [MEDICATION(S)] every day. Review of Resident #1's clinical records revealed the resident's last skin assessments was 03/16/2021 and there were no skin checks for the month of February. In an interview on 04/08/2021 at 10:28 am, LVN A stated, she usually follows the wound doctor during his rounds every Thursday because the facility doesn't have a wound care nurse. She also stated, after the wound doctor's visit, the nurses are responsible to initiate new orders for their residents. She stated, Resident #1's dressing changes orders were changed to daily due to lots of drainage from the wounds. In an interview on 04/08/2021 at 3:35 pm, LVN B stated she worked on 03/25/2021(Thursday) and received new orders for Resident #1's wound care. She also stated, she did not put the new orders for Resident #1 in the computer on the same day. She stated, I usually wait for the weekend to put the orders in the computer, but I am not sure of the date I put those orders in the computer. She stated, Resident #1's wound care order was changed from three times a week to daily. She also stated, the wound care doctor changed the orders today (04/08/2021) back to 3 times a week because the daily wound care was not effective. She then realized, the orders she initiated in the computer on 03/29/2021(Monday) was not right, it was three times a week instead of daily. LVN B then stated, I must have mistakenly put it in the computer for three times a week instead of every day. Observation on 04/09/2021 at 6:55 pm, Resident #1's left leg wound dressing was saturated with brownish drainage, dressing is dated 04/08/2021, the pillow/sheets under the Resident #1's leg is saturated with brownish drainage from left leg. In an interview on 04/09/2021 at about 7:00 pm, RN A stated, she will notify the night shift nurse to change Resident #1's wound dressings. She stated, the night shift nurse does the dressing wound dressing changes for Resident #1 and sometimes the wound care nurse. She then stated, I have never changed his dressing before, the computer system in down so I don't know what treatment to put on his wounds. In an interview on 04/09/2021 at 7:52 pm, ADON A stated, we do not have a wound care nurse, the nurses do their own wound care, we have a nurse who comes on her off days to make rounds with the wound doctor. She also stated, it is not ok for a nurse to say she will wait for the weekend to initiate orders on a latter day because that is a delay in care that leads to neglect. If an order is not put in correctly it will lead to delay in care and not the right outcome. She stated, her expectation is for the nurses to initiate orders the same day, if for some reason the nurses are not able to initiate the orders, it should be communicated so she can initiate the orders same day. She later stated, if a Resident's wound dressing is saturated, it is her expectation for the nurse to do the dressing change. She also stated, there should already be a PRN order in place to change as needed. She also stated, if the Nurse is not sure of the treatment needed, it is ok to do a wet to dry dressing and notify the doctor. In an interview on 04/10/2021 at 6:46 pm, the interim DON stated, the facility does not have a wound care nurse, LVN A follows the wound doctor on Thursday during his visits. She also stated the nurses are responsible to initiate wound care orders or any orders, no matter what the orders are. She also stated the nurses are responsible to assess the resident's skin weekly and it is documented in the computer. She also stated, it is the responsibility of the ADON to monitor or audit all skin assessment. She stated, she has not had ADON for about 5 weeks, and since there was no ADON, it was her responsibility to audit but she is just one person and cannot do it all. She stated, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not expect the nurse to wait for few days before putting in an order, that will lead to delay in services, worsen wound. It can be considered a neglect not taking care of orders immediately. In an interview on 04/12/2021 at 11:44 am, the wound doctor stated treatment orders should be initiated the next scheduled time the. He also stated wound care orders being changed from 3 times a week to every day can be due to more drainage and or the medication being applied. He stated, if there is a drainage, the wound dressing should be changed. He also stated, wound care is very painful for Resident #1, it takes up to 20 to 30 minutes to be done, we are trying to keep Resident #1 comfortable as much as possible and to keep the wounds clean. In an interview on 04/12/2021 at 1:21 pm, Resident #1 stated his left leg hurts a lot and he did not feel like the pain medications helps. He also stated, when his wound dressing is fresh and clean, it feels better but when it stays long, and the dressing is soiled it hurts a lot. Review of Resident #3's face sheet revealed a [AGE] years old male DOB 05/06/1974 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15. It also indicated pressure ulcer of right heel, stage 3. Review of Resident #3's Care Plan which was undated revealed the resident is on IV antibiotic therapy for infection, at risk for pressure ulcer. The facility failed to ensure a plan of care for Resident #3's right heel pressure ulcer. Resident #3 was not listed on the facility wound track log. The facility failed to ensure Resident #3's wound was being monitor; last skin assessment was 03/16/2021. In an interview on 04/09/2021 at 6:37 pm, RN A stated Resident #3 had a wound doctor appointment today. She also stated, when a wound doctor writes new wound care orders, she had no idea who initiates the orders in the computer. She stated, there were no new orders from Resident #3's wound care visit today. She also stated, she has never been trained on wound care at this facility. Review of facility's wound care tracking log on 04/10/2021, revealed Resident #3 wound was not being tracked. On 04/11/2021, the surveyors requested documents from RN A that Resident #3 brought back from his wound care visit on 04/09/2021. Review of Resident #3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Daily cleanse with half strength dakins solution, apply [MEDICATION(S)], Silver Alginate, ABD, and Kerlix/kling to keep dressing in place. Review of Resident #3's clinical records revealed Resident #3's new wound care order was not implemented; Resident #3 continue to get the previous wound care order. It was noted the nurses were signing off doing Resident #3's wound care daily. See previous wound care order Cleanse R heel daily with half strength Dakin's solution. Pat dry with 4x4. Apply Santyl to the base of the wound, cover with gauze, ABD and kling to keep dressing in place. Change daily. one time a day related to pressure ulcer of right heel. In an interview on 04/12/2021 at 1:10 pm, Resident #3 stated the nurses usually change his wound dressing on Monday/Wednesday/Friday. He also stated, His wound dressing was changed on Friday, 04/09/2021 at the wound care center and next dressing change was done on today, Monday 04/12/2021. He also stated, It's been like this forever, there is always a concern about carrying out orders. I am worried about my foot; I can't get infection. In an interview on 04/12/2021 at 11:08 am, NP B from the wound care center stated Resident #3 was seen by her on 04/09/2021 and there were new orders. She also stated, it is her expectation for the orders to be initiated on 04/09/2021, if it is not initiated, it will hinder the wound from healing, the resident's wound will continued to be debrided. It is putting him at increased risk for infection, putting him at risk for amputation. It will also delay his hyperbaric treatment. In an interview on 04/09/2021 at 7:52 pm, ADON A stated, we do not have a wound care nurse, the nurses do their own wound care, we have a nurse who comes on her off days to make rounds with the wound doctor. She also stated, it is not ok for a nurse to say she will wait for the weekend to initiate orders on a later day because that is a delay in care that leads to neglect. If an order is not put in correctly it will lead to delay in care and not the right outcome. She stated, her expectation is for the nurses to initiate orders the same day, if for some reason the nurses are not able to initiate the orders, it should be communicated so she can initiate the orders same day. She later stated, if a Resident's wound dressing is saturated, it is her expectation for the nurse to do the dressing change. She also stated, there should already be a PRN order in place to change as needed. She also stated, if the Nurse is not sure of the treatment needed, it is ok to do a wet to dry dressing and notify the doctor. In an interview on 04/10/2021 at 6:46 pm, the interim DON stated, the facility does not have a wound care nurse, LVN A follows the wound doctor on Thursday during his visits. She also stated the nurses are responsible to initiate wound care orders or any orders, no matter what the orders are. She also stated the nurses are responsible to assess the resident's skin weekly and it is done in the computer. She also stated, it is the responsibility of the ADON to monitor or audit all skin assessment. She stated, she has not had ADON for about 5 weeks, and since there was no ADON, it was her responsibility to audit but she is just one person and cannot do it all. She stated, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not expect the nurse to wait for few days before putting in an order, that will lead to delay in services, worsen wound. It can be considered a neglect not taking care of orders immediately. The DON stated, I am responsible for training the staff, I can't speak for the past, the nurses that have been here has been here for a while. I don't know what they were trained on until January 2021. I have not done training on wound care for my nurses. She also stated the nurses are responsible to do skin assessment weekly In an interview on 04/11/2021 at 2:32 PM the Administrator stated the broken wound care system was a known issue before the state showed up. She stated she had issues with filling positions and the DON was interim, but her expectations were for the system to be monitored for compliance and it was not. The Administrator stated that the broken system did not happen over a period of weeks or days, it happened over a long period of time and things were not being taken care of as it should have been resulting in residents not getting the care they need. Review of the facility's policy Skin Management System dated 05/2019 reflected A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These e

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents, for 4 Residents (R#1, R#3, R#5, R#6,) of 11 residents selected on the sample for medication and treatment administrations, in that: The facility failed to have a system in place for Resident's medications and treatments administration in the event there is a power outage, disasters or computer system failure, thereby causing Residents to not receive scheduled medications and treatments on 04/09/2021 from 12:30pm to 9:55pm, as evidence by the following: A. Resident#1 wound dressing was not changed by RN A when saturated with brownish drainage from the wound, the sheet/pillow in place to keep leg elevated was also stained with the brownish drainage. B. Resident #6 did not receive insulin as ordered at 11:30 am and 4:30pm and PRN medication when requested. C. Resident #3 was administered medications by LVN C without verification of Physician orders. D. Resident #5 was not administered insulin as ordered and scheduled at 12:00 pm, 5:00 pm and 8:00 pm even though her blood glucose at 5:00 pm was greater than 400. These failures resulted in an Immediate Jeopardy situation on 04/10/2021. While the IJ was removed on 04/13/2021, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. These deficient practices affected 4 residents and could affect all residents in the facility resulting in residents not receiving a therapeutic effect from medications and treatment ordered, potential effect include [CONDITION(S)], change in condition, pain, hospitalization . Findings include A. Review of Resident #1's face sheet revealed an [AGE] year-old male DOB 05/29/1929 with admitted [DATE]. Diagnoses include pain, falling, cognitive impairment, heart failure, Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 000, staff interview indicated memory problems. Review of Resident #1's Care Plan with target date 04/08/2021 revealed has ADLs self-care deficits, has stasis ulcer to my Left anterior leg and a trauma area to my Left med calf, stage 4 pressure ulcer on my sacrum. Review of Resident #1's wound care physician notes dated 04/08/2021 revealed Resident #1 has the following wounds: left anterior leg venous ulcer, right lateral leg stage 4 pressure ulcer, left heel pressure/deep tissue injury, right lateral malleolus stage 4 pressure ulcer, left posterior leg venous ulcer, left lateral heel unstageable pressure ulcer, right medial heel arterial ulcer, left lateral malleolus unstageable pressure ulcer, left distal medial leg venous ulcer. Observation on 04/09/2021 at 6:55pm, Resident #1's left leg wound dressing was saturated with brownish drainage, dressing was dated 04/08/2021, the pillow/sheets under the Resident #1's leg was saturated with brownish drainage from left leg. In an interview on 04/09/2021 at about 7:00 pm, RN A stated, she will notify the night shift nurse to change Resident #1's wound dressings. She stated, the night shift nurse does the dressing wound dressing changes for Resident #1 and sometimes the wound care nurse. She then stated, I have never changed his dressing before, the computer system is down so I don't know what to treatment to put on his wounds. In an interview on 04/09/2021 at 7:30pm, ADON B stated RN A did not talk to her about Resident #1's wounds and dressing changes. She also stated, I have helped a nurse over night to hold the resident's leg up. I don't know when Resident #1's next wound care is schedule, the computer system is down, and I am unable to tell. She stated, neglect is not attending to Resident's needs, not cleaning the resident, not providing wound care, not providing the care within the scope of practice. I have not done wound care for Resident #1. In an interview on 04/09/2021 at 7:52 pm, ADON B stated, the computer system has been down since 12:30pm. She also stated, I do not know how the nursing staff were able to give resident's medications from 12:30pm to present. The February's TARS and MARS are the only ones available and they are not accurate. I have called twice, [NAME] has called, she is on the phone with the company, trying to figure out and fix the problems. The administrator was on her way to print out the MARS and TARS at home when the surveyor walked into the facility on [DATE] at 5:30pm. In an interview on 04/09/2021 at 8:21 pm, ADON B stated, there are night medications for the residents she cannot administer because the computer system is down and there is no access to the MARs and TARs, and she doesn't know what to do. She stated, I cannot administer medications by memory, I have not worked this hall before. In an interview on 04/09/2021 at 8:23 pm, the Administrator stated the computer system has been down since 12:30pm. She also stated, she had some Face sheet, TARS and MARS out at the nurse's station. She then stated, I was going to print the MARs and TARs when you walked in the facility, I have outside access. She then stated, the DON went home to rest because she's working tonight. She stated, I can't explain how the medication were administered to residents from 12:30pm to present, I do not know if medications were administered or not and if nurses were able to give their medication from 12:30 to present. I am not a nurse. In an interview on 04/09/2021 at 8:41 pm, the Regional nurse stated, the backup Plan on how to retrieve the MARs and TARs from Point Click Care (the computer system the being used for electronic records) in the event the computer system is down was but was unable to print right now. She also stated, there is a computer out there with a red plug and it's used for emergency, you go through steps to get the MARs and Tars. She then stated, the administrator spoke with IT and they said they were fixing it; I think she thought it was coming back up. She was waiting. I can't tell you how the residents got their medications from 1:00 pm to present. Observation on 04/09/2021 at 8:55pm, nursing staff noted at the computer that is designated for retrieving MARs and TARs in the event of computer failure and is unable to retrieve the documents. The backup plan was not working. In an interview on 04/09/2021 at 9:15 pm, ADON A stated, I do not know what the backup plans for medication administration for this facility in the event the computer system is down. I haven't been here long enough, no one has updated me. In an interview on 04/09/2021 at 9:23 pm, LVN F stated, I am not able to administer medications or perform wound care right now because the computer system is down, I don't know what to give. She also stated, she has to log onto the system to be able to administer PRN medication. She stated she did not know what to do in situations like these, she did not know where to look, the system has never gone down like this. B. Review of Resident #6's face sheet revealed [AGE] years old female DOB 01/03/1955 with admitted [DATE] and readmitted [DATE]. Diagnoses include cough, chronic pain elsewhere, restless leg syndrome, Hypertension. Review of Resident #6's MDS assessment dated [DATE] revealed a BIMS score of 14, indicating mild cognitive impairment. Review of Resident #6's Care Plan revealed the resident has ADLs self-care performance deficit. Review of Resident #6's physician order revealed the following: [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 35 unit subcutaneously at bedtime for DM, scheduled for 8:00 pm -Start Date- 02/15/2021 Insulin [MEDICATION(S)] (1 Unit Dial) Solution Pen injector 100 UNIT/ML Inject 16 unit subcutaneously before meals for DM, schedule at 11:30 am and 4:30pm -Start Date- 02/28/2021 1130 It was noted Resident #6 did not receive 11:30 am and 4:30pm insulins as ordered. Observation on 04/09/2021 at about 9:28 pm, Resident #6 asked LVN F for medication, Resident #6 did not specify the medication at this time. LVN F stated, I am sorry, I am unable to give your medication at this time, the computer system is down. LVN F stated Resident #6 usually ask for cough syrup at this time. She also stated, If someone wants pain medication now there is nothing I can do, I have to verify orders, I can't do anything without the MARs. I have to wait for a printout of the MARs and TARs or for the system to come back on before administering any medication. In an interview on 04/09/2021 at 9:32 pm, LVN E stated, I have not given the residents their night medications because we do not have the MARs available, the computer system is not running and I do not know what to administer. She stated she usually start administering night medications by 6:30pm -6:45 pm, will not administer medications until the computer system is back on. LVN E then stated, we are supposed to have printed MARs and TARs on each hall, and I am not sure how often it is changed or reprinted. She ended by saying she did not have old MARs and TARs from last month, all she had was current face sheet. C. Review of Resident #3's face sheet revealed a [AGE] years old male DOB 05/06/1974 with admitted [DATE]. Diagnoses include stage 3 pressure ulcer to right heel, [CONDITION(S)], essential hypertension, transplanted organ and tissue status, [CONDITION(S)] [CONDITION(S)]. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15. Review of Resident #3's Care Plan which was undated revealed the resident is on IV antibiotic therapy for infection, at risk for pressure ulcer. Review of Resident #3's physician orders reflected the following: [MEDICATION(S)] Tablet Delayed Release 180 MG (Mycophenolate Sodium) Give 2 tablet by mouth two times a day related to, transplanted organ and tissue status, scheduled for 6 am-1 pm and 6 pm-1 am. Start date of 03/08/2021 [MEDICATION(S)] Capsule 1 MG Give 3 capsule by mouth at bedtime related to transplanted organ and tissue status, scheduled for 6 pm-1 am. Start date of 03/08/2021 give with 0.5MG to equal 3.5MG [MEDICATION(S)] Capsule 0.5MG Give 1 capsule by mouth at bedtime related to transplanted organ and tissue status, scheduled for 6 pm-1 am. Start date of 03/08/2021 give with 3MG to equal 3.5MG [MEDICATION(S)] Solution Reconstituted 1 GM Use 1 gram intravenously every 8 hours for wound infection until 04/15/2021 23:59, scheduled at 4pm, start date 03/12/2021 Observation on 04/09/2021 at about 6:55pm, LVN C was observed administering medication to Resident # 3. . She also stated, the previous month MAR is not good to use because the medication might be changed or completely discontinued and that could lead to medication errors and I consider that medication errors. In an interview on 04/10/2021 at 12:26 pm, MA B stated she worked on 04/09/2021 from 6am-6pm. She also stated, I did not administer medications yesterday because the computer system was down. I am not sure when the system went down but I administered medication up to 11am. I did not give any medication by memory. She also stated, if the residents do not get their medications it is a problem. In an interview on 04/10/2021 at 1:26 pm, LVN D stated she worked on 04/09/2021. She stated, I did not give all my medications yesterday (04/09/2021) because the computer system was down. I don't know the exact time the system went down but from 1 pm to about 7pm I did not give medications. I did residents accu check and did not give insulin because I couldn't guess what to give. I didn't give Coumadin; I can't guess what to give. I told the night nurse to give. She added by saying, if a medication is ordered and it is not given, it is considered neglect. We have had the system going down but not for that long. The administrator did not show me TARs and MARs on her phone. D. Review of Resident #5's face sheet revealed [AGE] years old female DOB 01/17/1947 with admitted [DATE] and readmitted [DATE]. Diagnoses include type 1 diabetes with ketoacidosis without coma, essential hypertension, dehydration. Review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 3, indicating severely cognitive impairment. Review of Resident #5's Care Plan which was undated revealed the resident is diabetic, has ADLs self-care performance deficit related to muscle weakness and debility, at risk for pressure ulcer. Review of Resident #5's physician orders reflected the following: No sugar added house supplement 2.0 120cc TID three times a day for weight loss, scheduled at 7:00 am, 12:00 pm and 5:00 pm -Start Date-10/11/2020 1200 [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for DM, scheduled at 8:00 pm -Start Date- 11/03/2020 2000 NovoLOG [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 20 unit subcutaneously with meals for DM1. Hold if patient does not eat or gluc < 120 -Start Date- 01/05/2021 scheduled at 8:00 am, 12:00 pm and 5:00 pm NovoLOG [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 299 = 0; 300 - 349 = 2; 350 - 399 = 3; 400+ = 5 Notify provider, subcutaneously with meals for DM1 -Start Date- 11/05/2020 1200 In an interview on 04/10/2021 at 1:51 pm, RN A stated she worked on 04/09/2021. She stated, I was not able to administer medications yesterday, I was only able to give insulin in the morning, the computer system went down by 11:30 am. We notified the DON and Administrator, they stated we cannot do anything about it because we do not know the dosages of the medications. She also stated she did not know the backup plan of what to do when the computer system is down. She then stated, when the computer system is down, the nurses and medication aides do not have access to the TARs and MARs and without the TARs and MARs, they cannot administer medications. She stated, she performed accu checks yesterday (04/09/2021) but did not give insulins. She further stated, Resident #5's blood glucose during dinner was up to 400, and she did not give her insulin. When asked what did she do about Resident #5's high blood glucose, she stated she took away Resident #5's vanilla shake to prevent her sugar from getting higher. She said she told ADON B about Resident #5's blood glucose level. In an interview on 04/10/2021 at about 6:46 pm, the interim DON stated she left early on 04/09/2021 to go and rest because she was working that night. She stated she was aware the computer system was down prior to leaving the facility and the Administrator was contacting IT. She stated, ADON A was in the facility when she left the facility and the Administrator was aware. She stated there is a backup plan for MARs and TARs recovery for when the computer system goes down. She also stated she did not attempt to recovery MARs and TARs because usually IT gets the problem fixed with 15-20 minutes. She stated, the computer system failure is a problem to medication administration because it makes it difficult for the nurses and medication aides to be able to administer medications. If the nurses and medication aide don't have MARs and TARs, they are not able to administer medications. She also stated, she did not find out from Nursing staff how they were able to administer medication yesterday, 04/09/2021 because the computer system hadn't been down long when she left the facility. She also stated she was not aware that some Resident's medications were not given yesterday (04/09/2021). She stated, she should have been notified by ADON A, the nurses and medication aides if a medication was not given. She further stated, if a resident does not receive medication as ordered, it is not following the physician's order and can be classified as a medication error. She ended by saying it is not OK to administer a medication by memory. ADON A stated, the nurse can check blood glucose by memory but as far as giving insulin, no. The Nurse should call the doctor for a one-time order for a high blood sugar reading. In an interview on 04/11/2021 at 1:50 pm. The Administrator stated, the computer system went down around 12:45 pm on 04/09/2021. She stated the Regional nurse and majority of the staff also told her the system was down. She stated, usually the system/Internet do not stay down for long, she waited a little bit of time to see if it comes back on. She stated, she contacted IT at about 2:30pm, the DON was still in the facility. She stated, IT told her it needed to be expedited up to the next level and she contacted everyone, and they started working on it at that time. She also stated, the MARs for February was available and they would have reprinted the current MARs and TARs if they had the ability to do so. The nurses were supposed to use the February MARs/TARs to administer critical medication, we had those MARs and TARs as back-up. The Administrator stated usually the outage is for a short time and there is no break in services. There was a plan in place for PCC disaster guide, there is a folder on the desktop that has that plan in it. In an interview on 04/12/2021 AT 11:26 am, with the PA for the MD stated, if a medication is not administered for some reason, the nurses are expected to call her. She also stated, if the nurses are not able to administer insulin, she expects the staff to call her. She stated, if the blood sugar is high and out of the range of the order, the nurses are supposed to call her. She also stated, if the staff do not have access to the computer for some reason, they are supposed to call her. She stated she was not notified of Resident #5's blood glucose being as high as 400 on 04/09/2021 and was not aware the computer system was down on said date. She stated, if a resident's blood sugar is as high as 400 and they didn't get insulin, over time it will cause organ damage like the eyes and kidneys, there is no immediate effect for sugar that is not extremely high, it will be a long-term damage. She stated, if a resident missed blood pressure medications, it depends on the severity on the disease, one missed dose of blood pressure might lead to stroke to one Resident and nothing to another. She also stated, if a resident missed seizures medication it is questionable, it depends on the individual, it may cause a [CONDITION(S)] for some and for others it might not. She ended by saying, overall, she expects the staff to administer medications as ordered, if for some reason they are not able to administer a medication to notify her. Review of the facility's policy titled Medication Orders, revised November 2014 reflected: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. ---A current list of orders must be maintained in the clinical records of each resident ---Orders must be written and maintained in chronological order. Review of facility's policy titled Administration Procedure for all Medication; no revision date reflected: To administer medication in a safe and effective manner. --Review the 5 rights 3 times ---check MAR/TAR for order Notification of Physician/Prescriber ----held medication for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held. An Immediate Jeopardy was identified on 04/10/2021 at 12:11am. The Administrator and ADON were notified of the Immediate Jeopardy on 04/10/2021 at 12:11am and the IJ Template was given to the Administrator. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 04/11/2020 at 6:31 pm. 1. MARs and TARs will be copied and distributed in binders to the nurses' station by the tenth of each month in case the facility is presented with a situation that the EMR is not functional. This will be done by the DON and/or designee. This task was completed 4/10/21 a. At minimum a weekly audit will be completed by the DON and/or designee to ensure eMAR downloads have occurred and back-up with the identified computer. b. Identified computer for back up with MARS will test print at least monthly for at least one resident's MAR for validation of functionality by the DON and//or designee. c. When a new resident admits to the building the DON and/or nursing designee will print the MAR and TAR and place in the binder at the nurse's station. 2. Education of nurses and medication aides, by DON and/or nursing designee on the location of the resident MAR & TAR binder that will be at each nurses' station to be used in the event that the EMR is not functional. This education was started immediately after exit and will be completed by 4/11/21. This education will be done either in person or via phone for all licensed nurses and medication aides. The licensed nurses and medication aides will be educated prior to beginning their work assignment. 3. Education of nurses and medication aides, by the DON and/or nursing designee on the ability to recover resident information with the Point Click Care Disaster Recovery Guide. The education was started immediately after the surveyor left for the night and will be completed by 4/11/21. This education will be done either in person or via phone for all licensed nurses and medication aides. The licensed nurses and medication aides will be educated prior to beginning their work assignment. 4. The Point Click Care Disaster Recovery Guide will be added to the new nurse orientation program. 4/11/21 5. This guide will be located at the HUB nurses' station. Completed 4/9/21 by nursing administration. 6. In the event that paper MARS and TARS are utilized the DON and/or designee will distribute binders to each designated cart/station and make med pass observation q 4 hours to ensure the residents receive their prescribed medications and treatments as ordered during this event 7. Residents identified to have been impacted have been assessed by a Registered Nurse with no adverse outcomes completed by 4/11/2021. 8. An ADHOC QAPI meeting will be held with DON, Administrator, DCO, Medical Director and SVP on 4/10/21 The Survey Team monitored the current plan of removal as follows: Monitoring done from 04/11/2021 through 04/13/2021: In an interview on 04/11/2021 at 12:09 pm, LVN D stated, they were in-serviced on medication administration, crisis and interventions in the event the computer system goes down. She stated, in the event the computer system goes down, go to the paper MARs and TARs in the binders at each station. She was able to point at the binder. If a Resident's medication is not given, call the doctor for orders. Observation on 04/11/2021 at 12:35 pm revealed nurses and medication aides administering medications. In an interview on 04/11/2021 at 12:37 pm, MA B stated she was in-serviced on where to find the paper MARs in the event the computer system goes down and there is no access to point click care. She also stated the paper MARs are located at the nurse's station and was able to point it out. In an interview on 04/12/2021 at 12:38 pm, LVN A stated she had been in-serviced on the paper MARs and TARs being at the nurse's for when the computer system is down. She also stated, she is also aware to notify the doctor if a medication was not administered for some reason. In an interview on 04/12/2021 at 2:35 pm, LVN B stated, she was in-serviced on paper MARs and TARs in the event the computer system goes down. She also stated an instruction on how to retrieve the MARs and TARs from the backup computer. She was able to locate the paper MARs and TARs. In an interview on 04/12/2021 at 2:49 pm, ADON A stated she was in-serviced on printing the MARs and TARs at the end of the month, put it at each nurse's station, for emergency in the event the computer system goes down. She also stated, if for some reason a Resident's medication is not administered, document it, monitor the resident and notify the doctor. In an interview on 04/12/2021 at 4:01 pm, MA A stated, she was in-serviced if there is a power outage, to find my paper MARs, it's at the nurse's station in a big binder. She also stated, if I am unable to administer a medication, I will notify the nurse. Observation on 04/13/2021 at 10:30 am revealed binders at the nurse's station at the HUB containing MARs and TARs for all Residents, staff were practicing how to retrieve documents from the back up computer at the HUB in the event of disaster. Surveyor was presented an audit sheet for weekly checks for the backup computer. On 04/13/2021 at 12:16 pm, the Medical Records personnel was observed teaching the Receptionist on how to retrieve MARs and TARs from the backup computer in the event the computer system failure and disaster. The Medical Records personnel stated, she's training administrative staff how to retrieve MARs and TARs for when they are managers on duty on the weekends. She also showed a binder with the instructions, 1 copy in her office and another at the nurse's station. She stated she will test the system daily even though it should be done weekly. The surveyor was able to observe the process. In an interview on 04/13/2021 at 12:21 pm, the MDS nurse stated she was in-serviced on how to retrieve MAR and TARs in the event the computer system was down, and the staff were unable to access point click care. She stated the backup computer need to be plugged into the red plug and connected to the printer. Record review on 04/13/2021 reflected the facility initiated an in-service on 04/10/2021 on point click care disaster recovery for nurses and medication aides. The MARs and TARs will be at the nurse's station in a binder every month in case of emergency. On 04/13/2021 at 4:25 pm the facility Administrator were notified that the IJ was removed. However, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review, the facility failed to assess and provide treatment in accordance with professional standards of practice and based on the comprehensive person-centered care plan for four (4) out of eight (8) residents reviewed for quality of care. (Resident #1, #2, #3 and #4) A. The facility failed to ensure Resident #2's diabetic stasis ulcers to her left lower extremity and left anterior foot were assessed weekly to ensure Resident #2's ulcers did not decline. The facility further failed to ensure a plan of care was in place for Resident #2's diabetic ulcers, ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. The facility failed to ensure Resident #4's diabetic ulcers to her bilateral heels were treated daily per physician orders. C. The facility failed to initiate wound care orders for Resident #1 until 4 days later, from 03/25/2021 to 3/29/2021. The facility failed to implement Resident #1's wound care orders as ordered; it was not done every day as ordered but was done three times a week. RN A failed to perform wound care on Resident #1 even though his wound dressing was saturated. D. The facility failed to ensure a plan of care for Resident #3's right heel pressure ulcer. Resident #3 was not listed on the facility wound track log. The facility failed to ensure Resident #3's wound was being monitor; last skin assessment was 03/16/2021. These failures resulted in an Immediate Jeopardy situation on 04/10/2021. While the IJ was removed on 04/11/2021, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure placed facility residents at risk for worsening stasis and venous ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood) severe pain, and loss of limbs. Findings Include: A. Review of Resident #2's Face Sheet dated 04/10/2021 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to require extensive to dependent assist with ADLs. Resident #2 was assessed to have diabetic foot ulcers with application of dressings to feet. Review of Resident #2's Comprehensive Care Plan reviewed on 04/10/2021 reflected a focus area not dated Altered skin integrity related to wound to left heel. Interventions included assess skin on admit and weekly thereafter .Follow treatment per MD orders, keep responsible party updated on plan of care, notify physician of concerns . Further review of Resident #2's Comprehensive Care Plan reflected a focus area not dated The resident is on antibiotic therapy ([MEDICATION(S)] DS 800-160mg) related to infection (MRSA) left heel wound. The plan of care did not address any other wounds or ulcers. In an interview on 04/10/2021 at 1:33 PM Resident #2's FM stated the facility is ignoring doctor's orders and not treating Resident #2's foot per doctor orders and this was not the first time it has happened. She stated one person at the facility several weeks ago wrapped Resident #2's foot too tight (was not able to give date) and it caused a lot of damage to her foot by cutting off what little blood flow she had and it caused her toes to turn black and her foot develop more wounds. She stated last week the wounds to Resident #2's left foot got worse and the wound care clinic cultured them. She stated on Monday 04/05/2021 she called the wound care clinic to get the culture reports and they showed she had MRSA and E. coli in her wounds. She stated the wound care clinic told her they called in orders to the pharmacy for antibiotics for Resident #2 and had sent the information back to the facility with the resident. Resident #2's FM stated on Tuesday 04/06/2021 after her sister complained of not getting any antibiotics, she called the pharmacy and they stated the facility had not been picked up the medication. Resident #2's FM stated she called the facility and a facility nurse (she was not sure who) told her they could not pay attention to an order from wound care clinic they would have to call her primary doctor. Resident #2's FM stated on 04/08/2021 Resident #2 still did not have her antibiotics even after she called the facility to complain. Review of Resident #2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation and interview on 04/10/2021 at 2:42 PM Resident #2 was in her room in bed alert. A [NAME] Boot (used for offloading- pressure relief) was observed to her left foot and a dressing could be seen to the left foot. Resident #2 stated she went to the wound care doctor yesterday. Resident #2 stated that the nursing care at the facility is poor and further stated she is not sure the nursing staff know what they are doing. When asked if she was on antibiotics, she stated she was not sure and stated, that's a problem too. Resident #2 was not able to elaborate on that and did not present as fully orientated. Review of Resident #2's EMR reflected no weekly wound progress notes or wound assessments. An overdue alert was noted at the top of the assessments tab in the EMR indicating the weekly wound progress note was overdue and had not been done. Review of Resident #2's Nursing Admission assessment dated [DATE] reflected Resident #2 had a wound to her left heel; no description or measurements of the left heel wound were noted. Review of the facility's Weekly pressure injury QI Reports dated 03/02/2021 through 04/01/2021 which listed pressure and non-pressure areas reflected Resident #2 was not listed on the weekly tracking form. Review of the facility's Weekly pressure injury QI Report dated 04/08/2021 reflected Resident #2 was listed on form. The document indicated Resident #2 had a wound to the left heel. No measurements or assessment information to describe the wound was listed on the form. No other wound locations were listed on the form. Review of Resident #2's Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Left anterior & lateral ankle dated 03/11/2021 Clean with normal saline and 4x4 gauze. Paint area with [MEDICATION(S)], protect with foam. Change daily one a day for non-pressure chronic ulcer of left ankle. -Left Calcaneus (heel) dated 03/11/2021 Clean with normal saline and 4x4 gauze. Apply Barrier cream to macerated area, Iodoscorb (antimicrobial), cover bone with [MEDICATION(S)], cover wound with foam once daily three times week M-W-F. Do not wrap extremity tightly for chronic ulcer of left heel, midfoot with bone involvement. -Left Distal Foot dated 03/11/2021 Apply Iodoscorb, gauze and gauze wrap one daily 3 x week. Do not wrap extremity tightly. -Left Dorsal Foot dated 03/11/2021 clean wound with normal saline and 4x4 gauze. Paint area with [MEDICATION(S)], protect wound with foam. Change daily for acute [CONDITION(S)] left ankle and foot. In an interview on 04/10/2021 at 3:00 PM the DON stated after reviewing Resident #2's EMR that no wound assessments were done for Resident #2. When Surveyor asked about the Wound care Clinic notes from 04/09/2021 the DON stated she would have to ask medical records where they were. When the DON was asked why Resident #2 had no wound care assessments and has orders for four (4) wounds she stated she did not know. The DON after further review of Resident #2's EMR stated there were no wound care clinic assessments in her EMR. The DON stated Resident #2 was seen by a different wound care physician and was pretty sure she went to the wound care clinic on 04/09/2021. The DON stated Resident #2 should have weekly wound assessments in her record as well as the wound care clinic notes. Observation and interview on 04/10/2021 at 3:05 PM revealed RN A in Resident #2's room to perform wound care to Resident #2's left foot. RN A stated Resident #2 went to the wound care clinic on 04/09/2021. RN A removed the kerlix wrap from Resident #2's left foot to reveal Resident #2's fourth and fifth toes to be black and gangrenous. RN A then removed a foam dressing from Resident #2's left medial dorsal foot to reveal an area of eschar (dead tissue that sheds or falls off) (approximately 2 cm x 2.5 cm). Another foam dressing was removed to reveal two more areas of eschar one to the left lateral foot (approximately 4 cm x 1.5 cm) and another one to the left lateral foot (approximately 1 cm x 1 cm). Another foam dressing was removed by RN A to reveal another area of eschar to the left ankle (approximately 1cm x 1cm). RN A cleaned each area of eschar with [MEDICATION(S)]. RN A then removed a foam dressing from Resident #1's heel to reveal a heel ulcer with areas of eschar, bone exposed and areas of slough (a white or yellow covering on the base of the wound can prevent a wound from healing properly), the skin to the peri wound was macerated (the whiteness and loss of intact skin around wound margins as a result of dressing not able to pull or control excess fluid, skin damage caused by moisture) (Surveyor unable to approximate size related to resident's inability to have foot raised to the level necessary for full view). RN A then removed a large foam dressing from Resident #2's Left lateral lower leg to reveal a large full thickness stasis ulcer with areas of eschar and slough. The ulcers edges were red and epibole (rolled or curled-under closed wound edges) the wound measured approximately 12 cm x 4 cm. RN A applied [MEDICATION(S)] and a foam dressing to all ulcers expect the left heel and the fourth and fifth toes. RN A did not cover Resident #2's fourth or fifth toes or place gauze between the toes. RN A applied [MEDICATION(S)] to the heel and applied a [MEDICATION(S)] and foam dressing to the heel ulcer. In an interview on 04/10/2021 at 4:15 PM RN A was asked if Resident #2 had an order to treat her Left fourth and fifth toes in her EMR. RN A look at Resident #2's TAR and stated no. When asked about the treatment she performed on Resident #2's wounds she stated she just did what was ordered for the other areas. RN A then pulled out Resident #2's assessment from the wound care clinic dated 04/09/2021 from a folder on her medication cart and presented it to the Surveyor. Review of Resident #2's Wound care and hyperbaric medicine assessment dated [DATE] reflected orders for Resident #2's wound care that included orders for all six of Resident #2's wounds with changes in orders to her other wounds. Review of the orders reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Left distal foot Apply Iodosorb, gauze woven loosely between third, fourth and fifth toes, and secure with foam, change three times a week. Left Calcaneus Barrier cream to macerated peri wound, paint with [MEDICATION(S)], cover bone with [MEDICATION(S)], cover wound with border foam, change daily. All other wound orders were to apply [MEDICATION(S)] and bordered foam. In an interview on 04/10/2021 at 4:30 PM RN A was asked why the orders from Resident #2's NP A were not transcribed she stated the wound care nurse carries out the orders when the resident returns from the wound care clinic. When asked who the wound care nurse was, RN A stated it was LVN A. When asked if LVN A was not at the facility, what would happen, she stated LVN A would put the orders in when she got back. When asked if she gave LVN A the new orders for Resident #2, she shook her head no. When asked why all other nursing staff interviewed stated there was not a wound care nurse why did she think there was one. RN A stated she has seen LVN A making rounds with the Wound Doctor. When asked if she knew what the facility's policy was for carrying out physician orders, assessing wounds and the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/10/2021 at 6:30 PM the DON stated the facility did not have a wound care nurse. The DON stated LVN A made rounds with the Wound Care Doctor weekly, but the floor nurses were responsible for their own treatments, making sure orders were carried out and for weekly wound assessments for their residents. In an interview on 04/12/2021 at 10:00 AM NP A stated she had concerns and she was going to send it in regarding the care her patient is receiving at the facility. She stated last Monday on 04/05/2021 she sent orders for Resident #2 to have antibiotics when her cultures came back positive for MRSA and E. coli. NP A stated the orders were not carried out until 04/08/2021 she stated there are times when the wound dressings are not applied correctly causing restriction of blood flow and residents come to the clinic with more wounds than when they left. Review of NP A's Written statement dated 04/09/2021 reflected I am a wound care provider, providing wound care to patients with acute and chronic wounds .Many of my patients are residents of nursing homes and assisted living facilities and are transported to the wound care clinic weekly for routine wound care. When the patient is here in clinic with us, their wounds are assessed, dressed with appropriate wound dressings and orders for the continuation of their wound care, during the days they are not in our clinic, are sent back to their living facility where the expectation is the nursing staff there will execute the appropriate wound care as ordered. However, my experience with this facility has repeatedly been poor, placing my patients at risk for infection, injury, and in worst case, loss of limbs. There have been instances where the patient (Resident #2) presents to our wound care center with more wounds than they left with due to inappropriately placed wound dressings and bandages, causing restriction of blood flow. In this situation, the wrap was applied so tightly, it caused blood restriction in the limb of a patient with already poor perfusion. This led to the development of wounds on (Resident #2') feet, ankle, and lower leg, which have turned necrotic, and have led to the impending loss of two toes and likely loss of her leg in the future. In addition, when one of these new wounds became infected and an antibiotic was prescribed for the patient, the facility did not provide the medication to the patient even after the staff was contacted and notified a Rx had been electronically sent to their pharmacy and a hard copy of the order was faxed to them. The patient repeatedly tells wound care clinic staff, the facility did not provide wound care at the intervals listed on her orders, and that she feels she is at the mercy of the facility to ensure her safety and health, and she does not feel confident in their ability to provide care for her .The patient's family is equally concerned and frustrated and have tried to have the patient moved to another facility but due to insurance and lack of available facilities in the area, it has not been possible for this to occur. I fear my patient's health is in jeopardy at this location and I am not confident they can provide skilled wound care and execution of orders essential to their resident's medical needs. I feel it would be in the best interest of my patient and the other residents residing at the facility to have this facility thoroughly reviewed to ensure the safety, health, and well-being for the residents who live there. B. Review of Resident #4's Face Sheet reflected a [AGE] year-old female admitted to the facility n 08/16/2019 and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Annual MDS dated [DATE] reflected Resident #4 had a BIMS score of 15 indicating she was cognitively intact. Resident #4 was assessed to require extensive assist with ADLs. Resident #4 was assessed to have diabetic foot ulcers and application of dressing to feet. Review of Resident #4' s Comprehensive Care Plan (not dated) reflected The resident has (Stage 2) pressure ulcer L-heel or potential for pressure ulcer development related to immobility. Interventions included Administer treatments as ordered and monitor for effectiveness, Assess/ record/ and monitor wound healing (weekly) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . Further review reflected another focus area Resident has diabetic ulcer of the right heel related to diabetes . Review of Resident #4's Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Weekly Wound Progress noted dated 04/08/2021 reflected resident had two wounds one to right and left heel. With the right heel measuring 1 cm x 3cm x 0.1 cm and the left measuring 1.2 cm x 3.5 com x 0.3 cm with the right heel wound bed described as epithelial tissue and the left described as 50 percent slough and 50 percent granulation tissue. Observation/ and interview on 04/11/2021 at 12:08 PM revealed Resident #4 in her room alert and orientated. Resident #4 had a dressing to left and right heels. Resident #4's dressings were dated 04/08/2021. Resident #4 stated that getting her wounds treated could be a problem sometimes. Resident #4 further stated she had not had her dressing's changed in days. In an interview on 04/11/2021 at 12:15 PM RN A stated she was on Resident #4's hall and she was responsible for doing her wound care. When asked if she had done Resident #4's wound care since 04/08/2021, she stated no. When asked how many days she had been assigned down the hall she stated three. When RN A was asked why Resident #4's wound care had not been done she stated, I don't know what to say, I guess I missed it. In an observation on 04/11/2021 at 12:20 PM revealed RN A in Resident #4's room to do wound care. RN A attempted to remove the dressing from Resident #4's right heel and the dressing was stuck to the wound. Resident #4 verbalized pain and RN A stopped wound care to notify the physician. C. Review of Resident #1's face sheet revealed an [AGE] year-old male DOB 05/29/1929 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 000, staff interview indicated memory problems. Review of Resident #1's Care Plan which was undated revealed has ADLs self-care deficits, has stasis ulcer to my Left anterior leg and a trauma area to my Left med calf, stage 4 pressure ulcer on my sacrum. Review of Resident #1's wound care physician notes dated 04/08/2021 revealed Resident #1 has the following wounds: left anterior leg venous ulcer, right lateral leg stage 4 pressure ulcer, left heel pressure/deep tissue injury, right lateral malleolus stage 4 pressure ulcer, left posterior leg venous ulcer, right lateral heel unstageable pressure ulcer, right medial heel arterial ulcer, left lateral malleolus unstageable pressure ulcer, left distal medial leg venous ulcer. Resident #1 was seen by wound doctor on 03/25/2021 and the orders was not initiated until 3/29/2021. It was also noted, Resident #1's wound care was not done every day as ordered but was done three times a week. RN A failed to perform wound care on Resident #1 even though his wound dressing was saturated. See orders below from wound doctor Clean left anterior leg venous ulcer with normal saline, apply collagen and calcium alginate three times a week. Clean right lateral leg stage 4 pressure ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean left heel pressure/deep tissue injury with normal saline, pat dry, apply skin prep Clean right lateral malleolus stage 4 pressure ulcer with normal saline, apply silver alginate every day. Clean left posterior leg venous ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean right lateral heel unstageable pressure ulcer with normal saline, pat dry, apply [MEDICATION(S)] and cover with gauze every day. Clean right medial heel arterial ulcer with normal saline, pat dry, apply [MEDICATION(S)] every day Clean left distal medial leg venous ulcer with normal saline, pat dry, apply [MEDICATION(S)] every day. Review of Resident #1's clinical records revealed the resident's last skin check was 03/16/2021 and there were no skin assessments for the month of February. In an interview on 04/08/2021 at 10:28 am, LVN A stated, she usually follows the wound doctor during his rounds every Thursday because the facility doesn't have a wound care nurse. She also stated, after the wound doctor's visit, the nurses are responsible to initiate new orders for their residents. She stated, Resident #1's dressing changes orders were changed to daily due to lots of drainage from the wounds. In an interview on 04/08/2021 at 3:35 pm, LVN B stated she worked on 03/25/2021(Thursday) and received new orders for Resident #1's wound care. She also stated, she did not put the new orders for Resident #1 in the computer on the same day. She stated, I usually wait for the weekend to put the orders in the computer, but I am not sure of the date I put those orders in the computer. She stated, Resident #1's wound care order was changed from three times a week to daily. She also stated, the wound care doctor changed the orders today (04/08/2021) back to 3 times a week because the daily wound care was not effective. She then realized, the orders she initiated in the computer on 03/29/2021(Monday) was not right, it was three times a week instead of daily. LVN B then stated, I must have mistakenly put it in the computer for three times a week instead of every day. Observation on 04/09/2021 at 6:55 pm, Resident #1's left leg wound dressing was saturated with brownish drainage, dressing is dated 04/08/2021, the pillow/sheets under the Resident #1's leg is saturated with brownish drainage from left leg. In an interview on 04/09/2021 at about 7:00 pm, RN A stated, she will notify the night shift nurse to change Resident #1's wound dressings. She stated, the night shift nurse does the dressing wound dressing changes for Resident #1 and sometimes the wound care nurse. She then stated, I have never changed his dressing before, the computer system in down so I don't know what treatment to put on his wounds. In an interview on 04/09/2021 at 7:52 pm, ADON A stated, we do not have a wound care nurse, the nurses do their own wound care, we have a nurse who comes on her off days to make rounds with the wound doctor. She also stated, it is not ok for a nurse to say she will wait for the weekend to initiate orders on a latter day because that is a delay in care that leads to neglect. If an order is not put in correctly it will lead to delay in care and not the right outcome. She stated, her expectation is for the nurses to initiate orders the same day, if for some reason the nurses are not able to initiate the orders, it should be communicated so she can initiate the orders same day. She later stated, if a Resident's wound dressing is saturated, it is her expectation for the nurse to do the dressing change. She also stated, there should already be a PRN order in place to change as needed. She also stated, if the Nurse is not sure of the treatment needed, it is ok to do a wet to dry dressing and notify the doctor. In an interview on 04/10/2021 at 6:46 pm, the interim DON stated, the facility does not have a wound care nurse, LVN A follows the wound doctor on Thursday during his visits. She also stated the nurses are responsible to initiate wound care orders or any orders, no matter what the orders are. She also stated the nurses are responsible to assess the resident's skin weekly and it is documented in the computer. She also stated, it is the responsibility of the ADON to monitor or audit all skin assessment. She stated, she has not had ADON for about 5 weeks, and since there was no ADON, it was her responsibility to audit but she is just one person and cannot do it all. She stated, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not expect the nurse to wait for few days before putting in an order, that will lead to delay in services, worsen wound. It can be considered a neglect not taking care of orders immediately. In an interview on 04/12/2021 at 11:44 am, the wound doctor stated treatment orders should be initiated the next scheduled time. He also stated wound care orders being changed from 3 times a week to every day can be due to more drainage and or the medication being applied. He stated, if there is a drainage, the wound dressing should be changed. He also stated, wound care is very painful for Resident #1, it takes up to 20 to 30 minutes to be done, we are trying to keep Resident #1 comfortable as much as possible and to keep the wounds clean. In an interview on 04/12/2021 at 1:21 pm, Resident #1 stated his left leg hurts a lot and he did not feel like the pain medications helps. He also stated, when his wound dressing is fresh and clean, it feels better but when it stays long, and the dressing is soiled it hurts a lot. D. Review of Resident #3's face sheet revealed a [AGE] years old male DOB 05/06/1974 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15. It also indicated pressure ulcer, stage 3. Review of Resident #3's Care Plan which was undated revealed the resident is on IV antibiotic therapy for infection, at risk for pressure ulcer. The facility failed to ensure a plan of care for Resident #3's right heel pressure ulcer. Resident #3 was not listed on the facility wound track log. The facility failed to ensure Resident #3's wound was being monitor; last skin assessment was 03/16/2021. In an interview on 04/09/2021 at 6:37 pm, RN A stated Resident #3 had a wound doctor appointment today. She also stated, when a wound doctor writes new wound care orders, she had no idea who initiates the orders in the computer. She stated, there were no new orders from Resident #3's wound care visit today. She also stated, she has never been trained on wound care at this facility. On 04/10/2021, it was Resident #1 was not being tracked on the facility's wound tracking log. On 04/11/2021, the surveyors requested documents from RN A that Resident #3 brought back from his wound care visit on 04/09/2021. Review of Resident #3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Daily cleanse with half strength dakins solution, apply [MEDICATION(S)], Silver Alginate, ABD, and Kerlix/kling to keep dressing in place. Review of Resident #3's clinical records revealed Resident #3's new wound care order was not implemented; Resident #3 continue to get the previous wound care order. It was noted the nurses were signing off doing Resident #3's wound care daily. See previous wound care order Cleanse R heel daily with half strength Dakin's solution. Pat dry with 4x4. Apply Santyl to the base of the wound, cover with gauze, ABD and kling to keep dressing in place. Change daily. one time a day related to pressure ulcer of right heel. In an interview on 04/12/2021 at 1:10 pm, Resident #3 stated the nurses usually change his wound dressing on Monday/Wednesday/Friday. He also stated, His wound dressing was changed on Friday, 04/09/2021 at the wound care center and next dressing change was done on today, Monday 04/12/2021. He also stated, It's been like this forever, there is always a concern about carrying out orders. I am worried about my foot; I can't get infection. In an interview on 04/12/2021 at 11:08 am, NP B from the wound care center stated Resident #3 was seen by her on 04/09/2021 and there were new orders. She also stated, it is her expectation for the orders to be initiated on 04/09/2021, if it is not initiated, it will hinder the wound from healing, the resident's wound will continued to be debrided. It is putting him at increased risk for infection, putting him at risk for amputation. It will also delay his hyperbaric treatment. In an interview 04/10/2021 at 6:46 pm, the Interim DON stated, the facility do not have a wound care nurse, the nurses are responsible to perform wound care for residents on their hall. The DON stated, I am responsible of training the staff, I can't speak for the past, the nurses that have been here has been here for a while. I don't know what they were trained on until January 2021. I have not done training on wound care for my nurses. She also stated the nurses are responsible to do skin assessment weekly. In an interview on 04/11/2021 at 2:32 PM the Administrator stated the broken wound care system was a known issue before the state showed up. She stated she had issues with filling positions and the DON was interim, but her expectations was for the system to be monitored for compliance and it was not. Review of the facility's policy Skin Management System dated 05/2019 reflected A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented .All skin areas that are comprised will be documented on the Weekly Wound Progress .Wound progress is to be documented each week with measurements and wound descriptions .Interventions will be noted on the interim plan of care . An Immediate Jeopardy was identified on 04/10/2021 at 9:00 pm. The Administrator, the Senior Vice President and Regional Nurse were notified of the Immediate Jeopardy on 04/10/2021 at 9:00 pm and IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 04/11/2020 at 9:06 pm. 1. A facility skin sweep will be conducted by the DON and/or nursing designee beginning 4/10/21. This will be completed on 4/11/21. 2. Each resident will have a completed weekly skin form by the residents' charge nurse and/or a member of the nursing department. If any new skin areas are identified, the physician will be notified by the charge nurse and/or a member of the nursing department and treatments initiated as ordered. 4/11/21 3. The DON and/or nursing designee will maintain the weekly skin tracking form and any resident identified with a skin concern will remain on tracking until healed. 4/11/21 4. Licensed nursing staff will be educated by DON and/or designee on the wound care system and assessments beginning 4/10/21 with a completion of 4/11/21. This education will be done either in person or via phone for all licensed nursing staff. The licensed staff will be educated prior to beginning their work assignment if completed via phone. 5. DON and/or designee will educate the nurse aides and medication aides on the importance of informing the Nurse of any skin concerns and documenting utilizing the Stop and Watch PCC program. 4/11/21. The nurse aides and medication aides will be educated prior to beginning their work assignment if completed via a phone. 6. Residents with identified skin concerns will have a care plan written by the MDS coordinator and/or nursing designee. 4/11/21 7. DON and/or

Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for three of ten residents (Residents #1, 2, and 3) reviewed for neglect as evidenced by: The facility failed to protect Residents #1, 2, and 6 from sexual abuse after Resident #1 made an allegation on 3/1/2020, Resident #2 made an allegatioon on 8/30/2020, and Resident #6 made an allegation on 9/14/2020 that CNA C sexually abused them. These failures could have placed all residents at risk of unwanted sexual advances, abuse, and mistreatment. An Immediate Jeopardy existed from 9/9/2020 to 9/13/2020. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. Findings included: Record review of face sheet for Resident #1 reflected a [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS for Resident #1 reflected a BIMS score of 15 on both a quarterly assessment on 2/18/2020 and a quarterly assessment on 10/14/2020, indicating she had no cognitive impairment. Review of care plan for Resident #1 with a target date of 12/27/2020 reflected the following: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Immobility, Physical Limitations Slow res body but her mind is very active. Review of progress notes for Resident #1 dated 3/1/2020 at 3:06 p.m. reflected the following: Resident reported sexual abuse. Resident states CNA was touching her inappropriately (sic) during the past 2 showers on mondays. See witness statement for details. CNA removed from building, DON and Administrator notified. (RP) notified. (Local) Police notified. Review of facility investigation report form 3613-A dated 3/1/2020 reflected the alleged victim was Resident #1, a [AGE] year-old woman, who required extensive assistance with functional ability, was not independently ambulatory, was interviewable, and had the capacity to make informed decisions. The section titled Report Details reflected Resident #1 alleged CNA C inappropriately touched her breast and vaginal area. No signs and symptoms of issues at this time. Police notified reference number pending. Resident assessed by RN A with no injuries found. The section Description of Actions Taken reflected: suspended the CNA; asked the CNA for a statement; began Abuse and Neglect in-services with staff . The section titled Investigation Summary reflected the facility was unable to determine if the incident occurred because no signs or symptoms of abuse were found, and Resident #1 told the police she thought she was in a dream. Review of facility investigation report dated 3/1/2020 reflected the following statements: Statement by CNA D dated 3/2/2020 reflected Resident #1 reported to CNA D that CNA C played with her nipples and it made her feel uncomfortable. Statement by RN A on 3/1/2020 reflected RN A was notified by LVN B that Resident #1 had reported to CNA D an allegation of sexual abuse by CNA C. RN A and LVN B went to interview Resident #1, and she confirmed CNA C had been molesting her. Resident #1 described CNA C would stroke her nipples and asked her if she knew what a pearl tongue was and then told her it was the button on her vagina. The statement reflected Resident #1 said this happened in the shower twice. RN A told Resident #1 she would remove CNA C from her care and would report the incident to DON A and the Administrator. The statement reflected RN A interviewed CNA C about the allegation, and he denied it occurred. Statement by RN A, from observation of a police interview with Resident #1 on 3/1/2020, reflected Resident #1 stated she thought she was in a dream when these events occurred with CNA C, and, when she realized she wasn't, she reported it. She said she did tell CNA C to stop, he was inappropriate and it was not in his job description. She denied wanting to press charges. Review of Safe Surveys conducted on 3/1/2020 as part of the facility investigation report reflected no other resident in the facility made any disclosure of abuse. Review of assessment by RN A on 3/1/2020 reflected Resident #1 had no injuries or signs of psychological harm. Review of staffing sheets reflected CNA C did not work at the facility from 3/1/2020 to 3/4/2020 where he was reinstated from the 300 hall, where Resident #1 lived, to the 500 hall. Review of in-services reflected an Abuse/Neglect in-service conducted for all staff from 3/1/2020 to 3/4/2020. During an interview on 10/19/2020 at 9:40 a.m., Resident #1 stated she thought CNA C was a good aide and she liked him, but he shouldn't have done that. When asked what she meant she said, played with my nipples and my vagina. When asked if she remembered when, she said she didn't know but a long time ago. She stated she had not seen him since then, because he does not work with her. Review of face sheet for Resident #2 reflected a [AGE] year-old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS for Resident #2 conducted on 7/28/2020 reflected a BIMS score of 14, indicating little or no cognitive impairment. Review of care plan for Resident #2 with target date of 1/24/2021 reflected the following: I have an ADL Self Care Performance Deficit r/t dementia. I will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score through the review date. BATHING: I require assistance extensive assistance x2 with bathing/showering. BED MOBILITY: I require x2 staff participation to reposition and turn in bed. DRESSING: I require x1 staff participation to dress. EATING: I require total assistance to eat. TOILET USE: I require x2 staff participation to use toilet. TRANSFER: I require x2 staff participation with transfers. Review of progress notes for Resident #2 dated 9/14/2020 reflected the following: Resident stated that a staff member was inappropriate. SW evaluated the res for mental and emotional health issues for (behavioral health) referral. An assessment of the resident w/ PHQ-9 result was 5 mild depression. Res stated that she had not negative feelings at this time. No referrals were made at this time, but the referrals may be made at a later date. Continue care. Review of facility investigation report form 3613-A dated 9/14/2020 reflected the alleged victim was Resident #2, a [AGE] year-old woman, who required extensive assistance with functional ability, was not independently ambulatory, was interviewable, had the capacity to make informed decisions, and identified the perpetrator by name. The section titled Description of the Allegation reflected the following: Resident's son reported to Director of Nursing that resident reported to his sister (resident's daughter) that a CNA was changing her brief and put his finger in me. The section titled Provider Response reflected the following: Resident interviewed and verbally confirmed allegation. Notifications to Administrator, Medical Provider, and Resident primary contact (son). Reported to State agency via phone intake (case number). Investigation initiated. Law enforcement notified. Identified employee suspended pending investigation. Abuse and Neglect education initiated for facility staff. The section titled Investigation Summary reflected the following: Facility investigation completed including staff and resident interviews, review of care records, and review of employee file. Investigation did not identify any witness to alleged incident. Resident roommate had no knowledge or information in relation to incident. Employee denied allegation per interview and statement. Resident consistent in statement of events except for date and time of occurrence and presence of another staff member. Facility unable to confirm contact occurred, however, based on prior allegation involving same employee (learned when safe surveys were conducted) and resident BIMS score of 13, employee was terminated from employment. Review of staffing sheets for 9/9/2020 to 9/13/2020 reflected CNA A worked a 6 A.M. to 2 P.M. on the 500 hall (where both Resident #2 and 6 live) every day during this time span, including a double shift from 6 A.M. to 10 P.M. on 9/11/2020. During an interview on 10/19/2020 at 9:48 a.m., Resident #2 stated CNA C was changing her diaper, and then he stuck his finger inside me. When asked if she remembered when this occurred, she said not too long ago but could not specify. During a telephone interview on 11/2/20 at 10:35 a.m. the Detective stated she is investigating allegations CNA C sexually abused two different residents (Residents #1 and 2) and has interviewed everyone she can track down. She stated the allegation of abuse of Resident #1 was made back in March and reported to her police department. She stated an officer came out to take statements, and the investigation did not get assigned to CID, because there was not enough evidence that abuse had occurred. She stated she picked up that investigation when a second report was made regarding the abuse of Resident #2, because the allegations were so similar. She stated Resident #2 made an outcry that CNA C put his finger inside her, and that opened a can of worms that led to people being fired from the facility. She stated the resident originally told SNA J about the abuse at the end of August 2020, and SNA J reported to LVN L, who did not report the allegation to anyone else and no longer works at the facility. The Detective stated the resident again told ADM A on the 4th of September, and he and the SW interviewed her but didn't investigate any further or call the police department. The Detective stated on 9/14/2020, the resident's family member told DON A, who had no clue any of it had been occurring, and that's when the police department was notified, and they realized there had been another police investigation regarding to the same CNA and very similar allegations. An attempt was made on 11/2/2020 at 11:46 a.m. to interview SNA J by telephone, and a voicemail was left. During a telephone interview on 11/2/2020 at 11:05 a.m., CNA C stated Resident #2 had been in love with him and told him she wanted to marry him in presence of other residents and staff. He stated he does not know why she would accuse him of sexually abusing her. He stated he did provide her care, but all he ever did was help her. He then stated he was cleaning her during incontinent care, and some of the feces were inside her vagina, which he explained to her. He stated he had to put his finger inside her to clean out the feces, and he told her what he was doing and apologized for having to do it. He stated, after him saying sorry, he did not know why she would report it. He stated it wasn't his intention to harm her. He stated he no longer works at the facility. During a telephone interview on 11/2/2020 at 12:17 p.m., the SW stated the facility terminated her unfairly after she interviewed Resident #2 about CNA C touching her sexually. She stated what happened was ADM A brought Resident #2 to her, because Resident #2 had made a disclosure to him of sexual abuse, and he wanted a female to interview the resident. She stated she had knowledge of Resident #2 making similar allegations at a prior facility, and so she was not as concerned about these allegations. She stated she could not remember dates or times of when any of this was said. She stated the resident confirmed what she had told ADM A, ADM A said Okay, and what happened after that was beyond her pay grade. She stated, apparently ADM A did not report the incident or investigate further. She stated CNA C was on PTO when Resident #2 reported the incident, and they were supposed to talk to him before returned to work. She stated she is not sure what happened with that, and she has no knowledge about the resident being told to keep this confidential. During a telephone interview on 11/3/2020 at 1:55 p.m., ADM A stated Resident #2 came to him and said CNA C put his finger inside her. He stated she said the CNA was changing her brief and that he did have gloves on. ADM A stated he asked her if she thought he meant it sexually, and she said no. He stated she didn't seem to be in emotional distress, but he wanted to be sure, so he asked Resident #2 if she would speak with the SW, which she did. He stated the SW reported the main thrust of their conversation was Resident #2 thought CNA C was ignoring her after the incident with CNA C putting his finger inside her. He stated he did not report the initial allegation to law enforcement or the State Agency, because he didn't think there was an allegation. He stated, because it occurred during what was normal incontinent care, and she didn't say she was in any distress, it wasn't really an allegation of abuse but rather incidental contact. He stated a family member showed up a week later with a report to the interim DON (DON A) that suddenly was an allegation. He stated he should have reported and investigated the incident, and he didn't because he honestly just thought it was incidental contact during incontinent care. Review of face sheet for Resident #6 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., type two diabetes mellitus, [MEDICAL CONDITION], calculus of kidney with calculus of ureter, [MEDICAL CONDITION], moderate protein calorie malnutrition, non-pressure chronic ulcer of unspecified heel and mid foot limited to breakdown of skin, [MEDICAL CONDITION], dysuria, muscle wasting and atrophy, lack of coordination, and weakness. Review of quarterly MDS for Resident #6 dated 9/26/2020 reflected a BIMS score of 15, indicating little or no cognitive impairment. Review of care plan for Resident #6 with target date of 11/12/2020 reflected the following: The resident has an ADL self-care performance deficit r/t Impaired balance and tremors. I will maintain current level of function through the review date. BATHING/SHOWERING: I requires limited to extensive assist with showers. DRESSING:I require limited to extensive assist with dressing. TOILET USE: I require limited to extensive assist with toileting. Review of safe surveys of all residents in the facility conducted, as a response to the investigation of allegations of abuse of Resident #2 by CNA C, reflected that one resident disclosed abuse. The safe survey for Resident #6, contained the question, Has a staff member ever touched you inappropriately? If yes, please tell me what happened, when or if you reported it and who you reported it to? The answer written in was Yes- The Black Dude. In the section marked Comments, was written (Resident #6) stated that she never complained about any of this. Refused to discuss any of the above responses. During an interview on 11/2/2020 at 4:16 p.m., Resident #6 stated, when asked if anyone working at the facility had every touched her in a way that made her uncomfortable, she stated, I know who you are talking about. You are talking about (CNA C). Yes, he has done that to me. He always tries to raise my shirt when he is changing my diaper. I told him no, that he does not need to get up my shirt to clean up my diaper. During an interview on 11/2/2020, the RNC stated she became involved in the allegation of abuse of Resident #2 on 9/14/2020, when it was brought to the attention of DON A, who was the interim DON at the time and who had since moved on to another facility. She stated the family of the resident reported the resident had disclosed the alleged abuse, and during the course of the investigation, it became clear the resident had reported the incident previously to both SNA J and ADM A. The RNC stated SNA J followed proper procedure on 8/30/2020 by reporting to LVN L, but LVN did not follow proper procedure and failed to report it to anyone else. The RNC stated Resident #2 again made a disclosure to both ADM A and the SW on 9/4/2020, but they both failed to properly investigate or report the incident to the appropriate authorities. She stated LVN L had left her position just after SNA J reported the incident to her, and she has not returned contact with anyone from the facility regarding the matter. The RNC stated ADM A and the SW were both terminated when it was discovered they had not investigated or reported the allegation. She stated their excuse was they could not interview the alleged perpetrator, CNA C, because he was on PTO at the time of the disclosure, but then they allowed him to return to work on 9/9/2020 and never interviewed him or did anything else about the allegation. She stated if they had investigated, they would have discovered the previous allegation by Resident #1. She stated they still cannot conclusively determine the abuse occurred, but with two different residents on two different halls making almost the same allegation about CNA C, there was no way they could allow him to remain employed at the facility. She stated he was allowed to work on the same hall as Resident #2 with no restrictions from 9/9/2020 to 9/13/2020 because no one investigated. She stated one other resident on the hall, Resident #3, had also said something about the black man touching her inappropriately, but she could not determine for sure if it referred to CNA C, because Resident #3 would not discuss the issue in any detail. She stated she tried to send a couple different people in to speak with Resident #3, hoping the resident would open up about what had occurred for the right person, but she never would elaborate. Review of undated facility policy titled Operational Resident Care Policies reflected the following: CMS defines abuse as the willful infliction of intimidation resulting in emotional harm, sexual abuse including nonconsensual sexual conduct that would constitute an offense under Penal Code 21.08, Penal Code Chapter 22 .sexual assault. The policy also reflected: -follows state guidelines outlined in TDADS Provider Letter #19-17 dated July 10, 2019 -all staff have been notified that any abuse will not be tolerated at all -all allegations no matter what type will be investigated fully -prevention is through the Mission Statement and Employee Standards of Conduct -the resident receives a Resident's Bill of Rights which outlines the right to be free of abuser. Review of clinical documents for Resident #1 reflected she was referred to Social Services on 9/14/2020. Review of clinical documents for Resident #2 reflected she was referred to Social Services on 9/14/2020. Review of clinical documents for Resident #6 reflected she was referred to Social Services on 9/14/2020. Review of post-incident assessment of Resident #2 dated 9/14/2020 and completed by DON A reflected she had no injuries and indicated no emotional distress. Review of progress notes for Resident #2 reflected her physician was notified of the allegation of abuse. Review of facility investigation report reflected written statements taken from ADM A, SW, CNA C, SNA J, FM #1 and 2 of Resident #2, and from Resident #2 herself. Review of facility investigation report reflected safe surveys were conducted for all residents in the facility weekly starting 9/14/2020. Safe surveys themselves were included in the investigation paperwork. Review of facility investigation report reflected the incident was reported to the State Agency on 9/14/2020 at 2:51 p.m. Review of care plan for Resident #2 reflected it was updated on 9/14/2020 with a target date of 1/27/2021 to reflect the following: Resident has been assessed for actual trauma symptoms related to allegation of inappropriate sexual contact by staff member. Expresses feelings of comfort and safety in current environment. Denies emotional or psychological distress at this time. As manifested by: Upsetting thoughts or memories against their will; Upsetting dreams; Bodily Reactions such as: fast heartbeat/stomach churning; Difficulty falling asleep or staying asleep; Irritability anger or depression; Difficulty concentrating; Being jumpy or startled at something unexpected; Inability to cope with normal stresses of daily living; Inability to Trust; Cognitive difficulties; Other Rt. needs will be anticipated and met Rt. Will verbalize/display feelings/disposition of safeness in the community and with caregivers. Ask and observe the situations and interactions that create well-being, engagement and a sense of safety on the part of the resident/pt.- recognizing that man individuals who are long-stay residents have some level of cognitive impairment that may require additional sensitivities. Ask resident/pt., and when appropriate their families, about their preferences, including what will make them feel safer and more comfortable during their stay. Assess for recreational activities that distract or decrease anxiety or symptoms. Communicate with clarity, respect and transparency. Continued education and communication between resident and family. Encourage resident to verbalize feelings and specific triggers. (Events, Experience and/or Effect) that may manifest symptoms. Evaluate/monitor any pharmacological interventions for effectiveness and side effects. Explain each medical/care interaction in advance. IDT team and staff will continue to monitor for effectiveness of the individual's POC and goals. Inform/educate individuals and/or their families about the organization's commitment to trauma-informed care. Offer Spiritual/Religious support as requested/prn. Provide and ensure a safe environment by providing consistent caregivers. Psych Eval as ordered/prn. Review of ad hoc QAPI meeting reflected one was convened on 9/16/2020 including the medical director to discuss root cause and determine what system changes would be needed, including a 100% system audit related to the event. Review of facility staff list reflected CNA C, ADM A, and the SW were no longer employed at the facility. Review of in-services reflected several Abuse/Neglect/Reporting trainings conducted over 9/14/2020 to 11/2/2020 signed by all facility staff, regardless of discipline. Observation on 11/2/2020 at 2:51 p.m. revealed the facility AD was conducting safe surveys up and down hall 500. During interviews on 11/2/2020 between 1:10 p.m. and 6:05 p.m., six CNAs, three LVNs, and one housekeeper all described abuse/neglect/reporting procedures consistent with facility policy and regulatory guidelines. All of them stated they had been in-serviced on these policies within the previous month. An Immediate Jeopardy existed from 9/9/2020 to 9/13/2020. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for one (Resident #1) of five residents reviewed who required two person assistance with transfers. On 10/22/17 CNA A transferred Resident #1 from her bed to her wheelchair resulting in a 5 inch laceration to resident's right lower extremity which required emergency attention and sutures. Resident #1 should have been transfered with the assistance of two staff members per resident's MDS assessments and care plan. This failure affected 1 resident and had the potential to affect an additional 17 residents who required two person assistance with transfers by placing them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's face sheet revealed an [AGE] year old female who admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 0 indicating resident is rarely or never understood. Further review of MDS assessment revealed resident required two person physical assistance with bed mobility and two person physical assistance with transfers. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed resident required two person physical assistance with bed mobility and two person physical assistance with transfers. Review of Resident #1's Care Plan revised on 10/16/17 revealed that resident is unable to transfer herself, has potential for falls and requires two people for most transfers. Review of the facility's Confidential Employee Corrective Action Form dated 10/23/17 revealed on 10/22/17 CNA A transferred Resident #1 from bed to wheelchair by herself and caused a right lower extremity laceration requiring an emergency room visit and sutures. Further review of form revealed that DON confirmed that Resident #1 was care planned as a two person extensive assist with transfers. Further review of form revealed, Employee did not follow the care plan. Review of emergency department assessment dated [DATE] revealed Resident #1 sustained a 5 inch laceration that was down to the fascia, with fatty tissue exposed, and was in a half moon shape on right leg. Observation on 11/2/17 at 1:45 p.m. revealed a 4 to 5 inch healing wound with sutures to Resident #1's right lower extremity. During interview on 11/2/17 at 2:15 p.m. CNA A stated she transferred Resident #1 on 10/22/17 by herself with the use of a gait belt. She further stated Resident #1 must have hit her leg on the foot rests on her wheelchair during the transfer. She further stated after the transfer she looked down and saw that resident was bleeding profusely from her right lower leg. She further stated there is a computer on Resident # 1's hall referred to as a Care Tracker which provides information related to residents' care plan and needs. She further stated the Care Tracker read requires assistance and did not specify if Resident #1 required one or two person assistance with transfers. She further stated that is why she did not know that Resident #1 required two staff members with transfers. She further stated the Care Tracker has been updated to reflect two person assistance for Resident #1. During interview on 11/2/17 at 2:35 p.m. DON stated the Care Tracker should have reflected Resident #1's need for two person assistance with transfers instead of just indicating requires assistance with transfers. She further stated the Care Tracker has since been updated to reflect Resident #1's need for two person transfers. DON further stated the information in the Care Tracker should match each resident's assessments and care plans so that direct care staff can provide care according to each resident's care plan. DON further stated staff are expected to follow residents' care plans. DON further stated MDS nurses are expected to accurately input current care plan interventions into the Care Tracker so that direct care staff know exactly what type of care to provide. DON further stated CNAs are expected to look at each resident's information in the Care Tracker before starting every shift. During interview on 11/2/17 at 3:10 p.m. MDS Nurse stated they update the Care Tracker every time they complete a new MDS assessment or as needed. MDS Nurse further stated the Care Tracker should always reflect resident's most current care plans. MDS Nurse further stated she didn't know why Resident #1's Care Tracker information did not clearly indicate the need for two person assistance with transfers. MDS Nurse further stated, No one reads the care plans except for you surveyors. This surveyor asked MDS Nurse how direct care staff know each resident's specific care needs if they don't read the care plan; MDS Nurse shrugged her shoulders and made no reply. Review of facility policy titled Safe Lifting and Movement of Residents revised December 2013 read as follows: Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's mobility (degree of dependence) Review of facility policy titled Care Plans - Comprehensive revised July 2017 read as follows: The facility will develop and implement a comprehensive person-centered care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each resident's comprehensive care plan is designed to: incorporate risk factors associated with identified problems. The comprehensive care plan will include: The services that are to be furnished to attain or maintain the resident's highest practicable physical mental, and psychosocial well-being. There were 18 residents who required two person assistance with transfers according to list provided by DON.

Based on interview and record review the facility failed to ensure 1 of 1 Registered Nurse (RN) RN A provided services to meet professional standards when she failed to assess 1 of 4 residents (Resident #1) reviewed for incident/accidents. On 5/23/13 at approximately 10:05 PM Resident #1 was found on her bathroom floor. Two different staff went to the charge nurse, Registered Nurse (RN) A to have her come assess the resident before they moved her. When the nurse did not come Resident #1 started to attempt to get herself up off the floor. By the time the RN arrived 3 Certified Nurse Aides (CNA E, CNA N and an unknown CNA) were assisting her to her chair without a nurse assessment. This deficient practice affected one resident who had falls and went to the hospital with a fracture by not providing an assessment while the resident was on the floor after a fall. The findings Include: Review of Texas Administrative Code, STANDARDS OF NURSING PRACTICE reflected the following: Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients an shall: (A) Utilize a systematic approach to provide individualized, goal directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 5/10 13-5/14/13 Resident #1 was in the hospital with pneumonia. Review of physician' orders dated 5/14/13 reflected the following: 12. SPECIAL INSTRUCTIONS PT (physical therapy)/OT (occupational therapy) to evaluate and treat. Please apply modified compression wrap to bilateral lower extremity wounds (Kerlix and Ace wrap), to be changed twice a week and worn continuously. Review of Minimum Data Set ((MDS) dated [DATE] Significant Change: Transfer-extensive assistance of 1 person physical assist; falls since prior assessment-no injury. Review of discharge MDS dated [DATE]: Transfer-extensive assist-resident involved in activity, staff provide weight-bearing support; falls since admit/reentry/prior assessment-no injury. There was no IMMEDIATE NEEDS CARE PLAN initiated after falls. Review of Resident #1's care plan reflected last meeting on 4/17/13 resident attended. No new approaches or interventions were added. Review of her most current care plan reflected: Resident has the potential for falls related to decreased mobility. An interview on 5/28/13 at 3:45 PM the administrator stated Resident #1 went out to the hospital on [DATE] with a fracture. She stated she was at the facility the night before (5/27/13) talking with the son. An interview on 5/28/13 at 5:00 PM the interim DON stated, Apparently on the night of 5/23, the CNAs were taking Resident #1 to the bathroom, her legs gave out, the aides helped her to the floor and called for help. The charge nurse, RN A refused to go down there to assess. There was no incident report completed and brought to focus on the 24th." She stated when she asked the past DON about it she said, "Oh yea, I forgot to follow up on it." They called RN A in to ask her about the incident and RN A said "she was too busy to assess her (Resident #1)." She was asked to fill out an incident report. She sat in the office and wrote up the incident including the resident ' s vital signs (without any written documentation to refer to). There was nothing documented in the 24 hour report. Both nurses (RN A and the DON) were suspended pending investigation. In an interview on 5/28/13 at 5:35 PM CNA E stated she was caring for Resident #1 on the 2-10 shift on 5/23/13. Resident #1 was in the bathroom and her feet kept sliding. CNA E sat the resident back on the toilet and went to get help so didn ' t know about the fall, what exactly happened. When she and CNA-N got back to the bathroom Resident #1 was on the floor trying to push herself up. Her right leg was twisted behind her. Resident #1 was mad because the nurse wouldn ' t come. RN A told the aides to put Resident #1 to bed but she refused to go to bed. CNA D was trying to tell the nurse what to do (assess the resident prior to them moving her). The nurse never went into the bathroom she just wanted Resident #1 in bed. The nurse and the resident were arguing and CNA E left as her shift was over. She had never worked with that nurse (RN A) before. An interview on 5/29/13 at 12:05 PM with LVN J revealed that inside each resident ' s closet door there ' s a card that tells the resident's code status, transfer, and any other pertinent information for that resident. An interview on 5/29/13 at 12:05 PM Resident #5 revealed there are so many new people. They don ' t know how to use the Hoyer. He stated, " They ' re just killing me with it. " He said he told 100 hall ADON but nothing changed. An interview on 5/30/13 at 9:40 AM with CNA F revealed she worked 10p to 6a on Thursday night (5/23/13). Resident #1 had fallen and the nurse (RN A) did not do an assessment. She was confused because all she heard was " We got to get her up." CNA D told her they didn ' t do the assessment. RN A got mad at CNA D and was mad when she went to the resident ' s bathroom. She stated, " I didn ' t transfer her that night because Resident #1 wanted to stay in her chair and sleep that night. " The other shift (2p-10p) was still there around 10:30 PM. An interview on 5/30/13 at 10:10 AM CNA G stated she didn ' t recall what days she had Resident #1. She stated she fed her as needed. She worked 2p-10p shift the night Resident #1 fell . She fell on the morning shift on one day and a 2p-10p shift another day. An interview on 5/30/13 at 11:00 AM with CNA H revealed she hadn ' t taken care of Resident #1 since she moved off the 200 hall. She stated Resident #1 is a very demanding person, 'I want it done, and I want it done now.' She does not want to use a Hoyer or a Standing lift. She says she can stand and when she does she slides down. An interview on 5/30/13 at 11:55 AM with LVN B revealed Resident #1 won ' t let them use a Hoyer lift on her. Sunday (5/26/13) at 10:15 AM Resident #1 told the aide to put lotion on her bottom. She felt her right leg become unstable and asked to be lowered to the floor. The aide came to get her (LVN B), she called LVN C and the three of them got her up. LVN B was doing neuro checks and did a head to toe assessment. The next morning (5/27/13) at 7:15 AM she went to do insulins. She asked the resident what was wrong with her ankle. Resident #1 said her ankle didn ' t hurt, her back did. She was using her right foot on the foot rest for positioning to help ease the pain. She had Ace bandage wraps and thick blue socks on. Her right ankle was positioned oddly. Resident #1 said there was nothing wrong with her ankle. She had a very inverted ankle and said it was positioned that way. At 10:45 AM she called to notify Resident #1's son. An interview on 5/29/13 at 4:30 PM RN L, weekend supervisor and as needed charge nurse, stated she worked 5/27/13 after the fall (7p on 5/26-7a on 5/27/13). We do every 2 hour checks. Resident #1 likes things done a certain way. There were only 3 aides on that night. She stated she was in there (Resident #1's) at 8 PM, 9 PM, midnight, at 2 AM to check her blood sugar, 4 AM, and 5 AM. Resident #1 never complained of pain. She puts her right foot on the side of the footrest and did not allow the RN to move it. RN L stated she is very direct with her. Resident #1 sleeps in her power chair and she places her right foot to the side of the chair when she sleeps. She stated, " It ' s a good thing she has a seatbelt or she could fall out. " An interview on 5/30/13 at 11:45 AM with CNA D revealed she was coming in to work on the 24th and was asked to assist with Resident #1. There were 3 CNAs, the resident, and the chair in the bathroom. She went to tell the nurse (RN A) and she said ' Yes, I know I ' ll be there ' . She came to the resident room and told CNA D she knew how to do her job and pushed CNA D out the door. The last time she saw Resident #1 was the night before she went out to the hospital. She worked the 10p-6a shift and 3 CNAs moved her using a gait belt. CNA D told her the risks of falls every time they transfer her. Resident #1 told her ' Not everybody can sleep in a soft ass bed. ' She had her legs wrapped and blue hospital socks on. Her feet always look big. She never said anything about her foot hurting or her leg hurting. There was no assessment or x-ray after the fall. On the 24th RN A never looked at any part of her body. The CNA stated she didn ' t like RN A putting her hands on her; she pushed her out of the room. An interview on 5/30/13 at 12:15 PM CNA I stated she was called in to work Sunday night and arrived around midnight. CNA C answered Resident #1's light and she wanted to go to bed. Her foot looked twisted a bit but the other aides said it was OK. That night she didn ' t bare any weight and her weight was all on the 3 CNAs. In an interview on 5/31/13 at 11:00 AM with the Nurse Practitioner she stated Resident #1's foot was markedly deformed (on 5/27/13). She ordered an extra Tylenol #3 and an x-ray. Resident #1 said she didn ' t know what happened. She ' s non-compliant and her feet swell bad from being up in her power chair all day but she refuses una boots. The Hoyer lift is imperative and she refuses. Progress note dated 5/27/13 at 9:48 AM: evaluated today for follow-up per nursing request for ' pain and deformity to right ankle ' , patient is sitting up in electric wheel chair pleasant and cooperative NAD noted. Generalized weakness; ankle right side, limited range of motion, occurring for 1 day, the severity described as severe, it is worsened with movement, improved by rest, deformity of right ankle. Comments: along with pain and deformity, patient did have recent fall x 1 and apparently ' assisted to floor yesterday during a transfer ' , patient denies trauma with these incidents, patient states, " I don ' r remember how this happened " , AP, Lateral, and Mortise (ankle joint) x-ray and await results, patient also given Tylenol #3 x 1 extra dose and will continue to monitor, patient takes daily [MEDICATION NAME] for [DIAGNOSES REDACTED]. Review of incident/accident reports reflected the following: 1.) 5/27/13 at 7:45 AM Nurse noticed resident ' s ankle positioned awkwardly. When resident was asked she said nothing was wrong with it-that she had it positioned that way to accommodate her sore back due to sciatic nerve pain. Resident #1 insisted that she was fine (Please see witness statement). Vital signs: temperature (T) 97.6 degrees Fahrenheit, pulse (P) 79, respirations (R) 19, and blood pressure (B/P) 141/79. Doctor notified, chest x-ray ordered, sent to hospital for treatment. Son notified. Review of witness statement for 5/27/13 (that was signed 5/26/13) by LVN B reflected ' This AM about 7:30 AM during a chemstick for Diabetes, I noticed resident's ankle in a peculiar position. I asked the resident what happened to her ankle, she stated, " Nothing is wrong with my ankle. It is my back " . She went on to talk about her back pain and her sciatic nerve pain. I said " I don ' t know Resident #1, but your ankle doesn ' t look right to me. " When I went to examine it she firmly told me it was OK, just to stick her finger. A short time later she told me her leg and her ankle were not hurting. She said it was just positioned like that because she was using her right leg to position her body to accommodate her sore back. She often pushes down in her (right) foot while positioning herself in the wheel chair. She " lives " in that wheel chair and sleeps in it in lieu of her bed. She insisted she was fine. An hour later she sent for me to go see her. She told me she looked down and noticed her foot wasn ' t right. She said repeatedly that she did not know what happened. She was very surprised about it and continued to say she didn ' t know what happened. ' 2.) 5/26/13 at 10:15 AM after toileting, the resident was standing up holding rail as CNA M was applying lotion resident told her to ease her to the floor due to instability. CNA M guided resident to floor Vital signs: T 98, P 97, R 20, B/P 137/81. Aide provided: vital signs, assessment, gait belt applied with 3 person lift and transfer off floor to wheel chair. Neuro checks in place. 3.) 5/23/13 at 10:05 PM was notified by CNA that patient fell in bathroom. Was told by 2 CNAs. Went to room. Resident was being taken care of by her CNAs E and N. Three other CNAs in room also. No gait belt used as resident refused to allow CNAs to use them. Skin assessed. No bruises or breakdown. Denies pain. Vital signs stable B/P120/70, P 80, R 20. Refused T to be taken. Aid provided: CNA E was with patient alone in room, called for assistance, CNA N was first to arrive, stated that she saw patient on the floor with CNA E present. Physician and son notified at 11:25 PM. Final condition: Patient with no pain. Refused to lie down for skin assessment. She stood at the handrails in the bathroom. The administrator and interim DON confirmed that this incident report was written by RN A including vital signs while she was in the office on 5/24/13. Review of Resident #1's blood pressure done daily in May reflected 135-154/72-85. The morning of 5/24/13 at 9AM BP was 152/85 and pulse of 80. Review of inservices: 5/24/13 avoid delay of action on reportable events and 30 staff attended. There were 37 residents residing on 100 hall

Based on observations, interviews and record reviews the Administrator, Director of Nursing (DON), Assistant Director of Nurses (ADON) Y, and Charge Nurses W and U failed to administer the facility in a manner that enabled use of resources to maintain its residents' highest practicable physical, mental and psychosocial well-being when: (A) The DON and ADON Y failed to supervise Licensed staff when they did not consult the physicians of two (2) of two (2) residents observed with a red, itchy skin rash to ensure the residents received timely evaluation, treatment and precautions if needed (Residents #2 and #4). The facility failed to consult with Resident #2's physician for complaints of itching and rashes from 10/10/10 to 02/24/11. Resident #2 had multiple red pimples and open [MEDICAL CONDITION] starting at her left hand and extending up to her left shoulder. There resident also had multiple areas of broken skin where she had scratched her arm and an area above her left breast that was bleeding where she had scratched a lesion. Resident #2 expressed frustration that she had not received medication to treat the itching and was unable to see a dermatologist until March 2011. On 2/24/11, Resident #2 was diagnosed with [REDACTED]. hominis) and returned to the facility with an order for [REDACTED]. The facility failed to consult with Resident #4's physician for complaints of itching from 01/29/11 to 02/25/11. Resident #4 complained of itching on the areas of her skin that had had pimple-like, red and crusted bumps: her left knee and left upper leg covering more than half of her knee and the right knee covering 25 percent of her right knee. (B) The Administrator, DON, ADON Y, and Licensed Vocational Nurses (LVN) U and W failed to follow facility policy and procedure to prevent (3) three of three Certified Nurse Aides (CNAs A, B and C) and one (1) of one LVN (LVN V) who exhibited skin rashes form working in direct contact with residents pending [DIAGNOSES REDACTED]. Facility Charge Nurse, LVN V did not report her undiagnosed rash to the facility. Charge Nurses U and W, the ADON, DON and Administrator did not investigate CNAs A, B and C complaints of itching or [DIAGNOSES REDACTED]. An Immediate Jeopardy (IJ) was identified on 02/24/11 at 2:45 PM. While the IJ was removed on 02/25/11 at 2:45 PM, the facility remained out of compliance at a Scope of pattern and a Severity level of harm that was not Immediate Jeopardy while the facility continued staff training on isolation precautions and ensured ongoing accurate tracking and trending of infections were monitored in the facility. These deficient practices had the potential to contribute to wide spread of scabies and associated skin infections to all 150 residents. The Centers for Disease Control and Prevent (CDC) states: "Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). . . . The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. . . . Scratching the rash can cause skin sores; sometimes these sores become infected by bacteria." (http://www.cdc.gov/parasites/scabies/gen_info/faqs.html, updated 11/02/10, accessed 03/01/11.) The findings include: (A) Resident #2 Review of Resident #2's Face Sheet dated 02/24/11 revealed she was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's Nurse Summary dated 02/14/11 documented she was alert and oriented to person, place and time; had independent cognitive skills for daily decision making, and had no short- or long-term memory deficits. Review of Resident #2's Nurses' Notes revealed: - 09/28/10: "Antibiotic in progress for URI (upper respiratory infection), day 2 of 10. - 10/04/10 - "No adverse reactions to antibiotic." - 10/22/10: "Resident approached nursing station complaining of itching all over with rash noted on arms and legs. Allergic to [MEDICATION NAME] and states the cream not helpful . . . Received fax order from (Medical Director) for [MEDICATION NAME] 10 mg by mouth every day . . . resident refuses to take med from our doctor, only hers." A Fax Transmittal Form dated 10/22/10 documented contact with the Medical Director: "(Resident #2) complaining of itching all over. Noted with fine rash (on) arms. Resident unable to take [MEDICATION NAME] - allergic to med. One percent TAC cream, states it is not helping. Attempted to notify resident primary care physician unsuccessful. Please advise." There was no evidence a physician examined Resident #2's rash on 10/22/10, and that the facility contacted the physician for alternative treatment when she refused [MEDICATION NAME]. In an interview on 02/24/11 at 6:00 PM, LVN U CNAs A and B told her around early February that they had itching and rashes that they thought they got from Resident #2. The LVN stated she observed that Resident #2 had [MEDICAL CONDITION] on her hand, her skin was dry and cracked and she had some bumps toward the top of her hand when she saw her last, two days ago (02/22/11). LVN U stated Resident #2 saw several doctors, but she did not know if the physicians examined her skin. In an interview on 02/24/11 at 6:10 PM, LVN W stated she worked the 10:00 PM to 6:00 AM shift. She stated Resident #2 had a rash on her hands "for a long time," but she had not observed issues on her arm. The LVN stated she was responsible for Resident #2's weekly head to toe skin assessments and saw no other skin issues other than bruises from insulin injections. Observation during initial tour on 02/23/11 at 3:40 PM revealed Resident #2's door was closed with a sign that it should remained closed. When asked why the sign was on the door, ADON Y stated it was not an isolation precaution but instead was the resident's preference. Continued observation revealed Resident #2 sitting in her wheelchair. There were multiple red pimples and open [MEDICAL CONDITION] starting at her left hand and extending up to her left shoulder. The resident was reluctant to let the surveyor look at her arm, but multiple areas of broken skin were observed where she had scratched her arm and an area above her left breast 2 centimeters (cm) large was bleeding where she had scratched a lesion. Resident #2 stated she had the rashes since October 2010 and, in a frustrated tone, stated they itched and she had not received any medication to treat the itching. The resident stated she had been trying to see a dermatologist and did not have an appointment until March (2011). During follow-up observation/interview on 02/24/11 at 9:30 AM with LVN V and Resident #2, Resident #2 stated she had itching in the following areas: her right hip, right leg below the knee, under her left breast, on her left breast, her left arm, and near her right elbow. The resident would not allow LVN V or the surveyor to observe her left breast or under her left breast, but pimple-like bumps with open, crusted [MEDICAL CONDITION] were observed on her right hip, right leg below the knee, and on her left arm and right elbow. The upper left breast area had some dried blood where Resident #2 had scratched the lesion. Broken skin on the left arm where the resident had scratched were still observed. Resident #2 stated the rashes started in October 2010 and she had an appointment to see a dermatologist "next month" (March 2010). The resident stated she did not know what caused the rashes. LVN V stated Resident #2 had not been tested for scabies. No isolation precautions were observed. In an interview on 02/24/11 at 11:00 AM LVN V stated Resident #2 was very alert and oriented and made her own physician appointments. The LVN stated she did not know what her physicians looked at and whether they had diagnosed her skin rash since October 2010. LVN V stated she did not know who Resident #2's current physician was. In an interview on 02/24/11 at 11:30 AM, ADON Y stated the facility's secure unit (Halls 600 and 700) had an outbreak of scabies in December 2010. When asked if the facility had any documentation that Resident #2's rash from October 2010 was treated, ADON Y stated Resident #2's clinical record documented a physician ordered an antibiotic on 10/06/10 for a [DIAGNOSES REDACTED]. She was allergic to [MEDICATION NAME], so the Medical Director ordered [MEDICATION NAME] to treat an allergic reaction to the antibiotic. The resident refused the [MEDICATION NAME] because it was not ordered by her physician. The ADON stated the only other evidence she could find in Resident #2's clinical record that the facility addressed her itching was an order for [REDACTED]. The ADON stated she could not find anything else in the resident's clinical record documenting consulting the physician for the resident's rash. She stated the resident had a pending appointment with a dermatologist on 03/15/11 from the original 11/15/10 referral. Efforts to contact Resident #2's physician regarding her skin condition and why a dermatologist referral was made were unsuccessful. The clinical record did not correctly document who her physician was, the resident was unable to provide the physician's name, and the facility did not know who or if any physicians had examined her skin Review of Nurses' Notes from 10/22/10 to 02/23/11 and nursing summaries revealed no documentation of Resident #2's rash. Review of Resident #2's "Doctor's Progress Notes" on 02/24/11 revealed no physician progress notes [REDACTED]. In an interview on 02/24/11 at 11:45 AM, the DON and ADON confirmed Resident #2 had not been on antibiotics since October 2010 to possibly explain the rash and there was no evidence that a physician examined Resident #2's rash. The DON stated she "would not want it (Resident #2's rash) undiagnosed for that long (October 2010 to March 2011)." Review of Resident #2's Consolidated Physician order [REDACTED]. There were no current orders to treat itching skin. Review of Resident #2's Interdisciplinary Progress Notes dated 02/24/11 at 4:15 PM revealed: "Resident noted with rash on hands and arms, complains of itching. Refuse to have (Medical Director) assess kin. Order to send resident to ER (emergency room )." The Interdisciplinary Progress Note dated 02/24/11 at 10:30 PM documented: "Nurse from (hospital) ER called with report (of) [DIAGNOSES REDACTED]." ([MEDICATION NAME] is the brand name for [MEDICATION NAME]. It is an insecticide used in healthcare to eradicate parasites such as mites responsible for scabies.) Review of Resident #2's Discharge Instructions from the hospital dated 02/24/11 revealed, "Diagnosis: [REDACTED]. . . Prescriptions: [MEDICATION NAME] 5% Cream." Resident #4 Review or Resident #4's Face Sheet dated 10/29/10 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 02/23/11 at 3:30 PM revealed Resident #4 was not in her room. Her roommate was observed in the B bed. No isolation precautions were in place. In an interview/observation on 02/24/11 at 9:30 AM, Resident #4 was observed lying in bed. She complained of itching to her "knee cap." Observation of Resident #4's skin revealed several pimple-like, red and crusted bumps on her left knee and left upper leg covering more than half of her knee. The right knee was also observed to have pimple-like bumps that were not red, covering 25 percent of her right knee. LVN V stated the rash on her left knee started as an abrasion and she had not informed the physician of the rash. No isolation precautions were observed. Review of Resident #4's Nurse's Note dated 01/29/11 revealed: "Resident stated 'I had a bump on my left leg and I scratched it.' Observed small abrasion on right lower leg. New order written. Cleansed with normal saline, apply TAO, cover with non-stick dressing." There was no evidence that the physician examined the skin or that the facility consulted the physician for the itching that caused the resident to scratch her leg. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he just conducted a visual examine of Resident #4's skin for the first time and determined she had [MEDICAL CONDITIONS], with 70% of her left leg affected and less of her right. In an interview on 02/25/11 at 12:00 noon, (after Resident #2 had a confirmed case of scabies and the facility was informed of an Immediate Jeopardy) ADON Y stated the Medical Director said to "go ahead and treat Resident #4." Review of Resident #4's Nurse's Note dated 02/25/11 at 10:30 AM revealed: "new order for [MEDICATION NAME] cream 5%. Apply topically from neck to feet. Leave cream on for 12 hours for rash." Review of the Facility's Policy, "Management of Scabies" dated 06/01/07 revealed the following. "Procedure: Implement contact isolation. . . . Contact the attending physician. If the attending physician refuses to order treatment, notify the DON and/or Medical Director. . . ." "General Scabies Outbreak: 1. During a general scabies outbreak among residents and/or personnel, interdepartmental planning is essential to coordinate the treatment program." The policy and procedure did not address reporting rashes pending [DIAGNOSES REDACTED]. (B) Failure to prohibit staff with rashes from direct contact with residents: CNA C - During observation/interview on 02/24/11 at 10:50 AM, CNA C stated she had developed a rash on her left arm, stomach and legs about two weeks ago. She stated the rash itched a lot. The CNA was wearing short sleeves, and the red, open, crusted [MEDICAL CONDITION] were easily visible on her left arm. The CNA stated she did not have insurance, so she had not been to a doctor to have the rash diagnosed and treated. CNA C stated she reported the rash to her charge nurse who no longer worked at the facility and to the DON. CNA C was observed to provide care to residents on the 500 Hall. In a follow up observation/interview on 02/24/11 at 2:00 PM, in the presence of the DON, CNA C stated she told the charge nurse and the DON when the rash first appeared, "but the DON must have been having a bad day because now she says she doesn't remember." In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he visually examined CNA C's arm and stated it looked like a scabies infestation. Observation/interview at 02/24/11 at 5:45 PM revealed CNA C returned to the facility and was observed in the Assistant Administrator's office. The Administrator presented a dated payment receipt for CNA C's urgent care visit dated 02/24/11. In an interview on 02/25/11 at 8:30 AM, the DON stated CNA C was not working today. She stated the urgent care clinic did not do diagnostic scrapings of CNA C's skin to rule out scabies; but instead prescribed [MEDICATION NAME] (a corticosteroid that decreases the immune system's response to various diseases to reduces symptoms such as swelling and allergic-type reactions) and told her to use the cream the facility gave her to treat scabies, which the DON stated was [MEDICATION NAME] 5%. Review of the "6-2 Nurse Aide Schedule February 2011" revealed CNA C worked on the 500 hall on 02/01/11 through 02/03/11; 02/06/11 through 02/09/11; 02/12/11 through 02/15/11; and 02/18/11 through 02/21/11. LVN V - During an interview on 02/24/11 at 8:30 AM, LVN V stated she had a rash on her left arm that itched. Several pimple-like bumps were observed on her left arm. The LVN stated she had not been to the doctor to have the rash diagnosed or treated and had not reported the rashes to anyone in the facility. The LVN stated she got the rashes every six months and they usually resolved on their own. LVN V was observed to be providing care to Residents on the 200 Hall. CNA A - In a telephone interview on 02/24/11 at 3:00 PM, form employee CNA A stated she worked the 10:00 PM to 6:00 AM shift and had worked on 100, 200, 300 and 500 Halls. CNA A stated she had itching skin for a several months but did not connect that it might be scabies until late January 2011, early February 2011. She stated she asked nurses at the facility what they thought the rash was. She stated she went to a physician at the beginning of February 2011, who diagnosed the itching/rash as scabies. She stated she told ADON Y and the DON she had been diagnosed with [REDACTED]. The CNA stated she did not complete the treatment before she returned to work or before she resigned because she knew she got the infection at the facility and would just get it again. CNA A stated after she was diagnosed with [REDACTED]. She told ADON Y that she could not come to work because of the scabies: she had brought scabies home to the family and now she did not have a babysitter because the babysitter refused to watch the child. In an interview on 02/24/11 at 1:30 PM, the DON stated CNA A worked the 10:00 PM to 6:00 AM shift and was a "disgruntled employee." She stated she had poor performance with resident complaints that she did not answer the call light and attendance issues. The facility was about to terminate her but she resigned. The DON stated, in her "manifest resignation" CNA A said she was infected with scabies here. The DON stated CNA's letter dated 02/10/11 was the first time the facility was aware of CNA A concerns with scabies. In a follow-up interview on 02/24/11 at 5:00 PM, ADON Y stated she remembered CNA A called and said she went to the physician with a rash and had already talked to someone at the facility about it. ADON Y stated CNA A never provided proof. The CNA did not provide a physician's note clearing her from an absence on 02/05/11 because the CNA stated she went to the military clinic and the military clinic would not provide a note. In a telephone interview on 02/24/11 at 6:10 PM with ADON Y present, LVN W stated CNA A complained of a rash and asked the LVN to look at her arms. LVN W stated she saw one little bump that was not open. LVN W stated CNA A later said she had been diagnosed with [REDACTED]. In a telephone interview on 02/24/11 at 6:00 PM with ADON Y present, LVN U stated she worked the 10:00 PM to 6:00 AM shift. She stated CNA A complained of itching and bumps and asked the nurse to examine her skin. LVN U stated she "couldn't see much of anything, just marks across her skin from scratching." LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of CNA A's personnel file revealed she was employed at the facility from 11/01/10 to 02/10/11. Review of her letter dated 02/10/11 revealed: "In addition, I have contracted and been diagnosed with [REDACTED]. . a very contagious infection. I did contact this on the job at (the facility) and choose to no longer expose or subject my family to such inhumanity." Review of a handwritten note provided by the facility on 02/25/11 revealed: "(CNA A) attendance issue 02/05/11; 02/02/11 told nurse she was itching." Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA A was assigned to work on the 200 Hall from 02/03/11 to 02/06/11; and on 02/09/11 and 02/10/11. CNA B - In an interview on 02/23/11 at 2:00 PM, CNA B stated she was diagnosed with [REDACTED]. CNA B stated the physician did not do skin scrapings to diagnose the scabies because the physician told her the skin scrapings were often inconclusive. CNA B stated the physician told her he had previously diagnosed several staff members from the same facility using skin scrapings and visually diagnosed her rash as the same rash confirmed as scabies on other staff members. She stated she used the cream provided by the physician to treat the scabies and returned to work after two to three days; the last time she worked was two nights ago (02/21/11). CNA B stated she saw rashes like hers on Residents #2, #3 and #4. The CNA stated she told the Director of Nurses (DON) and LVN W in January 2011 that she had been diagnosed with [REDACTED]. CNA B stated, at her prompting, the DON looked at Resident #2's rash on her hands and stated it looked like winter [MEDICAL CONDITION]. CNA B stated LVN W told her Resident #2 had an appointment with a dermatologist in March 2011. The CNA stated she also recently told LVN V and was aware that CNAs D and A had been diagnosed and treated for [REDACTED]. In an interview on 02/24/11 at 5:30 PM, ADON Y stated she was not aware of CNA B's concerns of scabies. She stated she did not know whether she should call CNA B and require some sort of proof that she had been treated and cleared to return to work. ADON Y stated she did not know what the facility policy was for allowing an employee to return to work following a [DIAGNOSES REDACTED]. In an interview on 02/24/11 at 6:00 PM when asked if CNA B reported itching or rashes to her, LVN U stated "she might have mentioned it in passing." LVN U stated CNA B told her she thought the facility might be causing her rash. She stated CNA B complained of itching but never showed the LVN her skin. LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA B was assigned to work on the 200 Hall every day in February 2011 except 02/05/11, 02/06/11, 02/11/11, 02/12/11, 02/17/11, 02/18/11, 02/23/11, 02/24/11. In an interview on 02/24/11 at 8:30 AM CNA E stated she recently had a rash in one area of her arm. She described the rash as being itchy and pimple-like. She stated she did not go to a doctor to have it diagnosed or treated and did not report the rash to any of the facility staff members. She stated the rash had since gone away. CNA E was observed to provide care to residents on the 200 Hall. Attempts to interview CNA D were unsuccessful because the facility provided a non-working phone number. In an interview on 02/25/11 at 3:00 PM, the Corporate Consultant Nurse A stated CNA D reported to work that morning but was sent home because she had a suspicious rash. In an interview on 02/24/11 at 11:45 AM the surveyor met with the DON, ADON Y and Assistant Administrator regarding concerns that Resident #2 and Resident #4 had signs and symptoms of scabies with no isolation precautions; LVN V and CNA C had signs of symptoms of scabies and were providing care to residents; a physician had not examined the two staff members or two residents to rule out scabies; and CNAs A, B and C had reported complaints of signs and symptoms of scabies to facility staff (the ADON, DON, LVN W and U) and the facility had not conducted an investigation to rule out or control a scabies outbreak. In a follow-up interview on 02/24/11 at 1:20 PM, with the DON, Assistant Administrator and ADON Y, the DON stated they looked at Resident #2's skin. The DON stated the Resident's skin was dry and scaly, had scabs and scratches, bumps, and [MEDICAL CONDITION]. The DON added that she had not looked at Resident #4's skin because she was not in her room. The DON stated she had not looked at LVN V's skin or CNA C's skin. The DON stated the CNA C was still working on the floor and LVN V was still working on the floor with an orientee, finishing out her shift that ended at 2:00 PM. During the same interview the DON stated it was her expectation that no staff members be allowed to work around residents with an rash that was undiagnosed . After surveyor intervention, at 1:30 PM, ADON Y stated CNA C had been removed from the floor and CNA C was observed sitting in an upholstered chair in the front lobby. No isolation precautions were observed for Resident #2 and #4. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated Resident #2 refused to allow him to examine her skin. He examined Resident #4's skin and determined she had [MEDICAL CONDITIONS], with 70% of her left leg affected and less of her right. Observation of Resident #2's room at that time revealed no evidence of isolation precautions. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he examined LVN V's arm and determined it was not scabies; he examined CNA C's arm and stated it looked like a scabies infestation. Although it was requested at entrance on 02/23/11, in an interview on 02/25/11 at 9:20 AM, the DON, ADON Y, Administrator, and Assistant Administrator stated they had not found the facility's policy and procedure for addressing cross contamination by staff to residents. Review of the facility's Policy, "Skin Rashes" provided on 02/25/11 at 10:00 AM and dated August 2007 revealed: "A rash indicates an abnormal change in skin color or texture. . . . Procedure: An employee who presents with an unidentifiable skin rash must be examined by a physician to determine if the rash is a communicable disease which may be harmful to residents or other staff members in the LTC (long term care) environment. Upon notification of the rash by the staff member, they must be sent to a physician for clearance to return to work. If the physician deems it to be a communicable disease, i.e., scabies, the staff member must be treated with the appropriate medication before returning to duty The facility DON, ADON Y, and Assistant Administrator were informed of an Immediate Jeopardy (IJ) on 02/24/11 at 2:35 PM based on the facility's failure to protect from widespread nosocomial infection. The DON stated the Administrator was not in the building at that time. The Administrator was also informed on 02/24/11 at 2:40 PM. On 02/24/11 at 5:50 PM the following Plan of Removal was accepted. "Around 12:00 PM on February 24, 2011 (the surveyor) notified the DON, ADON and the Assistant Administrator that two residents and two employees had unexplained rashes." 1. The Medical Director was notified of two residents (200 hall) and two employees (one on 200 hall and one on 500 hall) with unknown rashes. (The Medical Director) agreed to visit the facility and he arrived at 1:55 PM. (The Medical Director) assessed one resident and one employee and determined it was [MEDICAL CONDITION] (200 hall) and not scabies. One resident (Resident #2, 200 Hall) refused to let the Medical Director assess. She refused to let the facility take contact precautions. Therefore (Resident #2) was sent to the emergency room to be assessed for rash. The employee on 500 hall (CNA C) was screened and may have scabies. The employee was immediately sent to outpatient clinic for [DIAGNOSES REDACTED]. 2. Charge Nurses were instructed to begin skin assessments on all residents for 200 hall and 500 hall. Housekeeping and Laundry were instructed to start deep cleaning and sanitizing every room. Assessments completed and no identified rashes. 3. An infection control in-service was conducted with all available staff. Staffing Coordinated was instructed to call all staff for mandatory in-service 02/24/11 at 4:30 PM. 4. All staff was questioned in reference to unidentified rashes and none were identified. 5. Assessments were conducted on all halls (100-500) to include the Special Care Unit (600-700) and no unidentified rashes were identified. 6. Infection control reports are reviewed and discussed at monthly QA (Quality Assurance) meetings. Any communicable disease is identified and treated according to protocol. 7. Any staff member with infected [MEDICAL CONDITION] will not be allowed to work. 8. Ongoing monitoring will be done by the DON and ADON weekly for four weeks and results reported to QA. Ongoing monitoring as needed. In an interview on 02/25/11 at 12:00 noon, the DON stated three additional residents were placed on isolation precautions since Resident #2 was confirmed to have scabies by the ER. With heightened awareness following the in-service mandated by the Plan of Removal, two other residents were observed by the night nurses to have suspicious rashes, Resident #3 and Resident #7. ADON Y stated the Medical Director said to "go ahead and treat Resident #4." Review of a facility in-service Record dated 02/24/11 revealed the facility in-serviced staff (including Housekeeping, Maintenance, Certified Nurse Aides, and Licensed Vocational Nurses) regarding reporting unexplained rashes and skin conditions, isolation and infection control precautions. Random interviews on 02/25/11 with Housekeeping, CNAs and Nurses verified understanding of the in-service. Rooms on Halls 200 and 500 were observed on 02/25/11 receiving a deep cleaning, isolation precautions were observed in place for Residents #2, #3, #4, and #7 at 2:45 PM on 02/25/11. Infection control logs regarding skin issues were observed to be updated for January 2011 at 2:45 PM on 02/25/11. Based on observations, interviews and record reviews, the immediacy was removed at a Scope of pattern and a Severity level of actual harm that was not Immediate Jeopardy on 02/25/11 at 2:45 PM because the facility had not yet had the opportunity to in-service all staff, ensure February 2011 infection control logs accurately documented the infections; or performed monitoring by the QA, DON and ADON. Review of the facility's CMS Form 672 dated 02/23/11 reflected a census of 150 residents, with 13 of residents who currently had rashes.

Based on observations, interviews and record reviews the facility failed to implement an Infection Control Program to investigate, control and prevent scabies infestations (human itch mite - Sarcoptes scabiei var. hominis) in the facility when: (A) Facility Licensed staff did not consult with physicians when two of two residents were observed with red, itchy rashes (Residents #2 and #4) to ensure the residents received evaluation, treatment and possible isolation precautions. The facility failed to consult with Resident #2's physician for complaints of itching and rashes from 10/10/10 to 02/24/11. Resident #2 had multiple red pimples and open lesions starting at her left hand and extending up to her left shoulder. There resident also had multiple areas of broken skin where she had scratched her arm and an area above her left breast that was bleeding where she had scratched a lesion. Resident #2 expressed frustration that she had not received medication to treat the itching and was unable to see a dermatologist until March 2011. On 2/24/11, Resident #2 was diagnosed with [REDACTED]. hominis) and returned to the facility with an order for [REDACTED].) The facility failed to consult with Resident #4's physician for complaints of itching from 01/29/11 to 02/25/11. Resident #4 complained of itching on the areas of her skin that had had pimple-like, red and crusted bumps: her left knee and left upper leg covering more than half of her knee and the right knee covering 25 percent of her right knee. (B) The facility Licensed staff did not prohibit (3) three of three Certified Nurse Aides (CNAs A, B and C) and one (1) of one Licensed Vocational Nurse (LVN V) who complained of signs and symptoms of scabies infestation from direct contact with residents pending [DIAGNOSES REDACTED]. Facility Charge Nurse, LVN V did not report her undiagnosed rash to the facility. The facility did not investigate CNAs A, B and C complaints of itching or [DIAGNOSES REDACTED]. (C) The facility failed to alert staff and visitors of isolation precautions for one of one residents with a confirmed nosocomial infection (Resident #6). There was no sign to alert staff and visitors that Resident #6 was under isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA) in his nares. (MRSA is a highly contagious bacteria responsible for difficult-to-treat infections in humans.) (D) The facility failed to track and trend skin infections in the secure unit (Halls 600 and 700) for January 2011. The facility did not document the origin of infection, culture date or treatment for [REDACTED]. The facility had six scabies infestations in the secure unit in December 2010. An Immediate Jeopardy (IJ) was identified on 02/24/11 at 2:45 PM. While the IJ was removed on 02/25/11 at 2:45 PM, the facility remained out of compliance at a Scope of pattern and a Severity level of harm that was not Immediate Jeopardy while the facility continued staff training on isolation precautions and ensured ongoing accurate tracking and trending of infections were monitored in the facility. These facility failures resulted in the potential for wide spread nosocomial infections to all 150 residents and disabled the facility's ability to track and trend and subsequently control facility acquired infections. The findings include: The Centers for Disease Control and Prevent (CDC) states: "Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). . . . The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. . . . Scratching the rash can cause skin sores; sometimes these sores become infected by bacteria." (http://www.cdc.gov/parasites/scabies/gen_info/faqs.html, updated 11/02/10, accessed 03/01/11.) (A) Resident #2 Review of Resident #2's Face Sheet dated 02/24/11 revealed she was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #2's Nurse Summary dated 02/14/11 documented she was alert and oriented to person, place and time; had independent cognitive skills for daily decision making, and had no short- or long-term memory deficits. Review of Resident #2's Nurses' Notes revealed: - 09/28/10: "Antibiotic in progress for URI (upper respiratory infection), day 2 of 10. - 10/04/10 - "No adverse reactions to antibiotic." - 10/22/10: "Resident approached nursing station complaining of itching all over with rash noted on arms and legs. Allergic to [MEDICATION NAME] and states the cream not helpful . . . Received fax order from (Medical Director) for [MEDICATION NAME] 10 mg by mouth every day . . . resident refuses to take med from our doctor, only hers." A Fax Transmittal Form dated 10/22/10 documented contact with the Medical Director: "(Resident #2) complaining of itching all over. Noted with fine rash (on) arms. Resident unable to take [MEDICATION NAME] - allergic to med. One percent TAC cream, states it is not helping. Attempted to notify resident primary care physician unsuccessful. Please advise." There was no evidence a physician examined Resident #2's rash on 10/22/10, and that the facility contacted the physician for alternative treatment when she refused [MEDICATION NAME]. In an interview on 02/24/11 at 6:00 PM, LVN U CNAs A and B told her around early February that they had itching and rashes that they thought they got from Resident #2. The LVN stated she observed that Resident #2 had edema on her hand, her skin was dry and cracked and she had some bumps toward the top of her hand when she saw her last, two days ago (02/22/11). LVN U stated Resident #2 saw several doctors, but she did not know if the physicians examined her skin. In an interview on 02/24/11 at 6:10 PM, LVN W stated she worked the 10:00 PM to 6:00 AM shift. She stated Resident #2 had a rash on her hands "for a long time," but she had not observed issues on her arm. The LVN stated she was responsible for Resident #2's weekly head to toe skin assessments and saw no other skin issues other than bruises from insulin injections. Observation during initial tour on 02/23/11 at 3:40 PM revealed Resident #2's door was closed with a sign that it should remained closed. When asked why the sign was on the door, ADON Y stated it was not an isolation precaution but instead was the resident's preference. Continued observation revealed Resident #2 sitting in her wheelchair. There were multiple red pimples and open lesions starting at her left hand and extending up to her left shoulder. The resident was reluctant to let the surveyor look at her arm, but multiple areas of broken skin were observed where she had scratched her arm and an area above her left breast 2 centimeters (cm) large was bleeding where she had scratched a lesion. Resident #2 stated she had the rashes since October 2010 and, in a frustrated tone, stated they itched and she had not received any medication to treat the itching. The resident stated she had been trying to see a dermatologist and did not have an appointment until March (2011). During follow-up observation/interview on 02/24/11 at 9:30 AM with LVN V and Resident #2, Resident #2 stated she had itching in the following areas: her right hip, right leg below the knee, under her left breast, on her left breast, her left arm, and near her right elbow. The resident would not allow LVN V or the surveyor to observe her left breast or under her left breast, but pimple-like bumps with open, crusted lesions were observed on her right hip, right leg below the knee, and on her left arm and right elbow. The upper left breast area had some dried blood where Resident #2 had scratched the lesion. Broken skin on the left arm where the resident had scratched were still observed. Resident #2 stated the rashes started in October 2010 and she had an appointment to see a dermatologist "next month" (March 2010). The resident stated she did not know what caused the rashes. LVN V stated Resident #2 had not been tested for scabies. No isolation precautions were observed. In an interview on 02/24/11 at 11:00 AM LVN V stated Resident #2 was very alert and oriented and made her own physician appointments. The LVN stated she did not know what her physicians looked at and whether they had diagnosed her skin rash since October 2010. LVN V stated she did not know who Resident #2's current physician was. In an interview on 02/24/11 at 11:30 AM, ADON Y stated the facility's secure unit (Halls 600 and 700) had an outbreak of scabies in December 2010. When asked if the facility had any documentation that Resident #2's rash from October 2010 was treated, ADON Y stated Resident #2's clinical record documented a physician ordered an antibiotic on 10/06/10 for a [DIAGNOSES REDACTED]. She was allergic to [MEDICATION NAME], so the Medical Director ordered [MEDICATION NAME] to treat an allergic reaction to the antibiotic. The resident refused the [MEDICATION NAME] because it was not ordered by her physician. The ADON stated the only other evidence she could find in Resident #2's clinical record that the facility addressed her itching was an order for [REDACTED]. The ADON stated the facility could not determine why the physician made a referral to a dermatologist on 11/15/10; there was nothing in the nurses' notes or other documentation to explain why. The ADON stated she could not find anything else in the resident's clinical record documenting consulting the physician for the resident's rash. She stated the resident had a pending appointment with a dermatologist on 03/15/11 from the original 11/15/10 referral. Efforts to contact Resident #2's physician regarding her skin condition and why a dermatologist referral was made were unsuccessful. The clinical record did not correctly document who her physician was, the resident was unable to provide the physician's name, and the facility did not know who or if any physicians had examined her skin Review of Nurses' Notes from 10/22/10 to 02/23/11 and nursing summaries revealed no documentation of Resident #2's rash. Review of Resident #2's "Doctor's Progress Notes" on 02/24/11 revealed no physician progress notes [REDACTED]. In an interview on 02/24/11 at 11:45 AM, the DON and ADON confirmed Resident #2 had not been on antibiotics since October 2010 to possibly explain the rash and there was no evidence that a physician examined Resident #2's rash. The DON stated she "would not want it (Resident #2's rash) undiagnosed for that long (October 2010 to March 2011)." Review of Resident #2's Consolidated Physician order [REDACTED]. There were no current orders to treat itching skin. Review of Resident #2's Interdisciplinary Progress Notes dated 02/24/11 at 4:15 PM revealed: "Resident noted with rash on hands and arms, complains of itching. Refuse to have (Medical Director) assess kin. Order to send resident to ER (emergency room )." The Interdisciplinary Progress Note dated 02/24/11 at 10:30 PM documented: "Nurse from (hospital) ER called with report (of) [DIAGNOSES REDACTED]." ([MEDICATION NAME] is the brand name for [MEDICATION NAME]. It is an insecticide used in healthcare to eradicate parasites such as mites responsible for scabies.) Review of Resident #2's Discharge Instructions from the hospital dated 02/24/11 revealed, "Diagnosis: [REDACTED]. . . Prescriptions: [MEDICATION NAME] 5% Cream." Resident #4 Review or Resident #4's Face Sheet dated 10/29/10 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 02/23/11 at 3:30 PM revealed Resident #4 was not in her room. Her roommate was observed in the B bed. No isolation precautions were in place. In an interview/observation on 02/24/11 at 9:30 AM, Resident #4 was observed lying in bed. She complained of itching to her "knee cap." Observation of Resident #4's skin revealed several pimple-like, red and crusted bumps on her left knee and left upper leg covering more than half of her knee. The right knee was also observed to have pimple-like bumps that were not red, covering 25 percent of her right knee. LVN V stated the rash on her left knee started as an abrasion and she had not informed the physician of the rash. No isolation precautions were observed. Review of Resident #4's Nurse's Note dated 01/29/11 revealed: "Resident stated 'I had a bump on my left leg and I scratched it.' Observed small abrasion on right lower leg. New order written. Cleansed with normal saline, apply TAO, cover with non-stick dressing." There was no evidence that the physician examined the skin or that the facility consulted the physician for the itching that caused the resident to scratch her leg. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he just conducted a visual examine of Resident #4's skin for the first time and determined she had eczema dermatitis, with 70% of her left leg affected and less of her right. In an interview on 02/25/11 at 12:00 noon, (after Resident #2 had a confirmed case of scabies and the facility was informed of an Immediate Jeopardy) ADON Y stated the Medical Director said to "go ahead and treat Resident #4." Review of Resident #4's Nurse's Note dated 02/25/11 at 10:30 AM revealed: "new order for [MEDICATION NAME] cream 5%. Apply topically from neck to feet. Leave cream on for 12 hours for rash." Review of the Facility's Policy, "Management of Scabies" dated 06/01/07 revealed the following. "Procedure: Implement contact isolation. . . . Contact the attending physician. If the attending physician refuses to order treatment, notify the DON and/or Medical Director. . . ." "General Scabies Outbreak: 1. During a general scabies outbreak among residents and/or personnel, interdepartmental planning is essential to coordinate the treatment program." The policy and procedure did not address reporting rashes pending [DIAGNOSES REDACTED]. (B) Failure to prohibit staff with rashes from direct contact with residents: CNA C - During observation/interview on 02/24/11 at 10:50 AM, CNA C stated she had developed a rash on her left arm, stomach and legs about two weeks ago. She stated the rash itched a lot. The CNA was wearing short sleeves, and the red, open, crusted lesions were easily visible on her left arm. The CNA stated she did not have insurance, so she had not been to a doctor to have the rash diagnosed and treated. CNA C stated she reported the rash to her charge nurse who no longer worked at the facility and to the DON. CNA C was observed to provide care to residents on the 500 Hall. In a follow up observation/interview on 02/24/11 at 2:00 PM, in the presence of the DON, CNA C stated she told the charge nurse and the DON when the rash first appeared, "but the DON must have been having a bad day because now she says she doesn't remember." In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he examined CNA C's arm and stated it looked like a scabies infestation. Observation/interview at 02/24/11 at 5:45 PM revealed CNA C returned to the facility and was observed in the Assistant Administrator's office. The Administrator presented a dated payment receipt for CNA C's urgent care visit dated 02/24/11. In an interview on 02/25/11 at 8:30 AM, the DON stated CNA C was not working today. She stated the urgent care clinic did not do diagnostic scrapings of CNA C's skin to rule out scabies; but instead prescribed [MEDICATION NAME] (a corticosteroid that decreases the immune system's response to various diseases to reduces symptoms such as swelling and allergic-type reactions) and told her to use the cream the facility gave her to treat scabies, which the DON stated was [MEDICATION NAME] 5%. Review of the "6-2 Nurse Aide Schedule February 2011" revealed CNA C worked on the 500 hall on 02/01/11 through 02/03/11; 02/06/11 through 02/09/11; 02/12/11 through 02/15/11; and 02/18/11 through 02/21/11. LVN V - During an interview on 02/24/11 at 8:30 AM, LVN V stated she had a rash on her left arm that itched. Several pimple-like bumps were observed on her left arm. The LVN stated she had not been to the doctor to have the rash diagnosed or treated and had not reported the rashes to anyone in the facility. The LVN stated she got the rashes every six months and they usually resolved on their own. LVN V was observed to be providing care to Residents on the 200 Hall. CNA A - In a telephone interview on 02/24/11 at 3:00 PM, form employee CNA A stated she worked the 10:00 PM to 6:00 AM shift and had worked on 100, 200, 300 and 500 Halls. CNA A stated she had itching skin for a several months but did not connect that it might be scabies until late January 2011, early February 2011. She stated she asked nurses at the facility what they thought the rash was. She stated she went to a physician at the beginning of February 2011, who diagnosed the itching/rash as scabies. She stated she told ADON Y and the DON she had been diagnosed with [REDACTED]. The CNA stated she did not complete the treatment before she returned to work or before she resigned because she knew she got the infection at the facility and would just get it again. CNA A stated after she was diagnosed with [REDACTED]. She told ADON Y that she could not come to work because of the scabies: she had brought scabies home to the family and now she did not have a babysitter because the babysitter refused to watch the child. In an interview on 02/24/11 at 1:30 PM, the DON stated CNA A worked the 10:00 PM to 6:00 AM shift and was a "disgruntled employee." She stated she had poor performance with resident complaints that she did not answer the call light and attendance issues. The facility was about to terminate her but she resigned. The DON stated, in her "manifest resignation" CNA A said she was infected with scabies here. The DON stated CNA's letter dated 02/10/11 was the first time the facility was aware of CNA A concerns with scabies. In a follow-up interview on 02/24/11 at 5:00 PM, ADON Y stated she remembered CNA A called and said she went to the physician with a rash and had already talked to someone at the facility about it. ADON Y stated CNA A never provided proof. The CNA did not provide a physician's note clearing her from an absence on 02/05/11 because the CNA stated she went to the military clinic and the military clinic would not provide a note. In a telephone interview on 02/24/11 at 6:10 PM with ADON Y present, LVN W stated CNA A complained of a rash and asked the LVN to look at her arms. LVN W stated she saw one little bump that was not open. LVN W stated CNA A later said she had been diagnosed with [REDACTED]. In a telephone interview on 02/24/11 at 6:00 PM with ADON Y present, LVN U stated she worked the 10:00 PM to 6:00 AM shift. She stated CNA A complained of itching and bumps and asked the nurse to examine her skin. LVN U stated she "couldn't see much of anything, just marks across her skin from scratching." LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of CNA A's personnel file revealed she was employed at the facility from 11/01/10 to 02/10/11. Review of her letter dated 02/10/11 revealed: "In addition, I have contracted and been diagnosed with [REDACTED]. . a very contagious infection. I did contact this on the job at (the facility) and choose to no longer expose or subject my family to such inhumanity." Review of a handwritten note provided by the facility on 02/25/11 revealed: "(CNA A) attendance issue 02/05/11; 02/02/11 told nurse she was itching." Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA A was assigned to work on the 200 Hall from 02/03/11 to 02/06/11; and on 02/09/11 and 02/10/11. CNA B - In an interview on 02/23/11 at 2:00 PM, CNA B stated she was diagnosed with [REDACTED]. CNA B stated the physician did not do skin scrapings to diagnose the scabies because the physician told her the skin scrapings were often inconclusive. CNA B stated the physician told her he had previously diagnosed several staff members from the same facility using skin scrapings and visually diagnosed her rash as the same rash confirmed as scabies on other staff members. She stated she used the cream provided by the physician to treat the scabies and returned to work after two to three days; the last time she worked was two nights ago (02/21/11). CNA B stated she saw rashes like hers on Residents #2, #3 and #4. The CNA stated she told the Director of Nurses (DON) and LVN W in January 2011 that she had been diagnosed with [REDACTED]. CNA B stated, at her prompting, the DON looked at Resident #2's rash on her hands and stated it looked like winter dermatitis. CNA B stated LVN W told her Resident #2 had an appointment with a dermatologist in March 2011. The CNA stated she also recently told LVN V and was aware that CNAs D and A had been diagnosed and treated for [REDACTED]. In an interview on 02/24/11 at 5:30 PM, ADON Y stated she was not aware of CNA B's concerns of scabies. She stated she did not know whether she should call CNA B and require some sort of proof that she had been treated and cleared to return to work. ADON Y stated she did not know what the facility policy was for allowing an employee to return to work following a [DIAGNOSES REDACTED]. In an interview on 02/24/11 at 6:00 PM when asked if CNA B reported itching or rashes to her, LVN U stated "she might have mentioned it in passing." LVN U stated CNA B told her she thought the facility might be causing her rash. She stated CNA B complained of itching but never showed the LVN her skin. LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA B was assigned to work on the 200 Hall every day in February 2011 except 02/05/11, 02/06/11, 02/11/11, 02/12/11, 02/17/11, 02/18/11, 02/23/11, 02/24/11. In an interview on 02/24/11 at 8:30 AM CNA E stated she recently had a rash in one area of her arm. She described the rash as being itchy and pimple-like. She stated she did not go to a doctor to have it diagnosed or treated and did not report the rash to any of the facility staff members. She stated the rash had since gone away. CNA E was observed to provide care to residents on the 200 Hall. Attempts to interview CNA D were unsuccessful because the facility provided a non-working phone number. In an interview on 02/25/11 at 3:00 PM, the Corporate Consultant Nurse A stated CNA D reported to work that morning but was sent home because she had a suspicious rash. In an interview on 02/24/11 at 11:45 AM the surveyor met with the DON, ADON Y and Assistant Administrator regarding concerns that Resident #2 and Resident #4 had signs and symptoms of scabies with no isolation precautions; LVN V and CNA C had signs of symptoms of scabies and were providing care to residents; a physician had not examined the two staff members or two residents to rule out scabies; and CNAs A, B and C had reported complaints of signs and symptoms of scabies to facility staff (the ADON, DON, LVN W and U) and the facility had not conducted an investigation to rule out or control a scabies outbreak. In a follow-up interview on 02/24/11 at 1:20 PM, with the DON, Assistant Administrator and ADON Y, the DON stated they looked at Resident #2's skin. The DON stated the Resident's skin was dry and scaly, had scabs and scratches, bumps, and lesions. The DON added that she had not looked at Resident #4's skin because she was not in her room. The DON stated she had not looked at LVN V's skin or CNA C's skin. The DON stated the CNA C was still working on the floor and LVN V was still working on the floor with an orientee, finishing out her shift that ended at 2:00 PM. During the same interview the DON stated it was her expectation that no staff members be allowed to work around residents with an rash that was undiagnosed . After surveyor intervention, at 1:30 PM, ADON Y stated CNA C had been removed from the floor and CNA C was observed sitting in an upholstered chair in the front lobby. No isolation precautions were observed for Resident #2 and #4. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated Resident #2 refused to allow him to examine her skin. He examined Resident #4's skin and determined she had eczema dermatitis, with 70% of her left leg affected and less of her right. Observation of Resident #2's room at that time revealed no evidence of isolation precautions. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he examined LVN V's arm and determined it was not scabies; he examined CNA C's arm and stated it looked like a scabies infestation. Although it was requested at entrance on 02/23/11, in an interview on 02/25/11 at 9:20 AM, the DON, ADON Y, Administrator, and Assistant Administrator stated they had not found the facility's policy and procedure for addressing cross contamination by staff to residents. Review of the facility's Policy, "Skin Rashes" provided on 02/25/11 at 10:00 AM and dated August 2007 revealed: "A rash indicates an abnormal change in skin color or texture. . . . Procedure: An employee who presents with an unidentifiable skin rash must be examined by a physician to determine if the rash is a communicable disease which may be harmful to residents or other staff members in the LTC (long term care) environment. Upon notification of the rash by the staff member, they must be sent to a physician for clearance to return to work. If the physician deems it to be a communicable disease, i.e., scabies, the staff member must be treated with the appropriate medication before returning to duty." (C) Interview/Observation during initial tour on 02/23/11 at 3:30 PM when ADON Y and the surveyor entered Resident #6's room revealed Resident #6 laying in bed. He had a face mask that he wore around his neck and put up to his mouth loosely when he spoke. When asked why he did that, ADON Y stated he had MRSA in his nares. Continued observation revealed ADON Y did not put on personal protective equipment (PPE) or offer PPE to the surveyor. There was no sign on the door to alert staff and visitors of isolation precautions. A bedside cabinet was just outside the room, but it was not visibly apparent that it contained PPE. This observation was confirmed by ADON Y who stated their should be a sign on his door to alert visitors of isolation precautions. ADON Y stated Resident #6 was the only resident with isolation precautions at that time. Observation on 02/25/11 at 9:45 AM, after surveyor intervention, revealed a sign on Resident #6's room: "All visitors please report to nurses' station before entering." Review of Resident #6's Face Sheet dated 12/01/10 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's History and Physical and a nurse summary dated 02/23/11 documented he had dementia and moderately impaired cognitive skills for daily decision making. Review of Resident #6's laboratory study dated 02/15/11 revealed the results of a lower respiratory sputum culture: "heavy growth of Methicillin Resistant Staphylococcus Aureus." Resident #6's hospital laboratory study dated 11/16/10 documented MRSA in a wound culture of the resident's left ankle. Review of the facility's "Contact Precautions" dated 1995 revealed: "Visitors: Report to nurse before entering. . . . Gloves: Wear gloves when entering patient room. Gown: Wear gown when entering patient room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent, or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing." (D) In an interview on 02/24/11 at 11:30 AM, ADON Y stated the facility's secure unit (Halls 600 and 700) had an outbreak of scabies in December 2010. Review of the facility's Infection Log dated 12/01/10 through 12/30/10 revealed the facility documented six residents in the secure unit had infections in the "other" category, with a handwritten note that "other" referred to skin scabies infections: five residents on the 600 Hall and one resident on the 700 Hall.. The same log documented two residents on the 600 hall and three residents on the 700 hall had skin infections but did not document the location, source, culture, or treatment method of the other skin infections. Review of the facility's Infection Log dated January 2011 revealed the facility documented six residents in the secure unit with infections in the "skin" category: two on the 600 Hall and four on the 700 Hall. The log documented that one resident received one dose of antibiotic but it was discontinued due to an allergic reaction; a second documented: "resident picking at wound re-infected site." The log did not provide any other documentation related to the location, source, culture, treatment or resolution of the skin infections. The log documented the average daily census was 48. Review of the "Monthly Resident Infection Analysis" signed 01/30/11 by the DON revealed it documented six infections in the secure unit in the site "skin": two on the 600 Hall and four on the 700 Hall. The same form documented a total of 11 infections in the secure unit. In the area for "number of infections by type" the facility documented only two infections by "e. coli;" the facility did not analyze any of the remaining 9 infections by category. In an interview on 02/25/11 at 11:00 PM, ADON Z stated he was the ADON of the secure unit. He stated the six skin issues in the secure unit in January 2011 were from skin tears that the residents picked at and infected or re-infected. ADON Z stated they were treated with antibiotics but no cultures were done to identify the organism or whether the organism was susceptible to the prescribed antibiotic. During the same interview the Assistant Administrator agreed that it was not possible to track and trend the infections without knowing whether the organisms were yeast, MRSA, scabies, etc. The Assistant Administrator instructed ADON Z to pull the resident records to verify the treatment and whether cultures were performed and to update the Infection Control log. In an interview on 02/25/11

Based on observations, interviews and record reviews the facility failed to (A) ensure (2) two of (2) two residents observed with red, itchy rashes (Residents #2 and #4) received the necessary care and services to attain or maintain the highest practicable physical and mental well-being when the facility did not ensure the residents received evaluation and timely treatment for [REDACTED]. The facility failed to consult with Resident #2's physician for complaints of itching and rashes from 10/10/10 to 02/24/11. Resident #2 had multiple red pimples and open [MEDICAL CONDITION] starting at her left hand and extending up to her left shoulder, multiple areas of broken skin where she had scratched her arm and an area above her left breast that was bleeding where she had scratched a lesion. Resident #2 expressed frustration that she had not received medication to treat the itching and was unable to see a dermatologist until March 2011. On 2/24/11, Resident #2 was diagnosed with [REDACTED]. hominis) and returned to the facility with an order for [REDACTED]. The facility failed to consult with Resident #4's physician for complaints of itching from 01/29/11 to 02/25/11. Resident #4 complained of itching on the areas of her skin that had had pimple-like, red and crusted bumps: her left knee and left upper leg covering more than half of her knee and the right knee covering 25 percent of her right knee. (B) prohibit three (3) of three Certified Nurse Aides (CNAs A, B and C) and one (1) of one Licensed Vocational Nurse (LVN V) who complained of signs and symptoms of scabies infestation from direct contact with residents pending [DIAGNOSES REDACTED]. An Immediate Jeopardy (IJ) was identified on 02/24/11 at 2:45 PM. While the IJ was removed on 02/25/11 at 2:45 PM, the facility remained out of compliance at a Scope of pattern and a Severity level of harm that was not Immediate Jeopardy while the facility continued staff training on isolation precautions and ensured ongoing accurate tracking and trending of infections were monitored in the facility. This deficient practice contributed to prolonged mental anguish, delayed treatment and the alleviation of persistent itchy rashes for 2 residents and resulted in the potential for widespread nosocomial and related skin infections to all 150 residents. The findings include: The Centers for Disease Control and Prevent (CDC) states: "Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). . . . The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. . . . Scratching the rash can cause skin sores; sometimes these sores become infected by bacteria." (http://www.cdc.gov/parasites/scabies/gen_info/faqs.html, updated 11/02/10, accessed 03/01/11.) (A) Resident #2 Review of Resident #2's Face Sheet dated 02/24/11 revealed she was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. muscle weakness and fatigue), convulsions/[MEDICAL CONDITIONS] reflux, [MEDICAL CONDITIONS], urinary tract infection, [MEDICAL CONDITION], and [MEDICAL CONDITION], and type 2 diabetes. Resident #2's Nurse Summary dated 02/14/11 documented she was alert and oriented to person, place and time; had independent cognitive skills for daily decision making, and had no short- or long-term memory deficits. Review of Resident #2's Nurses' Notes revealed: - 09/28/10: "Antibiotic in progress for URI (upper respiratory infection), day 2 of 10. - 10/04/10 - "No adverse reactions to antibiotic." - 10/22/10: "Resident approached nursing station complaining of itching all over with rash noted on arms and legs. Allergic to [MEDICATION NAME] and states the cream not helpful . . . Received fax order from (Medical Director) for [MEDICATION NAME] 10 mg by mouth every day . . . resident refuses to take med from our doctor, only hers." A Fax Transmittal Form dated 10/22/10 documented contact with the Medical Director: "(Resident #2) complaining of itching all over. Noted with fine rash (on) arms. Resident unable to take [MEDICATION NAME] - allergic to med. One percent TAC cream, states it is not helping. Attempted to notify resident primary care physician unsuccessful. Please advise." There was no evidence a physician examined Resident #2's rash on 10/22/10, and that the facility contacted the physician for alternative treatment when she refused [MEDICATION NAME]. In an interview on 02/24/11 at 6:00 PM, LVN U CNAs A and B told her around early February that they had itching and rashes that they thought they got from Resident #2. The LVN stated she observed that Resident #2 had [MEDICAL CONDITION] on her hand, her skin was dry and cracked and she had some bumps toward the top of her hand when she saw her last, two days ago (02/22/11). LVN U stated Resident #2 saw several doctors, but she did not know if the physicians examined her skin. In an interview on 02/24/11 at 6:10 PM, LVN W stated she worked the 10:00 PM to 6:00 AM shift. She stated Resident #2 had a rash on her hands "for a long time," but she had not observed issues on her arm. The LVN stated she was responsible for Resident #2's weekly head to toe skin assessments and saw no other skin issues other than bruises from insulin injections. Observation during initial tour on 02/23/11 at 3:40 PM revealed Resident #2's door was closed with a sign that it should remained closed. When asked why the sign was on the door, ADON Y stated it was not an isolation precaution but instead was the resident's preference. Continued observation revealed Resident #2 sitting in her wheelchair. There were multiple red pimples and open [MEDICAL CONDITION] starting at her left hand and extending up to her left shoulder. The resident was reluctant to let the surveyor look at her arm, but multiple areas of broken skin were observed where she had scratched her arm and an area above her left breast 2 centimeters (cm) large was bleeding where she had scratched a lesion. Resident #2 stated she had the rashes since October 2010 and, in a frustrated tone, stated they itched and she had not received any medication to treat the itching. The resident stated she had been trying to see a dermatologist and did not have an appointment until March (2011). During follow-up observation/interview on 02/24/11 at 9:30 AM with LVN V and Resident #2, Resident #2 stated she had itching in the following areas: her right hip, right leg below the knee, under her left breast, on her left breast, her left arm, and near her right elbow. The resident would not allow LVN V or the surveyor to observe her left breast or under her left breast, but pimple-like bumps with open, crusted [MEDICAL CONDITION] were observed on her right hip, right leg below the knee, and on her left arm and right elbow. The upper left breast area had some dried blood where Resident #2 had scratched the lesion. Broken skin on the left arm where the resident had scratched were still observed. Resident #2 stated the rashes started in October 2010 and she had an appointment to see a dermatologist "next month" (March 2010). The resident stated she did not know what caused the rashes. LVN V stated Resident #2 had not been tested for scabies. No isolation precautions were observed. In an interview on 02/24/11 at 11:00 AM LVN V stated Resident #2 was very alert and oriented and made her own physician appointments. The LVN stated she did not know what her physicians looked at and whether they had diagnosed her skin rash since October 2010. LVN V stated she did not know who Resident #2's current physician was. In an interview on 02/24/11 at 11:30 AM, ADON Y stated the facility's secure unit (Halls 600 and 700) had an outbreak of scabies in December 2010. When asked if the facility had any documentation that Resident #2's rash from October 2010 was treated, ADON Y stated Resident #2's clinical record documented a physician ordered an antibiotic on 10/06/10 for a [DIAGNOSES REDACTED]. She was allergic to [MEDICATION NAME], so the Medical Director ordered [MEDICATION NAME] to treat an allergic reaction to the antibiotic. The resident refused the [MEDICATION NAME] because it was not ordered by her physician. The ADON stated the only other evidence she could find in Resident #2's clinical record that the facility addressed her itching was an order for [REDACTED]. The ADON stated she could not find anything else in the resident's clinical record documenting consulting the physician for the resident's rash. She stated the resident had a pending appointment with a dermatologist on 03/15/11 from the original 11/15/10 referral. Efforts to contact Resident #2's physician regarding her skin condition and why a dermatologist referral was made were unsuccessful. The clinical record did not correctly document who her physician was, the resident was unable to provide the physician's name, and the facility did not know who or if any physicians had examined her skin Review of Nurses' Notes from 10/22/10 to 02/23/11 and nursing summaries revealed no documentation of Resident #2's rash. Review of Resident #2's "Doctor's Progress Notes" on 02/24/11 revealed no physician progress notes [REDACTED]. In an interview on 02/24/11 at 11:45 AM, the DON and ADON confirmed Resident #2 had not been on antibiotics since October 2010 to possibly explain the rash and there was no evidence that a physician examined Resident #2's rash. The DON stated she "would not want it (Resident #2's rash) undiagnosed for that long (October 2010 to March 2011)." Review of Resident #2's Consolidated Physician order [REDACTED]. There were no current orders to treat itching skin. Review of Resident #2's Interdisciplinary Progress Notes dated 02/24/11 at 4:15 PM revealed: "Resident noted with rash on hands and arms, complains of itching. Refuse to have (Medical Director) assess kin. Order to send resident to ER (emergency room )." The Interdisciplinary Progress Note dated 02/24/11 at 10:30 PM documented: "Nurse from (hospital) ER called with report (of) [DIAGNOSES REDACTED]." ([MEDICATION NAME] is the brand name for [MEDICATION NAME]. It is an insecticide used in healthcare to eradicate parasites such as mites responsible for scabies.) Review of Resident #2's Discharge Instructions from the hospital dated 02/24/11 revealed, "Diagnosis: [REDACTED]. . . Prescriptions: [MEDICATION NAME] 5% Cream." Resident #4 Review or Resident #4's Face Sheet dated 10/29/10 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 02/23/11 at 3:30 PM revealed Resident #4 was not in her room. Her roommate was observed in the B bed. No isolation precautions were in place. In an interview/observation on 02/24/11 at 9:30 AM, Resident #4 was observed lying in bed. She complained of itching to her "knee cap." Observation of Resident #4's skin revealed several pimple-like, red and crusted bumps on her left knee and left upper leg covering more than half of her knee. The right knee was also observed to have pimple-like bumps that were not red, covering 25 percent of her right knee. LVN V stated the rash on her left knee started as an abrasion and she had not informed the physician of the rash. No isolation precautions were observed. Review of Resident #4's Nurse's Note dated 01/29/11 revealed: "Resident stated 'I had a bump on my left leg and I scratched it.' Observed small abrasion on right lower leg. New order written. Cleansed with normal saline, apply TAO, cover with non-stick dressing." There was no evidence that the physician examined the skin or that the facility consulted the physician for the itching that caused the resident to scratch her leg. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he just conducted a visual examine of Resident #4's skin for the first time and determined she had [MEDICAL CONDITIONS], with 70% of her left leg affected and less of her right. In an interview on 02/25/11 at 12:00 noon, (after Resident #2 had a confirmed case of scabies and the facility was informed of an Immediate Jeopardy) ADON Y stated the Medical Director said to "go ahead and treat Resident #4." Review of Resident #4's Nurse's Note dated 02/25/11 at 10:30 AM revealed: "new order for [MEDICATION NAME] cream 5%. Apply topically from neck to feet. Leave cream on for 12 hours for rash." Review of the Facility's Policy, "Management of Scabies" dated 06/01/07 revealed the following. "Procedure: Implement contact isolation. . . . Contact the attending physician. If the attending physician refuses to order treatment, notify the DON and/or Medical Director. . . ." "General Scabies Outbreak: 1. During a general scabies outbreak among residents and/or personnel, interdepartmental planning is essential to coordinate the treatment program." The policy and procedure did not address reporting rashes pending [DIAGNOSES REDACTED]. (B) Failure to prohibit staff with rashes from direct contact with residents: CNA C - During observation/interview on 02/24/11 at 10:50 AM, CNA C stated she had developed a rash on her left arm, stomach and legs about two weeks ago. She stated the rash itched a lot. The CNA was wearing short sleeves, and the red, open, crusted [MEDICAL CONDITION] were easily visible on her left arm. The CNA stated she did not have insurance, so she had not been to a doctor to have the rash diagnosed and treated. CNA C stated she reported the rash to her charge nurse who no longer worked at the facility and to the DON. CNA C was observed to provide care to residents on the 500 Hall. In a follow up observation/interview on 02/24/11 at 2:00 PM, in the presence of the DON, CNA C stated she told the charge nurse and the DON when the rash first appeared, "but the DON must have been having a bad day because now she says she doesn't remember." In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he examined CNA C's arm and stated it looked like a scabies infestation. Observation/interview at 02/24/11 at 5:45 PM revealed CNA C returned to the facility and was observed in the Assistant Administrator's office. The Administrator presented a dated payment receipt for CNA C's urgent care visit dated 02/24/11. In an interview on 02/25/11 at 8:30 AM, the DON stated CNA C was not working today. She stated the urgent care clinic did not do diagnostic scrapings of CNA C's skin to rule out scabies; but instead prescribed [MEDICATION NAME] (a corticosteroid that decreases the immune system's response to various diseases to reduces symptoms such as swelling and allergic-type reactions) and told her to use the cream the facility gave her to treat scabies, which the DON stated was [MEDICATION NAME] 5%. Review of the "6-2 Nurse Aide Schedule February 2011" revealed CNA C worked on the 500 hall on 02/01/11 through 02/03/11; 02/06/11 through 02/09/11; 02/12/11 through 02/15/11; and 02/18/11 through 02/21/11. LVN V - During an interview on 02/24/11 at 8:30 AM, LVN V stated she had a rash on her left arm that itched. Several pimple-like bumps were observed on her left arm. The LVN stated she had not been to the doctor to have the rash diagnosed or treated and had not reported the rashes to anyone in the facility. The LVN stated she got the rashes every six months and they usually resolved on their own. LVN V was observed to be providing care to Residents on the 200 Hall. CNA A - In a telephone interview on 02/24/11 at 3:00 PM, form employee CNA A stated she worked the 10:00 PM to 6:00 AM shift and had worked on 100, 200, 300 and 500 Halls. CNA A stated she had itching skin for a several months but did not connect that it might be scabies until late January 2011, early February 2011. She stated she asked nurses at the facility what they thought the rash was. She stated she went to a physician at the beginning of February 2011, who diagnosed the itching/rash as scabies. She stated she told ADON Y and the DON she had been diagnosed with [REDACTED]. The CNA stated she did not complete the treatment before she returned to work or before she resigned because she knew she got the infection at the facility and would just get it again. CNA A stated after she was diagnosed with [REDACTED]. She told ADON Y that she could not come to work because of the scabies: she had brought scabies home to the family and now she did not have a babysitter because the babysitter refused to watch the child. In an interview on 02/24/11 at 1:30 PM, the DON stated CNA A worked the 10:00 PM to 6:00 AM shift and was a "disgruntled employee." She stated she had poor performance with resident complaints that she did not answer the call light and attendance issues. The facility was about to terminate her but she resigned. The DON stated, in her "manifest resignation" CNA A said she was infected with scabies here. The DON stated CNA's letter dated 02/10/11 was the first time the facility was aware of CNA A concerns with scabies. In a follow-up interview on 02/24/11 at 5:00 PM, ADON Y stated she remembered CNA A called and said she went to the physician with a rash and had already talked to someone at the facility about it. ADON Y stated CNA A never provided proof. The CNA did not provide a physician's note clearing her from an absence on 02/05/11 because the CNA stated she went to the military clinic and the military clinic would not provide a note. In a telephone interview on 02/24/11 at 6:10 PM with ADON Y present, LVN W stated CNA A complained of a rash and asked the LVN to look at her arms. LVN W stated she saw one little bump that was not open. LVN W stated CNA A later said she had been diagnosed with [REDACTED]. In a telephone interview on 02/24/11 at 6:00 PM with ADON Y present, LVN U stated she worked the 10:00 PM to 6:00 AM shift. She stated CNA A complained of itching and bumps and asked the nurse to examine her skin. LVN U stated she "couldn't see much of anything, just marks across her skin from scratching." LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of CNA A's personnel file revealed she was employed at the facility from 11/01/10 to 02/10/11. Review of her letter dated 02/10/11 revealed: "In addition, I have contracted and been diagnosed with [REDACTED]. . a very contagious infection. I did contact this on the job at (the facility) and choose to no longer expose or subject my family to such inhumanity." Review of a handwritten note provided by the facility on 02/25/11 revealed: "(CNA A) attendance issue 02/05/11; 02/02/11 told nurse she was itching." Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA A was assigned to work on the 200 Hall from 02/03/11 to 02/06/11; and on 02/09/11 and 02/10/11. CNA B - In an interview on 02/23/11 at 2:00 PM, CNA B stated she was diagnosed with [REDACTED]. CNA B stated the physician did not do skin scrapings to diagnose the scabies because the physician told her the skin scrapings were often inconclusive. CNA B stated the physician told her he had previously diagnosed several staff members from the same facility using skin scrapings and visually diagnosed her rash as the same rash confirmed as scabies on other staff members. She stated she used the cream provided by the physician to treat the scabies and returned to work after two to three days; the last time she worked was two nights ago (02/21/11). CNA B stated she saw rashes like hers on Residents #2, #3 and #4. The CNA stated she told the Director of Nurses (DON) and LVN W in January 2011 that she had been diagnosed with [REDACTED]. CNA B stated, at her prompting, the DON looked at Resident #2's rash on her hands and stated it looked like winter [MEDICAL CONDITION]. CNA B stated LVN W told her Resident #2 had an appointment with a dermatologist in March 2011. The CNA stated she also recently told LVN V and was aware that CNAs D and A had been diagnosed and treated for [REDACTED]. In an interview on 02/24/11 at 5:30 PM, ADON Y stated she was not aware of CNA B's concerns of scabies. She stated she did not know whether she should call CNA B and require some sort of proof that she had been treated and cleared to return to work. ADON Y stated she did not know what the facility policy was for allowing an employee to return to work following a [DIAGNOSES REDACTED]. In an interview on 02/24/11 at 6:00 PM when asked if CNA B reported itching or rashes to her, LVN U stated "she might have mentioned it in passing." LVN U stated CNA B told her she thought the facility might be causing her rash. She stated CNA B complained of itching but never showed the LVN her skin. LVN U stated she did not report the CNA's complaints to the DON or ADON because she did not think it was serious. Review of the "10-6 Nurse Aide Schedule February 2011" revealed CNA B was assigned to work on the 200 Hall every day in February 2011 except 02/05/11, 02/06/11, 02/11/11, 02/12/11, 02/17/11, 02/18/11, 02/23/11, 02/24/11. In an interview on 02/24/11 at 8:30 AM CNA E stated she recently had a rash in one area of her arm. She described the rash as being itchy and pimple-like. She stated she did not go to a doctor to have it diagnosed or treated and did not report the rash to any of the facility staff members. She stated the rash had since gone away. CNA E was observed to provide care to residents on the 200 Hall. Attempts to interview CNA D were unsuccessful because the facility provided a non-working phone number. In an interview on 02/25/11 at 3:00 PM, the Corporate Consultant Nurse A stated CNA D reported to work that morning but was sent home because she had a suspicious rash. In an interview on 02/24/11 at 11:45 AM the surveyor met with the DON, ADON Y and Assistant Administrator regarding concerns that Resident #2 and Resident #4 had signs and symptoms of scabies with no isolation precautions; LVN V and CNA C had signs of symptoms of scabies and were providing care to residents; a physician had not examined the two staff members or two residents to rule out scabies; and CNAs A, B and C had reported complaints of signs and symptoms of scabies to facility staff (the ADON, DON, LVN W and U) and the facility had not conducted an investigation to rule out or control a scabies outbreak. In a follow-up interview on 02/24/11 at 1:20 PM, with the DON, Assistant Administrator and ADON Y, the DON stated they looked at Resident #2's skin. The DON stated the Resident's skin was dry and scaly, had scabs and scratches, bumps, and [MEDICAL CONDITION]. The DON added that she had not looked at Resident #4's skin because she was not in her room. The DON stated she had not looked at LVN V's skin or CNA C's skin. The DON stated the CNA C was still working on the floor and LVN V was still working on the floor with an orientee, finishing out her shift that ended at 2:00 PM. During the same interview the DON stated it was her expectation that no staff members be allowed to work around residents with an rash that was undiagnosed . After surveyor intervention, at 1:30 PM, ADON Y stated CNA C had been removed from the floor and CNA C was observed sitting in an upholstered chair in the front lobby. No isolation precautions were observed for Resident #2 and #4. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated Resident #2 refused to allow him to examine her skin. He examined Resident #4's skin and determined she had [MEDICAL CONDITIONS], with 70% of her left leg affected and less of her right. Observation of Resident #2's room at that time revealed no evidence of isolation precautions. In an interview on 02/24/11 at 2:00 PM, the Medical Director stated he examined LVN V's arm and determined it was not scabies; he examined CNA C's arm and stated it looked like a scabies infestation. Although it was requested at entrance on 02/23/11, in an interview on 02/25/11 at 9:20 AM, the DON, ADON Y, Administrator, and Assistant Administrator stated they had not found the facility's policy and procedure for addressing cross contamination by staff to residents. Review of the facility's Policy, "Skin Rashes" provided on 02/25/11 at 10:00 AM and dated August 2007 revealed: "A rash indicates an abnormal change in skin color or texture. . . . Procedure: An employee who presents with an unidentifiable skin rash must be examined by a physician to determine if the rash is a communicable disease which may be harmful to residents or other staff members in the LTC (long term care) environment. Upon notification of the rash by the staff member, they must be sent to a physician for clearance to return to work. If the physician deems it to be a communicable disease, i.e., scabies, the staff member must be treated with the appropriate medication before returning to duty The facility DON, ADON Y, and Assistant Administrator were informed of an Immediate Jeopardy (IJ) on 02/24/11 at 2:35 PM based on the facility's failure to protect from widespread nosocomial infection. The Administrator was also informed on 02/24/11 at 2:40 PM. On 02/24/11 at 5:50 PM the following Plan of Removal was accepted. "Around 12:00 PM on February 24, 2011 (the surveyor) notified the DON, ADON and the Assistant Administrator that two residents and two employees had unexplained rashes." 1. The Medical Director was notified of two residents (200 hall) and two employees (one on 200 hall and one on 500 hall) with unknown rashes. (The Medical Director) agreed to visit the facility and he arrived at 1:55 PM. (The Medical Director) assessed one resident and one employee and determined it was [MEDICAL CONDITION] (200 hall) and not scabies. One resident (Resident #2, 200 Hall) refused to let the Medical Director assess. She refused to let the facility take contact precautions. Therefore (Resident #2) was sent to the emergency room to be assessed for rash. The employee on 500 hall (CNA C) was screened and may have scabies. The employee was immediately sent to outpatient clinic for [DIAGNOSES REDACTED]. 2. Charge Nurses were instructed to begin skin assessments on all residents for 200 hall and 500 hall. Housekeeping and Laundry were instructed to start deep cleaning and sanitizing every room. Assessments completed and no identified rashes. 3. An infection control in-service was conducted with all available staff. Staffing Coordinated was instructed to call all staff for mandatory in-service 02/24/11 at 4:30 PM. 4. All staff was questioned in reference to unidentified rashes and none were identified. 5. Assessments were conducted on all halls (100-500) to include the Special Care Unit (600-700) and no unidentified rashes were identified. 6. Infection control reports are reviewed and discussed at monthly QA (Quality Assurance) meetings. Any communicable disease is identified and treated according to protocol. 7. Any staff member with infected [MEDICAL CONDITION] will not be allowed to work. 8. Ongoing monitoring will be done by the DON and ADON weekly for four weeks and results reported to QA. Ongoing monitoring as needed. In an interview on 02/25/11 at 12:00 noon, the DON stated three additional residents were placed on isolation precautions since Resident #2 was confirmed to have scabies by the ER. With heightened awareness following the in-service mandated by the Plan of Removal, two other residents were observed by the night nurses to have suspicious rashes, Resident #3 and Resident #7. ADON Y stated the Medical Director said to "go ahead and treat Resident #4." Review of a facility in-service Record dated 02/24/11 revealed the facility in-serviced staff (including Housekeeping, Maintenance, Certified Nurse Aides, and Licensed Vocational Nurses) regarding reporting unexplained rashes and skin conditions, isolation and infection control precautions. Random interviews on 02/25/11 with Housekeeping, CNAs and Nurses verified understanding of the in-service. Rooms on Halls 200 and 500 were observed on 02/25/11 receiving a deep cleaning, isolation precautions were observed in place for Residents #2, #3, #4, and #7 at 2:45 PM on 02/25/11. Infection control logs regarding skin issues were observed to be updated for January 2011 at 2:45 PM on 02/25/11. Based on observations, interviews and record reviews, the immediacy was removed at a Scope of pattern and a Severity level of actual harm that was not Immediate Jeopardy on 02/25/11 at 2:45 PM because the facility had not yet had the opportunity to in-service all staff, ensure February 2011 infection control logs accurately documented the infections; or performed monitoring by the QA, DON and ADON. Review of the facility's CMS Form 672 dated 02/23/11 revealed a census of 150 residents. The CMS Form 672 dated 02/23/11 also documented 13 of those residents currently had rashes.