Every finding on record at Huntington Health Care & Rehabilitation Center

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored the kitchen refrigerator was labeled, dated and not expired. 2. The facility failed to ensure food stored in the kitchen dry storage area was labeled, dated, and not expired. These deficient practices could place residents at risk for foodborne illness.During an observation on 7/15/2025 at 10:15 AM revealed the following: #2 refrigerator contained (2) 46-ounce containers of opened and undated thickened lemon water. #3 refrigerator contained (2) pies with a graham cracker crust and unknown white filling that was opened, unlabeled and undated. #4 Freezer contained (5) bags of French fries that were unlabeled and undated. #5 freezer contained (2) cases of frozen egg products on the bottom shelf which were stored below meat products. The Dry storage area contained (5) 1.5-pound bags of crispy onions with no received date. During an interview on 7/16/2025 at 3:16 PM the DM said she had worked at the facility for about 1 1/2 months. She said she was responsible for checking for expired foods since she did not have a reliable person at that time. She said the cooks also knew they were supposed to label and date foods that were opened with an open and use by date. She said she overlooked the nectar thick liquids in refrigerator #2. She said the French fries were in freezer #4 since before her employment and she was trying to get them used up because she did not know how long they had been there. She said an unknowledgeable and untrained employee did not label and date the 2 pies in refrigerator #3. She said she was responsible for training staff, but she had not been employed very long and had not had time to train all staff on all things yet. She said the residents could get a potential food borne illness outbreak by consuming expired foods. During an interview on 7/16/2025 at 3:35 PM, the Administrator said all dietary staff should be checking for expired foods in the kitchen. He said the DM should be checking for expired food on days she checked the truck in, at the least but said it should be happening daily. He said food borne illnesses was the potential hazard to the resident. Record review of the facility's policy titled Food Receiving and Storage, dated October 2017, indicated: Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date) . 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #3 and Resident #14) and 3 of 7 staff (CNA D, CNA E and LVN G) reviewed for infection control. 1.The facility failed to ensure CNA D followed EBP (enhanced barrier precautions) for Resident #3 when providing care on 7/15/2025. 2. The facility failed to ensure the ice cooler's scoop compartment on hall 400 did not contain a towel with a black substance on 7/15/2025. 3. The facility failed to ensure LVN G washed or sanitized her hands during administration of IV medications to Resident #14 on 7/16/2025.Findings include: 1. Record review of Resident #3's facility face sheet, dated 7/16/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE].Record review of Resident #3's physician's consolidated orders, dated 7/16/2025, revealed Resident #3 had a primary diagnosis of sepsis (an infection in the blood) and required foley catheter care every shift. There was no order for EBP.Record review of Resident 3's comprehensive care plan, dated 6/25/2025, revealed Resident #3 had a foley catheter and was to show no signs or symptoms of a urinary infection. No intervention for EBP was listed.Record review of Resident #3's Annual MDS assessment, dated 6/13/2025, revealed Resident #3 had a BIMS of 07, which indicated moderately impaired cognition. Resident #3 had an indwelling catheter. During an observation on 07/15/2025 at 10:08 AM revealed Resident #3's door name had a red dot beside it. He was lying in bed and sat up on the side of the bed. Resident #3 had a catheter in place. CNA D came in to Resident #3's room and assisted him to his wheelchair. CNA D handled Resident #3's catheter bag without any PPE. She then reapplied his linen to his bed without gloves or other PPE. CNA D left Resident #3's room with a soiled linen bag without performing hand hygiene. There was not any PPE observed in the room or outside in the hallway.During an interview on 7/15/2025 at 10:10 AM, CNA D said she received training on infection control and EBP. She said Resident #3 required EBP and that was why he had a red dot by his name outside the door. She said with EBP she should have put on was a gown and gloves before providing any care and she should have washed her hands before leaving the room. She said by not following the infection control measures infections could spread.Record review of a Certified Nurse Aide Proficiency Evaluation Tool, dated 11/01/2024, revealed CNA D demonstrated satisfaction training for infection control.2. During an observation on 7/15/2025 at 10:54 AM, in the hallway of hall 400 was an ice cooler. The cooler had a compartment that had an ice scoop with a white towel inside that had a black substance on it along with the inside of the compartment.During an observation and interview on 7/15/2025 at 3:22 PM, CNA E was on hall 400 and said she was assigned to that hall (400) that day and had been working at the facility for a year. She said the nurse aides were responsible for passing ice to the residents about 2-3 times a day. She said they kept ice in a cooler on the halls and the ice scoop was kept in a tray by the cooler. She looked inside the ice scoop compartment and said the towel was dirty and the tray needed to be cleaned. She said they normally placed the scoop on a towel, and she guessed she never looked inside of the scoop compartment to see if it was dirty or not. She said residents could get sick if the scoop was dirty and they drank dirty ice water. She said there was dirt, and it definitely needed to be cleaned. CNA F was present on the hall and heard the conversation and took the cooler off of the hall.During an interview on 7/15/2025 at 3:31 PM, CNA F said the ice coolers were supposed to be taken to the kitchen once a week and the kitchen staff cleaned the coolers for them. She said she observed the compartment when she removed it from the hall, and it was dirty. She said they did not normally place a towel in the ice scoop compartment. She said using a towel could hold moisture and create germs and residents could get sick. 3. Record review of Resident #14's admission Record, dated 7/16/2025, indicated a [AGE] year-old male resident who was admitted to the facility on [DATE].Record review of Resident #14's active physician orders, dated 7/16/2025, indicated he had diagnoses of Parkinson's disease (a condition that affects the brain and spinal cord), UTI (an infection that affects the urinary system), dementia (a decline in thinking abilities such as memory that can interfere with daily life), and pneumonia (infection in the lungs). An order dated 7/14/2025 for meropenem intravenous solution (antibiotic) one gram every 8 hours related to pneumonia with a start date of 7/15/2025.Record review of Resident #14's MDS Assessments indicated he was admitted to the facility on [DATE] and only had an Entry Assessment.Record review of Resident #14's care plan indicated it was still in progress. During an observation on 7/16/2025 at 8:34 AM, LVN G was in the room of Resident #14 to administer IV antibiotics. She performed hand hygiene and donned PPE in the hallway which included a mask, gown and gloves. She entered the room, and the resident said he wanted to get in bed. She picked up an alcohol packet she dropped on the floor and placed it in the trash and helped to assist the resident in bed using a gait belt from his wheelchair. She removed her gloves and placed them in the trash and took a pair of gloves from her pocket and put on another pair of gloves without washing or sanitizing them. She cleaned the port with an alcohol swab, flushed his midline IV access with 10 ml normal saline, and attached the IV tubing to administer the antibiotics. She removed her PPE in the room and placed them in the trash. She gathered the trash and washed her hands. During an interview on 7/16/2025 at 8:58 AM, LVN G said during the administration of medications to Resident #14, the gloves should not have been in her pocket, and she should have sanitized her hands between glove changes. She said she had sanitizer in her pocket but Resident #14 threw her off (distracted) when he wanted to go back to bed. She said there could be a risk of carrying germs or infection to residents so hands should be washed or sanitized between glove changes. She said she had been employed at the facility for 2 years and did not want to carry germs or infection to residents, so hands should be washed or sanitized. During an interview on 7/16/2025 at 2:54 PM, the DON said she was the infection prevention nurse and was responsible for oversight of the infection prevention program. She said staff were trained on hire, annually and as needed on infection control measures including EBP. She said a resident who required EBP would have a red dot outside their door by their name and the staff were to apply a gown and gloves when providing direct care and before leaving the resident room, the PPE should be disregarded and hand hygiene performed. She said hand hygiene should be performed before and after care provided to residents and between dirty and clean glove changes. She said gloves should not be kept in their pockets. She said she expected all staff to follow the enhanced barrier precautions in order to decrease the spread of infections. She said the staff were responsible for taking the ice coolers to the kitchen once a week to get cleaned. She said she was not sure if any staff ever took the coolers to get cleaned or not. She said the scoop compartment should not have a towel inside as it could cause mold and harbor bacteria. She said residents could get sick.During an interview on 7/16/2025 at 3:17 PM, the Administrator said the DON was responsible for the infection control program. He said all staff were trained on infection control measures by the DON and expected all staff to follow the facility's policies for infection control and EBP. He said by not doing so infections could spread. He said hand hygiene should be performed between glove changes. He said towels should not be stored in the scoop compartment with the ice coolers. He said they could harbor mold and cause bacteria to grow, and residents could be at risk for infections.Record review of a RN/LVN Proficiency Evaluation for LVN G, dated 7/18/2024, indicated she was satisfactory with hand washing.Record review of the facility's policy titled Enhanced Barrier Precautions, dated 6/2024, indicated, .for residents for whom EBP are indicated, EBP is employed when performing the following high-contact care activities, transferring, changing linens, device care .Record review of the facility's policy titled Hand Washing, dated 8/2022, indicated, .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: After removing gloves Record review of the facility's policy titled Ice machines and ice storage chests revised January 2012 indicated, .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. 1. Ice making machines, ice storage chests/containers and ice can all become contaminated by: a. Unsanitary manipulation by employees, residents, and visitors; f. Clean and sanitize the tray and ice scoop daily

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 4 resident hallways (Hallway 100) and the main dining room reviewed for environmental concerns. 1. The facility failed to ensure rooms 101, 103, 106, and 107 did not have soiled floors on 7/15/2025 and 7/16/2025. 2. The facility failed to ensure the floors on 100 hallway did not have soiled floors on 7/15/2025 and 7/16/2025. 3. The facility failed to ensure the dining room did not have soiled floors on 7/15/2025 and 7/16/2025. These failures could place residents at risk of a diminished quality of life. Findings include: During multiple observations on 7/15/2025 from 4:02 PM to 4:21 PM and on 7/16/2025 from 9:00 AM to 9:15 AM; rooms 101, 103, 106 and 107 the 100 hallway and main dining room were observed with black residue on the floor tiles in the rooms and bathrooms and floors were sticky. There was a buildup of thick black residue at the base boards and around furniture. During an interview on 7/16/2025 at 10:08 AM, Housekeeper L said she swept and mopped the floors, but the facility no longer had a floor technician to deep clean the tiles. She said the cleaning solutions they used would not breakdown the black buildup and the tiles needed to be stripped and waxed. She said the floors being dirty could affect the residents' well-being. During an interview on 7/16/2025 at 11:18 AM, the Housekeeping Supervisor said she oversaw the cleaning of her staff and tried to buff the floors to make them cleaner, but it did not work. She said she was not capable of stripping and waxing the floor tiles and the facility no longer had a floor technician to do so. She said the floors not being clean could make the residents upset about the environment. During an interview on 07/16/2025 at 3:19 PM, the Administrator said the housekeeping supervisor was responsible for maintaining the facility environment and floors. He said they no longer had a floor technician and have not had any luck finding a new one. He said floors that were not maintained in a clean manner could affect residents' quality of life and he expected the floors and environment to be clean. Record review of the facility's policy titled Homelike Environment, dated February 2021, indicated .residents are provided a safe, clean, comfortable, and homelike environment

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 8 residents (Resident #9 and Resident #20) reviewed for quality of care.1.The facility failed to remove worn and damaged mechanical lift slings from service for Resident #9 on 7/15/2025 and 7/16/2025.2. The facility failed to ensure a bottle of peri-wash was not left in Resident #20's room on 7/15/25.This failure could place residents at risk of injuries due to environmental hazards.Findings included: 1.Record review of Resident #9's facility face sheet dated 7/16/2025 revealed he was a [AGE] year-old male that admitted to the facility on [DATE]. Record review of Resident #9's physician's consolidated orders dated 7/16/2025 revealed Resident #9 had a primary diagnosis of sepsis (infection in the body) and used a mechanical lift for all transfers. Record review of Resident #9's comprehensive care plan dated 7/15/2025 revealed Resident #9 had an ADL self-care performance deficit and required 2 staff to move between surfaces. Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed Resident #9 had a BIMS of 15 indicating intact cognition and was dependent of 2 or more staff for transfers. During an observation and interview on 7/15/2025 at 10:37 am Resident #9's lift sling under him had faded loops. He said the staff used a lift daily for him to transfer and the slings vary but mostly the loops were faded. During an observation on 7/16/2025 at 8:30 am Resident #9 was up in his wheelchair and the lift sling under him had faded loops. During an interview on 7/16/2025 at 8:46 am CNA C said that Resident #9 required a mechanical lift for transfers and before transfers the slings were to be inspected for holes, tears and frays but was not sure about the coloring or fading of the loops and fabric. She said that a sling used that was worn or old could cause resident injury. During an interview on 7/16/2025 at 11:18 am the Housekeeping Supervisor said she had been working in laundry and the lift slings were washed on regular cycle with no bleach and then dried. She said she had not been told to launder them any other way and there was no system for inspection before they returned to the hallway for staff to use. She said she could see how drying them could affect the fabric and if they were not cared for properly residents could become injured. During an interview on 7/16/2025 at 11:25 am the DON said that the lift slings should only be hung to dry, and the aides were to inspect them for fraying or faded colors before using. She said she was responsible for all things nursing and staff had been trained on hire and as needed on proper inspection of slings. She said she expected all nursing staff that used the slings to inspect them before use and not use any that were worn. She said using worn or faded slings could cause resident injury. During an interview on 07/16/2025 at 3:11 PM the Administrator said the CNAs had been trained on inspecting the lift slings for tears, fraying, and discoloring before using them. He said the sling pads should be washed and hung to dry to prevent damaging the sling fabric. He said worn and discolored slings could cause accidents and injuries and expected all slings to be kept in good repair. Record review of a facility policy titled Lifting and Movement of Resident-Safe dated 8/2022 indicated, .this home uses appropriate techniques and devices to lift and move residents . 2. Record review of a facility face sheet dated 7/16/25 for Resident #20 indicated she was an [AGE] year-old female admitted to the facility on [DATE].Record review of a diagnosis report dated 7/16/25 for Resident #20 indicated her primary diagnosis was senile degeneration of the brain (memory loss). Record review of a comprehensive MDS assessment dated [DATE] for Resident #20 indicated she was unable to complete the BIMS assessment and had severely impaired cognition. Record review of a comprehensive care plan dated 6/9/25 for Resident #20 indicated she had impaired cognitive function/dementia or impaired thought processes related to diagnosis including senile degeneration of the brain and Alzheimer's disease. During an observation on 7/15/25 at 10:37 am a bottle of peri-cleanse wash was observed in a tray table in Resident #20's room. The peri-wash bottle label said, keep out of reach of children. During an interview on 7/16/25 at 3:04 pm CNA B said she was unsure how the peri-wash got left in the resident room and said it should not be in there due to possible wandering residents and the cognitive status of the residents on the secured unit. She said it was a safety issue. During an interview on 7/16/25 at 3:15 pm the DON said if peri-wash was left in residents' rooms, especially in the secured unit, residents could possibly drink it, and it could cause harm. She said she would ensure staff knew not to leave it in residents' rooms going forward. During an interview on 7/16/25 at 3:25 pm the Administrator said the peri-wash should not be left in residents' rooms due to the risk of residents possibly consuming it and getting sick. He said administrative staff already did Scout rounds to check for things in residents' rooms that needed to be addressed. He said going forward, he would ensure staff knew to check for things that were labeled keep out of reach of children. Record review of a facility policy titled Homelike Environment dated 2021 read: .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . Record review of a facility policy titled Hazardous Areas, Devices and Equipment dated July 2017 read: .All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . and .A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: .g. Access to toxic chemicals .

Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #6) reviewed for PASRR (Preadmission Screening and Resident Review Services).The facility failed to ensure Resident #6 had a new level 1 PASSR completed with a new diagnosis of psychotic disorder with delusions (a mental disorder in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect) and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a range of emotional and physical problems).These failures could place residents at risk of not receiving the needed PASSR services to meet their individual needs and could result in a decreased quality of life. The findings included:Record review of a facility face sheet dated 7/16/25 for Resident #6 indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Record review of a diagnosis report dated 7/16/25 for Resident #6 indicated her primary diagnosis was senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior). She had diagnoses of psychotic disorder with delusions and major depressive disorder added on 9/9/24.Record review of a comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 06, indicating severely impaired cognition. Record review of a PASSR level I form completed on 6/21/24 for Resident #6 indicated the level I screening was negative for mental illness.During an interview on 7/16/25 at 11:43 am the MDS coordinator said she was responsible for PASSR. She said she did not have a new level I completed when Resident #6 had 2 new diagnoses added on 9/9/24 because she did not know she needed to do that. She said residents could possibly miss out on services they qualify for if PASSR evaluations were not done appropriately.During an interview on 7/16/25 at 3:15 pm the DON said the MDS coordinator was responsible for PASSR, but she (DON) provided oversight. She said going forward she would ensure the Local Authority was notified when a resident received a new psychiatric diagnosis. She said residents could miss out on services if PASSR evaluations were not completed appropriately.During an interview on 7/16/25 at 3:25 pm the Administrator said if PASSR evaluations were not done appropriately, residents could miss out on services and may not receive appropriate care. He said going forward, he expected his staff to have appropriate PASSR evaluations completed. A facility policy for PASRR was requested from Administrator on 7/16/25 at 10:00 am, but none was provided.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 4 residents (Resident #21) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #21. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (bipolar disorder) were present upon Resident #21's admission date on 9/27/2024. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.Findings included: Record review of an admission Record for Resident #21 dated 7/16/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old.Record review of active physician orders for Resident #21 dated 7/16/2025 indicated she had diagnoses of bipolar disorder (a mental illness that causes extreme shifts in mood), type 2 diabetes, and dementia (a decline in mental ability that can interfere with daily life).Record review of a Quarterly MDS Assessment for Resident #21 dated 5/19/2025 indicated she did not have any impairments in thinking with a BIMS score of 14. She had active diagnoses in the look back period of 7 days that included bipolar disorder. Record review of a care plan for Resident #21 dated 10/17/2024 indicated she had a mood problem related to bipolar and depression with interventions to administer medications for targeted behaviors and side effects.Record review of a PASRR Level 1 Screening (PL1) dated 10/1/24 for Resident #21 indicated she was negative for mental illness.During an interview on 7/16/2025 at 11:41 AM, the MDS Coordinator said she had been employed at the facility for 9 years and was responsible for all thing related to PASRR in the facility. She said Resident #21 admitted to the facility 9/27/2024 and had a diagnosis of bipolar on admission. She said she entered the PL1 dated 10/1/2024 and it was negative for mental illness, and it should have been positive. She said she would update the information and get a new PL1 entered so the local authority could come out and complete an evaluation for Resident #21. She said she would audit the other residents in the facility to ensure everyone's information was accurate. She said residents could be at risk of not getting the help and miss services if information was not correct.During an interview on 7/16/2025 at 3:45 PM, the DON said the MDS coordinator was responsible for ensuring accuracy of PASRR and a PASRR Level 1 screening should be completed before admission to the facility. She said the MDS Coordinator should review all diagnoses to ensure the PL1 was correct. She said going forward she along with the MDS Coordinator would be reviewing them before admission and complete an audit of all residents. She said if the PL1 was not accurate, residents could miss services, and they might not be able to provide proper care for them. During an interview on 7/16/2025 at 3:25 PM, the Administrator said the MDS Coordinator was responsible for all things PASRR. He said if the PASSR screenings were not accurate then residents may not receive appropriate care and services. He said the facility did not have a policy related to PASRR.

Based on interview, and record review the facility failed to review and revise the comprehensive care plan after each assessment for 1 of 4 (Resident #6) residents reviewed for care plan revisions.The facility failed to update Resident #6's care plans for hospice status.These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included:Record review of a facility face sheet dated 7/16/25 for Resident #6 indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Record review of a diagnosis report dated 7/16/25 for Resident #6 indicated her primary diagnosis was senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior).Record review of a comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 06, indicating severely impaired cognition. She was receiving hospice services as a resident in the facility. Record review of a physician's order summary report dated 7/15/25 for Resident #6 indicated she had the following order dated 3/24/25: .Admit to [name of hospice provider] hospice services . Record review of a comprehensive care plan dated 3/12/25 for Resident #6 indicated the care plan did not address hospice services. The care plan was not updated after the comprehensive MDS assessment dated [DATE] to reflect hospice status.During an interview on 7/16/25 at 3:08 pm the MDS coordinator said she was responsible for care plan updates. She said care plans should be updated after each MDS assessment. She said she must have just overlooked this care plan update for Resident #6. She said residents could miss out on care needed if care plans were not updated appropriately. She said she would ensure all care plan updates were done timely and correctly in the future.During an interview on 7/16/25 at 3:15 pm the DON said if care plans were not updated appropriately, residents may not receive appropriate care. She said going forward, she would ensure the MDS coordinator appropriately updated the care plans to include relevant information. During an interview on 7/16/25 at 3:25 pm the Administrator said if care plans were not updated as required, residents may not receive appropriate care. He said going forward, he would expect his staff to include needed information in the residents' care plans.Record review of a facility policy titled Care Plan - Resident dated 7/2018 read: .Individualize care to ensure the care plan is person centered for the unique needs of the resident. and .the care plan must be reviewed and revised (updated) at least every 90 days. and .all residents receiving either Hospice or Dialysis are to have care plans developed in conjunction with these organizations.

Based on observation, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (Resident #57) out of 2 residents observed for respiratory therapy.The facility failed to obtain physician orders for Resident #57's Bipap settings he used each night at the facility since his admission on [DATE].This failure could place residents who reside at the facility at risk for inaccurate care and communication of health conditions to other providers.Record review of Resident #57's electronic medical record and face sheet dated 7/16/2025 reflected he was admitted to the facility on [DATE]. His diagnoses included: cellulitis (bacterial infection of the skin and the deeper tissues beneath the skin), obstructive sleep apnea (sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway), nonrheumatic mitral valve insufficiency (mitral valve in the heart does not close properly).Record review of Resident #57's quarterly MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 14/15 on his BIMS which signified he was cognitively intact. He could ambulate independently with a walker. Resident #57 required supervision or touching assistance from staff with his ADLs. He was continent of bowel and occasionally incontinent of bladder. Resident #57's Bipap (non-invasive ventilation that helps people breathe easier) machine was present upon admission.Record review of Resident #57's comprehensive care plan date initiated 6/10/2025 indicated Enablers at this time. With interventions that included: Bipap at bedtime due to sleep apnea.Record review of Resident #57's Order Summer Report, Active as of: 7/16/2025 indicated a physician's order for bipap to be used at bedtime and as needed while sleeping. The physicians order did not indicate what the bipap settings were to be. Record review of Resident #57's medication administration record for July 2025 reflected: bipap to be used at bedtime and as needed while sleeping and was signed as administered twice daily from 7/1/25 through 7/16/25. During an observation on 7/15/2025 at 11:04 am, Resident #57 was in his room lying in his recliner with a Bipap machine on his bedside nightstand with the connected tubing and mask in a plastic bag hanging from the top drawer.During an interview on 7/15/2025 at 11:04 am with Resident #57, he stated he used the Bipap at night and brought it with him from home. He stated he needed the Bipap at night for extra oxygen and he used it every night. He stated he would put the Bipap mask on himself and all he did was turn on the machine. He said he did not know what the settings on the machine should be, but the nurse would know.During an interview on 7/16/2025 at 9:40 am LVN H, who was the charge nurse for Resident #57, said Resident #57 had a Bipap and used it every night. When asked what the setting were supposed to be she said she would look in the computer and see what the order was. LVN H then said she did not see the settings in the physician's order and would ask the DON where she could find what the settings were supposed to be. When LVN H was asked how she knew if the settings were correct, she said she did not know. During an interview on 7/16/2025 at 9:43 am the DON stated Resident #57 needed a physician's order for his Bipap settings and she did not know why it was not obtained when he was admitted . She stated without a physician's order, the treatment could be given at the wrong setting or time and cause discomfort or respiratory distress. During an interview on 7/16/2025 at 3:30 pm the Administrator said it was the charge nurse's responsibility to make sure bipap settings were entered into the system. He said the potential hazard of not obtaining a physician's order for the bipap settings would be for the resident to have respiratory distress. Review of the facility policy and procedure titled BiPap/CPAP dated August 2022 indicated it is the policy of this home that Bi-level Positive Airway Pressure (BiPap) and/or Continuous Positive Airway (CPAP) will be set up by a respiratory therapist with a physicians order.

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering for all drugs and biologicals to meet the needs of each resident for 1 of 12 months (May 2025).The facility failed to have a licensed pharmacist, 2 facility staff witnesses and sign the drug destruction log during drug destruction occurrence May 22, 2025.These failures could place residents at risk for misappropriation and drug diversion.Findings include:Record review of a Drug Destruction record, dated 5/22/25, indicated the attached sheets which contained the controlled substances were initialed only by the consultant pharmacist and contained no witness signatures.During an interview on 7/16/25 at 3:15 PM, the DON said if drugs were not destroyed appropriately and did not have the required witnesses, a drug diversion could happen. She said going forward, she would ensure the witnesses signed the attached sheets appropriately. Record review of the facility's policy titled Medication - Discontinued Medication / Destruction of Drugs, dated 8/2022, read: .It is the policy of this home to ensure that drugs are destroyed in accordance with Federal Regulations .the consultant pharmacist will arrange for the proper witnesses to be present for the destruction, and will destroy the medications

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 residents (Resident #23) reviewed for storage of medications and for 1 of 4 medication carts (Nurse Cart L) reviewed for pharmacy services.1.The facility failed to ensure Resident #23's 10 ml sterile normal saline prefilled syringe and intravenous site dressing were not kept at the bedside and was unable to be accessed by unauthorized personnel or residents on 07/15/25. 2.The facility failed to ensure expired Tresiba (insulin degludec) for Resident #30 was not on the nurse medication cart on 7/16/25. This failure could place residents at risk of unauthorized use of medication, accidental contaminations/use of an unprescribed medication, and adverse effects of medications. Findings include: 1.Record review of Resident #23's face sheet, dated 07/15/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. with diagnosis which included overactive bladder (bladder contracts with urgency to urinate), urinary tract infection (Infection of the urinary system) and chronic pain. Record review of Resident #23's quarterly MDS, dated [DATE], indicated Resident #23 had a BIMS score of 13, which indicated she was cognitively intact. Record review of Resident #23's physician order summary, dated 7/16/2025, indicated an order, dated 7/12/2025, to discontinue midline intravenous catheter (a venous device for infusion of intravenous antibiotics and/or fluids).During an observation and interview on 7/15/2025 at 10:40 AM, Resident #23 was observed leaving her room going to the shower. On the bedside table was a prefilled 10 ml syringe of sterile normal saline solution for intravenous use and a package containing a transparent dressing for covering an intravenous insertion site.During an observation and interview on 7/15/2025 at 1:30 PM, LVN A said the saline was left at the bedside to flush and change the site dressing of Resident #23's intra venous catheter which was currently discontinued. The dressing and 10ml of normal saline were removed from the bedside table. LVN A said all medications and dressings should be keep in a locked compartment to prevent contamination. LVN A said no medications should ever be left at the bedside and residents or visitors could tamper with and contaminate medications left at the bedside.During an interview on 07/16/2025 at 2:00 PM, the DON said she was responsible for ensuring all medications were stored in locked compartments and expected all medication to be stored in locked compartments of the medication room or medication carts. She said leaving medications at the bedside put the residents at risk for others tampering or contamination of the medications. During an interview on 7/16/2025 at 2:30 PM, the Administrator said he expected all medications should be stored in locked compartments of the medication room or medication carts. He said leaving medications at the bedside put the residents at risk for others tampering or contamination of the medications. 2.Record review of Resident #30's facility face sheet, dated 7/16/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE].Record review of Resident #30's physician's order summary report, dated 7/16/25, indicated his primary diagnosis was diabetes mellitus with diabetic neuropathy (a condition characterized by nerve damage due to prolonged high blood sugar levels).Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated a BIMS score of 15, which indicated intact cognition. He received daily insulin injections. Record review of Resident #30's comprehensive care plan, dated 6/10/25, indicated he had diabetes mellitus and interventions to administer medications as ordered. Record review of Resident #30's physician's order summary report, dated 7/16/25, indicated he had the following physicians order, dated 2/22/25: .Tresiba FlexTouch Subcutaneous Solution Pen-Injector 200 Unit/ml (Insulin Degludec) Inject 12 unit subcutaneously one time a day for diabetes During an observation of a nurse medication cart on 7/16/25 at 12:12 PM revealed a Tresiba injection pen for Resident #30, expiration date of the medication was 12/31/24. The pen was labeled as opened on 7/2/25.During an interview on 7/16/25 at 3:15 PM, the DON said if expired medications were not removed from the medication carts appropriately, residents could be at risk of not receiving an effective dose or could possibly be harmed. She said she and the ADON would check the carts monthly. She said going forward, she would ensure all medications were checked appropriately and discarded when necessary.During an interview on 7/16/25 at 3:25 PM, the Administrator said the nursing staff should have caught the expiration date on the insulin when she put it on the cart. He said a resident may not get the appropriate dose or potency or it may even cause illness if a resident received expired medications. He said he would be providing in-services to all nursing staff to ensure they properly checked expiration dates on medications going forward. Record review of the facility's Nursing Policy and Procedure Medication Storage-in the Home, dated 9-2022 reflected .Policy: It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure or misuse .2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e , medication aides, etc.) are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access .

Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 2 resident personal refrigerators (Resident #57) reviewed for food safety. 1. The facility failed to ensure the refrigerator for Resident #57 was clean and contained food items that were labeled and dated. 2. The facility failed to ensure the refrigerator for Resident #57 did not contain expired milk or expired whipped cream. These failures could place residents at risk for food borne illnesses.Findings included: Record review of Resident #57's electronic medical record and face sheet, dated 7/16/2025, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE]. His diagnoses included: cellulitis (bacterial infection of the skin and the deeper tissues beneath the skin), obstructive sleep apnea (sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway) and nonrheumatic mitral valve insufficiency (mitral valve in the heart does not close properly).Record review of Resident #57's quarterly MDS assessment, dated 6/23/2025, reflected he could understand others and be understood. He scored a 14/15 on his BIMS, which signified he was cognitively intact. Resident #57 could ambulate independently with a walker. Resident #57 required supervision or touching assistance from staff with his ADLs. He was continent of bowel and occasionally incontinent of bladder. Record review of Resident #57's comprehensive care plan, date initiated 3/8/2025 and revised on 3/21/2025, indicated Hyperlipidemia (high cholesterol) With interventions that included: Assure proper diet, document meal consumption.During an observation and interview on 7/15/2025 at 11:04 AM, Resident #57 said his personal fridge was usually cleaned by the staff when it needed it. Resident #57 said he got items out of the fridge himself. Resident #57 said he did not know the 1/2 gallon of milk was expired since 6/19/2025 or that the can of 13-ounce whipped cream had expired on 6/5/2025. During an interview on 7/15/2025 at 11:16 AM, CNA F said she took care of resident's personal refrigerators and checked for expired foods about once a week. She said it had been about 2 weeks since she cleaned out the fridge in Resident #57's room. She said she did not check the milk or the whipped cream to see if they were expired. She said she just forgot to check for expired food items. During an interview on 7/16/2025 at 3:25 PM, the DON said housekeeping was responsible for keeping residents' personal refrigerators clean. She said residents could get sick by consuming expired foods. During an interview on 7/16/2025 at 3:33 PM, the Administrator said housekeeping should be checking residents' refrigerators daily for temperatures, cleanliness, and for expired food. He said the potential hazard would be food borne illnesses that could lead to a variety of issues. During an interview on 7/16/2025 at 3:38 PM, Housekeeper K said she did not think they were allowed to touch any of the food inside the residents personal refrigerator, so she just checked the temperature and recorded it on the temperature logs. She said she cleaned Resident 57's room but not the inside of the fridge because she did not think they were allowed to touch the food. She said a resident could get food poisoning from consuming expired or molded food. During an interview on 7/16/2025 at 3:45 PM, the Housekeeping Supervisor said it was the housekeeper's responsibility to clean out residents' personal refrigerators. She said expired items were missed probably because the staff did not open the refrigerators like they were supposed to do. She said the potential hazard to the resident was food borne illness by consuming expired food. During an interview on 7/16/2025 at 3:51 PM, Housekeeper L said she had been doing housekeeping since January 2025. She said they looked at personal fridges daily and cleaned them as needed. She said food poisoning was the potential hazard to the resident by consuming expired foods. Record review of the facility's policy titled Refrigerator-Personal, dated August 2022, indicated: it is the policy of this home that resident's refrigerators will be checked weekly for cleanliness and remaining sanitary. 1. The Housekeeping Supervisor/designee will monitor resident's refrigerator weekly. 3. Clean and remove expired food as needed.

Based on interviews and record review, the facility failed to complete a comprehensive MDS assessment within 14 days after a significant change in the resident's mental or physical condition for 1 of 4 residents (Resident #6) reviewed for assessments. The facility failed to reassess Resident #6 following a hospice admission (specific care for the sick or terminally ill) on 03/24/25.This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.Findings included:Record review of a facility face sheet dated 7/16/25 for Resident #6 indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Record review of a diagnosis report dated 7/16/25 for Resident #6 indicated her primary diagnosis was senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior).Record review of a comprehensive MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 06, indicating severely impaired cognition. She was receiving hospice services as a resident in the facility. Record review of a physician's order summary report dated 7/15/25 for Resident #6 indicated she had the following order dated 3/24/25: .Admit to [name of hospice provider] hospice services .Record review of a comprehensive care plan dated 3/12/25 for Resident #6 indicated the care plan did not address hospice services.Record review of an electronic medical record for Resident #6 indicated the MDS tab in her chart did not indicate a significant change MDS done within 14 days after admission to hospice services.During an interview on 7/16/25 at 3:08 pm the MDS coordinator said she must have overlooked the significant change MDS after Resident #6's hospice admission. She said residents might miss out on orders, treatments and care if the MDS assessment was not done accurately or timely. She said she would ensure significant change MDS assessments were done timely going forward.During an interview on 7/16/25 at 3:15 pm the DON said if an MDS was not completed timely and accurately, residents may not receive appropriate care. She said going forward, she would ensure significant change MDS assessments were completed timely. During an interview on 7/16/25 at 3:25 pm the Administrator said if MDS assessments were not completed appropriately, residents may not receive appropriate care. He said going forward, he expected the MDS coordinator to complete MDS assessments appropriately.Record review of a facility policy titled Resident Assessments dated November 2019 read: .A significant change in status assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for major improvement or decline . and .A SCSA is required when a resident: a. enrolls in a hospice program .

Based on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #52) reviewed for notification of changes in that: The facility did not notify Resident #52's physician for a significant change in weight. (weight loss of 25.8 pounds in 30 days.) This deficient practice could place residents at risk of not having their physician notified of changes resulting in a delay in continuity of care.The findings were: Record review of Resident #52's face sheet, dated 7/16/2025, revealed Resident #52 admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a group of conditions that affect movement and posture), dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), and lack of coordination. Record review of Resident #52's quarterly MDS dated [DATE] revealed Resident #52 was rarely or never understood and was moderately impaired for daily decision making. Record review of the same document, revealed the following item: Section GG, Item GG130 Self Care.Review of this item revealed Resident #52 required moderate assistance with eating and substantial assistance with toileting, bathing and dressing. Record review of the weights tab in the electronic medical record for Resident #52 indicated: 6/1/25 weight 137.0 lbs. 6/7/25 weight 182.9 lbs. gain of 45.9 lbs. 7/14/25 weight 157.1 lbs. loss of 25.8 lbs. Record review of Resident #52's care plan, dated 7/16/25 revealed the following focus area initiated on 8/28/24: The resident is resistive to care, Refused meal on 5/19/25 Record review of Resident #52's Progress Notes, dated 6/1/25 thru 7/16/25 revealed no documentation indicating that the resident's primary care physician was notified of any significant weight changes. During an interview on 7/16/25 at 12:15 pm with the DON, she said she was currently in charge of monitoring resident weight variances. She stated the previous assistant director of nursing was responsible for monitoring weights and following up on any changes, but she was relieved of her duties last week. The DON stated she took over monitoring residents' weights this week. She said the CNAs on each hall were responsible for weighing residents at the first of the month. She said a resident list of who needed to be weighed was given to the CNAs. She said the resident weights were turned into the charge nurse and the charge nurse entered the data into the resident's Electronic Medical Record (EMR). She said the EMR system would alert the nurse to any weight variances and the residents that had a weight variance were placed on a list for reweight. She said that if there was a variance after the reweight, the ADON that oversaw the weight program was responsible for contacting the doctor, resident representative, and the dietician. She said notifications were documented in the nurse's progress note. She stated she was not aware of Resident #52's weight variance and that he would be weighed again today. She stated a possible reason for the variance could be related to the weight of the resident's wheelchair not being subtracted from the weight in combination with recent hospitalizations that included intravenous fluid administration. She stated that she expected the charge nurse to document weights timely, and for reweights to be performed the next day. She stated that the doctor should be notified after the reweigh confirms a variance as well as the responsible party and dietician. She said the nurse should document notifications in the progress notes. She said if the physician was not notified it could result in the resident not receiving interventions needed. She said she expected the charge nurse to recognize when a resident required a reweigh and that variances were reported to the physician. She stated that moving forward she would be performing the weekly audits of resident weights. Resident # 52 was reweighed on 7/16/2025 with a weight of 157.0 lbs. In an interview on 07/16/25 at 3:15 pm the Administrator stated that the DON was now responsible for monitoring resident's weights and ensuring that monthly and weekly weights were completed. He stated the ADON that was responsible for monitoring resident weights was relieved of her duties the previous week. He stated the DON would be reviewing all resident weights and following the facility's policy and procedure on the facility weight system. The Administrator expected the nursing staff to follow the facility policy on weighing residents and notifying the primary care physician and dietician when needed. He said if the physician was not notified of weight variances the residents may not receive orders and evaluations needed to address potential problems. The former ADON was not available for interview. Record review of Nursing Policy and Procedure for Weight System dated 9/2022 indicated .3. Any resident with a significant weight loss will be reweighed. 5. weight variances will be reviewed at the weekly. 7. The Director of Nursing/Designee will ensure that the Physician, Responsible Party and the Dietician will be notified in a timely manner and documented in the clinical record software.

Based on interview and record review, the facility failed to provide documentation for transfer or discharge by resident's physician for 1 of 1 resident (Resident #1) reviewed for discharge requirements. The facility failed to provide a reason for Resident #1's discharge by the resident's physician and the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at current facility. This failure could place residents at risk of not having the needed records when transferring care and services and causing a disruption in their care and/or services. Findings included : Record review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Hodgkin lymphoma (a type of cancer that affects the lymphatic system), diabetes, (a condition that affects blood sugar levels), dementia, (a group of systems affecting memory, thinking, and social abilities), and anxiety disorder, (a group of mental health conditions that cause fear, dread and symptoms that are out of proportion to the situation). Record review of Resident #1's initial MDS dated [DATE] reflected no BIMS needed as Resident #1 was rarely/never understood, had memory problems and moderately impaired cognition skills for daily decision making. Section D reflected Resident #1 having several days of being short tempered, easily annoyed. Section E reflected Resident #1 having 1 to 3 days of physical and verbal behavioral symptoms directed towards others and wandering. Record review of Resident #1's baseline care plan dated 2/10/25 reflected the following: Resident #1 could not communicate easily with the staff and did not understand the staff. Resident #1 required set up or clean-up assistance with ADL's. Resident #1 was alert, and cognitively impaired. Resident #1 was taking psychotropic medications. Record review of Resident #1's nurse progress note dated 2/10/25 at 3:00 p.m. signed by LPN D reflected Resident #1 arrived at the facility via family transport. Resident #1 was alert and oriented to self. Record review of Resident #1's nurse progress note dated 2/10/25 at 4:32 p.m. signed by LVN E reflected a med review was performed with the RP and MD. Received an order to increase Ativan to 1 mg three times a day due to anxiety. Record review of Resident #1's nurse progress note dated 2/10/25 at 6:20 p.m. signed by LPN D reflected the following: Elopement Evaluation: History of elopement while at home. Wandering behavior, a pattern or goal directed. Wanders aimlessly or non-goal directed. Wandering behavior likely to affect the safety or well-being of self/others. Record review of Resident #1's nurse progress note dated 2/11/25 at 5:06 p.m. signed by the SW reflected the following: Resident recently admitted into the facility, residing on the memory care unit. History of wandering, and resident was noted to be wandering on the unit. Record review of Resident #1's nurse progress note dated 2/12/25 at 2:32 p.m. signed by LVN F reflected CNA C was exiting the secured unit when Resident #1 came up and was trying to exit as well. Resident #1 was banging on the door, then grabbed CNA C's hands and was stomping her feet trying to get her out of his way so that he could exit the unit. The Administrator came and spoke with Resident #1 and calmed him down. Resident #1 then went to sit in the chair in the hallway of the secured unit. Record review of Resident #1's nurse progress note dated 2/12/25 at 3:43 p.m. signed by LVN F reflected CNA H's statement: [Resident #1] was trying to get out another resident's window. I tried to redirect him, and he threatened to hit me in the face, and he finally walked out of the resident's room and went into the tv room and tried to get out the window. Me and [LVN B] finally got him out of the room. He then grabbed [Resident #2's] wheelchair and started pushing her really fast and picking the wheelchair up trying to dump her out. [Resident #1] was putting his fist at [LVN B] telling her he was going to hit her. I then ran off the unit to get the Administrator. When I got back [Resident #3] had punched [Resident #1] because he was threatening to hit the women. LVN B's statement reflected: [Resident #1] became very agitated when I and [CNA H] attempted to reorient him. [Resident #1] kept trying to open the doors to the secure unit to go home, and when he saw he couldn't open the doors he then began trying to open the windows. I was able to get him away from the windows and back into the main hallway. Once he was in the main hallway he got behind another resident's wheelchair and started pushing and shoving her into the wall. I ran in front of the wheelchair to prevent the resident from falling out of the chair while [Resident #1] kept trying to punch me and shove other residents. At the same time this was happening, [CNA H] ran out of the unit to get the Administrator and other nurses. Between all of them, they were able to get [Resident #1] in his room and calm him down. Resident now sitting in his room with family member and calm at this time. Record review of Resident #1's nurse progress note dated 2/12/25 at 11:58 p.m. signed by LVN G reflected that Resident #1 remained in the secured unit, family member in the room at the moment. Resident #1 showed no signs or symptoms of acute distress, denied being in any pain or discomfort and showed no signs of aggression at this moment. Fluids at bedside and call light in reach. Record review of Resident #1's nurse progress note dated 2/13/25 at 10:30 a.m. and signed by the SW reflected Resident #1 had exhibited behaviors since admission, awaiting final acceptance from behavioral hospital. Record review of Resident #1's nurse progress note dated 2/13/25 at 5:04 p.m. signed by LVN F reflected that Resident #1 was discharged to the behavioral hospital. Record review of Resident #1's discharge summary with a discharge date of 2/13/25 signed by the Medical Director reflected the following: Resident #1 was having behaviors during stay at the facility and was transported to a behavioral hospital. Resident #1 was not accepted back to the facility at this time. Facility attempted to assist with placement. Record review of behavioral hospital records dated 3/4/25 reflected the following: Patient is very flat and despondent. I just [NAME] get through to people, he is bizarre and tangential. He is on edge and can be violent. He was kicking a nurse recently at the nurses station, he is very impulsive. The patient returned to behavioral hospital after being discharged on 2/24/25 and admitted to the hospital with community acquired pneumonia. Patient originally admitted to behavioral hospital for violence and aggression. While at the hospital, this patient continued to show signs of increased agitation and physical aggression towards others. Hospital staff reported he physically kicked a nurse resulting in the hospital calling a code grey (signifies an active aggressor situation, requiring immediate action) and this patient being placed in restraints. Behavioral hospital staff report behaviors are demanding, intrusive and easily agitated. Patient placed on 1:1 (1 staff member to 1 resident) for safety. This patient lacks insight and has impaired judgement. He remains unstable and a danger to others requiring admission to complete treatment. During an interview on 4/2/25 at 12:50 p.m. the SW stated she was not sure how the 30-day notice worked when a resident was discharged to another facility, as they were not our resident anymore. During an interview on 4/2/25 1:00 p.m. LVN A stated she had worked in the facility since 1/27/25. LVN A stated Resident #1 was very temperamental, and one time he had barricaded the door so no one could get in or out of the memory care unit. LVN A stated Resident #1 told her he was going to San [NAME] to see his parents. LVN A stated that occurred the day before he was sent out. During an interview on 4/2/25 1:21 p.m. LVN B stated she had worked in the facility for 1 year and 2 months. LVN B stated the night before the incident Resident #1 had some agitation but was able to be calmed down. LVN B stated in the afternoon on the day of the incident, it was like a switch flipped. LVN B stated Resident #1 wanted to leave the facility. LVN B stated she took Resident #1 to the tv room and gave him some lunch, and about 45 minutes later he became very aggressive. Resident #1 began banging on the doors and the windows. LVN B stated the aide and her reoriented Resident #1 for about 5 minutes. Resident #1 stated he was leaving one way or another and would do away or kill anyone who tried to stop him. LVN B stated when they took Resident #1 to the tv room, they tried to separate him from the other residents. Resident #1 opened the window in the tv room and tried to crawl out. Resident #1 had his head out the window. LVN B stated they talked to him and got him back in. LVN B stated Resident #1 came running down the hall and got behind Resident #2. Resident #1 kept pushing her in her wheelchair and tried running her into the wall. LVN B stated Resident #1 then kept lifting her wheelchair up and down. LVN B stated Resident #1 kept cussing and threatening the staff. LVN B stated the aide went and got more help. LVN B stated a family member was also notified and came to the facility. LVN B stated when a staff member was coming into the secured unit, Resident #1 pushed his way out the door and ran out of the unit. LVN B stated Resident #1 was transferred out the next day, and the family member stayed with him until he was transferred. LVN B said Resident #1 had grabbed her but did not hurt her. During an interview on 4/2/25 2:00 p.m. the DON stated that Resident #1 was admitted to the facility from home where he had care takers 24 hours a day. The DON stated Resident #1 would get out of the house and would go out in the street. The DON stated the police said he almost got hit by a car and told the family something had to be done, or they would have to do something. The DON stated on the day of the incident Resident #1's family member stayed with him until he was transferred. The DON stated she had talked to Family Member J the beginning of the week he was to be discharged from the behavioral hospital but did not remember the exact date. The DON stated Family Member J was upset Resident #1 was not coming back and stated she had not been issued a 30-day notice. The DON stated she told Family Member J that due to Resident #1's behavior, he posed a threat to the other residents. The DON stated Family Member J was mad and told the DON that if she had any other concerns she could call her other family member. The DON stated she had spoken to the Admissions Coordinator and the DON at the behavioral hospital. The DON at the behavioral hospital said the facility they had no choice to take Resident #1 back, and that she was calling the State. The DON stated she contacted the Ombudsman and told her what had happened. The Ombudsman told her she was making the right decision, and to make sure everything was documented, as the behavioral hospital may report them. The DON stated the SW at the behavioral hospital was helping them with referrals. The DON stated Resident #1's behaviors had not changed while at the behavioral hospital. The DON stated there should have been a 30-day notice given, but she thought that his behaviors would improve after going to the behavioral hospital. The DON stated she was confident with her decision to not accept Resident #1 back in the facility in order to protect the other residents and the staff. The DON stated Family Member K who sat with Resident #1 until he was transferred stated she was not surprised this happened. The DON stated the behavioral hospital was notified on 3/6/25 that Resident #1 would not be able to return to the facility, and both Family Members J and K were also made aware. During an interview on 4/2/25 3:15 p.m. the Administrator stated Resident #1 had tried to attack another resident on 2/12/25 and was sent out the next day to the behavior hospital. The Administrator stated a family member sat with Resident #1 until he was sent out. The Administrator stated he had spoken to Family Member J on the day of the incident, and she had asked if Resident #1 was going to be able to return to the facility. The Administrator stated he told her that if Resident #1's behavior improved he could, if not, he would not be able to return, and that he could not make her any promises. Family member J stated she understood. The Administrator stated Family member K was upset due to the behavioral hospital telling the family that the nursing home had no intentions of ever taking Resident #1 back, which was not true. The Administrator stated he had a discussion with Family Member J before Resident #1 was sent out letting her know that there was a chance of Resident #1 not being able to return to the facility, depending on his behaviors. The Administrator stated Family Member K was told the same thing. The Administrator said a 30-day notice was not provided to Resident #1. The Administrator said the discharge summary signed by the Medical Director did not include the specific resident needs the facility could not meet. The Administrator stated they did not have any policies pertaining to discharges and followed CMS and TAC guidelines. During an interview on 4/3/25 10:17 a.m. CNA C stated she had worked in the facility for 12 years. CNA C stated she was working the day Resident #1 was sent out. CNA C stated Resident #1 was very physical, always trying to hit the staff. CNA C stated he had stomped on her foot one day stating he wanted to go home. CNA C said every time the door to the unit was open, he would try to get out. Record review of the State Operations Manual section 483.15 reflected the following: §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- .(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; . §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Based on record review and interviews the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement granted the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing. The facility did not ensure the arbitration agreement allowed the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long Term Care Ombudsman. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of an undated Admission Agreement page 9 titled Arbitration and page 18 titled Dispute Resolution Plan indicated the agreement did not grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing, and did not allow the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long Term Care Ombudsman. During an interview on 05/29/24 at 9:17 AM the Administrator said that he was responsible for the admission agreements and was not aware of the requirements of the arbitration agreement. He said no resident has entered a binding arbitration and he was completing the paperwork that was supplied by corporate office. He said if the arbitration agreement was not per the regulation, it could affect the resolution and he expected that the arbitration agreement followed the regulation. The administrator said the facility did not have a policy regarding binding arbitrations and followed the admission agreement.

Based on record review and interviews the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility failed to ensure the arbitration agreement included provision of a neutral arbitrator. The facility failed to ensure the arbitration agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of an undated Admission Agreement page 9 titled Arbitration and page 18 titled Dispute Resolution Plan indicated the agreement did not ensure the provision of a neutral arbitrator and did not ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. During an interview on 05/29/24 at 9:17 AM the administrator said that he was responsible for the admission agreements and was not aware of the requirements of the arbitration agreement. He said no resident has entered a binding arbitration and he was completing the paperwork that was supplied by corporate office. He said if the arbitration agreement was not per the regulation, it could affect the resolution and he expected that the arbitration agreement followed the regulation. The administrator said the facility did not have a policy regarding binding arbitrations and followed the admission agreement.

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to empty ash trays and keep trash out of the ash trays in the designated smoking area on 5/29/2024. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The findings included: During an observation on 05/29/24 at 8:25 AM the designated smoking area had 2 ash trays present. One ash tray was overflowing with cigarette butts and the other ash tray had a paper towel that had presence of burn marks . During an interview on 05/29/24 at 8:29 AM HSK A said the maintenance director was responsible for maintaining the smoking area and she would empty the trash. She said that in her training she was taught that residents were to be supervised during the smoke break to ensure they did not put their cigarettes in the trash can or keep a lighter. She said that paper in the ash trays and excessive butts could cause a fire. During an interview on 05/29/24 at 8:31 am the maintenance supervisor said the housekeeping department and the staff supervising the smokers were responsible for maintaining the area in a safe manner. He said he did clean up any butts on the ground and spray for pest as needed but the daily cleaning and emptying of the ash trays were the responsibility of the housekeepers. He said if trash and paper were placed in the ash trays, or the ash trays were not emptied regularly it could cause a fire . During an interview on 05/29/24 at 8:40 am the administrator said the housekeeping department was responsible for maintaining the smoking area in a clean and safe manner. He said the staff that assist the smokers were also responsible and had been taught to ensure the ash trays were emptied and no trash was in the ash trays, but that training had been a while ago. He said if the ash trays contained excessive butts and trash, it could cause a fire. He said he expected the smoking area to be maintained with each smoke break. Record review of a facility policy dated 11/2022 titled Smoking indicated, .All ashtrays and trash will be checked on a regular basis by the staff monitoring smoke breaks to ensure compliance with HHSC regulations, no trash or other foreign debris is allowed to be put in ash trays .

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 12 residents reviewed for quality of care. (Resident #3, #33, and #38) The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility face sheet dated 5/29/24 for Resident #3 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dysphagia, muscle weakness, and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #3 indicated that he had a BIMS score of 15 which indicated that he was cognitively intact Section GG (Functional Abilities and Goals) indicated that he required substantial/maximal assist for transfers. Record review of a comprehensive care plan dated 12/30/23 for Resident #3 indicated that he required assistance with transfers and required a mechanical lift at times. Record review of physician orders dated 5/29/23 for Resident #3 indicated that he had the following physician order dated 1/31/24: Patient transfer in least restrictive fashion with variable level of independence due to patient inconsistency with fatigue/participation. Variable transfer needed to promote patient self-function mobility while maintaining safety. Transfers may vary from 1-person to Hoyer lift (mechanical lift) with Hoyer lift pad in wheelchair at all times. Record review of a facility face sheet dated 5/29/24 for Resident #33 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hypertension (high blood pressure), hyperlipidemia (high cholesterol), and Alzheimer's disease. Record review of a quarterly MDS assessment dated [DATE] for Resident #33 indicated that she had a BIMS score of 99 which indicated that she was unable to complete the interview for mental assessment. Section GG (Functional Abilities and Goals) indicated that she required substantial/maximal assist for transfers. Record review of a comprehensive care plan dated 1/16/24 for Resident #33 indicated that she required a Hoyer lift transfer X 2. Record review of a physician order report dated 5/29/24 for Resident #33 indicated that she had the following physician order dated 2/28/24: Hoyer lift for all transfer X 2 staff members. Record review of a facility face sheet dated 5/29/24 for Resident #38 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dysphagia, pneumonia, and asthma. Record review of a quarterly MDS assessment dated [DATE] for Resident #38 indicated that the BIMS score could not be conducted due to resident being rarely/never understood. Section GG (Functional Abilities and Goals) indicated that she was dependent with transfers. Record review of a comprehensive care plan dated 5/15/24 for Resident #38 indicated that she required a Hoyer lift for transfers. Record review of a physician order report dated 5/29/24 for Resident #38 indicated that she had the following physician order dated 5/17/24: may be transferred using Hoyer lift. During an observation on 5/28/24 at 9:09 am Resident #33 was observed in her room sitting up in a chair with a Hoyer sling observed underneath her. The colors of the sling were faded, and loose strings were observed along the edging seam. It was a blue mesh sling, unable to find the label. During an observation on 5/28/24 at 9:50 am Residents #3 and #38 were both observed up in the common area of the facility with Hoyer slings underneath them. Resident #38's pad had faded straps and loose strings. Resident #3's blue mesh sling was observed with faded straps and multiple loose strings observed along the edging of the sling. During an interview on 05/28/24 at 10:02 AM the DON said CNAs were responsible for inspecting pads before use and residents could be at risk for falls, if worn pads were used. She said the pad could break during use and the resident could fall. During an interview on 5/30/24 at 10:50 am the Administrator said CNA's were responsible for checking lift pads for safety before using them on a resident. He said residents could be at risk for injury if an aide used a lift pad that was worn. Going forward he expected that any equipment that was not in appropriate working condition be reported and replaced. During an interview on 5/20/24 at 11:01 am the DON said CNAs and nurses were responsible for checking the lift pads before using. She said residents could be at risk for potential harm from pad ripping and causing a fall. Going forward she expected staff to inspect pads before use and if label was not legible, or if there were any frays or discoloration, not to use the pad. Record review of a facility policy titled Mechanical Lift dated 8/2022 read .It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition . Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 5/29/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen. Temperature logs for the dishwasher, refrigerator 1, refrigerator 2, freezer 1, and freezer 2 were missing recorded temperatures. This failure could place residents who ate from the kitchen at risk of foodborne illness. Findings included: During an observation on 5/28/2024 at 9:20 AM, temperature log located at the dishwashing station with May 2024 on top of page had temperature checks missing from 05/20/2024 thru 05/27/2024. Temperature logs with May 2024 at heading for freezer 1 had recorded temperatures missing for 05/13/2024 thru 05/25/204, freezer 2 missing recorded temperatures for 05/14/2024 thru 05/25/2024, refrigerator 1 recorded temperatures missing for 05/14/2024 thru 05/25/2024, and refrigerator 2 recorded temperatures missing for 05/14/2024 thru 05/27/2024. During a record review of temperature logs dating from January 2024 thru April 2024, no missing recorded temperatures noted. During an interview on 5/29/2024 at 8:45 AM, the dietary manager said that the morning shift was responsible for checking the temperatures of the freezers and the refrigerators. She said that the temperature of the dish washer was checked three times a day. She said that the dietary aide filled the temperature log out. She said that she expected the staff to complete the temperature logs. She said that she has not had any mechanical issues with any of her equipment. She said that the temperatures were monitored daily, but that the staff does not always remember to fill the temperature log in. She said that she expected the logs to be completed daily. She said that not monitoring temperatures can result in food not being stored at the correct temperature resulting in foodborne illnesses that could cause residents to become ill. In an interview with the administrator on 5/30/2024 at 9:41 AM, the administrator said that he expected the temperature logs in the kitchen to be completed daily. He said that the dietary manager was responsible for monitoring compliance with monitoring temperatures of the refrigerator, freezer, and dishwasher. He said that he expected the dietary manager to check the log daily. He said that not monitoring the temperature of the appliances used could result in food spoilage and foodborne illness that can result in making the residents ill. Review of policy titled Storage Refrigerators from Dietary Services Policy and Procedure Manual 2006 stated Storage refrigerators shall have thermometers frequently monitored throughout the day. Temps are recorded on the Refrigerator/Freezer temperature log. Review of policy titles Dishwashing Preparation and Dishwashing from Dietary Services Policy and Procedure Manual 2006 stated .Minimum temperature of 120 degrees F.the dish machine should be tested for proper temperature and PPM (parts per million) of sanitizing solution. Facilities shall use an approved test kit to measure the parts per million of the chemical solutions . on a daily basis. Any abnormal test results shall be reported to the Dietary Service Manager.

Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 3 of 7 residents reviewed for respiratory care (Residents #15, #29, and #1). The facility failed to ensure the external filters of Resident's #15, #29, and #1 oxygen concentrators were free of dust buildup on 5/28/2024. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1.Record review of a face sheet dated 5/29/2024 for Resident #15 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute respiratory failure (lungs cannot release enough oxygen into the blood), Parkinson's disease (a chronic disorder that causes difficulty moving, tremors, and stiffness), COPD (a group of lung disease that cause difficulty breathing), and Type 2 diabetes. Record review of a Quarterly MDS assessment dated [DATE] for Resident #15 indicated he did not have any impairment in thinking with a BIMS score of 15. He had special treatments, procedures, and programs while a resident that included oxygen therapy during the 14 day look back period. Record review of a care plan dated 2/23/2024 for Resident #15 indicated he suffered from COPD and had the potential for impaired gas exchange. Interventions included oxygen as ordered with protocol. Record review of active physician orders for Resident #15 undated indicated an order for oxygen at 3 Liters per minute via (through) nasal cannula (tubing with prongs that go into the nostrils) prn, and to change oxygen tubing every week on Sunday at bedtime with a start date of 1/29/2024. During an observation on 5/28/2024 at 9:02 AM, in the room of Resident #15 who was not present, had an oxygen concentrator with an external filter that had a large amount of white dust buildup. 2. Record review of a face sheet dated 5/29/2024 for Resident #29 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of schizoaffective disorder bipolar type (a mental illness that has both a mood disorder and manic episodes), COPD, and hypertension. Record review of an Annual MDS Assessment for Resident #29 dated 5/21/2024 indicated he did not have any impairment in thinking with a BIMS score of 15. He had special treatments, procedures, and programs and was on oxygen therapy while a resident during the 14 day look back period. Record review of a care plan for Resident #29 dated 12/19/2022 indicated he received oxygen therapy with interventions to administer oxygen therapy as ordered. Record review of active physician orders for Resident #29 undated indicated an order to change oxygen tubing and wash filter every week on Sunday dated 10/26/2022. Record review of a TAR for Resident #29 dated May 2024 indicated an order to change oxygen tubing and wash filter every week on Sunday that started on 10/30/2022 was administered as indicated by a check mark on May 26, 2024, by LVN D. During an observation and interview on 5/28/2024 at 9:02 AM, Resident #29 was present in his room and said he had been a resident at the facility for 4 years. He was on oxygen via nasal cannula at 3 Liters/min and the external filter had a large amount of white dust buildup. He said he did not remember the last time the filter was cleaned. 3. Record review of a face sheet dated 5/29/2024 for Resident #1 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of pneumonia (lung infection), acute and chronic respiratory failure (lungs cannot release enough oxygen into the blood), and COPD. Record review of a TAR for Resident #1 dated May 2024 indicated an order to change oxygen tubing, nebulizer tubing, and mask, and wash oxygen filter every week on Sunday with a start date of 10/18/2023. It was administered on May 26, 2024, by LVN D as indicated by a check mark. Record review of active physician orders for Resident #1 undated indicated an order to change oxygen tubing and wash oxygen filter every week on Sunday dated 10/18/2023. Record review of a Quarterly MDS Assessment for Resident #1 dated 4/15/2024 indicated she did not have any impairment in thinking with a BIMS score of 15. Special treatments, procedures, and programs indicated she had oxygen therapy while a resident during the 14 day look back period. During an observation and interview on 5/28/2024 at 9:53 AM, Resident #1 was in bed awake on oxygen at 3 Liters/min via nasal cannula with the tubing dated 5/26 and the external filter had a large amount of dust. She said she had been a resident at the facility for [AGE] years and did not remember the last time they cleaned the filter. During an interview on 5/29/2024 at 7:50 AM, LVN B said the charge nurses were responsible for cleaning the oxygen filters every Sunday on the night shift from 6pm-6am. She said if a resident was on continuous oxygen there was an order on the TAR to clean the filters but not if a resident only used oxygen prn. Attempted a phone interview on 5/29/2024 at 7:44 AM with LVN D who worked Sunday night 5/26/2024 and no return call was received. During an interview on 5/30/2024 at 9:35 AM, the DON said she had been employed at the facility for 1 year. She said the night shift nurses on Sunday night were responsible for cleaning the filters on the oxygen concentrators. She said there should be orders on the resident's TAR with oxygen orders to clean them weekly. She said if the filters were not cleaned it could cause an exacerbation of disease processes that they had. She said she cleaned the filters of Resident #1 and #29 on 5/29/2024 but did not clean Resident #15's but would. She said going forward she would check all orders to ensure residents who had oxygen concentrators had orders to clean the filters. She said she expected the filters to be cleaned, when they were supposed to be cleaned every 7 days. During an interview on 5/30/2024 at 10:30 AM, the Administrator said the night nurses were responsible for cleaning the filters on the oxygen concentrators and they should be cleaned once a week. He said there was a risk for infections and the machine may not work properly if they were not cleaned. Record review of a facility policy titled Respiratory Therapy Equipment dated 8/2022 indicated, .It is the policy of this home that residents on respiratory therapy will have appropriate treatment. Oxygen Administration: 9. Wash filters from oxygen concentrator every 7 days in soapy water. Rinse and squeeze dry .

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 17 residents reviewed for abuse. (Resident # 44) The facility did not implement and develop effective care plan interventions to prevent Resident #56 from sexually abusing Resident #44. Resident #56 had a history of [REDACTED]. On 4/8/19 Resident #56 slid his hand up Resident #44's thigh and touched her vagina. Resident #44 said after the incident she was afraid Resident #56 was going to come into her room at night and she did not go to bed until she knew he was in bed. An Immediate Jeopardy (IJ) situation was identified 04/24/19. While the IJ was removed on 4/25/19 at 10:17 a.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place female residents who resided on the secured Memory Care unit at risk for abuse. Findings included: 1. Physician orders [REDACTED].#56, admitted [DATE], was a [AGE] year-old male with [DIAGNOSES REDACTED]. Resident #56 received [MEDICATION NAME] (used to treat behaviors) 250 milligrams (mg) every 12 hours with start date of 3/15/10. There was a laboratory order for [MEDICATION NAME] level to be drawn monthly with a start date of 3/19/19. A physician letter dated 02/01/19 for Resident #56 indicated .Discussed resident's inappropriate behavior at length with the Director of Nursing of the facility and have deemed that psychiatric services are not warranted at this time due to the extent of the patient's dementia . A nursing note dated 02/08/19 at 6:00 p.m. indicated Resident #56 was showing an increase in sexual behaviors, flashing his genitals at staff and other residents, hollering loudly and cursing. An order was received to increase [MEDICATION NAME] (used to treat behaviors) from 25 mg every night to 25 mg twice a day. A plan of care dated 02/08/19 indicated Resident #56 had inappropriate behavior .Flashing genitals and grabbing boobs . The approaches included .Staff will monitor resident every 2 hours, Redirect resident with inappropriate behavior, Psych consult as indicated, Notify MD and family of changes . An incident and accident report dated 02/17/19 indicated Resident #56 attempted to touch an employee in her private area; another resident reported seeing Resident #56 grab another female resident's breast. A nursing notes dated 02/17/19 at 6:15 p.m. indicated, .Reported by CNA Resident (#56) touched her inappropriately in private area. She attempted to redirect and instruct the resident that type of behavior was inappropriate. The resident then grabbed another female resident by breasts. M.D. and responsible party notified. Awaiting order to transfer to (local behavioral hospital) . A Social Work progress noted date 02/18/19, no time documented, indicated Resident #56 exhibited behaviors over the weekend. A local behavioral hospital was called 02/17/19 and 02/18/19. A letter from Resident #56's psychiatrist dated 2/18/19 indicated .psychiatric services are not warranted at this time due to the extent of the patient's dementia . A nursing note dated 02/21/19 at 2:20 p.m. indicated Resident #56 was admitted to a local behavioral hospital. A nursing note dated 03/07/19 at 1:45 p.m. indicated Resident #56 was readmitted to secured memory care unit. The most recent MDS dated [DATE] indicated Resident #56 was moderately impaired and usually understood others. Resident #56 displayed verbal behavior symptoms directed toward others and was limited to one person assist with ADLs. Resident #56 had no physical behaviors. A nursing note dated 03/14/19 at 2:00 p.m., indicated, .CNA notified nurse of 2 residents fighting. Both nurses entered unit and residents were face to face. CNA notified nurse that Resident (#56) grabbed her shirt and arm and another male resident grabbed him by the face and shirt knocking his glasses off. He was attempting to help CNA. Nurse separated residents. No injuries. Started every 15-minute checks . A physician order [REDACTED]. The 15 Minute Surveillance Program forms from 3/14/19 to 3/23/19 indicated Resident #56 received 15-minute checks for his location. There was no other documentaion of 15-minute checks for Resident #56 after 3/23/19. A care plan conference summary dated 03/14/19 indicated Resident #56 had aggressive behavior on this date, and the behavioral hospital was unable to take the resident. The summary indicated the family was made aware of a 30-day discharge notice, and that if Resident #56 had another aggressive or combative episode, he would be immediately discharged . During an interview on 4/23/19 at 4:20 p.m., the DON said discharge was discussed with Resident # 56's family during care plan meeting on 3/14/19 due to his aggressive behaviors. She said Resident #56's physician changed his medication to [MEDICATION NAME] and his behaviors improved so the discharge was not implemented. A plan of care dated 03/14/19 indicated Resident #56 had inappropriate behavior .Touching others and physical aggression . The approaches included .Staff will monitor resident every 2 hours, Redirect resident with inappropriate behavior, Psych consult as indicated, Notify MD and family of changes . There were no new interventions noted. A nursing note dated 03/15/19 at 2:30 p.m. indicated, .Another resident (unnamed) stated Resident (#56) attempted to 'hit me and called me a prick.' Resident very agitated, yelling, upset. Redirection was attempted and not successful . The physician ordered to increase Klonopin from 1 mg at bedtime to 1 mg twice a day, give one dose now. A Social Work progress noted date 03/15/19, no time documented, indicated another behavioral facility was contacted, but had no beds available. A physician encounter summary-progress note dated 03/21/19 indicated Resident #56 .Demonstrates aggressive behavior (inappropriate sexual behavior towards other residents has improved) . The 1 Hour Surveillance Program forms from 3/24/19 to 4/2/19 indicated Resident #56 received 1 hours checks for his location. There was no other documentation of 1 hour surveillance or 15 minute checks for Resident #56 from 4/3/19- 4/23/19. A physician order [REDACTED].>The clinical record from 4/3/19 to 4/23/19 did not contain documentation Resident #56 was monitored for his location every 15 minutes or hourly. A nursing note dated 4/23/19 at 1:30 a.m. indicated physician orders [REDACTED]. The clinical record from 3/19/19 to 4/23/19 did not contain laboratory results for Resident #56's [MEDICATION NAME]. A Social Work progress note date 04/23/19, no time documented, indicated the responsible party was informed Resident #56 would be immediately discharged that evening for the safety of others. 2. Physician orders [REDACTED].#44, admitted ,[DATE], was a 65 - year old admitted with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #44 was cognitively intact and had no behaviors. She was independent with set up help only for ADLs. The care plan dated 4/26/19 indicated Resident #44 did not have behaviors. A nursing note dated 04/08/19 at 11:00 p.m., indicated Resident #56 was showing sexual misconduct to female residents on the unit. He rolled up in his wheelchair to Resident #44 and said, What is that? and raised her dress up while putting his hand on her private area. The incident was witnessed by CNA F. An incident and accident report dated 04/23/19 indicated on 04/08/19, Resident #56 .slid his hand up . Resident #44's .thigh and touched her vagina . During an observation and interview on 04/24/19 at 8:50 a.m., Resident #44 was sitting in her room on her bed. She said I was sitting at the table in the hallway. Resident (#56) was in his wheelchair and wheeled up to me and reached between my legs. I wear baggy clothes, nothing provocative. He rolls up to other residents and says, I'm horny. She said I don't remember if I pushed him away or slapped his hand, but I told him to get away and I let CNA F know. She was sitting across from me, so I am not sure if she saw his hands. No one has come to talk to me about this incident until last night (4/23/19). Resident #44 said I was afraid he would come in my room at night since he was two doors down. Most of the time I didn't go to bed until I knew he was in bed. Resident #44 said she feels at peace now that he is gone. Resident #44 said she had seen Resident #56 slap staff and other female residents on the butt. Resident #44 said she would get up and leave if Resident #56 showed up. During an interview on 04/23/19 4:00 p.m., the DON said Resident #56 had behaviors and had a couple of stays at a local behavioral hospital. She said Resident #56 was placed on [MEDICATION NAME] and had no problems since. The DON said Resident #56's behaviors were triggered when someone got into his space. The DON said she conducted care plans and that Resident #56 was care planned for touching other residents. She said Resident #56 was sent out to the behavioral hospital on [DATE] for inappropriate behavior. The DON said the family had been served a 30-day notice and then the physician agreed to try Resident #56 on [MEDICATION NAME]. The DON said Resident #56 never tried to get in bed with anyone, that his sexual behaviors mainly had to do with staff. The DON said none of the residents on the (secure) unit would be able to consent to being touched. The DON said she was not aware of the 04/08/19 incident until 04/23/19 and no reports had been called into the state agency. During an interview on 4/23/19 at 4:50 p.m., the DON, ADON, and administrator said they would begin 15-minute checks on Resident #56, talk with the resident's wife, re-serve a 30-day notice to the resident/family, fill out an incident report, investigate and report if needed. The administrator asked If he touched her and she didn't say anything, is that ok? Would that make a difference? The administrator said he was the abuse coordinator. During an interview on 04/24/19 at 8:30 a.m., the DON said Resident #56 was given an immediate discharge on 4/23/19 at 6:00 p.m. She said The family was not happy, but I felt this was the best thing to do to protect the other residents. I talked to (Resident #56's) wife. The DON said CNA F witnessed Resident #56 raise Resident #44's dress and put his hand on her private area on 4/8/19 at 11:00 p.m., and the CNA reported the incident to LVN G. She said LVN G did not make note in the report book or let anyone know about the incident. During an interview of 04/24/19 at 8:43 a.m., CNA H said she never observed any behaviors from Resident #56 but said He pats staff on the rear end a lot. I would tell him that was inappropriate. During an interview of 04/24/19 at 9:11 a.m., LVN G said she was providing a medication pass on 4/8/19 when CNA F reported to her she had witnessed Resident #56 raise Resident #44's dress and put his hand on her private area. She said she did not do anything but put Resident #56 to bed. LVN G said she had never received training on abuse/neglect regarding Resident #56. During an interview on 04/24/19 at 9:16 a.m., CNA F said she worked on 4/8/19 and was sitting at the table with Resident #44. She said she was unsure of the time. She said she did not see Resident #56 touch Resident #44 but said Resident #44 told her as soon as it happened. Resident #44 told CNA F that she told Resident #56 to move and he ran his hand up her crotch. CNA F said she removed Resident #56 and told him that was inappropriate behavior. CNA F said she reported this incident to LVN G. CNA F said Resident #56 would slap staff on the rear and if you got to close, he would look at you and say num num num. She said Resident #56 has become rather docile lately but when he is alert, he is all hands! She said Resident #56 was always trying to touch Resident #44's leg. During an interview on 04/24/19 at 10:23 a.m., SNA said in (MONTH) 2019, Resident #56 asked for someone to come in his room as she was walking down the hall. She said When I went in the room, he addressed me with 'sweetie, darling, and baby.' Resident (#56) then stated, 'Come sit on my lap and we will talk.' SNA said he reached out and touched her in her crotch area, and she pulled around to the side of his wheelchair and he kissed her on the right ear. SNA said she reported the incident to LVNs [NAME] and F. She said she wrote a statement and gave it to LVN [NAME] but had not heard anything else. SNA said she found out today that LVN [NAME] did not have the paper work, and did not turn it in. SNA said Resident #56 had angry aggressive moments and she was not aware of anyone he had harmed. An undated Abuse Prevention Program policy indicated the following for resident to resident abuse .It is the policy of the facility to protect residents from harm at all times. This includes protection from other residents. The following process will be followed if resident to resident abuse occurs: If a resident to resident incident occurs, staff should immediately intervene. Separate the residents and take them to areas away from each other until the situation has subsided .Monitor the resident every 15 minutes to assess the behavior and ensure he/she is safe. Once the resident has calmed down, monitor the resident closely when he/she returns to the general environment to ensure the behavior does not happen again .The behavior must be documented and the abuse coordinator or director of nurses must be notified. In addition, the resident's representative and physician should be notified . The abuse coordinator will notify the state agency . all allegations will be investigated . The administrator was informed on 04/24/19 at 11:23 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's Plan of Removal was accepted 04/24/19 at 5:06 p.m. and included: .On 04/23/2019, the facility began in-servicing the staff on the Abuse Prevention Program. The root causes of the problems are: 1. A nurse did not follow the Abuse Prevention reporting policy, after a staff member followed the policy and reported a sexual abuse to her. The nurse did not report the sexual abuse to the Abuse Coordinator, DON or Administrator; however, she documented the incident in the nurse notes. During the employee orientation, the new nurse received abuse training by the Administrator. 2. Staff did not report sexual inappropriate behavior by the resident to their supervisor, DON, Administrator or Abuse Coordinator. The focus of the in-service was reporting Sexual Abuse, Abuse, Exploitation, Misappropriation of resident property, Mistreatment and Neglect. The DON or designee will in-service the staff prior to the beginning of their next shift. The staff must also report any sexual or physical abuse of a resident or staff to their supervisor, Abuse Coordinator, DON and /or Administrator. An Incident Report and a nurse note are required. The incident should be noted on the 24-hour report. Texas has an immediate reporting policy. The secure unit was created for exit seeking patients and memory care unit. We are not accepting physical and sexual behaviors. If a patient is admitted and exhibits physical or sexual behaviors, they will be placed on 15-minute checks and/or one on one, until transferred to Oceans Behavioral hospital. We will review the clinical records from Oceans and determine, if we can meet their medical needs. If readmitted , the behavior will be Care Planned by the Social Worker. The charge nurse will have the staff monitor the behavior from the 24-hour report. The Don or designee will monitor the 24-hour report for behaviors and ensure each is acted on and reported. Each shift will document any behavior. The staff will be educated on the Abuse Prevention Policy, which includes reporting all physical and sexual abuse to staff or residents. This must be immediately reported to their supervisor, Abuse coordinator, DON and/or Administrator. If the resident has additional behaviors, the facility will issue a 30-day discharge or an immediate discharge. The DON or designee will test employees, conduct periodic in-services and randomly ask employees questions about Abuse Prevention . On 4/25/19 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: The facility training included in-services on reporting sexual abuse, abuse, exploitation, misappropriation of resident property, mistreatment and neglect, and a questionnaire on Abuse Prevention. Who to report to, what to report, when to report and what circumstances to be reported were discussed. All staff were able to correctly answer these questions. The staff in- serviced included: 20 Nurses, MAs, CNAs,13 staff from maintenance, housekeeping, dietary, physical therapy, transport, activities, and administration. 8 nurses, MAs, and CNAs; 4 dietary employees;4 Physical Therapy employees and 7 ancillary/administrative employees were interviewed, from different shifts, on the different types of abuse, who to report to, when to report and where to document incidents. All staff were able to verbalize the correct answers. On 04/25/19 at 10:17 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse of residents for 1 of 17 residents reviewed for abuse. (Resident #44). The facility did not investigate or report an allegation of sexual abuse immediately to the administrator and the state agency when Resident #56 sexually abused Resident #44. Resident #56 had a history of [REDACTED]. On 4/8/19 Resident #56 slid his hand up Resident #44's thigh and touched her vagina. Resident #44 said after the incident she was afraid Resident #56 was going to come into her room at night and she did not go to bed until she knew he was in bed. An Immediate Jeopardy (IJ) situation was identified 04/24/19. While the IJ was removed on 4/25/19 at 10:17 a.m., the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place female residents who resided on the secured Memory Care unit at risk for abuse. Findings included: An undated Abuse Prevention Program policy indicated the following for resident to resident abuse .It is the policy of the facility to protect residents from harm at all times. This includes protection from other residents. The following process will be followed if resident to resident abuse occurs: If a resident to resident incident occurs, staff should immediately intervene. Separate the residents and take them to areas away from each other until the situation has subsided .Monitor the resident every 15 minutes to assess the behavior and ensure he/she is safe. Once the resident has calmed down, monitor the resident closely when he/she returns to the general environment to ensure the behavior does not happen again .The behavior must be documented and the abuse coordinator or director of nurses must be notified. In addition, the resident's representative and physician should be notified . The abuse coordinator will notify the state agency . all allegations will be investigated . 1. Physician orders [REDACTED].#56, admitted [DATE], was a [AGE] year-old male with [DIAGNOSES REDACTED]. Resident #56 received [MEDICATION NAME] (used to treat behaviors) 250 milligrams (mg) every 12 hours with start date of 3/15/10. There was a laboratory order for [MEDICATION NAME] level to be drawn monthly with a start date of 3/19/19. A physician letter dated 02/01/19 for Resident #56 indicated .Discussed resident's inappropriate behavior at length with the Director of Nursing of the facility and have deemed that psychiatric services are not warranted at this time due to the extent of the patient's dementia . A nursing note dated 02/08/19 at 6:00 p.m. indicated Resident #56 was showing an increase in sexual behaviors, flashing his genitals at staff and other residents, hollering loudly and cursing. An order was received to increase [MEDICATION NAME] (used to treat behaviors) from 25 mg every night to 25 mg twice a day. A plan of care dated 02/08/19 indicated Resident #56 had inappropriate behavior .Flashing genitals and grabbing boobs . The approaches included .Staff will monitor resident every 2 hours, Redirect resident with inappropriate behavior, Psych consult as indicated, Notify MD and family of changes . An incident and accident report dated 02/17/19 indicated Resident #56 attempted to touch an employee in her private area; another resident reported seeing Resident #56 grab another female resident's breast. A nursing notes dated 02/17/19 at 6:15 p.m. indicated, .Reported by CNA Resident (#56) touched her inappropriately in private area. She attempted to redirect and instruct the resident that type of behavior was inappropriate. The resident then grabbed another female resident by breasts. M.D. and responsible party notified. Awaiting order to transfer to (local behavioral hospital) . A Social Work progress noted date 02/18/19, no time documented, indicated Resident #56 exhibited behaviors over the weekend. A local behavioral hospital was called 02/17/19 and 02/18/19. A letter from Resident #56's psychiatrist dated 2/18/19 indicated .psychiatric services are not warranted at this time due to the extent of the patient's dementia . A nursing note dated 02/21/19 at 2:20 p.m. indicated Resident #56 was admitted to a local behavioral hospital. A nursing note dated 03/07/19 at 1:45 p.m. indicated Resident #56 was readmitted to secured memory care unit. The most recent MDS dated [DATE] indicated Resident #56 was moderately impaired and usually understood others. Resident #56 displayed verbal behavior symptoms directed toward others and was limited to one person assist with ADLs. Resident #56 had no physical behaviors. A nursing note dated 03/14/19 at 2:00 p.m., indicated, .CNA notified nurse of 2 residents fighting. Both nurses entered unit and residents were face to face. CNA notified nurse that Resident (#56) grabbed her shirt and arm and another male resident grabbed him by the face and shirt knocking his glasses off. He was attempting to help CNA. Nurse separated residents. No injuries. Started every 15-minute checks . A physician order [REDACTED]. The 15 Minute Surveillance Program forms from 3/14/19 to 3/23/19 indicated Resident #56 received 15-minute checks for his location. There was no other documentation of 15-minute checks for Resident #56 after 3/23/19. A care plan conference summary dated 03/14/19 indicated Resident #56 had aggressive behavior on this date, and the behavioral hospital was unable to take the resident. The summary indicated the family was made aware of a 30-day discharge notice, and that if Resident #56 had another aggressive or combative episode, he would be immediately discharged . During an interview on 4/23/19 at 4:20 p.m., the DON said discharge was discussed with Resident # 56's family during care plan meeting on 3/14/19 due to his aggressive behaviors. She said Resident #56's physician changed his medication to [MEDICATION NAME] and his behaviors improved so the discharge was not implemented. A plan of care dated 03/14/19 indicated Resident #56 had inappropriate behavior .Touching others and physical aggression . The approaches included .Staff will monitor resident every 2 hours, Redirect resident with inappropriate behavior, Psych consult as indicated, Notify MD and family of changes . There were no new interventions noted. A nursing note dated 03/15/19 at 2:30 p.m. indicated, Another resident (unnamed) stated Resident (#56) attempted to 'hit me and called me a prick.' Resident very agitated, yelling, upset. Redirection was attempted and not successful. The physician ordered to increase Klonopin from 1 mg at bedtime to 1 mg twice a day, give one dose now. A Social Work progress noted date 03/15/19, no time documented, indicated another behavioral facility was contacted, but had no beds available. A physician encounter summary-progress note dated 03/21/19 indicated Resident #56 .Demonstrates aggressive behavior (inappropriate sexual behavior towards other residents has improved) . The 1 Hour Surveillance Program forms from 3/24/19 to 4/2/19 indicated Resident #56 received 1 hours checks for his location. There was no other documentation of 1 hour surveillance or 15 minute checks for Resident #56 from 4/3/19- 4/23/19. A physician order [REDACTED].>A nursing note dated 4/23/19 at 1:30 a.m. indicated physician orders [REDACTED]. The clinical record from 3/19/19 to 4/23/19 did not contain laboratory results for Resident #56's [MEDICATION NAME]. A Social Work progress note dated 04/23/19, no time documented, indicated the responsible party was informed Resident #56 would be immediately discharged that evening for the safety of others. 2. Physician orders [REDACTED].#44, admitted ,[DATE], was a 65 - year old admitted with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #44 was cognitively intact and had no behaviors. She was independent with set up help only for ADLs. The care plan dated 4/26/19 indicated Resident #44 did not have behaviors. A nursing note dated 04/08/19 at 11:00 p.m., indicated Resident #56 was showing sexual misconduct to female residents on the unit. He rolled up in his wheelchair to Resident #44 and said, What is that? and raised her dress up while putting his hand on her private area. The incident was witnessed by CNA F. An incident and accident report dated 04/23/19 indicated on 04/08/19, Resident #56 .slid his hand up . Resident #44's .thigh and touched her vagina . During an observation and interview on 04/24/19 at 8:50 a.m., Resident #44 was sitting in her room on her bed. She said I was sitting at the table in the hallway. Resident (#56) was in his wheelchair and wheeled up to me and reached between my legs. I wear baggy clothes, nothing provocative. He rolls up to other residents and says, I'm horny. She said I don't remember if I pushed him away or slapped his hand, but I told him to get away and I let CNA F know. She was sitting across from me, so I am not sure if she saw his hands. No one has come to talk to me about this incident until last night (4/23/19). Resident #44 said I was afraid he would come in my room at night since he was two doors down. Most of the time I didn't go to bed until I knew he was in bed. Resident #44 said she feels at peace now that he is gone. Resident #44 said she had seen Resident #56 slap staff and other female residents on the butt. Resident #44 said she would get up and leave if Resident #56 showed up. During an interview on 04/23/19 4:00 p.m., the DON said Resident #56 had behaviors and had a couple of stays at a local behavioral hospital. She said Resident #56 was placed on [MEDICATION NAME] and had no problems since. The DON said Resident #56's behaviors were triggered when someone got into his space. The DON said she conducted care plans and that Resident #56 was care planned for touching other residents. She said Resident #56 was sent out to the behavioral hospital on [DATE] for inappropriate behavior. The DON said the family had been served a 30-day notice and then the physician agreed to try Resident #56 on [MEDICATION NAME]. The DON said Resident #56 never tried to get in bed with anyone, that his sexual behaviors mainly had to do with staff. The DON said none of the residents on the (secure) unit would be able to consent to being touched. The DON said she was not aware of the 04/08/19 incident until 04/23/19 and no reports had been called into the state agency. During an interview on 4/23/19 at 4:50 p.m., the DON, ADON, and administrator said they would begin 15-minute checks on Resident #56, talk with the resident's wife, re-serve a 30-day notice to the resident/family, fill out an incident report, investigate and report if needed. The administrator asked If he touched her and she didn't say anything, is that ok? Would that make a difference? The administrator said he was the abuse coordinator. During an interview on 04/24/19 at 8:30 a.m., the DON said Resident #56 was given an immediate discharge on 4/23/19 at 6:00 p.m. She said The family was not happy, but I felt this was the best thing to do to protect the other residents. I talked to (Resident #56's) wife. The DON said CNA F witnessed Resident #56 raise Resident #44's dress and put his hand on her private area on 4/8/19 at 11:00 p.m., and the CNA reported the incident to LVN G. She said LVN G did not make note in the report book or let anyone know about the incident. During an interview of 04/24/19 at 8:43 a.m., CNA H said she never observed any behaviors from Resident #56 but said, He pats staff on the rear end a lot. I would tell him that was inappropriate. During an interview of 04/24/19 at 9:11 a.m., LVN G said she was providing a medication pass on 4/8/19 when CNA F reported to her she had witnessed Resident #56 raise Resident #44's dress and put his hand on her private area. She said she did not do anything but put Resident #56 to bed. LVN G said she had never received training on abuse/neglect regarding Resident #56. During an interview on 04/24/19 at 9:16 a.m., CNA F said she worked on 4/8/19 and was sitting at the table with Resident #44. She said she was unsure of the time. She said she did not see Resident #56 touch Resident #44 but said Resident #44 told her as soon as it happened. Resident #44 told CNA F that she told Resident #56 to move and he ran his hand up her crotch. CNA F said she removed Resident #56 and told him that was inappropriate behavior. CNA F said she reported this incident to LVN G. CNA F said Resident #56 would slap staff on the rear and if you got to close, he would look at you and say num num num. She said Resident #56 has become rather docile lately but when he is alert, he is all hands! She said Resident #56 was always trying to touch Resident #44's leg. During an interview on 04/24/19 at 10:23 a.m., SNA said in (MONTH) 2019, Resident #56 asked for someone to come in his room as she was walking down the hall. She said When I went in the room, he addressed me with 'sweetie, darling, and baby.' Resident (#56) then stated, 'Come sit on my lap and we will talk.' SNA said he reached out and touched her in her crotch area, and she pulled around to the side of his wheelchair and he kissed her on the right ear. SNA said she reported the incident to LVNs [NAME] and F. She said she wrote a statement and gave it to LVN [NAME] but had not heard anything else. SNA said she found out today that LVN [NAME] did not have the paper work, and did not turn it in. SNA said Resident #56 had angry aggressive moments and she was not aware of anyone he had harmed. The administrator was informed on 04/24/19 at 11:23 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's Plan of Removal was accepted 04/24/19 at 5:06 p.m. and included: .On 04/23/2019, the facility began in-servicing the staff on the Abuse Prevention Program. The root causes of the problems are: 1. A nurse did not follow the Abuse Prevention reporting policy, after a staff member followed the policy and reported a sexual abuse to her. The nurse did not report the sexual abuse to the Abuse Coordinator, DON or Administrator; however, she documented the incident in the nurse notes. During the employee orientation, the new nurse received abuse training by the Administrator. 2. Staff did not report sexual inappropriate behavior by the resident to their supervisor, DON, Administrator or Abuse Coordinator. The focus of the in-service was reporting Sexual Abuse, Abuse, Exploitation, Misappropriation of resident property, Mistreatment and Neglect. The DON or designee will in-service the staff prior to the beginning of their next shift. The staff must also report any sexual or physical abuse of a resident or staff to their supervisor, Abuse Coordinator, DON and /or Administrator. An Incident Report and a nurse note are required. The incident should be noted on the 24-hour report. Texas has an immediate reporting policy. The secure unit was created for exit seeking patients and memory care unit. We are not accepting physical and sexual behaviors. If a patient is admitted and exhibits physical or sexual behaviors, they will be placed on 15-minute checks and/or one on one, until transferred to Oceans Behavioral hospital. We will review the clinical records from Oceans and determine, if we can meet their medical needs. If readmitted , the behavior will be Care Planned by the Social Worker. The charge nurse will have the staff monitor the behavior from the 24-hour report. The Don or designee will monitor the 24-hour report for behaviors and ensure each is acted on and reported. Each shift will document any behavior. The staff will be educated on the Abuse Prevention Policy, which includes reporting all physical and sexual abuse to staff or residents. This must be immediately reported to their supervisor, Abuse coordinator, DON and/or Administrator. If the resident has additional behaviors, the facility will issue a 30-day discharge or an immediate discharge. The DON or designee will test employees, conduct periodic in-services and randomly ask employees questions about Abuse Prevention . On 4/25/19 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: The facility training included in-services on reporting sexual abuse, abuse, exploitation, misappropriation of resident property, mistreatment and neglect, and a questionnaire on Abuse Prevention. Who to report to, what to report, when to report and what circumstances to be reported were discussed. All staff were able to correctly answer these questions. The staff in- serviced included: 20 Nurses, MAs, and CNAs and13 staff from maintenance, housekeeping, dietary, physical therapy, transport, activities, and administration, 8 nurses, MAs, and CNAs, 4 dietary employees, 4 Physical Therapy employees, and 7 ancillary/administrative employees were interviewed, from different shifts, on the different types of abuse, who to report to, when to report and where to document incidents. All staff were able to verbalize the correct answers. On 04/25/19 at 10:17 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent development of a pressure injury for 1 of 2 residents reviewed for pressure injury. (Resident #57) The facility did not prevent the development and worsenning of a pressure injury for Resident #57. Resident #57 had a low risk for the development of a pressure injury, however, she acquired an unstageable pressure injury to her left buttock after admission to the facility. The facility did not adress abnormal [MEDICATION NAME] and protein levels dated 2/22/19 until after the development of the unstageable pressure injury. (4/11/19) This failure could place residents at risk for development of new pressure injuries and worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#57, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #57 had blanchable redness to her buttocks. A Braden Score assessment dated [DATE] for Resident #57 was scored at 14 which indicated a low risk for a pressure injury (less than 12 indicated a high risk for pressure ulcer development). The laboratory results dated [DATE] indicated Resident #57 had a low [MEDICATION NAME] level (helps determine nutritional status) of 2.6 grams per deciliter (G/DL) (normal range 3.5 to 5.4 G/DL) and a low protein level at 5.2 G/DL (normal range 6 to 8.3 G/DL). The clinical records dated 2/22/19 through 4/10/19 for Resident #57 did not address the abnormal laboratory results. An MDS dated [DATE] for Resident #57 indicated moderate impairment of cognition. She required extensive assistance of one person for bed mobility, and total assistance of two people for transfers and bathing. The MDS indicated Resident #57 was always incontinent of bowel and bladder and required total assistance with incontinent care. The MDS indicated she was at risk for developing pressure ulcers but had no pressure ulcers at the time of the MDS assessment. A nursing note dated 03/27/19 at 4:45 p.m., indicated Resident #57 fell out of bed onto floor while trying to adjust her body in bed. No bruise on her bottom was documented as an injury. An incident report dated 04/04/19 at 4:00 p.m., indicated Resident #57 had an unmeasured bruise to left buttock observed during incontinent care. An incident report dated 04/05/19 at 5:00 p.m., indicated Resident #57 had an unmeasured sheared area to left buttock on the prior bruised area. During an interview on 04/24/19 at 08:36 a.m., LVN [NAME] said she completed the incident report on 4/5/19 regarding the sheared area on Resident #54's bottom. She said the pressure injury developed in the same exact broken-down area as the pressure injury now. An investigation of incidents report dated 04/05/19 and untimed for Resident #57 indicated the conclusion to the shear was the resident's buttock rubbed against the brief or padding during transfer. A care plan dated 04/05/19 indicated Resident #57 had a sheared area to left buttock to be treated with mediseptic. (skin protectant cream to treat adult diaper [MEDICAL CONDITION], denuded skin and minor burns) There was no mention of padding or turning/ repositionining. A physician order [REDACTED].#57 required her to have an air mattress, begin [MEDICATION NAME] (aides in wound healing), stress tab (treats vitamin deficiency due to poor nutrition) and Promod (protein supplement which reverses protein deficiency which contributes to wound formation). Also, cleanse stage 2 pressure injury to her left buttock with wound cleanser, pat dry, apply santyl (a debrider to removed dead tissue) and cover with dry dressing every day. A care plan dated 04/11/19 indicated Resident #57 had a stage 2 pressure injury to her left buttock to be treated with santyl and a dry dressing, .perform treatment as ordered, encourage dietary/fluid intake, turn/reposition every two hours and as needed, use padding between pressure areas and positioning devices . A weekly pressure ulcer record dated 04/11/19 for Resident #57 indicated the stage 2 press ulcer measured 1.5 centimeters (cm) X 2.0 cm X <0.2 cm with pink wound bed. A weekly pressure ulcer record dated 04/17/19 for Resident #57 indicated the stage 2 pressure ulcer measured 1.5 cm X 1.5 cm X not measurable. An initial wound evaluation (wound care doctor's report) dated 04/22/19 indicated Resident #57 had a shear wound on her left buttock which measured 2.3 cm X 2.0 cm X not measurable with necrotic tissue. The physician removed some necrotic tissue during the visit and ordered santyl to be continued. During an observation and interview on 04/22/19 at 09:43 AM Resident #57 was lying in bed slightly tilted to her left side on a low air loss mattress. She said her left side did not move. She also said she has a sore on her bottom that they were taking care of every day. During an interview on 04/22/19 at 2:17 p.m., the responsible party said Resident #57 had a stroke on 1/31/19. He said he visited Resident #57 daily. He said the area on her left buttock started out like a bruise. The responsible party said they had since decided the area on her left buttock was a pressure injury. He said after they discovered the pressure ulcer, they put an air mattress on the bed and started giving her shakes to help with her nutrition. During an observation on 04/23/19 at 8:45 a.m. with LVN J, Resident #57 was lying in bed on her right side and had a round open area to her left sacrum the size of a quarter. The wound bed was completely covered with slough (necrotic tissue). During positioning, the resident's left side was limp and without movement from the resident. LVN J said the wound care doctor measured the wound on 04/22/2019. During an interview on 04/23/19 at 11:52 a.m., CNA A said she provided care for Resident #57. She said Resident #57 wiggles in bed and attempted to move, but her left side did not move. During an interview on 04/23/19 at 12:03 p.m., CNA B said she provided care for Resident #57. She said the area on Resident #57's left buttock started out red and they were keeping an eye on it. She said the area progressed and now required wound care. During an interview on 04/24/19 at 9:15 a.m., the DON said she staged the shear area for Resident #57. She said on 04/11/19 Resident #57's physician identified the shear on Resident #57's left buttock as a stage 2 pressure injury. She said she saw Resident #57's stage 2 pressure injury on 04/22/19 and there was slough in the wound bed. She said a wound bed with slough should be staged as unstageable, but it was a shear and not a pressure ulcer. During an interview on 04/24/19 at 1:15 p.m., CNA C said she provided care for Resident #57. She said the area on Resident #57's left buttock had not been there too long. She said it started out as a dime sized, round purple spot and the purple spot peeled off while she was off. During an interview on 04/24/19 at 1:18 p.m., CNA D said she provided care for Resident #57. She said Resident #57 had an approximately dime sized purple spot on her left buttock that started peeling. She said Resident #57 might have got it from sitting up in her wheelchair too long because she argued with them about not wanting to lie down. CNA D said they asked night shift to lay her down sometimes and therapy did not always let them know when they were through with exercises and she was left sitting up in her wheelchair. During an observation and interview on 04/25/19 at 8:13 AM, Resident #57 was sitting up in her bed on the low air loss mattress. She said she was told the sore on her bottom was caused from sitting or riding too much in her wheelchair. A pressure ulcer treatment policy dated (MONTH) 2014 indicated .review the resident's care plan to assess for any special needs of the resident . Review current Braden Scale . Focus on . Assessing the resident and the current status of the pressure ulcer . Suspected deep tissue injury: purple or maroon localized area of discolored intact skin . Due to damage of underlying soft tissue from pressure and/or shear Unstageable: full thickness tissue loss in which the base of the ulcer is covered by slough . In the sound bed . Wound Care Education Institute accessed 04/26/2019 http://blog.wcei.net/2016/02/is-it-really-a-bruise-get-the-bigger-picture-on-skin-[MEDICAL CONDITION] indicated .Suspected deep tissue injuries (DTIs) share some qualities with bruises in that they are non-blanchable, intact and appear in similar colors - purple or maroon. But here is the key difference DTIs are due from damage from pressure or shear. You are more likely to find them over a bony prominence and in patients with a history of immobility unlike bruises, DTIs deteriorate rapidly . The National Pressure Ulcer Advisory Panel at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 5/1/19 noted the following pressure ulcer definitions: .The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The initial pressure ulcer stage does not change despite healing. If the pressure ulcer has been classified at a higher numerical stage than what it was observed, it should be continued to be classified as the higher numerical stage . .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed . https://www.npuap.org/wp-content/uploads/2012/03/Shear_slides_with_animation.pdf accessed 04/26/19 indicated .shear is understood to be a major contributor to the formation of pressure ulcers . https://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf accessed 04/26/19 indicated .Adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown .

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 residents reviewed for ADLs. (Resident #s 3 and 4) Resident #3 requested assistance with incontinent care after recieving her breakfast in bed. CNA A did not assist Resident #3 with incontinent care; the CNA said she could not provide incontinent care since breakfast trays had been passed on the hall. Resident #3 said she was embarrassed, felt helpless and wanted to cry. Resident #4 was in bed begging for water, but her call light was out of reach on the floor; therefore, she could not call for assistance. This failure could place the 18 residents who were totally dependent upon staff at risk for a decline in their ADLs, self-esteem and nutrition. Findings included: 1. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 had clear speech, understood others and made herself understood. Resident #3 was cognitively intact . This MDS indicated Resident #3 was always incontinent of bowel and bladder and was totally dependent upon two staff members for transfers, toilet use and bathing. This MDS indicated Resident #3 was diagnosed with [REDACTED]. A care plan dated 08/14/17 indicated Resident #3 had self-care deficits and required assistance with ADLs as noted: 2 person total assist with bathing, toileting and transferring. The goal was for all of Resident #3's ADL care needs to be met per staff and she will be kept clean, dry and odor free. Approaches included .assure call light is within reach and answered promptly .assure of proper peri care after each incontinent episode .turn and reposition every 2 hours . This care plan was reviewed and continued 10/11/17. During a continuous observation and interview on 10/18/17 at 8:48 a.m., Resident #3 was laying on her back in her bed with the head of the bed elevated and covered with only a sheet. There was a bed pad underneath Resident #3 that had a large brown and yellow ring and the acidic smell of urine was very strong. Resident #3 said she was so [***] ing cold because her sheet and her gown were soaked with urine. The bottom of Resident #3's hospital gown was dark green and wet as she held it up for this surveyor to see. Resident #3's sheet was also wet. Resident #3 said her back was wet and was observed to visibly shiver. She was positioned sideways in the bed with her head bent forward and chin touching her chest. She complained of pain due to how her body was positioned because she said she could not reposition herself, they have to help me. And I don't know why they left my head so high. Resident #3 said she had pressed her call light and told CNA A she was wet and needed incontinent care about 6:30 a.m. but was told she had to wait. She said she was changed during the Resident #3 said the staff frequently turn her call light off without providing the needed care and told she had to wait. She said it usually took the CNAs about an hour to come back after they turned off her call light without assisting her. Resident #3 said, I'm embarrassed because I stink and can't do anything about it. They tell me I have to wait in pee and don't think about how the person in this situation must feel. I'm helpless and they don't care. They take their time coming back and all I can do is lay here cold and feeling like[***] I wanna cry. During a continuous observation on 10/18/17 at 9:01 a.m., Resident #3 pressed her call light button. At 9:24 a.m., Student N entered the room, turned off the call light and, without asking Resident #3 what she needed, said We will have to get back to you. Student N pulled back the privacy curtain, saw the surveyor at bedside and said, Oh, (Resident #3) what do you need? Resident #3 said she was cold and wet and needed to be changed. Student N left the room. CNA A returned at 9:33 a.m. to provide incontinent care. During an interview on 10/18/17 at 9:35 a.m., CNA A said she worked the 6:00 a.m. - 6:00 p.m. shift. CNA A said Resident #3 had not been provided incontinent or had her brief changed this shift. CNA A said Resident #3 complained of being wet and asked for incontinent care this morning when I delivered her breakfast tray around 8:30 a.m. A written statement delivered to the state agency office by the Administrator on 10/19/17 at 1:10 p.m., CNA A wrote she worked Resident #3's hall on 10/18/17 and at 7:45 a.m. she delivered breakfast trays. CNA A wrote she sat (Resident #3's) tray down and sat her up in the bed for breakfast. (Resident #3) then notified me that she was wet and needed to be changed. I looked at her brief and saw that only one line on it had changed colors. I then informed (Resident #3) we could not change her at the moment because there were breakfast trays on the hall and her roommate (Resident #4) was eating in her room .I then told (Resident #3) we would change her after breakfast and we had picked up trays off the hall. After we picked up trays .we noticed that two of our fall risk residents were trying to get in bed. So we attended to them before changing (Resident #3) .the state surveyor asked when Resident #3 began asking me (CNA A) to be changed. I informed her (the state surveyor) she (Resident #3) asked when I gave her, her breakfast tray. I then explained to her (the state surveyor) that we had other resident that had to be attended to before we had made it to (Resident #3) around 9:30 a.m.we noticed the pad looked wet. A written statement delivered to the state agency office by the Administrator on 10/19/17 at 1:10 p.m., CNA B wrote he responded to Resident #3's call light at 8:45 a.m. on 10/18/17 and Resident #3 said she needed to be changed. CNA B wrote Resident #3 was changed around 9:30 a.m. During an interview on 10/19/17 at 1:21 p.m., the Owner said Resident #3 did not always tell the truth. 2. admission orders [REDACTED]. Resident #4 was ordered a regular mechanical soft diet, a pressure alarm for her bed and she was to be in the feeder room for all meals. An undated preliminary care plan indicated Resident #4 was alert and oriented to self, place and circumstances, required assistance with transfers, bed mobility, eating, grooming and toilet use and utilized a wheelchair for ambulation. This plan indicated she was continent of bowel and bladder with a regular mechanical soft diet. A fall risk evaluation dated 10/17/17 indicated Resident #4 scored a total of 15, which placed her at high risk for falls. A Safe Smoking assessment dated [DATE] indicated Resident #4's short and long term memory was OK but she was unable to make competent decisions. During an observation and interview on 10/18/17 at 8:45 a.m., Resident #4 was laying cross ways in her bed with her call light out of reach and no bed alarm. The call light was wrapped in the oxygen tubing underneath the bedside table without a clamp. Resident #4 did not have ice or water pitcher in her room. Resident #4 was on her back with her arms outstretched repeating Water! Water! Resident #4 said she had not had water or anything to drink all night. Resident #4 said, Please, help me! Please, I'm thirsty, please, water, water! During a continuous observation on 10/18/17 from 9:01 until 9:33 a.m., and from 9:38 a.m., until 10:08 a.m., Resident #4 was laying in her bed with her call light out of reach and no bed alarm. She did not have ice or water pitcher in her room. Resident #4 was on her back with her arms outstretched repeating Water! Water! During an observation and interview on 10/18/17 at 9:36 a.m., Resident #7 was observed ambulating in the hallway outside of Resident #4's room with a water pitcher in hand. Resident #7 said she was thirsty. She said the CNAs had not passed ice or water this morning so she was getting her own. Resident #7 was observed to get ice from a blue cooler in the corner by the 100 hall shower room without staff assistance. During an observation and interview on 10/18/17 at 10:08 a.m., the SW provided Resident #4 with water. The SW said she was very thirsty. LVN C was present in the room at this time. A written statement delivered to the state agency office by the administrator on 10/19/17 at 1:10 p.m., CNA A wrote she worked Resident #4's hall on 10/18/17 and at 7:45 a.m. she delivered breakfast trays. CNA A wrote Resident #4 was eating breakfast in her room unassisted. During an interview on 10/18/17 at 11:00 a.m., LVN C said Resident #4 was very thirsty. She said she did not know why Resident #4 did not have water or a water pitcher available to her. LVN C said Resident #4 had no fluid restrictions. LVN C said she did not know Resident #4 required assistance with meals and Resident #4 was served her breakfast in her bed. LVN C said she did not know if Resident #4 had fluids with breakfast or not because she ate unassisted this morning. During an interview on 10/18/17 at 1:00 p.m., the ADON said Resident #4 was not on any fluid restrictions and should have had water available at her bedside and within reach. The ADON said the CNA's usually pass water and ice between 10:00 a.m. and 10:30 a.m. every morning but were late this morning because she and the DON told them to focus on making all of the resident's restrooms were clean, commodes secured to the floor and shower rooms in order because of yesterday's environmental concerns. During an interview on 10/18/17 at 3:13 p.m., the DON said she saw Resident #4 in the dining room for breakfast and was sure she had fluids with her meals. During an interview on 10/18/17 at 3:21 p.m., DON, ADON and the MDS Coordinator said fluid intake was not documented so they had no way of knowing for sure if Resident #4 had fluids or not. They said it was a problem Resident #4 needed help and couldn't get it. The CMS 672, dated 10/17/17, indicated there were 18 residents were totally dependent upon staff.

Based on observation, interview and record review, the facility failed to ensure treatment and care was provided for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 7 residents reviewed for dignity. (Resident # 3) Resident #3 requested assistance with incontinent care after receiving her breakfast in bed. CNA A did not assist Resident #3 with incontinent care; the CNA said she could not provide incontinent care since breakfast trays had been passed on the hall. Resident #3 said she was embarrassed, felt helpless and wanted to cry. This failure could place the 18 residents who were totally dependent upon staff for toilet use at risk for decreased self-esteem and self-worth as well as increased depression. Findings included: Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 had clear speech, understood others and made herself understood. Resident #3 was cognitively intact. This MDS indicated Resident #3 was always incontinent of bowel and bladder and totally dependent upon two staff members for transfers, toilet use and bathing. A care plan dated 08/14/17 indicated Resident #3 had self-care deficits and required total assistance of 2 staff persons with bathing, toileting and transferring. The goal was for all of Resident #3's ADL care needs to be met per staff and she .will be kept clean, dry and odor free . Approaches included .assure call light is within reach and answered promptly .assure of proper peri care after each incontinent episode .turn and reposition every 2 hours . This care plan was reviewed and continued on 10/11/17. During a continuous observation and interview on 10/18/17 at 8:48 a.m. until 9:33 a.m., Resident #3 was lying on her back in her bed with the head of the bed elevated and covered with only a sheet. There was a bed pad underneath Resident #3 that had a large brown and yellow ring. The acidic smell of urine was very strong. Resident #3 said she was so [***] ing cold because her sheet and her gown were soaked with urine. The bottom of Resident #3's hospital gown was dark green and wet. Resident #3's sheet was also wet. Resident #3 said her back was wet and she was visibly shivering. She was positioned sideways in the bed with her head bent forward and chin touching her chest. Resident #3 complained of pain due to how her body was positioned because she said she could not re-position herself, they have to help me. And I don't know why they left my head so high. Resident #3 said she had pressed her call light and told CNA A she was wet and needed incontinent care about 6:30 a.m., but was told she had to wait. She said she was changed during the 10:00 p.m. to 6:00 a.m., shift. Resident #3 said the staff frequently turned her call light off without providing the needed care and told she had to wait. She said it usually took the CNAs about an hour to come back after they turned off her call light without assisting her. Resident #3 said, I'm embarrassed because I stink and can't do anything about it. They tell me I have to wait in pee and don't think about how the person in this situation must feel. I'm helpless and they don't care. They take their time coming back and all I can do is lay here cold and feeling like[***] I wanna cry. During a continuous observation on 10/18/17 at 9:01 a.m. until 9:33 a.m., Resident #3 pressed her call light button. At 9:24 a.m., Student N entered the room, turned off the call light and, without asking Resident #3 what she needed, said We will have to get back to you. Student N pulled back the privacy curtain, saw the surveyor at bedside and said, Oh, (Resident #3) what do you need? Resident #3 said she was cold and wet and needed to be changed. Student N left the room. CNA A returned at 9:33 a.m., and provided incontinent care for Resident #3. During an interview on 10/18/17 at 9:35 a.m., CNA A said she worked the 6:00 a.m. - 6:00 p.m. shift. CNA A said Resident #3 had not been provided incontinent or had her brief changed this shift. CNA A said Resident #3 complained of being wet and asked for incontinent care this morning when I delivered her breakfast tray around 8:30 a.m. A written statement delivered to the state agency office by the administrator on 10/19/17 at 1:10 p.m., CNA A wrote she worked Resident #3's hall on 10/18/17 and at 7:45 a.m. she delivered breakfast trays. CNA A wrote she sat (Resident #3's) tray down and sat her up in the bed for breakfast. (Resident #3) then notified me that she was wet and needed to be changed. I looked at her brief and saw that only one line on it had changed colors. I then informed (Resident #3) we could not change her at the moment because there were breakfast trays on the hall and her roommate (Resident #4) was eating in her room .I then told (Resident #3) we would change her after breakfast and we had picked up trays off the hall. After we picked up trays .we noticed that two of our fall risk residents were trying to get in bed. So we attended to them before changing (Resident #3) .the state surveyor asked when Resident #3 began asking me (CNA A) to be changed. I informed her (the state surveyor) she (Resident #3) asked when I gave her, her breakfast tray. I then explained to her (the state surveyor) that we had other resident that had to be attended to before we had made it to (Resident #3) around 9:30 a.m.we noticed the pad looked wet. A written statement delivered to the state agency office by the administrator on 10/19/17 at 1:10 p.m., CNA B wrote he responded to Resident #3's call light at 8:45 a.m. on 10/18/17 and Resident #3 said she needed to be changed. CNA B wrote Resident #3 was changed around 9:30 a.m. During an interview on 10/19/17 at 1:21 p.m., the facility owner said Resident #3 did not always tell the truth. The CMS 672, dated 10/17/17, indicated there were 18 residents were totally dependent upon staff for toilet use.

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 3 of 4 residents reviewed for pressure injuries. (Resident #s 37, 22, and 5) 1. Resident #37 was identified as being at risk for pressure injuries. The resident developed a facility -acquired pressure injury to his left lateral foot that was not identified by staff until it was unstageable. The facility did not address or provide the resident with pressure relief. 2. Resident #22 was admitted without pressure injuries and was at low risk for the development of pressure injuries. The resident developed two facility-acquired pressure injuries that worsened to unstageable. The facility did not provide the resident with pressure relief. 3. The facility did not ensure pressure relief for Resident #5's bilateral ankles. Both ankles had Stage 3 non-healing pressure injuries. This failure could place 8 residents with pressure injuries at risk for the development of new pressure injuries or worsening of existing pressure injuries. Findings included: 1.Physician orders [REDACTED].#37, admitted [DATE] was an [AGE] year old male with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The most recent MDS dated [DATE] indicated memory problems, moderately impaired cognitive skills, and fluctuating behaviors of inattention and disorganized thinking. The MDS also indicated Resident #37 was totally dependent on staff for ADLs and always incontinent of bowel and bladder. Resident #37 had impaired range of motion in both lower extremities. Resident #37 was at risk of developing pressure injury and had a stage 4 pressure injury measuring 1 cm (centimeter) (length) x 0.8 cm (width) x 0.2 cm (depth) and containing slough at the time of the assessment. There were no pressure injuries on the prior assessment. A care plan dated 1/1/16 indicated interventions for an unstageable wound on Resident #37's left foot including special air bed, turning every two hours while in bed and every hour when in Geri chair. A non-pressure skin condition report for Resident #37 dated 1/1/16 indicated a red blanchable area to side of right foot with unstageable area measuring 1 cm x 1 cm. During an interview on 5/18/16 at 10:00 a.m., LVN F said the non-pressure skin condition report for Resident #37 dated 1/1/16 incorrectly identified the location of the unstageable wound as Resident #37's right foot when it should have indicated his left foot. A resident status sheet for Resident #37 dated 3/27/16 indicated an air mattress and to float (elevate) heels. A physician order [REDACTED]. A physician order [REDACTED]. A weight monitoring sheet dated May 2016 indicated Resident #37 weighed 204.8 pounds. During observation on 5/16/16 at 10:30 a.m. and 4:15 p.m., Resident #37's air mattress was on the firmest setting, 350 pounds. During observations on 5/17/16 at 9:10 a.m., 12.20 p.m. and 3:30 p.m., Resident #37's air mattress was set at the midpoint between 300 - 350 pounds. During an interview on 5/17/16 at 4:00 p.m., the RN consultant said the settings for air mattresses should be based on Resident #37's weight and nurses should check the settings of the air mattress to ensure they were set to the correct weight. During an observation and interview on 5/17/16 at 4:20 p.m., Resident #37's air mattress was set at the midpoint between 300-350 pounds. LVN D said she did not know anything about the settings on the air mattress. During an observation and interview on 5/16/16 at 16:15 a.m., CNA E said she routinely provided care for Resident #37 and that his heels were supposed to be elevated. Resident #37s heels were touching the mattress. Weekly pressure ulcer records indicated the following progression of Resident #37's unstageable pressure injury left lateral foot: 1/8/16 1.0 cm x 1.0 cm x 0.0 depth with dark purple wound bed; 1/15/16 0.4 cm x 0.5 cm, unable to determine depth with dark purple wound bed; 1/22/16 0.5 cm x 0.5 cm x 0.1 cm depth with 100 % granulation; 1/29/16 0.7 cm X 0.7 cm x 0.0 cm depth with dark brown wound bed; 2/5/16 0.8 cm x 0.7 cm x 0.0 depth with 100 % yellow slough in wound bed; 2/12/16 0.7 cm x 0.7 cm x 0.2 cm depth with 100 % granulation in wound bed; 2/19/16 0.9 cm x 0.9 cm x 0.3 cm depth with 100 % granulation in wound bed; 2/26/16 1.0 cm x 0.6 cm x 0.2 cm depth with 50% granulation and 50% yellow slough; 3/4/16 1 cm x 0.8 cm x 0.2 cm depth with 50% granulation and 50% yellow slough; 3/11/16 1 cm x 0.8 cm x 0.2 cm depth with 50% granulation and 50% yellow slough 3/18/16 1.2 cm x 1.3 cm x 0.2 cm depth with 50% granulation and 50% yellow slough; 3/25/16 1.4 cm x 1.0 cm x 0.2 cm depth with 50% granulation and 50% yellow slough; 4/1/16 1 cm x 1 cm x 0.2 cm depth with 50% granulation and 50% yellow slough; 4/8/16 1.0 cm x 1.2 cm x 0.2 cm depth wound bed red with yellow around edges; 4/15/16 1.0 cm x 1.2 cm x 0.2 cm depth wound bed red with yellow around edges; 4/22/16 1.5 cm x 1.0 cm x 0.2 cm depth wound bed 100% red; 4/29/16 1.0 cm x 0.6 cm x 0.2 depth with 100% granulation; 5/6/16 1.0 cm x 0.9 cm x 0.2 cm depth with 100% granulation; and 5/16/16 0.8 cm x 0.6 cm x 0.2 cm depth with100% granulation. During observation of wound care and interview on 5/18/16 at 10:15 a.m., pressure ulcer on Resident #37's left lateral foot measured 0.9 cm long x 0.7 cm wide x 0.1 cm deep. The wound bed had 75% granulation tissue and 25% slough. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 05/20/16 indicated the following: Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed . 2. Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders included bed cradle, Arginade (supplement to promote wound healing) twice a day, and Stress tablet (supplement) daily. The most recent MDS dated [DATE] indicated Resident #22 had moderately impaired cognition, required limited assistance with bed mobility, and had no pressure injuries. A Braden scale for predicting pressure injury risk dated 04/10/16 indicated Resident #22 was at low risk for pressure injury development. A care plan initiated 04/17/16 indicated Resident #22 had the potential for alteration in skin integrity related to fragile skin. Interventions included skin assessments weekly. A care plan initiated on 04/21/16 indicated Resident #22 had an unstageable pressure injury to the left and right great toe. A weekly pressure ulcer record for Resident #22 dated 04/21/16 indicated a Stage 2 to the left great toe measuring 1.2 cm x 1 cm x less than 0.2 in depth. The wound bed had 100 % granulation. The right great toe was noted unstageable with a 100% blood blister to the wound bed. The wound measured 1 cm x 1 cm. The preventive measures included turn every two hours, pillows for repositioning, multivitamins, and bed cradle. A telephone order for Resident #22 dated 04/21/16 indicated clean the left great toe with normal saline and apply collagen. The order noted to apply sureprep to the right great toe. A telephone order for Resident #22 dated 04/26/16 indicated to discontinue collagen and apply sure prep twice day to the left great toe. The order for the right great toe remained unchanged. The weekly pressure ulcer record for Resident #22 dated 04/29/16 indicated the wound to the left great toe increased in size. It measured 1.5 cm x 1 cm x less than 0.2 cm in depth. The wound bed had 100% dark granulation. The right great toe worsened. The size of the wound remained unchanged but pressure injury had 100% black eschar. There were no changes in the preventive measures. They included turn every two hours, pillows for repositioning, multivitamins, and bed cradle. A telephone order for Resident #22 dated 04/29/16 noted to discontinue the bed cradle. The weekly pressure ulcer record for Resident #22 dated 05/06/16 indicated the wound to the left great toe worsened to unstageable. It measured 1.1 cm x 1 cm. The wound bed had dark eschar. Preventative measures included turn every two hours, pillows for positioning, and multivitamins. During an observation on 05/16/16 at 2:45 p.m., Resident #22 was observed lying in bed wearing heel booties. Resident #22 has black eschar to the top of his left and right great toe. During and observation on 05/16/16 at 4:45 p.m., Resident #22 was observed lying in bed under a blanket, bedspread and sheet which rested on his feet. During and observation on 05/17/16 at 12:16 p.m., Resident #22 was observed lying in bed under a blanket, bedspread and sheet which rested on his feet. During an interview on 05/17/16 at 3:51 p.m., the RN consultant said the bed cradle was discontinued because the resident kept his foot against it but they were not sure if it caused the pressure injuries. The RN consultant then stated, I don't know what else we could have done. The Regional Nurse Consultant said Resident #22 was put on a low bed after a fall and the the bed cradle would not fit on his bed. During an observation and interview on 05/18/16 at 9:45 a.m., Resident #22 had a bed cradle on his low bed. The DON and ADON said they found it in storage. The ADON stated, It works keeping the blankets and sheets off his feet. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 05/20/16 indicated the following: .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 3. Physician orders [REDACTED].#5 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders also indicated Resident #5 had Stage 4 pressure injuries to her right and left ankle. The most recent MDS dated [DATE] indicated Resident #5 had severely impaired cognition, was totally dependent on staff for all activities of daily living, had impaired range of motion to all extremities, was totally incontinent, and could not communicate needs. The MDS also indicated Resident #5 had one Stage 3, four Stage 4, and one unstageable pressure injuries. Care plans for Resident #5 dated 04/14/16 indicated the onset date of the left ankle pressure injury was 11/25/14 and onset date of the right ankle pressure injury was 03/19/15. The care plans indicated both pressure injuries were unstageable. The care plans for each pressure injury was identical and interventions included: special air bed, positioning pillows, heel protectors,and turn every two hours. The care plan had no updates or specific instructions for relieving pressure to Resident #5's right and left ankles. During an interview on 05/17/16 at 3:50 p.m., the RN consultant said she did all the care plans and all care plans were on the residents' charts. A Braden scale for Resident #5 dated 04/14/16 indicated she was a moderate risk for pressure injury development. Weekly pressure ulcer records for Resident #5 indicated the following: 05/13/16: left ankle, Stage 4, 1.6 x 1.2 x 0.2 cm, large amount of serosanguinous (blood/serum) drainage 05/13/16: right ankle, Stage 4, 2.0 x 1.5 x 0.2, large amount of serosanguinous drainage. An undated weight record indicated Resident #5's May 2016 weight was 154 pounds. During an observation on 05/16/16 at 9:59 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was 320 pounds. During an observation on 05/16/16 at 3:25 p.m., Resident #5 was lying on her left side in bed. She had heel protectors on both feet and her left ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was 320 pounds. During an observation on 05/17/16 at 10:10 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was 320 pounds. During an observation on 05/17/16 at 11:43 a.m., Resident #5 was lying on her left side in bed. She had heel protectors on both feet and her left ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was 320 pounds. During an observation on 05/17/16 at 4:15 p.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was 320 pounds. During an interview on 05/17/16 at 4:50 p.m., the RN consultant said the nurses should be checking air mattresses to ensure they were set to the correct weight. During an observation on 05/18/16 at 10:07 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. Her air mattress setting was now 150 pounds. During an observation and interview on 05/18/16 at 11:03 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. The ADON provided wound care and the DON and CNA G assisted. The left ankle pressure injury was a Stage 4 and measured 2.0 x 1.3 x 0.4 cm. The right ankle pressure injury was a Stage 4 and measured 0.8 x 0.7 x 0.4 cm. When wound care was completed, the ADON left the room. CNA G put heel protectors on both feet and the DON assisted positioning Resident #5 on her right side. Her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. The DON and CNA pulled up the covers. During an interview on 05/18/16 at 11:55 a.m., the ADON said the charge nurses had been doing residents' treatments, but she was now doing them. She said Resident #5's wounds were chronic. She was not aware that Resident #5 had unrelieved pressure to the pressure injuries on both ankles. The ADON said she would see if hospice could get a different mattress. During an observation and interview on 05/18/16 at 4:25 p.m., Resident #5 was lying on her left side in bed. She had a heel protector on her left foot and her left ankle was lying on the bed with nothing to float the ankle and relieve pressure. A PROFO (pressure relief ankle foot orthosis) boot was on her right lower extremity. The ADON said only one boot came and the other would be delivered tomorrow. The ADON said the boot was on her right foot because the physician said to put the boot on the worst wound which was the right. During an observation on 05/19/16 at 5:06 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. She did not have the PROFO boot on either foot. The boot was on the floor by the closet. During an observation on 05/19/16 at 9:55 a.m., Resident #5 was lying on her right side in bed. She had heel protectors on both feet and her right ankle was lying on the bed with nothing to float the ankle and relieve pressure. She did not have the PROFO boot on either foot. The boot was on the floor by the closet. A Prevention of Pressure Ulcers care plan revised February 2014 indicated the following: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time .2. The most common site of a pressure ulcer is where the bone is near the surface of the body including .ankles .4. Pressure ulcers are often made worse by continual pressure . Interventions and Preventative Measures: Residents with Risk Factors .5. Risk Factor -- Immobility .b. Use pillows, wedges, or other off-loading devices to keep bony prominences such as knees or ankles from touching each other .c. When in bed, every attempt should be made to 'float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or other devices . The National Pressure Ulcer Advisory Panel website http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Pressure-Ulcer-Stages-Categories.pdf accessed 05/19/16 indicated the following: Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The CMS 672 dated 05/16/16 indicated 8 residents had pressure injuries.