Every finding on record at Kingwood Rehabilitation and Healthcare Center

Based on observation, interview, and record review the facility failed to ensure the environment remained as free of accident hazards as possible for 5 of 8 residents' rooms (Resident #16, Resident #10, Resident #34, Resident #59 and Resident #84) and 1 of 1 shower rooms (600 hall shower) reviewed for accidents. The facility failed to maintain water temperatures at a safe temperature level on the 600 hall in Resident #16, Resident #10, Resident #34, Resident #59 and Resident #84's bathroom sinks and the 600-hall shower room. This failure could place residents at risk of injuries and burns. Findings include:Resident #16In an observation and interview on 8/11/26 at 9:51 a.m., Resident #16 was in his wheelchair coming out of the bathroom. He said he did not have any concerns with his care and went to the bathroom on his own.In an observation on 8/12/26 at 9:58 a.m., Resident #16's bathroom sink, this Surveyor took the hot water temperature and the temperature was 124.1 degrees Fahrenheit.Resident #10Record review of Resident #10's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with late onset and type 2 diabetes.Record review of Resident #10's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. She needed assistance from staff with ADL care. In an observation and interview on 8/11/26 at 1:49 p.m., Resident #10's bathroom sink, the hot water was hot to touch, and this Surveyor removed fingers from the water after approximately 3-4 seconds. Resident #10 said she used her restroom sink but mixed the hot and cold water when she used it. She said she never burned herself and did not have concern about the water being too hot.In an observation on 8/12/26 at 10:01 a.m., Resident #10's bathroom sink, this Surveyor took the hot water temperature was 123.4 degrees Fahrenheit.In an observation on 8/12/26 at 11:45 a.m., Resident #10's bathroom sink, the Maintenance Director took the hot water temperature with his thermometer and the temperature was 123.9 degrees Fahrenheit. Maintenance Director said the water was too hot and needed to be adjusted. He said he normally kept the temperature at 115 degrees Fahrenheit.Resident #34Record review of Resident #34's face sheet dated 8/13/26 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included moderate dementia. Record review of Resident #34's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She needed assistance from staff with ADL care.In an observation on 8/12/26 at 10:03 a.m., Resident #34 washed her hands and exited her bathroom. This Surveyor took the hot water temperature of the sink and the temperature was 121.6 degrees Fahrenheit.In an observation on 8/12/26 at 11:50 a.m., Resident #34's bathroom sink, the Maintenance Director took the hot water temperature and the temperature was 122 degrees Fahrenheit. Resident #59In an observation and interview on 8/11/26 at 1:27 p.m., Resident #59's bathroom sink, the hot water was hot to touch, and this Surveyor removed fingers from the water after approximately 2-3 seconds. Resident #59 said she used her bathroom but did not have concerns with the hot water and said she never burned herself. Resident #84Record review of Resident #84's face sheet dated 8/13/26 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses were encephalopathy (group of conditions that cause brain dysfunction), major depressive disorder, and dementia.In an observation and interview on 8/11/26 at 10:14 a.m., Resident #84's bathroom sink, the hot water was hot to touch, and this Surveyor removed fingers from the water after approximately 2 seconds. In an observation on 8/12/26 at 11:52 a.m., Resident #84's bathroom sink, the Maintenance Director took the hot water temperature and the temperature was 123 degrees Fahrenheit. In an observation on 8/12/26 at 11:56 a.m. of the 600-hall shower revealed the temperature of the hot water was 121 degrees Fahrenheit according to the Maintenance Director. In an observation and interview on 8/12/26 at 12:00 p.m., of the hot water tank on the 600 hall revealed the temperature was set to 127 degrees Fahrenheit and then lowered to 120 degrees Fahrenheit by the Maintenance Director. The Maintenance Director said he adjusted the hot water tank temperature to 115 degrees Fahrenheit approximately 3 weeks ago and did not know how the temperature got to 127 degrees Fahrenheit. He said approximately 2 weeks ago he tested the hot water temperatures on the 600 hall in the resident rooms and it measured at 117 degrees Fahrenheit. At the time he did not lower the hot water tank because he thought 117 degrees Fahrenheit was ok. He said he tried to keep the temperature between 110 degrees Fahrenheit and 115 degrees Fahrenheit because if it was too hot it could burn the residents' skin. He did not know how the water temperatures rose from 117 degrees Fahrenheit two weeks ago to the current temperatures of 121 degrees Fahrenheit-124 degrees Fahrenheit and no one complained to him about the hot water.In an interview on 8/12/26 at 2:38 p.m., the Administrator said hot water temperatures out of the residents' faucets/sinks should be between 110 degrees Fahrenheit and 115 degrees Fahrenheit due to regulations and safety. She said the water heater temperature should be lowered and water retested to ensure temperature was in the correct range. The Maintenance Director was responsible to ensure temperatures were in the correct range. She said temperature logs were completed weekly and entered into the work order life safety system. She reviewed the life safety book for completeness and any missing documentation but was more focused on staffing and clinical since she started working at the facility. She said the risk of hot water being above range could range from personal preference to skin irritations or burns. She said no skin burns or irritation was reported or seen and no one expressed concerns over the hot water temperatures to her knowledge.Record review of the facility's policy Safe Water Temperatures revised 4/2026 revealed, .It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy Expectation and Compliance Guidelines:. 5. Water temperatures will be set to a temperature of no more than 115 degrees Fahrenheit, or the state's allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.

Based on observation, interview, and record review, the facility failed to ensure a complete and accurate PASARR screening was completed for residents with a mental disorder or an intellectual disability for 2 of 9 residents (Resident #'s 53 and 70) reviewed for PASARR Level I screenings.The facility did not ensure an accurate PASARR level 1 screening was completed for Resident #53 and Resident #70. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.Findings include:Record review of Resident #53's undated face sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE] with diagnoses of essential hypertension (primary), seizures, hypothyroidism (inadequate thyroid function), atrial fibrillation (abnormal heart rhythm which causes blood clots), urinary retention, bipolar disorder, age related physical debilities, and protein malnutrition. Resident #53 later received diagnoses of dementia (2/10/22), mood disorder (11/29/21), anxiety disorder (4/22/22), adjustment disorder (2/10/22), and depression (1/5/23). Record review of Resident #53's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 indicated severe cognitive impairment. Record review of Resident #53's PASARR level 1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) dated 1/13/25 read in part, .Is there evidence or an indicator this is an individual that has a Mental Illness? No. On a previous undated PASARR from 2021, it read in part, .Is there evidence or an indicator this is an individual that has a Mental Illness? No. On a PASARR dated 09/17/2024 it read in part, .Is there evidence or an indicator this is an individual that has a Mental Illness? No. Observation and interview on 8/11/26 at 10:02 a.m., Resident #53 was lying in a low bed with a fall mat on the side of the bed. She did not respond when asked if she had breakfast, how long she'd been here, and when asked if she had any concerns about her care at the facility. Her family member (Resident in the same room) stated that she doesn't speak and that she's kind of out of it ever since her dementia got to this point.Record review of Resident #70's undated face sheet revealed she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of heart failure and heart disease (primary), COPD (lung disease), chronic kidney disease, type II diabetes, and MDD (Major Depressive Disorder). On 8/14/26 upon examining resident's chart that morning, primary diagnosis was listed as dementia, it had not been the previous evening. Record review of Resident #70's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicated minor cognitive impairment. Observation and interview on 8/11/26 at 10:45 a.m., Resident #70 was lying in a low bed with a fall mat on the side of the bed. She said that she had had a fall last week when trying to transfer herself. She said that she hit her face & her back hurts. She said that the facility is providing pain medication. She said that she is on hospice. Record review of Resident #70's PASARR level 1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) dated 10/7/25 read in part, .Is there evidence or an indicator this is an individual that has a Mental Illness? No. Interview on 08/13/26 at 1:35 p.m., the MDS coordinator said she was admitted with a diagnosis of essential hypertension (on 8/17/21) and a diagnosis with bipolar disorder (8/17/21). She said that Resident #53's PASARR level 1 screenings dated 9/17/24 and 1/13/25 were negative and was unsure why mental illness was marked no by the previous MDS nurse. She said bipolar disorder and MDD were listed in the Diagnostic and Statistic Manual for mental disorders. She said Resident #53 and #70 were unable to have a PASARR Evaluation completed because their PASARR screening was negative. She said she was responsible for the accuracy of the PASARR screenings to ensure residents received services if needed. She said she had taken this position over within the last several months and had reviewed the PASARR screenings. She said she thought she reviewed Resident #70's screening but must have missed that they put negative for mental health. She said she must have overlooked Resident #'s PASARR and accidentally missed where question 2 was answered no for mental illness. She said upon hire she was provided with a PASARR guide but was not instructed to review screenings for residents who already resided in the facility. She stated that PASARR is so comprehensive that it can be confusing and hard to understand, but she will have every resident chart reviewed to ensure that all resident screenings are complete, accurate, and up to date. She said that the risks to a resident with an inaccurate PASARR could be danger to the resident. Interview on 08/13/26 at 3:43 p.m., the DON stated that she is unable to answer questions about PASARR due to her having just taken over the position 2 weeks prior. She stated that her expectation is for the MDS nurse to review residents' PASARR regularly (quarterly at minimum) for changes in screening. She said whenever there is an in house change for the resident then PASARR should be reviewed.Interview on 8/13/26 at 4:05 p.m., the Administrator stated that her expectation is for the MDS nurse to reevaluate residents for PASARR screening whenever there is a quarterly care plan review, when the MDS is due, and anytime there is a significant change. She said the interdisciplinary team should also be communicating and coordinating with the MDS nurse. She said that residents seeing psychiatry and psychology should be frequently reevaluated for any new diagnoses. She stated that she will have every resident audited to ensure there are no other residents with inaccurate PASARR. She said the risks to residents with an inaccurate PASARR could be them missing out on essential services that they need and are entitled to. Record review of the facility's admission PASARR Protocols policy dated 3/23 read in part, .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.a.PASARR Level I - initial pre-screening that is completed prior to admissioni.Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.ii.Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission.b.PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include:c.A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).d.A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.Record review of Texas Health and Human Services Detailed Item by Item Guide for completing the PASARR Level I Screening Form for Referring Entities Version 1.0 dated November 2019 provided by the Administrator read in part, .Section C: PASARR Screen. Intent: this section is to be completed by the referring entity for people suspected of having mental illness, or an intellectual or developmental disability. Steps for Assessment: A. conduct psychiatric diagnostic evaluation or identify current diagnoses. C 0100. Mental Illness . a mental illness is defined as the following: a schizophrenic, mood paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability.Record review of Texas Health and Human Services Mental Illness/Dementia Resident Review form dated September 2018 provided by the social worker read in part, .Definition of MI: a schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but Not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder.

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #84) reviewed for care plans.The facility failed to ensure Resident #84's fall mat was in place on 8/11/26 and 8/13/26 according to the plan of care.This failure could place residents at risk of injury and unmet needs.Findings included:Record review of Resident #84's face sheet dated 8/13/26 revealed an [AGE] year-old female who readmitted on [DATE]. Her diagnoses were encephalopathy (group of conditions that cause brain dysfunction), contusion of scalp (bruise on the scalp caused by trauma that damages small blood vessels without breaking the skin), major depressive disorder, and dementia.Record review of Resident #84's significant change in status MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. She needed assistance from staff with ADL care. She had no falls indicated since admission/entry or reentry or the prior assessment.Record review of Resident #84's care plan dated 7/27/26 revealed she had an actual fall with injury, hematoma (a solid swelling of clotted blood within the tissues), laceration to her head (a tear or ragged cut in skin or flesh), related poor body balance, resident favors one side of the body, initiated 7/5/26. Interventions included to place floor mat to the left side of bed.In an observation and interview on 8/11/26 at 10:14 a.m., Resident #84 was lying in bed with no fall mat at the bedside. She said she previously had a fall during a brief change and hit her head on the edge of the bed. She said after the fall facility staff added a grab bar to her bed to aid with turning but said she did not have a fall mat. In an observation and interview on 8/13/26 at 9:01 a.m., Resident #84 was in bed with no fall mat at the bedside. There was a fall mat propped up against the wall behind a chair. Resident #84 said she did not have a fall mat. In an observation and interview on 8/13/26 at 12:18 p.m., CNA S said Resident #84 was a fall risk because she previously had a fall. She said the nurse normally instructed her on what was needed for the resident. She said the resident had a fall mat in the room, but it might have been taken out to be cleaned. She said the last time she saw the fall mat in place was Monday, August 10th. Observation revealed CNA S entered Resident #84's room, retrieved the fall mat from the wall and placed it on the floor at the resident's bedside. She said she had not noticed the fall mat up against the wall and the mat was important in case she fell. In an interview on 8/13/26 at 1:01 p.m., the DON said Resident #84's fall mat was against the wall. She was unsure why Resident #84 required a fall mat but said she was responsible to ensure fall interventions were followed from the plan of care. She said if the fall mat was not in place and the resident had a fall; she could injure herself.In an interview on 8/13/26 at 2:32 p.m., the ADON said during morning angel rounds staff normally checked resident rooms for various things including floor mats. She said sometimes housekeeping staff move the floor to mop and clean the floor. She saw the floor in place around 6 a.m. this morning (8/13/26) but the CNAs started moving around in the room and could move the mat for easier access to the resident. She said she saw that the fall mat was not on the floor yesterday 8/12/26 and mid-morning. She reported it to someone but was running down the hall.In an interview on 8/13/26 at 2:44 p.m., the Administrator said she expected staff to place the fall mat back in place after providing care to help prevent injury in case of a fall. Record review of the facility's Comprehensive Care Plans policy revised 4/2026 revealed in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record review the facility failed to ensure that residents who required colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of three residents (Resident #2) reviewed for quality of care. The facility failed to ensure adequate and consistent colostomy care was provided every 3 days. Resident #2 went 6 days without her colostomy bag being changed. This failure could place residents at risk of physical and mental health decline and could cause pain and further discomfort.Findings include: Record review of Resident #2's face sheet, dated 07/22/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included dementia (persistent loss of intellectual functioning), paraplegia (paralysis of the legs and lower body), type 2 diabetes mellitus (high blood sugar), morbid (severe) obesity due to excess calories, colostomy status (a surgical opening in the colon for the abdomen), urogenital implants (surgical device to assist in the function of urinary tract), unspecified convulsions (seizures), neuromuscular dysfunction of bladder (nerve and muscles that control the bladder muscle does not function properly), insomnia (hard to fall asleep), pressure ulcer of left buttock/Stage 4, carrier of carbapenem-resistant Acinetobacter baumanni (antibiotic resistance genes that allow the bacteria to make enzymes), overactive bladder (sudden need to urinate), vitamin D deficiency (lack of vitamin D in the body), chronic pain syndrome, chronic embolism and thrombosis (blood clot) (forms or persists in the large vein that carries deoxygenated blood from the lower body to the heart) of inferior vena cava (major veins of the body), gastroparesis (muscles in the stomach do not move food as they should) and bacterial infection (single-celled microorganisms, enter the body and grow uncontrollably or produce toxins that damage tissues). Record review of Resident #2's Annual MDS, dated [DATE], revealed she had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #2 ambulated with a wheelchair and was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear and required substantial/maximal assistance for shower/bathe self, upper body dressing, and personal hygiene. Resident #2 was also dependent on staff for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, tub/shower and sit to stand and walk 10 feet did not occur. Resident #2 had an indwelling catheter and ostomy. Record review of Resident #2's Care Plan, dated 6/2/26, revealed Resident #2 had a colostomy at LLQ, dated 1/3/25, and she was to have adequate emptying of bowels daily and evidence any signs or symptoms of obstruction or constipation. The interventions were to monitor bowel output daily, nursing staff would change colostomy bag as needed, provide stoma care daily as instructed and PRN and report any abnormalities to the MD, LPN and RP. Record review of Resident #2's Orders, as of 7/22/26, revealed:Colostomy to LLQ as needed change colostomy bag and wafer as needed, dated 5/27/25.Colostomy to LLQ every day shift every 3 days (s) change colostomy bag and wafer every 3 days, dated 5/28/25.Colostomy to LLQ every shift colostomy care Q shift and PRN use stoma paste and/or powder around the ostomy, dated 5/27/25.Enhanced suprapubic catheter every shift with high-contact care activities, dated 6/5/25. Record review of Resident #2's MAR revealed:Colostomy to LLQ every day shift every 3 day(s) change colostomy bag and wafer every 3 days order, dated 5/27/25 on 7/19/26 it was signed by LVN C. Record review of Resident #2's Progress notes did not reveal the Colostomy bag was changed on 7/17/26, 7/18/26, 7/19/26, 7/20/26 or 7/21/26. In an interview on 7/22/26 at 8:50 AM with Resident #2, she stated some of the staff took care of her colostomy bag and some of them did not. Resident #2 stated some if the CNA's didn't know how to let the air out of the colostomy bag. Resident #2 stated the staff changed her colostomy bag today. Resident #2 explained she had the same colostomy bag on for 6 days because the nurse on the 2 to 10 PM shift forgot. She stated the colostomy bag was just changed this morning. Resident #2 stated the colostomy bag was usually changed every 3 days by the nurse. Resident #2 said there was a lot of redness and blood sometime and the skin around the colostomy was really sore and it was because they had not been changing the colostomy bag. She stated the CNA's should be trained to at least burp the colostomy (let the gas out), but they went to get the nurse. Resident #2 stated her colostomy lasted 6 days and she mentioned that it needed to be changed. In an interview on 7/22/26 at 9:10 AM with LVN B, she stated Resident #2 was alert and oriented times 4 and she had a colostomy bag. LVN B stated she changed Resident #1's colostomy bag this morning, 7/22/26 and Resident #2 told her the colostomy was not changed for 6 days. LVN B stated the CNA's were able to burp the colostomy bags, but not change it. LVN B stated she told the night nurse. LVN B stated the colostomy should be changed at least every 3 days. She stated if the bag was in tack and her skin was good it was alright. LVN B stated it was Resident #2's preference to have it changed more often. LVN B stated the protocol for Resident #2 was 3 days. In an interview on 7/22/26 at 10:27 AM with RN A, she stated she was the weekend supervisor, but she did not work the halls. RN A stated colostomy bags should be changed every 3 days or when they were full. In an interview on 7/22/26 at 10:59 AM with CNA C, she stated she provided care for Resident #2 and she was alert and oriented times 4 (patient was fully aware of their Person, Place, Time, and Situation, indicating normal cognitive function and mental awareness) and she checked Resident #2's colostomy and emptied the colostomy bag and burped it. CNA C stated she worked with Resident #2 yesterday, 7/21/26, and the nurse was LVN D yesterday, 7/21/26. CNA C stated Resident #2 mentioned her colostomy bag had not been changed today, 7/22/26 and she told the nurse and that was why LVN B changed it. CNA C stated she had been burping Resident #2's colostomy bag, but it was the nurses responsibility to keep up with the colostomy bag and the days to make sure it was changed. In an interview on 7/22/26 at 12:10 PM with CNA A, she stated anytime Resident #2 had gas in the colostomy bag they burp it, and if it needed to be emptied, they emptied it. In an interview on 7/23/26 at 10:10 AM, LVN E stated she had only worked at the facility two times on 7/15/26, Wednesday on the (200 Hall) and 7/16/26, Thursday on the 400 and 600 hall. LVN E stated she was PRN. She stated on Wednesday, 7/15/26, the night shift nurse LVN F gave report. LVN E stated she did not recall anything with Resident #2's colostomy. She stated she checked Resident #2's foley, colostomy, blood pressure and blood sugar. She stated Resident #2's colostomy had not been emptied, so she emptied it, and there was residue on the bag, but the bag was flat. LVN E stated the night shift nurse (LVN F) said Resident #2 called her in there a few times for the colostomy. In an interview on 7/23/26 at 11:10 AM with CNA E, she stated she worked the 200 hall most of the time. CNA E stated she worked on 7/17/26, and 7/18/26, and 7/20/26. CNA E stated she worked with Resident #2 sometimes, but she worked the back. CNA E stated she answered Resident #2's call light a lot, even when she did not have Resident #2, she helped her. CNA E stated she was her CNA on 7/20/26. She stated she did not recall noticing if the colostomy bag had been changed or not. She stated Resident #2 had an agency nurse. In an attempted interview on 7/23/26 at 11:33 AM with LVN D, there was no answer and a message could not be left. In an interview on 7/23/26 at 11:35 AM with CNA D, she stated she worked on 7/17/26 Friday, Saturday 7/18/26 and Sunday, 7/19/26 and she answered Resident #2's call light and emptied her colostomy bags. She remembered one day and it was all clear and no bowel movement in it but she did not remember what day it was. CNA D stated every time she went in there it always had BM. She needed to be burped. CNA D stated there was an agency nurse and one time the agency nurse had to leave. In a telephone interview on 7/23/26 at 11:43 AM with LVN C, she stated she was an Agency nurse and she did recall Resident #2. LVN C stated she had to empty her colostomy a few times, and there were no problems. LVN C stated one of the CNA's did not want to empty the colostomy. LVN C stated she was there Saturday, 7/18/26 and Sunday, 7/19/26. LVN C stated she never changed Resident #2's colostomy bag. LVN C stated she received report LVN D changed Resident #2's colostomy on 7/17/26. In an interview on 7/23/26 at 12:14 PM with CNA F she stated she just started working at the facility on 7/2/26. CNA F stated she emptied Resident#2's colostomy bag when asked. She stated there was an agency nurse (LVN D) who changed the colostomy bag. CNA F stated the nurses usually changed the colostomy bag at 5 AM before she went in. CNA F stated she did not see LVN D change the colostomy bag, but she told her she changed it at 5 AM on that morning. CNA F stated Resident #2 called her when it needed to be burped. CNA F stated the colostomy bag was full when she went in. She stated another CNA emptied it before and CNA F stated she emptied it again and put the clamp back on it. CNA F stated on Sunday 7/19/26, she never saw the colostomy bag that full before. CNA F stated she worked Friday 7/17/26, Saturday 7/18/26 and Sunday 7/19/26. CNA F stated the CNA's just emptied and burped the colostomy bag according to her training. In an interview on 7/23/26 at 12:28 PM with the NP, she stated if the colostomy bag was not changed it was not sterile. The NP stated the facility gave Resident #2 a new bag every 3 days and she could get a new bag if she needed it more often. The NP stated the colostomy was a dirty site, and the colostomy bag could become softer and leak more. The NP stated the stoma was not bleeding because of the bag, but it could make the skin burn if not changed. The NP stated the colostomy had two parts and if the colostomy bag was leaking it could burn the skin because it was acid. The NP stated it should have been changed twice in 6 days. In an interview on 7/23/26 at 2:00 PM with the DON, she stated it was important to follow the physician orders. She stated the colostomy order was to change the colostomy bag every 3 days, but it depended on the bags. The DON stated Resident #2 produced a lot of gas. In an interview on 7/23/26 at 2:44 PM with Administrator B, she stated she always instructed her staff to document that Administration was done, but they were not to sign for any other staff. She stated she would have the nurse come in and sign and EMAR. Administrator B stated if Resident #2 did not have her colostomy bag changed there would be a danger of discomfort. Record review of the facility policy, dated 12/2024 and revised on 4/2025, revealed, It is the policy of this facility to ensure that residents who require colostomy, urostomy, or ileostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Definitions: Ostomy - any type of surgically created opening of the gastrointestinal or genitourinary tract for discharge of body waste. Colostomy - a stoma that has been constructed by connecting a part of the colon onto the anterior abdominal wall. The frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's person-centered care plan.

Based on observations , interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 11 residents (CR#1 and Resident # 58) reviewed for adequate supervision and accident hazards. -CR #1 left the faciity on [DATE] around 5:45pm and the facility was not aware of CR #1's whereabouts until 06/20/2025 at 8:42pm when they received notice CR #1 was found walking on the road near the facility . This was determined to be an IJ on 6/26/25 for CR #1's elopement. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 06/29/2025 at 11:40am with the Administrator and DON, While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because the facility's need for continued monitoring of implemented procedures. -There was an empty O2 tank sitting on the floor unsecured in Resident # 58's room. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored. Findings: CR #1 Record review of CR #1's face sheet dated 06/25/2025 reflected an [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included Alzheimer's Disease (a neurodegenerative disorder which causes decline in memory, thinking and behavior), Type 2 diabetes mellitus (high blood sugar), chronic kidney disease, Major Depressive Disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities which disrupts the ability to function in everyday life), Hypertension (high blood pressure), overactive bladder, Dementia (a general term to describe decline in cognitive function, memory loss, difficulty communicating, impaired reasoning and changes in personality), and insomnia (difficulty or inability to sleep). Record review of CR #1's Quarterly MDS dated [DATE], CR #1 had a BIMS score of 6, indicating severe cognitive impairment. CR #1 required partial to moderate assistance with her ADLs including oral and personal hygiene, dressing, showering or bathing, and toileting. She required setup assistance for walking from 10 to 50 feet and supervision for walking 150 feet. CR #1 was frequently incontinent with urine and occasionally incontinent with bowel. Record review of CR #1's care plan captured 06/25/2025, she was care-planned for elopement on 6/20/25, with interventions including 1 to 1 assistance, anticipating and meeting resident needs and explaining/reinforcing why behaviors were inappropriate and/or unacceptable to the resident. CR #1 was not previously care-planned for being at risk of elopement. Record review of CR #1's Kardex care sheet, undated, CR #1 had interventions for staff to report any attempts to exit the facility to the IDT, family and MD as indicated and record in the clinical record. She was also planned for IDT care plan over the phone with resident's RP to review current placement versus close/lock unit due to resident recent elopement. Record review of CR #1's progress notes, on 6/20/2025 at 1:34am she was resting in bed with no distress noted. On 6/20/2025 at 8:41pm, the DON was notified via phone that CR #1 was sitting on the floor by her walker near a college and taken to the ER. RP was notified 6/20/2025 at 9:01pm. On 06/21/2025 at 2:57am, a nurse documented that CR #1 was ordered to be on 1-to-1 supervision when she returned to the facility. CR #1 had returned from the hospital around 4:45am that day. A later note at 1:27pm, CR #1 was documented as being one-on-one care with aide due to an elopement on 6/20/2025 and CR #1 door was open, and resident was able to come in and out with supervision. Further review showed from September 2024 to June 2025, CR #1 was not mentioned having any exit-seeking or elopement incident. Record review of CR #1's elopement risk assessments completed 1/15/2025 and 3/19/2025, the assessments reflected CR#1 had a history of elopement or attempted to leave the facility without informing staff. No interventions were selected for either assessment. An additional elopement risk assessment was completed 06/12/2025 which reflected that CR #1 was marked yes for verbally expressing desire to go home, packing belongings or stayed near the exit, and there was a note reading usually resident sits at the lobby. CR #1 was also selected yes for having Alzheimer's, being cognitively impaired with poor decision-making skills related to intermittent confusion, cognitive deficits or disorientation, ambulating independently and had a walker. Record review of CR #1's psychology assessment on 06/3/2025, CR #1 was seen in her room and reiterated she continued to miss her family and would like to be home with them. Record review of CR #1's skilled nurse charting on 06/21/2025, CR #1 was on 1-on-1 care with an aide due to elopement on 06/20/2025. Record review of CR #1's pain assessment done on 06/21/2025, CR #1 stated not being in pain. Record review of CR #1's skin evaluation done on 06/21/2025, CR #1 refused full body skin assessment, staff evaluated CR #1's upper and lower extremities only with no injuries. Record review of CR #1's 15-minute check sheet for 6/21/2025, she was monitored and staff signed off on her for reasons of fall between 6/21/25 at 4:45am to 9:00pm before being transferred to the hospital. Record review of CR #1's hospital records dated 06/21/2025, CR #1 was found by a bystander who called emergency services when she was found walking unsteadily on the road. Bystander assisted CR #1 to the side of the road until law enforcement came. CR #1 was witnessed falling twice and denied hitting her head or loss of consciousness. CR #1 was brought to the hospital after bystanders saw her acting confused. CR #1 complained of back and neck pain. CR #1 was seen for a fall, AMS and found walking on the road. CR #1 reported chronic lower extremity swelling and the hospital documented CR #1 with pain level of 6. CR #1's CT scan had no acute findings. CR #1 had right leg pain and UTI (asymptomatic). Record review of CR #1's Order Summary dated 06/25/2025, there were no orders for monitoring due to wandering or exit-seeking. CR #1 had orders for Aricept Oral Tablet 10 MG with an order date of 5/21/2025 for dementia, Divalproex Sodium Tab Delayed Release 125 MG with a start date of 11/6/24 for mood disorder, and Escitalopram Oxalate Tab 10 MG with a start date of 11/6/24 for Major depressive disorder. In an interview on 06/25/2025 at 11:40am with CR #1's RP, she said she received a call on 06/202/25 on 9:49pm stating that CR #1 walked out of the building, was fine and going to the hospital. She said when she spoke to staff at the hospital stated her mom was there for 2 hours already and CR #1 was covered in feces. The RP said CR #1 reported to her that she fell in the street. She said the doctor said she had an X-Ray and CT scan completed and the hospital discharged CR #1 back to the facility on [DATE] at 5:00am. Interview on 05/26/2025 at 1:20pm with CNA GG, CNA GG worked at the facility since March 2025 and worked 6am-2pm and 2pm-10pm as needed. CNA GG was not working at the facility when CR #1 eloped and had never seen CR #1 leave before but said CR #1 was always wandering and walking down one particular hall. CNA GG said staff are to round on residents at least every two hours and had in-services on elopement and residents with dementia after the elopement. Interview on 05/26/2025 at 1:29pm with CNA O, CNA O was assisting in the dining room on 06/20/2025 when CR #1 eloped. CNA O received notification CR #1 was missing between 7pm-8pm that same day. CNA O never heard CR #1 saying she wanted to leave the facility. Staff should round every two hours and CNA O rounds every 30 minutes to 1 hour. If a resident was missing, CNA O would try to look for them and if unsuccessful would report the missing resident to the nurse, charge nurse and Administrator immediately. CNA O had an in-service on elopement after CR #1's elopement. Interview on 05/25/2025 at 1:39pm with CNA P, CNA P worked the morning shift on 06/20/2025 and did not see CR #1 leave the facility. The last time CNA P saw CR #1 was around 2:00pm at the end of CNA P's shift. CNA P never saw CR #1 try to leave or vocalize the desire to leave the facility. CNA P did 1-to-1 monitoring for CR #1 when CR #1 was re-admitted to the facility on [DATE].CNA P received 1-to-1 and facility-wide in-service about the elopement policies and procedures after CR#1's elopement. CNA P said she had received in-services on resident elopement and resident with dementia since working at the facility. In an interview on 06/25/2025 at 2:00 PM CNA GP, she stated she had been working at the facility for 3 years. CNA GP said she was not present at work when CR #1 eloped. CNA GP said CR #1 would like to stay in her room a lot but, would come out her room for coffee and activities, and that she was mobile with her walker. CNA GP said CR #1 would say she wanted to go home often and be with her family. She said the hallway exit doors are all locked and would set off the alarms, but the front door to the facility was not locked but now are locked since CR #1 eloped. CNA GP said the front door is important with lots of traffic after dinner because families leave out and sometimes will hold the door open for residents thinking they are okay to be outside alone. She said she doesn't know all the details but believed CR #1 went through the front door. CNA GP stated she has no concerns of any abuse, neglect, or elopement at the facility. In an interview on 06/25/2025 at 3:00 PM with NP B stated she was shocked that CR #1 left the community as CR #1 was not an elopement risk and she was not care-planned for elopement because NP B had not witnessed or heard CR #1 wanting to leave the community. NP B said she was not concerned about change of condition for CR #1 and was aware the results from the hospital returned negative. NP B said CR #1 was mobile with her walker and was active with therapy services and that CR #1 was normally calm and to herself and liked to eat lunch in her room. NP B stated the community was not a restraint/ locked community and did not utilize a wander guard system. NP B said staff were not aware that CR #1 was exit seeking. Staff had been in-serviced since the incident and an alarmed keypad has been implemented to the front door. Interview on 05/25/2025 at 3:05pm with LVN I, LVN I said CR #1 walked around a lot depending on her mood and would sit at nurse's station. In the past, CR #1 would sometimes walk up to and rattle the double doors and staff had to redirect her, but this was not recent. LVN I said CR #1's family was aware of this. LVN I was not there when CR #1 eloped. LVN I had received in-services on resident elopement and resident with dementia before and after CR #1's elopement but she did not remember the dates. CR #1 had never gotten out of the facility so LVN I did not know if risk of elopement would be care-planned but knew that CR #1 was assessed for elopement risk. LVN I did not know CR #1's risk score. Interview on 06/25/2025 at 2:54pm with CNA C, CNA C heard that CR #1's exit-seeking behavior had been going on for some time and staff would redirect her back. CNA C had seen CR #1 in the dining room eating on 6/20/2025 at 5:30pm to 5:40pm and CNA C was taking another resident to their room. CNA C had been notified CR #1 had left around 7:30pm-8:30pm during last rounds. CNA C said when CR #1 came back to the facility she was observed trying to leave the building again. CNA C received in-services on resident elopement and resident with dementia. CNA C would report elopements or missing residents and report it to the charge nurse and document it. CNA C would redirect residents back to the facility if she saw them leave. Interview on 06/25/2025 at 3:44pm with the Administrator and DON, the Administrator said she was the Interim Administrator and began work on 06/02/2025 and the DON was Interim and had started working in the building at the end of May 2025. The Administrator said that her investigations found that CR#1 left unassisted. CR #1 told the Administrator she wanted to walk by the college to the hospital. The Administrator said an aide last saw CR #1 on 6/20/2025 around 5:45pm in the front lobby and a CMA last gave CR #1 medication at 6:00pm but the Administrator could not remember who the CMA was. The DON received a phone call from the facility's Marketing Director on 6/20/2025 at 8:45pm that a bystander found CR #1 walking down the road, and that bystander called the Marketing Director to see if CR #1 was a resident at the facility. The DON then told the Administrator and the Quality Assurance Nurse who were both still in the building. The facility did a head count, and the DON called CR #1's doctor and RP after speaking to the bystander to locate CR #1. The bystander told the DON that CR #1 was on the floor near the college and was with the bystander and another unidentified male. CR #1 had an incontinent episode. The bystander reported that she called EMS who came and took CR #1 to the hospital. The DON said the hospital did not report any injuries, and CR #1's blood and UA tests came back negative, and CR #1 was discharged back to the facility. When CR #1 came back to the facility she reported wanting to leave again and became agitated, so she was placed on 1-to-1 monitoring every 15 minutes before she was moved to a hospital psych unit for treatment. The Administrator and DON were not aware CR # 1 was an elopement risk. The DON said CR #1 was later assessed and found to be an elopement risk, and she was placed in the elopement binder. The DON had about 5 residents who have wandering behaviors, but none expressed wanting to go out and leave the building. CR #1's RP told the Administrator and DON after the elopement incident that CR #1 was found having left the building in the past, but no date was clarified. The Administrator said the front doors locked at 7pm daily. After CR #1's elopement, the Administrator put red boxes on all facility doors including the front door so if anyone tried to open the door the alarm would activate. The DON said the facility notified the family members regarding the new alarm system and if families wanted to visit after hours to call the phone number located on a sign at the front door. The Administrator and DON in-serviced staff to not share the code to the doors. The DON said the facility had no elopements since this incident. The DON said risk of elopements should have been in the care plan but the facility was previously under a different company so all of the old care plans might not have transferred over like for CR #1. The DON said there was an elopement binder already, but after CR #1's elopement assessed all current residents for elopement again and updated the binder. The DON said there were no wander guards, and the facility would not be able to accept CR #1 again because she was a fast walker, could walk on her own and was adamant about leaving. The bystander's information was requested from the DON, but it was not provided by survey exit. Interview on 06/26/2025 at 10:31am with LVN FZ, he said on 06/20/2025 he got to work early at 5:20pm and remembered seeing CR #1 in the lobby. LVN Z did not report to work until 6:15pm after a meeting. He did not hear about CR #1 being an elopement risk, and that he would get that information through reports. If a resident tried to leave he would redirect them to their rooms and ensure their safety, then assess, document and report the incident to someone in Administration. LVN FZ would check all the rooms and bathrooms and if the resident could not be found LVN FZ would call the DON and Administrator. Record review of the facility's policy on elopement and wandering residents last reviewed or revised 06/2025 read in part, The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicate with appropriate staff . Record review of the facility's policy on documenting in the medical record last reviewed or revised 04/2025 read in part, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record . Record review of the facility policy and procedure entitled, Accidents and Supervision date revised 1/25 read in part . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazard(s) and risk(s) .Evaluating and analyzing hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .Monitoring for effectiveness and modifying interventions when necessary . All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. Record review of the facility's policy on routine resident checks last reviewed or revised 04/2023 read in part, Staff shall make routine resident checks to help maintain safety and well-being. This was determined to be an IJ on 6/26/25 for CR #1's elopement. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 06/29/2025 at 11:40am with the Administrator and DON, While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because the facility's need for continued monitoring of implemented procedures. The following plan of removal was accepted on 6/27/25 at 11:11am. PLAN OF REMOVAL [Name of facility] Date: 06/26/2025 F689- Accidents/supervision Problem: The facility failed to ensure CR #1 received adequate supervision to prevent elopements after she eloped from the facility on 06/20/2025 and was last accounted for at 5:50pm. CR #1 was located by a bystander who saw CR #1 walking down the street from the facility and called emergency services and CR#1 went to the hospital. Immediate action: 1. 6/20/25 The facility administrator completed a self-report incident to HHSC due to resident elopement. 2. 6/26/25 The facility DON/Designee conducted an audit of residents with high risk for Elopement risk based on updated assessment and history of exit seeking behaviors. 7 residents identified to be at risk. All included in the Elopement Binder. Completed 6/27/25 3. On 6/26/25 The VP of Clinical Services conducted a 1:1 in-service with the Admin and DON on the facility Elopement Policy focusing on timely implementation of interventions aimed to prevent and mange residents with wondering and exit seeking behaviors, to include adding chosen interventions to the person center care plans. Interventions: 4. On 6/26/25 the Administrator/designee repeated an elopement drill with all facility departments staff, evening, night and day shifts to ensure understanding of the process. This included a review of the Elopement Binder, identification of exit seeking behaviors and interventions to immediately implement such as 1:1 supervision. Staff was instructed to utilize the Elopement binder/The resident care profile and the Kardex to identify residents at risk for Elopement/exit seeking episodes. Complete 6/27/25 5. On 6/26/25 the Administrator/Designee initiated an in-service with all facility staff on elopement policy and procedure and residents rights to ensure staff understands all residents have the rights to have adequate supervision. Completed 6/27/25 6. On 06/26/25 the DON/Designee initiated an in-service with nursing staff on immediately reporting all resident exhibit exit seeking behaviors to the Administrator and interim DON to seek guidance and ensure appropriate interventions are put in place following a resident's exit seeking behaviors. Projected completion 6/27/25. 7. On 6/26/25 The facility front door is scheduled to be automatically locked from 5pm to 8am. Staff was promptly in-service by the DON/Designee on the door locking scheduled and code 6/26/25. Projected completion 6/27/25. 8. On 6/26/5 the facility maintenance director re-in-service all staff on how to activate and deactivate the alarm upon sounding with a key, a key will be kept with each floor nurses and the DON. Upon sounding of the alarms staff was instructed to assess the area for residents and conduct a head count upon the sounding of the alarm. The nurse will immediately initiate code white with any missing residents. 9. On The Administration/designee conducted a resident council meeting to make them aware of the changes to the doors as well as the front door automatic locking times. Ongoing Projected Completion 06/27/25 Any staff member not present or in service will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 10. On 06/25/25 The interim DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the interim DON/designee if any staff are unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 06/27/25 11. An impromptu QAPI meeting was conducted with the facility's Medical Director on 06/26/25 to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 06/26/25. Monitoring/Observations/Interviews/Record reviews: Record review of the IJ binder: - On 6/20/25 the facility administrator completed a self-report incident to HHSC due to CR #1's elopement. -On 6/26/25 The facility DON/Designee conducted an audit of residents with high risk for Elopement risk based on updated assessment and history of exit seeking behaviors. 8 current residents identified to be at risk and their face sheets were included. -In-service records on elopement, elopement and wandering, possible exit-seeking behaviors and reporting to the Administrator and DON, and resident rights policy were reviewed and signed by staff from all departments. The Administrator and DON received and signed for in-services on 06/26/2025 from the VP of Clinical Services on Elopements and Wandering Residents. -A copy of the drill for locating missing residents titled Alert Code WHITE which listed staff disciplines and their corresponding responsibilities. -A copy of the Elopement Incident Search Assignment blank form which listed sectors on the premises with staff assigned and post-search report and time columns. -A copy of the Missing Resident Audit which was a check-off list for staff if a resident was missing. -A copy of the Critical Behavior Monitoring Log listing 15-minute intervals and space for staff to initial resident observations. -Proof of purpose and installation date of the 365-day 24-hour timer/controllers for the front door were installed on 06/22/2025. -Resident Council Meeting sheet addressing door alarm and signed by residents in attendance. -Elopement Training Validation Questionnaires completed and signed by staff on 06/28/2025 with questions including elopement prevention measures, codes to call, and who to notify after an elopement completed by 06/28/2025. -IJ Template signed by the DON. The Template had a note reflecting that a QAPI Meeting was held with the Medical Director on 06/26/2025 at 4:45pm. -The QA Meeting summary sheet dated 06/26/2025 listing out steps the facility took after the elopement and signed off by the Medical Director, Administrator, Director of Nursing, and IDT staff member. Observations of resident hallways, primary and secondary alarms showed active and locked. Interviews on 06/29/2025, residents said they felt safe and comfortable at the facility, had their call lights answered in a timely manner and all services provided. Interview on 06/28/2025 at 1:18pm with CNA D, she received in-services on elopement, which included reporting elopements to the Administrator/Abuse Coordinator and the DON, how the new alarm system worked and what to do during a Code [NAME] elopement incident. CNA D said ways to prevent elopement included getting residents involved in activities and redirecting them to other things. If a resident is missing, one person from each hall will coordinate the search and if the resident is still missing to contact the Administrator and family. Interview on 06/28/2025 at 1:26pm with CNA V, she received in-services on elopement and the alarm system. If a resident was walking to the door, CNA V should let a nurse know and to keep an eye on the resident. If a resident eloped, she would do a head count and let everyone know, including nurses and the Administrator. CNA V was also in-serviced all doors in resident hallways were locked 24/7. Interview on 06/28/2025 at 1:43pm with LVN AA, she received in-services on protocols on elopement, elopement prevention and exit-seeking behaviors and how to reset the alarm. LVN AA said nurses had a key to reset alarms if it went off, if residents were missing staff should spread out and attempt to locate the resident and after 30 minutes if resident is still missing staff should notify the Administrator and DON. If a resident was wandering toward the door, they should be placed under 1-to-1 monitoring and the family should be notified. Staff should keep an eye on residents and lay eyes on residents every two hours. LVN AA said residents' exit-seeking behaviors should be in their care plan and in their orders for monitoring of exit-seeking behaviors. Interview on 06/28/2025 at 2:07pm with the Quality Assurance Nurse, she said she received and conducted in-services for staff on elopement. The Quality Assurance Nurse covered topics such as exit-seeking behaviors like forcing doors open and verbalizing things like having to go home to their kids and staff should redirect if they can and service on the second alarm system which was an additional layer to the 15-second delay on hallway doors. Staff were also trained on the code white drill for elopement and the facility conducted an elopement drill. The Quality Assurance Nurse said the eight residents in the Elopement Binder were identified as high risk because they had verbalized wanting to go home. The Quality Assurance Nurse said floor nurses did not do care plans, but MDS Nurses and nurse managers could. Interview with the MDS Consultant on 06/28/2025 at 2:13pm, she said she received elopement and changes in condition in-services. The MDS Consultant learned about the process of elopement such as the code and alarms, head counts, and notifying the Administrator, DON, physician and family when there are changes in condition such as an elopement. Interview on 06/28/2025 at 11:44pm with CNA MM, she worked from 10pm to 6am. She received in-services on elopement and care plans. Signs of elopement included verbalizing the desire to leave and going towards the exit door. If CNA MM saw a resident do these things, she would bring them back and keep an eye on them and tell the nurses. CNA MM also received in-services on the elopement drill and codes. Interview on 06/28/2025 at 6:40pm with RN TT, she worked night shift and received in-services on elopement and wandering residents and care plans and that she should report any signs of elopement such as residents asking to go home to the doctor, family and management. She said incidents should be documented and nurses should make a report. RN TT had in-services on how the alarm system worked. Interview on 06/28/2025 at 7:33pm with LVN PP, she worked night shift and said information on a resident's elopement risk would be in the Elopement Binder at the nurse's station. LVN PP was in-serviced on monitoring residents if they showed signs of exit-seeking and to assign someone to monitor 1-on-1 and inform the Administrator, DON, the physician and the resident's RP about attempts or actual elopements. All nurses had a key to the door alarm systems. LVN PP received an elopement drill. Interview on 06/28/2025 at 10:16pm with CNA IM, she said she received a list of residents with elopement risks, elopement drills, and exit-seeking prevention strategies like monitoring, checking doors, and providing activities to keep residents occupied. Signs and symptoms of exit-seeking were talking about eloping, bringing up old memories and wandering. If CNA IM saw a resident elope, she would report it to the charge nurse, and she could find the information in the resident's medical chart and Kardex. CNA IM said staff should round every 1-2 hours on residents. Interview on 06/28/2025 at 11:48pm with LVN OO, she said she was an agency staff and worked night shift. LVN OO had in-services and huddles on elopement and care-plans. During an elopement, nurses should print out the census and check on rooms. LVN OO received an elopement drill training. If a resident stated leaving or packing up room, staff were to redirect residents and let their supervisor know, do a change in condition assessment and let the Administrator, DON, the physician and family know. LVN OO said staff could look at white binder for elopement risk residents with facesheet, and also look in the resident's medical chart for demographics, special interventions, care plans, and rounding every 2 hours unless residents had a special care plan requiring more frequent rounding. Interview on 06/29/2025 at 9:31am with CNA J, he worked from 10pm to 6am and received in-services on elopement and the alarm systems. CNA J would report to the nurse if residents mentioned wanting to go home and taking transportation. CNA J would redirect residents back to their room if he saw them wandering or [TRUNCATED]

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and furnish services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 11 residents (CR #1and Resident #34) reviewed for comprehensive care plans.The facility failed to care plan CR #1 for risk of elopement and document interventions prior to CR #1 eloping from the facility on 06/20/2025 around 4:45pm and did not know her whereabouts until 06/20/2025 around 8:40pm.The facility failed to assess and follow-up on Resident #34 in a timely manner when resident experienced excessive coughing/choking episode while eating breakfast on 06/24/25 at 8:48AM.This was determined to be an IJ on 6/26/25. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 06/29/2025 at 11:40am with the Administrator and DON. While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of no harm with potential for more than the minimal harm that is not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.Findings Included: CR #1 Record review of CR #1's face sheet dated 06/25/2025 reflected an [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included Alzheimer's Disease (a neurodegenerative disorder which causes decline in memory, thinking and behavior), Type 2 diabetes mellitus (high blood sugar), chronic kidney disease, Major Depressive Disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities which disrupts the ability to function in everyday life), Hypertension (high blood pressure), overactive bladder, Dementia (a general term to describe decline in cognitive function, memory loss, difficulty communicating, impaired reasoning and changes in personality), and insomnia (difficulty or inability to sleep). Record review of CR #1's Quarterly MDS dated [DATE], CR #1 had a BIMS score of 6, indicating severe cognitive impairment. CR #1 required partial to moderate assistance with her ADLs including oral and personal hygiene, dressing, showering or bathing, and toileting. She required setup assistance for walking from 10 to 50 feet and supervision for walking 150 feet. CR #1 was frequently incontinent with urine and occasionally incontinent with bowel. Record review of CR #1's care plan, she was care-planned for elopement on 6/20/25, with interventions including 1 to 1 assistance, anticipating and meeting resident needs and explaining/reinforcing why behaviors were inappropriate and/or unacceptable to the resident. CR #1 was not previously care-planned for being at risk of elopement. Record review of CR #1's Kardex care sheet, undated, under toileting focus area CR #1 had interventions for staff to report any attempts to exit the facility to the IDT, family & MD as indicated and record in the clinical record. She was also planned for IDT care plan over the phone with resident's RP to review current placement versus close/lock unit due to resident recent elopement. Record review of CR #1's progress notes, on 6/20/2025 at 1:34am she was resting in bed with no distress noted. On 6/20/2025 at 8:41pm, Interim DON was notified via phone that CR #1 was sitting on the floor by her walker near a college and taken to the ER. RP was notified 6/20/2025 at 9:01pm. On 06/21/2025 at 2:57am, a nurse documented that CR #1 was ordered to be on 1-to-1 supervision when she returned to the facility. CR #1 had returned from the hospital around 4:45am that day. A later note at 1:27pm, CR #1 was documented as being one-on-one care with aide due to an elopement on 6/20/2025 and CR #1 door was open, and resident was able to come in and out with supervision. Further review showed from September 2024 to June 2025, CR #1 was not mentioned having any exit-seeking or elopement incident. Record review of CR #1's elopement risk assessments completed 1/15/2025 and 3/19/2025, the assessments reflected CR#1 had a history of elopement or attempted to leave the facility without informing staff. No interventions were selected for either assessment. An additional elopement risk assessment was completed 06/12/2025 which reflected that CR #1 was marked yes for verbally expressing desire to go home, packing belongings or stayed near the exit, and there was a note reading usually resident sits at the lobby. CR #1 was also selected yes for having Alzheimer's, being cognitively impaired with poor decision-making skills related to intermittent confusion, cognitive deficits or disorientation, ambulating independently and had a walker. Record review of CR #1's psychology assessment on 06/3/2025, CR #1 was seen in her room and reiterated she continued to miss her family and would like to be home with them. Record review of CR #1's skilled nurse charting on 06/21/2025, CR #1 was on 1-on-1 care with an aide due to elopement on 06/20/2025. Record review of CR #1's pain assessment done on 06/21/2025, CR #1 stated not being in pain. Record review of CR #1's skin evaluation done on 06/21/2025, CR #1 refused full body skin assessment, staff evaluated CR #1's upper and lower extremities only with no injuries. Record review of CR #1's 15-minute check sheet for 6/21/2025, she was monitored and staff signed off on her for reasons of fall between 6/21/25 at 4:45am to 9:00pm before being transferred to the hospital. Record review of CR #1's hospital records dated 06/21/2025, CR #1 was found by a bystander who called emergency services when she was found walking unsteadily on the road. Bystander assisted CR #1 to the side of the road until law enforcement came. CR #1 was witnessed falling twice and denied hitting her head or loss of consciousness. CR #1 was brought to the hospital after bystanders saw her acting confused. CR #1 complained of back and neck pain. CR #1 was seen for a fall, AMS and found walking on the road. CR #1 reported chronic lower extremity swelling and the hospital documented CR #1 with pain level of 6. CR #1's CT scan had no acute findings. CR #1 had right leg pain and UTI (asymptomatic). Record review of CR #1's Order Summary, there were no orders for monitoring due to wandering or exit-seeking. CR #1 had orders for Aricept Oral Tablet 10 MG with an order date of 5/21/2025 for dementia, Divalproex Sodium Tab Delayed Release 125 MG with a start date of 11/6/24 for mood disorder, and Escitalopram Oxalate Tab 10 MG with a start date of 11/6/24 for Major depressive disorder. In an interview on 06/25/2025 at 11:40am with CR #1's RP, she said she received a call on 06/202/25 on 9:49pm stating that CR #1 walked out of the building, was fine and going to the hospital. She said when she spoke to staff at the hospital stated her mom was there for 2 hours already and CR #1 was covered in feces. The RP said CR #1 reported to her that she fell in the street. She said the doctor said she had an X-Ray and CT scan completed and the hospital discharged CR #1 back to the facility on [DATE] at 5:00am. Interview on 06/25/2025 at 1:20pm with CNA GG, CNA GG worked at the facility since March 2025 and worked 6am-2pm and 2pm-10pm as needed. CNA GG was not working at the facility when CR #1 eloped and had never seen CR #1 leave before but said CR #1 was always wandering and walking down one particular hall. CNA GG said staff are to round on residents at least every two hours and had in-services on elopement and residents with dementia. Interview on 06/25/2025 at 1:29pm with CNA O, CNA O was assisting in the dining room on 06/20/2025 when CR #1 eloped. CNA O received notification CR #1 was missing between 7pm-8pm that same day. CNA O never heard CR #1 saying she wanted to leave the facility. Staff should round every two hours and CNA O rounds every 30 minutes to 1 hour. If a resident was missing, CNA O would try to look for them and if unsuccessful would report the missing resident to the nurse, charge nurse and Administrator immediately. Interview on 06/25/2025 at 1:39pm with CNA P, CNA P worked the morning shift on 06/20/2025 and did not see CR #1 leave the facility. The last time CNA P saw CR #1 was around 2:00pm at the end of CNA P's shift. CNA P never saw CR #1 try to leave or vocalize the desire to leave the facility. CNA P did 1-to-1 monitoring for CR #1 when CR #1 was re-admitted to the facility on [DATE].CNA P received 1-to-1 and facility-wide in-service about the elopement policies and procedures. CNA P said she had received in-services on resident elopement and resident with dementia since working at the facility. In an interview on 06/25/2025 at 2:00 PM CNA GP, she stated she had been working at the facility for 3 years. CNA GP said she was not present at work when CR #1 eloped. CNA GP said CR #1 would like to stay in her room a lot but, would come out her room for coffee and activities, and that she was mobile with her walker. CNA GP said CR #1 would say she wanted to go home often and be with her family. She said the hallway exit doors are all locked and would set off the alarms, but the front door to the facility was not locked but now are locked since CR #1 eloped. CNA GP said the front door is important with lots of traffic after dinner because families leave out and sometimes will hold the door open for residents thinking they are okay to be outside alone. She said she doesn't know all the details but believed CR #1 went through the front door. CNA GP stated she has no concerns of any abuse, neglect, or elopement at the facility. In an interview on 06/25/2025 at 3:00 PM with NP B stated she was shocked that CR #1 left the community as CR #1 was not an elopement risk and she was not care-planned for elopement because NP B had not witnessed or heard CR #1 wanting to leave the community. NP B said she was not concerned about change of condition for CR #1 and was aware the results from the hospital returned negative. NP B said CR #1 was mobile with her walker and was active with therapy services and that CR #1 was normally calm and to herself and liked to eat lunch in her room. NP B stated the community was not a restraint/ locked community and did not utilize a wander guard system. NP B said staff were not aware that CR #1 was exit seeking. Staff had been in-serviced since the incident. Interview on 06/25/2025 at 3:05pm with LVN I, LVN I said CR #1 walked around a lot depending on her mood and would sit at nurse's station. In the past, CR #1 would sometimes walk up to and rattle the double doors and staff had to redirect her, but this was not recent. LVN I said CR #1's family was aware of this. LVN I was not there when CR #1 eloped. LVN M had received in-services on resident elopement and resident with dementia. CR #1 had never gotten out of the facility so LVN I did not know if risk of elopement would be care-planned but that CR #1 was assessed for risk. Interview on 06/25/2025 at 2:54pm with CNA C, CNA C heard that CR #1's exit-seeking behavior had been going on for some time and staff would redirect her back. CNA C had seen CR #1 in the dining room eating on 6/20/2025 at 5:30pm to 5:40pm and CNA C was taking another resident to their room. CNA C had been notified CR #1 had left around 7:30pm-8:30pm during last rounds. CNA C said when CR #1 came back to the facility she was observed trying to leave the building again. CNA C received in-services on resident elopement and resident with dementia. CNA C would report elopements or missing residents and report it to the charge nurse and document it. CNA C would redirect residents back to the facility if she saw them leave. Interview on 06/25/2025 at 3:44pm with the Administrator and DON, the Administrator said she was the Interim Administrator and began work on 06/02/2025 and the DON was Interim and had started working in the building at the end of May 2025. The Administrator said that her investigations found that CR#1 left unassisted. CR #1 told the Administrator she wanted to walk by the college to the hospital. The Administrator said an aide last saw CR #1 on 6/20/2025 around 5:45pm in the front lobby and a CMA last gave CR #1 medication at 6:00pm but the Administrator could not remember who the CMA was. The DON received a phone call from the facility's Marketing Director on 6/20/2025 at 8:45pm that a bystander found CR #1 walking down the road, and that bystander called the Marketing Director to see if CR #1 was a resident at the facility. The DON then told the Administrator and Quality Assurance Nurse who were both still in the building. The facility did a head count, and the DON called CR #1's doctor and RP after speaking to the bystander to locate CR #1. The bystander told the DON that CR #1 was on the floor near the college and was with the bystander and another unidentified male. CR #1 had an incontinent episode. The bystander reported that she called EMS who came and took CR #1 to the hospital. The DON said the hospital did not report any injuries, and CR #1's blood and UA tests came back negative, and CR #1 was discharged back to the facility. When CR #1 came back to the facility she reported wanting to leave again and became agitated, so she was placed on 1-to-1 monitoring every 15 minutes before she was moved to a hospital psych unit for treatment. The Administrator and DON were not aware CR # 1 was an elopement risk. The DON said CR #1 was later assessed and found to be an elopement risk, and she was placed in the elopement binder. The DON had about 5 residents who have wandering behaviors, but none expressed wanting to go out and leave the building. CR #1's RP told the Administrator and DON after the elopement incident that CR #1 was found having left the building in the past, but no date was clarified. The Administrator said the front doors locked at 7pm daily. The Administrator put red boxes on all facility doors including the front door so if anyone tried to open the door the alarm would activate. The DON said the facility notified the family members regarding the new alarm system and if families wanted to visit after hours to call the phone number located on a sign at the front door. The Administrator and DON in-serviced staff to not share the code to the doors. The DON said the facility had no elopements since this incident. The DON said risk of elopements should be in the care plan but at the facility was previously under a different company so all of the old care plans might not have transferred over. The DON assessed all current residents for elopement and put residents at risk in the binder. The DON said there were no wander guards, and the facility would not be able to accept CR #1 again because she was a fast walker, could walk on her own and was adamant about leaving. The bystander's information was requested from the DON, but it was not provided by survey exit. Interview on 06/26/2025 at 10:31am with LVN FZ, he said on 06/20/2025 he got to work early at 5:20pm and remembered seeing CR #1 in the lobby. LVN Z did not report to work until 6:15pm after a meeting. He did not hear about CR #1 being an elopement risk, and that he would get that information through reports. If a resident tried to leave he would redirect them to their rooms, ensure their safety, assess, document and tell someone from Administrator. LVN FZ would check all the rooms and bathrooms and if the resident could not be found LVN FZ would call the DON and Administrator. Interview on 06/26/2025 at 4:27pm with the MDS Consultant, she said she was not the facility's main MDS Nurse but now she came to assist with the facility as needed. The facility's Clinical team was in charge of care plans now and that the facility did not have an in-house MDS Nurse. The MDS Nurse said she did not assist with care planning. The MDS Nurse said that nurses reviewed charts, 24-hour reports and meetings to care plan for residents and that residents at risk of elopement should have been care-planned. If residents' needs were not in the care plan, staff would not know how to care for them Record review of the facility policy on Quality of Care revised February 2023 reflected in part: .Each resident will be provided care and services to attain or maintain his/or her highest practicable physical, mental, and psychosocial well-being.A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. Record review of the facility policy on Resident Rights revised January 2025 reflected in part: .The facility will ensure that all directed care and indirect staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Record review of the facility's policy on comprehensive care plans last reviewed or revised 01/2025 read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . Record review of the facility's policy on documenting in the medical record last reviewed or revised 04/2025 read in part, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record . Record review of the facility policy and procedure entitled, Accidents and Supervision date revised 1/25 read in part. The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazard(s) and risk(s).Evaluating and analyzing hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s).Monitoring for effectiveness and modifying interventions when necessary. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. This was determined to be an IJ on 5/26/25. The Administrator and DON were notified on 5/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 5/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 05/29/2025 at 11:40am with the Administrator and DON, While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because the facility's need for continued monitoring of implemented procedures. The following plan of removal was accepted on 5/27/25 at 2:24pm. PLAN OF REMOVAL [Name of Facility] Date: 6/26/25 F 656 Comprehensive Care Plans Problem: - The facility failed to develop and implement a comprehensive person-centered care plan for each resident when CR #1 was not care planned for being an elopement risk when CR #1 eloped from the facility on 06/20/2025 and was last accounted for at 5:50pm. CR #1 was located by a bystander who saw CR #1 walking down the street from the facility and called emergency services and CR#1 went to the hospital. CR#1 No longer reside in the facility. Immediate action: 1. 6/20/25 The facility administrator completed a self-report incident to HHSC due to resident elopement. 2. 6/26/25 The facility DON/Designee conducted an audit of residents with high risk for elopement based on updated assessment and history of exit seeking behaviors to ensure their comprehensive person-centered care plans are updated, are appropriate and meet their individual needs. 7 residents identified to be at risk, all included to the elopement binder. Completed 6/27/25 3. On 6/26/25 The VP of Clinical Services conducted a 1:1 in-service with the Admin and DON on the facility Elopement Policy focusing on timely implementation of interventions aimed to prevent and manage residents with wondering and exit seeking behaviors, to include adding chosen interventions to the person center care plans upon admission/readmission and with changes in condition. Interventions: 4. On 6/27/25 the DON/Designee conducted a 1:1 in-service with the facility interim MDS Nurse and nurse managers on timely care planning of residents identified to have wondering behaviors and or who are at Elopement risk upon admission/readmission and with changes in condition. Completed 6/27/25 5. On 6/26/25 the DON/Designee initiated an in-service with the facility staff how to identify residents who are at risk for elopement/ exit seeking as indicate in the plan of care/Kardex, resident care profile and the elopement binder. Projected completion on 6/27/25 6. On 6/26/25 the DON/Designee initiated an in-service with the facility nursing staff on immediately reporting residents with escalating exit seeking behavior to the nurse, DON, and or Administrator to seek guidance and ensure appropriate interventions are put in place. Projected completion 6/27/25 7. On 6/26/25 the DON/Designee initiated and in-service with the nurse managers and licensed nurses on the Facility Policy Elopement and Wandering Residents focusing on promptly updating resident Elopement Risk Assessment and placing adequate interventions in place following a new admission/readmission and exit seeking/elopement episode to include interventions to meet the residents' individualized needs, DON/MDS nurse and Designee will monitor care plans for appropriateness and completion. Completion date 6/27/25 Ongoing Projected completion 6/27/25 Any staff member not present or in service, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring: 8. On 6/26/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 6/27/25 9. Starting on 6/26/25 the facility Adm/Don and designee will review prior day Elopement assessments risk/exit seeking behaviors documentation to ensure the comprehensive care plan is up to date and include individualized, appropriate and effective interventions. Any identified concerns will be addressed at that time. Completed 6/27/25 10. 6/26/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 6/26/25 Record review of the IJ plan binder: -The Facility Administrator completed a self-report on 06/20/2025 after CR #1 left the facility with her walker unassisted. At 5:45pm 81 y/o female left Facility grounds with her walker unassisted. Hospital notified of resident update, no fractures. Family, Physician, Interim DON and Interim Administrator informed, head count for all residents. Implementation of critical behavior log. -On 06/26/2025 the facility audited all residents at high risk for elopement and had listed out their risk scores and categories of risk (no, low and high risk). There were 8 residents' facesheets including CR #1 which had their photos. The 8 residents had updated elopement risk assessments, physician orders for monitoring of behavior every shift and updated care plans as of 06/29/2025. -The Administrator and DON received a 1-to-1 in-service from the VP of Clinical Services on the facility's Elopement Policy which was last revised 07/2023 whose topics included timely implementation of interventions, adding chosen interventions to care plans upon admission/readmission and with changes in condition. The Administrator DON signed separate sheets confirming they received the in-service on 06/26/2025. -VP of Clinical Services conducted a 1-1 in-service with the Administrator and DON on the facility Elopement Policy. [NAME] RN was VP of Clinical Services. Date: 6/26/25, subject was Elopement policy and procedure. [NAME] signed the policy in-service titled Elopements and Wandering Residents with a date implemented 07/2023. [NAME] LNFA signed 06/26/25 Elopement policy and procedures. -DON/Designee conducted in-services with interim MDS nurse and nurse managers on timely care planning of residents identified to have wandering behaviors and those at risk upon admission/readmission with changes in condition. Completed 6/27/25. The MDS Consultant signed 6/26/25, instructed by the VP of Clinical Operations and ensure timely and accurate completion of care plans upon admission/readmission and changes in condition. It should be in the care plan development should include appropriate interventions such as adding residents to the binder. Quality Assurance Nurse was in-serviced. - 6/26/25 the Don/Designee initiated in-service to be completed 6/27/25 with facility staff how to identify residents who are at risk of elopement/exit seeking as indicated in the Plan of care/Kardex, resident care profile and elopement binder. - On 6/26/25 DON initiated an in-service on immediately reporting residents with escalating exit seeking behavior to the nurse, DON and or Administrator to seek guidance and ensure appropriate interventions. Completed on 6/27/25. - On 6/26/25 DON/Designee initiated in-service with the nurse manager and licensed nurses on the Facility Policy Elopement and Wandering Residents focusing on promptly updating resident Elopement Risk Assessment and adequate interventions. DON/MDS Nurse and Designee to monitor care plans for appropriateness and completion. -6/26/25 DON/designee - will begin a questionnaire to validate the effectiveness of the training. Immediate re-education will be completed if staff unable to answer. Projected completion 6/27/25. Quizzes placed in the binder. -6/26/25 review prior day Elopement assessment risk/exit seeking behaviors documentation to ensure the comprehensive care plan is up to date and include individualized, appropriate and effective interventions. Completed 6/27/25. -6/26/25 an impromptu QAPI meeting was conducted with facility's MD to notify potential for non-compliance. Plan approved 6/26/25. Interview on 06/28/2025 at 1:43pm with LVN AA, she received in-services on protocols on elopement, elopement prevention and exit-seeking behaviors and how to reset the alarm. LVN AA said nurses had a key to reset alarms if it went off, if residents were missing staff should spread out and attempt to locate the resident and after 30 minutes if resident is still missing staff should notify the Administrator and DON. If a resident was wandering toward the door, they should be placed under 1-to-1 monitoring and the family should be notified. Staff should keep an eye on residents and lay eyes on residents every two hours. LVN AA said residents' exit-seeking behaviors should be in their care plan and in their orders for monitoring of exit-seeking behaviors. Interview on 06/28/2025 at 2:07pm with the Quality Assurance Nurse, she said she received and conducted in-services for staff on elopement. The Quality Assurance Nurse covered topics such as exit-seeking behaviors like forcing doors open and verbalizing things like having to go home to their kids and staff should redirect if they can. The Quality Assurance Nurse said the eight residents in the Elopement Binder were identified as high risk because they had verbalized wanting to go home. The Quality Assurance Nurse said floor nurses did not do care plans, but MDS Nurses and nurse managers could. Interview with the MDS Consultant on 06/28/2025 at 2:13pm, she said she received elopement, care plan and changes in condition in-services. The MDS Nurse learned about the process of elopement such as the code and alarms, head counts, and notifying the Administrator, DON, physician and family when there are changes in condition such as an elopement. Interview on 06/28/2025 at 11:44pm with CNA MM, she worked from 10pm to 6am. She received in-services on elopement and care plans. Signs of elopement included verbalizing the desire to leave and going towards the exit door. If CNA MM saw a resident do these things, she would bring them back and keep an eye on them and tell the nurses. Interview on 06/28/2025 at 6:40pm with RN TT, she worked night shift and received in-services on elopement and wandering residents and care plans and that she should report any signs of elopement such as residents asking to go home to the doctor, family and management. She said incidents should be documented and nurses should make a report. A resident's plan of care would be found in their medical chart and the Kardex (a list of focus areas and interventions that could be accessed by any staff). RN TT had in-services on how the alarm system worked. Interview on 06/28/2025 at 7:33pm with LVN PP, she worked night shift and said information on a resident's elopement risk would be in the Elopement Binder at the nurse's station. LVN PP was in-serviced on monitoring residents if they showed signs of exit-seeking and to assign someone to monitor 1-on-1 and inform the Administrator, DON, the physician and the resident's RP about attempts or actual elopements. LVN PP received an elopement drill. Residents at risk of elopement would be care-planned which could be found in their medical chart and Kardex. Interview on 06/28/2025 at 10:16pm with CNA IM, she said she received a list of residents with elopement risks, elopement drills, and exit-seeking prevention strategies like monitoring, checking doors, and providing activities to keep residents occupied. Signs and symptoms of exit-seeking were talking about eloping, bringing up old memories and wandering. If CNA IM saw a resident elope, she would report it to the charge nurse, and she could find the information in the resident's medical chart and Kardex. CNA IM said staff should round every 1-2 hours on residents. Interview on 06/28/2025 at 11:48pm with LVN OO, she said she was an agency staff and worked night shift. LVN OO had in-services and huddles on elopement and care-plans. During an elopement, nurses should print out the census and check on rooms. LVN OO received an elopement drill training. If a resident stated leaving or packing up room, staff were to redirect residents and let their supervisor know, do a change in condition assessment and let the Administrator, DON, the physician and family know. LVN OO said staff could look at white binder for elopement risk residents with facesheet, and also look in the resident's medical chart for demographics, special [TRUNCAT

Based on observation, interview, and record review the facility failed to ensure that 1 (Resident #61) of 5 residents reviewed for hearing services, received proper treatment to maintain hearing capabilities. -The facility did not complete an Audiology (hearing) referral for Resident #61 who was hard of hearing until 06/27/25. -The facility failed to identify that Resident #61's hearing aids were not functioning properly when resident placed new batteries in hearing aids. This failure could place residents at risk for further decrease in communication, social engagement, and decrease in quality of life.Findings included: Record review of Resident #61's face sheet dated 06/26/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 04/02/24. Resident's diagnoses included dementia (brain disorder that causes problems with thinking, memory, and behavior), type 2 diabetes mellitus (body has trouble controlling blood sugar and using for energy), heart failure, heart disease, depression, adult failure to thrive, and hypertension (high blood pressure). Record review of Resident #61's quarterly MDS dated [DATE] section B (Hearing, Speech, and Vision) reflected resident had a hearing aide with moderate difficulty in hearing. Further review reflected a BIMS score of 4 indicating severe cognitive impairment. Record review of #61's Physician Order Summary Report for the month of June 2025 reflected the following order: -Dated 11/07/24 Audiology (hearing) as needed. Record Review of the facility Audiology binder for residents receiving services for Audiology did not reflect Resident #61 being on the list for services. Record review of Resident #61's Comprehensive Care Plan not dated reflected that Resident #61 was being care planned for impaired communication AEB hearing loss right/left both AEB wearing hearing aids. The interventions included: refer to audiology for hearing consult as ordered, report to the nurse changes in ability to communicate, possible factors which cause/make worse/better communication problems. Observation on 06/24/25 at 9:47AM was Resident #61 awake in bed with TV on in his room. While trying to communicate with resident, it was observed that resident was significantly having difficulty hearing the surveyor. Interview on 06/24/25 at 9:47AM with Resident #61 said he could not hear good and had been waiting on getting some help with his hearing aids. Interview on 06/26/25 at 12:43PM with MDS Consultant she said she had been working for the company for 8 years. The MDS Consultant said she was working in the place of the facility MDS nurse due to this staff member being on leave. The MDS Consultant said it was a team effort that consisted of herself, MDS nurse in the facility, charge nurse, nurse manager, and the DON that ensured residents were receiving the necessary social services. The MDS Consultant said she did not participate in the meetings held at the facility. The MDS Consultant said the surveyor would have to refer to the DON. The MDS Consultant said the facility did not have a full time Social Worker in the facility, but the Corporate Social Worker came to the facility when needed. Interview on 06/26/25 at 3:02PM with the DON said it was herself, and a Social Worker from a sister facility that was ensuring that residents that required social services including audiology were being seen by the physician. Interview on 06/26/25 at 4:46PM with LVN ZZ said he was an agency nurse and was Resident #61's primary care nurse . LVN ZZ said it was his first day working at the facility. LVN ZZ said he was not aware that Resident #61 was hard of hearing. LVN ZZ said he received report from the night nurse who he believed was an agency nurse as well that reported no changes. Interview on 06/27/25 at 2:11PM with the DON said she would have to see if a referral had been done for Resident #61 to receive audiology services. Interview on 06/27/25 at 3:15PM said she sent a referral to Audiology on 06/27/25 because Resident #61was not on the list for audiology services. Interview on 06/28/25 at 10:29AM with the DON she said she assessed Resident #61 on 06/27/25 and that Resident #61 had hearing aids, but apparently something happened to his hearing aids. The DON said Resident #61 said his hearing aid was not working. The DON said Resident #61 had been seen by audiology services but could not locate a documentation of resident being seen by audiology. The DON said she did not speak with the staff to see if they were aware of Resident #61's hearing aids were not working. When the DON was asked what did it place Resident #61 at risk for when resident was hard of hearing, hearing aids not working properly, and resident not receiving audiology services, the DON said she did not know, and that the surveyor would have to speak with the Social Worker to answer that question. Interview on 06/28/25 at 12:27PM with the Social Worker via phone she said she only came to the facility once a month. The Social Worker said she was at the facility on June 6th and reviewed all residents' charts regarding their CODE status. The Social Worker said she spoke with the residents to see if they had any concerns about anything. The Social Worker said the previous DON was working at the time when she was last at the facility. The Social Worker said she had been working with the present DON remotely on a weekly basis sometimes more than once a week about any questions or referrals that needed to be done, or anything related to social services. The Social Worker said her job description included getting the following services for residents that needed them: Podiatry (a branch of medicine that focus on the study and diagnoses of the foot, ankle, and lower limb), Psychology (study of the mind and behavior), vision, hearing, and dental. The Social Worker said she spoke with the present DON on 06/27/25 regarding audiology referrals for a few residents at the facility but she did not remember who the residents were. The Social Worker said the DON was needing guidance on how to fill out a referral. The Social Worker said she did not assess the residents for the above services mentioned. The Social Worker said it was the role of a Social Worker to attend the clinical meetings held by the DON and gather information on what resident would benefit from certain social services. The Social Worker said it was the nurses, MDS Coordinator, and DON that divided up this task in assessing the residents for social services. The Social Worker said the facility had a big change in management and that she was not aware that Resident #61 was hard of hearing. The Social Worker said after reviewing Resident #61's chart, Resident #61 had been residing at the facility since 2021. The Social Worker said until resident could be seen by the audiologist, the facility could utilize a white board to communicate with Resident #61. The Social Worker said by not having Resident #61 on audiology services, it placed him at risk for decrease in communication and understanding. Interview on 06/28/25 at 2:30PM with the DON she said she had placed a communication book in Resident #61's room on 06/27/25. The DON said when she went to Resident #61's room on 06/27/25 she did not see any delay in communicating with Resident #61. The DON said it was the surveyor only that mentioned that Resident #61was hard of hearing. Interview on 06/29/25 at 10:15AM with LVN J said she was Resident #61's primary nurse. LVN J said Resident #61 had hearing aids but did not recall when the last time Resident #61's hearing aids or batteries for the hearing aid had been checked. LVN J said Resident #61 put his own hearing aids in his ear. Observation on 06/29/25 at 10:18AM of Resident #61 revealed he was awake in bed with personal belongings at the bedside along with a communication binder. LVN A was attempting to communicate with Resident #61. It was observed that Resident #61 was not hearing LVN J as she was trying to communicate with him. Resident #61 had batteries he said for his hearing aids and that the batteries were not working properly. Resident #61 took a pack of batteries that were at the bedside. Resident #61 took 2 batteries of the pack demonstrating that when he placed the batteries in his hearing aid, his hearing aids still did not work. LVN J attempted to use the communication binder, but Resident #61was not understanding what LVN J was trying to communicate to him. The expiration year on the battery package could not be read clearly. Interview on 06/29/25 at 10:20AM with LVN J she said Resident #61's hearing was not good. LVN J said this placed Resident #61 at risk for not being able to communicate with staff therefore placing Resident #61at risk for withdrawal due to him not being able to communicate with people. Interview on 06/29/25 at 10:30AM with Resident #61 by way of writing questions on paper that he could read and answer the questions asked. Resident #61 said it was his family that bought him the batteries to place in his hearing aid. Resident #61said the batteries would not work and had been waiting to get help regarding his hearing. Resident #61said he could not remember the last time he had his hearing aids checked, or his hearing tested. Resident #61said he did not like not being able to hear or communicate with people. Interview on 06/29/25 at 10:57AM with CNA H she said she worked at the facility full time from 6:00AM-2:00PM. CNA H said Resident #61 was hard of hearing but could put his own hearing aids in his ears. CNA H said she was not aware of resident hearing aids not functioning properly. Record review of the facility policy on Social Services revised October 2024 reflected in part: .The facility, regardless of size, will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest, practicable physical, mental, and psychosocial well-being.The Social Worker, or social service designee, will pursue the provision of any identified need for medically-related social services for the resident.The Social Worker, or social service designee, will monitor the resident's progress in improving physical, mental and psychosocial functioning.

Based on observation, interview and record review the facility failed to properly store, label, and/or secure medications and biologicals for 1 of 4 medication carts (400 hall medication cart), in accordance with State and Federal laws, all drugs and were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to for 1 of 14 residents reviewed for medication administration (Resident #67).The facility failed to ensure Resident #67 medication was not left unattended on [DATE], 600-hall medication cart had medication open not dated.This failure could place residents at risk to having access to unauthorized medication and/or lead to possible harm or drug diversion and receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions.Findings included: Record review of Resident #67's face sheet, dated [DATE], revealed Resident #67 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of: chronic atrial fibrillation( irregular heart beat) atherosclerosis of coronary artery (fatty materials like build up inside your arteries) bypass graft(s), with angina pectoris, anorexia, diarrhea, unspecified, muscle wasting and atrophy, not elsewhere classified, other lack of coordination, muscle weakness, generalized other abnormalities of gait and mobility, cognitive communication deficit, dysphagia (difficulty swallowing), depression (mood swing), acute kidney failure, personal history of malignant neoplasm of breast (cancer) hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (Stroke) affecting right dominant side, cerebral infarction, atrial fibrillation and flutter, gastro-esophageal reflux disease with esophagitis, without bleeding, acute cystitis ( sudden bladder infection) without hematuria (bleeding) , urinary tract infection, diabetes mellitus due to underlying condition with diabetic nephropathy and gastrostomy tube. Record review of Resident #67's quarterly MDS, dated [DATE], revealed Resident #67 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #67 was dependent of staff for all ADLs. Observation on [DATE] at 8:45 AM, during medication pass with LVN J, Resident #67 was lying in bed. LVN J pulled up a blister packet of Carvedilol oral tablet 3.125 mg, Famotidine oral tablet 40 mg, Misoprostol oral tablet 100 mcg, and a bottle of Sucralfate suspension 1gm/10ml tablet from the medication and placed the medication on top of the medication cart. LVN J stated I have to check Resident #67's blood pressure before administering the medication Resident#67's bp was 84/39 p87, LVN J recheck bp 88/51 p86, and she left the room to the parked medication cart to get the manual bp cuffs at 9:00 am and left the medication cart unlocked and then checked bp it was bp 163/62 p69, and then picked up 60 cc syringe checked Resident residual via GT, it was 5cc return to stomach, the door was wide open. At 9:13 AM LVN J went to prepared the medication left on the medication cart, stated am sorry it took me a longer period to check the bp. LVN J prepared the medication crushed the meds and in a medication cup. at 9:21 am LVN J went in the Resident #67's room to administer medication and left the door open, did not pulled the curtain in-between the roommate and she left her medication cart unlocked while administering the medication. Interview with LVN J on [DATE] at 5:45 PM, LVN J said she was nervous and forget to close the door. Observation on [DATE] at 12:43 PM with LVN GG, she said she checks the medication cart for expired whenever she works.1. Voltaren (Arthritis pain) 150 gram (5.29 oz) open not dated and no name. Interview with LVN GG she did not know when it was opened, and it supposed to be dated2. Hydrocortisone cream 2 oz open not dated and no name3. Mupirocin cream USP 2% (30g net wet) opened not dated 4. Clobetasol Propionate USP 0.05% opened not dated 45grams 5. Triamcinolone Acetone 0.5% (15gm) opened not dated. In an interview with LVN GG on [DATE] at 1:04 PM she said she if the medications were opened and not dated, she would not know its effectiveness. In an interview on [DATE] at 3:00PM the DON and Consultant Pharmacist said the facility did not have any policy on dating the creams the pharmacist were not supposed to be dated it and the pharmacist dispensing those ointments always placed the opened date on them.

Based on observation, interview and record review, the facility failed to 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 (Residents #8 and #41) of 4 residents reviewed for infection control practices. -LVN A did not wipe his accu-check machine between after using it on Resident #8 and Resident #41 to check their blood glucose and did not store the accu-check machine properly to prevent infection on 06/24/2025. This failure could put residents at risk of a spread of infection and diseases due to not following infection control policies and procedures.Findings included: Record review of Resident #8's face sheet dated 06/25/2025, reflected she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included obesity, type 2 diabetes mellitus (high blood sugar), personal history of urinary tract infections, hypertension (high blood pressure), blindness in one eye, and chronic kidney disease. Record review of Resident #41's face sheet dated 06/25/2025, reflected she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), hypotension (low blood pressure), iron deficiency, dementia (decline in cognitive function in areas like thinking, memory, and reasoning), and anxiety disorder (disorder characterized by prolonged periods of extreme worry). Observation on 6/24/25 at 9:47 AM of Resident #8's medication pass, revealed LVN A did not wipe the accu-check machine (machine used to measure blood sugar) after checking the blood glucose and placed it inside the medication cart. LVN A immediately went to Resident #41's room and checked Resident #41's blood glucose with the same machine. LVN A then placed it in his uniform pocket and then placed it in the top drawer of his medication cart without wiping or sanitizing the accu-check machine. In an interview on 6/24/25 at 10:23AM with LVN A, he said Residents #8 and #41 were not on isolation and in his previous state of employment, common practice was not to clean the accu-check machine between residents except if the residents were on contact isolation (a set of precautions to prevent spread of infectious diseases). LVN A said he did not have any orientation in the facility. LVN A said he knew wiping the accu-check machine was to prevent infection. He just started with the facility. In an interview on 6/26/2025 at 4:00pm with the DON, the DON said that she expected nurses to make sure they were preventing infections, agency staff were required to do competencies and quizzes before taking a shift, and that the DON would upload training to the agency staff communication portal so that transmission infection and disinfectant equipment could be addressed. The DON also said she expected staff to use the facility-provided antimicrobial wipes. Record review of the facility's policy on their infection prevention and control program last reviewed or revised 01/2025 read in part, all staff are responsible for following all policies and procedures related to the program, .environmental cleaning and disinfection shall be performed according to facility policy .all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 37 opportunities, resulting in a 8 percent medication error involving for 1 of 14 residents (Resident #67) reviewed for medication errors. LVN J did not administer the full dose of carvedilol oral tablet 3.125 mg (carvedilol=medication used to help lower blood pressure and reduce the workload of the heart).Misoprostol oral tablet 100 mcg (misoprostol= medication used to protect the stomach against acid damage, and decreases the amount of acid produced by the stomach) and Famotidine oral tablet 40 mg (famotidine) (medication used to reduce the amount of acid produced in your stomach) as ordered by the Physician to Resident #67 on 6/24/25. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.The findings included: Record review of Resident #67's face sheet, dated 6/24/25, revealed Resident #67 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: chronic atrial fibrillation( irregular heart beat) atherosclerosis of coronary artery (fatty materials like build up inside your arteries) bypass graft(s), with angina pectoris, anorexia, diarrhea, unspecified, muscle wasting and atrophy, not elsewhere classified, other lack of coordination, muscle weakness (generalized other abnormalities of gait and mobility, cognitive communication deficit, dysphagia ( difficulty swallowing), depression ( mood swing), acute kidney failure, personal history of malignant neoplasm of breast (cancer) hemiplegia and hemiparesis ( paralysis of one side of the body) following cerebral infarction ( Stroke) affecting right dominant side, cerebral infarction, atrial fibrillation and flutter, gastro-esophageal reflux disease with esophagitis, without bleeding, acute cystitis ( sudden bladder infection) without hematuria (bleeding) , urinary tract infection, diabetes mellitus due to underlying condition with diabetic nephropathy and gastrostomy tube. Record review of Resident #67's quarterly MDS, dated [DATE], revealed Resident #67 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #67 was dependent of staff for all ADLs. Record review of Resident#67's physician orders revealed the following: - Order date was 2/4/25 (carvedilol) give 1 tablet via g-tube every 12 hours related to chronic venous hypertension (idiopathic) with other complications. Famotidine oral tablet 40 mg (famotidine) give 1 tablet via peg-tube every 12 hours related to gastro-esophageal reflux disease with esophagitis. Misoprostol oral tablet 100 mcg give 1 tablet via g-tube before meals and at bedtime related to gastro-esophageal reflux disease with esophagitis, without bleeding. Sucralfate suspension 1gm/10ml take 10ml g tube before meal at bedtime. Observation on 6/24/25 at 8:45 AM, during medication pass with LVN J, Resident #67 was lying in bed. LVN J punched up blister packet of Carvedilol oral tablet 3.125 mg, Famotidine oral tablet 40 mg, Misoprostol oral tablet 100 mcg, and a bottle of Sucralfate suspension 1gm/10ml tablet from the medication and placed the medication on top of the medication cart. LVN J stated I have to check Resident #67's blood pressure before administering the medication and then picked up 60 cc syringe checked Resident residual via GT, it was 5cc return to stomach. At 9:13 AM LVN J went to prepare the medication left on the medication cart, stated I am sorry it took me a longer period to check the blood pressure. LVN J prepared the medication crushed each meds in a medication cup. At 9:21 am LVN J went in the Resident #67's room to administer medication after diluting it in water, LVN J did not stir or rinse the medications in the cup, LVN J had a lot of residue of Carvedilol, Famotidine and Misoprostol in the medication cup and after medication administration, LVN J was about to discarded the medication cup. The nurse surveyor picked up the medication cups and showed LVN J the residual and she acknowledged the residuals in the medication cups and then added water to the medication cups and administered it via Resident #67's GT. Interview with LVN J on 6/24/25 at 5:45 PM, she said if medication was not given in totality the resident would not get required effects of the medication. LVN J said she had GT training, she was neruous. During an interview on 6/26/25 at 5:35 PM, the Administrator and DON they said the risk of not getting the medication as ordered by the doctor could affect therapeutic effectiveness. The DON said not giving medication as ordered by the doctor could cause more health issues and potency of the medication in the blood. She said she would be in-servicing the staff. Review of the facility policy revised 2012 and titled administering medications reflected, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #34) reviewed for resident rights. -The facility failed in notifying Resident #34's physician on 06/24/25 right away when resident had a significant change in condition. Resident experienced a choking episode while eating his breakfast at 8:48AM on 06/24/25. This failure placed all residents in the facility who may experience a significant change in condition at risk for harm or injury if not reported to the physician in a timely manner. Record review of Resident #34's face sheet dated 06/26/25 revealed an [AGE] year-old man admitted to the facility on o2/24/22 and again on 04/03/23. Resident diagnoses included the following: Parkinson's Disease (disorder that effects movement, often included tremors {shaking}, aphasia (language disorder effecting a person's ability to communicate), cerebral infarction (a condition where blood flow to the brain is blocked causing brain tissue damage), and gastro-esophageal reflux disease (digestive disease in which stomach content irritates the food pipe lining). Record review of Resident #34's quarterly MDS dated [DATE] reflected a BIMS score of 14 indicating that resident cognition was intact. Section K (Swallowing/Nutrition Status) did not reflect coughing or choking during meals or when swallowing medications. Further review reflected mechanically altered diet. Section O (Special Treatments, Procedures, and Programs) did not reflect resident receiving-Speech-Language Pathology. Record review of Resident Physician Order Summary Report for the month of June 2025 reflected the following orders:-Dated 01/17/25 Speech to evaluate and treat as indicated-Dated 06/10/25 Xanax 0.5mg 1 tablet by mouth every 8 hours for anxiety-Dated 06/25/25 Stat order for chest X-ray Record review of Resident #34's MAR for the month of June 2025 reflected that the facility was administering medication Xanax 0.5mg 1 tablet my mouth every 8 hours. Record review of Resident #34's stat chest x-ray report dated 06/25/25 reflected no pleural effusion (buildup of fluid between the tissues that line the lungs and the chest).Record review of a swallow screen done by the Speech Language Pathologist done 06/28/25 for Resident #34. The Speech Language Pathologist recommended evaluation for possible downgrade in texture with RP sharing that resident had ongoing difficulties with swallowing and did not want to downgrade resident diet.Record review of Resident #34's Comprehensive Care Plan with last review date of 06/16/25 did not reflect resident being care planned for history of difficulty in swallowing or coughing when eating.Record review of Resident #34's Nursing Progress Notes reflected that the facility had not done an SBAR on 06/24/25 regarding resident choking episode but reflected the following documentation:-Dated 06/24/25 at 14:40 (2:40PM) facility spoke with the RP of Resident #34 regarding cough episode and the need to use oxygen. Per RP, resident getting to the end of the month and usually gets more anxious.-Dated 06/24/25 at 18:03 (6:03PM) Hospice was called to reorder lorazepam 1mg PRN, expected to be delivered 06/25/25. Observation on 06/24/25 at 8:48AM of Resident #34 sitting in wheelchair with bedside table in front of him. Resident breakfast tray was sitting on the bedside table Resident started choking excessively with face turning red and then blue. Resident call light was not in reach but sitting on resident bed by pillow that was at the head of resident bed. The surveyor called for help. Resident had eaten approximately 90 % of breakfast. On Resident plate was a 1/2 of toast and a small amount of what appeared to be oatmeal in bowl. LPN B arrived too room with 2 other staff members. When LPN B observed Resident #34's choking she said, Oh My GOD. LPN B attempted to apply the Heimlich maneuver while resident was sitting in wheelchair but was not successful. Resident continued to choke, and the surveyor called for more staff to come. LPN B was trying to lean Resident #34 forward in his wheelchair while patting on resident back. LPN B started preparing to place resident on oxygen via nasal cannula while LVN A agency nurse left the room and returned to room with oxygen saturation device to check resident oxygen saturation. At this time, resident was already receiving oxygen. By this time resident appeared to be in less stress with no further signs of cyanosis (blue skin). When LVN A agency nurse placed the oxygen saturation device on resident's finger, he said resident oxygenation was at 95%. Shortly after, LVN A agency nurse said resident oxygen saturation was ranging between 97-98 %. Resident remained on oxygen at the time of the readings. Before the surveyor exited Resident #34's room, she asked LPN B and LVN A agency nurse if they were going to notify the physician of resident choking incident. Both LPN B and LVN A agency nurse said yes repeatedly that they would notify the physician of the incident. Interview on 06/24/25 at 9:01 AM with CNA BB said she was Resident #34's CNA. CNA BB said resident was able to transfer himself to and from bed to his wheelchair freely. Interview on 06/25/25 at 1:28PM with Resident #34 said he recalled the choking incident on 06/24/25 during breakfast. Resident said the incident scared him. Resident said recently he was beginning to have issues with swallowing but did not say if he told anyone about this.Interview on 06/25/ 25 at 1:58PM the DON said Resident #34 did not experience choking instead, was just coughing. The DON said LPN B told her resident had anxiety episodes and was not choking. The DON said LPN B told her this on 06/24/25 after the incident had happen. The DON said therefore, LPN B administered oxygen to Resident #34. Further interview with the DON after being informed by the surveyor that Resident #34 was eating his breakfast at the time of the incident. The DON said she was not aware that resident was eating during the time of the incident and that she would immediately start in-service with the staff on choking precautions, assessment, and inquiring what type of diet resident was on, if resident diet needed to be changed, and reporting change in condition to resident physician, or hospice doctor if resident was on hospice. The DON said by not assessing the resident properly and reporting to the physician in a timely manner could place the resident at risk for aspiration. The DON was asked for the facility policy on reporting to the physician when there was a change in condition, resident assessment, and choking precautions. Interview on 06/25/25 at 2:04PM with LPN B said she worked at the facility from 6AM-6PM full time. LPN B said when the surveyor called for the nursing staff to come to Resident #34's room, she observed the resident sitting in front of his breakfast tray coughing excessively and had his hands on his wheelchair with his eyes closed and mouth open. LPN B said she attempted the Heimlich maneuver, but it was hard to wrap her arms around resident waist. LPN JB said the other nurse that came in the room was an LVN A agency nurse and CNA RR. LPN B said she pulled out her phone to shine light in resident mouth and did not see any food in resident mouth. LPN B said because she did not see any food in resident's mouth and resident had calmed down, she had determined that resident was not choking. LPN B said some signs and symptoms of silent aspiration were blue lips, drop in oxygen saturation, not being able to move. LPN B said the reason she placed resident on oxygen via nasal cannula was because resident was coughing for so long. LPN B said the reason she did not document the incident or contact the NP, or physician was because resident had calm down and was able to respond. LPN B said when a resident experienced a change in condition example choking and it was not reported to the physician or NP in a timely manner, it placed the resident at risk for aspiration pneumonia and respiratory distress. LPN B said she had been working at the facility since April of 2025 and that she was a brand-new nurse. LPN B said his was her first job as a nurse. LPN B said she had not received any in-service on choking or silent aspiration. In a later interview on 06/29/25 at 12:10PM with LPN B said she had been-in serviced on the signs and symptoms of choking (cyanosis, grabbing at the throat, not being able to cough), notify the resident doctor immediately along with the family, DON, and the Administrator. LPN B said she had to complete an SBAR because it would be considered a change in a resident's condition. LPN B said when an SBAR was done, it automatically uploaded in the Nursing Progress Notes. LPN B said some signs that a resident could be experiencing silent aspiration was wheezing and abnormal lung sounds. LPN B said she was aware that Resident #34 had dysphagia (difficulty swallowing).Interview on 06/25/25 at 2:23PM with CNA MM said when she went to Resident #34's room, he was coughing non-stop and resident breakfast tray was sitting in front of him. CNA MM said she also passed out snacks to the residents and had never witnessed Resident #34 coughing while eating. CNA MM said she could not remember if the facility had in-serviced her on choking due to the facility giving so many in-services. CNA MM said if she witnessed a resident coughing excessively non-stop or choking, she would check to see if resident had something in their mouth, attempt to perform the Heimlich maneuver, and let the nurse know what happened so they could assess the resident. CNA MM said she had been working at the facility for 3 years. Interview on 06/25/25 at 4:30PM with NP R at the facility said she was not the NP for Resident #34. NP R said she heard the DON in-servicing the staff and asked what was going on. NP R said the DON told her that Resident #34 had experienced a coughing episode on 06/24/25 and asked her to assess resident. NP R said she assess Resident #34 and resident lung sounds were clear. NP R said she gave a stat order for a chest x-ray to rule out aspiration. NP R said some signs of silent aspiration could be difficulty breathing and respiratory distress, and excessive coughing while eating meals. NP R said this would be considered a change in a resident's condition. NP R said she would want to be notified right away so that she could intervene by giving orders one being a chest x-ray. NP R said if notification to the physician/NP was delayed it placed the resident at risk for respiratory illness. Interview on 06/26/25 at 11:15AM with LPN B said on 06/24/25 she was not Resident #34's primary care nurse. LPN B said the primary care nurse for Resident #34 was LVN J. LPN B said she told LVN J resident had experienced some excessive coughing while eating breakfast. LPN B aid she did not notify the Physician, just told LVN J about the incident and did not know what LVN J after she told her. Interview on 06/26/25 at 11:25AM via phone with LVN J said she worked at the facility on the 6AM-6PM shift. LVN J she was Resident#34's primary are nurse on 06/24/25 for the 6AM-6PM shift. LVN J said she was told by LPN B that a surveyor had said that resident was choking while eating breakfast. LVN J said LPN B told her that Resident #34 was not choking when she arrived too resident room and that resident coughing had resolved. LVN J said she called the hospice company, and they did not provide any new orders. LPN J said she did not document her actions taken regarding the incident. LVN J said when a resident experience a change in condition the physician needed to be notified. LVN J said she had been working at the facility for over 3 years and could not remember if she had received in-service on choking/silent aspiration, maybe when she was first hired. LVN J said some signs of silent aspiration was excessive coughing while eating and shortness of breath.Interview on 06/27/25 at 1:12PM with the Medical Doctor at the facility said he was Resident #34's physician. The Medical Doctor said Resident #34 was on hospice service. The Medical Doctor said resident had Parkinson's disease and had a history of stroke with some dysphagia which resident sometimes had the tendency to choke but had never aspirated. The Medical Doctor said resident was on a mechanical soft diet chopped meats. The Medical Doctor said the facility had called him but could not remember on what day or the time telling him Resident #34 had choked but coughed it up. The Medical Doctor said his NP was NP RR. The Medical Doctor said his NP RR gave the facility an order to do a stat chest x-ray and speech evaluation. The Medical Doctor said his NP RR spoke with Resident #34 as well. The Medical Doctor said he would want to be notified right away if a resident experienced continuous coughing or choked while eating for the safety of the resident and due to the risk of aspiration. The Medical Doctor said some signs and symptoms of silent aspiration was coughing when trying to eat especially when consuming liquids, wheezing, change in the color of resident skin turning red and going blue. Interview on 06/27/25 at 2:11PM with the DON said she called the NP RR on 06/24/25 she thinks around 11:00AM of Resident #34's coughing incident. The DON said she told NP RR Resident #34 was stable and therefore the NP RR did not give any further orders. The DON said she had also contacted the hospice company and informed them of resident coughing. The DON said hospice said they were going to come and see resident, but did not give a day when they would be coming to the facility. The DON said another reason she did not document was because she was busy doing other task at the facility and that the nurses had already assess Resident #34 and said that resident was okay. The DON said she did not learn until the next day 06/25/25 that the nurses did not document the incident or their assessment. The DON said she told the nurses that they needed to document as a late entry. The DON said she told LPN B that she needed to do an SBAR and document in the Nursing progress notes as well. The DON said it was important to do an SBAR because it was a form of communication regarding the resident's care. The DON said when resident care was documented, it placed the resident at risk for not receiving necessary treatment. Interview on 06/27/25 at 3:20PM via phone NP RR said she did not come to the facility often and could not remember the last time she had been at the facility. NP RR said she was the medical doctor who was seeing Resident #34's NP. NP RR said she only came to the facility with the medical doctor needed her to cover for him. NP RR said she could not remember what day the facility had called her regarding Resident #34. NP RR said the facility told her that Resident #34 had experienced a coughing episode. NP RR said she asked the facility if resident was okay. NP RR said the facility told her that Resident #34 was stable. NP RR said she did not give any new orders for Resident #34. NP RR said she thought that the facility had called the medical doctor about the incident. NP RR said that it was NP R that gave an order for stat chest X-ray. Interview on 6/29/25 at 9:39am Administrator said she did not know a lot of things that were happening in the facility. The Administrator said the staff needed to make sure resident care plans were addressing the resident needs. Interview on 06/29/25 at 10:27AM with the DON, the DON said when the nursing staff assessed resident, they did not document in a timely manner all interventions taken and had to document late entries. The DON said the facility had done in-services with the staff on choking vs. coughing, residents at high risk of aspiration who diagnoses included Parkinson's disease, CVA's, and dysphagia. The DON said the facility were now assigning staff to make rounds during mealtimes to monitor the residents at mealtimes. The DON said the Speech Pathologist came to the facility to elaborate on the importance of observing residents while eating, making sure resident's position was properly aligned when eating to prevent choking, and to facilitate better swallowing for the resident. The DON said she would continue to quiz and monitor the staff until the facility was confident that all staff understood the circumstances that could place resident at risk for harm. The DON said she would continue to review the resident's care plans, quarterly meetings, and know the revision timeline. The DON said she had updated a list for the nurses to contact the physician within in a shift involving incidents and accidents. The DON said the NF would be utilizing their resources; Speech Pathologist, Nurse Practitioners, and Physician to further educate the staff on residents with swallowing problems. Record review of the facility policy on Notification of Changes in condition revised May 2025 revealed in part: The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification.Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include:1. Accidentsa. Resulting in injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include:a. Life-threatening conditions, orClinical complications

Based on interviews and record review the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (CR2, R#1, R#2) of 9 residents reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in that: The facility failed to ensure CR #2's wound interventions were implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent deterioration and infection, which resulted in hospitalization with severe sepsis and surgical wound debridement. Facility failed to provide wound care daily as ordered for ordered for R#1 and R#2 when the residents did not receive wound care for 5/25/2025. An Immediate Jeopardy (IJ) was identified on 5.28.2025. The IJ template was provided to the Administrator and DON on 5.28.2025 at 1:15p.m. While the IJ was removed on 6.1.25 at 6:25pm, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm. Findings included: Record review of CR#2's face sheet revealed a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted [DATE] and discharged [DATE] with a diagnosis of Osteomyelitis of vertebra, sacral and sacrococcygeal region. Record review of CR#2's Annual MDS assessment dated 3.13.25 revealed a BIMS score of 15 (cognitively intact). Section GG (Functional Abilities) revealed, CR#2 is impaired on both sides (lower extremity-hip, knee, ankle, foot), uses a wheelchair. CR#2 need substantial/maximal assistance with oral, toilet, and personal hygiene, shower/bathe, upper and lower body dressing and putting on/taking off footwear; requires partial/moderate assistance to roll left and right; has an Indwelling catheter (carries the urine out of the body) and Ostomy (collects waste); paraplegic (inability to move the lower parts of the body). Section M (Skin Conditions) revealed CR#2 is at risk and has stage 3 and 4 pressure ulcers. Record review of CR#2's orders dated 1.2.2025 revealed the following: Ascorbic Acid Tablet 500 MG one time a day for wound healing related to unspecified skin changes, Order date 1/3/2025-05/22/2025; Colostomy to LLQ (bottom left area of abdomen) every day shift, every 3-days Change colostomy bag and wafer (piece of pouch that sticks to the body) every 3 days-Order date 1/2/2025-05/22/2025; Type of wound: Pressure (injury to skin and underlying tissue) and MASD (Moisture-Associated Skin Damage) caused by prolonged exposure to moisture. Location of wound: right and left buttocks, and left post upper thigh, irrigate or cleanse wound bed with normal saline, nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Collagen and Cal Alginate cover (Wound dressing) with dry dressing secure dressing with tape as needed Order date 3/26/2025-5/22/2025; Type of wound: Pressure stage 3. Location of wound: Right Gluteus (buttock) irrigate or cleanse with normal saline, Nexodyn solution (wound care solution containing hypochlorous acid) or wound cleanser, pat dry and apply or pack collagen & Cal alginate cover-Order date 3/28/25-5/22/2025; Type of wound: Pressure stage 4. Location of wound: left buttock irrigates or cleanse wound bed with Normal saline, Nexodyn solution (wound care solution containing hypochlorous acid) or wound cleanser, pat dry and apply or pack collagen & Cal alginate cover-Order date 5/5/25-5/22/2025; Type of wound: PRESSURE Location of wound: LEFT Phone GLUTEUS Irrigate or cleanse wound bed with Normal sallne, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABD (abdomen) PAD AND DRY DRESSING Secure dressing with: TAPE; Type of wound: PRESSURE Location of wound: LEFT GLUTEUS Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABO PAD AND DRY DRESSING Secure dressing with: TAPE-Order date 2/27/2025- 5/22/2025; Type of wound: PRESSURE Location of wound: LEFT UPPER POSTERIOR THIGH irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABD PAD AND DRY DRESSING Secure dressing with: TAPE PAIN CODE Order date 2/27/2025-05/22/2025; WEEKLY SKIN ASSESSMENT. COMPLETE HEAD TO TOE SKIN ASSESSMENT AND DOCUMENT FINDINGS ON WEEKLY SKIN OBSERVATION TOOL UDA every day shift every Tue -Order Date- 01/02/2025- 05/22/2025; COLOSTOMY TO LLQ every shift COLOSTOMY CARE QSHIFT AND PRN USE STOMA PASTE AND/OR POWEDER AROUND THE OSTOMY -Order Date 01/02/2025-05/22/2025; Enhanced Barrier Precautions (EBP) every shift with high contact care activities. -Order Date- 04/22/2025-05/22/2025; OBSERVE AND MONITOR MIDLINE ABD SURGICAL INCISION FOR PROPER HEALING, NO INFECTION AND APPROXIMATION EVERYDAY, EVERY SHIFT every day and night shift -Order Date 01/14/2025-05/22/2025; Santyl External Ointment 250 UNIT/GM (Collagenase)Apply to RIGHT HEEL topically related to PRESSURE ULCER OF RIGHT HEEL, STAGE 4 -Order Date 03/27/2025-05/22/2025, Type of wound: [NAME] Location of wound: LEFT GLUTEUS Irrigate or cleanse wound bed with Normal saline, Nexodyn solution o wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN ANDCALALG Cover with:(6X6) SUPRAABSORBENT SILICONE BORDERED DRSG. Secure dressing with: MEDIFIX TAPE-Order Date 01/16/2025- 5/22/2025; Type of wound: PRESSURE DTI Location of wound: RIGHT HEEL (CORRECTION TO LOCATION) Irrigate or cleanse wound bed with Nonnal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): SANTYL AND CAL ALGINATE Cover with: DRY DRESSING Secure dressing with: TAPE Order Date 03/21/2025-5/22/2025; Type of wound: PRESSURE STAGE 4 - Location of wound: LEFT POSTERIOR THIGH_ Irrigate or cleanse wound bed with Normak saline, Nexodyn solution o wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN ANDCALALG Cover with: DRY DRESSING Secure dressing with: TAPE AS NEEDED -Order Date 04/17/2025-05/22/2025. Record review of CR#2's care plan dated 3.27.2025 revealed the following: Focus: [CR#2] Requires Wound Care Management Goal: [CR#2] Wound will be free of signs or symptoms of infection. Target Date: 6.19.2025 Interventions: Evaluate ulcer characteristics, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no signs of improvement on current wound regimen, Provide Wound Care per Treatment Order Focus: [CR#2] requires assistance to perform functional abilities in Self Care and mobility (AEB), unsafe or poor quality in functional range of motion (Specify- to upper or lower, right or left, etc. r/t Medically complex conditions transfer with Hoyer lift) Goal: [CR#2] will have improvement in functional abilities in the following areas by end of their skilled stay. Target date 6.19.2025. Interventions: Provide the following self-care assistance: (Specify in A-H below-Partial, Substantial/Maximal A. Eating: Independent B. Oral hygiene: Independent C. Toilet Hygiene: Substantial/Maximal E. Shower/Bathe self: Partial/Moderate F. Upper body Dressing: Independent G. Lower body Dressing: Substantial/Maximal H. Putting on/taking off footwear: Substantial/Maximal I. Personal Hygiene: Independent Focus: [CR#2] has Specify: Suprapubic Catheter present and is at risk for UTI and complications due to catheter use R/T Neurogenic bladder. Goal: [CR#2] will be/remain free from catheter-related complications through review date. Target Date: 6.19.2025. Interventions: Check tubing for kinks throughout each shift, encourage fluid intake, monitor for leg strap placement and change as needed, monitor for s/sx of discomfort on urination and frequency, monitor urinary output amount, color, odor and sediments, etc. report abnormal to MD. Focus: [CR#2] has potential fluid deficit r/t Dx of Septicemia Goal: [CR#2] will be free of symptoms of dehydration and maintain moist mucous, membranes, good skin turgor. Target Date: 6.19.25 Interventions: Monitor and document intake and output as per facility policy; Monitor/document/report PRN any s/sx monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increase pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes, obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated Focus: [CR#2] has stage 4 pressure injury to left buttock, left posterior upper thigh and stage 3 PI to right buttock. Goal: [CR#2] Pressure injury will be free from signs and symptoms of infections. Target Date: 6.19.25; will remain free of pressure injury through the next review date. Target date: 6.19.25; will show granulation and reduction in size through review date. 6/19/25 Interventions: Add additional supplements as needed, administer treatment to decubitus ulcers(s) as ordered. If no wound improvement notify MD/NP to obtain new orders (1.16.2025: Collagen and cal alginate daily; 3.17.2025: Collagen and cal alginate with dry drsg (dressing) daily); assist resident with Turning & repositioning during rounds and as needed; monitor and report MD and RP and s/s of infection. Weekly skin assessment, notify M.D. for Ulcers that are deteriorating, as needed. 1.16.25 Left gluteus 12x10x0.4cm and left upper posterior thigh 9x9.8x0 cm; 3.17.2025 Left buttock - 10x10x0.4cm and left upper posterior thigh 9x10x0.3cm and right buttock 8.8x8x0.2; Focus: [CR#2] has a pressure DTI pressure injury to bilateral heels d/t Goal: [CR#2] will have no complication from wound. Target date: 6.19.2025. Interventions: Assist with turn/repositioning during rounds and as needed Focus: [CR#2] is on antibiotics for osteomyelitis and is at risk for adverse reactions. Goal: [CR#2] Infection will be resolved or resolving at the end of antibiotic therapy and resident will not have any adverse reactions to antibiotic therapy. Target date.6.19.2025 Interventions: Assess effectiveness of interventions and adjust plan as indicated. Focus: [CR#2] has a colostomy Goal: [CR#2] will have adequate emptying of bowels daily and evidence any signs of symptoms of obstruction or constipation until next review. Target date: 6.19.2025. Interventions: Monitor bowel put daily, nursing statff will change colostomy bag as needed, provide stoma care daily as instructed and prn. Report any abnormalities to MD and RP. Focus: [CR#2] has the history of osteomyelitis a vertebrae sacrococcygeal region and is at risk for recurrent infection to bones. Goal: [CR#2] will not experience signs and symptoms of osteomyelitis unaddressed during review. Target date 6.19.2025 Interventions: encourage resident to report abnormal pain to bones, labs as ordered, medications as ordered, monitor for s/s of infection as needed and report abnormalities, therapy to screen and eval as needed. Focus: [CR#2] as paraplegia. At risk for complications related to conditions. Goal: [CR#2] will have no complications related to condition through the next review date. Target date 6.19.2025. Interventions: Encourage to maintain physical activity within limits, monitor 4 autonomic dysreflexia (overreaction of the nervous system) symptoms such as hypertension (high blood pressure), diaphoresis (excessive sweating), dizziness, anxiety, increase spasticity (stiff muscles), flushing of the skin, bradycardia (low heart rate), cool pale skin, visual disturbances, Focus: [CR#2] has diagnosis of Paraplegia and is at risk for contracture and skin breakdown. Goal: [CR#2] will not develop contractures until the next review. Target date: 6.19.2025, Resident will not develop skin breakdown until the next review. Target Date: 6.19.2025. Interventions: Report any skin breakdown to MD, Staff to provide all ADL care, weekly skin assessment. Focus: [CR#2] has frequent UTI's and is at risk for increased temperature, dehydration, and pain/discomfort. Goal: [CR#2] frequency of UTI's will that decrease, and resident will not have c/o (care of) pain discomfort, temp. will remain with in baseline limits until the next review. Target date: 6/19/2025. Interventions: give meds per order -monitor labs-report abnormals to M.D, monitor for increased temp, dehydration, pain discomfort, etc-report to M.D., Monitor to assure proper peri care (washing anal and genital area) is done, monitor urine for sediment, color, odor, amount, etc-report abnormal to MD. VOHRA_5/8/2025_ Stage 4 Pressure Wound of the Left Buttock wound size: 9.8x10.4x0.0.4_Dressing Treatment Plan: Primary Dressing(s): Alginate calcium apply twice daily for 30 days; Santyl apply once daily for 16 days Secondary Dressing(s) Gauze island w/ bdr apply twice daily for 30 days Peri Wound Treatment House barrier cream apply twice daily for 30 days VOHRA_5/8/2025_Stage 4 Pressure Wound of the Left Posterior Thigh wound size: 9x7.5.0.3_Dressing Treatment Plan: Primary Dressing(s): Collagen sheet apply twice daily for 30 days; Alginate calcium apply twice daily for 30 days Secondary Dressing(s) Gauze island w/ bdr apply twice daily for 30 days Peri Wound Treatment House barrier cream apply twice daily for 30 days VOHRA_5/8/2025_Stage 4 Pressure Wound of the right heel wound size: 4.4x7x0.3 VOHRA_5/8/2025_Stage 3 Pressure Wound of the right buttock_Resolved. VOHRA_5/15/2025_ Stage 4 Pressure Wound of the Left Buttock wound size: 12.3x10.4x0.0.4_Dressing Treatment Plan: Primary Dressing(s): Alginate calcium apply twice daily for 23 days; Sodium hypochlorite solution (dakins) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: 0.25% soaked gauze in wound bed. Secondary Dressing(s) Gauze island w/ bdr apply twice daily for 23 days Peri Wound Treatment House barrier cream apply twice daily for 23 days VOHRA_5/15/2025_Stage 4 Pressure Wound of the Left Posterior Thigh wound size: 9x8.5.0.3_Dressing Treatment Plan: Primary Dressing(s): Alginate calcium apply once daily for 23 days; Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days Secondary Dressing(s) Gauze island w/ bdr apply twice daily for 23 days Peri Wound Treatment House barrier cream apply twice daily for 23 days VOHRA_5/15/2025_Stage 4 Pressure Wound of the right heel wound size: 4.4x5.2x0.3 DRESSING TREATMENT PLAN Primary Dressing(s) Alginate calcium apply once daily for 30 days; Collagen sheet apply once daily and as needed: if saturated, soiled, or dislodged. For 23 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 23 days Record Review of skin observation tool dated 5/13/25 at 5;19pm revealed CR#2's sacrum wound with no other comments. In a Telephone interview with FM B on 5.22.2025 at 3:40pm, FM B stated CR#2 is currently in the local hospital. FM B stated CR#2 was not turned properly and her wounds became worst, which resulted in a colostomy bag. He stated staff refused to communicate with him although he sent several emails to the DON regarding this issue. FM B stated the staff do not answer phones half of the time and when he would visit the facility, he would see employee on their personal phones not caring for residents. FM B stated when employees noticed him looking at them then they would begin working. FM B stated CR#2's room was so on the 200 Hall most times. FM B stated as a results of the lack of care CR#2 received, he continued calling and emailing the DON who would always tell him the issue would be addressed. FM B stated he received the same response, which is frustrating. He stated he called in to the state about this issue and it was not addressed. FM B stated CR#2 can speak and understand. She is paraplegic. FM B stated CR#2 has been at the facility since 2015. FM B stated CR#2 was not being seen daily by the wound care nurse either because the wound care nurses quit or got fired; and then other floor nurses who are not good at doing wounds would try. FM B stated CR#2 was not being turned as required by aides. He stated he has addressed this multiple times. FM B stated CR#1's treatment at this facility was just horrible. Another issue FM B stated he spoke with DON and Administrator about was staff would not change CR#2's urine bag and it backed up causing multiple UTI's. In an interview with ADON A on 5/23/25 at 3:42pm -she stated CR#2 has resided in the facility for 10 years and has a chronic suprapubic catheter. She stated CR#2 goes monthly to have her suprapubic catheter changed. She stated the wounds are not being resolved because CR#2 stays moist in those areas, however, CR#2 was being treated. ADON A stated when CR#2 went to hospital the sacrum womb got worse (stage 4) while she was there, not at the facility. ADON A stated CR#2 had to have a colostomy bag. ADON A stated CR#2 was being turned every 2 hours. ADON A stated CR#2 can reposition herself by grabbing hold of the bar. She stated the previous wound care nurse took care resident before her employment was terminated. ADON A stated the WCD makes rounds every week on Thursday. In an interview with WCN on 5/23/25 at 3:57pm who stated she has recently been task to provide wound care. She stated she is a nurse that does wounds. WCN stated she completed CR#2's wound care a couple of times. She stated CR#2's sacrum wound was stage 4. She stated she doesn't know what previous instruction was given to former wound care nursing staff from wound care doctor because she only was observing. WCN stated the last time wound care was provided on CR#2 was around 5/15/2025 with WCD and weekend wound care nurse, LVN F. WCN stated CR#2 had some serious wounds that were always draining. She stated there were 3 wounds that she observed, one on the sacrum (buttocks), one on the left thigh and one on the right heel. She stated when it was time for her (WCN) to do wound care on CR#2 she transferred to the local hospital. In an Interview on 5.24.25 at 7:30am with HNM- She stated CR#2 arrived at the hospital emergency room on 5/18/2025 at 8:37pm. The admitting diagnosis was: Severe Sepsis; however, she stated according to doctors' notes, CR#2's chief complaint was her sacral (buttock) wound. HNM stated CR#2 is currently in surgery for wound debridement. The HNM stated upon CR#2's arrival to emergency room, CR#2 vitals were: B/P: 108/88 Temp: 97.9 Pulse: 88 Respirations: 18 WBC: 11.37 In an Interview with CR#2 on 5/24/2025 at 12:35pm - she stated that her wound was very bad, which is the reason why she had to have the surgery for debridement at the hospital this morning. CR#2 stated that she was supposed to be changed twice a day and turned every 2 hours. However, she was only changed one time per day on the 1st shift and never on the 2nd shift. CR#2 stated she complained multiple times to all the staff, including DON and administrator and nothing was resolved. She stated FM B called and spoke with the DON, and he has spoken with the nurses on her shift, and nothing has never really been done to address or resolve her sacrum wounds. CR#2 stated in fact, the wounds worsened over time. She stated sometimes her butt hurts so bad she didn't know what to do other than cry and endure the pain. CR#2 stated she came to the hospital on 5.18.25 due to low blood pressure; However, she was informed she had severe sepsis. CR#2 stated that the WCD put in his note that she was to be turned several times each shift and her bandages should be changed twice, one time on 1st shift and once on 2nd shift. CR#2 stated she was only changed one time and that was after lunch prior to 2nd shift. CR#2 stated she was supposed to have been changed then put in her chair. CR#2 stated she has not been put in the chair for the last two weeks. CR#2 stated her bandages were always soaking wet and her wounds were always draining. CR#2 stated last week, she could not remember the exact date day or shift, an agency nurse came in and removed her bandages, washed, and cleaned her wounds. CR#2 stated a little later that same day and shift, an agency CNA came in to give her wash up, and when she rolled her over, she noticed that there were no bandages on her wounds and that her wounds were open because the agency nurse never redressed her bandages after cleaning her wounds. CR#2 stated that she has never been turned every two hours on the shift. She stated a lot of times she would have to call her children who would call the facility and demand a nurse, or someone come to her room and turn her. CR#2 stated that she has never refused wound care and never will because she knows just how important that is to her. She stated that she's trying to get better and hopefully one day she can go home. CR#2 stated she has been left to lie in her own poop for hours without being changed. She stated she's had to call her children who have had to call the facility to have a nurse go to her room and change her. CR#2 stated that first shift is a little short of staff, but second shift has been short of staff for quite some time and in order to have the call light answered it would be at least an hour or two. CR#2 stated in January 2025, she had a colonoscopy bag. She stated she had a colonoscopy, and it found a mass on her, but it was not cancer. She stated the colonoscopy bag was a result of wounds and that her wounds are so bad, and the care is so bad at the facility, the doctors at the hospital did not want to take a chance and continue letting her sit in her poop with open wounds. CR#2 stated staff barely changed her urine bags and they would stay full which resulted in her getting multiple UTI's. On 05/26/25 at 10:06AM Observation of Wound Care for R#1 in room [ROOM NUMBER] A-bed by WCN and LVN B. R#1 was resting in bed to her left side on an air mattress and was not inter-viewable. R#1's right hip dressing date on old dressing read 05/24/25 with moderate amount of dark brown, black color drainage on old dressing. WCN said the last time she worked at the facility doing dressing changes was on 05/24/25. R#1's wound bed was approximately the size of a silver dollar coin with inside tissue appearing pink reddish in color. In an Interview with CNA D 5/26/2025 at 10:30am she stated she has worked at the facility for 3 years and has worked with CR#2. She was nice and stated that she turned CR#2 every two hours. CNA D stated CR#2 is extremely verbal and will tell staff what she needs because she is direct in her words. CNA D stated she has not witnessed CR#2 refusing care. She stated CR#2 complained often about 2-10 shift not bathing her. She stated CR#2 was currently 2-10 bath. CNA D stated she would give CR#2 her baths if she had time on her shift. CNA D Stated resident has asked nurses to flush he catheter. CNA D stated CR#2 does not like poop to get on her and demands to get changed immediately. CNA D stated CR#2 would only refuse to get out of bed during the times she is in a lot of pain. CNA D stated she will inform the WCN or charge nurse when CR#2 has issues or refuse care. She stated R#2 did not get his bandaged changed on 5/25/2025 and she noticed the 5/24/2025 when she went into the room with the WCN. In an interview with WCN on 5/26/25 at 10:47am who stated she has recently been task to provide wound care. She stated she is a nurse that does wounds. WCN stated she completed CR#2's wound care a couple of times. She stated CR#2's sacrum wound was stage 4. She stated she doesn't know what previous instruction was given to former wound care nursing staff from wound care doctor because she only was observing. WCN stated the last time wound care was provided on CR#2 was around 5/15/2025 with WCD and weekend wound care nurse, LVN F. WCN stated CR#2 had some serious wounds that were always draining. She stated there were 3 wounds that she observed, one on the sacrum (buttocks), one on the left thigh and one on the right heel. She stated when it was time for her (WCN) to do wound care on CR#2 she transferred to the local hospital. In reference to R#1 and R#2, the WCN stated the date on R#1's bandage 5/24/2025, and R#2's bandage was dated 5/24/2025. WCN stated the bandages should be changed daily. She stated her last working day was 5/24/25. WCN stated in her absence, the charge nurses should have replaced the bandages. WCN stated either the weekend wound care nurse or charge nurses should have provided wound care to residents and replaced the bandages and dated them as well. WCN stated not changing wound care bandages, not replacing bandages that have fallen off and not following doctors' orders for wound care could place resident at risk for infection. In a Telephone Interview with WCD on 5/26/2025 at 12:42pm - he stated CR#2 appeared to be OK the last time he seen her on 5.15.25. He stated that the residents' wounds are chronic but not progressing. WCD stated this was an issue, which is why he ordered Dakins Solutions. WCD stated he observes CR#2's wound bandages to be saturated when he comes to visit and had some concerns with the wounds and not progressing well. He stated that CR#2's bandages on her wounds would be soil. He stated one reason for the wound bandages would be if the catheter was not in properly or if the bandages were not being changed as ordered. The WCD stated he has not smelled any urine when he came to see CR#2. He stated CR#2 had a colostomy bag and a Foley catheter. WCD stated that a saturated dressing could increase infection and could lead to systemic also known as sepsis if not changed properly. He stated he noticed that CR#2 does not get out of bed as she should. WCD stated if wound dressings are not on the wound, it also increases the likelihood of bioburden infection that could also lead to sepsis. WCD stated CR#2 should get up out of the bed several times during the day for at least 60 minutes to two hours and then place back in bed. He stated when CR#2 refuses to get out of bed, facility staff should be a little more diligent with residents to encourage her to do so. WCD stated that he has known resident for many years and the one thing that she does not do is lie! In a telephone interview with CNA G 5/26/2025 at 2:45pm, she stated she was very familiar with CR#2 because she worked 6am-2pm shift was responsible for her care. She stated CR#2 moods would change when she was in pain. She stated CR#2's wounds were always open and draining, which made her bandages soiled. CNA G stated CR#2 would get up in the chair sometimes after receiving a bed bath; however, she would refuse when she was tired and hurting. CNA G stated she put resident up in chair when she would ask. She stated CR#2 was a two person assist and needed to be lifted with the help of a Mechanical lift. CNA G stated whenever she would see CR#2's colostomy bag leaking it was changed as needed. CNA G stated if CR#2's bandage had a little poop on it she wanted it changed immediately. CNA G stated in her opinion, a little poop on the bandage did not mean the bandage should be changed. CNA G stated because CR#2's bandage had a small amount of poop on it, it didn't need changing and this would upset CR#2. In a telephone interview with LVN F on 5/26/2025 at 3:40pm -She stated she worked the 6a-6p and worked the 200 hall and first half of 600 hall. She stated the treatment nurse is responsible for wound care; however, if treatment nurse isn't available then the floor/charge nurse is responsible. She stated she did not turn R#2 and didn't see the sacrum wound. LVN F stated she did not look at R#2's neck area. She stated the treatment nurse was in the building looking at all residents with wounds. LVN F stated when resident dressing comes off the treatment nurse is responsible, but the charge/floor nurse would be responsible if they become aware. LVN F stated it is important for dressing to be changed as ordered to eliminate infections and to ensure the wound to heals. If the dressing is not redressed it can get contaminated and could get infected. Record Review of R#1's undated face sheet was the [AGE] year-old female admitted to the facility on [DATE] with the diagnosis of Alzheimer's disease. Record Review of R#1's MDS dated [DATE] revealed no BIMS score, severely impaired, unable to respond, impaired on the lower extremities (both sides), uses a wheelchair. R#1 required substantial/maximal assistance in the areas of eating, oral & toileting hygiene, shower/bath, upper & lower body dressing, putting on and taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sit on side of bed, sit to stand, and chair/bed to chair transfer. R#1 is totally dependent on staff for Tub/Shower transfer. Section H (Urinary Toileting Program) R#1 is always in continent in the areas of urinary and bowel continence. Section M (Skin Conditions) revealed R#1 is at risk of developing pressure ulcers/injuries and has one or more unhealed pressures ulcers/injuries. R#1 has a stage 4 pressure ulcer and requires pressure ulcer/injury care and application of nonsurgical dressings. Record Review of R#1's May 2025 orders revealed Type of wound: abrasion located right lower media irrigate or cleanse wound bed with normal saline, nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): collagen cover with dry dressing. Order date 5/6/2025 5:32pm; Type of wound: open area Location of wound: Coccyx irrigate or cleanse wound bed with normal saline, nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): collagen Cover with dressing daily. Order Date-5/6/2025 at 5:35pm D/C-5/26/2025 at 1:11pm; Type of Wound: Pressure Sore Location of wound: Left Buttock. Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanse, pat dry and apply or pack (if applicable): Collagen. Cover with: Dry Dressing secure dressing with Tape. Order date-4/20/2025 at 5:23pm; Type of wound: Pressure Stage 4. Location of wound: Right hip irrigate or cleanse wound Fobed with Normal saline, Nexodyn solution or wound cleaner, pat dry and apply or pack (if applicable): 1/4 Iodoform packing strip and cal alginate. Cover with: Dry dressing. Secure dressing with: Tape. Order Date: 4/10/2025 at 11:11am. Record Review of R#1's Comprehensive Care Plan dat[TRUNCATED]

Based on interviews and record review the facility failed to immediately investigation, report and protect 1 (CR#3) of 9 residents reviewed for abuse and neglect. The facility failed to immediately investigate, report, and protect CR#3 when he reported being stabbed in the arm with an insulin needle and scratched on the nose by LVN B. They facility failed to prevent further potential abuse when the facility failed to remove CR#3 from LVN B care after the report of abuse. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for physical harm and mental anguish. Findings included: Record Review of CR#3's undated face sheet revealed a 51-year male initially admitted to the facility on [DATE], re-entry 5/16/2025 and discharged [DATE] with diagnosis of Parkinson Disease. Record review of CR#3's Orders dated 5/16/2025 revealed Gabapentin Oral Capsule 300mg 1 capsule by mouth in the evening related to Neuralgia and Neuritis. Order dated 5/16/2025-D/C 5/22/2025; Insulin Glargine (long-acting insulin used to treat diabetes) subcutaneous solution 100. Inject 20 unit subcutaneously (injection in the fatty tissue) in the morning related to Type 2 Diabetes Mellitus with other Diabetic Kidney Complication. Order date 5/16/2025 5:31pm - 5/22/2025 8:18am; Lantus SoloStar (Disposable prefilled) Subcutaneous solution Pen Injector 100 UNIT/ML inject 20 unit subcutaneously in the morning for DM related to type 2 diabetes mellitus with other diabetic kidney complication. Order date 5/2/2025-D/C (discontinued) 5/15/2025. Record review of CR#3's MDS dated [DATE] revealed CR#3 has a BIMS of 13 (indicates cognition is intact). CR#3 requires staff assistance with self-care, indoor mobility, upper extremity; he requires substantial/maximal assistance with eating, shower/bath and CR#3 requires partial/moderate assistance with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, toilet transfer, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand and chair/bed-to-chair transfer; CR#3 is occasionally incontinent. Record review of the I-Phone recordings on CR#3's phone revealed the following information: CR#3 stated he had a recording on his I-Phone, which had a date and time stamp, of him informing the DON on 10.4.2025 and Administrator 10.11.2025 of his abusive encounter with LVN B. The telephone recording on 10/4/2024 revealed a conversation between the DON and CR#3. It was regarding the treatment CR#3 received from LVN B. The DON is heard asking CR#3 what happened, and CR#3 stated that he was uncomfortable with LVN B providing his care because she jabbed a needle in his arm. CR#3 told DON that his arm hurt like hell. The CR#3 could be heard telling the DON that LVN B did not take his blood sugar before administering his insulin as ordered, even though it appeared that she did in the system. According to the recording, CR#3 expressed his fearfulness of LVN B and did not want DON to personally address the issue with LVN B for fear of retaliation. The DON could be heard stating that she will be in-serviced with other staff so it doesn't appear that LVN B would know where the complaint came from. She stated her in-service would let all staff know that the facility is the resident's home. CR#3 again informed the DON he feared for his life and didn't want anyone to know. The DON assured him she would not mention his name. The DON did tell him she would change his room and that she does not intend to move LVN B from the floor. You could hear CR#3 crying while telling DON. The telephone recording on 10/11/2024 revealed a conversation between administrator and CR#3. During the recording, CR#3 could be heard telling the administrator he spoke with the administrator concerning issues with LVN B at this time the administrator corrected him and identified the DON by her first name and told him she was the administrator. During the recording you could hear CR#3 tell administrator he was scared and didn't know who to trust. CR#3 told the administrator he asked the DON not to say anything, but later LVN B came in his room explaining her position with the aide at which time he told her to get out of his room. CR#3 stated he was scared that LVN B may have brothers who would come to the facility and informed administrator he knew that LVN B had daughters who also worked in the facility. During the recording, CR#3 could be heard telling the administrator LVN B hit him at which time administrator appeared to gasp and she could be heard saying, Oh No. During the conversation, CR#3 was heard telling administrator that LVN B came to his room and cursed him out and the administrator told him that she has had a previous conversation with LVN B about her Potty mouth. Administrator could be heard telling LVN B when he discussed his views and the jab with the insulin needle to his arm BON should have notified her immediately. In an interview 5.20.25 at 11:25am with CR#3 who was seated on his bed, appropriately dressed and just finished speaking with occupation therapist. CR#3 stated he has Parkinson disease and shakes really bad. He stated he has been treated horrible by the facility. CR#3 stated he was in 400 hall and was assaulted by LVN B in October 2024. He stated LVN B doesn't like him and was mean to him. He stated one day he was in his room crying when an aide came to him and asked if she could pray with him. LVN B stated while the two were praying the LVN B came in his room and began using foul (Cursing) language toward the aide and told her to get out of his room. He stated the employee was later terminated. Afterwards LVN B had to administer him his insulin shot. CR#3 stated LVN B jabbed him in the arm with the needle causing a lot of pain. CR#3 stated when LVN B gave him his pills she hit him in the face purposely. He stated he spoke with the DON initially then the Administrator who is the abuse coordinator. CR#3 stated next thing he knew; he was transferred to 200 hall believes this is retaliatory. In an interview on 5.20.25 at 12:23 pm with the DON regarding CR#3. The DON stated CR#3 is upset because he received a discharge notice due to non-payment. She stated the resident was moved from hallway 400 to 200 because he was transitioning from skilled nursing to LTC. She stated she remembers the resident complaining that his arm hurt after the LVN B gave him a shot. She stated she assessed his arm he did not have any marks or bruises from the jab. DON stated she did not complete a head-to-toe assessment, nor did she notify the abuse coordinator, nor did she call in the report. She stated the administrator is the abuse coordinator. She stated he told her LVN B was aggressive, and he did not want any dealings with her. She stated she couldn't remember the exact date this conversation occurred. The DON stated it was decided that CR#3 would have a room change; however, until there was a room on another hallway, LVN B was told to take a witness (another employee) in CR#3's room with her when she provided care CR#3. The DON told investigator that she stated she and administrator went to speak with resident today who became upset and had to be transported to local hospital. Interview on 5/29/2025 at 1:25pm with the Administrator -she stated she has been at the facility for 12 years and the abuse coordinator for as long as she has been here. She stated the resident never told her LVN B had jabbed or stabbed him in the arm. She stated if CR#3 had said he received a Jab or Stab from LVN B or any staff member, she would have expected CR#3 to come to her immediately. Administrator stated when CR#3 didn't feel safe with LVN B, the DON should have informed her immediately. The administrator stated if a resident stated they have been mistreated, abuse, or feel unsafe they should come and tell her since she is the abuse coordinator. She stated LVN B is scheduled to work on the skill hall (400 Hallway) 99% of the time. She stated LVN B should not have been providing care after CR#3 left her hall. She stated LVN B should not have been providing care after CR#3 left her floor because CR#3 didn't feel comfortable with her . Administrator stated CR#3 would not have felt comfortable being administered medication from LVN B. Administrator stated she and the DON went to CR#3's room on 5/20/25 to speak with him regarding his issues with LVN B. Administrator said she told resident that she heard there were some issues. She stated the DON told CR#3 he didn't tell her LVN B stabbed or jabbed him with the insulin needle. She stated CR#3 called DON a liar and appeared to lunge toward her aggressively and raising his voice. She stated CR#3 told her and the DON that they were giving him heart problems. She stated with CR#3's behavior she feared for the DON and the two left and called the ambulance because he complained of heart issues. Administrator stated she did not file a report with the state and should have. Record Review of Abuse, Neglect and Exploitation policy dated/implemented 01/2023 and Reviewed/Revised 01/2025 by Corporate RN stated, All reports of resident abuse (including injuries or unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. The following Plan of Removal submitted by the facility was accepted on 5.31.2025 at 1:16pm. PLAN OF REMOVAL Name of facility: Date: 05/30/25 F 610 -. Investigate/Prevent/Correct Alleged Violations Problem: The facility failed to immediately investigate, report, and protect the resident when CR#3 reported being stabbed in the arm with an insulin needle and scratched on the nose by LVN B. Immediate action: 1. On 05/29/25 The facility administrator completed a self-report incident to HHSC d/t allegation of physical abuse on resident CR#3. Staff and residents' interviews will be completed, and incident investigation will be sent to HHSC by end of day 05/31/25 2 LVN B was in serviced on abuse, neglect and exploitation and placed on administrative suspension pending investigation on 5/30/25 and employment was terminated on 05/31/25 Completion date 05/31/25 3. CR#3 resident is no longer a resident in the facility. The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 4. Resident interviews were conducted with residents who were able to participate and answer questions, no issues were identified. All alert residents were interviewed. A skin assessment audit was completed in all 89 residents residing in the facility and no issues were identified. Completion date 05/30/2025 5. The Facility Corporate nurse reviewed Abuse, neglect and Exploitation policy and procedure no changes were made. Completion 05/30/2025 6. PTA is no longer working for the facility. Rehab staff received an inservice on abuse, neglect and exploitation and incident and accidents facility policy and procedures. The QA corporate nurse inservice the rehab staff. Completion date 05/30/25 7. 5/30/25 The QA corporate nurse provided the inservice on resident rights following facility policy and procedures to all staff present, the DON sent the inservice to all other staff no present. Completed 5/30/25 8. 5/30/25 The QA Corporate nurse initiated and in-serviced on the corporate Compliance hotline to report any unresolved issues by the facility administration. The QA corporate nurse provided the inservice. Completion date 05/30/25 Interventions 9. The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 10. The [NAME] President of Operation conducted and in-service with the facility Administrator: Review of Abuse and Neglect and Exploitation Policy. The in-service included the company expectation to immediately initiate an investigation with any allegation of abuse and neglect including a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 05/30/25 11. On 5/30/25 The Corporate nurse/designee immediately initiated and in-service with all facility staff regarding Abuse and Neglect focusing on reporting any suspicious of abuse allegations immediately to the Administrator who is the abuse coordinator, including a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Staff will not provide direct resident care until the training has been completed. Completed 5/30/25 12. The [NAME] President of Operation conducted and in-service with the facility Administrator: The in-service included a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 5/30/25 13. The corporate nurse conducted an in-service with the DON: The in-service included a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 5/30/25 14. On 5/30/25 Resident council meeting was held with no abuse allegations concerns. 15. On 5/30/25 the Administrator reviewed the grievances from the last month, all grievances were addressed and up to date with no abuse concerns were identified. Completion 5/30/25. 16. On 5/30/25 the corporate nurse/Designee initiated an in-service with the facility staff on all six types of elder abuse. Completion 05/30/25 17. On 05/30/25 the corporate nurse/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting. Completion 05/30/25 18. On 5/30/25 the corporate nurse/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect to be reported to the administrator immediately. Completion 5/30/25 Any staff member who is not present or in service on 05/30/25 will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by corporate nurse/Designee, until all staff complete the in-services. Monitoring 1. On 05/30/25 the corporate nurse/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the corporate nurse/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completion 05/30/25. 2. An impromptu QAPI meeting was conducted with the facility's Medical Director on 05/30/25 to notify of the potential for non-compliance and the action plan implemented for approval. Completed 05/30/25. Monitoring of the facility's Plan of Removal included the following: Record Review of the 05/29/25 The facility administrator completed a self-report incident to HHSC d/t allegation of physical abuse on resident CR#3. Staff and residents' interviews will be completed, and incident investigation will be sent to HHSC by end of day 05/31/25 Record Review of the LVN B was in-serviced on abuse, neglect and exploitation and placed on administrative suspension pending investigation on 5/30/25 and employment was terminated on 05/31/25 Completion date 05/31/25 Record Review of the documentation CR#3 resident is no longer a resident in the facility. The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 Record Review of the Resident interviews were conducted with residents who were able to participate and answer questions, no issues were identified. All alert residents were interviewed. A skin assessment audit was completed in all 89 residents residing in the facility and no issues were identified. Completion date 05/30/2025 Record Review of the The Facility Corporate nurse reviewed Abuse, neglect and Exploitation policy and procedure no changes were made. Completion 05/30/2025 Record Review of the PTA is no longer working for the facility. Rehab staff received an inservice on abuse, neglect and exploitation and incident and accidents facility policy and procedures. The QA corporate nurse inservice the rehab staff. Completion date 05/30/25 Record Review of the 5/30/25 The QA corporate nurse provided the inservice on resident rights following facility policy and procedures to all staff present, the DON sent the inservice to all other staff no present. Completed 5/30/25 Record Review of the 5/30/25 The QA Corporate nurse initiated and in-serviced on the corporate Compliance hotline to report any unresolved issues by the facility administration. The QA corporate nurse provided the inservice. Completion date 05/30/25 Interventions Record Review of the The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 Record Review of the [NAME] President of Operation conducted and in-service with the facility Administrator: Review of Abuse and Neglect and Exploitation Policy. The in-service included the company expectation to immediately initiate an investigation with any allegation of abuse and neglect including a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 05/30/25 Record Review of the 5/30/25 The Corporate nurse/designee immediately initiated and in-service with all facility staff regarding Abuse and Neglect focusing on reporting any suspicious of abuse allegations immediately to the Administrator who is the abuse coordinator, including a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Staff will not provide direct resident care until the training has been completed. Completed 5/30/25 Record Review of the [NAME] President of Operation conducted and in-service with the facility Administrator: The in-service included a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 5/30/25 Record Review of the corporate nurse conducted an in-service with the DON: The in-service included a review of policy section III. Prevention of Abuse, Neglect and Exploitation. And section VI. Investigation of Allege Abuse, Neglect and Exploitation and Section VII. Protection of Resident. Completed 5/30/25 Record Review of the 5/30/25 Resident council meeting was held with no abuse allegations concerns. Record Review of the 5/30/25 the Administrator reviewed the grievances from the last month, all grievances were addressed and up to date with no abuse concerns were identified. Completion 5/30/25. Record Review of the 5/30/25 the corporate nurse/Designee initiated an in-service with the facility staff on all six types of elder abuse. Completion 05/30/25 Record Review of the 05/30/25 the corporate nurse/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting. Completion 05/30/25 Record Review of the 5/30/25 the corporate nurse/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect to be reported to the administrator immediately. Completion 5/30/25 Record Review of the documentation that says Any staff member who is not present or in service on 05/30/25 will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by corporate nurse/Designee, until all staff complete the in-services. Monitoring Record Review of the 05/30/25 the corporate nurse/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the corporate nurse/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completion 05/30/25. Record Review of the impromptu QAPI meeting was conducted with the facility's Medical Director on 05/30/25 to notify of the potential for non-compliance and the action plan implemented for approval. Completed 05/30/25. Interviews with the following staff from 5.31.2025 at 12:36 AM to 6.1.2025 6:25pm who worked all shifts and all days of the week revealed they had been in-serviced on Reporting Abuse and Neglect, Kardex, Stop and Watch, reporting and documenting when residents refuse care, turning and repositioning, change of condition and reporting, and documentation: RN, LVN B, LVN D, LVN E, LVN H, LVN I, LVN J, MA C, MDS, CNA E, CNA D, CNA J, CNA H, CNA I, CNA M, CNA U, CNA V, WCN, DON, and the Administrator. Each staff was asked if they understood all aspects of their training and they responded in the affirmative. Each staff understood their particular roles in the Abuse Neglect and reporting, documentation, stop and watch, change of condition and where to document this information. The Administrator was informed that the Immediate Jeopardy was removed on 6/1/2025 at 6:25 p.m. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on Interviews and record review the facility failed to implement the facility's abuse policy ensuring 1 (CR#3) of 9 residents was free from abuse reviewed for developing/implementing abuse policies. The facility failed to implement their abuse policy when CR #3 made an allegation of physical and verbal abuse. The allegation was not reported to the abuse coordinator or investigated and the alleged abuser had access to CR#3 after an allegation of abuse was made. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 at 6:25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for physical harm and mental anguish. Findings included: Record Review of Abuse, Neglect and Exploitation policy dated/implemented 01/2023 and Reviewed/Revised 01/2025 by Corporate RN stated, All reports of resident abuse (including injuries or unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention and my colon and d. Establish coordination with the QAPI program III. Prevention of abuse, Neglect, and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/ or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual regional care needs and behavioral symptoms. Record Review of CR#3's undated face sheet revealed a 51-year male initially admitted to the facility on [DATE], re-entry 5/16/2025 and discharged [DATE] with diagnosis of Parkinson Disease. Record review of CR#3's Orders dated 5/16/2025 revealed Gabapentin Oral Capsule 300mg 1 capsule by mouth in the evening related to Neuralgia and Neuritis. Order dated 5/16/2025-D/C 5/22/2025; Insulin Glargine (long-acting insulin used to treat diabetes) subcutaneous solution 100. Inject 20 unit subcutaneously (injection in the fatty tissue) in the morning related to Type 2 Diabetes Mellitus with other Diabetic Kidney Complication. Order date 5/16/2025 5:31pm - 5/22/2025 8:18am; Lantus SoloStar (Disposable prefilled) Subcutaneous solution Pen Injector 100 UNIT/ML inject 20 unit subcutaneously in the morning for DM related to type 2 diabetes mellitus with other diabetic kidney complication. Order date 5/2/2025-D/C (discontinued) 5/15/2025. Record review of CR#3's MDS dated [DATE] revealed CR#3 has a BIMS of 13 (indicates cognition is intact). CR#3 requires staff assistance with self-care, indoor mobility, upper extremity; he requires substantial/maximal assistance with eating, shower/bath and CR#3 requires partial/moderate assistance with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, toilet transfer, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand and chair/bed-to-chair transfer; CR#3 is occasionally incontinent Record review of the I-Phone recordings on CR#3's phone revealed the following information: CR#3 stated he had a recording on his I-Phone, which had a date and time stamp, of him informing the DON on 10.4.2025 and Administrator 10.11.2025 of his abusive encounter with LVN B. The telephone recording on 10/4/2024 revealed a conversation between the DON and CR#3. It was regarding the treatment CR#3 received from LVN B. The DON is heard asking CR#3 what happened, and CR#3 stated that he was uncomfortable with LVN B providing his care because she jabbed a needle in his arm. CR#3 told DON that his arm hurt like hell. The CR#3 could be heard telling the DON that LVN B did not take his blood sugar before administering his insulin as ordered, even though it appeared that she did in the system. According to the recording, CR#3 expressed his fearfulness of LVN B and did not want DON to personally address the issue with LVN B for fear of retaliation. The DON could be heard stating that she will be in-serviced with other staff so it doesn't appear that LVN B would know where the complaint came from. She stated her in-service would let all staff know that the facility is the resident's home. CR#3 again informed the DON he feared for his life and didn't want anyone to know. The DON assured him she would not mention his name. The DON did tell him she would change his room and that she does not intend to move LVN B from the floor. You could hear CR#3 crying while telling DON. The telephone recording on 10/11/2024 revealed a conversation between administrator and CR#3. During the recording, CR#3 could be heard telling the administrator he spoke with the administrator concerning issues with LVN B at this time the administrator corrected him and identified the DON by her first name and told him she was the administrator. During the recording you could hear CR#3 tell administrator he was scared and didn't know who to trust. CR#3 told the administrator he asked the DON not to say anything, but later LVN B came in his room explaining her position with the aide at which time he told her to get out of his room. CR#3 stated he was scared that LVN B may have brothers who would come to the facility and informed administrator he knew that LVN B had daughters who also worked in the facility. During the recording, CR#3 could be heard telling the administrator LVN B hit him at which time administrator appeared to gasp and she could be heard saying, Oh No. During the conversation, CR#3 was heard telling administrator that LVN B came to his room and cursed him out and the administrator told him that she has had a previous conversation with LVN B about her Potty mouth. Administrator could be heard telling LVN B when he discussed his views and the jab with the insulin needle to his arm BON should have notified her immediately. In an interview 5.20.25 at 11:25am with CR#3 who was in seated on his bed, appropriately dressed and just finished speaking with occupational therapist. CR#3 stated he has Parkinson disease and shakes really bad. He stated he has been treated horrible by the facility. CR#3 stated he was in 400 hall and was assaulted by LVN B in October 2024. He stated LVN B doesn't like him and was mean to him. He stated one day he was in his room crying when an aide came to him and asked if she could pray with him. LVN B stated while the two were praying the LVN B came in his room and began using foul (Cursing) language toward the aide and told her to get out of his room. He stated the employee was later terminated. Afterwards LVN B had to administer him his insulin shot. CR#3 stated LVN B jabbed him in the arm with the needle causing a lot of pain. CR#3 stated when LVN B gave him his pills she hit him in the face purposely. He stated he spoke with the DON initially then the Administrator who is the abuse coordinator. CR#3 stated next thing he knew; he was transferred to 200 hall believes this is retaliatory. In an interview on 5.20.25 at 12:23 pm with DON regarding CR#3. The DON stated CR#3 is upset because he received a discharge notice (4/25/2025) due to non-payment. She stated the resident was moved from hallway 400 to 200 because he was transitioning from skilled nursing to LTC. She stated she remembers the resident complaining that his arm hurt after the LVN B gave him a shot. She stated she assessed his arm he did not have any marks or bruises from the jab. The DON stated she did not complete a head-to-toe assessment, nor did she notify the abuse coordinator, nor did she call in the report. She stated the administrator is the abuse coordinator. She stated he told her LVN B was aggressive, and he did not want any dealings with her. She stated she couldn't remember the exact date this conversation occurred. The DON stated it was decided that CR#3 would have a room change; however, until there was a room on another hallway, LVN B was told to take a witness (another employee) in CR#3's room with her when she provided care CR#3. The DON told investigator that she stated she and administrator went to speak with resident today who became upset and had to be transported to local hospital. In an interview on 5.20.25 at 2:45pm with PTA -She stated CR#3 was receiving therapy and on the 400 Hall where most skilled residents are located. She stated during one visit, she noticed CR#3 was on the 200 hall and she asked him why he was transferred. She stated CR#3 told her he was mistreated by his nurse and transferred on another hallway. She stated CR#3 did not get into specifics; however told her he reported this information to DON and Administrator. Interview on 5/29/2025 at 1:25pm with the Administrator -she stated she has been at the facility for 12 years and the abuse coordinator for as long as she has been here. She stated the resident never told her LVN B had jabbed or stabbed him in the arm. She stated if CR#3 had said he received a Jab or Stab from LVN B or any staff member, she would have expected CR#3 to come to her immediately. Administrator stated when CR#3 didn't feel safe with LVN B, the DON should have informed her immediately. The administrator stated if a resident stated they have been mistreated, abuse, or feel unsafe they should come and tell her since she is the abuse coordinator. She stated LVN B is scheduled to work on the skill hall (400 Hallway) 99% of the time. She stated LVN B should not have been providing care after CR#3 left her hall. She stated LVN B should not have been providing care after CR#3 left her floor because CR#3 didn't feel comfortable with her . Administrator stated CR#3 would not have felt comfortable being administered medication from LVN B. Administrator stated she and the DON went to CR#3's room on 5/20/25 to speak with him regarding his issues with LVN B. Administrator said she told resident that she heard there were some issues. She stated the DON told CR#3 he didn't tell her LVN B stabbed or jabbed him with the insulin needle. She stated CR#3 called DON a liar and appeared to lunge toward her aggressively and raising his voice. She stated CR#3 told her and the DON that they were giving him heart problems. She stated with CR#3's behavior she feared for the DON and the two left and called the ambulance because he complained of heart issues. Administrator stated she did not file a report with the state and should have. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 at 6:25 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. The following Plan of Removal submitted by the facility was accepted on 5.31.2025 at 8:55am. PLAN OF REMOVAL (F-607) Name of facility: Date: 05/30/2025 F 607 - The facility will implement a written policy that prohibits abuse of residents. Problem: The facility failed to follow the facility's abuse policy by not reporting the allegation of physical abuse to HHSC and investigating allegations reported to the Administrator and DON Immediate action: 7. CR#3 resident no longer resides in the facility. 8. LVN B was removed from the schedule and placed on administrative suspension pending investigation. Completed 05/30/25 9. PTA is no longer working for the facility. Rehab staff received an inservice on abuse, neglect and exploitation and incident and accidents facility policy and procedures. The QA corporate nurse inservice the rehab staff. Completion date 05/30/25 10. The facility administrator immediately completed a self-report incident to HHSC d/t allegation of physical abuse on 05/30/2025. 11. On 05/30/25 The facility nursing management staff immediately initiated skin assessment focusing on any new skin concerns or discoloration, no issues noted. Completed 05/30/25 12. 5/30/25 The QA corporate nurse provided the inservice on resident rights following facility policy and procedures to all staff present, the DON sent the inservice to all other staff no present. Completed 5/30/25 13. Resident interviews were conducted with residents who were able to participate and answer questions, no issues were identified. All alert residents were interviewed. A skin assessment audit was completed in all 89 residents residing in the facility and no issues were identified. Completion date 05/30/2025 14. 5/30/25 The QA Corporate nurse initiated and in-serviced on the corporate Compliance hotline to report any unresolved issues by the facility administration. The QA corporate nurse provided the inservice. Completion date 05/30/25 Interventions: 15. The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 16. The [NAME] President of Operation conducted and in-service with the facility Administrator: Review of Abuse and Neglect and Exploitation Policy. The in-service included the company expectation to immediately initiate an investigation with any allegation of abuse and neglect including any signs and symptoms of sexual abuse. Completed 05/30/25 17. On 5/30/25 the corporate nurse/Designee initiated an in-service to all facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and exploitation. Completion 05/30/25 18. On 5/30/25 the corporate nurse/Designee initiated an in-service with the facility staff on all six types of elder abuse. Completion 05/30/25 19. On 05/30/25 the corporate nurse/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting. Completion 05/30/25 20. On 5/30/25 the corporate nurse/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect to be reported to the administrator immediately. Completion 5/30/25 Any staff member who is not present or in service on 05/30/25 will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by corporate nurse/Designee, until all staff complete the in-services. 1. On 05/30/25 the corporate nurse/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the corporate nurse/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completion 05/30/25. 2. An impromptu QAPI meeting was conducted with the facility's Medical Director on 05/30/25 to notify of the potential for non-compliance and the action plan implemented for approval. Completed 05/30/25. Monitoring of the facility's Plan of Removal included the following: Record Review of documentation CR#3 resident no longer resides in the facility. Record Review LVN B was removed from the schedule and placed on administrative suspension pending investigation. Completed 05/30/25. Record Review PTA is no longer working for the facility. Rehab staff received an inservice on abuse, neglect and exploitation and incident and accidents facility policy and procedures. The QA corporate nurse inservice the rehab staff. Completion date 05/30/25 Record Review of The facility administrator immediately completed a self-report incident to HHSC d/t allegation of physical abuse on 05/30/2025. Record Review of 05/30/25 The facility nursing management staff immediately initiated skin assessment focusing on any new skin concerns or discoloration, no issues noted. Completed 05/30/25. Record Review of 5/30/25 The QA corporate nurse provided the inservice on resident rights following facility policy and procedures to all staff present, the DON sent the inservice to all other staff not present. Completed 5/30/25. Record Review of Resident interviews were conducted with residents who were able to participate and answer questions, no issues were identified. All alert residents were interviewed. A skin assessment audit was completed in all 89 residents residing in the facility and no issues were identified. Completion date 05/30/2025 Record Review of 5/30/25 The QA Corporate nurse initiated and in-serviced on the corporate Compliance hotline to report any unresolved issues by the facility administration. The QA corporate nurse provided the inservice. Completion date 05/30/25 Interventions: Record Review of The Administrator received 1:1 inservice on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 05/30/25 Record Review of The [NAME] President of Operation conducted and in-service with the facility Administrator: Review of Abuse and Neglect and Exploitation Policy. The in-service included the company expectation to immediately initiate an investigation with any allegation of abuse and neglect including any signs and symptoms of sexual abuse. Completed 05/30/25 Record Review of the 5/30/25 the corporate nurse/Designee initiated an in-service to all facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and exploitation. Completion 05/30/25 Record Review of the 5/30/25 the corporate nurse/Designee initiated an in-service with the facility staff on all six types of elder abuse. Completion 05/30/25 Record Review of the 05/30/25 the corporate nurse/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting. Completion 05/30/25 Record Review of the 5/30/25 the corporate nurse/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect to be reported to the administrator immediately. Completion 5/30/25 Any staff member who is not present or in service on 05/30/25 will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by corporate nurse/Designee, until all staff complete the in-services. Record Review of 05/30/25 the corporate nurse/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the corporate nurse/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completion 05/30/25. Record Review of the impromptu QAPI meeting was conducted with the facility's Medical Director on 05/30/25 to notify of the potential for non-compliance and the action plan implemented for approval. Completed 05/30/25 Interviews with the following staff from 5.31.2025 at 12:36 AM to 6.1.2025 6:25pm who worked all shifts and all days of the week revealed they had been in-serviced on Reporting Abuse and Neglect, Kardex, Stop and Watch, reporting and documenting when residents refuse care, turning and repositioning, change of condition and reporting, and documentation: RN, LVN B, LVN D, LVN E, LVN H, LVN I, LVN J, MA C, MDS, CNA E, CNA D, CNA J, CNA H, CNA I, CNA M, CNA U, CNA V, WCN, DON, and the Administrator. Each staff was asked if they understood all aspects of their training and they responded in the affirmative. Each staff understood their particular roles in the Abuse Neglect and reporting, documentation, stop and watch, change of condition and where to document this information. The Administrator was informed that the Immediate Jeopardy was removed on 6/1/2025 at 6:25 p.m. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews and record reviews the facility failed to ensure 4 (CR#2, CR#3 R#1 and R#2) of 9 resident reviewed was free from abuse and neglect The facility failed to prevent neglect and failed to provide the required structures and processes in order to meet the needs of CR#2 when interventions were not implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent wound deterioration and infection, which resulted in hospitalization with severe sepsis and required surgical wound debridement. An Immediate Jeopardy (IJ) was identified on 5.28.2025. The IJ template was provided to the facility on 5.28.2025 at 1:15p.m. While the IJ was removed on 6.1.25 at 6:25p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. The facility failed to protect CR#3 from abuse from staff after his allegation of verbal and physical abuse and allowed the abuser to provide care before transferring CR#3 to another hall. CR #3 verbalized fear of the alleged abuse perpetrator (LVN B), and LVN B continued to work with CR#3 after the allegation. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the facility on 5.30.2025 at 1:27p.m. While the IJ was removed on 6.1.25 at 6:25p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for physical harm and mental anguish and neglect. Findings included: Record review of CR#2's face sheet revealed a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted [DATE] and discharged [DATE] with a diagnosis of COPD, Osteomyelitis of vertebra (rare bone infection that inflames and infects spinal disc), sacral and sacrococcygeal region (butt area). Record review of CR#2's Annual MDS assessment dated 3.13.25 revealed a BIMS score of 15 (cognitively intact). Section GG (Functional Abilities) revealed, CR#2 is impaired on both sides (lower extremity-hip, knee, ankle, foot), uses a wheelchair. CR#2 need substantial/maximal assistance with oral, toilet, and personal hygiene, shower/bathe, upper and lower body dressing and putting on/taking off footwear; requires partial/moderate assistance to roll left and right; has an Indwelling catheter (carries the urine out of the body) and Ostomy (collects waste); paraplegic (inability to move the lower parts of the body). Section M (Skin Conditions) revealed CR#2 is at risk and has stage 3 and 4 pressure ulcers. Record review of CR#2's orders dated 1.2.2025 revealed the following: Ascorbic Acid Tablet 500 MG one time a day for wound healing related to unspecified skin changes, Order date 1/3/2025-05/22/2025; Colostomy to LLQ (bottom left area of abdomen) every day shift, every 3-days Change colostomy bag and wafer (piece of pouch that sticks to the body) every 3 days-Order date 1/2/2025-05/22/2025; Type of wound: Pressure (injury to skin and underlying tissue) and MASD (Moisture-Associated Skin Damage) caused by prolonged exposure to moisture. Location of wound: right and left buttocks, and left post upper thigh, irrigate or cleanse wound bed with normal saline, nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Collagen and Cal Alginate cover (Wound dressing) with dry dressing secure dressing with tape as needed Order date 3/26/2025-5/22/2025; Type of wound: Pressure stage 3. Location of wound: Right Gluteus (buttock) irrigate or cleanse with normal saline, Nexodyn solution (wound care solution containing hypochlorous acid) or wound cleanser, pat dry and apply or pack collagen & Cal alginate cover-Order date 3/28/25-5/22/2025; Type of wound: Pressure stage 4. Location of wound: left buttock irrigates or cleanse wound bed with Normal saline, Nexodyn solution (wound care solution containing hypochlorous acid) or wound cleanser, pat dry and apply or pack collagen & Cal alginate cover-Order date 5/5/25-5/22/2025; Type of wound: PRESSURE Location of wound: LEFT Phone GLUTEUS Irrigate or cleanse wound bed with Normal sallne, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABD (abdomen) PAD AND DRY DRESSING Secure dressing with: TAPE; Type of wound: PRESSURE Location of wound: LEFT GLUTEUS Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABO PAD AND DRY DRESSING Secure dressing with: TAPE-Order date 2/27/2025- 5/22/2025; Type of wound: PRESSURE Location of wound: LEFT UPPER POSTERIOR THIGH irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN AND CAL ALGINATE Cover with: ABD PAD AND DRY DRESSING Secure dressing with: TAPE PAIN CODE Order date 2/27/2025-05/22/2025; WEEKLY SKIN ASSESSMENT. COMPLETE HEAD TO TOE SKIN ASSESSMENT AND DOCUMENT FINDINGS ON WEEKLY SKIN OBSERVATION TOOL UDA every day shift every Tue -Order Date- 01/02/2025- 05/22/2025; COLOSTOMY TO LLQ every shift COLOSTOMY CARE QSHIFT AND PRN USE STOMA PASTE AND/OR POWEDER AROUND THE OSTOMY -Order Date 01/02/2025-05/22/2025; Enhanced Barrier Precautions (EBP) every shift with high contact care activities. -Order Date- 04/22/2025-05/22/2025; OBSERVE AND MONITOR MIDLINE ABD SURGICAL INCISION FOR PROPER HEALING, NO INFECTION AND APPROXIMATION EVERYDAY, EVERY SHIFT every day and night shift -Order Date 01/14/2025-05/22/2025; Santyl External Ointment 250 UNIT/GM (Collagenase)Apply to RIGHT HEEL topically related to PRESSURE ULCER OF RIGHT HEEL, STAGE 4 -Order Date 03/27/2025-05/22/2025, Type of wound: [NAME] Location of wound: LEFT GLUTEUS Irrigate or cleanse wound bed with Normal saline, Nexodyn solution o wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN ANDCALALG Cover with:(6X6) SUPRAABSORBENT SILICONE BORDERED DRSG. Secure dressing with: MEDIFIX TAPE-Order Date 01/16/2025- 5/22/2025; Type of wound: PRESSURE DTI Location of wound: RIGHT HEEL (CORRECTION TO LOCATION) Irrigate or cleanse wound bed with Nonnal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): SANTYL AND CAL ALGINATE Cover with: DRY DRESSING Secure dressing with: TAPE Order Date 03/21/2025-5/22/2025; Type of wound: PRESSURE STAGE 4 - Location of wound: LEFT POSTERIOR THIGH_ Irrigate or cleanse wound bed with Normak saline, Nexodyn solution o wound cleanser, pat dry and apply or pack (if applicable): COLLAGEN ANDCALALG Cover with: DRY DRESSING Secure dressing with: TAPE AS NEEDED -Order Date 04/17/2025-05/22/2025. Record review of CR#2's care plan dated 3.27.2025 revealed the following: Focus: [CR#2] Requires Wound Care Management Goal: [CR#2] Wound will be free of signs or symptoms of infection. Target Date: 6.19.2025 Interventions: Evaluate ulcer characteristics, measure ulcer on at regular intervals, monitor ulcer for signs of infection, monitor ulcer for signs of progression or declination, notify provider if no signs of improvement on current wound regimen, Provide Wound Care per Treatment Order Focus: [CR#2] requires assistance to perform functional abilities in Self Care and mobility (AEB), unsafe or poor quality in functional range of motion (Specify- to upper or lower, right or left, etc. r/t Medically complex conditions transfer with mechanical lift) Goal: [CR#2] will have improvement in functional abilities in the following areas by end of their skilled stay. Target date 6.19.2025. Interventions: Provide the following self-care assistance: (Specify in A-H below-Partial, Substantial/Maximal A. Eating: Independent B. Oral hygiene: Independent C. Toilet Hygiene: Substantial/Maximal E. Shower/Bathe self: Partial/Moderate F. Upper body Dressing: Independent G. Lower body Dressing: Substantial/Maximal H. Putting on/taking off footwear: Substantial/Maximal I. Personal Hygiene: Independent Focus:[CR#2] has Specify: Suprapubic Catheter present and is at risk for UTI and complications due to catheter use R/T Neurogenic bladder. Goal:[CR#2] will be/remain free from catheter-related complications through review date. Target Date: 6.19.2025. Interventions: Check tubing for kinks throughout each shift, encourage fluid intake, monitor for leg strap placement and change as needed, monitor for s/sx of discomfort on urination and frequency, monitor urinary output amount, color, odor and sediments, etc. report abnormal to MD. Focus: [CR#2] has potential fluid deficit r/t Dx of Septicemia (blood infection) Goal: [CR#2] will be free of symptoms of dehydration and maintain moist mucous, membranes, good skin turgor. Target Date: 6.19.25 Interventions: Monitor and document intake and output as per facility policy; Monitor/document/report PRN any s/sx monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increase pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes, obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Focus: [CR#2] has stage 4 pressure injury to left buttock, left posterior upper thigh and stage 3 PI to right buttock. Goal: [CR#2] Pressure injury will be free from signs and symptoms of infections. Target Date: 6.19.25; will remain free of pressure injury through the next review date. Target date: 6.19.25; will show granulation and reduction in size through review date. 6/19/25 Interventions: Add additional supplements as needed, administer treatment to decubitus ulcers(s) as ordered. If no wound improvement notify MD/NP to obtain new orders (1.16.2025: Collagen and cal alginate daily; 3.17.2025: Collagen and cal alginate with dry drsg daily); assist resident with Turning & repositioning during rounds and as needed; monitor and report MD and RP and s/s of infection. Weekly skin assessment, notify M.D. for Ulcers that are deteriorating, as needed. 1.16.25 Left gluteus 12x10x0.4cm and left upper posterior thigh 9x9.8x0 cm; 3.17.2025 Left buttock - 10x10x0.4cm and left upper posterior thigh 9x10x0.3cm and right buttock 8.8x8x0.2; Focus: [CR#2] has a pressure DTI pressure injury to bilateral heels d/t Goal: [CR#2] will have no complication from wound. Target date: 6.19.2025. Interventions: Assist with turn/repositioning during rounds and as needed Focus: [CR#2] is on antibiotics for osteomyelitis and is at risk for adverse reactions. Goal: [CR#2] Infection will be resolved or resolving at the end of antibiotic therapy and resident will not have any adverse reactions to antibiotic therapy. Target date.6.19.2025 Interventions: Assess effectiveness of interventions and adjust plan as indicated. Focus: [CR#2] has a colostomy Goal: [CR#2] will have adequate emptying of bowels daily and evidence any signs of symptoms of obstruction or constipation until next review. Target date: 6.19.2025. Interventions: Monitor bowel put daily, nursing statf will change colostomy bag as needed, provide stoma care daily as instructed and prn. Report any abnormalities to MD and RP. Focus: [CR#2] has the history of osteomyelitis a vertebrae sacrococcygeal region and is at risk for recurrent infection to bones. Goal: [CR#2] will not experience signs and symptoms of osteomyelitis unaddressed during review. Target date 6.19.2025 Interventions: encourage resident to report abnormal pain to bones, labs as ordered, medications as ordered, monitor for s/s of infection as needed and report abnormalities, therapy to screen and eval as needed. Focus: [CR#2] as paraplegia. At risk for complications related to conditions. Goal: [CR#2] will have no complications related to condition through the next review date. Target date 6.19.2025. Interventions: Encourage to maintain physical activity within limits, monitor 4 autonomic dysreflexia (overreaction of the nervous system) symptoms such as hypertension (high blood pressure), diaphoresis (excessive sweating), dizziness, anxiety, increase spasticity (stiff muscles), flushing of the skin, bradycardia (low heart rate), cool pale skin, visual disturbances, Focus: [CR#2] has diagnosis of Paraplegia and is at risk for contracture and skin breakdown. Goal: [CR#2] will not develop contractures until the next review. Target date: 6.19.2025, Resident will not develop skin breakdown until the next review. Target Date: 6.19.2025. Interventions: Report any skin breakdown to MD, Staff to provide all ADL care, weekly skin assessment. Focus: [CR#2] has frequent UTI's and is at risk for increased temperature, dehydration, and pain/discomfort. Goal: [CR#2] frequency of UTI's will that decrease, and resident will not have c/o (complaint of) pain discomfort, temp. will remain with in baseline limits until the next review. Target date: 6/19/2025. Interventions: give meds per order -monitor labs-report abnormals to M.D, monitor for increased temp, dehydration, pain discomfort, etc-report to M.D., Monitor to assure proper peri care (washing anal and genital area) is done, monitor urine for sediment, color, odor, amount, etc-report abnormals to MD. In a telephone interview on 5.22.2025 at 3:40pm with FM B, he stated CR#2 is currently in the hospital. He stated CR#2 was not turned properly and her wounds became worst, which resulted in a colostomy bag. He stated nursing staff, including DON and Administrator, refused to communicate with him although he sent several emails to the DON regarding this issue. FM B stated the staff not answering phones half of the time and he would see them (employees) on their personal phones, then when they notice him looking at them then they would jump up and begin working. FM B stated CR#2 was somewhere on the 200 Hall. FM B stated because of CR#2 not being changed he would call the DON who would address this issue with staff, but nothing ever was corrected. FM B stated CR#2 can talk and let you know what's going on. He stated she is paraplegic. FM B stated CR#2 has been at the facility since 2015. He stated CR#2 was not seen daily by a wound care nurse because they either quit or get fired, then other nurses who are not good at doing wounds would try. FM B stated CR#2 treatment at this facility was horrible. FM B stated one issue is the staff would not change CR#2's urine bag and it backed up causing multiple UTI's. In an interview on 5/23/25 at 3:42 with ADON A - stated CR#2 was here for 10 years. She stated CR#2 has a chronic suprapubic catheter and she goes monthly to have her suprapubic catheter changed. She stated CR#2's wound stays moist, and she was being treated. ADON A stated when CR#2 went to the hospital; the sacrum womb got worse and became a stage 4. She stated CR#2 had to have a colostomy bag. ADON A stated CR#2 was being turned every 2 hours. ADON A stated CR#2 can reposition herself by grabbing hold of the bar. ADON A stated a previous wound care nurse took care CR#2. She stated the WCD makes rounds in the facility and sees residents, including CR#2, every week on Thursday. In an interview on 5/23/25 at 3:57pm with WCN - She stated she was in training and only completed CR#2's wound care a couple of times. She stated CR#2's sacrum wounds were stage 4. She stated she doesn't know what the instructions to staff from WCD as she was rounding with another wound care nurse and was to only observe and not take notes . She stated the wound care nurse who was rounding with her was more senior and responsible for taking notes. WCN stated the last time wound care on CR#2 was around 5/15/2025 with WCD and a previous weekend wound care nurse. She stated CR#2 had some serious wounds that were always draining. She stated there were 3 wounds, the sacrum (buttocks), one on the left thigh and one on the right heel. WCN stated a few days after CR#2 was seen by WCD she transferred to the hospital. In an interview on 5.24.25 at 7:30PM with HNM - She stated CR#2 arrived at the hospital emergency room on 5/18/2025 at 8:37pm. The admitting diagnosis was: Severe Sepsis; however, she stated according to doctors' notes, CR#2's chief complaint was her sacral (buttock) wound. HNM stated CR#2 is currently in surgery for wound debridement. The HNM stated upon CR#2's arrival to emergency room, CR#2 vitals were: B/P: 108/88 Temp: 97.9 Pulse: 88 Respirations: 18 WBC: 11.37 In an interview on 5/24/2025 at 12:35pm with CR#2 - she stated that her wound was very bad which is the reason why she had to have the surgery for debridement at the hospital this morning. She stated that she was supposed to have been changed twice a day however she was always changed only one time per day on the 1st shift and never on the 2nd shift . CR#2 stated she complained multiple times about her care, and her family has called and spoke with the DON. CR#2 stated the DON stated she has spoken with the nurses on her shift, and nothing has never really been done to address her butt wounds. CR#2 stated she came to the hospital on 5/18/2025 due to low blood pressure; However, afterwards the hospital informed her she had severe sepsis. CR#2 stated that the WCD at the facility noted she was to be changed twice daily, but her bandages were never changed but one time and that was after lunch. CR#2 stated WCD noted that she was supposed to be changed and put in her chair twice daily . CR#2 stated she has not been put in the chair for the last two weeks. She stated her bandages was always soaking wet and her wounds were always draining. CR#2 stated on one occasion last week, she could not remember the exact date day or shift that an agency nurse came in and washed and changed took the bandages off and cleaned her wounds. She stated that an agency CNA came in to give her wash up, and when she rolled her over, she noticed that there were no bandages on her wounds that her wounds were open because the agency nurse never redressed her bandages after cleaning her wounds. CR#2 stated that she was never turned every two hours on the shift. She stated a lot of times she would have to call her FM's who would call the facility. CR#2 stated that she has never refused wound care. She stated that she's trying to get better and hopefully one day she can go home. CR#2 stated she has been left to lie in her poop for hours without being changed. She stated she's had to call her who have had to call the facility to have a nurse go to her room and change her. CR#2 stated that first shift is a little short of staff, but second shift has been short of staff for quite some time and in order to have the call light answered it would be at least an hour or two. CR#2 stated in January 2025, she had a colonoscopy bag. She stated she had a colonoscopy, and it found a mass on her: but it was not cancer. CR#2 stated her choosing to have a colostomy bag was due to her sacrum wounds being so bad as a result of the bad care she was receiving at the facility, that the doctors and her family decided not to take a chance and continue letting her sit in her poop with open wounds. She stated staff barely changed her urine bags and they would stay full which resulted in urine back-up and her getting multiple UTI's. On 05/26/25 at 10:06AM Observation of Wound Care for R#1 in room [ROOM NUMBER] A-bed by WCN and LVN B. R#1 was resting in bed to her left side on an air mattress and was not inter-viewable. R#1's right hip dressing date on old dressing read 05/24/25 with moderate amount of dark brown, black color drainage on old dressing. WCN said the last time she worked at the facility doing dressing changes was on 05/24/25. R#1's wound bed was approximately the size of a silver dollar coin with inside tissue appearing pink reddish in color. In an Interview with CNA D on 5/26/2025 at 10:30am -She stated she has worked at the facility for 3 years. She stated she has worked with CR#2. CNA D stated she turned CR#2 every two hours. CNA D stated CR#2 was cognizant enough to inform nursing staff what she needs and wants and is direct in her words. CNA D stated she has not witnessed CR#2 refusing care. CNA D stated CR#2 complained often about the 2-10 shift CNA's not bathing or turning her. CNA D stated her bath/shower was scheduled on the 2-10 shift. CNA D stated she would give CR#2 her baths if she had time on her shift. CNA D stated she has observed CR#2 requesting a nurse to flush her catheter. CNA D stated CR#2 does not like poop to get on her or her bandages and she demands to get changed immediately. CNA D stated CR#2 would only refuse to get out of bed when she is in a lot of pain. CNA D stated she would inform the wound care nurse or charge nurse when resident has issues or refused care. CNA D stated R#2 did not get her bandaged changed on 5/25/2025 and she noticed the 5/24/2025 date when she went into his room with the WCN. In an interview with WCN on 5/26/25 at 10:47am who stated she has recently been task to provide wound care. She stated she is a nurse that does wounds. WCN stated she completed CR#2's wound care a couple of times. She stated CR#2's sacrum wound was stage 4. She stated she doesn't know what previous instruction was given to former wound care nursing staff from wound care doctor because she only was observing. WCN stated the last time wound care was provided on CR#2 was around 5/15/2025 with WCD and weekend wound care nurse, LVN F. WCN stated CR#2 had some serious wounds that were always draining. She stated there were 3 wounds that she observed, one on the sacrum (buttocks), one on the left thigh and one on the right heel. She stated when it was time for her (WCN) to do wound care on CR#2 she transferred to the local hospital. In reference to R#1 and R#2, the WCN stated the date on R#1's bandage 5/24/2025, and R#2's bandage was dated 5/24/2025. WCN stated the bandages should be changed daily. She stated her last working day was 5/24/25. WCN stated in her absence, the charge nurses should have replaced the bandages. WCN stated either the weekend wound care nurse or charge nurses should have provided wound care to residents and replaced the bandages and dated them as well. WCN stated not changing wound care bandages, not replacing bandages that have fallen off and not following doctors' orders for wound care could place resident at risk for infection . In a Telephone Interview with WCD on 5/26/2025 at 12:42pm - he stated CR#2 appeared to be OK the last time he saw her on 5.15.25. He stated that the residents' wounds are chronic but not progressing. The WCD stated this was an issue, which is why he ordered Dakins Solutions. The WCD stated he observed CR#2's wound bandages to be saturated when he comes to visit and had some concerns with the wounds and not progressing well. He stated that CR#2's bandages on her wounds would be soiled. He stated one reason for the wound bandages would be if the catheter was not in properly or if the bandages were not being changed as ordered. The WCD stated he has not smelled any urine when he came to see CR#2. He stated CR#2 had a colostomy bag and a Foley catheter. The WCD stated that a saturated dressing could increase infection and could lead to systemic also known as sepsis if not changed properly. He stated he noticed that CR#2 does not get out of bed as she should. The WCD stated if wound dressings are not on the wound, it also increases the likelihood of bioburden infection (presence of microorganisms in wound that impedes healing and lead to infection) that could also lead to sepsis. WCD stated CR#2 should get up out of the bed several times during the day for at least 60 minutes to two hours and then placed back in bed . He stated when CR#2 refuses to get out of bed, facility staff should be a little more diligent with residents to encourage her to do so. The WCD stated that he has known resident for many years and the one thing that she does not do is lie! In a telephone interview with CNA G 5/26/2025 at 2:45pm, she stated she was very familiar with CR#2 because she worked 6am-2pm shift was responsible for her care. She stated CR#2 moods would change when she was in pain. She stated CR#2's wounds were always open and draining, which made her bandages soiled. CNA G stated CR#2 would get up in the chair sometimes after receiving a bed bath; however, she would refuse when she was tired and hurting. CNA G stated she put resident up in chair when she would ask. She stated CR#2 was a two person assist and needed to be lifted with the help of a Mechanical lift. CNA G stated whenever she would see CR#2's colostomy bag leaking it was changed as needed. CNA G stated if CR#2's bandage had a little poop on it she wanted it changed immediately. CNA G stated in her opinion, a little poop on the bandage did not mean the bandage should be changed. CNA G stated because CR#2's bandage had a small amount of poop on it, it didn't need changing and this would upset CR#2. In a telephone interview with LVN F on 5/26/2025 at 3:40pm -She stated she worked the 6a-6p and worked the 200 hall and first half of 600 hall. She stated the treatment nurse is responsible for wound care; however, if treatment nurse isn't available then the floor/charge nurse is responsible. She stated she did not turn R#2 and didn't see the sacrum wound because the treatment nurse was making rounds. LVN F stated she did not look at R#2's neck area. She stated the treatment nurse was in the building looking at all residents with wounds. LVN F stated when a resident's wound care dressing comes off, the treatment nurse is responsible; however, if the treatment nurse isn't available, then the charge/floor nurse would be responsible if they become aware. LVN F stated it is important for dressing to be changed as ordered to eliminate infections and to ensure the wound to heals. If the dressing is not redressed it can get contaminated and could get infected. In a telephone interview with LVN G on 5/26/2025 at 3:58pm She stated she worked yesterday as the wound care nurse. She stated she cannot remember the resident wounds that were changed. She stated does not remember changing R#2's bandages and she stated she did not change R#1's bandages. LVN G stated each time she went to R#1's room, she was not in the room. She stated she went by the room [ROOM NUMBER]-5 times, and she noted that she had provided wound care because she was going to return to R#1's room, but she forgot. LVN G stated it is important to change wound bandages, so they don't create infections. If the dressing on the wound comes off the resident's wound, it should be cleansed and replaced immediately. If the wound is not cleansed and bandage did not get replace, the wound could get infected. LVN G stated she checked off in the MAR which appears she provided care because she intended to go back to R#1's room. She stated as a nurse, I absolutely should NOT have done that. She stated R#1 could have gotten an infection and been sick from it. In an interview with DON on 5/26/2025 at 6:00pm she stated she would oversee wound Care by ensuring unit managers who, were initially doing wound care, have access to the VOHRA notes for nurses to upload weekly notes. This is what will occur until the facility has a wound care nurse. The DON stated she is ultimately responsible for wound care; however, she delegates this responsibility to her nurse managers. She stated in the event the managers are unable to do it then they are responsible to find a floor nurse to do the wounds in their own particular areas. The DON stated if wound care bandages are not changed, the wound can deteriorate and get worse by possible infection. The DON stated it important for wound dressing to be changed as ordered for proper healing of wound and prevent infection. The DON stated if a resident's dressing comes off the CNA has to notify the charge nurse so a dressing can be reapplied. If the dressing comes off and the nurse observes it then they would go to the Emar (Electronic Medication Administration Record), read the treatment notes and re-do dressing themselves. If the wound is not redressed there is a risk for infection and further declined of the wound. In an interview with Administrator on 5/26/202 at 6:15pm -She stated that in the past the facility had a regular wound care nurse and if the wound care nurse had become ill or unable to continue the job as the wound care nurse there were back up people trained to do wound care. She stated the facility was allowed to call a staffing agency for wound care nurses. Administrator stated there is a unit manager assigned to do wounds or delegate a licensed nurse to that position . She stated it use to be the DON. She stated they have assigned a nurse to be the wound care nurse, LVN G. She stated she is in training but does wounds currently. LVN G is making that transition from the position as the unit nurse to the wound care nurse. She stated the wound care nurse's position is still open and posted in case LVN G changes her mind. However, the DON is ultimately responsible for wound care. Administrator stated if there isn't a nurse in the building who is able to do wounds the DON is qualified to do wound care. She stated the ADON B is the unit manager, and she is also qualified to do wound care. Administrator stated that if wound care bandages are not changed per doctors' orders it could be a possibility for the wound not to heal as expedient as it needs to be. She stated if a resident's dressing comes off the charge nurse should be informed so that it can be replaced. She stated if a CNA observes the dressing has come off of a resident's wound, they should inform charge nurse immediately because if the wound is not redressed, it could place resident at risk for it getting bigger or worse. Administrator stated her expectation out of nursing staff is to do their jobs, report any issues, treat residents kindly, ensure their changed and turned as ordered and fed. She states she expect the DON to be the leader in carrying out clinical expectation of caring for residents in this facility. Record review of the Abuse, Neglect and Exploitation policy dated 1/2023 written by Corporate RN revealed, the definition of abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. III. Prevention of abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of individual needs and behavioral symptoms H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 8. Failure to provide care needs such as comfort, safety, feeding, bathi[TRUNCATED]

Based on, interviews and record review the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (CR #1) reviewed for accidents and supervision, in that: The facility failed to ensure CR#1 was transferred properly per therapy assessments and instruction, by CNA B. CR#1, a bedbound resident, who was totally dependent on staff for care sustained an unexplained head injury and hip fracture in her room alone. The facility failed to ensure precautionary interventions in place for CR#1, who was a known fall risk. An Immediate Jeopardy (IJ) was identified on 5.22.2025. The IJ template was provided to the Administrator on 5.22.2025 at 1:07 p.m. While the IJ was removed on 5.25.25 at 3:38 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk of decline, and diminished quality of life. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]; on 3/16/2020 and discharged 5.14.2025 with a diagnosis of COPD, rheumatoid arthritis, contracture, right hand, congestive heart failure and dementia. Record review of CR#1's MDS dated [DATE] revealed, CR #1 has impaired communication AEB (as evidenced by) difficulty understanding others, CR #1 has substantial/maximal dependency on staff to meet all of her ADL needs. CR #1 is an extensive total assist times 1-2 staff for transfer, toileting and bathing, and limited assist times one with eating. Is at risk for falls and injury related to contusions, disorientation, incontinence, and poor safety awareness. CR#1 has a BIMS score of 5 (severe cognitive impairment) Co. Section GG (Functional Abilities) indicated CR#1 has an impairment on both sides, upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). CR#1is totally dependent on staff of all her personal hygiene needs. CR#1's needs substantial/maximal (Helper does more than half the effort) assistance with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, the ability to roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and CR#1's required partial/moderate assistance in the areas of eating, oral hygiene, and upper body dressing. Section O (special treatments, procedures, and programs) indicated CR#1 required oxygen therapy. Record review of CR#1's Orders revealed: Monitor pain level every shift; tramadol (Pain medication) HCI (Hydrochloride)-Give 1 tablet by mouth every 8 hours related to chronic pain syndrome (order date: 12/12/2024 at 1148-D/C date 5/19/2025); Acetaminophen (used for moderate pain) tab 325 MG give 1 tablet orally every 6 hours as needed for pain related to Chronic pain syndrome do not exceed more than 3 gm in 24 hours (Order date:11/8/2024 at 11:07am-D/C 5/19/2025 at 8:44am) Record Review of CR#1's care plan dated 5.21.2025, revealed the following: Focus: [CR#1] has impaired cognition function and impaired thought processes AEB (Short Term memory deficit, Impaired ability to make daily decisions, BIMS=5 related to dementia). Goal:[CR#1] needs will be met, and dignity will be maintained through the next review, Target Date: 8/5/025 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; ask yes/no questions to determine resident needs; Cue, reorient and supervise as needed; Don't argue or correct me if I get confused to reality; Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; redirect gently when needed for meals, room, daily activities; Use task segmentation to support short term memory deficits. Break tasks into one step at a time. Focus: [CR#1] has impaired communication AEB difficulty understanding others, difficulty finding words related to Dementia and Dysphagia Goal: [CR#1] will maintain current level of communication function through the review date. Target date: 8/5/2025. Interventions: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/ cues, use alternative communication tools as needed; Anticipate and meet needs; Ensure/provide a safe environment: call light in reach, adequate local air light, bed in lowest position and wheels locked, avoid isolation; monitor/document/report PRN any changes in: Ability to communicate, potential contributing factors for communication problems, potential for improvement; OT/PT/Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use or sign language as alternate communication to speech; refer to speech therapy for evaluation and treatment as ordered; Validate resident's message by repeating aloud. Focus: [CR#1] requires assistance to perform functional abilities in self-care and mobility AEB, unsafe or poor quality and functional range of motion to upper or lower, right or left, etc. r/t medically complex conditions Goal: [CR#1] will have improvement in functional abilities in the following areas by end of the skilled stay. Target Date: 8/5/2025 Interventions: Provide the following Self Care assistance: (SPECIFY in A-H below- Independent, Setup/Cleanup, Supervision/Touching, Partial/Moderate, Substantial/Maximal, Dependent) A. Eating: Partial/Mod; B. Oral Hygiene: Partial/Mod; C. Toilet Hygiene: Substantial/Max; E. Shower/Bathe self: Substantial/Max; F. Upper Body Dressing: Partial/Mod; G. Lower Body Dressing: Substantial/Max; H. Putting on/taking off footwear: Substantial/Max; I. Personal Hygiene: Dependent; Provide the following Mobility assistance: (Specify in A-H below-Independent, Setup/Cleanup, Supervision/Touching, Partial/Moderate, Substantial/Maximal, Dependent) A. Roll left to right: Substantial/Max; B. Sit to lying: Substantial/Max; C. Lying to sitting on the side of the bed and with no back support: Substantial/Max. B.Sit to Lying: Substantial/Max C. Lying to sitting on the side of the bed and with no back support: Substantial/Max D. Sit to Stand: Not Applicable E. Chair/Bed-to-chair transfer: Substantial/Max F. Toilet Transfer: Substantial/Max FF. Tub/Shower Transfer: Substantial/Max I. Walk 10 feet: Not Attempted Focus: [CR#1] has an ADL self-care performance deficit r/t Dementia, COPD (damaged lungs) Disease processes Goal: [CR#1] will improve current level of function through the review date. Target Date: 8/5/2025 Interventions: Provide the following assistance with ADL's in Self Performance and Staff Support: A. Bed Mobility: B. Transfer: Extensive - Total assist x1-2 staff H. Eating: Limited assist x1 staff I. Toileting; Extensive-Total assist x1 staff K. Bathing: Extensive assist x1 staff Focus: [CR#1] is at risk for falls and is at risk for increased falls and injury r/t confusion, disorientation, incontinence, poor safety awareness. Goal: [CR#1] dignity will be maintained. Incident of falls will be reduced, and no occurrence of injury will occur through next review. Target date: 8/5/2025. Interventions: Administer pain medications per MD order for any pain discomfort; anticipate needs, provide prompt assistance with ADL's and other special needs, assess for psych services; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; coordinate with appropriate staff to ensure a safe environment with floors free of clutter, adequate glare free light, call light accessible, bed in lowest position, handrails on walls, and personal items within reach; ensure that resident is wearing appropriate footwear or nonskid socks when ambulating or when up in wheelchair for mobility; evaluate for and supply adaptive equipment or devices as needed. Reevaluate as needed for continued appropriateness and to ensure the least restrictive device is used; Fall risk assessments per facility protocol; head to toe assessment post fall; monitor and report to MD and family for any injury from a fall, increased confusion and disorientation; participate in falling star program per facility protocol; proper position and body alignment when up in wheelchair; rehab screen/evaluate and treat as indicated for therapeutic exercises and safety measures; vital signs as needed, Neuro checks as needed. Focus: [CR#1] has had an actual fall with (Specify: No Injury-Injury, pain, hematoma, bruise, skin tear---major injury such as fracture, subdural hematoma, etc.) Confusion, poor balance, unsteady gait. Actual Falls: 5.14.2025 Hematoma, Pain Forehead abrasion Goal: [CR#1] Will have no further fall during the next 14 days. Target Date: 8/5/2025 Interventions: 2 persons assist for transfers post fall; administer pain medications prn per MD order for any pain or discomfort, anticipate needs, provide prompt assistance with ADL's and other special need, call MD and RP for any changes in condition, Continue interventions on the at-risk plan, encourage resident to ask and wait for assistance from staff, for no apparent acute injury, determine and address causative factors of the fall, head to toe assessment, ice pack applied, monitor and report to MD and RP for any injury from fall, monitor/document-report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation; Rehab consult for strength and mobility. Record review of facility video recorder, revealed the DON, LVN A and other unknown nursing staff standing outside CR#1's door. It appears to have time lapse. Record review of nursing notes dated 5.14.2025 revealed the following occurrences: At 3:45pm authored by LVN A notes CR#1's signs and symptoms of hematoma to left side of forehead that started on 5/15/2025. The note further stated that since the start of the injury, CR#1 condition has stayed the same. LVN stated the condition is worse upon touch. LVN A noted that CR#1's condition, symptom, or sign has not occurred before. Vitals were monitored. Both NP and FM notified 5/15/2025 at 3:45pm. At 5:13pm authored by DON indicated CR#1 was picked up by non-emergency transportation to transfer to hospital. FM called and made aware. At 6:11pm authored by LVN A stated she was in the hallway and was alerted by CR#1 crying out loud in distress. LVN A stated she walked into CR#1's room to assess. LVN A stated CR#1 expressed she was in pain on the left side of her body. LVN A stated she observed a hematoma the size of a walnut on the left side of CR#1 forehead with an abrasion. LVN A stated she immediately reported to the DON and NP, applied an icepack to the hemotoma and retrieved vitals. Bp (blood pressure) 135/74, Hr (heart rate) 94, O2 (oxygen) sat 95% on continuous O2, RR (respiratory rate) 20. CR#1 was already administered a scheduled Tramadol for pain. The LVN stated she called NEMS (non-emergency medical service), FM was called by DON. Record review of CR#1's pain level revealed the following: 5.14.2025 at 7:55am Level 0 5.14.2025 at 4:46pm Level 0 5.14.2025 at 5:39pm Level 10 5.14.2025 at 5:43pm Level 10 Review of CR#1's therapy records dated 5.14.2025 revealed the following: CR#1's Speech Therapy Treatment encounter notes indicated CR#1 is not to feed herself due to increased risk of choking and/or aspirations. CR#1 is on a puree diet with thin liquids. CR#1's Physical Therapy Treatment Encounter Notes indicated CR#1 bed mobility was not applicable because CR#1 was unable to sit up, roll from side to side nor was she able to sit on the bed. Transfers were not applicable as CR#1 required an Assistive Device During Transfers (Hoyer Lift). CR#1's Occupational Therapy Treatment Encounter notes indicated CR#1 was not tested on sitting balance or standing balance because she was unable to do either according to the DOR. Record Review of the Provider Investigative Report dated 5.14.2025 at 5:56pm revealed the following: Revealed on 5/14/25 at 3:45pm Neuro Checks started. LVN A statement stated she responded to CR#1 room after hearing yelling and crying out. She completed an assessment and noted a hematoma with abrasion. MA A statement said she seen CR#1 during lunch and CR#1 did not have knot on the side of her head; however, after lunch she did. MA B statement stated she did care for CR#1 before lunch. She administered CR#1 morning meds. After lunch she had knot on the head. LVN B statement stated she did not provide care; however, noted a hematoma on forehead with dried blood on it and CR#1 crying. Houston Police Report# 630297-25 (HPO) dated 5/15/2025. According to police officer notes, the report was called in 5/15/2025 at 7:50am. Police Officer entered the facility at 8:09am and exited the facility at 8:32am. Record Review of Facility Incident Reports from date range of 3.20.25 to 5.20.25 revealed no alert or awareness regarding CR#1. In an interview with PTA on 5.20.25 at 2:45pm who stated that she worked with CR#1 on 5/14/25 after lunch before 3:00pm because she completed therapy (range and motion with her legs and arms). PTA stated she would have noticed a knot on CR#1's head because prior to doing the therapy, she had to wash CR#1's face because it was dirty. She stated it appeared, based on the crust in CR#1's eyes, her face had not been washed that day. PTA stated during the therapy she did not notice any marks or bruises on resident head, face, arms, or hands. She stated CR#1 is a non-verbal communicator. PTA stated both of CR#1's hands are contracted, and she is dead weight. In an Interview with DOR On 5.20.25 at 4:00pm who stated CR#1 received range and motion physical therapy in her room between 2:45pm - 3:00pm (Give or take a few minutes). She stated she was asked by her PTA to check CR#1's personal Neuro wheelchair because the facility staff is using a wheelchair and not the Neuro wheelchair that was authorized after her assessment by the therapy department. The DOR stated she went to CR#1's room around 4:00pm to look at CR#1's Neuro wheelchair because CR#1 had been escorted around the facility in a wheelchair. DOR stated that she went into CR#1's room where she observed CR#1 lying in bed on her left side. She stated CR#1 had already been transferred from the wheelchair to her bed. During this time, DOR stated LVN A told her CR#1 had had a fall. She stated she did not observe CR#1's head because she was lying on her left side facing the nightstand with a sheet over her. However, while repairing the Neuro wheelchair. DOR stated CR#1 is unable to roll or move without staff assistance. She stated CR#1 is bedridden and considered dead weight. DOR stated there was no therapy goal for CR#1transfer out of bed because she was not appropriate because she could not sit independently. She stated the CR#1 hands are contracted and there were contracted orthotics (splints) in the office, but CR#1 transferred to the local hospital before it could be done. The DOR stated that an Assistive Device Used During Transfers would ONLY BE A HOYER LIFT or a Standing Life; however, since she is dead weight, the standing lift is not appropriate. She stated when she seen the resident, her bed was in a down position. In an interview with LVN A on 5.20.25 at 4:20pm she stated she was administering meds on the floor. She stated almost at 3:00pm CNA A was giving resident a bed bath. She stated CR#1 had 3:00pm scheduled meds. She stated when she went into the room, CR#1was laying on her left side. She stated during CR#1's bed bath she checked on CR#1 because she had a sacrum wound. LVN A stated she assisted CNA A pull resident up on the bed after the bed bath. LVN A stated before she left the room, she administered the scheduled medication, tramadol then assisted CNA A pulled CR#1 up to the head of the bed with the bed pad, then she left out of the room. She stated she went to the cart to make a notation of administering the medication on the MAR's system. At approximately 5-10 minutes later, LVN A said she heard CR#1 scream and say, God something wrong. She stated CR#1 continued praying and saying, something is wrong. LVN A stated CR#1was alone in her room. She stated CR#1 had on her nasal cannula, a green bonnet, and her gown. LVN A stated CNA A had moved on to the next resident, so she was in the room alone with CR#1. She stated she moved the bonnet and observed the hematoma. LVN A stated she went to notify DON and returned to CR#1's room and completed a head-to-toe assessment. She stated she has never seen CR#1turn or roll on her own. She stated CR#1 did not have the hematoma when she administered the tramadol medication for her 3:00pm scheduled meds. Arrived at local hospital 5.20.25 at 6:30pm - Interviewed with ICUN who stated CR#1 arrived on 5.14.2025 and the admitting diagnosis was terminal illness and left femur fracture. She stated hospital records noted swelling on the left side of the CR#1's head. She stated CR#1 was discharged today to rehab facility. In a telephone interview with CNA A 5.20.25 at 7:03pm. She stated on 5.14.2025, she worked at 2:00PM because she works the second shift 2:00 PM to 10:00 PM. She stated she had given CR#1 a bath, which was a little bit after 3:00PM because there was another resident she had to bath prior to CR#1. She stated when she was almost done giving CR#1 her bed bath LVN A walked into the room and administered medication to CR#1. CNA A stated that she asked LVN A to help her pull CR#1 up to the head of the bed as CR#1 is a two person assist. CNA A stated during the bed bath, she cleaned CR#1's eyes and did not see any bumps and bruises in her facial area. CNA A stated CR#1 was not moaning while she was giving her a bed bath. CNA A stated she finished the bed bath and dressed the resident and left. CNA A stated she returned to CR#1's room and LVN A told her that CR#1 had a knot on her head. CNA A stated she was not in the room when LVN A observed the knot on the residence head. CNA A stated she observed the knot was on the left side of CR#1 head. CNA A stated that resident did not hit her head or anything while she was giving her a bed bath, CR#1 did not fall while giving her a bed bath, and she did not accidentally hit the resident while giving her a bed bath. CNA A stated there's no possibility that CR#1 bumped her head while she was caring for her. CNA A stated that if she had seen an unusual mark or a bruise on CR#1 she would have reported it to her supervisor or the nurse manager as soon as possible. CNA A stated CR#1 uses a specialized wheelchair and is a 2 person assist. CNA A stated CR#1 is bottom heavy. CNA A stated she did CR#1's bed bath alone. She stated she used a hospital gown on 5.14.2025 because she wasn't going dining room for dinner. CNA A stated her last day of training for abuse and neglect was last year. In a telephone interview on 5.21.2025 at 7:30am with FM she stated she received a call on 5.14.2025 between 3:00pm - 3:45pm by a CNA C whom she knows from working with CR#1 for the last 8 years. She stated CNA C informed her that while caring for another resident who reside in the room next to CR#1 when she heard CR#1 screaming. FM stated CAN C told she immediately went into CR#1's room to check on her and found CR#1 lying on her back in the middle of the bed with a knot on her head that was bleeding. FM stated CNA C informed her that she observed CNA A and CNA B standing in the hallway across from CR#1's room and could not understand why they did not go into the room to check on CR#1. FM stated CNA C stated the DON was standing at the nurses' station speaking with LVN A when CAN C approached DON and told her what she had observed. FM stated this was around 3:55pm when she received a call from the DON. During this call, FM stated she could hear CR#1 screaming in the background and DON told her that she and LVN was in CR#1's room. FM stated DON stated she was calling the ambulance. FM stated after 20 minutes had gone by without a call back from the DON she called the DON back and was told CR#1 wasn't being transported through emergency transportation, but the facility called a non-emergency transportation to pick her up. FM stated after CR#1 was admitted into the hospital she received a call from the asking how CR#1 was doing. FM stated she told the DON CR#1 has a broken hip too. FM stated the DON asked if the hip was a new injury and she responded in the affirmative. FM stated the DON sounded surprised that CR#1 had a new injury. FM stated she was told by the hospital medical staff that CR#1 needed surgery; however, due to CR#1's age ([AGE] years old), the hospital stated they would not be able to do surgery because CR#1 is not strong enough to survive it. FM stated she saw CR#1 Mother's Day (5.11.2025) and the Monday (5.12.2025) afterward and there was no issues, bumps or bruises. FM stated CR#1's bed has never been in a low position. FM stated on a prior occasion the facility had taken resident to the hospital for a knee injury. FM stated it was a small fracture. She stated DON told her CR#1 was fragile and any little bump could happen because her age, bones being brittle, bump in wheelchair could also be an issue. FM says CR#1 has been transferred to a local hospice care facility. In a Telephone Interview with CNA C on 5.21.2025 at 9:10am. CNA C stated she found CR#1 just after 3:00pm. CNA C stated on 5.14.2025 she was called in to the facility by the administrator to work the front desk. CNA C stated she previously worked for the facility full-time, but now she only works PRN. CNA C stated she is familiar with CR#1 as she has worked with her for nearly 8 years. CNA C stated on 5.14.2025 a little after 3:00pm she transported a resident to his room. She stated she then went to check on another resident who is in the room next to CR#1. CNA C stated she heard screaming in the room next to the resident's room she was in and immediately went into CR#1's room. CNA C stated CNA A & CNA B were standing in hallway and could hear her also; however, both just stood there and did not move. CNA C stated CR#1 was laying on her back and she could visually see CR#1 with the knot on the left side of her head and it was bleeding. CNA C stated she immediately went to the end of the hall by nurses' station and told the DON CR#1 was screaming and bleeding. CNA C stated the DON told LVN A to go to CR#1's room and told LVN A to call CR#1's FM. CNA C stated resident laid there for about an hour and a half. CNA C stated she came to check on CR#1 and observed a bag of ice (look like in a Ziploc bag), without being covered in a cloth, on resident's forehead. CNA C stated CR#1 was visually cold, shaking and screaming, please help me I'm cold and hurt. CNA C stated this is when she returned to the front desk and called her daughter back and told the daughter her mom was cold, shaking and had not been picked up by the ambulance yet. In an interview with AD on 5.21.2025 at 1:14pm - she stated she was doing her Angel rounds around 3:45 PM on 5.14.2025 and she passed by CR#1's room and heard her talking out loud. AD said she assumed CR#1 and her roommate, both who has been diagnosed with dementia, was talking, which is not uncommon, however; this time the voice was a little bit louder than usual. AD stated that she looked into the residents' room, and observed the lights off, the blinds on the window were open so there was a little bit of light coming through. AD stated she did not walk into CR#1's room so she did not observe any bruise on CR#1. She stated that she continued to her resident's room and soon afterwards she seen the DON at the resident room. In a Telephone Interview with CNA B on 5.21.2025 at 3:27pm -she stated she works the morning shift (6am - 2pm) shift on the 500 Hallway. She stated she is familiar with the CR#1. She stated on 5.14.2025 after lunch she did a one person assist with CR#1 using the gait belt by herself. CNA B stated CR#1 did not complain of pain at the time she put her in bed. CNA B stated the resident did not have any marks or bruises on her. CNA B stated CR#1 does not give bed baths on the morning shift because she gets it on the 2nd shift (2pm-10pm). CNA B stated resident is dead weight which means she doesn't and can't move which is why when she transfer CR#1 she must ensure the bed is at the same height as the chair CR#1 is being transferred from. CNA B stated she has no idea how CR#1 received a mark on her forehead. CNA B stated she put CR#1 in bed on the left side. She stated the bed is always at a low position. In a Follow Up interview with DOR on 5.21.2025 at 4:15pm she stated if a resident is dead weight there should not be a one person assist with a gait belt. She stated this could cause injury to the resident and staff. She stated any resident that is unable to move should be transferred or lifted with a Hoyer lift. She stated she is familiar with CR#1 from assessments working with her in therapy. She stated CR#1 is dead weight and should be transferred with a Hoyer lift and not a gait belt. DOR stated CR#1's hands are contracted and if there was an accident during a transfer by one person and she was accidently dropped, CR#1 would not be able to break the fall or assist herself. DOR stated this is a high risk of resident injury. In an Interview with NP on 5.21.25 at 9:30am the NP stated there was a concerned regarding CR#1's injury when she was informed. NP stated she was notified of CR#1's injury and instructed the facility to send CR#1 out to hospital. NP stated non-emergency transport was okay. NP stated she completed her own investigation when she was in facility. NP stated she spoke with the CNA A who was providing care to CR#1. She stated the CNA A told her she didn't know how CR#1 got the bump on her head. NP stated CNA A told her, while giving resident her bath, she used a roll sheet (pad) to roll her on her side, then held onto her left hip and washed her backside with the right hand. She stated CNA A told her she did not see any bump or bruises. NP stated CR#1 has osteoporosis and is very frail. NP stated she doesn't believe CR#1 was abused or neglected. She stated that she does believe that when the CNA A rolled CR#1on her side, the CR#1 may have hit her head on either the wheelchair that was on the side of the bed or the bedside table or tray table. NP stated if CR#1 had fallen, she would have sustained, based on her frail and brittle condition, multiple injuries, and multiple fractures. NP stated CR#1 sustained a fractured hip located between ball joint and hip. NP stated she believes CNA A didn't see CR#1 hit her head while giving care. NP stated CR#1's pain was delayed, which is why she screamed afterwards. NP stated she checked hospital records and there were no signs of brain bleed. NP stated the bump on CR#1's head didn't come out of nowhere. NP stated her synopsis is CR#1 could have hit her head on wheelchair or tray that was at her bedside. NP stated the CNA A told her she held CR#1's hip with her left hand. NP stated this could have caused the hip was fractured between bold joint and hip. NP continued stating CR#1 could fracture easily because she was brittle. NP stated she does not suspect abuse. NP stated CR#1's comorbidities due to brittle bones could very well been cause during the care she was receiving from CNA A. Can't say she fell. She was told one can gave bed bath. In an Interview with DON on 5.21.2025 at 11:14am she stated the hematoma could have occurred when CR#1 was turned over during her bed bath. DON stated CNA A said the bedside table and wheelchair was by CR#1's bed. DON stated CNA A told her CR#1's injuries were unintentional, and she believes CNA A. According to the camera, the screaming began after bed bath. DON stated she believes it happened during an earlier timeframe it took time for the swelling. Stated she will look to see if there. As far as fracture goes, the nurse completed a head-to-toe assessment. She Stated CNA A used padding to turn resident (resident is dead weight). Stated can have her hand on left hip to bathing her backside. Stated resident never complained. She stated she will send me the ADL policy. When asked why resident went .out 911 she stated she felt that resident was stabled, assessments were completed along with neuro-checks. In an interview with Administrator on 5.21.2025 at 11:50am. She stated 5/14/2025 she was informed about CR#1. She stated a head-to-toe assessment was complete and Neuros started. The administrator stated she was informed CR#1 had a knot on her forehead area. An investigation was initiated and called in to the state. She stated she was informed later about CR#1's hip fracture. She stated the facility did everything they were supposed to do in this situation including filing a police report. She stated at this time she believes her staff followed protocol. Record Review of Facility's Provision of Quality-of-Care Policy dated 2/2023 revealed the following: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibilities for interventions on the care plan will be clearly identified. An Immediate Jeopardy (IJ) was identified on 5.22.2025. The IJ template was provided to the Administrator on 5.22.2025 at 1:07 p.m. While the IJ was removed on 5.25.25 at 3:38 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. The following Plan of Removal submitted by the facility was accepted on 5/23/2025 at 6:46 p.m. PLAN OF REMOVAL Name of facility: Date:5/23/25 F689- Accidents/supervision Problem: -The facility failed to ensure the resident environment remained free of accident hazards as is possible in that residents receive adequate supervision and assistance when being transferred. -The facility failed to ensure adequate supervision for CR#1, a bedbound resident, who is totally dependent on staff for care resulting in CR#1's sustained hematoma to head and fractured hip. -The facility failed to ensure CR#1 was transferred properly by using a gait belt. CR#1 was transferred to the hospital for further evaluation and treatment 5/14/25. C.N.A #1 is no longer employed by our facility d/t failure to immediately report

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 8 residents (Resident #68, Resident #18, Resident #25, and Resident #3) reviewed for pharmacy services. -LVN J and LVN C failed to ensure the narcotic count was correct during shift change for Resident #68, Resident #18, Resident #25, and Resident #3. - LVN J failed to document the administration of narcotic medications in a correct manner for Resident #68, Resident #18, Resident #25, and Resident #3. -Staff administered Tramadol 50 mg instead of Tramadol 37.5 mg - Acetaminophen 325 mg as ordered by the Physician to Resident #68 for an unknown period. These failures could place residents at risk for drug diversion and delay in medication administration. Findings include: Resident #68 Record review of Resident #68's face sheet dated 5/16/24 revealed an [AGE] year-old male who readmitted on [DATE]. His diagnoses included pain, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory failure, and type 2 diabetes. Record review of Resident #68's significant change MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. He required supervision from staff with ADL care. Record review of Resident #68's care plan dated 3/26/24 revealed he was a risk for pain. Interventions were to administer pain medication as ordered. Record review of Resident #68's Physician Orders for May 2024 revealed an order for Tramadol 37.5 mg - Acetaminophen 325 mg tablet give 1 tablet twice a day, order date 3/26/24. There were no orders for Tramadol 50 mg. Record review of Resident #68's Nurse MAR for May 2024 revealed Tramadol 37.5 mg - Acetaminophen 325 mg tablet was scheduled for 8:00 a.m. and 8:00 p.m. There was a check mark documented by LVN J on 5/15/24 at 8:00 p.m. that indicated it was administered. Tramadol 50 mg was not listed on Resident #68's MAR. Record review of Resident #68's Controlled Substance Log for Tramadol 50 mg twice a day revealed the last administration documented was on 5/16/24 at 8 a.m. with a quantity of 20 tablets remaining. The previous documentation was on 5/15/24 at 8 a.m. There was no documentation for 5/15/24 at the 8:00 p.m. dose by LVN J. In an observation and interview on 5/16/24 at 12:03 p.m. of Resident #68's Tramadol 50 mg oral tablet (not Tramadol 37.5 mg - Acetaminophen 325 mg as ordered by the Physician) on the 200-hall nurse cart with LVN C revealed there were 19 tablets remaining. LVN C said the night nurse might not have documented the administration of the night dose from 5/15/24 on the narcotic log. Interview on 5/16/24 at 3:26 p.m. LVN C said he was administering the Tramadol 50 mg to Resident #68 instead of the combination medication (Tramadol 37.5 mg - Acetaminophen 325 mg) that was ordered by the MD for a while. He said he did not notice it was a different medication and believed the hospice company made a mistake when assisting with filling the medication. He said the Tramadol 50 mg was the only medication on the nurse cart. He said he should check the MD order and make sure it was the right medication and same milligram. Resident #18 Record review of Resident #18's face sheet dated 5/16/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included nondisplaced fracture shaft of left tibia, osteoarthritis (inflammation of one or more joints), need for assistance with personal care, and pain. Record review of Resident #18's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Record review of Resident #18's care plan dated 5/16/24 revealed he was a risk for pain. Interventions were to administer pain (Tylenol #3) medication as ordered. Record review of Resident #18's Physician Orders for May 2024 revealed an order for Acetaminophen (Tylenol)-Codeine #3 every 6 hours as needed for pain, order date 11/8/22. Record review of Resident #18's Nurse MAR for May 2024 revealed Acetaminophen-Codeine #3 was documented as administered by LVN J on 5/15/24 at 10:29 p.m. Record review of Resident #18's Controlled Drug Administration Record for Acetaminophen-Codeine 300-30 mg every 6 hours as needed revealed the last administration documented was on 5/15/24 at 10 a.m. with a quantity of 15 tablets remaining. There was no documentation for 5/15/24 at 10:29 p.m. by LVN J. In an observation and interview on 5/16/24 at 12:12 p.m. of Resident #18's Acetaminophen-Codeine 300-30 mg on the 200-hall nurse cart with LVN C revealed there were 14 tablets remaining on the blister pack. LVN C said the night nurse gave Resident #18 the medication last night (5/15/24) but did not sign the narcotic log. He said he did not notice the discrepancy when he and LVN J counted the narcotics during shift change. Resident #25 Record review of Resident #25's face sheet dated 5/16/24 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves), vascular dementia, and chronic pain syndrome. Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. Record review of Resident #25's care plan dated 5/16/24 revealed she was at risk for pain. Interventions were to administer pain medication as ordered. Record review of Resident #25's Physician Orders for May 2024 revealed an order for Norco 10-325 mg give 1 tablet every 4 hours as needed for pain, order date 11/8/22. Record review of Resident #25's Nurse MAR for May 2024 revealed Norco 10-325 mg was documented as administered by LVN J on 5/15/24 at 11:08 p.m. Record review of Resident #25's Controlled Drug Administration Record for Hydrocodone-APAP (Norco) 10-325 mg as needed revealed the last administration documented was on 5/14/24 at 8 p.m. with a quantity of 57 tablets remaining. There was no documentation for 5/15/24 at 11:08 p.m. by LVN J. In an observation and interview on 5/16/24 at 12:16 p.m. of Resident #25's Norco 10-325 mg on the 200-hall nurse cart with LVN C revealed there were 56 tablets remaining on the blister pack. LVN C said the night gave Resident #25 the medication last night (5/15/24) but did not sign the narcotic log. Resident #3 Record review of Resident #3's face sheet dated 5/16/24 revealed a [AGE] year-oldfemale who readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), pain disorder exclusively related to psychological factors (mental and emotional aspects that affect our behavior, health, and personality), hypertension (high blood pressure), and pain. Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. Record review of Resident #3's care plan dated 2/12/24 revealed she was at risk for pain. Interventions were to administer pain medication as ordered. Record review of Resident #3's Physician Orders for May 2024 revealed an order for Tramadol 50 mg give 1 tablet as needed every 6 hours, order date 5/16/24. There were no additional Tramadol orders listed prior to 5/16/24. Record review of Resident #3's Nurse MAR for May 2024 revealed Tramadol 50 mg had an order and start date of 5/16/24. There was no documentation of administration from 5/1/24 - 5/15/24. Record review of Resident #3's Controlled Drug Administration Record for Tramadol 50 mg 1 tablet by mouth every 6 hours as needed revealed Tramadol was documented as administered on 5/3/24 at 8 p.m. and 5/13/24 at 8 p.m. The last administration documented was on 5/14/24 at 8 p.m. with a quantity of 13 tablets remaining. In an observation on 5/16/24 at 12:23 p.m. of Resident #3's Tramadol 50 mg on the 200-hall nurse cart with LVN C revealed there were 12 tablets remaining on the blister pack. In a telephone interview on 5/16/24 at 12:17 p.m. LVN J said she worked on 5/15/24 from 6 p.m. - 6 a.m. She said she recalled administering the narcotic medications to Resident #68, Resident #18, Resident #25, and Resident #3 but may have forgotten to sign it on the narcotic sheet. She said she normally signed on the narcotic sheet when she administered the medication. She said she and LVN C conducted the narcotic count during shift change this morning, 5/16/24 and did not recall any discrepancies. She said it was important to ensure accuracy of the narcotics to verify if a pill was missing or administered. She said any discrepancies would be reported to the DON. Interview on 5/16/24 at 12:35 p.m. LVN C said LVN J was in a hurry this morning, 5/16/24 while doing narcotic counts during shift change. He said that may be the reason Resident #68, Resident #18, Resident #25, and Resident #3's narcotic count was not accurate. He said he was responsible for ensuring the narcotics were accurate. He said when administering narcotic medication, he should document on the computer and on the narcotic log after administering the medication to ensure nothing is missed. Interview on 5/16/24 at 12:58 p.m. the ADON said the off going and on coming nurse should conduct a narcotic count during shift change to ensure the number of pills match the number listed on the narcotic log. She said it was best practice for nursing staff to document on the narcotic sheet as soon as the narcotic was administered. She said if there were any discrepancies, nursing staff should call management. Interview on 5/16/24 at 1:44 p.m. the Administrator said she expected all narcotics to be accounted for. Record review of the facility's undated Controlled Substances policy read in part: .Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Policy Interpretation and Implementation: .4 . a control sheet must be made for each substance . The record must contain: . c. quantity received; d. number on hand; h. date and time received; i. time of administration . l. signature of nurse administering medication . 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services .

Based on interviews, observations, and record review, the facility failed to ensure residents were provided with a reasonable accommodation to access the ability to call for staff assistance through a communication system for one of twenty-four (Resident #79) reviewed for call system placement. -Resident #79's call light cord was wrapped around the call light base on the wall in an area inaccessible to the resident. This failure could place this resident or other residents at risk for not having their call light answered timely in an emergency and staff not being aware of an emergency situation for an extended period of time, injury, or death. Findings include: Record review of Resident #79's face sheet revealed a [AGE] year-old man admitted on [DATE]. Record review of Resident #79's diagnoses detail report dated 5/15/2024 revealed his diagnoses included metabolic encephalopathy (brain disease, damage, or malfunction usually related to inflammation within the body), pulmonary embolism (condition in which one of the pulmonary arteries in the lungs was blocked by a blood clot), type 2 diabetes mellitus (condition resulting from insufficient production of insulin, causing high blood sugar), chronic kidney disease (condition that impairs kidney function), dementia (group of symptoms that affects memory, thinking and interferes with daily life), syncope and collapse (fainting), conversion disorder (mental condition in which a person experiences blindness, paralysis, or other nervous symptoms that cannot be explained by illness or injury) with seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) or convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), affective disorder (a set of psychiatric disorders, also called mood disorders), need for assistance with personal care, and anxiety disorder (group of mental illnesses that cause constant fear and worry). Record review of Resident #79's quarterly MDS dated [DATE] with an ARD of 3/25/2024 revealed a BIMS score was not completed because he was rarely or never understood. The MDS documented he had long and short-term memory problems, and his cognitive skills for daily decision making were severely impaired. Per the MDS, Resident #79 was unable to recall the current season, location of his room, staff names and faces, or that he was in a bed in a nursing facility. The MDS revealed he had no impairment of either his upper or lower extremities, and he used a wheelchair for mobility. The MDS documented he required assistance, or was totally dependent on staff, for all ADL's. Record review of Resident #79's care plan undated care plan revealed a focus on his ADL care need with interventions including placing the call light within reach. Record review of Resident #79's EHR revealed he was receiving wound care daily. Observation on 5/14/2024 at 8:58 AM of Resident #79 revealed he was sleeping in his bed. Resident #79's bed was in a lowered position. Resident #79's call light was not in a position he could reach. The call light was wrapped around the call light station on the wall. There was no means for Resident #79 to get to or press the call button. Interview on 5/14/2024 at 9:00 AM with CNA A, she said a resident's call light should be in a position he/she could reach. CNA A said Resident #79's call light was not in a position he could reach as it was curled around the call light station on the wall. CNA A uncurled the call light cord and placed it on the bed by Resident #79's hand. CNA A said the purpose of a call light was to allow residents to call staff to assist them. CNA A said if a resident did not have access to the call light, he/she may have an emergency such as a fall and not be able to get needed assistance. Interview on 5/14/2024 at 9:22 AM with LVN B, she said the purpose of a call light was to allow residents to call for help. LVN B said if a resident's call light was not within reach, he/she could not call for assistance when needed. LVN B said the staff were to look at the call light placement every two hours. LVN B said a call light should not be wound up and hanging on the wall, in an area inaccessible to a resident. LVN B said if a call light was wound up on the wall, the resident could not call for help in an emergency. Interview on 5/14/2024 at 9:35 AM with the Admin, she said she expected the call lights should be answered timely and placed where the residents can use them. The Admin said a call light wrapped up on the wall, not near a resident, would not meet her expectations. The Admin said the resident could not call for help in an emergency. The Admin said the facility had provided staff with training related to call lights and their placements. Record review of the facility's undated Answering the Call Light policy revealed a policy statement which read The purpose of this procedure is to respond to the resident's requests and needs. The policy documented the call light should be within easy reach of the residents.

Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for 1 of 18 residents (Resident #48) reviewed for PASARR evaluations. The facility failed to refer Resident #48 to the appropriate, State-designated authority when she was diagnosed with delusional disorder (firmly held false beliefs), mood disorder (psychiatric disorders that impact emotions), generalized anxiety disorder (over worry), psychosis (difficulty determining what is real or not), and bipolar disorder (mood disorder with ups and downs). This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #48's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE], with diagnoses of high blood pressure, high cholesterol, anxiety, depression, psychosis (difficulty determining what is real or not), diabetes (body does not produce enough insulin or resists it), chronic obstructive pulmonary disease (lungs do not get enough oxygen), mood disorder (psychiatric disorders that impact emotions), and chronic back pain. Record review of Resident #48's Admission MDS assessment dated [DATE], revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The assessment revealed the resident was not evaluated by PASRR and did not have a Serious Mental Illness. Under the diagnoses, anxiety and depression were checked. The MDS revealed the resident had been taking antipsychotics and antidepressants. Record review of Resident #48's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 4 out of 15, which indicated severely impaired cognition. The assessment revealed the resident was not evaluated by PASRR and had no Serious Mental Illness. The resident had impairment on one side of her upper and lower extremities and used a wheelchair. She was dependent with toileting hygiene, showers/baths, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. She was always incontinent of bowel and bladder. She had diagnoses of anxiety, depression, and a psychotic disorder. She was taking antipsychotics and antidepressants. Record review of Resident #48's undated care plan, revealed a Focus: Resident was at risk or potential for anxious/agitation d/t dx: anxiety (Onset: 6/8/23). Goal: Resident would minimize episodes of anxiety daily and ongoing over the next 90 days; AEB: anxiety would not interfere with functional abilities through the next 90 days (Start: 1/12/24, Review: 7/3/24). Interventions: Administered anti-anxiety medications as ordered and reported effects and effectiveness to physician as indicated. Observed resident for episodes of anxiety, such as: excessive worrying, fear, feeling of impending doom, insomnia (trouble sleeping), nausea, palpitation (heart skips a beat) or trembling and implemented interventions as ordered by physician. Focus: Resident was at risk or potential for feeling down, depressed or hopeless d/t dx: depression (Onset: 6/8/23). Goal: Resident would exhibit no signs and symptoms of depression daily and ongoing over the next 90 days (Start: 6/12/23, Review: 7/3/24). Interventions: Administered anti-depression (Zoloft/Trazodone) medication as ordered and reported effects and effectiveness to physician as indicated. Focus: Resident was at risk or potential for behavior's r/t psychosis (difficulty determining what is real or not) with delusions (firmly held false beliefs) and mood disorder, aeb: combative/aggressive behaviors with hx of bipolar (mood disorder with ups and downs) with delusions (firmly held false beliefs) (Onset: 6/16/23). Goal: Resident would minimize episodes of psychosis (difficulty determining what is real or not) with delusions (firmly held false beliefs) daily and ongoing over the next 90 days (Start: 6/12/23, Review: 7/3/24). Interventions: Administered anti-psychotic (Seroquel) medication as ordered and reported effects and effectiveness to physician as indicated. Focus: Resident was at risk for adverse reaction to psychotropic drug use d/t anti-depressant (Zoloft/Trazodone) drug use r/t dx: depression (Onset: 6/8/23). Goal: Resident would have no injury related to antidepressant medication usage/side effects daily and ongoing over the next 90 days (Start: 6/12/23, Review: 7/3/24). Interventions: Administered anti-depression (Zoloft/Trazodone) medication as ordered and reported effects and effectiveness to physician as indicated. Resident was at risk for adverse reaction to psychotropic drug use d/t antipsychotic (Seroquel) drug use r/t dx: psychosis (difficulty determining what is real or not) with delusions (firmly held false beliefs) and mood disorder and dx: bipolar (mood disorder with ups and downs) (Onset: 6/16/23). Goal: Resident would have no injury related to anti-psychotropic medication usage/side effects daily and ongoing over the next 90 days (Start: 6/12/23, Review: 7/3/24). Interventions: Administered anti-psychotic (Seroquel) medication as ordered and reported effects and effectiveness to physician as indicated. Record review of Resident #48's previous hospital records from 6/9/23, revealed she had a history of depression/mood disorder (psychiatric disorders that impact emotions). She was discharged to the facility on antipsychotics and antidepressants. Record review of Resident #48's PASRR Level 1 Screening from 6/12/23 performed by the MDS Coordinator, revealed the resident had no evidence or indication of Mental Illness. Record review of Resident #48's Physician Orders from MD A revealed the following orders: -Trazodone 50mg, 1 PO QHS for insomnia (trouble sleeping). Ordered on 8/9/23 at 2:51pm. -Levetiracetam 250mg, 1 PO BID for psychosis (difficulty determining what is real or not). Ordered on 11/1/23 at 4:45pm. -Sertraline HCL 50mg, 1 PO QD for depression. Ordered on 11/16/23 at 4:59pm. -Behavioral-Monitor and document any behaviors, every day 6:30am and 6:30pm. Ordered on 1/17/24 at 3:55pm. -Behavioral-Monitor and document and side effects related to use of antipsychotic medication, every day 6:30am and 6:30pm. Ordered on 1/17/24 at 3:56pm. -Behavioral-Monitor and document any side effects related to use of antidepressant medication, every day 6:30am and 6:30pm. Ordered on 1/17/24 at 3:57pm. -Quetiapine Fumarate 300mg, 1 PO QHS for delusional disorders (firmly held false beliefs). Ordered on 2/13/24 at 10:30am. Record review of Resident #48's Psychiatric Initial Assessment from 10/16/23 by NP A, revealed the resident was being treated for Bipolar disorder. Record review of Resident #48's May 2024 MAR revealed she was receiving Sertraline 50mg for depression, Levetiracetam 250mg for psychosis, and Quetiapine Fumarate 300mg for delusional disorders. In an interview with the MDS Coordinator on 5/16/24 at 12:50pm, she said when Resident #48 came to the facility she was on Seroquel for a mood disorder and that was all. She did not think that qualified for a mental disorder. She said she did not receive any of the resident's medical records until a couple months later. She said the hospital's PASRR was negative, so she did not know she needed to do anything else. She did not realize until 5/15/24 when the State Surveyor asked about the PASRR being negative, that she realized the resident had several mental health diagnoses. She said she submitted a new PASRR on 5/15/24 and someone was supposed to come and screen the resident within a few days. She said if the resident was not screened properly, they would fall through the cracks and not get services they might need. Record review of the facility's policy and procedure on Preadmission Screening (PASRR) (version 11/2017) read in part: Our facility will ensure that all new admission are appropriately screened prior to admission to determine that the individual requires nursing facility level of care and to identify any specialized services that may be necessary. The facility does not admit any new resident with serious mental illness or mental retardation unless a preadmission screening has been completed and the state has determined that the facility can supply the care and services appropriate to the resident's condition (and the state will provide any specialized services that are required to treat the special condition). This policy is applicable to all residents [regardless of payor source] being admitted to a nursing facility bed that is certified for Medicare and/or Medicaid. Upon or before application for admission, the admissions coordinator will obtain the following information for each candidate: recent medical history and physical and/or; record of recent or current hospital stay; listing of medications; listing of diagnoses; recent nursing notes .personal information; information regarding payment source. Ensure positive Preadmission PL1s are submitted via state software to the Local Intellectual and Developmental Disability Authority (LIDDA) or Local Mental Health Authority (LMHA) .Review the recommended Specialized Services on the PASRR Evaluation (PE) when an alert is received. Certify the ability to meet the individuals needs on the PL1. Invite LIDDA/LMHA to the PASRR Interdisciplinary Team (IDT) meeting and to all care plan meetings. Finalize Specialized Services to be delivered by the NF and LIDDA/LMHA. Document Specialized Services to be delivered by the NF and LIDDA/LMHA in the resident's comprehensive care plan. Initiate delivery of Specialized Services within 20 business days of the IDT meeting date.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #35) of 18 residents reviewed for quality of care. -LVN M failed to document notification to NP B of Resident #35's blood sugar of 422 on 5/13/24, and failed to document and/or give 10u of Insulin that was ordered by NP B for Resident #35's blood sugar. This failure could place the resident at risk for high blood sugar, and possible hospitalization . Findings include: Record review of Resident #35's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admitted [DATE]. He had diagnoses of Type 2 Diabetes (body does not produce insulin or resists it), benign prostatic hypertrophy (enlarged prostate), cerebrovascular accident (stroke), anxiety, depression, hypertension (high blood pressure), insomnia (trouble sleeping), high cholesterol, constipation, gout (build up of acid in joints), over active bladder, and dysphagia (trouble swallowing). Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, which indicated normal cognition. The MDS revealed a diagnosis of Diabetes Mellitus (body does not produce insulin or resists it) and confirmed the resident was receiving Insulin injections. Record review of Resident #35's undated care plan revealed a Focus: Resident was at risk or potential for hyper/hypoglycemia (high/low blood sugar) episodes secondary to dx: diabetes mellitus with neuropathy (nerve pain) (Onset: 11/13/20). Goal: Resident would minimize risk for hyper/hypoglycemia (high/low blood sugar) episodes daily and ongoing over the next 90 days (Start: 7/14/23, Review: 7/20/24). Interventions: Assisted with maintaining stable blood sugars; obtained blood sugars as ordered and reported any abnormalities. Assessed response to the Insulin (Lantus/Trulicity) adjustments and reported to Physician; Observed for symptom of hyper/hypoglycemia (high/low blood sugars). Record review of Resident #35's May 2024's blood sugars revealed a blood sugar of 422 (normal is 70-120) on 5/13/24 at 10:55pm, by LVN M. Record review of Resident #35's May 2024 Nurse MAR Notes, revealed on 5/13/24 at 10:57pm LVN M documented she checked off the task of Diabetic: Fingerstick blood sugars every AC/HS, Notify NP if BLOOD SUGARS ARE < 70 or > 120 and that the resident's blood sugar was 422. There was no documentation that she notified the NP or that Insulin was given. Record review of Resident #35's Physician Orders revealed an order from NP B from 11/7/23 at 1:48pm that read: -Diabetic: Fingerstick blood sugars every AC/HS, Notify NP if BLOOD SUGARS ARE < 70 or > 120. Every day at 7:00am, 12:00pm, 5:00pm, and 8:00pm. Record review of Resident #35's Progress Notes on 5/16/24, revealed there were no notifications to the NP of the blood sugar of 420 on 5/13/24. Record review of Resident #35's Physician Orders and Discontinued Physician Orders on 5/16/24, revealed there were no orders for Insulin on 5/13/24. Interview with NP B on 5/16/24 at 10:00am, she said she entered orders to notify her of blood sugars less than 70 or more than 120 for all of her diabetic residents. She said she expected staff to call her every time that parameter was met. She said she had that order to keep the lines of communication open between the staff and her regarding the resident's blood sugar, so she knew what was going on. She said she received a lot of phone calls, but it did not bother her. She said she also received notifications in person when she was at the facility. NP B said she was pretty sure LVN B called her about Resident #35's blood sugar of 422 but she could not find it in her phone. She said she would have given LVN B orders to give the resident Insulin since his blood sugar was so high. Interview with RN P on 5/16/24 at 10:44am, she said if there was an order with parameters to call the NP if the blood sugar was less than 70 or greater than 120, then they called the NP each time and documented it in the progress notes. She said the NP would usually give orders for Insulin and they would put the order in as a one-time dose. The order and the conversation would be entered in the progress note. She said if the NP was not notified, the resident's blood sugar would remain high and it could cause problems for the resident. Interview with the ADON on 5/16/24 at 1:16pm, she said her expectation was that the staff would call the NP each time the blood sugar was out of range from the order. She said the notification would be entered in the progress notes of the resident and then an order for Insulin would be entered as a one-time order or a PRN order. Per the ADON, she said NP B texted her and informed her that she ordered 10u of Insulin for Resident #35. The ADON said maybe LVN M forgot to put the orders in since there were no orders for the Insulin found in the resident's records. The ADON said if the nurse did not notify the NP, the blood sugar could get too high, and the resident would have to be hospitalized . Interview with Resident #35 on 5/16/24 at 1:35pm, he said he remembered his blood sugar being high a few days back, but he felt okay and did not feel dizzy, shaky, or weak. He did not remember if the nurse gave him insulin or not. A message was left for LVN M on 5/16/24 at 1:40pm, but she did not return the call. Record review of the facility's Policy and Procedure on Charting and Documentation (no date) read in part: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record .All incidents, accidents, or changes in the resident's condition must be recorded .Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment .Notification of family, physician or other staff, if indicated . Record review of the facility's Policy and Procedure on Change in a Resident's Condition or Status (Revised May 2017) read in part: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a(n): .Specific instruction to notify the Physician of changes in the resident's condition .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on record review, and interviews, the facility failed to ensure the safety and supervision of one (Resident CR2) of one residents reviewed for falls, in that: -While pericare was being provided by Certified Nursing Assistant (CNA) 8, the CNA 8 rolled CR2 away from her. CR2 fell out of bed, onto his head, and sustained a left forehead and periorbital soft tissue contusion/hematoma (bruise) to the head. This failure could place all residents who needed pericare at risk of falls and injury. Findings included: CR2 Record review of CR2's facility's Provider Investigation Report, provided by the facility, dated 10/23/20, indicated, Functional Ability: Extensive. Independently Ambulatory: No. Witnesses: No. CNA failed to follow proper procedure when providing peri care. On 10/23/20, CNA was cleaning the resident and turned him toward the opposite side, as she was trying to go to the other side, resident rolled out of bed and she ran to get the nurse . Upon follow up assessment nurse noted that the resident had a knot on his left eyebrow and bruising to the left eyelid. Resident was sent out to the hospital . Record review of CR2's Emergency Department Record, provided by the facility, dated 10/23/20, indicated Complaint: Fall . Per nursing home report to EMS, pt (patient) sustained an unwitnessed fall and struck his head. Per patient he fell while being transferred and landed on his head . Primary impression: Contusion, orbital rim. Record review of CR2's undated Face Sheet, provided by the facility, indicated R2 was admitted to the facility on [DATE] and discharged to the emergency roiagnom on [DATE]. Admitting diagnoses included Transient Cerebral Ischemic Attack (TIA), Cognitive Communication deficit, Muscle Weakness, need for assistance with personal care, and lack of coordination. Record review of CR2's Baseline Care Plan, provided by the facility, dated 10/21/20, indicated CR2 was at risk for falls. Further review of the Baseline Care Plan indicated CR2 required assist of one staff for bed mobility, assist of two or more for transferring, assist of one person for toileting and assist of two or more for grooming/hygiene. The Baseline Care plan indicated CR2 was incontinent of bowel and bladder. Record review of CR2's Nursing Progress Notes, provided by the facility, dated 10/23/20 at 4:54 AM, indicated, Certified Nursing Assistant CNA requested assistance. Resident found lying on floor. CNA said she was changing resident and resident fell . Resident was alert, denied pain or injury. Told resident we would be getting him up and back in bed. Used a sheet to lift resident back into bed . No apparent injury noted. Informed resident he would be going to hospital. Resident refused and said, 'Its ok things happen . It's ok I'm not going to the hospital. Record review of CR2's Nursing Progress Notes, provided by the facility, dated 10/23/20 at 5:03 AM, indicated, Resident continues to refuse to go to hospital despite encouragement . No signs of changes. Record review of CR2's Nursing Progress Notes, provided by the facility, dated 10/23/20 at 10:12 AM, indicated, Resident sent to [name of Hospital emergency room ] for further evaluation. Record review of CR2's [name of Hospital] History of Present Illness (HPI) Notes, provided by the facility, dated 10/23/20, indicated, On [MEDICATION(S)], comes to ED (Emergency Department) as Level 2 trauma activation for fall on [MEDICATION(S)]. Pt (patient) endorsed that he was stood up pt was being transferred from bed this AM when he fell and hit L (left) side of head . Pain only to L (left) orbital (eye socket) area . Awake, alert, no acute distress . CT face showed only soft tissue swelling and [CONDITION(S)].Pt. and his family are asking for him to be discharged to a rehab facility . Pt. was cleared by trauma team. Pt. will be discharged to rehab. Record review of CR2's [name of Hospital] Computerized Axial Tomography (CAT) Scan results, provided by the facility, dated 10/23/20, indicated, Left forehead and periorbital soft tissue contusion/hematoma without facial fracture. Record review of CR2's [name of Hospital] CAT Scan results of the brain/head, provided by the facility, dated 10/23/20, indicated, Moderate left frontal scalp hematoma without underlying fracture. Interview with the Administrator on 5/13/21 at 10:40 AM, the Administrator said, that the incident had been reported to her. She couldn't remember by who, but once it was reported to her, she immediately reported it to the State. The Administrator said she was told the CNA had turned the resident the wrong way from her which was wrong. Her expectation was that the CNA should have turned the resident towards her when changing him. The Administrator said that she would then delegate to the staff to do immediate in-services, suspensions, etc which was done immediately. The CNA was suspended immediately and the facility held an all staff in-service immediately. CNA received additional training one-on-one Interview on 5/13/21 at 1:50 PM, the Director of Nursing (DON) said that the CNA (identified as CNA 8) turned the resident away from her while she was providing care and he fell out of bed. She (the CNA) was by herself and she knew that she needed to have two people at the time. Our procedure is that she (the CNA) should have turned the resident towards her instead of away from her. The DON then said, She (referring to CNA 8) knew she did it the wrong way. Our process has been that if you are not sure about a resident, it is always better to be safe, and have another person with you to turn or change them. Interview on 5/13/21 at 3:15 PM, CNA 8 said, He (referring to CR2) was on the call light. When I went in to change him, he had a large BM (bowel movement) all over him and his blankets. I started to change him. I rolled him to me, and I cleaned him on one side. Then I needed him to roll away from me, so I put him on his back, then I walked to the other side of the bed. As I was on the other side of the bed, I rolled him away from me. I turned my back and reached to grab my wipes and I had my back to him. I wasn't thinking at the time. He reached for the headboard and fell to the floor. CNA 8 then said, I knew I made a mistake by rolling him away from me. CNA 8 then said, when he fell out of bed, I went and got the nurse. The nurse assessed him then me, the nurse and another staff put him on a sheet and put him back to bed. CNA 8 said, Prior to this, I knew that if I needed help, I should have gotten help. I just wasn't thinking. Interview on 5/14/21 at 7:55 AM, Licensed Vocational Nurse (LVN)15 said, When I came in on the morning shift, I saw a knot on his (referring to CR2) head and a giant bruise on his face. I asked him (referring to CR2) what happened, and he said when they turned him in bed, he rolled out of the bed onto the floor. He was not making sense with his words. I continued to do neuro checks and we decided to send him out to the hospital to be evaluated. Interview on 5/14/21 at 9:17 AM, the Assistant Director of Nursing (ADON) said, Just because the CNA activity screen that was in our old computer system said he (CR2) was a one person assist for bed mobility, personal hygiene, and toileting, it also depends on the CNA. If they do not feel comfortable, they should go get another CNA. The ADON then said, The CNA (referring to CNA 8) knew she should not have turned the resident away from her when this happened. Interview on 5/14/21 at 9:15 AM, Registered Nurse (RN)16 said, From what I recall, I came in on day shift and I overhead there was one CNA changing him (referring to CR2) and he fell out of bed. I remember seeing a large knot on his forehead, then he was sent out to the hospital. Record review of an undated facility policy titled, Repositioning indicated, Steps in the procedure: Repositioning the resident in bed . Use two people and a draw sheet to avoid shearing while turning or moving the resident . Record review of an undated checklist titled, Making an Occupied Bed Competency Checklist indicated, Purpose: To provide a clean, comfortable bed for the resident who is not able to get out of bed . Assist resident to roll over linen toward you, and assure that resident is comfortable and safe .

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (Residents #1) of 2 residents reviewed for accidents. The facility failed to follow Resident #1's care plan to have 2 staff assist with bed mobility which resulted in the resident off the bed on his face, sustaining swelling and bleeding of his nose and lip; and causing him to receive hospital treatment. This failure affected one resident, placing him at risk of of injuries and reduced quality of life. Findings Included: Resident #1 Record review of Resident #1's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan dated 4/24/19 revealed he had decreased mobility and ADL functions and required extensive assist with 2 persons for bed mobility, transfers and toileting. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated he was cognitively intact. He required extensive assistance from two persons for bed mobility, toilet use and transfers. Record review of Resident #1's MDS assessment dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated he was cognitively intact. He required extensive assistance from two persons for bed mobility, toilet use and transfers. Record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of twelve (12) which indicated moderate cognitive impairment. He required extensive assistance from two persons for bed mobility, toilet use and transfers. Interview and observation on 7/2/19 at 9:55 a.m., Resident #1 said on 5/18/19 his brief needed to be changed and his linens were wet. He said CNA A came in to change him alone. He said CNA A started to change his brief while in the bed. Resident #1 said to CNA A that he thought it would be better if he took him out of bed to change the soiled sheets. Resident #1 said CNA A said I've got it and proceeded to roll the resident on to his right side towards CNA [NAME] Then Resident #1 said CNA rolled him back onto his left side over the rolled-up sheets away from CNA [NAME] Resident #1 said when he rolled that direction, he rolled off the bed onto the floor. He hit his face on the floor and was in pain. CNA A called other staff to come help get him off the floor. Resident #1 said he was sent to the hospital. There was no floor mat beside his bed. Record review of facility investigation report dated 6/26/19 revealed Resident #1 had swelling to his nose, lips and cheeks. Record review of nurses' notes dated 5/18/19 revealed Resident #1 was instructed to roll over during incontinent care and fell to the floor, resident assessed, vitals taken and sent to ER. Swelling to nose and lip. Record review of witness statement dated 5/18/19 signed by CNA A stated On May, 18 2019, I went to Resident #1's room to change him. The bed was wet. So, I got my supplies. When it was time to roll, he said ok and roll to the side a did not stop. He landed on the floor. I went and got the nurse and picked him up and put him in the bed. And his nose was bleeding. Resident #1 rolled himself over. Record review of Facility Fall Committee Notes dated 5/18/19 revealed the following: New Intervention - Educated CNAs to beware of positioning before asking the resident to roll and have them roll toward, not away. Record review of Individual Education Form dated and signed 5/21/19 by CNA A in section items reviewed: Be aware of resident getting close to the edge of bed when providing care. Have them roll toward you, not away. Record review of training by the facility dated 5/21/19 conducted by DON revealed in the summary conclusion section: Be mindful of residents getting close to edge of bed when providing care. Always have them roll towards you, not away. Record review of facility incident report QA/CQI log dated (MONTH) 2019 revealed Resident #1's 5/18/19 fall was not listed. This report was provided to the Surveyor on 7/2/19. Interview on 7/2/19 at 3:25 p.m. with DON said she was notified on the day of the incident with Resident #1. She said he was sent ER. DON said you learn during nursing school you can change occupied beds and the roll the resident towards you if you are alone. She said she did remember Resident #1 told her he asked CNA A if it would better to get him up into his wheelchair to change the sheets. She said she thought the 2-person assist was implemented after the fall. During the interview the DON was asked to look at Resident #1's current care plan. She confirmed his assistance level was a 2 person assist. She said we should have had two people per the care plan. She said maybe the care plan was not updated. She said the MDS level of assistance needed is carried over to the care plan. She did not have access to CNA A's personnel file since the HR staff had left for the day with the key to the files. She said she did not have a policy that addressed changing the bed sheets. Interview on 7/2/19 at 4:05 p.m. with DON said their weekly therapy meetings that Resident #1 required moderate amount of assistance and that was the information they were putting in the kiosk so aides would know how to provide care. Maybe the care plan was not updated. Record review of facility Care plan - comprehensive Policy not dated revealed the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. #2. The comprehensive care plan is based on a thorough assessment that includes .MDS #3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area. b. Incorporate risk factor associated with identified problems.

Based on observation, interview, and record review the facility failed to ensure 1 of 7 residents (Resident # 2) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: -On 6/9/14, Resident # 2 was transferred to her bed by (1) CNA (CNA B), when Resident required extensive two-person transfers. Resident #2 complained of severe right leg pain on the morning of 6/10/14, and reported her leg was injured when she was transferred to her bed the night of 6/9/14 by a CNA (unnamed). The charge nurse was notified by a CNA. Two CNA's then transferred Resident # 2 to a wheelchair and took her to breakfast in the dining room and returned her to bed. Nursing staff did not assess her or give her pain medication until 9:45 AM. X-rays were not done until after 4:00 PM that evening and Resident # 2 was not sent to the emergency room until after 5:00 PM. Resident # 2 had a spiral fracture to her right tibia (lower leg). This failure affected 1 resident and placed 152 residents at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings include: Complaint # 1 Record review of Resident # 2's medical records revealed she was admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 2's quarterly MDS assessment dated [DATE] revealed she scored 5 of 15 possible correct answers on the BIMS (severe cognitive Impairment). She required extensive two person assistance with bed mobility and transfers; extensive one person assistance with dressing, toilet use, and personal hygiene; and limited one person assistance with locomotion and eating. She was frequently incontinent of bowel and bladder. She used a wheelchair for ambulation and was able to self-propel with her feet. Record review of an Incident/Accident Report dated 6/09/14 revealed the incident/accident occurred in the resident's room. The Type of Injury was "Fx Tibia" and an x was marked on the right leg on the diagram. Description of what happened read, "Resident stated it happened during transfer from wheelchair to the bed." The report was signed by the DON on 6/11/14. Record review of an Incident Investigation and Interdisciplinary Post-Fall assessment dated [DATE] revealed "Resident said it happened during transfer from w/c to the bed. Hit on side of bed." An attached Witness Statement signed by the DON on 6/11/14 read, "This writer spoke to (Resident # 2) and daughter at bedside. Both daughter and resident stated that resident broke her leg while being put to bed because her leg hit the side of bed. Spoke to CNA who put resident to bed and she stated that to her knowledge she didn't notice (Resident # 2) bang her leg on the bed and resident didn't complain of pain at that time." Further review of the Incident investigation revealed a second attached Witness Statement read, "On Tuesday, June 10 around 6:30 AM I went into Rm 216 b which is (Resident # 2) room to wake her up for breakfast. She was already awake and saw me and said "Oh honey I've had a rough night." I asked her what happened? She said "my leg hurts so bad." I pulled the cover from over her to look at her leg and she said it hurts to even move it. I asked her "What happened to your leg?" She said that the girl who put her to bed last night picked her up and her leg hit the rail when she was putting her to bed. I reported it to the nurse and then went and got my co-worker and she went and talked to (Resident # 2) who then told her the same thing." Record review of an X-Ray report dated 6/10/14 at 4:11 PM revealed it read that x-rays of the right femur, knee, leg, ankle & foot revealed "Hip and knee joints show [MEDICAL CONDITION] changes. No knee joint effusion is seen. A nondisplaced spiral fracture through the shaft of the tibia and distal portion is seen. Diffuse osteopenia is seen. Impression: 1. Fracture shaft of the tibia and the distal portion is seen." Record review of Resident # 2's nurse's notes revealed a note dated 6/10/14 at 10:00 AM read, "C/o of severe pain to R lower leg area, no S/S of redness, but when touched crying out for pain. RP @ bedside & resident told LVN that somebody put her in bed & dropped her & her leg. Gave [MEDICATION NAME] for pain @ this time." This note then documented a request for x-ray from the NP. At 1430 documentation read that the x-ray was done at that time. Record review of Resident # 2's MAR indicated [REDACTED]. The time "945" was documented under LVN B's initials on the MAR. Observation and interview with Resident # 2 on 6/25/14 at 9:10 AM revealed she was sitting in a wheelchair in her room next to her bed with her lower right leg in a splint and lying on an elevated foot pedal. When asked how the fracture to her leg occurred, Resident # 2 responded that she could not remember anything about how it happened. She stated she only remembered that it hurt a lot. In an interview with LVN B on 6/25/14 at 1:20 PM she stated when she came to work at 6:00 AM on 6/10/14 the CNA's reported that Resident # 2 was in pain. She stated she was not able to look at Resident # 2's leg when she first arrived because she had to go to the dining room. She stated she was the assigned nurse on duty for breakfast in the dining room every morning. She stated she could not go and assess Resident # 2 until breakfast was all over with. She stated when she saw Resident # 2 she was in a lot of pain and was really crying and upset. She stated her daughter was in the room. She stated Resident # 2 told her she hurt her leg when someone put her to bed. LVN B stated she then called and got an order for [REDACTED]. In an interview with CNA A on 6/27/14 at 11:09 AM she stated when she went into Resident # 2's room at 6:30 AM on 6/10/14 she reported her leg was hurting and she appeared to be in pain. She stated her leg hurt to touch or move. She stated Resident # 2 made cries when she tried to move her leg. CNA A stated she reported it to LVN B and she told her she would check her. CNA A stated Resident # 2 wanted coffee. She stated to keep Resident # 2 from putting weight on that leg, she got another CNA to assist her to transfer her to the wheelchair and she then took her to the restorative dining room to eat breakfast. She stated when she was done they put her back in bed. CNA A stated Resident # 2 was still complaining of a lot of pain in her leg when they transferred her back to the bed after breakfast. In an interview with LVN A on 6/27/14 at 10:53 AM he stated he was on duty on the 2:00 PM-10:00 PM shift on 6/09/14 on Resident # 2's hall. He stated "That evening she did not complain of anything." He stated on the next evening he came in and found that she had a fracture. He stated she told him she hit her leg when being put to bed. He stated he sent her out to the ER that evening after he got the results of the x-rays back. He stated he was unsure of the time. In an interview with CNA B on 6/27/14 at 11:25 AM she stated on 6/09/14 she transferred Resident # 2 into bed. She stated Resident # 2 assists with the transfer. She stated she changed her brief and changed her into her pajamas. She stated she also transferred and provided care to her roommate at the same time. She stated Resident # 2 "got in the bed just fine. It was a normal night. She was laughing and talking. She was moving side to side and moving both legs just fine." CNA B stated nothing happened that night. She stated the next night when she came in and found out she had a fracture she was "shocked" and "hurt." She stated she asked Resident # 2 why she didn't tell her she hit her leg. She stated Resident # 2 told her she couldn't remember. In an interview with a family member on 6/30/14 at 9:30 AM she stated she went to see Resident # 2 on 6/08/14 and her leg was fine that day. She stated she did not go to the facility on [DATE]. She stated when she arrived at the facility on 6/10/14 sometime around 10:30 AM Resident # 2 was in a lot of pain. She stated she found LVN B and asked her if she had assessed Resident # 2. LVN B told her no. She stated LVN B told her she was bringing pain medication to her right then. The family member stated they went to Resident # 2's room and LVN B looked at her leg and asked the family member if she wanted her to get x-rays done. The family member stated they did not do the x-rays until late in the day and did not call to let them know they were sending her to the emergency room until after 5:00 PM. When she was asked if Resident # 2 was able to tell her what happened, she stated she just told her that "someone threw her in the bed and she hit her leg." The family member was asked if she knew who it was or when it happened. She stated, "Absolutely not. We don't. And the reason we don't know is because no one had reported anything." The family member stated no one notified them of the injury. Policy regarding change of condition and assessments was requested but not provided by the time of exit from the facility. According to the facility's Resident Room Roster the census was 153.