Every finding on record at La Frontera Nursing & Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of six residents reviewed for supervision.The facility failed to ensure Resident #1 did not eloped from the facility on 07/26/26 that resulted in an abrasion to Resident #1's forehead. The noncompliance was identified as PNC. The IJ began on 07/26/26 and ended on 07/26/26. The facility corrected the noncompliance before the investigation began.This failure could place residents requiring supervision at risk for injury and accidents.The findings included:Record review of Resident #1s face sheet dated 08/13/26 reflected an [AGE] year-old-male with an original admission date of 11/24/25. Diagnoses included Alzheimer's (progressive brain disorder that slowly destroys memory and thinking skills) and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7 (moderatecognitive impairment). Resident #1 did not require a mobility device and was ambulatory. Record review of Resident #1's care plan reflected he was at risk for elopement/wandering with unsafe boundaries due to cognitive impairment, judgment and aimlessly ambulating through facility and safety awareness. Resident #1's care plan also reflected that he walked out of the facility's front door on 07/26/26.Review of video surveillance footage dated 07/26/26 at approximately 8:03 a.m., revealed Resident #1 wandered into the front lobby area and gestured to a newly hired housekeeper who was by the nurse's station to be let out of the facility. The housekeeper entered the door code allowing him to exit the facility. Resident #1 was wearing a wander guard on his ankle at the time. When the housekeeper entered the door unlocked, and Resident #1 exited the facility without activation the alarm.In an interview on 08/13/26 at 8:04 a.m., Resident #1 could not recall the incident. In an interview on 08/13/26 at 10:12 a.m., the DON stated early on 07/26/27 at approximately 8:03 a.m. HK A was by the nurse's station, cleaning, when she saw what she thought was a male visitor wave at her to let him out. HK A was a new employee and did not recognize the male visitor was Resident #1. The DON stated HK A went to the front lobby and entered the front door code disarming Resident #1's wander guard he was wearing on his ankle, and Resident #1 exited the facility. The DON stated at approximately 8:06 a.m., CNA B went into Resident #1's room to drop off his breakfast tray and realized he was not in the room or the restroom, which was highly unusual. The DON stated, at that time, CNA B informed CNA C and together they reported Resident #1 was missing. The DON stated staff initiated code pink which meant there was a missing person, and staff immediately began a head count and started searching the facility and surrounding area outside. The DON stated HK A immediately notified staff that she let someone out of the facility and thought it was a visitor. The DON stated staff did not stop searching until they were notified at approximately 9:00 a.m. that Resident #1 was located at a nearby emergency room. The DON stated after investigating the incident, Resident #1, who had not displayed any exit seeking behaviors prior, exited the facility and walked down a sidewalk approximately two blocks away to a shopping center. The DON stated at that shopping center was a doctor's clinic. The DON stated the doctor of that clinic observed Resident #1 at approximately 8:30 a.m. who appeared to be confused and noted with an abrasion to his forehead due to a fall he sustained while walking. The DON stated the doctor offered to help Resident #1 as Resident #1 stated he lived nearby. The DON stated that when Resident #1 could not say where he lived, the doctor drove Resident #1 to a local emergency room at approximately 9:00 a.m. The DON stated at that time, Resident 1's responsible party, doctor, and local law enforcement had already been notified, and police immediately located Resident #1 at the emergency room. The DON stated the facility was notified Resident #1 was located and at approximately 9:10 a.m., the ADON arrived at the emergency room to stay with the resident. The DON stated Resident #1's family was notified and they arrived at the emergency room shortly after. The DON stated Resident #1 was examined and did not have any other injuries other than the abrasion. The DON stated Resident #1 was discharged from the emergency room and arrived back at the facility at approximately 12:00 p.m. that same day. The DON stated Resident #1's wander guard was checked and was functioning properly along with the wander guard door alarm located in the lobby. The DON stated HK A was suspended pending investigation and had a one-to-one in-service on wandering residents and elopement with HK A. The DON stated HK A had elopement training upon hire as well. The DON stated all staff were in-serviced on wandering residents, identifying exit seeking behaviors, and conducted random elopement drills with all staff during various shifts. The DON stated staff could not return to work until all the in-services were completed. The DON stated all departments, including housekeeping and dietary, were in-serviced and were made aware of what residents had wander guards and what to do in case exit seeking behavior was identified. The DON stated Resident #1 was alert, able to state his name, ambulatory and primarily required supervision. The DON stated the facility had interventions in place to prevent Resident #1 from eloping, including the use of a Wander Guard and daily checks to ensure it was functioning properly. The DON stated the incident occurred early on a Sunday morning when there was minimal traffic. The DON identified the potential risks associated with the resident leaving the facility as sustaining a fall.In an interview on 08/13/26 at 11:07 a.m., HK A stated at approximately 8:03 a.m. she was working near the nurse's station near the front lobby when she saw a man waving at her and motioning to be let out the front door. HK A stated she thought the man was a visitor, entered the door code and let the man out. HK A stated she went back to work when at approximately 8:06 a.m. she realized the facility initiated a code pink and immediately informed staff that she let someone out the front door who she thought was a visitor and did not know if that could be who they were looking for. HK A stated after a head count was conducted, it was identified that Resident #1 was missing. HK A stated she went outside the facility and started searching for Resident #1 until the facility was notified that Resident #1 was located at a local emergency room. HK A stated she was suspended pending investigation and was in-serviced to not open the door for anyone and participated in elopement drills. HK A stated only nurses are allowed to let anyone out so that they could verify if that person was a resident or not. HK A stated she was also in-serviced on all residents who wander and wear wander guards and to identify exit seeking behavior. In an interview on 08/13/26 at 11:27 a.m. CNA B stated on 07/26/26 at approximately 8:06 a.m. she was taking Resident #1's breakfast tray to his room when she noticed he was not in there. CNA B stated that was unusual, because Resident #1 was always in his room waiting for breakfast. CNA B stated she checked the restroom, and when she realized he was not in there either, she informed her partner CNA C, and they immediately notified staff that Resident #1 was missing. CNA B stated they immediately initiated a code pink and a head count on all residents was initiated. CNA B stated Resident #1 was the only resident missing. CNA B stated staff searched for Resident #1 until they received a call that he was located.In an interview on 08/13/26 at 11:38 a.m., the ADON stated Resident #1 was aware of his surroundings, was easily redirected, and had not displayed exit seeking behaviors prior to the incident. The ADON stated when the facility was notified that Resident #1 was at the emergency room, she left the facility and went to stay with Resident #1 as he was evaluated. The ADON stated Resident #1 had an abrasion to his forehead due to an apparent fall, but no other injuries were noted. The ADON stated Resident #1 was discharged from the emergency room and arrived back at the facility at approximately 12:00 p.m. The ADON stated she did an assessment of the resident, and it appeared he was at his baseline physically and emotionally. The ADON stated Resident #1was placed on one-to-one monitoring out of precaution for approximately 72 hours. The ADON identified the potential risks associated with Resident #1 leaving the facility unsupervised as being involved in a fall and sustaining an injury.In an interview on 08/13/26 at 11:59 a.m., the ADM stated, at the time of the incident, whenever the front door code was entered, it would disarm the wander guard system. The ADM sated Resident #1 was not close enough to the door on the morning of 07/26/26 to set off the alarm. The ADM stated the MD was checking the wander guard door alarm weekly, and provided the maintenance logs which were verified. The ADM stated at the time of the incident, Resident #1's wander guard was functioning properly, and staff checked all wander guards daily to ensure those were functioning properly as well. The ADM stated elopement drills were conducted with all shift at random times. The ADM stated the facility had gone to great lengths to ensure there had been no elopements since the year 2024 when he took over as the Administrator, and unfortunately, the incident was human error. The ADM stated, after the incident, the alarm company came to the facility and adjusted the wander guard door alarm system. The ADM stated when the door code was entered, the wander guard alarm system would alarm and will not stop. Record review of the facility's Elopement Response & Exit Seeking Management policy dated January 2023 reflected: Guideline:A.Elopement Response: Unable to locate resident1.If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises.2.Conduct a head count of all residents to validate safety.3.If the resident is not located after the initial interior and exterior search, notify Administrator/DNS. 4.Confirm all doors and windows are secured.5.Inspect all door locking systems and door alarms to include any type of exit seeking alarm devices to validate functionality and operational.8. Notify local and state authorities as indicated. B. Response following the location of the resident:1. Once located and safety confirmed, conduct an assessment.2. Place resident on enhanced monitoring, consider 1:1 For a specified time as needed to ensure the safety of resident or consider placement in secured unit for continued monitoring and safety. The IDT should review and determine the continued need for additional monitoring efforts. C. Additional Action Responses:1. The resident will be assessed by the IDT to include but not limited to the physician, nursing, social service, and mental health provider member. 3. Validate that a new Exit Seeking Risk Assessment has been completed post event.5. Conduct an in-service to re-educate team members on exit seeking behaviors, interventions to prevent exit seeking, proactive measures to maintain the safety of our residents, should exit seeking behaviors occurs.6. Update the plan of care accordingly. Record review and verification of the corrective action implemented by the facility beginning on 08/13/26:A Four-Step Plan was implemented on 07/26/26Immediate Action Taken dated 07/26/26: Resident #1 was immediately identified as missing and the facility's Missing Person protocol was activated. Team members initiated an immediate search of the building and surrounding areas. Administrator, Director of Nursing and leadership team were notified immediately. Verified through various staff interviews that the ADM and DON were notified of the incident dated 07/26/26. Resident #1's responsible party, local authorities, and attending physician were notified. Verified through various staff interviews on 08/13/26. Resident was safely located and transferred to the hospital for evaluation, ADON remained with Resident #1 throughout the emergency department evaluation to ensure continuity of care and provide updates to the family and healthcare providers. Resident #1 returned to the community and was assessed by licensed nursing staff. Verified through interviews with the DON, ADON, and record review the facility's incident investigation on 08/13/26. A complete inspection of all exit doors, Wander Guard receivers and alarm systems was completed with no equipment malfunction identified. Verified through interviews with the Administrator, DON, record review and observation of functioning front lobby's wander guard alarm system and all exit doors on 08/13/26. Resident #1's Wander Guard was verified to have been in place and functioning appropriately. Immediate one-to-one education was completed with the team member regarding resident identification, exit door security, and the expectation that no resident is allowed through an exit door without nursing authorization. Verified through various staff interviews and record review of HK A's in-service on 08/13/26. Nurses inspected all residents noted with Wander Guard devices and validated that 100% were in place on the identified resident(s) and functional. Verified through various staff interviews and record review of residents' daily wander guard functionality tests on 08/13/26. Administrator and Maintenance director immediately conducted safety inspections of all exit doors, alarms on doors, and Wander Guard systems to ensure proper functioning and safety. Outcomes revealed no negative outcomes. Verified through staff interviews with Administrator, DON, observation of functioning front lobby's wander guard alarm system, and record review the weekly maintenance logs starting on January 01/06/26 on 08/13/26. Event timeline and interviews commenced, and investigation commenced. Administration/Social Worker/Director of Nursing/Designee to conduct staff interviews to identify concerns of exit seeking behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated to ensure appropriate interventions are in place. Verified through various staff interviews and record review of residents' plan of care on 08/13/26.Outcome: Continue with 6 residents with Wander Guard. Verified through interview with the DON and record review of a list of residents with wander guards on 08/13/26. As a precautionary and reinforcement measure, Regional Nurse conducted re-education to the Director of Nursing and Administrator regarding:o Missing Person Response & Elopement/Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol.o Identifying and Responding to Triggers to Prevent Elopement and Behaviors.o Preventing, Identifying and Reporting Abuse and Neglect.Verified through interviews with the Administrator, DON, and record review of in-services on 08/13/26.System Response: The interdisciplinary team completed a root cause analysis and determined the resident exited after a non-clinical team member unintentionally opened the exit door believing Resident #1 was a visitor. Verified through interviews with the Administrator and DON on 08/13/26. Resident #1's care plan, Kardex, Elopement Bidner, Wander Guard status and supervision interventions were reviewed and confirmed to be current. Verified through interviews with the DON, record review of residents' plan of care, Kardex, and the Elopement Binder on 08/13/26. The facility reviewed the process for controlling secured exits and reinforced that all team members, regardless of department, are responsible for preventing unauthorized resident exits. Exit door monitoring expectations and responses procedures were reinforced with all departments. Verified through various staff interviews on 08/13/26. Community leadership completed an audit of all residents identified as exit-seeking to verify:o Wander Guard present and functioningo Care plan updatedo Elopement binder accurateo Appropriate supervision interventions in placeVerified through interviews with the Administrator, DON, various staff, observation of staff performing functionality tests on resident wander guards, record review of the Elopement Binder, and residents' plan of care on 08/13/26.Mandatory Education/Retraining: Administrator/Director of Nursing/Nurse Manager Designee conducted retaining to all team members prior to assuming next shift, all full-time, part-time, and any staff on leave and PRN were educated/trained prior to working next shift, and newly hired nursing staff will receive the retraining during orientation, and prior to assuming their work assignment. Elopement Prevention and Missing Person Response Resident identification before opening secured exit doors Responsibility of every employee to stop and redirect residents approaching exit doors Wander Guard awareness and purpose Documentation and reporting expectations following any elopement or attempted elopement ANE, Abuse and Neglect identifying/preventing and reporting. Additional one-to-one education completed with the involved housekeeping employee. Competency validation by return demonstration and verbal questioning.Verified through interviews with the Administrator, DON, various staff interviews, and record review of in-services/training documentation on 08/13/26. In-services began on 07/26/26 and are on-going. Additional Training for Licensed Nurses Specific Responsibilities: Nurse's responsibility for conducting a thorough assessment to include the new admission assessment and completing required documentation. Nurses' responsibility ensuring that the process for assessing and identifying resident(s) with exit seeking behaviors or identified risk for exit seeking/elopement. Thus, immediately implementing appropriate interventions to include but not limited to placing the Wander Guard device and adhering to the process of monitoring placement/functionality, ensuring the proper monitoring orders are in place, implementing 1:1 monitoring until further instructed by the DON/Nurse Manager/Administrator. At no time should a newly identified resident at risk for exit seeking/elopement should not have safety interventions as mentioned implemented or be left unattended. Nurses' responsibility for initiating and managing a Missing Person Response & Elopement/Exit Seeking Risk and Proper Response to Missing Resident Elopement Protocol. Administrator/Director of Nursing/Designee will conduct Elopement/Missing Person Response Drills on all shifts initially, then random shifts to identify competency or to identify additional education is needed. Verification interviews beginning on 08/13/26 at 10:00am, HK A, CNA B, CNA C, LVN D, CNA E, LVN F, the dietary aide, CNA G, HK H, RN I, and the Receptionist from various shifts were able to identify the elopement process, wandering residents, knowledge of only nursing staff opening the front lobby door besides receptionist, identify code pink as missing resident and the different types of abuse and neglect. Monitoring Response: Administrator/Social Worker/Director of Nursing/Designee will conduct random daily rounds 3 days a week, to validate the safety and well-being of our residents. Findings will be documented on a monitoring tool and retained in the designated survey binder. Verified through interviews with the DON and record review of the survey binder on 08/14/26. DNS/Designee will conduct random audits (3 times weekly) of residents identified as elopement risks to verify Wander Guard placement, functionality and Elopement Binder Accuracy. Random exit door observations on all shifts to ensure staff appropriately challenge and redirect residents approaching exits 2 times a week. Results will be reviewed during QAPI, and additional corrective actions will be implemented if trends are identified for the next 2 months. QAPI Monitoring: Director of Nurses/Assistant Director of Nurses review during Clinical Morning Meeting all new admissions/readmissions, 24-hour report, progress notes, SBARS/COCs and risk management reports to identify Wandering/Exit seeking/Elopement risks behaviors and concerns. This will take place daily 5-7 days a week for the next 2 months. Findings will be documented on a monitoring tool and retained in the designated survey binder. This plan and all education and auding tools will be placed in a binder and kept with the Administrator or Director of Nursing. This plan will remain in place for the next 2 months and the findings will be reported to the QAPI committee during a monthly meeting for the next 2 months. The QAPI committee will determine compliance or identify a need for additional training.

Based on observation, interviews and record review, the facility failed to ensure the pass out of resident food was done in accordance with professional standards for food service safety for 1 of 10 residents and the storage of food in accordance with professional standards for food service safety1 of 1 unit refrigerators (resident refrigerator RR #1), 1 of 1 resident freezer (resident freezer RF #1) and 1 of 1 resident walk in pantry( walk in pantry WP#1) reviewed for storage, preparation and sanitation. The facility failed to ensure items in the refrigerators were covered and sealed to prevent exposure to air and cause cross contamination. The facility failed to ensure food items in the resident's freezer were covered or sealed to prevent exposure to air and cause cross contamination. The facility failed to ensure CNA G did not grab resident's' cup and bowls by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. These failures could place residents at risk of foodborne illnesses.Findings included:Record review of Resident# 26 face sheet dated 07/15/2026 indicated a [AGE] year old male with diagnosis of anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities)rheumatoid arthritis(is a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness, but it can also impact other body systems), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), dementia (A group of thinking an social symptoms that interferes with daily functioning), and cognitive communication(a condition where communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem).In record review of Resident #26 MDS indicated a BIMS summary score 5 which indicates severe cognitive impairment; suggests significant cognitive decline, functional abilities for eating are substantial/ maximal assistance. Observation and Initial tour of the kitchen on 07/14/26 at 8:45 a.m., revealed in the facility freezer a box of sausage patties uncovered exposed to air causing them to be exposed to the air and causing cross contamination. Observation of the facility refrigerator revealed a bag of cheese, a container of cooked chicken, and a package of corn tortillas left unsealed and exposed to air and causing cross contamination. Observation of the dry pantry revealed a loaf of bread undated and a bottle of pancake syrup open in use with no open date. Observation of dining services in the facility dining room CNA G was seen grabbing the drink glass of Resident #26 and help him drink from it. In observation of the feeding of Resident #26 with help from CNA #26 she did not remove the tray that was used to bring his food to the table. In an interview on 07/14/26 at 2:41 PM with Resident #26 the resident was not able to answer questions as he had trouble communicating and when asked if he had ever became sick with the food from the facility he simply nodded no. In an interview 07/15/2026 at 11:25 AM with DA E she stated is wan not safe to have unsealed food items in the refrigerator and freezer as it can become contaminated and if served to residents could make them sick. DA E stated all items in the dry pantry should be labeled with and expiration date and or an open date. DA E stated cooking or using an expire expired item can make a resident ill. DA stated it was every kitchen staff member's responsibility to make sure all items are dated, sealed, and not expired in the refrigerator, freezer and dry pantry. DA E stated the last in-service was about a month ago for storage and they have different in-services every month. In an interview on 07/15/2026 at 11:32 with DA F AM she stated that all food stored in the dry pantry should be dated with either the expiration date or open date and all food stored in the refrigerator or freezer should be labeled with date entered and seal to protect the food from cross contamination. DA F stated it was the entire kitchen staff responsibility to make sure all the food was stored and labeled properly in the dry storage room, freezer, and refrigerator. Da F stated the last in-service she received was last month. In an interview 07/15/2026 at 11:16 AM with the DS was she stated using expired food items can diminish the quality of the food because it is not at its best. The DS stated using expired food items can make a resident sick especially a compromised resident. The DS stated all food stored in the freezer, refrigerator and dry storage room food items should be correctly sealed close, have an open on date, the expiration date with month and year, and use by date. The DS stated the bag of cheese, sausage patties, corn tortillas, and container of chicken must have either been just used for breakfast and not closed correctly. The container of chicken had just been stored the day before and not closed correctly and all items that were open were thrown away immediately. The DS stated she does inventory every two weeks with all food and the bread had not been used and pancake syrup had been used and was overlooked and not dated. The DS stated she has monthly meetings and she has trainings on different areas of the kitchen that need attention. In an interview07/16/2026 at 2:34 PM with CNA G she stated she was nervous when handing out drinks and resident food bowls and cups did not realize she was gabbing from the lid. CNA G stated the correct way to grab a cup bowl or glass is by the side of handle and reason one does not grab a cup, bowls and glass from the lid was because the lid becomes contaminated which can make a resident become ill. In record review of the policy and procedure for food storage was undated and stated To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedured. To ensure freshness, store opened and bulk items in tightly coved containers. All containers must be labeled and dated. Refrigeratorsd. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Freezers e. store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #3, Resident #17, Resident #92) of 6 residents reviewed for infection control. 1. The facility failed to implement the required elements for transmission-based precautions (specialized infection control measures used in addition to Standard Precautions for patients known or suspected to be infected with highly transmissible pathogens), including signage for Resident #3. 2. The facility failed to ensure the WCN placed a barrier between Resident #92's wound and his brief when she performed wound care on 07/15/26. 3. The facility failed to ensure MA D disinfected the blood pressure cuff before use for Resident #17 on 07/16/26. These failures could place residents at risk for healthcare associated with cross-contamination and infections. The findings included: 1. Record review of Resident #3's face sheet dated 07/14/26 revealed a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), dementia (a progress disorder that impairs the thought processes, such as memory, thinking, reasoning, and decision-making), pressure ulcer of right heel, stage 3 (a full-thickness skin loss where fat is visible, but muscle, tendon, and bone are not), pressure ulcer of left heel, unstageable (a severe wound where the true depth is hidden by dead tissue), Unspecified Escherichia coli as the cause of diseases (intestinal bacteria that cause diseases elsewhere in the body), and extended spectrum beta lactamase resistance (when bacteria develops enzymes that destroy a wide range of common antibiotics). Record review of Resident #3's Care Plan initiated on 03/21/26 revealed a focus of an unstageable pressure ulcer to left heel and a Stage 3 pressure ulcer to the right heel. Interventions included ISOLATION: CONTACT ISOLATION PRECAUTIONS (infection control measures used to prevent the spread of germs spread through direct or indirect touch): Ensure infection site is contained prior to leaving room, date initiated 06/24/26. The Care Plan also revealed a focus of, at risk for infection, r/t compromised medical condition. Interventions included, administer antibiotic as per MD orders and Isolation Precautions as clinically indicate, date initiated: 06/24/26. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 3 which indicated Resident #3 was severely cognitively impaired. The MDS also revealed an active diagnosis of a Multidrug-Resistant Organism (MDRO) (a germ that is resistant to many antibiotics) infection. Record review of Resident #3's Order Summary Report as of 07/14/26 revealed an order for ISOLATION: CONTACT ISOLATION PRECATUIONS. The order date was 06/24/26 with a start date of 07/13/26 and an end date of 07/30/26. During an observation on 07/14/26 at 10:40 AM, signage on Resident #3's door indicated EBP (infection control measures used to prevent the spread of multidrug-resistant organisms (MDROs)) precautions. During an interview on 07/14/26 at 10:45 AM, LVN A stated Resident #3 was on EBP (precautions because of the wounds to his heels. LVN A stated that she was not aware of any changes in transmission-based precautions. LVN A stated she needed to ask ICS if there had been changes. During an interview on 07/14/26 at 10:53 AM, LVN A stated Resident #3 needed to be on contact precautions, not EBP precautions. LVN A stated ICS had not specified to her that there needed to be a sign to change outside Resident #3's door. LVN A stated the sign outside Resident #3's door needed to indicate contact precautions because there was an order for it due to Resident #3's wounds. LVN A stated it was important to have the correct sign on Resident #3's door for protection of the resident and the roommate; if the incorrect sign was on the door, there was a risk of contamination and more infection. During an interview on 07/14/26 at 12:02 PM, the ICS stated that the contact precautions order for Resident #3 had been in place since 07/13/26. The ICS stated she missed the sign change; there should have been a contact precautions sign instead of the EBP sign. The ICS stated it was important to have the correct sign on Resident #3's door because it gave staff a heads up that the resident in the room is on contact precautions and that the correct PPE (special equipment you wear to create a barrier between the person wearing it and germs such as exam gloves, infection control apparel, face masks) needed to be worn inside the room. The ICS stated that if the proper precautions were not taken, Resident #3 was at risk of contamination of other body parts or a risk of contamination of other residents. During an interview on 07/16/26 at 2:56 PM, the DON stated doctor's orders indicating any type of infection were reviewed daily by ICS. The DON stated ICS was responsible for changing the sign on Resident #3's door but missed it. The DON stated that he did spot checks to ensure the correct signage was on the door but had not yet checked #3's door. The DON stated he had already conducted an in-service (teaching) regarding contact precautions and what PPE needed to be worn when entering Resident #3's room. The DON stated it was important to have the correct sign on the door because it prevented spreading infection into the building. 2. Record review of Resident #92's admission record dated 07/16/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), chronic kidney disease (when the kidneys are damaged and can't filter blood as well as they should), cognitive communication deficit (difficulty with communication), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), hypertension (high blood pressure), left below the knee amputation (surgical removal of the lower part of the leg), peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke). Record review of Resident #92's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7 which indicated he had severe cognitive impairment. Record review of Resident #92's physician order summary report reflected the following order: Cleanse stage 4 pressure ulcer with normal saline, pat dry, apply Santyl (ointment used to clear dead tissue from chronic skin ulcers and severe burns), pack with calcium alginate dressing (when placed on a draining wound, the calcium fibers of this highly absorbent, seaweed-derived wound pad react with wound fluid to form a protective, non-stick gel that maintains a moist healing environment and allows for painless, residue-free removal) and cover with Optifoam (foam wound dressing that absorbs fluid and creates an optimal healing environment) ordered on 01/21/26. During an observation on 07/15/26 at 2:49 pm the WCN rolled Resident #92 onto his left side, pulled half of his brief down and tucked under left hip, exposing his sacrum (the triangular bone at the base of the spine) to facilitate wound care. The WCN did not place a barrier between Resident #92's skin and his brief. When the WCN was finished with Resident #92's wound care, he was rolled back onto his back and the WCN resecured his brief. This observation reflected Resident #92's brief was very wet with urine as the yellow stripes in front were blue and the front of the brief was bulging. The WCN left Resident #92 in a wet brief after the wound care was completed. In an interview on 07/15/26 at 3:40 pm, the WCN stated there should have been something placed between the wound and the bed or brief to prevent contamination of the wound when wound care was performed. The WCN stated not putting something between the resident's wound and his brief could cause cross contamination of the wound and could lead to infection or hospitalization. The WCN stated she did not notice Resident #92's brief was wet when she resecured it after wound care. In an interview on 07/15/26 at 4:00 pm the ICS stated the WCN should have placed a barrier between the resident's wound and the brief when she performed wound care to prevent possible contamination of the wound. The ICS stated the WCN had an infection control and wound care in-service and check off on 06/24/26. She stated infection control in-services were done monthly and as needed and the last one was earlier this month. In an interview on 07/15/26 at 4:20 pm, the DON stated when wound care was performed, it was important to place a barrier between the wound and whatever surface was below or around the wound to prevent accidental contamination of the wound which could lead to infection or hospitalization. He stated infection control in-services were done monthly and as needed and the last one was within the last two weeks. 3. Record review of Resident #17's admission record dated 06/17/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included atherosclerotic heart disease (buildup of fats and other substances in and on the artery walls of the heart causing decreased blood flow and/or clots), bradycardia (slow heartbeat), chronic kidney disease (when the kidneys are damaged and can't filter blood as well as they should), hypertension (high blood pressure), and type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke). Record review of Resident #17's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. Record review of Resident #17's physician order summary report reflected the following orders: Metoprolol Succinate ER (Extended Release 24 Hour) Oral Tablet 100 MG. Give 1 tablet by mouth one time a day related to Atherosclerotic heart disease. Hold if SBP less than 100 or HR less than 60 bpm ordered on 02/07/25. Valsartan Oral Tablet 320 MG. Give 1 tablet by mouth one time a day related to hypertension. Hold if SBP less than 100 ordered on 02/07/25. During observation of medication administration on 07/16/26 at 9:57 am, MA D did not disinfect the blood pressure cuff between resident uses before using it to check Resident #17's blood pressure. In an interview on 07/16/26 at 10:09 am, MA D stated she was supposed to wipe the blood pressure cuff down between residents. She stated it was important to disinfect the blood pressure cuff because of infection control. MA D stated if the blood pressure cuff was not disinfected between residents it could cause inadvertent cross contamination or infections to spread. MA D stated she did not disinfect the blood pressure cuff because she was nervous and forgot. She stated in-services on infection control were once a month and the last in-service which included medication pass and disinfecting equipment was about a week ago. In an interview on 07/16/26 at 3:02 pm, the ICS stated the blood pressure cuff was supposed to be wiped down and air dried between resident use. She stated it was important to prevent indirect infection. The ICS stated not disinfecting the blood pressure cuff could cause cross contamination or infection and lead to hospitalization or even death. She stated in-services on disinfection of resident use equipment were done monthly and as needed and the last one was last week. Record review of the WCN's Licensed Nurse Competencies Checklist dated 06/24/26 reflected the WCN met competencies for Infection Control-Dressing change: clean and sterile. Record review of the facility's Infection Prevention and Control policy dated 03/13/19 and revised 04/2024 reflected in part: Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Staff Responsible: Includes all staff to include direct and indirect care functions, contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the community, and students in the community's nurse aid training programs or from an affiliated academic institution. 9. Prevention of Infection (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation; (9) implementing appropriate isolation precautions when necessary; and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC); (10) disinfecting multi-patient use equipment or supplies after each use and stored appropriately; 10. Isolation Precautions Implementation of and discontinuation of isolation precautions should be in collaboration with the licensed nurse, physician, nurse practitioner, medical director and if indicated through collaboration with the state or local health department. The following will be considered and reviewed when determining appropriate isolation precautions: CDC Resources for Isolation Precautions. 11. Categories: Types of Isolation Precautions Transmission-based isolation precautions have been adopted by our community to guide team members to have appropriate isolation techniques implemented when necessary. There are three types of transmission-based isolation precautions: Airborne, Contact, and Droplet. In addition to Standard Precautions, Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. a. Examples of infections requiring Contact Precautions include, but are not limited to: Gastrointestinal, respiratory, skin, or wound infections or multidrug-resistant bacteria; EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. 12. Implementation of Isolation and/or Precautions: Post clear signage (link is to CDC's example of precaution door signage) on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) Additional Considerations: Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Record review of the facility's Medication Administration policy dated 03/2019 and revised 01/2024 reflected in part: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose (e.g., pulse with digitalis).

Based on observation, record review, and interview, the facility failed to promote resident independence and dignity while dining for one out of ten residents observed while dining. The facility failed to ensure the dignity of Resident #26 while dining by not removing the tray the food was carried on to his table by staff. This failure could place residents who their meals in the dining room, at risk for lack of supervision, assistance, and respect. Findings included: Record review of Resident# 26 face sheet dated 07/15/2026 indicated a [AGE] year old male with diagnosis of anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities)rheumatoid arthritis(is a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness, but it can also impact other body systems), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), dementia (A group of thinking an social symptoms that interferes with daily functioning), and cognitive communication(a condition where communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem). In record review of Resident #26 MDS indicated a BIMS summary score 5 which indicates severe cognitive impairment; suggests significant cognitive decline, functional abilities for eating are substantial/ maximal assistance. In an interview on 07/14/26 at 2:41 PM with Resident #26 he was hard to understand the answer to the questions as he had trouble communicating. When the state surveyor asked to node yes or no to the question of if he wanted the food to stay on his tray he nodded no and did it bother him that was only resident with food that remained on the tray his answer was hard to understand so he just nodded yes. In an interview with CNA G stated the tray is usually removed unless the resident requests the tray remain with his food on the table. CNA G stated the only reason the tray are removed is to make the resident feel more dignified in the dinning area. The dining room should be a homelike environment and the resident is to eat as the resident ate a home. CNA G stated she was in a rush to fed Resident #26 so she forgot to remove the tray. In an interview with the ICS she stated all staff is instructed to remove the tray for each resident, so they feel like they are eating at their home with dignity. The ICS stated when people ate at a home they do not have trays and the residents are to have a homelike environment with silverware and napkins to keep residents clean. The ICS stated no resident should be made to feel undignified or disrespected while in the facility. The ICS stated she makes unannounced visits to the dining room to observe all policy and procedures for dining and resident rights are being implemented. In record review of resident rights policy and procedure dated 02/2017 Statement of Resident Rights stated the community should educate, encourage, and honor the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. Residents/Patients do not give up their rights when entering a [NAME] Community. 4. To be treated with courtesy, consideration and respect; Exercise of Rights Residents will have the right to exercise their rights as residents of the community and as citizens or residents of the United States. Residents will have the right to be free of interference, coercion, discrimination, and reprisal from the community in exercising his or her rights. The community will provide autonomy and choice to all residents, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the communities' rules, as long as those rules do not violate a regulatory requirement.

Based on observation, interview and record review the facility failed to provide a safe environment for residents in 2 of 4 hallways (Verde and [NAME]) with 2 of 2 unlocked doors in [NAME] hallway and 1 out of 4 unlocked doors Verde Hallway for non-residential rooms. 1.The facility failed to ensure a safe environment for the residents of the [NAME] Hall by not securing the clean linen closet door in the was able to be locked properly after use and lead to the possible contamination of the clean linen by a resident. 2.The facility failed to ensure a safe environment for the resident of the [NAME] Hall by not securing the door of the storage room with trash, dirty linen and a sink was properly closed shut and locked after use. 3.The facility failed to ensure the shower room door in the Verde Hall waslocked which contained a hand sanitizer, mechanical lift, and a large wheel chair. These failures have the potential to result in injury to residents.The findings included: In the initial facility observation on 07/14/26 at 9:53 AM the [NAME] Hall revealed the only storage room door was left unlocked containing a trash bin, a linen bin, and a sink with no staff in the hallway to monitor. The storage room contained a trash bin, a linen bin, and a sink with and could be a hazard for a with a resident with a cognitive mental condition which can result in the resident possibly ingesting items from trash and could become contaminated with biohazards and spread them among other residents. Observation of [NAME] Hall revealed a linen closet unable to close due to the lock hole covered with paper and tape which a resident could result in the contamination of clean linen. In observation of the shower room in the Verde Hall it was left unlocked which contained a large wheelchair, a Hoyer lift and hand sanitizer which a resident with mental cognitive issues could be ingested and result in harm. In an interview on 07/14/2026 at 1:45 PM with the maintenance man he stated he usually does a monthly check on all the doors to all in the facility to make sure they are all in working condition and can be locked. The maintance man stated the linen closet door in the [NAME] Hall with the lock hole covered with paper and tape must have occurred recently he was not aware it was covered and could not say who did it as was used by the CNA's, housekeeping, and at times nursing. The Maintance man stated storage room in the [NAME] Hall was just not locked after use but it was able to be locked. The shower room in the Verde room was not locked after use, but it could be locked with a key. The Maintenance man stated the administrator has decided to put a pad lock on all doors that need to be locked for resident safety. In an interview on 07/14/26 at 4:53 pm, the Adm stated they were changing the doorknob to that unlocked shower room in the Verde Hall was being changed to a combination lock today. The Adm stated the door to the shower room was unlocked because it was a key lock and maybe the key got lost. The Adm stated it was not being used as a shower room, but as a storage room. The Adm stated if a resident got into the shower room, they could have drank the hand sanitizer that was on the counter leading to the resident getting sick and possibly having to go to the hospital. The Adm stated he did not know about the linen closet lock hole being covered and could result in clean linen getting contaminated. The linen closet door or any door int he facility should not have had paper in the lock hole preventing the door to stay shut and locked. The Adm stated he was not aware the storage room in the [NAME] room was not being locked but will be changed to a pad lock today as well. The Adm stated a resident with cognitive mental issues could become sick if they wondered in and tried to eat trash which could result in the resident in hospital and can lead to death. The Maintenance man will continue to make checks on the conditions of locks on a monthly basis, and the staff will be in serviced on make sure all non-resident doors are locked after use. Record review of the facility's Physical Environment dated 01/2023 stated Environmental issues the community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. Preventative maintenance The community has a preventive maintenance program that ensures that all essential mechanical, electrical, and patient-care equipment is in safe operating condition.The preventive maintenance program is characterized by the following: It is ongoing and under the direction of a qualified and experienced maintenance director. Routine testing and maintenance of all equipment is scheduled, and records of the testing and maintenance are kept in an organized manner.

Number of residents sampled: Number of residents cited: Based on observations, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 (Resident #38) of four residents reviewed for physical environment.The facility failed to ensure Resident #38 had a working call light in the room.This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.Findings included:Record review of Resident #38's admission Record dated 07/16/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (nerve damage caused by prolonged high blood sugar), Anxiety Disorder, Essential (Primary) Hypertension (high blood pressure with no identifiable medical cause), and Need for Assistance with Personal Care.Record review of Resident #38's quarterly MDS assessment dated [DATE] reflected a BIMS score of 5 which indicated he had severe cognitive impairment. Record review of Resident #38's quarterly care plan dated 06/01/26 revealed under interventions/tasks; Remind resident regularly to call for assistance in efforts to prevent falls.During an observation on 07/14/26 at 10:03 am Resident #38's call light was observed to be missing the red button used to press to call for assistance and was not functioning.In an interview on 07/14/26 at 10:05 am Resident #38 nodded yes and said yes when he was asked if he used the call light. He did not answer when he was asked if he knew the call light wasn't working.In an interview on 07/14/26 at 10:08am CNA B said Resident #38 used his call light when he needed assistance. She said she did not know the call light had been broken, but she had rounded frequently to see if he needed anything. She said Resident #38 also sometimes yelled out to call when he needed something or if he needed help. CNA B said call lights were supposed to be within reach of a resident and were supposed to be working. She said if call lights were not working, Resident #38 couldn't get the help he needed. In an interview on 07/14/26 at 10:41 am LVN C said Resident #38 used his call light anytime he needed something or needed help. She said call lights should be working, and she knew his call light had worked yesterday. LVN C said if call lights didn't work, a resident could have a delay in care if they had a medical emergency. In an interview on 07/14/26 at 11:26 am the MS said when a call light doesn't work, the nurses or cna's would tell him or input the work order request in the facility's system. The MS also said each department head was assigned certain resident rooms that were checked every morning and if something in the rooms need repairs, or wasn't working, they would let him know. The MS said he checks the call light system every month to make sure it was working. In an interview on 07/14/26 at 4:31 pm the ADM said all residents had department heads/managers assigned specific resident rooms. He said the managers were responsible for rounding or checking each resident room every morning to make sure residents were fine, rooms were clean, call lights were within reach. He said if call lights or anything needed to be fixed, they fixed or replaced it as soon as possible. The ADM said he was responsible for checking Resident #38's room. He said he didn't get a chance to check it earlier because the state surveyors entered the building and he started attending to them. He said Resident #38 also called out if he needed anything. When asked, the ADM did not specify, he only said anything could have happened if Resident #38's call light had not worked, and he needed to call for assistance.Record review of the facility's Routine Resident Care policy dated 03/14/19 and revised 01/2024 reflected in part:Compliance Guidelines:Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene and safety. Care is taken to maintain resident safety at all times.GUIDELINES:.9. Resident call lights should be answered timely and resident requests are addressed, if permitted. Call lights should be placed within easy reach of the resident.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 4 of 4 residents (Resident #7, #24, #25, and #26) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting for Resident #7, #24, #25, and #26. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Findings included: Record review of Resident #7 ' s Authorization Request for NFSS most recent form was dated and submitted 11/05/2020. Record review of Resident #7 ' s face sheet, dated 05/28/25, revealed a [AGE] year-old male with an admission date of 06/10/2019. His diagnoses included Unspecified Intellectual Disabilities, Mental Disorder, Functional Quadriplegia (the inability to move due to a disability or physical condition, not related to spinal or brain damage), Legal Blindness, and Mood Disorder. Record review of Resident #7 ' s Quarterly MDS Assessment, dated 03/02/25, revealed no BIMS score as resident was rarely or never understood. The MDS also revealed Resident #7 had a memory problem, difficulty focusing attention, and a mental disorder, not otherwise specified. Resident #7 was also completely dependent in hygiene and toileting. Record review of Resident #7 ' s care plan, initiated 09/17/24 and revised 05/22/25, revealed Resident #7 was at risk for self-care deficits, falls, skin concerns, pain, infections, nutritional and hydration concerns, and emotional distress. Resident #7 ' s interventions included coordinating all essential medical and/or mental health visits, provide care and safety checks throughout the shift, provide nutrition and hydration within prescribed diet, activities as tolerated, and collaborate with IDT and resident representative. Record review of Resident #7 ' s PASRR progress note, dated 03/14/25, revealed quarterly meeting was held with Border Region PASRR Habilitation Coordinator. No changes were noted or reported at that time. Record review of Resident #7 ' s progress note, dated 05/14/25, revealed Quarterly/Monthly meeting held with the PASRR Habilitation Coordinator, and no changes were noted or reported. Record review of Resident #7 ' s Habilitation Service Plan, dated 03/14/25, revealed the Habilitation Coordinator met with the IDT regarding Resident #7 ' s renewal of services. Recommendations included continued independent living skills for one hour, twice per week, for 90 days. Record review of Resident #7 ' s PASRR PCSP Form, quarterly meeting, dated 03/14/25, revealed resident was PASRR positive for IDD. Attendance included Resident #7, LIDDA - Habilitation Coordinator, MDS nurse, and Provider Supervisor. Durable medical equipment and specialized service recommendations included customized manual wheelchair, habilitation coordination, and independent living skills training. In an interview on 05/28/25 at 4:30 PM with the PASRR Program Specialist, she stated if the NFSS PASRR specialized services were recommended at the IDT meeting but were not initiated within 20 business days following the date the services were agreed to in the IDT meeting, the resident would not receive a PASSR specialized service. She stated the facility was given a specific timeframe to submit the NFSS requests to avoid a regulatory complaint. The facility did not meet this timeframe. According to the PASRR Program Specialist, the last IDT meeting forms submitted for Resident #7 were 06/07/24. In an interview on 05/29/25 at 8:00 AM with the DON, he stated he was only able to find Resident #7 ' s PASRR level 1 from 2019, Resident #7 ' s NFSS form from 2020, and Resident #26 ' s NFSS form from 2021, but he was unable to find a current or recent NFSS form for any of the Residents #7, #24, #25, and #26 reviewed for PASRR. He stated there definitely would not be one after July 2024 since they had not had a current NPI number to be able to submit or upload forms due to the fact that the facility had switched ownership in September, 2024, and they were still waiting to get the NPI number. He stated they had submitted all the documents to for the NPI, but they were still waiting for it to be approved. Record review of Resident #26 ' s face sheet, dated 05/28/25, revealed a [AGE] year-old female with an admission date of 01/17/2018. Her diagnoses included Cerebral Palsy (a group of conditions affecting movement and posture caused by brain damage before birth), Epileptic Seizures (caused by abnormal electrical activity in the brain, leading to uncontrolled bursts of activity that could affect sensation, behaviors, awareness, and muscle movements), Unspecified Intellectual Disabilities, Functional Quadriplegia (the inability to move due to a disability or physical condition, not related to spinal or brain damage), and Dysphagia (difficulty swallowing). Record review of Resident #26 ' s care plan, initiated 09/19/24, revealed Resident #26 was at risk for self-care deficits, falls, skin concerns, pain, infections, nutritional and hydration concerns, and emotional distress. Resident #26 ' s interventions included coordinating all essential medical and/or mental health visits, provide care and safety checks throughout the shift, provide nutrition and hydration within prescribed diet, and report any need to re-evaluate specialized services and/or plan of care to service coordinator as well as resident representative. Record review of Resident #26 ' s Quarterly MDS Assessment, dated 04/21/25, revealed no BIMS score as resident was rarely or never understood. The MDS also revealed Resident #26 had a memory problem, severely impaired cognitive skills, difficulty focusing attention, and a mental disorder. Resident #26 was also completely dependent in hygiene and toileting. Record review of Resident #26 ' s Habilitation Service Plan, dated 04/23/25, revealed the Habilitation Coordinator met with the IDT regarding Resident #26 ' s PASRR services. Recommendations included continued independent living skills for one hour, twice per week, for 90 days. Record review of Resident #26 ' s progress note, dated 05/12/25, revealed monthly meeting held with Border Region PASRR Habilitation Coordinator, and no changes were noted or reported. Record review of Resident #26s PASRR and PCSP forms, quarterly meeting, dated 11/15/1924, revealed resident was PASRR positive due to his Spastic Quadriplegic Cerebral Palsy((SQCP). Attendance included Resident #26 LIDDA/Habilitation Coordinator, MDS nurse, and Provider Supervisor. Durable medical equipment(DME) and specialized occupational therapy(OT), specialized physical therapy(PT) and specialized speech therapy OT recommendations included customized manual wheelchair, habilitation coordination, and independent living skills training Record review of Resident #26's PASRR PCSP dated 01/10/25 revealed Resident #26 will continue to receive PASRR services, habilitation coordination, and Independent Living Skills. Resident #24 face sheet dated 05/29/25 reflected a [AGE] year old male who was admitted on [DATE]. Resident #26 records revealed he had a diagnosis Spastic Quadriplegic Cerebral Palsy((SQCP) is a severe form of cerebral palsy affecting all four limbs, resulting in stiff muscles and difficulty with movement and coordination. In record review of Resident #26 physician's order's dated 05/01/2025 and progress report summary dated 05/01/2025 revealed from 12/17/24 and 05/12/2025 no orders for any type of quarterly meeting the resident was noted to be sent to be processed . In record review of Resident #26 care plan revealed the resident was at risk for experiencing discomfort or pain related to cerebral palsy and morbid medical conditions. Resident #24 had chronic health conditions and morbid conditions that had affected my physical function and may further affect my quality of life. Refer to skilled therapy services for strengthening, mobility as well as oxygen conservation techniques as indicated. Resident is considered PASRR positive IDD- intellectual disability or development disorder. Interventions consist of administer my medication to relieve my pain as recommended by my doctor and attempt non-pharmacological interventions to promote comfort. relaxation Record review of Resident #25's admission record revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included conversion disorder with seizures or convulsions (a condition in which emotional or psychological stress causes physical symptoms such as shaking of the body), Down syndrome (a genetic condition that causes intellectual disability and developmental delays), unspecified epilepsy (a neurological condition that causes recurring seizures), and developmental disorder of speech and language (communication disorder that interferes with learning, understanding, and using language). Record review of Resident #25's quarterly MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. The MDS also revealed that Resident #25 was completely dependent on staff for eating, hygiene, toileting, and ADLs. Record review of Resident #25's care plan dated 09/23/24 and revised on 03/11/25 revealed Resident #25 had a self-care deficit, impaired cognitive function, problems communicating needs or wants, and was PASRR positive. Interventions included coordinating all essential medical and/or mental health visits, provide care and safety checks throughout the shift, provide nutrition and hydration within prescribed diet, and report any need to re-evaluate specialized services and/or plan of care to service coordinator as well as resident representative. Resident #25 ' s specialized service was agreed upon DME of a specialized wheelchair. Record review of Resident #25's progress notes revealed notes dated 01/10/25, 03/14/25, 04/09/25, and 05/14/25 which indicated a monthly meeting was held with the [Agency name] PASRR Habilitation Coordinator, and no changes were noted or reported. Record review of Resident #25's Restorative Review dated 02/24/25 revealed a periodic review of Resident #25 ' s restorative programs which included bed mobility and range of motion programs would be discontinued and rehabilitation services would be initiated. Record review of Resident #25's PASRR Level 1 screening dated 09/03/24 reflected there was evidence or an indicator that Resident #25 had an intellectual disability and a developmental disability. In an interview on 05/29/25 at 3:25 PM with the MDS nurse, she stated after reviewing and looking, they were only able to find two NFSS requests for PASRR specialized services forms for all the PASRR reviewed residents, and those two forms found were from 2020. She stated she knew for sure there had not been any NFSS forms submitted since at least July of 2024. She stated the facility continued to have the IDT PASRR meetings, they just were not able to submit or upload any of the forms to the portal because they had not had an NPI number since September of 2024, and prior to that, their systems had crashed in July or August of 2024. Record review of the facility 's policy Specialized Rehabilitative Services, implemented February 2017 and revised January 2023, revealed specialized rehabilitative services were administered by qualified personnel pursuant to a written physician order to ensure the rehabilitative services as prescribed by a physician and to maximize potential outcomes. Specialized rehabilitative services were provided according to the resident ' s assessment and care plan.

Based on interview, observation, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 5 residents (Resident #9) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #9's Midodrine order. 2. The facility failed to administer Resident #9's order for Midodrine as prescribed in May of 2025 by administering Midodrine 8 times outside of physician ordered parameters. These failures could place residents at risk for complications, as well as jeopardize their health and safety. Findings included: Record review of Resident #9's face sheet, dated 05/28/25, revealed a [AGE] year-old male with an admission date of 04/06/2023. Resident #9's diagnoses included End Stage Renal Disease (an advanced stage of Chronic Kidney Disease when the kidneys can no longer filter waste or fluid from the blood), Dependence on Renal Dialysis, Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), Hypertensive Heart and Chronic Kidney Disease without Heart Failure, Atherosclerotic Heart Disease (plaque build up in arterial walls), Peripheral Vascular Disease (disorder of the blood vessels that can involve narrowing, blockage or spasm of the vessel wall). Record review of Resident #9's MDS assessment, dated 03/11/25, revealed a BIMS score of 14, which revealed intact cognition. Record review of Resident #9's care plan initiated 09/18/24 revealed Resident #9 was at risk for cardiac complications such as chest pain, shortness of breath, fatigue, dizziness, poor endurance, poor activity tolerance, and edema. Interventions included administering medications as ordered by the physician and monitoring vital signs as indicated and reporting abnormal findings to the physician as indicated. Another care plan initiated 04/18/25 addressed Resident #9's End Stage Renal Disease and Heart Disease with interventions to administer medications as recommended by the physician and monitor vital signs as indicated. Record review of Resident #9's physician orders started 09/19/24 revealed an active order for Midodrine 5mg, take 4 tablets by mouth every Tuesday, Thursday, Saturday and hold for a SBP greater than 120, but, then, the directions for this same order revealed take 4 tablets by mouth every Tuesday, Thursday, and Saturday. Hold for SBP less than 120. Midodrine is a medication primarily used to treat low blood pressure. Record review of Resident #9's current, clarified physician order started 05/29/25 revealed a clarified order for Midodrine 10mg, give 2 tablets once a day on Tuesday, Thursday, and Saturday. Hold for a systolic blood pressure greater than 120. Record review of Resident #9's MAR for May 2025 revealed Midodrine 5mg, give 4 tablets one time a day every Tuesday, Thursday and Saturday related to End Stage Renal Disease; hold for SBP greater than 120. May 2025 MAR revealed Midodrine was administered incorrectly 8 times. MAR for May 2025 revealed Midodrine was given as follows: 05/01/25 - b/p 160/64 - Midodrine administered by Med-Aide-A 05/03/25 - b/p 118/86 - Midodrine administered - not listed 05/06/25 - b/p 164/50 - Midodrine administered by Med-Aide-A 05/08/25 - b/p 141/53 - Midodrine administered - LVN-E 05/10/25 - b/p 159/72 - Midodrine administered by Med-Aide-A 05/13/25 - b/p 163/67 - Midodrine administered by Med-Aide-A 05/15/25 - b/p 126/55 - Midodrine administered by RN-B 05/17/25 - b/p 118/62 - Midodrine administered - not listed 05/20/26 - b/p 167/82 - Midodrine HELD 05/22/25 - b/p 150/61 - Midodrine Administered by Med-Aide-A 05/24/25 - b/p 120/68 - Midodrine Administered - not listed 05/27/25 - b/p 132/62 - Midodrine Administered by Med-Aide-A In an interview on 05/27/25 at 3:45 PM with Resident #9 he stated he felt good today. He was observed smiling, up in his wheelchair in his room. He was very talkative and stated how much he liked the facility and staff. He denied ever experiencing any type of abuse in the facility. He stated the nurses always checked his vital signs and gave him his medications when he was supposed to get them. In an interview on 05/28/25 at 3:20 PM with RN-B, he stated he knew Midodrine was used to increase the blood pressure for residents with hypotension (low blood pressure), and he gave it outside of the recommended or ordered parameters because he knew Resident #9 got hypotensive with dialysis. He stated he would not have given the Midodrine if the residents SBP was greater than 130. He stated if Resident #9's blood pressure became too elevated he could develop a stroke or hypertensive crisis. He stated going forward he would double check the physician orders, as well as the recommended and ordered parameters. In an interview on 05/28/25 at 3:30 PM with the DON, he stated Midodrine was used for hypotension, and if Resident #9's blood pressure had become too elevated he could have developed dizziness, headache, or even a stroke. He stated the nurses knew they were supposed to follow the ordered and recommended parameters for blood pressure medications. He stated he contacted the physician and clarified the order, and it was changed and added to Resident #9's MAR, as well as an in-service was started regarding checking blood pressures and administering medications appropriately and accurately. In an interview on 05/29/25 at 8:37 AM with Med Aide-A, she stated Midodrine was used to raise the blood pressure when someone had hypotension (a low blood pressure). She stated there was no excuse for why she gave the medication when she should not have. She stated sometimes she got in a rush and forgot to check the parameters of the order prior to administering. She stated she was already in-serviced yesterday regarding administering this medication wrong. She stated if Resident #9's blood pressure had become excessively elevated he could have experienced dizziness, headache, stroke, and/or ultimately death. She stated Resident #9 was cognitively alert and was always able to express when something was wrong, or he felt bad. Record review of the facility policy Pharmacy Services: Provision of Medication and Biologicals, implemented February 2017 and revised November 2023, revealed Team members will report drug errors and adverse drug reactions to the resident's physician in a timely manner. Record review of the facility policy Medication Administration, implemented March 2019 and revised January 2024, revealed a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure the ice machine chute was free of scratches with removable black substances in the scratches and around them. The facility failed to ensure the meat slicer was covered properly when not in use and remained free of dust and debris. The facility failed to ensure hairnets were worn before entering the kitchen and made readily available. The facility failed to ensure the underside of the shelf directly above the steam table holding food was free of grime. The facility failed to ensure a pair of black plastic tongs were free of crevices and not melted. The facility failed to ensure an 18-quart container of rice did not have a scoop inside of it in the dry storage area. The facility failed to ensure proper scoops were used in the rice container instead of an ordinary cup. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the cleaning schedule was followed and monitored. The facility failed to ensure all left over items in the refrigerators had use-by dates. These failures could place residents who received meals and/or snacks from the kitchen and satellite kitchens at risk for food contamination and food borne illness. Findings included: During the initial tour and observation of the kitchen on 05/27/25 at 12:30 pm revealed the chute inside the ice machine had a removable black-brown substance along the edge where the ice dumped out. The chute had multiple scratched areas on it with the same removable black-brown substance in the scratches. The cover on the meat slicer was askew and only partially covering the meat slicer. The cover had dust and other debris on it and the exposed areas of the meat slicer had dust and debris on it. Employees were seen entering the kitchen before putting on hairnets. There were no hairnets available near the two outer doors to the kitchen; one led outdoors toward an employee parking lot, the other led into the dining area. Hairnets were observed inside the kitchen on top of the ice machine near the door to the dining area. The underside of the shelf directly above food holding on the steam table had a removable gritty, brownish substance in clumps. There was a pair of black plastic tongs in a drawer with other utensils. The tongs were deformed in a way melted plastic looked, and the tongs had deep crevices in the pick-up end with a flakey, brownish substance in the crevices. The juice gun had a thick red substance stuck in the nozzle. Labeled items in the refrigerators did not have use-by dates. During a return visit and observations of the kitchen on 05/29/25 at 11:15 am revealed hairnets were not readily available outside the kitchen doors. The juice gun had a thick red substance in the nozzle. Labels in the refrigerator did not have use-by dates on the leftovers: multiple trays of beverages including tea, milk, and thickened liquids, potatoe salad, lunch meat, beans, multiple trays of desserts, and all other containers. In an interview with the DS on 05/27/25 at 12:40 pm, she said the inside of the ice machine was cleaned every four days and maintenance cleaned the filters monthly. She said the exterior of the ice machine was wiped down daily. She said the black-brown substance looked like mold and dirt. She said the meat slicer should have been covered properly to prevent dust and debris getting on the inside. She said the dust and debris could get into the food and make residents sick. She said she did not know who was responsible for the meat slicer. The DS said hairnets were used to cover hair to keep hair from getting into the food. She said hair in food was unsanitary and could make the residents sick because of cross contamination. She said the kitchen staff all had hairnets but would not say if they put them on before or after entering the kitchen. She said hairnets were available. She said she had to get them from her office (within the kitchen area). She said she was unaware of the removable gritty, brownish substance in clumps on the underside shelf directly above food holding on the steam table. She said the removable gritty, brownish substance in clumps could drop onto the food, contaminate it, and make residents sick. She said all food related items should be labeled and dated and did not know what use by dates meant. She said she was responsible for everything in the kitchen. In an interview with the RD on 05/27/25 at 12:45 pm, she said she did not know what the removable black-brown substance was on the ice chute in the ice machine, but it looked like dirt and guessed it could have been mold. She said the cover on the meat slicer was barely covering it and the meat slicer was dirty because the cover was more off than on. She said hairnets had to be worn at all times while in the kitchen. She said she did not know where the DS kept them or why they were not readily available. She said all food related items in the kitchen must be labeled and dated, including use-by dates. She said food that was past its use by date could make residents sick if consumed and should be discarded. She said the crevices in the black tongs could harbor bacteria, cross contaminate the food, and make residents sick. She said she needed to in-service the kitchen staff on cleaning and labeling. In an interview with the DA on 05/29/25 at 11:25 am, she said the juice gun was cleaned every two days, the last cleaning being Tuesday, 05/27/25. She said they were told to only remove the outer nozzle and wipe the inner nozzle with a towel. She said the inner nozzle was not clean. She said she was not sure how long it had been since the juice gun had been cleaned. She said the dietary aides were supposed to be cleaning it. She said the red substance in the nozzle was because of the thickener. She said not cleaning the juice gun could make residents sick. In an interview with the DS on 05/29/25 at 11:30 am, she said the juice gun was cleaned every three days, the last cleaning Monday, 05/26/25. She said she was not sure why the juice gun was not clean if it was cleaned on Monday or Tuesday. She said she was responsible for monitoring the cleaning schedule. She said she was not monitoring the cleaning schedule. She said she was only looking at the cleaning schedule to see if the items were checked off. She said the daily cleaning schedule for 05/26/25 and 05/27/25 had been checked off as having been done for the juice gun. She said the juice gun was not clean. In an interview with the DA on 05/29/25 at 3:25 pm, she said her initials were on the daily cleaning schedule dated Monday 05/26/25 as having cleaned the juice gun. She said she could not remember if she had or had not done it. In an interview with the ADM on 05/29/25 at 4:25 pm, he said he would start conducting daily walking rounds with the DS in the kitchen from now, on. Record review of the facility's Daily kitchen 29-item cleaning checklists dated 01/06/25-05/26/25 revealed a total of 140 opportunities: #14. Food service employees wear hair restraints .that could spread into food, the task was not marked as done 42 times. 19. Clean .juice machine ., the task was not marked as done 42 times. 20. Clean and sanitize slicer. Cover. The task was not marked as done 79 times. The weeks of 02/17/25, 03/17/25, 04/07/25, 04/28/25, 05/05/25, and 05/19/25 were missing. Record review of the facility's Weekly kitchen 7-item cleaning checklists dated 01/06/25-05/26/25 revealed a total of 140 opportunities with 119 tasks not marked as having been done. There were 4 weeks missing for January, 3 weeks missing for February, 2 weeks missing for March, 1 week, 4 days missing for April, and 2 weeks missing for May. Record review of the facility's Monthly kitchen 6-item cleaning checklists dated 01/06/25-05/26/25 revealed a total of 28 opportunities with 23 tasks not marked as having been done. Record review of the facility's kitchen in-services revealed: 12/01/24 Sanitizing, Cleaning, 03/25/25 Kitchen Sanitation, 04/01/25 Services Management, 04/21/25 Adaptive Equipment, 05/08/25 Refrigeration Food Storage, 05/27/25 Carbon Build-up, Cleaning Schedules, Thermometers in fridge/freezer, and temp recording, Personal Hygiene, Cross-contamination, hair nets, wear and tear from cooking equipment. Record review of the RD's in-service dated 05/08/25, titled, Refrigeration Food Storage revealed under Date Marking, Food items must be labeled with dates if they are prepared and held for more than 24 hours .Under Refrigeration Storage Limits, use all leftovers within 72 hours. Discard items that are over 72 hours old. Immediately throw out any foods showing signs of spoilage or are past their expiration dates. Record review of the facility policy dated 10/01/18, titled Cleaning Schedules revealed under Policy: The facility will maintain a cleaning schedule prepared by the Nutrition and Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. 3.The Nutrition and Food Service Manager or designee will verify that the tasks were completed as assigned. The Daily, Monthly, and Weekly cleaning schedules within the policy listed juice machine was to be cleaned daily. Record review of the facility policy dated 10/01/18, titled, Food Storage revealed under Procedures: 1. Dry storage rooms, e. Provide scoops for items stored in bins, such as sugar, flour, rice, and other items. Store scoops covered in a protected area near the food containers .2. Refrigerators, e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on interview and record review, the facility failed to ensure each resident and/ or their representative and the IDT were invited to attend/participate in the care plan meetings including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #25) reviewed for care plan timing and revision. The facility failed to ensure Resident #25 had quarterly care plan reviews or meetings that included the appropriate IDT members and resident and/or resident representative in February 2025 and May 2025 (2 out of 3). The facility failed to ensure the care plan was revised within 7 days after the quarterly assessment that was dated 2/19/25. These failures could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings included: Record review of Resident #25's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included conversion disorder with seizures or convulsions (a condition in which emotional or psychological stress causes physical symptoms such as shaking of the body), Down syndrome (a genetic condition that causes intellectual disability and developmental delays), unspecified epilepsy (a neurological condition that causes recurring seizures), and developmental disorder of speech and language (communication disorder that interferes with learning, understanding, and using language). Record review of Resident #25's quarterly MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. The MDS also reflected that Resident #25 was completely dependent on staff for eating, hygiene, toileting, all transfers, and all ADLs. Review of all of Resident #25's MDS reports on 05/29/25 reflected she had a quarterly MDS done on 11/19/24 and 2/19/24. A quarterly MDS dated [DATE] showed in progress. Record review of Resident #25's assessments tab in the EMR on 05/29/25 reflected two entries titled, IDT: Care Plan Conference and Advanced Care Planning Review that were dated 09/24/24 and 11/26/24. The form dated 09/24/24 and signed by the SW indicated the MDS nurse, dietary manager, social worker, activity director, and the RP participated in the meeting, however in the additional comments section it stated, Called RP via phone call no answer only VM left again. The form dated 11/26/24 and signed by the ADON indicated the dietary manager, social worker, activity director, ADON, and RP participated in the meeting. There were no other entries that indicated an IDT care plan conference was held for Resident #25. Resident #25's assessments tab also reflected entries dated 12/19/24, 01/24/25, and 02/24/25 that were titled, IDT: Restorative Review. The Restorative Review dated 12/19/24 reflected it was an initial therapy referral review and Resident #25 was to be discharged from OT on 11/19/24 and start a bed mobility program and an active range of motion program for deficits of bed mobility and positioning and limited ROM. The Restorative Review dated 01/24/25 reflected it was a periodic review of Resident #25's bed mobility and range of motion programs. This review reflected the IDT had reviewed the plan of care and the programs were appropriate and would be continued. The Restorative Review dated 02/24/25 reflected it was a periodic review of Resident #25's bed mobility and range of motion programs. This review reflected the IDT had reviewed the plan of care and the programs would be discontinued. Additional comments reflected Rehab services initiated. All the Restorative reviews were signed by the MDS nurse. These restorative reviews did not address Resident #25's desire to learn to write her name. Record review of Resident #25's care plan dated 09/23/24 and revised on 03/11/25 reflected Resident #25 had a self-care deficit, impaired cognitive function, problems communicating needs or wants, and was PASRR positive. Interventions included coordinating all essential medical and/or mental health visits, provide care and safety checks throughout the shift, provide nutrition and hydration within prescribed diet, and report any need to re-evaluate specialized services and/or plan of care to service coordinator as well as resident representative. Resident #25's specialized service was agreed upon DME of a specialized wheelchair. This care plan did not address Resident #25's desire to learn to write her name. This care plan indicated Resident #25 only required 1 person assistance with bathing/showering, bed mobility, dressing and grooming, eating and drinking, hygiene, turning and repositioning, and transfers which is not what her quarterly MDS dated [DATE] reflected. Record review of Resident #25's Habilitation Service Plan dated 09/25/24 reflected it was the initial meeting and discussion of PASRR services. This meeting was attended by Resident #25, the habilitation coordinator, the MDS nurse and the provider supervisor (who was not a facility staff member) and indicated the RP was unable to be reached. Identified IDD habilitative specialized services were habilitation coordination monthly and independent living skills for 1 hour, 2 times per week, to achieve Resident #25's goal of learning to write her name. It was signed by the habilitation coordinator on 05/17/24. (Not an error on the date by this writer). Record review of Resident #25's Habilitation Service Plan dated 12/18/24 reflected it was the quarterly meeting and discussion of PASRR services. This meeting was attended by Resident #25, Resident #25's RP, the habilitation coordinator, the MDS nurse and the provider supervisor (who was not a facility staff member). Identified IDD habilitative specialized services were habilitation coordination monthly and independent living skills for 1 hour, 2 times per week, to achieve Resident #25's goal of learning to write her name. It was signed by the habilitation coordinator on 12/18/24. Record review of Resident #25's Habilitation Service Plan dated 3/14/25 reflected it was the quarterly meeting and discussion of PASRR services. This meeting was attended by Resident #25, the habilitation coordinator, the MDS nurse and the provider supervisor (who was not a facility staff member). There was no documentation on whether or not the RP was contacted for this meeting. Identified IDD habilitative specialized services were habilitation coordination monthly and independent living skills for 1 hour, 2 times per week, to achieve Resident #25's goal of learning to write her name. In the pertinent information section it was documented, It is important to [Resident #25] to continue to receive her independent living skills because she wants to learn how to write in order to be able to write her name. It was agreed that the independent living skills is beneficial to [Resident #25] as it appears that she enjoys it and really wants to learn to write her name. It was signed by the habilitation coordinator on 03/14/25. Record review of Resident #25's progress notes reflected notes dated 01/10/25 (monthly), 03/14/25 (quarterly), 04/09/25 (monthly), and 05/14/25 (monthly) which indicated a monthly or quarterly meeting was held with the [Agency name] PASRR Habilitation Coordinator, and no changes were noted or reported. In an interview on 05/29/25 at 3:25 PM and at 4:29 PM, the MDS nurse stated the last IDT meeting for Resident #25 was 11/26/24. She stated she was going to look to see if there had been any more IDT meetings since then. The MDS nurse stated IDT consisted of the SW, dietary manager, activities director, nursing staff, the provider, and therapy staff. She stated that the habilitation coordinator was usually only here for the monthly PASRR meetings and were not part of the IDT care plan meeting. The MDS nurse stated she was the only facility staff member present for the PASRR meeting on 03/14/25 and it could not be considered an IDT meeting if all the disciplines were not present. The MDS nurse stated they did discuss her entire plan of care at the PASRR meeting. In an interview on 05/29/25 at 3:56 PM and 4:35 PM, the RMDS nurse gave this surveyor a printed page of Resident #25's progress notes that reflected the same progress notes documented above. The RMDS nurse stated that the quarterly meeting held with the [Agency name] PASRR Habilitation Coordinator was the quarterly IDT meeting for the facility. As documented above, Resident #25's RP was not present, and the only facility staff member present was the MDS nurse. The RMDS nurse stated IDT meant, we all sit down and discuss the resident's plan of care. It can consist of the nurse, SW, activities can attend, the DON, and the administrator, if needed. The RMDS further stated they tried to involve the LIDDA, also, for Resident #25. When asked why she considered the PASRR meeting on 03/14/25 an IDT meeting, the RMDS nurse stated because the MDS nurse was there. The RMDS nurse stated if the MDS nurse held the meeting alone, then she would not consider it an IDT meeting. The RMDS nurse stated the facility used a system called Care Feed to notify the RP of meetings and it would show in the Direct Messages in the resident's chart. The RMDS stated the facility was one month late for the quarterly IDT/ care plan meeting that should have been done in February, but the facility was not late for the May IDT meeting because the last meeting was in March, so the next one was not due until June. Record review on 05/29/25 of the facility's Direct Messages for Resident #25 reflected the following messages: 01/27/25 Message from [nursing facility] would like to inform you dear family members we are keeping all our residents safe and warm during this winter freeze storm. Stay safe and warm. Thank you for your attention. God Bless you! 02/21/25 (4 messages in English) Good morning, dear family members, here at [nursing facility] we strive to keep our residents safe and happy as well as their personal belongings. However, we would like to recommend you take any jewelry or personal valuable belongings, if any, for safekeeping at your home. If there are any questions, please contact Social Services Director [name] at [phone number]. 03/03/25 (7 messages in Spanish) the same as the 4 valuables messages in English that were sent on 02/21/25. 05/01/25 (1 message in English, 1 message in Spanish) Dear Family, we would like to send this friendly reminder in case of any questions or concerns that you might have, please contact our community administrator [name] at [phone number], or Director of Nursing Services [name] at [phone number] to further assist you. Thank you for all your support and preference for your loved one's skilled nursing care. There were no messages to advise the RP of scheduled IDT/care plan meetings. In an interview on 05/29/25 at 4:18 PM, the DON stated he sometimes attended the IDT meetings and RPs/family members were notified of care plan meetings through the facility's Direct Message system that sent a text message to the RP/family. In an interview on 05/29/25 at 5:39 PM with the MDS nurse, DON and RMDS nurse, the MDS nurse stated it was important for all pertinent disciplines and the RP/resident to be present because it was an IDT meeting, and everyone needed to take part in the resident's [NAME] of care. The DON stated, If the disciplines and the RP/resident were not present for the meetings it could affect the resident's holistic care. The DON also stated they (the IDT team) were made aware of the resident's plan of care in morning meetings because all of the disciplines were in those meetings. The DON stated the SW emailed the department heads to inform them of upcoming IDT/Care plan meetings. The RMDS nurse stated, Even though we made not have the entire team there, we discuss all aspects of the resident's care as a whole. There are some meetings depending on the resident's needs, that the doctor or ombudsman have to be present. Record review of the facility's Care Plan Policy dated February 2017 and revised January 2023 reflected in part: Interdisciplinary means that professional disciplines work together to provide the greatest benefit to the resident. The care plan should be prepared, reviewed, and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually, and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions. The care plan should be reflective of resident's/representative's input, goals, and desired outcomes and should include the interdisciplinary team, to include but not limited to the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. The care plan should be utilized in conjunction with the entire medical record. The care plan should serve as a guide, that identified risks, direct care needs, care choices, and care preferences. The resident and his or her advocate are encouraged to attend the care plan meeting as desired by the resident . The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the community.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect. The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 01/14/2025 around 6:30 PM when housekeeper A notified the administrator and DON of her suspicion of abuse regarding Resident #1. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse. The findings included: Record review of Resident #1 face sheet dated 04/19/2025 revealed Resident #1 was an [AGE] year-old- male who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses of Alzheimer's disease (cognitive impairment) and dementia (cognitive impairment). Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 5 which meant severely cognitively impaired and was dependent on staff for ADLs. Record review of Resident #1's Care Plan date implemented 09/18/2024 I may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress. Goal: Resident's condition will be stable, and his/her needs will be anticipated and met as indicated. Interventions: Resident's emotional needs will be supported, and resident will adjust to placement without any sign of emotional distress noted. Resident will not experience a health decline, will tolerate medication/treatment and progress towards goals established until the comprehensive plan of care can be developed. Therapy services as ordered by the physician. Social Services as indicated. Mental health providers as ordered. Coordinate all essential medical and/or mental health provider visits or telehealth visits as indicated. Provide care and safety checks throughout shift. Nutrition/hydration (food/foods) within prescribed diet. Provide care and services as indicated. Provide teaching regarding medications, treatment, care, and health status as needed. Activities as tolerate. Administer medication, care & treatments as per MD recommendation. Provide ADL care as indicated. Monitor psycho-social status or monitor behaviors to establish targeted behaviors. Monitor vital signs & health condition as indicated. Notify PCP & RP of any change in condition as clinically indicated. See nurse for any care related questions or concerns. Record review of the facility's Provider Investigation Report regarding Resident #1 dated 01/17/2025 revealed Description of the allegation: staff reported a concern regarding the attitude of a nurse toward a resident. The housekeeper stated that she observed [Resident #1] calling for assistant and felt the nurse responded with a rough attitude. Was the incident reported to the police yes case number 2025-001298. Record review of Resident #1's local law enforcement police report printed timestamped 04/22/2025 at 8:21AM revealed case number 2025-00011298, report detailed that event occurred from 01/14/2025 at 12:00AM to 01/14/2025 at 8:00PM. Additionally, facility reported date and time: 01/21/2025 at 11:29PM which revealed the facility reported the allegation of abuse 7 days after the allegation was made. Narrative on January 21, 2025, police responded to [facility] to incident report. During an interview on 04/19/2025 at 10:28AM dispatcher for the local law enforcement agency stated case number 2025-001298 was not a case number and stated 2025-00011298 was called in by the facility administrator on 1/21/2025 around 11:29AM, which was 7 days after the allegation was made on 01/14/2025. During a phone interview on 04/19/2025 at 11:28AM the local law enforcement officer who responded to the 01/21/2025 call regarding Resident #1 stated when he initiated his onsite investigation on 01/21/2025, he was notified by the administrator that the incident regarding Resident #1 had transpired several days before the administrator called in the allegation of abuse. The local law enforcement officer stated he interviewed Resident #1 and other staff members but did not find any definitive evidence that the allegation of abuse occurred. The local law enforcement officer stated he filled out a report shortly after he completed his facility on-site visit on 01/21/2025 and the report he completed would accurately depict the timeframe of when the facility called in the allegation of abuse. During an interview on 04/19/2025 at 2:19PM the Administrator and DON stated their protocol was to suspend LVN A pending investigation results. Both stated they gathered information from the housekeeper on 01/14/2025 and commenced a head-to-toe assessment for Resident #1 and notified Resident #1's [family member]. Both stated they called the police department within 24 hours when the allegation was made on 01/14/2025. Both stated they never found any definitive evidence of abuse as Resident #1 never verbalized any allegation of abuse or mistreatment nor did they find any skin irregularities or behavioral abnormalities. Both stated the investigation took roughly 5 days to complete. Both stated they commenced their investigation with residents on 01/14/2025 thru 01/15/2025, followed by staff members. Both stated they treated the allegation as abuse and notified the proper entities including state agencies and local law enforcement. Both did not verbalize a definitive answer of what potentially could occur if the local law enforcement agency is not called within 24 hours. Both reiterated the facility notified the local law enforcement within 24 hours after the allegation of abuse was made. The Administrator said it was his responsibility for reporting any allegation of abuse to the state agency and local authority. Record review of the facility's Abuse and Neglect in-service dated 01/15/2025 revealed Reviewed the process of reporting all allegations of abuse and neglect. Understanding the process of preventing, identifying, and reporting all allegations/suspicions. [facility] policy for preventing, identifying, and timely reporting all suspicions and/or allegations of abuse and neglect, the [state agency] guidance/provider letter and adhering to the timely reporting per regulation. Community has a 2-hour reporting window on certain abuse and neglect allegations. Record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy and procedures date/revised January 2024 documented, Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's 19-17 are reported immediately, Not later than 24hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, State authorities should be notified of reports of abuse described above which alleges that: 4. A resident has been a victim of any act or attempted act of abuse or neglect.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of one residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 2 hours. On 04/21/2024, Resident #1 eloped from the facility through the employee dining area (formally assisted living dining area) door sometime after 1:00pm. The facility was notified by another local facility located approximately one block away at approximately 2:30 pm, that Resident #1 was brought into their facility after a passerby saw Resident #1 on the sidewalk by the road next to their facility. The passerby assumed Resident #1 resided at their facility since Resident #1 was located across the street. The noncompliance was identified as PNC. The PNC began on 04/21/24 and ended on 09/17/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The findings included: Record review of Resident #1's face sheet dated 11/20/24 reflected an [AGE] year-old-female admitted to the facility on [DATE]. Diagnoses included Alzheimer's (brain disorder that destroys memory and thinking skills), Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday tasks), and type two diabetes (insufficient production of insulin in the body). Record review of Resident # 1's elopement risk assessment dated [DATE]. Resident #1 was not found to be an elopement risk at that time. Record review of Resident # 1's physician order dated 03/12/24 reflected a Wanderguard. Record review of Resident #1's MDS dated [DATE] reflected a BIMS (brief mental score) of 3 (severe cognitive impairment) dated 3/13/24. Resident #1 was ambulatory and did not require the use of mobility devices. Interview on 11/19/24 at 10:00 am the ADON stated the incident happened on a weekend and she received a call from the Administrator at that time that Resident #1 had eloped but was back in the facility. The ADON stated she came to the facility and checked on Resident #1 and there was no injuries or distress noted. The ADON stated a dietary aide heard the alarm on the door and looked outside but did not go outside to see if anyone was out there and did not notify any staff members. The ADON stated Resident #1 did not have exit seeking behaviors prior to the incident. The ADON stated Resident #1 did have a wander guard and the door alarm was working but was not equipped with a wander guard alarm on that door, just a regular alarm that goes off when pushed. The ADON stated Resident #1 was ambulatory and was able to walk without assistance. The ADON stated Resident #1 was calm but was unable to recall what had happened. The ADON stated LVN A stated he received a call from a nearby nursing facility asking if Resident #1 belonged to the facility. The ADON stated the nearby nursing facility stated a passerby saw Resident #1 on the sidewalk and drove her to the nearby nursing facility thinking the resident resided at that facility since Resident #1 was across the street. The ADON stated LVN A picked up Resident #1 at the nearby nursing facility and brought her back to the facility where the ADON conducted a head-to-toe assessment. The ADON stated there are no exit seeking residents at this time. The ADON stated Resident #1 was picked up by her family the next day and taken home. In a phone interview on 11/19/24 at 10:36 am the Dietary Aide stated he was washing dishes when he heard an alarm go off. The Dietary Aide stated he went to the employee dining room, looked out the door and the windows and did not see anyone. The Dietary Aide stated it was his mistake that he did not go outside to check if there was a person and did not notify staff. In a phone interview on 11/19/24 at 11:02 am LVN A stated the incident was a long time ago and was not sure if he could remember the details. LVN A stated he remembered receiving a call from the nearby nursing facility to let them know they had a resident at the facility they thought was their resident. LVN A stated he drove to the nearby nursing facility and brought Resident #1 back to the facility and conducted a head-to -toe assessment and there were no obvious injuries reported. LVN A stated he could not remember when the nearby nursing facility called, but stated he last saw Resident #1 around 1:00 pm in the main dining room eating and he had left to continue his rounds. LVN A stated Resident #1 did not appear to be in any distress and Resident #1 could not recall the incident but was happy to see LVN A. LVN A stated Resident #1 did not display exit seeking behaviors prior to the incident. In a phone interview on 11/19/24 at 11:46 am the nearby nursing facility weekend supervisor stated the receptionist called her to the front stating a resident was found outside and was brought in by someone passing by. The nearby nursing facility weekend supervisor stated the person driving by stated they saw Resident #1 on the sidewalk by the road and brought her to their facility because it was lightly raining outside and thought it was odd she was outside and was possibly a resident at their facility. The nearby nursing facility weekend supervisor stated Resident #1 stated she was ok and that she lived down the block. The nearby nursing facility weekend supervisor stated she noticed Resident #1 had a wanderguard on her ankle and realized Resident #1 was from another facility. The nearby nursing facility weekend supervisor stated she called the facility and asked if they had a resident by the name the Resident #1 gave. The nearby nursing facility weekend supervisor stated the line got disconnected and she called the facility multiple times with no answer, so she called the local law enforcement for assistance. The nearby nursing facility weekend supervisor stated the police came to the facility and informed the other facility they needed to pick up the resident after confirming Resident #1 did reside at the facility. The nearby nursing facility weekend supervisor stated a nurse from the facility came and took the resident back to the facility Resident #1 resided in. The nearby nursing facility weekend supervisor stated that was sometime in the afternoon, approximately around 1:00 to 5:00 pm. In an interview on 11/19/24 at 4:26pm the Administrator stated all employees were re-trained on the elopement process and the new door locks/alarms when [NAME] took over on 9/17/24 as well as replaced all doors locking mechanisms and added extra security with replacing cameras and installing a two-way communicator at the nurse's station and receptionist desk. The Administrator stated he was not sure what training or interventions were done when the incident originally took place but when he came on board, he started brand new with re-educating all staff and adding the extra security to ensure it did not happen again. The Administrator stated he was not the administrator at the time of the elopement but there has not been an elopement of any resident since the incident. In an interview on 11/20/24 at 9:30am the Director of Clinical Operations stated when [NAME] took over, they immediately conducted an ADHOC (a meeting that is necessary or needed) meeting and a 4-point plan including complete door and camera assessment, ordering of equipment, resident re-assessments, and education. The Director of Clinical Operations stated the facility has continued elopement education monthly and were continuing elopement drills. Stated there has not been another elopement incident since. In an interview on 11/20/24 at 10:44am the Maintenance Director stated the back dining room exit door was no longer accessible to residents as the dining room is no longer in use. The MD stated all the exit doors have been upgraded with new locking mechanisms, a new wanderguard alarm was installed on the front door cameras have been installed/repaired, and the front door remains locked at all times and the receptionist has a fob to open it. The MD stated at the nurse's station, a monitor was installed that alerts staff when an exit door is opened and displays what exit door has been. The MD stated there was now a two-way communication speaker at the front door that connects to the nurse's station and receptionist area. The MD stated all staff were trained on the new exit doors and how they work. The MD stated he was conducting Monday through Friday exit door checks to ensure all exit doors are functioning properly. The MD stated all exit doors when opened, will alarm and the alarm will not turn on off unless a code or key is used. The MD stated the facility now uses the TELS (program used for work orders and facility maintenance needs) program for all maintenance needs so he can be aware if there are issues with a door as well as anything in the facility. Record review of facility's Elopement Response and Exit Seeking Management policy dated January 2023 stated: B. Response following the location of the resident: 1. Once located and safety confirmed, conduct an assessment. 2. Place resident on enhanced monitoring, consider 1:1 for a specified time as needed to ensure the safety of resident or consider placement in secured unit for continued monitoring and safety. The IDT should review and determine the continued need for additional monitoring efforts. 3. Update the Exit Seeking-Elopement Risk Assessment as indicated. 4. Review and/or update the care plan as indicated. 5. If the community is equipped with a Wander Guard or Roam Alert System, assess the resident's need for a wander guard or roam alert monitoring device (i.e. bracelet); if needed, obtain order from physician and notify representative. 6. Notify Administrator and DON 7. Notification of Physician/N.P./P.A. 8. Notification of resident's representative 9. Notify [NAME] Support & CSO Support 10. Update the plan of care accordingly. In an interview beginning on 11/19/24 at 8:30am LVN A, CNA B, LVN C, SW, Admissions Coordinator, and Dietary Aide from various shifts were able to identify the elopement process, wandering residents, knowledge on the new door alarms/locks, what to do if the door alarm sounds, locate cause of alarm, do not reset alarm without determining who entered or exited, identify code orange as the elopement code, and the different types of abuse and neglect. Record review and verification of the corrective action implemented by the facility beginning on 04/21/24: Resident #1 was discharged from the facility on 4/22/24. oResident #1 was placed on 15-minute checks and 1:1 monitoring. Verified through record review and interview with ADON on 11/20/24. oRe-educated and in-serviced staff beginning on 04/21/24 regarding: Verified through interviews with various staff members and record review of in-services on 11/20/24. -Elopement and Wandering Residents -What to do when door alarm sounds, locate cause of alarm, locate person who went out or in the door. -Do not reset alarm without determining who entered or exited. oAll new admissions will have wandering assessment completed. Verified through record review on 11/20/24. oAll residents were assessed for elopement risk begnning on 4/21/24. Verified through record review and interview with ADON on 11/20/24. oDaily (Monday-Friday) exit door checks by maintenance, notify administrator immediately if any of the doors appear to malfunction. Verified through interviews with Maintenance Director and record review of maintenance log on 11/19/24. oAll residents have an updated wandering assessment. Currently no residents are an elopement risk. Verified through record review and interview with DON and Administrator on 11/20/24/ oRemoved all non-functional and abandon door locking devices beginning on 9/17/24. Verified through record review of invoices and interviews with Maintenance Director and Administrator on 11/20/24. oAll exit doors received new touch-sensor bars with delayed egress magnetic locking hardware beginning on 9/17/24. Verified through record review, observations, and interview with Maintenance Director and Administrator on 11/19/20. oAll staff were educated on operation of new door locks. Verified through staff interviews and record reviews beginning on 11/19/24. oRewired remote door locking annunciator at nurse station to provide visual indication of unlocked doors beginning on 9/17/24. Verified through observation of nurse's station and interview with Maintenance Director and DON on 11/20/24. oRepaired camera system and replaced all non-functioning interior cameras beginning on 9/17/24. Verified through interview with Maintenance Director and record review on 11/20/24. oInstalled reset only door ajar alarms on all exit doors. Installed 10yr lithium batteries to ensure continuous operation beginning on 9/17/24. Verified through interview with Maintenance Director on 11/20/24. (Maintenance Director will monitor battery for proper functioning.) oInstalled a wander management system on the front door for enhanced security beginning on 9/17/24. Verified through observation and interview with Administrator on 11/20/24. oInstalled a two-way communication device on the front door to nurse station and receptionist desk beginning on 9/17/24. Verified through observation on 11/20/24. oInstalled a set of double egress doors (with delayed egress locks) at back corridor to ensure the back wings are secure from free access by staff and residents beginning on 9/17/24. Verified through observation and interview with Maintenance Director on 11/19/24. oAdded a digital building management system for maintenance (TELS) beginning on 9/17/24. TELS is a system used in the nursing facility where maintenance work orders can be inputted by staff members. Verified through interview with Maintenance Director and Administrator on 11/20/24. oInterviews beginning on 11/19/24 at 8:30am, various staff members were able to correctly identify the elopement procedures, what to do when the door alarm goes off, and identified code pink as the code for elopement. oNo other incidents of elopement have occurred since Resident #'1's elopement incident. Verified through record review and interview with the DON and Administrator on 11/19/24.

Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility did not have a completed Facility Assessment specific to cyber-attacks. This failure could place all residents at a risk for a lack of necessary resources and services. Findings Included: During an observation on 08/31/2024 at 11:00AM the facility had multiple resident's MARs and TARs on the conference table, and additionally upon further observation the clinical staff were using paper charting without any use of internet capable devices including computers and/or laptops. During the entrance conference and interview on 08/31/2024 at 11:07AM The administrator stated the facility was experiencing a facility wide technology black out. The administrator stated on Wednesday 08/28/2024, roughly around mid-day, noon time, he received a notification from his corporate company that nationally, the corporation was experiencing a viral cyber-attack. The administrator stated his immediate directive from corporate was to remove ethernet cables from all internets capable devices, which included computers and laptops. The administrator stated once the ethernet cables were removed the facility did not have access to the residents' electronic health records and were in a technology black out. The administrator stated later that day on 08/28/2024, the corporate administration gave permission to the clinical staff to use their own personal hot spots as an attempt to maintain internet continuity of care, and to check if the electronic health records were available. The administrator stated he himself, experienced difficulty with utilizing his own hot spot on his personal device. The administrator stated he could not confirm with certainty that all clinical members had any success with using their hot spots to be able to chart on the residents' electronic health records. The administrator stated on 08/29/2024, his clinical staff including his ADON A notified him the electronic health records online portal withdrew all access to the electronic health records, and the clinical staff did not have accessibility to physician orders, MARs, and TARs. The administrator reiterated multiple times the facility was not prepared for a viral cyber-attack and experienced a black-out from 08/28/2024 thru 08/30/2024. The administrator stated the contracted pharmacy were notified of the lack of physician's order for all residents on 08/28/2024, and those MARs and TARs were finally delivered on Friday 08/30/2024. The administrator stated when the MARs and TARs arrived, ADON A and other clinical members worked together to organize the orders and disperse them to the nurses. The administrator stated the disbursement happened on 08/30/2024 around noon time. The administrator stated he recalled during a specific event on either 08/28/2024 or 08/29/2024, a new unnamed LVN consistently requested orders for her residents, and ADON A could not provide the requested information as the facility did not have the information readily available. The administrator stated the corporation is attempting to rectify the situation as soon as possible and is hopeful on Tuesday 09/03/2024 an on-site IT technician will fix the cyber-attack problem that affected the facility's computer systems. The administrator stated he has been with the company for two weeks, and stated the facility had no idea that this type of event (cyber-attack) would ever happen to them. The administrator did not reply when questioned about the potential negative events that could have happen as a result of not being emergently prepared for a cyber-attack. The administrator stated going forward the facility will task the medical record personnel to print out all resident's MARs and TARs at the beginning of each month as an effort to mitigate any future cyber-attacks. The administrator stated the facility does conduct facility assessments for natural disasters annually, however had no preparation for this viral cyber-attack as it was the first of its' kind. The administrator stated due to the lack of internet connectivity and accessibility, all online electronic health records are inaccessible. The administrator stated no resident was sent to the emergency room for any ailment during 08/28/2024 thru 08/30/2024. During an interview on 09/01/2024 at 1:23PM the Interim DON and ADON A both stated cyber-attacks was not something they were prepared for. Both stated the facility was usually given ample warning when storms will affect their facility, and as a preparatory effort, both will instruct the medical records personnel to print out all residents MARs and TARs to have readily available for their clinical staff to maintain continuity of care. Both stated their plan was to implement a backup system for cyber-attacks as they would both direct the medical record employee to print out all residents' MARs and TARs first of the month every month. Both stated potentially, residents could have received inappropriate care or treatment/medication orders as a result for not having physician's orders, MARs and TARs readily available during 08/28/2024 thru 08/30/2024.ADON A stated when the cyber-attack was initially discovered on 08/28/2024, she reviewed the emergency facility binder that housed all the residents MARs and TARs from a natural disaster scare earlier this year, and saw the printed date was April 2024 and was not current. Both reiterated multiple times the facility was unprepared for the disastrous viral cyber-attack. Record review of the facility's records revealed they did not have a facility assessment specifically for cyber-attacks. Record review of the facility's Continuity of Operations Planning ([NAME]) policy revised dated August 2018 documented, Continuity of Operations Planning ([NAME]) is considered a critical component of overall disaster and emergency preparedness. 1. This facility recognizes the importance of continuing operations following a crisis or disaster situation. 2. As part of the [NAME], the Disaster Preparedness Planning team shall review and identify crucial/essential functions, personnel and other factors that must remain operational immediately following a crisis or disaster. 3. Continuity of Operations Planning helps ensure that the facility can sustain operations that are absolutely vial including administrative and business components of the facility (records, payroll, finance, funding, insurance etc.). 4. The intent of the [NAME] is to maintain the safety of facility occupants (residents, staff and visitors) as well as allow the facility to provide services immediately following a critical event.

Based on observation, interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible and systematically organized for 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) who were reviewed for medical records. The facility failed to maintain accurate, thorough, complete and readily accessible medical records including physician orders, daily documented progress notes, blood pressure readings for residents that take blood pressure medications, glucose reading results for residents that have orders for glucose checks, MARs, and TARs for residents within the facility from 08/28/2024 thru 08/30/2024. This failure could have negatively affected the well-being of all residents as there was no documentation of services provided, if/when medications were administered appropriately in accordance with physician orders, and the residents current medical status. Findings included: Record review of minimally 5 residents was unsuccessful as the facility did not provide electronic health record access upon request on 08/31/2024. Unable to review care plans, MDS', thorough progress notes, thorough MARs and TARs, physician orders, vital signs, face sheets, and glucose reading results. The facility did provide written paper MARs/TARs that were backdated upon confirmation of managerial clinical staff. The facility was still amid a technological viral cyber-attack, and the electronic health record software portal removed all access to patient information pending cyber-attack resolution/rectification by the facility corporation. Record review of the facility's collective written nursing notes, entitled Nurse's Notes, dated 08/29/2024 2-10PM shift [NAME]/[NAME] hall detailed no specific room numbers nor nursing signatures/names, revealed 12 residents were documented on out of 81 residents that resided within the facility. Record review of the facility's collective written nursing notes, entitled Nurse's Notes, dated 08/30/2024 2-10PM shift, hall unknown, resident room numbers unknown, documenter unknown, revealed 6 residents documented on out of 81 residents that resided within the facility. On 08/31/2024 at 3:22PM requested ADON A to present all daily documented nursing notes from 08/28/2024-08/30/2024 for all residents within the facility. On 09/01/2024 at 1:23PM LVN A's written nursing notes were presented and revealed: On 08/28/2024 LVN A 2PM-10PM shift, documented internet down, as well as check marks for various medications including psychotropic medications, for residents in rooms 101a thru 116, however there is no definitive indication if medications were given or held for 27 residents out of 81. No nursing documentation were noted for rooms 117-230. On 08/29/2024 LVN A 2PM-10PM shift, documented internet down, as well as check marks for various medications including psychotropic medications, for residents in rooms 101a thru 116, however there is no definitive indication if medications given or were held for 27 residents out of 81. No nursing documentation were noted for rooms 117-230. On 08/30/2024 LVN A 6AM-2PM shift medication aid documented internet down and 29 resident blood pressures. The document had rooms 117A-131B Verde hall, [NAME] hall (unknown room numbers), followed by an additional document with rooms 201A-216B with blood pressure results. No blood pressures were documented for 08/28/2024 (for 2-10PMshift, or 10PM-6AM shift) as well as on 08/29/2024 (for 6AM-2PM shift, 2PM-10PM shift, and 10PM-6AM shift) On 08/30/2024 LVN A 2PM-10PM shift, documented internet down, as well as check marks for various medications including psychotropic medications, for residents in rooms 101a thru 116, however there is no definitive indication if medications were given or held for 27 residents out of 81. No nursing documentation were noted for rooms 117-230. Record review of Resident #1's TAR, with a written date of August 2024 revealed, written order date 08/14/2024, written instructions, cleanse stage 4 PU to sacrum with wound cleanser, dab dry apply collagen dressing followed by alginate dressing and cover with absorbent dressing and secure with tape daily and PRN if dressing falls off or it becomes soiled. Within the document, shift 2 (2PM-10PM) to complete wound care. Documented wound care was completed on 08/29/2024, however on 08/28/2024, and 08/30/2024 there was no documented wound care performed. Record review of Resident #2's TAR, with a written date of August 2024 revealed, written order date 08/20/2024, written instructions, cleanse unstageable PU to sacrum with wound cleanser, dab dry, apply Santyl to wound bed and cover with gauze dressing, daily and PRN if dressing falls off or it becomes soiled. Within the document, shift 1 (6AM-2PM) to complete. Additionally, a check mark is written within the 08/29/2024 box indicating wound care was completed, however on 08/30/2024, and 08/31/2024 no check mark was in the box, indicating wound care was not completed. Record review of Resident #3's TAR, with written date of August 2024 revealed, order date 06/11/2024, written instructions, cleanse diabetic ulcer to plantar as of left foot with wound cleanser, dab dry, apply Santyl and (no frequency noted i.e., daily, as needed, every other day etc.). Additionally, written was shift 2 (2PM-10PM) to perform care. Check mark was documented on 08/29/2024, however no check mark was within 08/28/2024 or 08/30/2024 box indicating wound care was not completed. Record review of Resident #4's MAR, order date 08/10/2024 revealed, Mirtazapine (antidepressant) 15MG Tablet for: Remeron, give 15MG by mouth at bedtime for depression, documented within the 08/30/2024 box was a check mark, however on 08/28/2024 and 08/29/2024 there was no documented check mark within the respective boxes indicating medications were not given. Additionally, order date:03/13/2024, within the same MAR, Resident #4 to receive Lisinopril 5MG tablet: Administer 0.5 tablet by mouth 8:00 in the morning every day. If BP is less than 90/60 administer med and call MD, take and record pulse 0.5tablet=2.5MG. Documented administration on 08/31/2024, however on 08/29/2024 and 08/30/2024 no medication administration is recorded, nor any blood pressure reading within their respective designated boxes, indicating Lisinopril was not administered according to physician orders. Record review of Resident #5's MAR, order date 01/13/2024 revealed, Resident #5 to receive Carbidopa/Levodopa (treat Parkinson's disease) 25-100MG tablet: take 1 tablet by mouth three times daily (8A,12P,4P). Documented within the MAR, Resident #5 received medication on 08/30/2024 at 4PM, and on 08/31/2024 at 8AM,12PM, and 4PM. On 08/28/2024 the 12PM, AND 4PM boxes had no check marks indicating medication was not administered per physician orders. On 08/29/2024 the 8AM, 12PM, 4PM boxes had no check marks indicating medication was not administered per physician orders. On 08/30/2024 the 8AM and 12PM boxes had no check marks indicating medication was not administered per physician orders During an observation on 08/31/2024 at 11:30AM multiple MARs/TARs for various residents were observed in the conference room indicating paper charting was in affect within the facility. During an observation on 09/01/2024 at 1:23PM observed multiple staff members including the Interim DON, and ADON A, in an activities room surrounded by at least 7-9 resident's paper MARs/TARs. Each member had a writing utensil in hand and were inscribing within the MAR/TAR pages. During an interview on 08/31/2024 at 12:11PM TN A stated on Wednesday 08/28/2024 she was notified by ADON A that the facility was experiencing a viral cyber-attack which impacted all electronic health records. TN A stated on Wednesday 08/28/2024 she verbally instructed all nurses that wound care was to be done by the nurses as she was directed to help with another facility task. TN A stated she verbally instructed each nurse on how to perform the wound care as she did not have access to orders, MARs or TARs. TN A stated from 08/28/2024-08/30/2024 she did not document on any paper chart or write within any nurse's paper notes, and reiterated she did not have access to document. TN A stated on 08/30/2024 MARs and TARs arrived and she attempted to back document on the affected dates of 08/28/2024-08/30/2024.TN A gave no definitive answer when asked how she accurately ensured wound care was being carried out appropriately not only by her but also the nurses on 08/28/2024-08/30/2024. TN A stated wounds could potentially get worse if not appropriately documented on, as it a tool that physicians use to monitor the care a resident receives, and some physicians may increase or change the frequency of care. TN A stated documentation, either in MARs or TARs, is essential to each resident's care. TN A reiterated the reason she did not document precisely when she provided wound care to her residents, was that she did not have access to chart. During an interview on 08/31/2024 at 1:30PM RN B stated she was new to the facility. RN B stated on 08/28/2024 she was notified by ADON A that the facility was experiencing a technological viral cyber-attack and would not have access to the online electronic health record of her residents. RN B stated she pleaded with the clinical administration for paper orders, MARs, or TARs for her residents to appropriately document and care for her residents. RN B stated she requested these items multiple times on 08/28/2024, 08/29/2024, and 08/30/2024. RN B stated each time she requested the essential documents her administration clinical staff members told her they did not have any orders, MARs/TARs to give. RN B stated from 08/28/2024 to 08/30/2024 she administered care/medications from memory and did not document the administration/care because she had no resident record to document on. RN B stated she doodled on pieces of paper some random charting, and at times she inquired to other tenured nurses about pain PRN orders, because she did not know exact dosages to administer. RN B stated she feared for the safety of her residents and her license. RN B stated documenting is critical for each resident, as it is a critical way to ensure care and medications are being provided according to physician's orders. RN B stated she wanted to be truthful and continued by stating she was verbally instructed to perform wound care on a resident (could not recall), she stated she had no orders to follow only what was verbalized to her from the wound care treatment nurse, on an unknown day. RN B stated she recalled she performed the wound care but did not document it as she did not have the resident's chart to document on. RN B stated on 08/30/2024 the facility received MARs and TARs for the whole facility but was not given immediately as the administration clinical staff were sorting out the orders. RN B stated, when asked about Resident #4, and Resident #5's medications administration, she could not recall specifically giving or being notified of any non-administration, about the above-mentioned medications. RN B stated, when asked about Resident #2's wound care, she stated she recalled providing wound care on 08/28/2024 but did not document the care as she did not have nurse's notes, or TARs readily available to her. RN B stated she does not know if the wound care treatment nurse performed wound care for Resident #2 on 08/29/2024 or 08/30/2024. During an interview on 08/31/2024 at 3:05PM, RN A stated when he arrived on Wednesday, he did not have access to his residents online electronic health records, nor any paper charts from 08/28/2024-08/30/2024. RN A stated he did chart some notes on nurse's note paper, and when the three nurse's note pages were shown to him, RN A stated the penmanship was entirely his. RN A stated he documented what he could on 08/29/2024 and 08/30/2024 but did not document every specific medication or care provided, no definitive reason given. RN A stated on 08/30/2024 he recalled receiving MARs and TARs for his residents and has attempted to back document for 08/28/2024-08/30/2024. RN A stated, when asked about Resident #4, and Resident #5's medications administration, he could not recall specifically giving or being notified of any non-administration, about the above-mentioned medications. RN A stated when asked about Resident #1, Resident #2, and Resident #3's wound care, RN A stated he does recall performing wound care for Resident #1 and Resident #3, but only documented Resident #1's care on 08/30/2024 but does not recall documenting wound care on 08/28/2024 nor 08/29/2024, additionally does not recall documenting wound care for Resident #3 for days 08/28/2024,08/29/2024, and 08/30/2024. RN A stated accurate documentation is essential to ensure all residents receive the appropriate care. RN A stated there could be a potential negative outcome should medications and care not be documented precisely as it could affect the well-being of every resident. During an interview on 08/31/2024 at 3:22PM MA A stated she did not keep a log of blood pressure readings when she gave blood pressure medications when the cyber-attack occurred from 08/28/2024-08/30/2024. MA A stated she checked blood pressures prior to administering any blood pressure medication. MA A stated she will usually document blood pressure results within the respective resident's electronic health record but did not from 08/28/2024-08/30/2024 because she had no access to online health records nor paper MARs or TARs.MA A stated she could not recall the residents she administered blood pressure medications, but stated she followed the medication blister pack instructions that had printed medication instruction labels with resident's name. MA A stated by not documenting appropriately within a resident's chart either online or on paper, the nurses and clinicians would not have accurate documentation of care and could potentially affect the residents negatively. MA A stated blood pressure medications and diabetic medications are critical to the well-being of those taking them. MA A stated if medications are not documented as being administered, the nurses could give an additional dosage. MA A stated on 08/30/2024 she recalled being notified about MARs and TARs arriving to the facility but did not have the capability of documenting on them as the clinical administration was sorting out the MARs/TARs. MA A stated, when asked about Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5's medications administration, she could not definitively recall specifically giving or notifying any nurse of non-administration, of the above-mentioned medications. During an interview on 09/01/2024 at 1:23PM the Interim DON and ADON A both stated cyber-attacks is not something they were prepared for. Both stated the facility wass usually given ample warning when storms would affect their facility, and as a preparatory effort, both will instruct the medical records personnel to print out all residents MARs and TARs to have readily available for their clinical staff to maintain continuity of care. Both stated their plan was to implement a backup system for cyber-attacks as they would both direct the medical record employee to print out all residents' MARs and TARs first of the month every month. ADON A stated she wanted to remain honest and continued by stating nurses were administering care and medications from memory because the facility did not have any orders, MARs or TARs readily available for the facility residents from 08/28/2024-08/30/2024. ADON A stated on 08/28/2024 when the cyber-attack occurred, she instructed all clinical staff to document on paper nurse's notes, but as she reviewed the documentation, she verbalized only two nurses followed her directive, LVN A and RN A, which she continued by stating was unacceptable. Both stated no person was sent to the hospital during the specific time frame. Both stated potentially, residents could have received inappropriate care or treatment/medication orders as a result for not having physician's orders, MARs and TARs readily available during 08/28/2024 thru 08/30/2024. ADON A stated nurses have attempted to back chart on the paper MARs/TARs from 08/28/2024-08/30/2024. ADON A stated when the cyber-attack was initially discovered on 08/28/2024, she reviewed the emergency facility binder that housed all the residents MARs and TARs from a natural disaster scare earlier this year, and saw the printed date was April 2024 and was not current. Both reiterated multiple times the facility was unprepared for the disastrous technological viral cyber-attack. Record review of the facility's Charting and Documentation policy revised dated December 2006 documented, 1. Signification observations, medications administered, services performed, etc., will be documented in the resident's clinical records.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for 5 of 7 residents (Residents #17, #19, #26, #33, and #56) reviewed for individual in-room activity programming, as evidenced by: 1. Resident #17 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 2. Resident #19 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 3. Resident #26 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. 4. Resident #33 did not have an in-room activity plan developed and implemented to meet his individual interests, abilities, and needs. 5. Resident #56 did not have an in-room activity plan developed and implemented to meet her individual interests, abilities, and needs. This failure could place the residents at risk for isolation, decline in cognitive status, and decreased feelings of well-being within their environment. The findings included: 1. Resident #17 Review of the Resident #17's Face Sheet, dated 3/14/2024, revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: hypertension (high blood pressure); atrial fibrillation (abnormal heartbeat); congestive heart failure (the heart does not pump blood as well as it should and cannot supply enough blood to meet the body's needs); cerebral infarction (stroke); speech and language deficits following cerebrovascular disease (difficulty or not able to speak); chronic obstructive pulmonary disease (lung disorder that affects breathing); hypothyroidism (thyroid disorder); and gastro-esophageal reflux disease (back-up of stomach acid into the throat). Review of Resident #17's Annual MDS Assessment, dated 6/04/23, revealed the BIMS was not able to be completed and the resident had short-term and long-term memory problems. The assessment documented the staff had assessed the resident's activity preferences as listening to music. Review of Resident #17's comprehensive care plan revealed a care plan dated 10/17/23 that documented the resident was unable to participate in activities due to bedrest. The documented goal was for the resident to enjoy individual activities and maintain the highest level of independence daily and ongoing over the next 90 days. The documented approaches were to schedule activities in room daily and to create an activity plan based on the resident's preferences. Review of the Activity Progress Note dated 2/15/24 revealed Resident #17 had attended the valentine party along with her family and everyone was in good spirits. The note documented the resident would continue to be brought to music events. Observation on 3/12/24 at 10:05 AM revealed Resident #17 was lying on her left side in bed with positioning pillows between legs. The resident's feet were swollen. She was using oxygen via nasal cannula and had a feeding tube. Resident #17's eyes were open, and she was making vocal noises and coughing. The head of the bed was elevated. She did not respond verbally when her name was spoken. Observation on 3/12/24 at 4:25 PM revealed Resident #17 was in bed with oxygen in use and the tube feeding infusing via pump. Resident #17 made eye contact but did not speak. In an interview on 3/14/24 at 11:36 AM, the Activity Director stated she talked with Resident #17 in her room and the resident understood. She stated Resident #17 could look at magazines. The Activity Director stated Resident #17 did not verbalize a lot, but she did understand and did try to respond. She sated she tried to see Resident #17 in her room [ROOM NUMBER] times per week and tried to engage the resident in conversation. The Activity Director stated she though Resident #17 would benefit from outdoor activity, such as sitting on the patio. She stated she needed to let the CNAs know in the morning if she had something planned for the residents who were usually in their beds in their rooms. 2. Resident #19 Review of Resident #19's Face Sheet, dated 3/14/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: hemiplegia affecting left nondominant side (left sided weakness); osteoporosis (deterioration of bone tissue causing bones to become weak and brittle); cerebral infarction (stroke); hypertension (high blood pressure); fractured right femur (right hip fracture); osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone); pain; hyperlipidemia (high cholesterol); anxiety disorder; and major depressive disorder. Review of the Nursing Note, dated 1/22/24, revealed Resident #19 fell from her wheelchair and landed on her right hip. She was transferred to the emergency room and was admitted to hospital. Review of the Nursing Note, dated 1/26/24, revealed Resident #19 returned to the facility from the hospital with a diagnosis of fracture of unspecified part of neck of right femur (right hip fracture). Review of Resident #19's comprehensive care plan revealed it was revised 1/26/24 to address history of falls, fracture right hip, and pain. Review of Resident #19's Activity Assessment, dated 1/26/24, revealed the following: Average Time Involved in Activities: Some - from 1/3 to 2/3 of time. Recent Changes to Activity Involvement: Decrease in activity involvement. Reason for Recent Activity Change: other - fall injury. Review of Resident #19's Medicare 5-day MDS Assessment, dated 2/02/24, revealed a BIMS score of 13 out of 15 (cognitively intact); pain management; fall with major injury; activity preferences: participate in religious practices - very important; listen to music, animals/pet, current news, group activities, go outside - somewhat important. Review of Resident #19's comprehensive care plan revealed a care plan dated 2/05/2024 that documented the resident was unable to participate in activities due to bedrest. The documented goal was for the resident to enjoy individual activities and maintain the highest level of independence daily and ongoing over the next 90 days. The documented approaches were to schedule activities in room daily and to create an activity plan based on the resident's preferences. Review of the Activity Note, dated 2/20/24, revealed documentation Resident #19 has decreased her attendance in activities due to a fall at the facility but will return to attend when she recovers. Resident is visited in her room to check in with her and hope for a speedy recovery. Review of Resident #19's Social Service Note, dated 2/20/24, revealed documentation the annual / readmission care plan was reviewed with the IDT at this time. Resident has decreased activities participation due to having fall incident and fracture recovery process. Resident continues yelling at times during the day when wanting attention or needing pain medication. Sometimes resident will request to be seated in wheelchair but at this time is not safe for her to be up in wheelchair due to history of falls and fracture. Continue to monitor her behavior. Observation on 3/11/24 at 12:34 PM revealed Resident #19 was lying in a low bed and had not yet been served the lunch meal. Observation on 3/11/24 at 12:41 PM revealed Resident #19 was lying in bed, was awake, and the television was on in the room. During an observation and interview on 3/12/24 at 5:21 PM, Resident #19 was resting in bed. She stated she liked to attend parties and singing activities. In an interview on 3/14/24 at 12:10 PM, the Activity Director stated Resident #19 had been on bedrest since she fell a couple weeks ago. She stated the resident liked to color, enjoyed pet visits (dog) every month, and playing loteria (Spanish bingo). The Activity Director stated the resident attended group activities when able and used to lead the rosary prayer group. The Activity Director stated she only visited Resident #19 last week for this month and had brought her a Coke. 3. Resident #26 Review of Resident #26's Face Sheet, dated 3/14/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: unspecified intellectual disabilities; nonpsychotic mental disorder; epileptic seizures (a brain condition that causes recurring seizures); chronic kidney disease (gradual loss of kidney function that can lead to kidney failure); hypothyroidism (thyroid disorder); hyperlipidemia (high cholesterol); dysphagia (swallowing problem); and gastrostomy status (feeding tube). Review of Resident #26's Annual MDS Assessment, dated 8/16/2023, revealed the BIMS was not able to be completed. The assessment documented the staff had assessed the resident's activity preferences as listening to music. No other activity preferences had been selected. Review of Resident #26's comprehensive care plan, dated 1/24/2018, revealed a care plan documented the resident did not demonstrate interest in organized activities and documented a goal for the resident to participate in activities within her capabilities. The documented approaches included in-room visits 3 times weekly for sensory stimulation, invite the resident to activities, and familiarize the resident with the nursing home environment and activity programs on a regular basis. Review of Resident #26's Quarterly Activity Assessment, dated 2/25/24, revealed documentation for the resident's goal to accept one-to-one activity visits for at least 15 minutes 2 times weekly. The assessment documented the resident was in good health and would be visited in-room [ROOM NUMBER] times weekly for conversation and sensory stimulation and would attend any special events during the next 90 days. The assessment documented to remind the resident of special events and escort her to and from her room. Observation on 3/12/24 at 10:37 AM revealed Resident #26 was lying in bed, rolling around, and making grunting noises. She was observed to have a feeding tube. The resident's bed had padded half side rails and a fall mat was on the floor at the bedside. In an interview on 3/14/24 at 6:03 PM, the Activity Director stated she did not have documentation of in-room visits with Resident #26. She stated she was in Resident #26's room last week and hung some pictures in her room and played some music, but she did not document this. 4. Resident #33 Review of Resident #33's Face Sheet, dated 3/14/2024, revealed a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: mood disorder with depressive features; pain; and dementia with anxiety. Review of Resident #33's Admission MDS Assessment, dated 10/12/23, revealed a BIMS score of 12 out of 15 (moderate cognitive impairment) and his activity preferences of current news and favorite activities were somewhat important. Review of Resident #33's comprehensive care plan revealed a care plan dated 10/19/23 which documented the resident had very little participation in activities. The documented goal was for the resident to participate in activities of choice over the next 90 days. The approaches included Social Service visits to discuss interests and past social patterns in the community, refer to psychological counseling/mental health specialist, provide privacy for family and friend visits, provide opportunities for increased socialization, introduce to other residents, encourage social conversations, and one-to-one visits. Review of the Activity Assessment, dated 1/26/24, revealed the resident participated in Socialization activities and had attended a coffee social and one-to-one activity visits 2 times weekly. (The assessment did not specify the type or topic of one-to-one activity.) Observation on 3/12/24 at 10:55 AM revealed Resident #33 was lying on his back on low bed with floor mats on both sides of bed. The resident's eyes were closed. A geri-chair was observed in a corner of the room. (A geri-chair is a specialized reclining chair that offers more versatility and support than a conventional wheelchair can provide.) Observation on 3/12/24 at 4:41 PM revealed Resident #33 was lying on his back in bed and was hollering loudly speaking in Spanish. In an interview on 3/14/24 at 12:03 PM, the Activity Director stated Resident #33 had been brought to group activities in a geri-chair. She stated he started yelling and screaming. She stated he was very hard of hearing. She stated he came to a coffee social and was calm while he drank coffee, and then became anxious. The Activity Director stated Resident #33 had hearing impairment and behavioral concerns. 5. Resident #56 Review of Resident #56's Face Sheet, dated 3/14/2024, revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: Parkinson's disease (chronic and progressive movement disorder with tremors, stiffness, and slowing of movement); chronic obstructive pulmonary disease (lung disorder affecting breathing); anxiety disorder; restlessness and agitation; depression; hypertension (high blood pressure); dementia; hyperlipidemia (high cholesterol); chronic embolism and thrombosis of lower extremities (blood clots in legs); and edema (fluid retention). Review of Resident #56's Annual MDS Assessment, dated 9/04/2023, revealed a BIMS score of 3 out of 15 (severely cognitively impaired). The resident's activity preferences had been completed by staff and no activity preferences were selected. Review of Resident #56's comprehensive care plan revealed a care plan dated 3/07/2023 that documented the resident was unable to tolerate usual activities due to poor endurance. The care plan goal was to continue one-to-one visits. The care plan was revised 2/09/2024 and included a documented approach to assess the resident's response to new activity plan and modify as needed, and create an activity plan based on resident's preferences. Observation on 3/11/24 at 1:29 PM revealed Resident #56 was resting on her right side in bed using oxygen via nasal cannula. She was awake, alert, and made eye contact when her name was spoken. Floor mats were located on both sides of her bed. Observation on 3/12/24 at 3:57 PM revealed Resident #56 was resting on her back in bed. In an interview on 3/14/24 at 11:16 AM, the Activity Director stated she visited Resident #56 in her room. She stated Resident #56 was sometimes assisted into a geri-chair but she was never taken out of her room. The Activity Director stated Resident #56 could not participate in physical activities. The Activity Director stated she would open the window blinds, turn on the television, or play music on her iPhone for the resident. The Activity Director stated she did not document any notes in the resident's record or complete an activity assessment. She stated she only completed assessments for new admissions, re-admissions, and yearly's (annual assessments). The Activity Director stated she spoke with the Super CNA (lead CNA) about getting Resident #56 up in a geri-chair to see if she could tolerate sitting up and how long. She stated Resident #56 had not attended any group activities. The Activity Director stated she did not think she had seen Resident #56 this month. She stated she tried to see all the residents every month. In an interview on 3/14/24 at 11:36 AM, the Activity Director stated she had not developed specific in-room activity plans for the residents who remained in their rooms. She stated she did not keep documented records of one-to-one visits with individual residents and did not document the date, time, or what she did during her visits with individual residents. The Activity Director stated she completed Activity Assessments when they populated for residents who were new admissions or re-admissions from the hospital after she received a prompt to complete an assessment in the electronic health record system. In an interview on 3/14/24 at 7:41 PM, the DON stated the Activity Director should have an activity log with documentation of in-room activities. She stated the Activity Director was probably nervous because it was her first survey. She stated she would explain to her what was needed. Review of the facility's Recreation Services policy and procedure for Individual Programming, dated 12/1999, revealed [in part]: Policy Regularly scheduled programming will be provided to all residents who are unable and/or unwilling to attend group activities. Purpose Individual programming ensures that all residents who are unable and/or unwilling to participate in group programs have consistent, goal-oriented, and individualized recreation opportunities. Individual interventions: Structured individual programs will be developed based on each resident's assessed needs. Scheduling: The individual program will be provided according to a consistent schedule identifying specific days of the week, the time frame in which the program will occur, and residents who will receive services within the specified time frames. Each resident's individual program will include interventions which meet the resident's assessed social, emotional, physical and cognitive functioning needs. These approaches will reflect the resident's lifestyle and interests and will be incorporated into the interdisciplinary care plan . Individual participation record: Specific service provided and resident response to the activity will be documented on an Individual Participation Record and utilized to evaluate progress toward goal attainment.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident # 81) reviewed for infection control practices. CNA A failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #81. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #81's face sheet, dated 03/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included UTI (infection of the urinary tract), retention of urine, and hemiplegia (paralysis of one side of the body). Record review of Resident #81's MDS Annual Assessment, dated 12/17/23 reflected Resident #81 was dependent with most ADLs and was always incontinent of bowel and bladder. Resident #81 had a BIMS score of 10 (moderate cognitive impairment). Observation and interview on 3/12/24 at 10:42 a.m. of incontinence care for Resident #81 revealed CNA A, before the start of care, washed her hands and gathered supplies. She then donned gloves and removed Resident #81's urine soiled brief. She did not sanitize her hands or change gloves before she placed a clean sheet, pad, and brief on the bed partially underneath the resident and touched the dirty linen and incontinent pad which was still laying on the bed. She then performed incontinent care and removed the soiled linen and her gloves and sanitized her hands. She applied new gloves and finished making the bed and fastened the resident's brief. She gathered the soiled supplies in a bag and washed her hands before leaving the room. She stated she knew she should have changed gloves and sanitized her hands before touching the clean linen and brief. She stated this could lead to in infection. In an interview on 3/12/24 at 10:50 AM, CNA A did not speak English but was able to relay through an interpreter that she had received infection control training recently. CNA A stated cross contamination was mixing clean with dirty and that she should have washed her hands before she retrieved Resident #81's clean brief and fastened it. She stated Resident #81 could get an infection for not following good infection control practice. In an interview on 3/12/24 at 10:50 AM the DON stated she was aware of some of the concerns raised about infection control practices. She explained the wound care nurse was responsible for infection control in the facility. She stated the Nurses trained and monitored staff with return demonstration. The DON stated aides were expected to follow standard precaution which included washing hands and changing gloves while providing care. She stated CNA A knew she should change gloves and sanitize her hands when touching a clean area after removing a soiled brief. She stated failure to practice good hand hygiene could result in an adverse outcome for the resident due to infection. Record review of the facility's policy and procedure for Handwashing/Hand Hygiene, dated as revised February 2018, reflected the following [in part]: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and h. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents f. Before donning sterile gloves. g. Before handling clean or soiled dressings, gauze pads, etc. ii. Before moving from a contaminated body site to a clean body site during resident care . m. After removing gloves

Based on observation, interview, and record review the facility failed to ensure that the daily nurse staffing information, including the facility name, the current date, the total number and actual hours worked by RNs, LVNs, and CNAs, and the resident census, was posted on a daily basis for 3 of 3 staffing postings reviewed for daily staffing. The facility failed to update the daily staffing information posting on (include the dates) to reflect the actual hours worked by licensed and unlicensed staff. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 03/11/24 at 10:00 am, revealed the daily staffing pattern was posted on the door of the medication room however the staffing information revealed the number of staff scheduled for each shift 6A-2P, 2P-10P, and 10P-6A. The staff posting should include the actual time worked during that shift for each category and type of nursing staff. Observation on 03/12/24 at 10:30 am, revealed the daily staffing pattern was posted on the door of the medication room did not reflect the actual hours worked by licensed and unlicensed staff. Observation on 03/13/24 at 11:00 am, revealed the daily staffing pattern was posted on the door of the medication room did not reflect the actual hours worked by licensed and unlicensed staff. Observation on 03/14/24 at 10:00 am, revealed the daily staffing pattern was posted on the door of the medication room did not reflect the actual hours worked by licensed and unlicensed staff. During an interview with the DON on 03/14/24 at 6:20 pm, She stated she knew that it is a requirement that the Nurse Staffing Posting should be updated and posted daily, but the Administrator posts the staffing sheet. She further stated failure to post the actual hours worked could cause confusion on staffing and resident care issues and not give the public an accurate number of staff and staff hours present on any given shift. During an interview with the Administrator on 3/14/24 at 8:30 pm, stated, he posts the staffing pattern on a daily basis and not posting the actual hours worked was an oversight on his part and not having the actual hours staff works each shift could give the residents and the public inaccurate information on the number of staff working and hours worked on any given shift Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, showed [in part]: Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift .will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3 .The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN [registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift 41944 FACILITY Sufficient and Competent Nurse Staffing

Based on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Survey Agency) for 1 of 5 resident (Resident #1) reviewed for reporting serious bodily injuries. The facility failed to report to Health and Human Services Commission when Resident #1 was found on the floor with laceration above left eye that required 5 sutures. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included: Record review of Resident #1's face sheet dated 08/19/2022 revealed a [AGE] year-old female with an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 3 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's occupational therapy progress note dated 8/10/22 revealed Resident #1 required mod (50% assistance) assistance for hygiene and grooming in sitting, and max (75% assistance required) assistance for upper body dressing. Record review of Resident #1's physical therapy progress note dated 8/15/22 revealed Resident #1 required min (25% assistance) assistance and use of a 4-wheel walker to ambulate 20 feet, and min (25% assistance) assistance for bed mobility and transfers. Record review of Resident #1's Morse fall assessment score dated 07/30/2022 revealed a score of 50 which indicated Resident #1 was a high fall risk. Record review of Residents #1's care plan dated 08/01/2022 revealed Resident #1 was a fall risk and had a goal to minimize risk for falls daily and ongoing over the next 90 days. Interventions for this goal, dated 08/01/22 were, Prefers [NAME] tennis shoes, refer to PT for eval, uses wheel chair for long distance mobility, uses tab alarm while in the chair and bed, remind to ask staff for assistance with ambulation, refer to restorative nursing program, needs a night light to help see at night. Monitor for change in condition that may warrant increased supervision/assistance and notify the physician, keep walker within reach at all times, assist with 1 staff member for all ambulation, assist with stand by assist for all ambulation, low bed with mats, assure that area is adequately lit and free from clutter, fall precautions, keep bed in lowest position. Keep call light in reach and encourage to use, pharmacy to review medications after each fall and therapy to screen after each fall Record review of in-house incident report from 8/15/22 revealed Resident #1 was found by CNA C face down on floor in her room with adult brief around her legs and laceration above left eye. Record review of Resident #5 medical chart from 8/15/22 revealed Resident was assessed by LVN B with injury of laceration above eye noted and pain on left shoulder of 8/10. MD was notified by LVN B. Record Review of TULIP (HHSC online incident reporting application) on 08/18/2022 at 3:30 p.m. revealed the facility had not made a self-reported incident involving Resident #1. During an interview on 08/19/22 at 12:30 pm, the Administrator stated he was the abuse coordinator and was responsible for reporting any allegations of abuse, neglect, exploitation, and injuries of unknown origin resulting in serious bodily injuries. The Administrator stated staff had been trained at minimum annually, but he liked to train them quarterly over reporting of any allegations that resulted in serious bodily injury. The Administrator stated he and the DON were primarily responsible for training staff. When asked what procedures are followed for unwitnessed falls with injury the Administrator stated, Immediate investigation, if it has an injury we take care of the resident, but we need to investigate right away, notifying all and getting resident help. If it's a serious injury we report within 2 hours. If we don't we go on with it. We have a process, if at some time we find something serious we report it right then. If there's a repeat fall I ask about interventions and progress interventions. The Administrator stated the date of incident involving Resident #1 was on 08/15/22. The Administrator stated on 8/16/2022 he had asked his leadership staff about any falls with injury that would be reportable and stated he wasn't made aware of any. The Administrator stated he had not been made aware of any injury until 8/18/2022. The Administrator was asked if he was aware of the reporting time frames for incidents of allegations that resulted in serious bodily injury he stated, yes, allegation of abuse or anything serious is 2 hours if not its 24 hours. When asked if the incident was reported within that time frame, the Administrator stated, no. When asked if the incident was reported to any state agency the Administrator stated, no. When asked why it was not reported the Administrator stated, we knew what the cause was, and we knew it was associated with a fall based on the 3 separate interviews and everything just made sense and I had no evidence of neglect, and I just I didn't see anything there. The Administrator stated the fall was unwitnessed. When asked if Resident #1 was interviewed and able to explain what happened, the Administrator stated, Not to me but to 3 other individuals at 3 different times. I believe she was interviewed on the same day. When asked if Resident #1 was cognitively impaired the Administrator stated, based on BIM score, yes. The Administrator stated they have daily meetings with leadership during their morning meetings to know of any incidents, if those incidents had any injury and if they need to be reported. When asked how not reporting allegations that result in serious bodily injury negatively affect the residents, the Administrator stated It effects their quality of life, their everything, it can even shorten their life, they can get depressed psychologically. Sending them to the hospital puts them at risk of getting other illness and it can increase residents' confusion. During an interview on 08/19/2022 at 11:35a.m., RN A stated the Administrator was the abuse coordinator and was responsible for reporting allegations of abuse, neglect, exploitation, and injuries of unknown origin resulting in serious bodily injuries. RN A stated staff was required to complete training over abuse, neglect, exploitation, and reporting annually. RN A stated the incident of Resident #1's fall happened on 08/15/22 with initial injury of a gash on left eyebrow that RN A noted during her assessment. RN A stated the findings at hospital were 4 sutures to laceration. RN A stated Resident #1 was cognitively impaired. RN A stated reporting time for abuse its 2 hours and reportables like this is 24 hours. RN A stated the incident involving Resident #1 was not reported to any state agency because The other nurse, LVN B told me that she was coming out of the bathroom, and she fell . By the time I went in she was already in the wheelchair. I didn't think there was a need to report it. RN A stated, We go over any deadlines and incidents before morning meeting to see what needs to be reported or followed up on. RN A stated fall involving Resident #1 on 8/15/22 was unwitnessed. RN A was asked, are you are able to determine exactly what happened during an unwitnessed fall involving a resident with impaired cognition such as Residents #1 with a BIMs score of 3? RN A stated, No, because they are by themselves and if they are cognitively impaired you wouldn't be able to. When asked how not reporting allegations that result in serious bodily injury can negatively affect the residents, RN A stated, If they needed further evaluation and they didn't get it or not receiving appropriate treatment on time that can have a negative impact. When RN A was asked what's the facilities policy on reporting allegations resulting in bodily injury, RN A state, We have to investigate, look into it and interview staff that were present but yeah we follow closely with the state guidelines and make sure if it needs to be reported that it's done within the time frame it needs to be reported in. During an interview on 8/18/2022 at 5:20pm, LVN B stated the Administrator was the abuse coordinator. LVN B stated the incident involving Resident #1 had occurred on 08/15/22 or 08/16/22. LVN B stated he had been notified by CNA C that Residents #1 was on the floor. LVN B stated he had walked into the room and Resident #1 was face down with a lot of blood and her brief around her ankles. LVN B stated Residents #1's initial injury was the laceration above the eye. LVN B stated he interviewed Resident #1, who stated I'm trying to go upstairs with my mother. LVN B stated he had explained to Resident #1 that she had just fell but stated Resident #1 kept coming back to having to go see her mother. LVN B stated he notified the MD who told him to monitor the resident in facility. LVN B stated he was concerned about the amount of blood lost and asked the MD if Resident #1 could be sent out. LVN B stated the fall had been unwitnessed and stated Resident #1 was cognitively impaired to an extent, stating, She has incidents of lucidly, she can carry a conversation, but the conversation can be skewed. But if she is sundowning she will be confused. LVN B stated he was not aware if the incident was reported to any state agency. LVN B stated he followed his protocol to do his monitoring and reporting and then notify everyone above him. LVN B stated not reporting allegations that result in serious bodily injury could negatively affect the residents because If it's not reported and depending on the nature of the injury it can cause severe complications and in certain extreme cases possibly even death or long-standing chronic pain and therefore we are not meeting the patient's needs During an interview on 8/19/22 at 5:00pm, CNA C stated the date of incident involving Resident #1 was on 8/15/22,. CNA C stated he had heard a call for help while assisting another resident. CNA C stated he had walked into Resident #1's room and found her face down with her adult brief around her knees. CNA C stated he had asked Resident #1 what happened and if she was okay and then went to alert LVN B. When asked if Resident #1 was cognitively impaired, CNA C stated Yes, I believe she is. When asked if Resident #1 was a good historian CNA C stated, she has her moments, but it comes and goes. CNA C stated the fall was unwitnessed. Record review of a facility policy titled Abuse Investigation and Reporting with a version date of July 2018 stated under section Reporting stated the following, 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility;. It also stated 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two(2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. twenty-four (24) hours of the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observation, interviews, and record review, the facility failed to ensure that three (Residents #60, #61, and #65) of three residents with indwelling urinary catheters reviewed received the appropriate treatment and services to prevent Urinary Tract Infection (UTI's): The facility failed to ensure Resident #60, #61, and #65's urinary drainage tubing and bag were kept from touching and resting on the floor. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTI's. The findings included: Resident #60 Record review of Resident #60's Face Sheet dated 10/20/21 documented an [AGE] year-old male admitted [DATE] and readmitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #60's Minimum Data Set (MDS) dated [DATE] documented: -Bed mobility: Total dependence required two person physical assist. -Toilet use: Total dependence required two person physical assist. -Personal hygiene: Total dependence required two person physical assist. Record review of Resident #60's Care plan dated 12/16/2020 revised on 7/12/21 documented Urinary Catheter: indwelling. Care plan Goal: Will minimize risk for infection and skin breakdown related to indwelling catheter daily and ongoing over the next 90 days. Interventions: -Will place basin under Foley bag to prevent it from touching the floor [start date 10/18/21] -Monitor Catheter tubing for kinks or twists in tubing [start date 6/21/21] During an observation of Resident #60's Foley catheter drainage bag and tubing on 10/19/21at 4:24 PM revealed it was hanging from the bed on the right side of the bed and the tubing and bag were sitting on the floor mat. During an observation and interview on 10/19/21 at 4:40 PM, Licensed Vocational Nurse (LVN) B went into Resident #60's room to observe the Foley catheter bag and tubing touching the ground. She stated, it [The Foley catheter bag and tubing] should not be touching the ground. she lifted the bed a little to get the drainage bag and tubing off the floor. She revealed it was important that the tubing and drainage bag should have a barrier between it and the floor to prevent risk of infection. Resident #61 Record review of Resident #61's Face Sheet dated 10/20/21 documented a [AGE] year-old female admitted [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #61's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor tubing for kinks; urine collection bag positioned below the bladder and off floor Q Shift. Record review of Resident #61's Comprehensive Care Plan date 09/15/21 documented Urinary Catheter: Indwelling r/t healing decubitus sacral ulcer. Will minimize risk for infection and skin breakdown related to Indwelling catheter daily and ongoing over the next 90 days. Interventions: Change catheter tubing/bag as specified, Catheter care every shift, Monitor skin for s/s infection or irritation, Ongoing assessment for s/s of urinary tract infection. Record review of Resident #61's Admission Minimum Data Set, dated dated dated [DATE] revealed Resident #61 had short and long term memory problem with severe cognitive impairment. Resident #61 had an indwelling urinary catheter. Observation of Resident #61 on 10/19/21 at 4:27 PM revealed she was laying in bed, with her eyes closed. Resident #61's indwelling urinary catheter drainage bag and tubing were visible and hung on the left side of the lower bed frame, with the bottom of the drainage bag and tubing resting on the visibly dirty blue floor mat. Resident #65 Record review of Resident #65 Face Sheet dated 10/02/21 documented an [AGE] year-old female admitted [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #65 entry Minimum Dat Set revealed Resident #65 had short and long term memory problem with severe cognitive impairment. Resident #65 had an indwelling urinary catheter. Record review of Resident #65's Comprehensive Care Plan dated 09/14/21 documented Urinary Catheter: Indwelling related to aid in healing stage 3 sacral ulcer. Will minimize risk for infection and skin breakdown related to Indwelling catheter daily and ongoing over the next 90 days. Monitor catheter tubing for kinks or twists in tubing . Record review of Resident #65's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #65 on 10/19/21 at 4:28 PM revealed she was laying in bed, with her eyes closed. Resident #65's indwelling urinary catheter drainage bag and tubing was visible and hung on the left side of the lower bed frame, with the bottom of the drainage bag and tubing resting on the floor. In an interview with LVN B on 10/19/21 at 4:29 PM, she said the indwelling catheter bag and tubing should not be touching the floor. After inspecting Resident #61's and 65's indwelling urinary catheters, LVN B said the drainage bag and tubing were resting on the floor and then she raised Resident #61's and 65's bed to prevent the indwelling urinary drainage bag and tubing from touching the floor. LVN B said she and the CNAs were responsible for ensuring that the indwelling urinary catheter drainage bag were off the floor. LVN B said the indwelling urinary catheter drainage bag and tubing touching the floor would place the resident at risk for urinary infection. In an interview on 10/20/21 at 01:48 PM with DON it was revealed the nursing staff should have knowledge of placement and position of foley catheter and the bag. The intervention should be monitoring and making sure the catheters were not touching the ground. There should be a barrier between the bag/tubing and the floor. She stated, it was important to make sure the Foley catheter bag and tubing are not touching the floor to prevention contamination and possible infections. Record review of the facility Catheter Care, Urinary policy and procedure dated September 2019 documented The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control: .2 .b. Be sure the catheter tubing and drainage bag are kept off the floor Based on observation, interviews, and record review, the facility failed to ensure that three (Residents #60, #61, and #65) of three residents with indwelling urinary catheters reviewed received the appropriate treatment and services to prevent Urinary Tract Infection (UTI's), in that: The facility failed to ensure Resident #60, #61, and #65's urinary drainage tubing and bag were kept from touching and resting on the floor. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTI's. The findings included: Resident #60 Record review of Resident #60's Face Sheet dated 10/20/21 documented an [AGE] year-old male admitted [DATE] and readmitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #60's Minimum Data Set (MDS) dated [DATE] documented: -Bed mobility: Total dependence required two person physical assist. -Toilet use: Total dependence required two person physical assist. -Personal hygiene: Total dependence required two person physical assist. Record review of Resident #60's Care plan dated 12/16/2020 revised on 7/12/21 documented Urinary Catheter: indwelling. Care plan Goal: Will minimize risk for infection and skin breakdown related to indwelling catheter daily and ongoing over the next 90 days. Interventions: -Will place basin under Foley bag to prevent it from touching the floor [start date 10/18/21] -Monitor Catheter tubing for kinks or twists in tubing [start date 6/21/21] During an observation of Resident #60's Foley catheter drainage bag and tubing on 10/19/21 at 4:24 PM revealed it was hanging from the bed on the right side and the tubing and bag were sitting on the floor mat. During an observation and interview on 10/19/21 at 4:40 PM, (LVN) B went into Resident #60's room to observe the Foley catheter bag and tubing touching the ground. She stated, it [T the Foley catheter bag and tubing] should not be touching the ground. She lifted the bed a little to get the drainage bag and tubing off the floor. She revealed it was important that the tubing and drainage bag should have a barrier between it and the floor to prevent risk of infection.

Based on observation, interview, and record review the facility failed to provide services that met professional standards for one (R #60) of 5 residents reviewed for standards of care. 1.) Resident #60: -LVN A failed to accurately measure Resident #60's Stage 4 Pressure ulcer as per the facility's policy and procedure. This failure could place residents at risk for lack of appropriate care and treatment. Findings include: Record review of Resident # 60's Face Sheet dated 10/20/21 documented an [AGE] year-old male admitted [DATE] and readmitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 60's Care Plan dated 7/17/21 documented Skin integrity, Impaired, Stage IV. Location: Sacrum Pressure Ulcer. Interventions: Assess changes in skin status that indicate worsening of pressure ulcer and notify the physician. Record review of Resident # 60's Minimum Data Set (MDS) dated [DATE] documented: -Bed mobility: Total dependence required two-person physical assist. -Toilet use: Total dependence required two-person physical assist. -Personal hygiene: Total dependence required two-person physical assist. During an observation of Resident # 60's wound care on 10/20/21 at 10:00 AM by LVN A, it was revealed she put on new gloves to measure the pressure wound. She measured the wound at 6cm in length by 8cm in width. During measuring she measured from the healed part of the wound to the end of the other side of the healed part of the wound that surrounded the opened part of wound. LVN A revealed she was measuring from the top healed part of the wound to the end of the other side. She never measured the wound itself. In an interview with LVN A on 10/20/21 at 10:18 AM, it was revealed she was educated her on how to measure wounds on 10/18/21 by the treatment nurse. She stated, I personally measured the whole healed part of the wound and the opened part as one big wound, that part use to be the wound but is now healed, which is probably wrong. She stated she doesn't input the wound measurements because the wound care nurse does it when she comes to do the wound care. She revealed, on the computer record of wound measurements documented by the treatment nurse, the last wound care measurement taken on 10/18/21 was 1.5 cm in length and 3 cm in Width and 0.1 cm in depth. In an interview with DON on 10/20/21 at 01:33 PM, it was revealed the nursing staff should be aware of basic wound care and they had been trained recently. She revealed LVN A had been trained for wound assessment and measuring on 10/19/21. It was revealed the DON and treatment nurse monitored the licensed staff with anything to do with wounds and they educated licensed staff with hands on training of wound. DON revealed the treatment nurse was in charge of wound care and measurements of wounds, but if she's not working, the nurses are in charge of taking care of the wounds. DON stated, LVN A had already told her that she didn't measure the wound correctly because she measured the scar tissue, which was healed, that shouldn't have been measured. She revealed wound measurement should have only be the measurement where the break down in the skin begins and ends, not the healed area. She revealed the importance of measuring the wound correctly, is to find out how the wound is doing and if it's improving. Record review of Weekly skin care tracking report dated 10/18/21 thru 10/22/21 documented Resident # 60's stage 4 to Sacrum measured . 10/7/21- 2 cm Length, 3.4 cm Width, 0.1cm Depth. 10/15/21- 1.5cm Length, 3.2cm Width, 0.1cm Depth. 10/18/21- 1.5cm Length, 3cm Width, 0.1cm Depth. Record review of the facility's undated Wound Measurement Policy and Procedure revealed . Purpose: Wound measurement is an essential part of wound assessment.Continuous monitoring of changes in wound size is an important way of evaluating response to treatment. Steps in the Procedure: 1. Greatest length and width method: In this method the greatest length and the greatest width of the wound are measure across the diameter of the wound, from wound edge to the opposite wound edge.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free from accident hazards on four of six halls in which water temperatures were tested . The facility allowed water temperatures in resident rooms on the Lila, Azul, Blanco and Rosa halls to reach hazardous levels, including the room of one resident with severe cognitive impairment (R#27) and the halls where 12 residents (R#29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41) who were cognitively impaired, wandered, and could not safely mix water resided. The above failures resulted in an Immediate Jeopardy (IJ) situation on 10/23/17. While the IJ was removed on 10/25/17, the facility remained out of compliance at potential harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could affect 13 residents who were ambulatory, cognitively impaired and unable to safely regulate the water temperatures due to their poor cognitive functioning. The findings were: During initial tour on 10/23/17, R#27 resided in room 228 (Rosa hall), and water temperature checked by maintenance supervisor was 119 degrees Fahrenheit. R#27 Review of R#27's Undated face sheet revealed the following: --DOB: 01/29/29 (age 88 /female) --Stay start: 10/01/13 --Hospital return date: 06/25/17 --DX: Dementia, Type II Diabetes,Unspecified mood (affective) disorder, Primary generalized arthritis, Review of R#27's Quarterly MDS dated [DATE] revealed: --BIMS summary score of 06 (severe impairment) --R#27 required limited assistance from one person for handwashing and bathing. --active DX -Alzheimer's Dementia Review of R#27's Care Plan dated 09/07/17 revealed: --Resident tends to wander in the facility. --Risk of elopement. --Has gone out of the facility and walked to the sidewalk. --Resident states she is going home. Wanderguard in place. --Resident has been observed removing her wanderguard. --Resident will minimize the risk of leaving facility or being lost daily and ongoing over the next care plan review. Reveiew of R#27's Care Plan dated 09/07/17 revealed: --Will minimize confusion by reorienting resident daily and ongoing by next care plan review. Review of R#27's Care Plan dated 09/07/17 revealed: --Resident has difficulty making self understoood and has difficulty understanding others. --Loses train of thought. --Resident will be able to communicate ADL needs and will have ADL needs met daily and ongoing by next care plan review. Review of R#27's Care Plan dated 07/31/14 revealed: --Resident has fragile skin with potential for bruising and skin tears. --Resident is at risk of injury and skin tears. --Will minimize risk for bruising and skin tears through next care plan review Review of R#27's Care Plan dated 09/07/17 revealed: --Resident has poor safety awareness --Resident is at risk for falls. --Resident uses the walker for ambulation and has unsteady gait. --Will minimize the risks for falls and injuries daily and ongoing over next care plan review. On initial tour of the Lila hall which began at 12:50 p.m. on 10/23/17, the water temperatures in room 118 and 123 felt hot to the touch. On initial tour of the Rosa hall accompanied by the Director of Nurses (DON) which began at 1:50 p.m. on 10/23/17,the water temperatures in some of the rooms felt hot to the touch. On 10/23/17 the water temperatures were taken by the Maintenance Supervisor (MS) on the Rosa hall using the facility's thermometer. Rosa hall -room 218 at 1:59 p.m. 116 degrees Fahrenheit (F) -room 220 at 2:01 p.m. 120 degrees F. -room 222 at 2:02 p.m. 116 degrees F. -room 224 at 2:04 p.m. 118 degrees F. -room 228 at 2:06 p.m. 119 degrees F. On 10/23/17 at 2:08 p.m., the MS stated he did not know it was a concern when the water temperatures were at or above 110 degrees F. On 10/23/17 at 2:09 p.m., the DON said the water temperatures should not be that hot, but DON did not know the proper temperature range. At 2:27 p.m. on 10/23/17, accompanied by the Administrator, surveyor checked the water temperature in room 118 of the Lila hall and it read 131.7 degrees. At 2:34 p.m. on 10/23/17, accompanied by the Administrator, surveyor checked the water temperature in room 126 on the Lila hall and it read 129.3 degrees. At 2:30 p.m. on 10/23/17, accompanied by the Administrator, surveyor checked the water temperature in room 123 of the Lila hall and it read 130.5 degrees. The Administrator said that the MS was outside checking the boiler temperatures which provided water to the rooms with high water temperatures. At 2:50 p.m. on 10/23/17, the Administrator said all boilers were set at 102 to 105 degrees maximum. Review of Water Temperature records from the water temperature log book revealed no temperatures above 110 degrees for water temperatures recorded from June, 2017 to September, 2017. Review of Water Temperature records revealed the following: 10/18/17 at 3:32 p.m.: Azul Room #108 was 125 degrees Lila #125 was 128 degrees 10/23/17 at 11:11 a.m.: Azul #105 was 118 degrees Lila #119 was 119 degrees Blanco #318 was 117 degrees On 10/23/17 a document titled Bed Status by Location was provided by the ADON. The document had the names of all residents who were ambulatory higlighted. The ADON explained she had written NO next to each of the names of the residents who were unable to regulate the water temperature on thier own and had access to personal in-room sinks and faucets. On 10/23/17 Record review of Bed Status by Location document revealed 10 Residents who were identified by the ADON as being ambulatory, severely cognitively impaired and unable to regulate water temperatures,and who lived on the hallways where the hot water temperatures were discovered to be above the limit: The following residents resided on Azul hall, where high temperatures were recorded in two rooms: R#31, R#32, R#33, R#29 The following residents resided on Lila hall, where high temperatures were recorded in three rooms: R#37, R#38, R#39 The following residents resided on Rosa hall, where high temperatures were recorded in five rooms: R#40, R#41 The following resident resided on Blanco hall, where high temperatures were recorded in one room: R#34 Review of R#29's Undated face sheet revealed: --DOB 08/28/28 (age 89/female) Stay start: 01/04/16 --DX: Alzheimeres disease-unspecified, Type II diabetes, Muscle wasting and atrophy, Essential hypertension Review of R#29's Quarterly MDS dated [DATE] revealed: --BIMS summary score of 03 (severe impairment) --Resident #29 required extensive assistance from one person for handwashing and bathing --active DX - Alzheimer's Disease . Non- Alzheimer's Dementia Review of R#29's Care Plan dated 07/03/17 revealede: --Potential for incresed confusion secondary to Alzheimer's Disease and Dementia. --Will minimize episodes of sonfusiondaily and ongoing through next care plan reivew Review of R#29's Care Plan dated 07/03/17 revealed: --Resident has a hx of wandering, has wanderguard in place --Will minimize risk for wandering daily and ongoing through next care plan review Review of R#29's Care Plan dated 07/03/17 revealed: --Resident had difficulty making self understood and has difficulty understanding others. --Has Dx of Alzheimer's and Dementia --Resident's needs will be anticipated and met daily and ongoing over the next care plan review. In an interview at 4:20 p.m. on 10/23/17, the MS said he was hired to work as the MS for the facility on 10/09/17. The MS said he had experience working in maintenance for other businesses but did not have experience working in nursing homes. The MS said someone was coming on 10/24/17 from another facility to train him on the specifics of the MS job. The MS said he reviewed the water temperature log books that were left in his office by the former MS and it appeared that water temperatures were taken weekly by the previous MS. When shown the log which indicated the water temperatures for the Azul and Lila wings were over 110 degrees on 10/18/17, and the water temperatures for the Azul, Lila and Blanco wings were over 110 degrees on 10/23/17, the MS said he did not know that these temperatures were too high so he did not notify anyone that there was a problem with water temperatures. The facility's Safety of Water Temperatures Policy and Procedure (undated) documented This policy and procedure is a guideline only. POLICY STATEMENT: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. POLICY INTERPRETATION AND IMPLEMENTATION: 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Risk Factors for Scalding in the Elderly: Direct-care staff shall be informed of risk factors for scalding/burns that are more common in the elderly, such as; a. Decreased skin thickness; b. Decreased skin sensitivity; c. Peripheral neuropathy; d. Reduced reaction time; e. Decreased cognition; f. Decreased mobility; and g. Decreased communication. On 10/23/17 at 4:05 p.m., the survey team identified Immediate Jeopardy due to the above failures regarding water temperatures. On 10/23/17 at 5:00 p.m., the facility Administrator was notified that an Immediate Jeopardy situation had been identified due to the above failures. On 10/24/17 at 11:43 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The facility's final Plan of Removal documented: Water Temperature Checks Procedure: To test and assure that water temperatures are maintained at required degrees throughout the facility. The facility will maintain water temperatures between 100 degrees and 110 degrees per the requirements. 1. Maintenance supervisor or designee will conduct a water temperature test from all Resident rooms on each unit for the next week. After that, the temperature recording of water temperatures will be from randomly selected rooms on each wing. 2. The facility had Chavarria's Plumbing conduct an inspection of all facility water boilers to assure proper functioning. This inspection was conducted on 10/23/17. 3. The facility nursing staff will monitor the water temperatures on 10/23/17 from 8:00pm until 6:00am to assure the temperatures are appropriate for the Residents' use. Any irregularities in temperatures will be reported to the facility's Administrator and a notice will be made to not use said water basins until notified of acceptable temperatures. The temperatures on 10/24/17 will be monitored by the Maintenance staff to assure continued compliance. 4. These water temperature tests will be recorded from the Resident room water basins and Resident shower rooms and adjustments will be made to assure the temperatures are appropriate for use by the Residents. The Administrator will monitor all recorded water temperatures. 5. The Director of Nursing and the Administrator conducted an in-service with the nursing staff on adjusting the appropriate water temperatures for the Residents' use. This in-service was conducted on 10/23/17 and 10/24/17. The Administrator and Maintenance staff conducted water testing and regulated water temperatures on 10/23/17, 10/24/17, and 10/25/17. In an interview at 12:50 p.m. on 10/24/17, the Administrator said the former MS was hired in May, 2006. The former MS became ill and worked off and on for the facility over the last year, and assistants were assigned some of the MS duties while he was sick. The current MS was hired on 10/09/17 after giving two weeks notice to his former employer. The MS from another facility owned by the same company was unable to come down to train the MS for approximately two weeks because he was on vacation one week and the next week the facility he was assigned to was being surveyed and he could not leave. The Administrator said former maintenance staff were very competent but were not available to train the new MS hired on 10/09/17 because they had resigned. The Administrator said he was aware that water temperatures in the facility sometimes would go a little high and he said he told the MS to keep an eye on the water temperatures. The Administrator said the MS did his own research on water temperatures and lowered the water temperatures to 108 and then 102 on 10/23/17 later in the day. The Administrator said he was stunned that the water temperatures were as high as they were, and he said he was glad there were no burns reported. The Administrator said no one in the facility bathed by themselves and he had no reports of hot water temperatures. The Administrator said a local plumbing company came out to check the water on the evening of 10/23/17 and found all of the water boilers to be in good working condition, but the temperature gauge on the Lila hall was found to be defective. The Administrator said the Rosa wing was built with water pipes in the attic on one side, and the water could get hotter than in other places. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by checking water temperatures for safe temperatures below 110 degrees. On 10/24/17 at 1:11 p.m., the water temperature of room 118 of the Lila wing was slightly over 110 degrees, and the water temperature of room 123 of the Lila wing was 110.6 degrees. On 10/24/17 at 4:00 p.m., the water temperatures were checked by surveyor and the Administrator, and the results revealed: Blanco Hall, Room #318 was 128.7 degrees Rosa Hall, Room #218 was 121.8 degrees Rosa Hall, Room #224 was 112.9 degrees On 10/25/17 at 9:13 a.m., water temperatures checked by surveyor, the MS and the MS trainer revealed temperatures on the Lila wing rooms 131, 123 and 118 were 111 degrees. The water temperature in room 228 of the Rosa wing was 112.5 degrees. On 10/25/17 at 4:50 p.m., the facility Administrator was notified that the IJ was removed. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. Review of a list of residents who were independently ambulatory and had severe cognitive impairment, and unable to regulate water temperatures, provided by the Assistant Director of Nurses (ADON) A, revealed 12 residents.

Based on observation, interview, and record review. The facility failed to provide services that met professional standards for three Residents (R #3, R #4 and R #5) of three Residents reviewed for standards of care. -LVN P did not consult the Physician for settings for Alternating Pressure/ Low Air Loss mattresses(APM/LAL) for R #3, R #4 and R #5. -LVN P did not know the manufacturer's recommendation for R #3, R #4 and R #5's APM/LAL mattresses. -The facility did not follow recognized standards of practice, in that: R #5 was admitted to the facility with pressure ulcers however, · her ulcer worsened from a Stage 2 to a Stage 3; · developed a new Stage 2 pressure ulcer; · three open areas surrounding the ulcer were not assessed, identified or documented until the surveyor's inquiry. · The Wound Care Nurse determined if a wound was healing by visual observation rather than measurements. · The facility's identification of wound location, assessments, and documentation of the ulcers were contradictory and inconsistent between forms. This deficient practice placed 14 residents at risk of skin breakdown due to not receiving specialized mattress settings as per manufactures guidelines. The findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; . (D) Accurately and completely report and document: (i) the clients status including signs and symptoms; (ii) nursing care rendered; .(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; .(H) Make reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications ; . (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; . (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . The facility's undated Wound/Skin Policy documented Each resident admitted to this facility will be assessed and monitored for skin condition on a regular basis to prevent skin breakdown unless developed of pressure sores is unavoidable due to his/her medical condition. Each resident with skin breakdown/pressure sores will receive the services and treatment to decrease risks of prevention of infection, promote early wound healing, id possible and prevent new pressure sores from developing if possible. Policy Interpretation and Implementation: Licensed Nurses will assess the resident's skin condition as follows: .4. Any observed changes by the Licensed Nurse; 5. Weekly on all residents as per schedule, and document in the treatment record; . 7. All residents will be assessed for risk of skin breakdown using the Braden Scale Form. This will be done upon admission and updated at least every 90 days thereafter. 8. A plan of care for risk breakdown will be initiated and implemented for each resident with a Braden Scale score of 17 and below . 10. When a resident has an open area upon admission, this will be documented on the resident Admission Assessment. 11. Accurate measurements/documentation will be done weekly during the wound rounds. 12. A Licensed Nurse will assess all open areas. Assessment includes stage, size, depth, odor, drainage and surrounding skin condition. Nursing notes must include notification of physician and family. 13.If a resident has multiple wound sites, a complete and separate treatment order and documentation will be written for each site. 14. DON/designee will assess all wounds if need . 15.If no improvement is noted by the 14th day, the treatment regimen will be revised as deemed appropriate 19. Determine etiology or cause of wound to be able to determine Treatment Plan . 20. Stage describe it as partial or full thickness loss instead of Stage 2, 3, or 4. 21. Stage pressure ulcer, as to what it is. Use the term resolved, instead of healed . 23. Don't leave wounds open to air and keep wound temperature warm to hasten wound healing. 24. Wound healing starts at the perimeter. Prioritize in treating the surrounding skin irritation . The facility's undated Pressure Ulcer Protocol documented Document initial assessment of pressure area in the Pressure Ulcer Documentation Record and updated at least weekly for effectiveness of treatment interventions. The facility's undated Pressure Ulcers Policy and Procedure documented At the time a pressure ulcer is identified, the following must be put into place immediately. 1. Make sure the resident is placed immediately on a pressure-relieving device. 2. Initiate and document on the weekly skin sheet. 3. Initiate and document on the daily pressure ulcer record 4. Call Medical Doctor for treatment orders 5. Notify Responsible Party 6. Write treatment order correctly 7. Obtain dietary consult. Supplements, increased protein, large portions, vitamin therapy, etc. 8. Turn schedules: Q 2 hr, and document on treatment sheet 9. Hydration Schedule document on treatment sheet 10. Make sure all pertinent information is documented in nurse's notes 11. Initiate Care Plan immediately and update weekly. R #4 R #4's Face Sheet dated 06/01/16 revealed R #4 was a [AGE] year old male re-admitted to the facility on [DATE] with the following diagnoses; Gastrostomy Status (surgical opening into the stomach for the purpose of administering medications, nutrition and fluids), Urinary Tract Infection, [MEDICAL CONDITION] (respiratory disease which obstructs the air exchange in the lungs), Contracture, [MEDICAL CONDITION] (circulatory impairment in the extremities), Diabetes, Kidney Failure, [MEDICAL CONDITION], Hypertension and Surgical Wound. R #4's Physician Telephone Order dated 06/11/16 revealed Air Mattress to be in place at all times. R #4's consolidated Physician order [REDACTED]. R #4's consolidated Physician order [REDACTED]. R #4's Admission Minimum (MDS) data set [DATE] revealed R #4 was rarely/never understood or understands others. R #4 had moderately impaired vision, and was totally dependent with bathing, transfers, bed mobility and dressing with the assistance of two people. R #4 had upper and lower extremity range of motion impairment. R #4 received more than 51% of caloric intake and more than 501 cc/day fluid intake through his gastric tube. R #4 was incontinent of bowel and had a urinary catheter. R #4 was receiving the following Skin and Ulcer Treatments: Pressure reduction device, for chair and bed, was on a turning/repositioning program and had Nutrition or Hydration intervention to manage skin problems. R #4 weighed 161 pounds. R #4's Care Plan (review date 07/16/16) revealed Resident has fragile Skin with potential for bruising and skin tears .Assist to turn and reposition Q2h and PRN . R #4's Care Plan (problem onset 11/12/10) revealed Resident is totally dependent on staff for ADLs due [MEDICAL CONDITION] Rt. [MEDICAL CONDITION], poor cognition; requires assistance of 2 persons to transfer .*Turn, reposition and provide incontinent care q2hrs and prn . On 08/29/16 at 3:40 p.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds, static mode. On 08/30/16 at 9:05 a.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds, static mode. On 08/31/16 at 8:10 a.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds static mode. R # 5 Review of the facility's Admission and Discharge Report dated 08/31/16 revealed R #5 was admitted on [DATE] from the hospital and was discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and was discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and was discharged on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital. Review of R #5's Face Sheet dated 08/19/16 revealed R #5 was [AGE] years-old and had [DIAGNOSES REDACTED]. in the stomach used to administer medications, hydration, and feeding of formula) status, [MEDICAL CONDITION], Resistance to [MEDICATION NAME] related antibiotics,[MEDICAL CONDITION] due to [MEDICAL CONDITION] (MRSA), Type 2 Diabetes Mellitus with other Diabetic Kidney complication, Infectious Gastroenteritis and [MEDICAL CONDITION], Acquired Absence of Right Leg above knee, Disruption of wound, unspecified, Urinary Tract Infection, Acute [MEDICAL CONDITION], Cerebral Infarction, Hyperlipiderma, Long Term (current) use of Insulin, Acquired absence of Limb, Acquired absence of Left Leg below knee, Other Malaise and Heart Failure. Review of R #5's Initial Admission Nursing Evaluation dated 12/22/15 revealed R #5 had one Stage 2 Pressure Ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red of pink wound bed, without slough), upon admission to the facility. The most severe tissue type for any pressure ulcer was a 22= Granulation tissue, (pink or red tissue with shiny, moist, granular appearance). The facility failed to document the number of Stage 2 pressure ulcers that were present upon admission/entry and the date of discovery of the Stage 2 pressure ulcer. There was no documented evidence of R #5's number of unhealed pressure ulcers at each stage and the dimensions of unhealed Pressure Ulcers. Further review of the Admission Nursing Evaluation form revealed the assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 02/12/16 revealed R #5 was readmitted to the facility with one Stage 3 Pressure Ulcer (Stage 3: Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) Pressure Ulcer. There is no documented evidence of R #5's number of unhealed Pressure Ulcers at each stage, the dimensions of unhealed Stage 3 Pressure Ulcers (Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon or muscle. Slough may be present but does not obscure the depth of tissue loss), and the most severe tissue type for any pressure ulcer. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 03/05/16 revealed R #5 was readmitted to the facility with two Stage 2 Pressure Ulcers. There is no documented evidence of R #5's number of unhealed Pressure Ulcers at each stage, the dimensions, and the most severe tissue type for any pressure ulcer. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 06/19/16 revealed R #5 was readmitted to the facility with one Stage 2 Sacral (Sacrum-large, triangular bone at the base of the spine) Ulcer. There is no documented evidence of R #5's Stage 2 dimensions and the most severe tissue type for any pressure ulcer. Review of R #5's Physician Telephone Orders dated 06/23/16 revealed 2. Air Mattress to be in place at all times. Review of R #5's Wound Care Sheet for 06/2016 revealed the following: Stage II Ulcer to right sacral area (CA) Stage II Ulcer to left Sacral area (CA) Unstageable Ulcer to Upper left Stump (CA) Unstageable Ulcer to Lower left Stump (CA) Review of R #5's Braden Scale for Predicting Pressure Sore Risk dated 06/21/16 revealed a Total Score of 9 (9 or below = Severe Risk). Further review revealed no updated score for R #5's re-admission on 08/18/16. Review of R #5's Physician Telephone orders dated 06/23/16 revealed an order for [REDACTED]. Review of R #5's Consolidated Physician order [REDACTED]. R #5's Physician ordered a weekly and PRN Skin Assessment, and an Air Mattress in place at all times. Review of R #5's consolidated Physician orders [REDACTED].#5 received [MEDICATION NAME] Renal @ 45 ML/HR 18 HRs per peg tube via pump. To provide 810 cc/24 hours and 1620 KCAL/24 Hrs. Dispense 24 ready to hang bags with 99 refills monthly. Further review revealed Vitamin C 500 MG, Give 1 Tab via peg tube BID. Proheal SF. Give 30 ML via peg tube QID. Review of R #5's Comprehensive Plan of Care dated 08/19/16 revealed R #5 had an ulcer to the Lt Residual Limb 6.5 X 5.5 X 0.7 to receive Vitamin C 500 BID, Cerovite 10 ML daily, and Proheal SF QID. Review of R #5's Hospital Records dated 08/04/16 revealed R #5's left thigh wound culture was positive for Proteus Mirabilis and Pseudomonas Aeruginosa MDR as well as Sputum Culture with [DIAGNOSES REDACTED] Pneumoniae.[MEDICAL CONDITION] also isolated from the wound culture. Review of R #5's Physician Telephone Order dated 08/18/16 revealed R #5 was placed on Contact isolation due to infection of wound and Urinary Tract Infection [MEDICAL CONDITION] on readmit. Review of R #5's August 2016 Wound Care Sheet revealed the following: Stage III Ulcer to Lt Residual Limb (FA-Facility Acquired), start date 08/19/16 Stage II Sacral Ulcer (CA), start date 08/19/16 Stage III Sacrum (FA), start date 08/30/16 Surgical Wound to Left Popliteal, start 08/19/16 Review of R #5's Admission Nursing Evaluation dated 08/18/16 revealed R #5 required 2 person assist for transfers as R#5 was non-weight bearing, required an Air Mattress supportive device. R #5 was admitted with a Gastrostomy tube for eating and nutrition and was dependent on staff for all her Daily Living activities. Further review revealed R#5 was admitted to the facility with two Pressure Ulcers. One Pressure Ulcer was identified as a Stage 2 with a discovery date of 06/19/16 and the second Pressure Ulcer was identified as a Stage 3. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. The document revealed dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar was identified as A. Pressure Ulcer Length: Longest length from head to toe was 6.5 centimeters (cm). B. Pressure Ulcer Width: Widest Width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length was 5.5 cm. C. Pressure Ulcer Depth Depth of the same pressure ulcer from the visible surface to the deepest area was 0.7 cm. The most Severe Tissue Type for Any Pressure Ulcer was identified as 2= Granulation tissue( pink or red tissue with shiny, moist, granular appearance.) R #5's General Skin Condition was identified as Reddened, Rash, Moist, and [MEDICAL CONDITION] bilateral forearm. R #5 has bilateral amputations to lower extremities. Review of R #5's Nursing Notes dated 08/18/16 revealed R #5 was readmitted to the facility and was placed on contact isolation due [MEDICAL CONDITION] of Left (L) stump. R #5 also had a wound vac to L stump, has an ulcer to the sacrum and left stump. There was no documented evidence of the dimensions noted. Review of R #5's Weekly Skin Integrity Review dated 08/18/16 revealed the following: Stage II Ulcer to sacrum with dressing. Bruises, Rash, and Redness were noted. There is no documented evidence of the dimensions of R #5 s Stage II Ulcer. Review of R #5's Pressure Ulcer Healing Chart (PUHC) dated 08/19/16 revealed a Stage 2 Ulcer located at Sacrum with dimensions of Length X Width was 7 (7= 4.1--8.0), Exudate Amount was 1 (1=Light), Tissue Type 2 (2 =Granulation Tissue), Pressure Ulcer Scale For Healing (PUSH) PUSH Total Score 10. Review of R #5's Physician Telephone Order dated 08/19/16 revealed R #5 was admitted with a Stage III to Lt Residual Limb, and a Stage II Sacral Ulcer (CA). Review of R #5's Wound Care Flow Sheet dated 08/19/16 to 08/30/16 revealed documentation on 08/19/16 of R #5's Stage 2 Pressure Ulcer to the Sacrum as 3 x 1.5 x 0.1 cm. There was no documented evidence of weekly dimensions noted. Review of R #5's Comprehensive Plan of Care dated 08/19/16 revealed R #5 had a Pressure Ulcer located on Sacrum; measurements were documented as 3x1.5x0.1 cm Initial Evaluation. · These measurements do not correlate with the measurements documented on the measurements length x width of 7=4.1 to 8.0, dated 08/19/16 on R #5's Pressure Ulcer Healing Chart (PUHC). Further review revealed Intervention/Approaches were to Inspect skin integrity and document findings every 24 hours. Treatment was ordered on [DATE] for a Specialty Mattress. Review of R #5's Weekly Skin Integrity Review dated 08/21/16 revealed the following: Documented rash and redness to R #5's bilateral buttocks but did not document any open areas. Further review of R #5's Stage 2 Sacrum Pressure Ulcer Healing Chart (PUHC) dated 08/25/16 revealed Length X Width was 5 (5= 2.1-3.0 cm), Exudate Amount was 1 (1=Light), Tissue Type 2(2= Granulation Tissue), PUSH Total Score was 8. Interview with Licensed Vocational Nurse (LVN) P on 08/30/16 at 10:13 a.m. LVN P gathered all treatment supplies from her Treatment Cart outside of R #5's room, LVN P stated R #5 had a Stage 2 to her sacrum that was acquired at the hospital on [DATE]. LVN P said upon return to the facility on [DATE] the wound measured 3.0 cm X 1.5 cm X 0.1 cm. The surveyor accompanied LVN P into R #5 bedroom. R #5 layed on an air mattress that was set on 350 pounds. (R #5's Monthly Weight Report documented a weight of 130 pounds for August 2016)LVN P removed R #5 sacral dressing. R #5's left and right buttocks were discolored red and light purple in multiple areas. The skin of both buttocks appeared soft. R #5's sacrum had an open area with white and yellow tissue in the wound bed with red surrounding the open area. The wound had some serous (clear fluid) drainage with odor. R #5's right buttock had three red open areas located approximately one to two centimeters away from her sacral open wound. LVN P said R #5's wound and buttocks Looked the same as they did yesterday. There was slough (Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) in it yesterday as well. Yes, it is a Stage 2. The surveyor asked LVN P what the additional three open areas were considered; LVN P responded Her skin is red and excoriated with denuded areas from excoriation. LVN P measured R #5's sacral wound and said out loud 2.4 X 1.0 X 0.2 cm. LVN P did not measure R #5's additional three open areas to her right buttocks because They are not pressure ulcers. LVN P did not thoroughly clean R #5's reddened and purple skin throughout her buttocks nor did she treat R #5's open areas on her right buttock. Observation of R #5 receiving wound care by LVN P on 08/31/16 beginning at 11:30 a.m. revealed R #5 had a new open area above R #5 sacral wound that was not present on 08/30/16. The open area was red. At this time the DON entered the room and observed R #5's buttocks. LVN P said She has a new Stage 2 Pressure Ulcer, this was not here yesterday. LVN P said R #5's Physician Assistant (PA) Looked at the sacral wound yesterday and said it was a Stage 3 due to the slough. There is more slough than yesterday. He did not say anything about the other open areas. Those open areas are denuding from excoriation. LVN P did not explain how R #5's right buttock open areas were determined to be denuding versus pressure ulcers. LVN P said she did not know the date when the right buttock open areas were discovered. LVN P said Yes, it is possible the areas could be pressure due to her fragile skin. Upon the surveyor's request, LVN P measured R #5's three open areas of her right buttock and stated First one on top is: 1.2 X 0.4 cm.; the second below the first is: 1.0 cm X 1.0 cm; and the third below the second is: 0.5 X 1.0 cm. LVN P said she had not measured any of the three open areas of R #5's buttocks before. LVN P's definition of denuding was like tearing of the top layer of skin off the area or a blister. The DON said she had not assessed R #5 since her last re-admission. Interview on 08/31/16 at 4:00 p.m. with LVN P identified herself as the facility Wound Care Nurse stated she takes measurements once a week and documented the dimensions on the Wound Care Flow Sheet. The LVN P stated she was supposed to document R#5's Pressure Ulcer Stage II dimensions yesterday (08/30/16) but she had forgotten. Review of R #5's Comprehensive Plan of Care dated 08/31/16 revealed R #5 had a New Pressure Ulcer located on the upper sacrum; measurements were documented as 0.3 x 0.4 cm Initial eval. Date ulcer was discovered was 08/31/16. Review of R #5's Wound Care Flow Sheet dated 08/31/16 revealed R #5 had a New Pressure Ulcer, Stage II located on the sacrum. The Pressure Ulcer was identified as having no undermining/tunneling, Drainage was scant and serosanguinous and no color. The wound was red in color, granulation tissue and surrounding tissue continue blanchable redness, with x 2 areas of decreased denuded skin. Further review of R #5's Wound Care Flow Sheet under date 09/01/16 revealed the wound was red in color, had granulation tissue, surrounding tissue continue with blanchable redness with new tx to bil. buttocks. Review of R #5's Wound Care Flow Sheet dated 08/31/16 revealed R #5 had a new Pressure Ulcer Stage II located on the upper sacrum; measurements were documented as 0.3 x 0.4 cm. Review of R #5's Nurses Notes dated 08/31/16 10:45 a.m. LVN P documented upon wound care to sacral area Stage III Ulcer noted would to have increased slough, continues with granulation tissue. Also noted a small open area above Stage III sacral ulcer with red wound base, serosarguinous scant exudate. R #5 continues with blanchable redness & excoriation had decreased. Further review, revealed documentation on 08/31/16 at 1258, a call to PA (Physician Assistant) to inform him of new Stage II ulcer to upper sacrum. Also informed PA that Stage III sacral ulcer had increased slough. Review of R #5's Nurses notes dated 08/31/16 at 5:40 p.m. revealed documentation of wound measurement of new Stage II sacral ulcer, measurement of 0.3 x 0.4 cm. Review of R #5's Physician Assistant Progress notes dated 08/31/16 revealed the following:1) Stage III sacral ulcer with slough, 2) Stage II Ulcer with slough, 3) multiple excoriated buttock area, 4)[MEDICAL CONDITION] to L popliteal area. · According to the facility's Admission Nursing Evaluation Form and the National Pressure Ulcer Advisory Panel (NPUAP), Stage 2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red and pink wound bed, without slough. May also present as an intact or open/ruptured blister. On 08/31/16 at 3:08 p.m., interview with the DON and LVN P revealed the DON reviewed R #5's Wound Care Flow Sheets and Nurses Notes beginning on date 08/18/16 and confirmed the documents did not match with what she saw on R #5 on 08/31/16. The DON said R #5's buttocks and pressure ulcer was more extensive and complicated than documented on the documents. The DON stated LVN P did not include a description of the rash/reddened areas/open areas in her documentation. The DON further stated the nurses should document on the weekly skin assessment to reflect exactly what is seen of the wound and surrounding skin. The DON said she expected LVN P and the other nurses to document accurately including completing the body diagram with pointing out areas of wounds, description of the wounds , and dimensions of the wounds. The DON stated LVN P failed to document correctly on the Wound Care Flow Sheet. The DON stated that day (08/31/16) she observed R #5 had slough, open areas but were not documented on the Wound Care Flow Sheet by LVN P. The DON confirmed R #5 had a new Pressure Ulcer Stage I and it was cleaned by LVN P that day (08/31/16). The DON stated the three open areas on R #5's right buttock were denuded skin as per LVN P but could be pressure ulcers. The DON stated LVN P monitored R #5's pressure ulcers daily and the floor nurses would monitor or provide care if LVN P was not at the facility. LVN P said she had her own personal log she used to document her dimensions and then would transfer the measurements to the Wound Care Flow Sheet. LVN P provided her personal Log that included R #5's sacral ulcer measurement of 1.8 X 1.0 X 0.1 cm dated 08/26/16. The DON stated the Wound Care Flow Sheet was the only sheet she would use, and would take measurements of the pressure ulcers to see if the size had decreased and healing, therefore the documentation needed to be accurate. LVN P stated the new open areas were not measured before and stated she was 100% sure the areas were getting smaller, were not bleeding, and less deep and shiny. LVN P stated she determined if R #5's pressure ulcers and open areas were healing by her visual assessment and not any measurements. LVN P stated she was only responsible to take care of the Pressure Ulcers and the nurses would take care of everything else. LVN P confirmed she did not clean or treat R #5's open areas on her right buttocks because they were not pressure ulcers and the nurse aides cleaned the areas with cleaning wipes and applied skin protectant cream to the area. The DON said a visual assessment without documentation was an unacceptable method for determining whether a wound was getting better or worse. The DON said documentation of the nurses visual assessment was important and required so that other staff and the physician could review and follow-up on the wounds. The DON stated LVN P was not only responsible for R #5's sacral ulcer but also her entire buttocks that was broken down. The DON stated R #5's Physician Assistant had been at the facility on 08/30/16 to assess R #5, however did not see R #5 because she was out of the facility at [MEDICAL TREATMENT]. (NOTE: Interview with LVN P on 08/31/16 at 11:30 a.m., LVN P said R #5's PA looked at her wound) The DON stated R #5's PA was informed that R #5 had slough and the PA ordered Duoderm dressing every other day. LVN P stated yesterday (08/30/16) R #5 had slough, and today R #5's slough was worse and LVN P had and notified R #5's Physician that day (08/31/16). LVN P stated she reviewed weekly skin assessments every Wednesday. LVN P further stated she took measurements once a week and documented the measurements on the Wound Care Flow Sheet. LVN P stated she was supposed to document R#5's Stage II measurements yesterday (08/30/16), but had forgotten to record it on the Wound Care Flow Sheet. The DON stated LVN P was responsible for the overall care of R #5's wound area. When the LVN P was asked the meaning of excoriation, she stated burnt skin, open skin, like a diaper rash. LVN P further stated a Stage II was an open area, red, no slough, shallow open blister. LVN P stated R #5's open areas with redness were not Stage II's because they were part of excoriated skin. LVN P stated that it could be possible that R #5's open wounds could be a Stage II. LVN P stated since R #5 was re-admitted on [DATE], she had fewer wounds. LVN P further stated R #5's wounds would come and go but from 08/29/16 to 08/30/16, she had fewer wounds and that was the reason she stated R #5's wounds were healing. The DON confirmed R #5's sacral ulcer had deteriorated as evidenced by starting as a Stage II to a Stage III, a new Stage II developed, and her surrounding skin was impaired. R #3 R #3's Face Sheet dated 08/30/16 revealed R #3 was an [AGE] year old female admitted to the facility 03/28/14 with the following diagnoses; Gastrostomy Status, Dysphagia (difficulty swallowing), Pathological Fracture Hip, Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), Dementia and Hypertension. R #3's consolidated Physician order [REDACTED]. (Start date 03/28/14) R #3's consolidated Physician order [REDACTED]. R #3's quarterly MDS dated [DATE] revealed R #3 was usually understood and usually understands others. R #3's cognition was moderately impaired. R #3 required extensive assistance with bed mobility, dressing, bathing, and personal hygiene with the assistance of one person. R #3 was incontinent of bladder and occasionally incontinent of bowel. R #3 was receiving the following Skin and Ulcer Treatments: Pressure reduction device, for chair and bed, was on a turning/repositioning program and had Nutrition or Hydration intervention to manage skin problems. R #3 weighed 133 pounds. R #3 had one stage IV pressure ulcer that measured 1.4 cm X 0.6 cm X 0.2 cm. R #3's Care Plan (problem onset dated 04/03/14) reviewed 03/10/16 revealed Total dependence on staff for incontinent care is incontinent of bladder. Requires extensive assistance for bathroom use for bowel movement .Approaches .Incontinent pads checked and changed when wet every two hours and prn. Pressure reducing mattress. Turn and reposition every two hours . On 08/29/16 at 6:12 p.m., observation revealed R #3's APM/LAL mattress was set at 300 pounds. R #3 said her bed was to hard. On 08/30/16 at 10:55 a.m., interview with CSC G revealed he sets up all the mattresses the same way at 320 PSI because that was the Universal Setting CSC G said that he never received any formal training how to set up the APM/LAL mattresses, that the person that was working Central Supply before him showed him how to set up the mattresses. This Surveyor pointed at the Pressure Adjust Knob labeled LBS on the air pump and asked what LBS was meant? CSC G said it means pounds. During this same interview the DON was present and said Licensed V

Based on observation, interview, and record review the facility failed to ensure a resident who enters the facility without pressure ulcers does not develop pressure ulcers and a resident having pressure ulcers received the necessary care and services to promote healing and prevent new sores from developing for three Resident (R #5) of six residents reviewed for pressure ulcers. 1.) The facility did not follow recognized standards of practice, in that: R #5 was admitted to the facility with pressure ulcers however, · her ulcer worsened from a Stage 2 to a Stage 3; · developed a new Stage 2 pressure ulcer; · three open areas surrounding the ulcer were not assessed, identified or documented until the surveyor's inquiry. · The Wound Care Nurse determined if a wound was healing by visual observation rather than measurements. · The facility's identification of wound location, assessments, and documentation of the ulcers were contradictory and inconsistent between forms. 2.) The facility did not consult the Manufacturer for settings for Alternating Pressure/Low Air Loss mattresses (APM/LAL) for R #3, R #4 and R #5. The facility did not check suitable pressure correctly for R #3, R #4 and R #5's APM/LAL according to manufacturer's recommendation. These deficient practices could place nine residents with pressure ulcers and 15 residents in the facility with Alternating Pressure/ Low Air Loss mattress's (APM/LAL) receiving preventative skin care and services at risk of skin breakdown or worsening of pressure ulcers due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, inappropriate treatment, impairment in skin integrity, delay in wound healing, complications, hospitalization , and a decreased quality of life. The findings included: 1.) Review of the facility's Admission and Discharge Report dated 08/31/16 revealed R #5 was admitted on [DATE] from the hospital and was discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and was discharged to the hospital on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital and was discharged on [DATE]. R #5 was readmitted to the facility on [DATE] from the hospital. Review of R #5's Face Sheet dated 08/19/16 revealed R #5 was [AGE] years-old and had [DIAGNOSES REDACTED]. in the stomach used to administer medications, hydration, and feeding of formula) status, [MEDICAL CONDITION], Resistance to [MEDICATION NAME] related antibiotics,[MEDICAL CONDITION] due to [MEDICAL CONDITION] (MRSA), Type 2 Diabetes Mellitus with other Diabetic Kidney complication, Infectious Gastroenteritis and [MEDICAL CONDITION], Acquired Absence of Right Leg above knee, Disruption of wound, unspecified, Urinary Tract Infection, Acute [MEDICAL CONDITION], Cerebral Infarction, Hyperlipiderma, Long Term (current) use of Insulin, Acquired absence of Limb, Acquired absence of Left Leg below knee, Other Malaise and Heart Failure. Review of R #5's Initial Admission Nursing Evaluation dated 12/22/15 revealed R #5 had one Stage 2 Pressure Ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red of pink wound bed, without slough), upon admission to the facility. The most severe tissue type for any pressure ulcer was a 22= Granulation tissue, (pink or red tissue with shiny, moist, granular appearance). The facility failed to document the number of Stage 2 pressure ulcers that were present upon admission/entry and the date of discovery of the Stage 2 pressure ulcer. There was no documented evidence of R #5's number of unhealed pressure ulcers at each stage and the dimensions of unhealed Pressure Ulcers. Further review of the Admission Nursing Evaluation form revealed the assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 02/12/16 revealed R #5 was readmitted to the facility with one Stage 3 Pressure Ulcer (Stage 3: Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) Pressure Ulcer. There is no documented evidence of R #5's number of unhealed Pressure Ulcers at each stage, the dimensions of unhealed Stage 3 Pressure Ulcers (Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon or muscle. Slough may be present but does not obscure the depth of tissue loss), and the most severe tissue type for any pressure ulcer. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 03/05/16 revealed R #5 was readmitted to the facility with two Stage 2 Pressure Ulcers. There is no documented evidence of R #5's number of unhealed Pressure Ulcers at each stage, the dimensions, and the most severe tissue type for any pressure ulcer. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. Review of R #5's Admission Nursing Evaluation dated 06/19/16 revealed R #5 was readmitted to the facility with one Stage 2 Sacral (Sacrum-large, triangular bone at the base of the spine) Ulcer. There is no documented evidence of R #5's Stage 2 dimensions and the most severe tissue type for any pressure ulcer. Review of R #5's Physician Telephone Orders dated 06/23/16 revealed 2. Air Mattress to be in place at all times. Review of R #5's Wound Care Sheet for 06/2016 revealed the following: Stage II Ulcer to right sacral area (CA) Stage II Ulcer to left Sacral area (CA) Unstageable Ulcer to Upper left Stump (CA) Unstageable Ulcer to Lower left Stump (CA) Review of R #5's Braden Scale for Predicting Pressure Sore Risk dated 06/21/16 revealed a Total Score of 9 (9 or below = Severe Risk). Further review revealed no updated score for R #5's re-admission on 08/18/16. Review of R #5's Physician Telephone orders dated 06/23/16 revealed an order for [REDACTED]. Review of R #5's Consolidated Physician order [REDACTED]. R #5's Physician ordered a weekly and PRN Skin Assessment, and an Air Mattress in place at all times. Review of R #5's consolidated Physician orders [REDACTED].#5 received [MEDICATION NAME] Renal @ 45 ML/HR 18 HRs per peg tube via pump. To provide 810 cc/24 hours and 1620 KCAL/24 Hrs. Dispense 24 ready to hang bags with 99 refills monthly. Further review revealed Vitamin C 500 MG, Give 1 Tab via peg tube BID. Proheal SF. Give 30 ML via peg tube QID. Review of R #5's Comprehensive Plan of Care dated 08/19/16 revealed R #5 had an ulcer to the Lt Residual Limb 6.5 X 5.5 X 0.7 to receive Vitamin C 500 BID, Cerovite 10 ML daily, and Proheal SF QID. Review of R #5's Hospital Records dated 08/04/16 revealed R #5's left thigh wound culture was positive for Proteus Mirabilis and Pseudomonas Aeruginosa MDR as well as Sputum Culture with [DIAGNOSES REDACTED] Pneumoniae.[MEDICAL CONDITION] also isolated from the wound culture. Review of R #5's Physician Telephone Order dated 08/18/16 revealed R #5 was placed on Contact isolation due to infection of wound and Urinary Tract Infection [MEDICAL CONDITION] on readmit. Review of R #5's August 2016 Wound Care Sheet revealed the following: Stage III Ulcer to Lt Residual Limb (FA-Facility Acquired), start date 08/19/16 Stage II Sacral Ulcer (CA), start date 08/19/16 Stage III Sacrum (FA), start date 08/30/16 Surgical Wound to Left Popliteal, start 08/19/16 Review of R #5's Admission Nursing Evaluation dated 08/18/16 revealed R #5 required 2 person assist for transfers as R#5 was non-weight bearing, required an Air Mattress supportive device. R #5 was admitted with a Gastrostomy tube for eating and nutrition and was dependent on staff for all her Daily Living activities. Further review revealed R#5 was admitted to the facility with two Pressure Ulcers. One Pressure Ulcer was identified as a Stage 2 with a discovery date of 06/19/16 and the second Pressure Ulcer was identified as a Stage 3. The assessment did not include the date of the oldest stage, and did not indicate the location or the measurements of the Pressure Ulcer on the body diagram. The document revealed dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar was identified as A. Pressure Ulcer Length: Longest length from head to toe was 6.5 centimeters (cm). B. Pressure Ulcer Width: Widest Width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length was 5.5 cm. C. Pressure Ulcer Depth Depth of the same pressure ulcer from the visible surface to the deepest area was 0.7 cm. The most Severe Tissue Type for Any Pressure Ulcer was identified as 2= Granulation tissue( pink or red tissue with shiny, moist, granular appearance.) R #5's General Skin Condition was identified as Reddened, Rash, Moist, and [MEDICAL CONDITION] bilateral forearm. R #5 has bilateral amputations to lower extremities. Review of R #5's Nursing Notes dated 08/18/16 revealed R #5 was readmitted to the facility and was placed on contact isolation due [MEDICAL CONDITION] of Left (L) stump. R #5 also had a wound vac to L stump, has an ulcer to the sacrum and left stump. There was no documented evidence of the dimensions noted. Review of R #5's Weekly Skin Integrity Review dated 08/18/16 revealed the following: Stage II Ulcer to sacrum with dressing. Bruises, Rash, and Redness were noted. There is no documented evidence of the dimensions of R #5 s Stage II Ulcer. Review of R #5's Pressure Ulcer Healing Chart (PUHC) dated 08/19/16 revealed a Stage 2 Ulcer located at Sacrum with dimensions of Length X Width was 7 (7= 4.1--8.0), Exudate Amount was 1 (1=Light), Tissue Type 2 (2 =Granulation Tissue), Pressure Ulcer Scale For Healing (PUSH) PUSH Total Score 10. Review of R #5's Physician Telephone Order dated 08/19/16 revealed R #5 was admitted with a Stage III to Lt Residual Limb, and a Stage II Sacral Ulcer (CA). Review of R #5's Wound Care Flow Sheet dated 08/19/16 to 08/30/16 revealed documentation on 08/19/16 of R #5's Stage 2 Pressure Ulcer to the Sacrum as 3 x 1.5 x 0.1 cm. There was no documented evidence of weekly dimensions noted. Review of R #5's Comprehensive Plan of Care dated 08/19/16 revealed R #5 had a Pressure Ulcer located on Sacrum; measurements were documented as 3x1.5x0.1 cm Initial Evaluation. · These measurements do not correlate with the measurements documented on the measurements length x width of 7=4.1 to 8.0, dated 08/19/16 on R #5's Pressure Ulcer Healing Chart (PUHC). Further review revealed Intervention/Approaches were to Inspect skin integrity and document findings every 24 hours. Treatment was ordered on [DATE] for a Specialty Mattress. Review of R #5's Weekly Skin Integrity Review dated 08/21/16 revealed the following: Documented rash and redness to R #5's bilateral buttocks but did not document any open areas. Further review of R #5's Stage 2 Sacrum Pressure Ulcer Healing Chart (PUHC) dated 08/25/16 revealed Length X Width was 5 (5= 2.1-3.0 cm), Exudate Amount was 1 (1=Light), Tissue Type 2(2= Granulation Tissue), PUSH Total Score was 8. Interview with Licensed Vocational Nurse (LVN) P on 08/30/16 at 10:13 a.m. LVN P gathered all treatment supplies from her Treatment Cart outside of R #5's room, LVN P stated R #5 had a Stage 2 to her sacrum that was acquired at the hospital on [DATE]. LVN P said upon return to the facility on [DATE] the wound measured 3.0 cm X 1.5 cm X 0.1 cm. The surveyor accompanied LVN P into R #5 bedroom. R #5 layed on an air mattress that was set on 350 pounds. (R #5's Monthly Weight Report documented a weight of 130 pounds for August 2016)LVN P removed R #5 sacral dressing. R #5's left and right buttocks were discolored red and light purple in multiple areas. The skin of both buttocks appeared soft. R #5's sacrum had an open area with white and yellow tissue in the wound bed with red surrounding the open area. The wound had some serous (clear fluid) drainage with odor. R #5's right buttock had three red open areas located approximately one to two centimeters away from her sacral open wound. LVN P said R #5's wound and buttocks Looked the same as they did yesterday. There was slough (Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) in it yesterday as well. Yes, it is a Stage 2. The surveyor asked LVN P what the additional three open areas were considered; LVN P responded Her skin is red and excoriated with denuded areas from excoriation. LVN P measured R #5's sacral wound and said out loud 2.4 X 1.0 X 0.2 cm. LVN P did not measure R #5's additional three open areas to her right buttocks because They are not pressure ulcers. LVN P did not thoroughly clean R #5's reddened and purple skin throughout her buttocks nor did she treat R #5's open areas on her right buttock. Observation of R #5 receiving wound care by LVN P on 08/31/16 beginning at 11:30 a.m. revealed R #5 had a new open area above R #5 sacral wound that was not present on 08/30/16. The open area was red. At this time the DON entered the room and observed R #5's buttocks. LVN P said She has a new Stage 2 Pressure Ulcer, this was not here yesterday. LVN P said R #5's Physician Assistant (PA) Looked at the sacral wound yesterday and said it was a Stage 3 due to the slough. There is more slough than yesterday. He did not say anything about the other open areas. Those open areas are denuding from excoriation. LVN P did not explain how R #5's right buttock open areas were determined to be denuding versus pressure ulcers. LVN P said she did not know the date when the right buttock open areas were discovered. LVN P said Yes, it is possible the areas could be pressure due to her fragile skin. Upon the surveyor's request, LVN P measured R #5's three open areas of her right buttock and stated First one on top is: 1.2 X 0.4 cm.; the second below the first is: 1.0 cm X 1.0 cm; and the third below the second is: 0.5 X 1.0 cm. LVN P said she had not measured any of the three open areas of R #5's buttocks before. LVN P's definition of denuding was like tearing of the top layer of skin off the area or a blister. The DON said she had not assessed R #5 since her last re-admission. Interview on 08/31/16 at 4:00 p.m. with LVN P identified herself as the facility Wound Care Nurse stated she takes measurements once a week and documented the dimensions on the Wound Care Flow Sheet. The LVN P stated she was supposed to document R#5's Pressure Ulcer Stage II dimensions yesterday (08/30/16) but she had forgotten. Review of R #5's Comprehensive Plan of Care dated 08/31/16 revealed R #5 had a New Pressure Ulcer located on the upper sacrum; measurements were documented as 0.3 x 0.4 cm Initial eval. Date ulcer was discovered was 08/31/16. Review of R #5's Wound Care Flow Sheet dated 08/31/16 revealed R #5 had a New Pressure Ulcer, Stage II located on the sacrum. The Pressure Ulcer was identified as having no undermining/tunneling, Drainage was scant and serosanguinous and no color. The wound was red in color, granulation tissue and surrounding tissue continue blanchable redness, with x 2 areas of decreased denuded skin. Further review of R #5's Wound Care Flow Sheet under date 09/01/16 revealed the wound was red in color, had granulation tissue, surrounding tissue continue with blanchable redness with new tx to bil. buttocks. Review of R #5's Wound Care Flow Sheet dated 08/31/16 revealed R #5 had a new Pressure Ulcer Stage II located on the upper sacrum; measurements were documented as 0.3 x 0.4 cm. Review of R #5's Nurses Notes dated 08/31/16 10:45 a.m. LVN P documented upon wound care to sacral area Stage III Ulcer noted would to have increased slough, continues with granulation tissue. Also noted a small open area above Stage III sacral ulcer with red wound base, serosarguinous scant exudate. R #5 continues with blanchable redness & excoriation had decreased. Further review, revealed documentation on 08/31/16 at 1258, a call to PA (Physician Assistant) to inform him of new Stage II ulcer to upper sacrum. Also informed PA that Stage III sacral ulcer had increased slough. Review of R #5's Nurses notes dated 08/31/16 at 5:40 p.m. revealed documentation of wound measurement of new Stage II sacral ulcer, measurement of 0.3 x 0.4 cm. Review of R #5's Physician Assistant Progress notes dated 08/31/16 revealed the following:1) Stage III sacral ulcer with slough, 2) Stage II Ulcer with slough, 3) multiple excoriated buttock area, 4)[MEDICAL CONDITION] to L popliteal area. · According to the facility's Admission Nursing Evaluation Form and the National Pressure Ulcer Advisory Panel (NPUAP), Stage 2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red and pink wound bed, without slough. May also present as an intact or open/ruptured blister. On 08/31/16 at 3:08 p.m., interview with the DON and LVN P revealed the DON reviewed R #5's Wound Care Flow Sheets and Nurses Notes beginning on date 08/18/16 and confirmed the documents did not match with what she saw on R #5 on 08/31/16. The DON said R #5's buttocks and pressure ulcer was more extensive and complicated than documented on the documents. The DON stated LVN P did not include a description of the rash/reddened areas/open areas in her documentation. The DON further stated the nurses should document on the weekly skin assessment to reflect exactly what is seen of the wound and surrounding skin. The DON said she expected LVN P and the other nurses to document accurately including completing the body diagram with pointing out areas of wounds, description of the wounds , and dimensions of the wounds. The DON stated LVN P failed to document correctly on the Wound Care Flow Sheet. The DON stated that day (08/31/16) she observed R #5 had slough, open areas but were not documented on the Wound Care Flow Sheet by LVN P. The DON confirmed R #5 had a new Pressure Ulcer Stage I and it was cleaned by LVN P that day (08/31/16). The DON stated the three open areas on R #5's right buttock were denuded skin as per LVN P but could be pressure ulcers. The DON stated LVN P monitored R #5's pressure ulcers daily and the floor nurses would monitor or provide care if LVN P was not at the facility. LVN P said she had her own personal log she used to document her dimensions and then would transfer the measurements to the Wound Care Flow Sheet. LVN P provided her personal Log that included R #5's sacral ulcer measurement of 1.8 X 1.0 X 0.1 cm dated 08/26/16. The DON stated the Wound Care Flow Sheet was the only sheet she would use, and would take measurements of the pressure ulcers to see if the size had decreased and healing, therefore the documentation needed to be accurate. LVN P stated the new open areas were not measured before and stated she was 100% sure the areas were getting smaller, were not bleeding, and less deep and shiny. LVN P stated she determined if R #5's pressure ulcers and open areas were healing by her visual assessment and not any measurements. LVN P stated she was only responsible to take care of the Pressure Ulcers and the nurses would take care of everything else. LVN P confirmed she did not clean or treat R #5's open areas on her right buttocks because they were not pressure ulcers and the nurse aides cleaned the areas with cleaning wipes and applied skin protectant cream to the area. The DON said a visual assessment without documentation was an unacceptable method for determining whether a wound was getting better or worse. The DON said documentation of the nurses visual assessment was important and required so that other staff and the physician could review and follow-up on the wounds. The DON stated LVN P was not only responsible for R #5's sacral ulcer but also her entire buttocks that was broken down. The DON stated R #5's Physician Assistant had been at the facility on 08/30/16 to assess R #5, however did not see R #5 because she was out of the facility at [MEDICAL TREATMENT]. (NOTE: Interview with LVN P on 08/31/16 at 11:30 a.m., LVN P said R #5's PA looked at her wound) The DON stated R #5's PA was informed that R #5 had slough and the PA ordered Duoderm dressing every other day. LVN P stated yesterday (08/30/16) R #5 had slough, and today R #5's slough was worse and LVN P had and notified R #5's Physician that day (08/31/16). LVN P stated she reviewed weekly skin assessments every Wednesday. LVN P further stated she took measurements once a week and documented the measurements on the Wound Care Flow Sheet. LVN P stated she was supposed to document R#5's Stage II measurements yesterday (08/30/16), but had forgotten to record it on the Wound Care Flow Sheet. The DON stated LVN P was responsible for the overall care of R #5's wound area. When the LVN P was asked the meaning of excoriation, she stated burnt skin, open skin, like a diaper rash. LVN P further stated a Stage II was an open area, red, no slough, shallow open blister. LVN P stated R #5's open areas with redness were not Stage II's because they were part of excoriated skin. LVN P stated that it could be possible that R #5's open wounds could be a Stage II. LVN P stated since R #5 was re-admitted on [DATE], she had fewer wounds. LVN P further stated R #5's wounds would come and go but from 08/29/16 to 08/30/16, she had fewer wounds and that was the reason she stated R #5's wounds were healing. The DON confirmed R #5's sacral ulcer had deteriorated as evidenced by starting as a Stage II to a Stage III, a new Stage II developed, and her surrounding skin was impaired. The facility's undated Wound/Skin Policy documented Each resident admitted to this facility will be assessed and monitored for skin condition on a regular basis to prevent skin breakdown unless developed of pressure sores is unavoidable due to his/her medical condition. Each resident with skin breakdown/pressure sores will receive the services and treatment to decrease risks of prevention of infection, promote early wound healing, id possible and prevent new pressure sores from developing if possible. Policy Interpretation and Implementation: Licensed Nurses will assess the resident's skin condition as follows: .4. Any observed changes by the Licensed Nurse; 5. Weekly on all residents as per schedule, and document in the treatment record; . 7. All residents will be assessed for risk of skin breakdown using the Braden Scale Form. This will be done upon admission and updated at least every 90 days thereafter. 8. A plan of care for risk breakdown will be initiated and implemented for each resident with a Braden Scale score of 17 and below . 10. When a resident has an open area upon admission, this will be documented on the resident Admission Assessment. 11. Accurate measurements/documentation will be done weekly during the wound rounds. 12. A Licensed Nurse will assess all open areas. Assessment includes stage, size, depth, odor, drainage and surrounding skin condition. Nursing notes must include notification of physician and family. 13.If a resident has multiple wound sites, a complete and separate treatment order and documentation will be written for each site. 14. DON/designee will assess all wounds if need . 15.If no improvement is noted by the 14th day, the treatment regimen will be revised as deemed appropriate 19. Determine etiology or cause of wound to be able to determine Treatment Plan . 20. Stage describe it as partial or full thickness loss instead of Stage 2, 3, or 4. 21. Stage pressure ulcer, as to what it is. Use the term resolved, instead of healed . 23. Don't leave wounds open to air and keep wound temperature warm to hasten wound healing. 24. Wound healing starts at the perimeter. Prioritize in treating the surrounding skin irritation . The facility's undated Pressure Ulcer Protocol documented Document initial assessment of pressure area in the Pressure Ulcer Documentation Record and updated at least weekly for effectiveness of treatment interventions. The facility's undated Pressure Ulcers Policy and Procedure documented At the time a pressure ulcer is identified, the following must be put into place immediately. 1. Make sure the resident is placed immediately on a pressure-relieving device. 2. Initiate and document on the weekly skin sheet. 3. Initiate and document on the daily pressure ulcer record 4. Call Medical Doctor for treatment orders 5. Notify Responsible Party 6. Write treatment order correctly 7. Obtain dietary consult. Supplements, increased protein, large portions, vitamin therapy, etc. 8. Turn schedules: Q 2 hr, and document on treatment sheet 9. Hydration Schedule document on treatment sheet 10. Make sure all pertinent information is documented in nurse's notes 11. Initiate Care Plan immediately and update weekly. 2.) R #4 R #4's Face Sheet dated 06/01/16 revealed R #4 was a [AGE] year old male re-admitted to the facility on [DATE] with the following diagnoses; Gastrostomy Status (surgical opening into the stomach for the purpose of administering medications, nutrition and fluids), Urinary Tract Infection, [MEDICAL CONDITION] (respiratory disease which obstructs the air exchange in the lungs), Contracture, [MEDICAL CONDITION] (circulatory impairment in the extremities), Diabetes, Kidney Failure, [MEDICAL CONDITION], Hypertension and Surgical Wound. R #4's Physician Telephone Order dated 06/11/16 revealed Air Mattress to be in place at all times. R #4's consolidated Physician order [REDACTED]. R #4's consolidated Physician order [REDACTED]. R #4's Admission Minimum (MDS) data set [DATE] revealed R #4 was rarely/never understood or understood others. R #4 had moderately impaired vision, and was totally dependent with bathing, transfers, bed mobility and dressing with the assistance of two people. R #4 had upper and lower extremity range of motion impairment. R #4 received more than 51% of caloric intake and more than 501 cc/day fluid intake through his gastrostomy tube. R #4 was incontinent of bowel and had a urinary catheter. R #4 was receiving the following Skin and Ulcer Treatments: Pressure reduction device, for chair and bed, was on a turning/repositioning program and had Nutrition or Hydration intervention to manage skin problems. R #4 weighed 161 pounds. R #4's Care Plan (review date 07/16/16) revealed Resident has fragile Skin with potential for bruising and skin tears .Assist to turn and reposition Q2h and PRN . R #4's Care Plan (problem onset 11/12/10) revealed Resident is totally dependent on staff for ADLs due [MEDICAL CONDITION](stroke) with Rt. [MEDICAL CONDITION] (paralysis on one side of the body), poor cognition; requires assistance of 2 persons to transfer .*Turn, reposition and provide incontinent care q2hrs and prn . On 08/29/16 at 3:40 p.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds, static mode. On 08/30/16 at 9:05 a.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds, static mode. On 08/31/16 at 8:10 a.m., observation revealed R #4 was lying on an APM/LAL Mattress that was set on 280 pounds static mode. R #3 R #3's Face Sheet dated 08/30/16 revealed R #3 was an [AGE] year old female admitted to the facility 03/28/14 with the following diagnoses; Gastrostomy Status, Dysphagia (difficulty swallowing), Pathological Fracture Hip, [MEDICAL CONDITION] (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), Dementia and Hypertension. R #3's consolidated Physician order [REDACTED]. (Start date 03/28/14) R #3's consolidated Physician order [REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) sacral Ulcer (CA): Cleanse With NS, Dab Dry, Apply Skin Prep to Periwound, apply Puracol Followed By Foam And [MEDICATION NAME] Tape QOD And PRN Until Healed. R #3's quarterly MDS dated [DATE] revealed R #3 was usually understood and usually understood others. R #3's cognition was moderately impaired. R #3 required extensive assistance with bed mobility, dressing, bathing, and personal hygiene with the assistance of one person. R #3 was incontinent of bladder and occasionally incontinent of bowel. R #3 was receiving the following Skin and Ulcer Treatments: Pressure reduction device, for chair and bed, was on a turning/repositioning program and had Nutrition or Hydration intervention to manage skin problems. R #3 weighed 133 pounds. R #3 had one stage IV pressure ulcer that measured 1.4 cm X 0.6 cm X 0.2 cm. R #3's Care Plan (problem onset dated 04/03/14) reviewed 03/10/16 revealed Total dependence on staff for incontinent care is incontinent of bladder. Requires extensive assistance for bathroom use for bowel movement .Approaches .Incontinent pads checked and changed when wet every two hours and prn. Pressure reducing mattress. Turn and reposition every two hours . On 08/29/16 at 6:12 p.m., observation and interview revealed R #3's APM/LAL mattress was set at 300 pounds. R #3 said her bed was to hard. On 08/30/16 at 8:50 a.m., the surveyor accompanied LVN C to R #3's bedroom. Observation revealed R #3's APM/LAL mattress was set at 300 pounds. LVN C stated the 300 setting meant the firmness of the bed. LVN C said the resident's weight had nothing to do with the mattress settings. On 08/30/16 at 10:55 a.m., interview with CSC G revealed he sets up all the mattresses the same way at 320 PSI because that was the Universal Setting CSC G said that he never received any formal training how to set up the APM/LAL mattresses, that the person that was working Central Supply before him showed him how to set up the mattresses. Surveyor pointed at the Pressure Adjust Knob labeled LBS on the air pump and asked what LBS was meant? CSC G said it means pounds. During this same interview the DON was present and said Licensed Vocational Nurse (LVN) P was responsible for obtaining the physician's orders [REDACTED]. The DON said she would assume the APM/LAL beds were set up according to the resident's weight. During this same interview with the DON present, LVN P said she had never consulted with the Physician for the settings on the resident's air mattresses. Surveyor requested LVN P to provide a demonstration in a empty bed on how she would check the bed for proper pump setting. LVN P said when the resident was lying in the bed she would feel the mattress. (LVN P placed both hands on the side of the mattress and pressed down). On 08/31/16 at 8:30 a.m., interview with the DON revealed if the APM/LAL mattresses were not set up correctly then that could defeat the purpose of the bed. The DON said it had never occurred

Based on observation, interview and record review the facility failed to keep the residents free of physical restraints (full size siderails), which were not required to treat medical symptoms for four out of four residents ( R's #1, #2, #3, and #4) whose charts were reviewed. R #1 sustained a [MEDICAL CONDITION] when she attempted to get out of bed and fell . R #2 had full siderails up that were not required to treat the resident's medical symptoms. R #3 had full siderails up that were not required to treat the resident's medical symptoms. R #4 had full siderails up that were not required to treat the resident's medical symptoms. The failure to keep residents free of full size siderails without being used to treat a medical condition could result in further injury, limit their mobility and decrease their independence to the 15 residents identified by the Director of Nurses (DON) as being at risk for falls. The findings were: R #1: Review of R #1's Face Sheet dated 11/21/11 revealed she was admitted on [DATE], readmitted on [DATE] and discharged on [DATE] "with return anticipated." Her [DIAGNOSES REDACTED]." Review of R #1's Fall Risk dated 10/30/11 revealed a score of 9. A score of 10 or above represents High Risk. The form did not show any other date the Fall Risk was completed. Review of R #1's Care Plan dated 11/02/11 revealed, "Problem: At risk for falls R/T (related to) decreased mobility and cognitive deficit. Noted to attempt to get up out of w/c(wheel chair). Will have order for bed alarm and w/c alarm for her safety. Approaches: Put bedside rails up whenever resident is in bed; Give resident verbal reminders not to ambulate or transfer without assistance; Instruct resident on appropriate use of safety device/appliance; Analyze previous falls by resident to determine whether pattern/trend can be addressed; W/C ALARM IN PLACE; BED ALARM IN PLACE." Handwritten problem was added on 11/02/11 revealed, "Pt had a fall on 11/2/11, and Pt sustained a fall on 11/07/11." Handwritten approaches revealed, " *Monitor resident closely-11/3/11; Bed alarm to be on at all times-11/9/11; Monitor for bed alarm and chair alarm to be working properly 11/9/11. Review of R #1's Nursing Notes dated 10/31/11, 11/01/11,11/08/11, 11/09/11, 11/10/11, 11/11/11, 11/13/11, 11/14/11 and 11/15/11 during the 10:00 p.m. to 6:00 a.m. shift revealed, "Bedrails up X 2." Review of R #1's Nursing Note dated 11/02/11 at 2:00 p.m. revealed, "was notified by Certified Nurse Aide (CNA "B") resident was sitting on the floor between w/c (wheelchair) and bedside chair. Siderails up in bed. Assessed and no injury recommended res.(resident) to call for assistance to prevent further falls and injuries. Res. stated was going to the B/Rm (bathroom). Call light was within reach. Res. was taken to the B/Rm and voided." The note was signed by Licensed Vocational Nurse (LVN) "A." Review of "Witness Statement" by CNA "B" concerning R #1 dated 11/02/11 at 2:00 p.m. revealed in Spanish, "she got off the bed by herself with the siderails up, she was going to the bathroom, I found her sitting." Review of R #1's Nursing Note dated 11/07/11 revealed, "resident was found on the floor with back towards the side of bed apparently resident was trying to get up by herself and she slipped slidding down onto floor. Denies any pain or discomfort at the time, 0 visible injuries noted." Review of R #1's Nurse's Note dated 11/11/11 at 10:00 a.m. by LVN "A" revealed, "continues getting up from w/c or sliding out of bed at foot of bed. Reminded to call for assistance. Call light within reach and bed alarm while in bed. w/c alarm while in w/c." Review of R #1's Nurse's Note dated 11/20/11 at 6:15 a.m. revealed, "CNA ("C") informed me that pt was c/o (complaining of) pain to RLE. Upon assessment, I noted multiple greenish-purple bruises to R outer thigh and L rotated extremity. Unable to flex knee and extend foot. c/o pain upon palpation. Unable to explain how bruises were developed. Denied having any recent falls. Pt is forgetful and reoriented frequently. Paged Dr. and returned call with new orders for x-ray of R femur." Review of R #1's Medical X-ray on Wheels dated 11/20/11 revealed "Views of the right femur show a subcapital [MEDICAL CONDITION] hip that is slightly displaced." Interview with the Facility Administrator on 12/12/11 at approximately 1:15 p.m. revealed he had called in the incident because at the time the incident was of unknown origin, but since then the Director of Nurses (DON) had spoken to the resident's sister and the sister had reported the resident told her R #1 had attempted to get up on her own and fell . Interview with the DON on 12/12/11 at approximately 1:20 p.m. revealed she had spoken to R #1's sister and the sister reported R #1 had told her she had tried to get up from bed by herself and she had fallen. Interview with CNA "C" on 12/13/11 at 10:50 a.m. revealed she worked the weekend of the 19th and 20th of November, the 6:00 a.m. to 2:00 p.m. shift. CNA "C" revealed when she attempted to provide care to R #1 she complained of pain to her right leg. CNA "C" stated she had worked with R #1 on Saturday also, but R #1 did not complain of pain that day. CNA "C" stated the resident was always restless and wanted to go to the restroom constantly. CNA "C" stated she was not sure what had occurred but added she (CNA "C") was very good at raising the bed siderails and making sure the bed pad alarm was set. CNA "C" added the resident had been found walking previously, when she should have been in bed. CNA "C" was asked what else she was to do to prevent R #1 from falling. CNA "C" replied the nurses told her to raise the siderails to prevent falls, but wasn't notified of anything different. Interview with LVN "A" on 12/13/11 at 11:25 a.m. revealed R #1 was always wanting to get up and go to the restroom. LVN "A" stated she never saw the resident use the call light, but was always trying to get up from bed and the wheelchair. LVN "A" stated the resident had a bed alarm, wheelchair alarm and siderails. She added the resident was unsteady on her feet. LVN "A" added R #1 would scoot herself to the foot of the bed to try to get out of bed. LVN "A" stated that on 11/02/11 the CNA had come to report to her that the resident was out of bed, but had not fallen to the floor, but was found sitting on the floor. R #2: Review of R #2's Face Sheet dated 07/08/11 revealed she was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]." Review of R #2's Care Plan dated 04/21/10 revealed, "Problem-Potential to fall d/t (due to)unsteady balance. Requires assistance x 1 for transfers.Wheelchair is primary mode of transportation. Tends to lean forward. Goal and Target Date-Will minimize risk for falls or injury thru next careplan review-03/12/12. Approaches-*Put bedside rails up whenever resident is in bed, *Give resident verbal reminders not to ambulate or transfer without assistance, *Assist with transfers as needed, *Wheel resident as needed and *Call bell within reach at all times. Review of physician's orders [REDACTED]. Review of Incident/Accident Report dated 12/01/11 at 8:15 p.m. concerning R #2 revealed "noted resident laying on floor on her L side. c/o pain to R hip with ROM. 0 further injuries noted." The incident report stated the resident had been in bed; bedrails ordered, present but were down. Observation on 12/13/11 at 9:05 a.m. in R #2's room revealed she was in bed, and CNA "D" was offering her applesauce. R #2 had the right siderail up. It was a full size rail. Interview with CNA "D" revealed the resident was unable to see, and CNA "D" would leave the siderails up depending on whether the CNA thought the resident would fall. CNA "D" added R #2 doesn't like the siderails up, and she will yell because she likes to get up and go to the bathroom. CNA "D" stated if R #2 is restless the CNA would lift the siderails so R #2 wouldn't fall. When asked how she knew which residents should have the siderails up, CNA "D" replied the CNA would ask the nurse. Observation on 12/13/11 at 9:35 a.m. revealed R #2 in bed with both siderails up. At 9:40 a.m. R #2 told surveyor she wanted to get up. CNA "E" came to assist R #2. CNA "E" lowered the siderails and R #2 was upset stating, "why do you put the siderails up." CNA "E" responded,"so you won't fall." R #2 stated, "I won't fall, I don't know why you do that, I don't fall." CNA "E" was asked what else R #2 had in place to prevent her from falling. CNA "E" responded she had a pad alarm for the bed and a tab alarm for her wheelchair. When questioned further about the siderails, CNA "E" stated she was told to raise the siderails for anyone at risk for falls. Surveyor observed CNA "E" put R #2 to bed and raised the siderails. R #3 Review of R #3's FACE SHEET dated 09/30/11 revealed the resident was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED].(one leg), [MEDICAL CONDITION] (serious bacterial skin infection), Open Wound of Leg, Hypertension, Dmii Wo Cmp Nt ST Uncntr (Diabetes, type II without complication, not stated as uncontrolled), Coronary Artery Anomaly (abnormalities of the arteries of the heart), Malign Neopl Vagina (cancer of the vagina), Senile Dementia Uncomp, Ampt Above Knee Unilat,[MEDICAL CONDITIONS] ([MEDICAL CONDITION]-resistant Staphylococcus aureus-a bacterium responsible for several difficult to treat infections in humans)." Review of FALL RISK ASSESSMENT for R #3 dated 09/28/11 revealed a score of 12. Total score of 10 or above represented HIGH RISK. Review of Physician order [REDACTED]." Review of Care Plan for R #3 dated 08/29/11 revealed, "Problem-Potential for falls/injuries due to impaired visual functioning, limited mobility due to amputations of lower extremities. Goal & Target Date-*Resident will have no injuries daily and ongoing by next care plan review. 12/29/11. Approaches-*Explain location of food on tray when needed. *Explain all procedures. *Announce self when entering residents area. *Special precautions in emergencies. *Encourage independence in ADL's. *Reorient resident if furniture is moved or change in environment. *Assist with transfers. One staff member to aide in transfers." Observation on 12/12/11 at approximately 1:40 p.m.during initial tour revealed R #3 in room [ROOM NUMBER]b had both her legs amputated and had full siderails. The siderail on the right side was padded. Observation on 12/13/11 at 8:55 a.m. revealed R #3 in bed with her siderails up. The siderail on the left side was fully padded. R #4 Review of R #4's FACE SHEET dated 07/27/10 revealed resident was admitted on [DATE] with the [DIAGNOSES REDACTED]." Review of FALL RISK ASSESSMENT for R #4 dated 12/02/11 revealed a score of 18. Total score of 10 or above represented HIGH RISK. Review of Physician order [REDACTED]. Review of R #4's Care Plan dated 10/15/10 revealed, "Problem-Resident requires siderails X 2 for safety and to aid with mobility r/t impaired cognitive ability 2ndry to Alzheimer's. Goal-*Resident will have no falls or injuries thru next care plan review 03/08/12. Approaches-*Siderails down when transferring patient, *Monitor for safety q shift, *Instruct resident to use call light to request assistance, *Visual checks at least q 2hrs & Prn, *Siderails up X 2 when in bed." Observation on 12/13/11 at approximately 9:00 a.m. revealed R #4 in bed. R #4 had just eaten her breakfast in bed. R #4 had the right side siderail up. Interview with the DON on 12/12/11 at approximately 1:45 p.m. revealed R #4 was confused at times and would try to get up from her bed, but had not sustained a recent fall. Interview with the DON on 12/13/11 at 10:05 a.m. in R #3's room when asked why there were so many full siderails, she revealed they helped as enablers or for repositioning. Surveyor asked the DON if she had consents for the siderails and she stated she did not. The DON then asked if one was needed. When asked how she knew who needed the siderails for repositioning, she attempted to ask R #3 if she could turn herself. R #3 did not respond to the DON. Surveyor asked if assessments had been done to make that determination, and the DON reported there were no assessments. She added she did not know if R #3 used the siderails for repositioning. DON was asked if that was the same bed R #1 was in and she replied it was. In reference to R #4, the DON stated she had not fallen in a long time. When asked what else the facility had tried to prevent R #4 from falling, she replied, "having the call light close, assisting with transfers, monitoring side effects of medications." When asked if she had physical restraint reductions, she replied, "we don't use restraints here." When asked to provide a list of residents that were at risk of falls, the DON provided a list of fifteen residents. The facility was given the opportunity to provide additional information concerning physical restraints. No additional information was provided.