Every finding on record at Legend Oaks Healthcare and Rehabilitation Center -

Based on observation, interview and record review the facility failed to respect the residents right to personal privacy and confidentiality of his or her personal and medical records including 1 of 1 Staff (OTA C) during observations of staff providing care and services. OTA C failed to lock the screen or close her laptop when she walked away from it. This deficient practice could result the resident's medical information being read by anyone walking down the hallway. The findings were:Observation and interview on 5/12/26 at 5:38 PM revealed an open laptop in the rehabilitation gym. The laptop was sitting on a table in front of a window exposed to the hallway. Anyone walking down the hall would have view of it. There were no staff in sight. Surveyor walked into the gym and called out multiple times and OTA C came out of a back office. She stated it was her laptop and was apologetic that she left it open. OTA C stated she stepped away for a minute but should not have left the screen open because it revealed protected resident information and it was a HIPAA violation if anyone else read the information on the screen. Interview on 5/13/26 at 10:05 AM with the DON revealed if OTA C was working on a resident's file, she should have secured it by locking or closing the laptop to ensure the resident's privacy. The DON stated if anyone else read the resident information it would be a violation of HIPAA and the resident's information could be compromised. Review of a facility policy, Resident Rights, dated 10/25, read It is the policy of this facility that Our residents have certain rights and protections under federal and state law that help ensure they receive the care and services necessary. One essential job function is to protect and promote our residents' rights. 8. Receive Privacy and Confidentiality in Clinical Records and personal information shall be always maintained. Records of medical treatment, care, communications, meetings, visitors, or resident groups should be maintained private by staff.

Based on observation and interview the facility failed to ensure each resident received food prepared in a form designed to meet their individual needs for 1 of 1 Resident (Resident #2) observed for a puree diet. Nursing staff failed to ensure Resident #2 received a puree diet as prescribed by his physician. On 5/12/26 he received sugar cookies with his lunch meal. This deficient practice could cause the residents to aspirate or choke and could lead to the resident's death. The findings were:Record Review of Resident #2's face sheet, dated 5/15/26, revealed he was admitted to the facility on [DATE] with a diagnosis of dysphagia (trouble swallowing) following cerebral infarction (stroke). Record Review of Resident #2's admission MDS assessment, dated 4/27/26, revealed his BIMS score of 12 of 15 reflective of moderate cognitive impairment. Further review revealed Resident #2 had a swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications and complaints of difficulty or pain when swallowing. Nutritional approaches included mechanically altered diet and therapeutic diet. Record Review of Resident #2's Care Plan, dated 4/27/26, revealed he had a nutritional problem or potential nutritional problem related to dysphagia. One of the approaches included to provide, serve diet as ordered. Record Review of Resident #2's consolidated physician orders for May 2026 revealed an order, LCS/Renal, diet puree texture, thin liquids. Record Review of the dinner menu dated 5/12/26 included barbeque pork riblette, Italian pasta salad, baked beans, Texas toast and sugar cookies. Observation on 5/12/26 at 5:53 PM revealed Resident #2 was served the dinner meal in puree texture but was also served 2 sugar cookies. Further observation revealed Resident #2 opened the package of sugar cookies, took a couple of bites and he started coughing. LVN A provided water for Resident #2 to drink and he quit coughing. Interview on 5/12/26 at 6:00 PM with LVN A revealed she checked the meal trays for the residents who were eating in their room including Resident #2's meal tray. LVN A stated she checked the trays to ensure they received the diet per physician orders. She stated she did not notice that Resident #2's meal tray included 2 sugar cookies. She stated Resident #2 was on a puree diet because he had problems swallowing and stated he could choke from eating the sugar cookies. LVN A stated she saw Resident #2 coughing when he was eating the sugar cookies, and she provided water and he quit coughing. Interview on 5/13/26 at 12:30 PM with the DON revealed Resident #2 was on a puree diet and should not have received 2 sugar cookies with his dinner tray on 5/12/26. She stated Resident #2 had dysphagia and could choke because of eating the cookies or any food that was not in puree texture. Interview on 5/15/26 at 1:00 PM with the DON revealed she would provide a policy related to resident's receiving therapeutic meals per physician orders. It was not provided by the time of exit on 5/15/26 about 3:30 PM.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 4 halls (Hall 400) observed for a safe environment. Nursing staff failed to ensure the entrance of the oxygen storage room was not obstructed and that the full containers were separated from the empty containers. This deficient practice could result in oxygen cylinders being tipped over and result in a combustion or fire. The findings were: Observation and interview on 5/12/26 at 5:22 PM revealed the oxygen storage room was located on the 400 hall. The DON opened the door to the oxygen room, and the door immediately hit an item behind the door as soon as the DON opened the door. Observation revealed a full oxygen cylinder on a stand behind the door. There were also multiple empty oxygen stands on the left side of the room further obstructing the passage into the room. Observation revealed the DON was unable to walk freely into the storage room without moving oxygen stands out of the room and the full oxygen cylinder on the stand, behind the door, out of the way. Even when clearing these items, there was minimal space to walk into the room. Further observation revealed a full cylinder stored on the side where the empty oxygen cylinders were stored. There was an empty sign on the wall over the empty cylinders. Interview with the DON revealed the full oxygen cylinder on the stand placed behind the door should not be there because staff could knock it over onto the other full oxygen cylinders. She stated it could cause an explosion and or a fire causing a safety risk for the residents on the 400 hall. The DON further stated it was difficult to walk into the storage room because it was cluttered with the empty oxygen stands upon opening the doors. She stated nursing staff could find it difficult to grab an oxygen cylinder and could delay providing a resident with oxygen as needed. She stated a staff member could grab the full oxygen cylinder when removing the empty cylinders and mistakenly drop the cylinder. The DON stated it was facility policy to store the empty cylinders together on one side and to store the full oxygen cylinders on the opposite side. Review of facility policy Policy/Procedures - Nursing Clinical, subject: Oxygen Handling and Storage, dated 5/2007, read Policy: It is the policy of this facility to provide proper use and handling of oxygen tanks in the facility. Procedures: Storage: Storage of oxygen tanks must be accompanied in a safe manner. All tanks must be secured to a wall within a chain or heavy cable. Full tanks will be separated from empty tanks and identified as such.

Based on observation, interview and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 7 Residents (Resident #3) whose records were reviewed. The facility failed to ensure Resident #3's call light was within reach so he could ask for help as needed. This deficient practice could result in residents not being able to ask for assistance as needed. The findings were:Record Review of Resident #3's face sheet, dated 5/15/26, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified Dementia, generalized weakness and below the knee amputation/right lower extremity. Record Review of Resident #3's admission MDS assessment, dated 4/27/26, revealed Resident #3's BIMS score was 9 of 15 reflecting moderate cognitive impairment and he required partial/moderate assistance to total assistance with ADLs. Review of Resident #3's Care Plan, dated 4/26/26, revealed Resident #3 had ADL Self Care Performance Deficit related to generalized weakness, gait/balance problems and below the knee amputation/right lower extremity and Resident #3 was at risk for falls related to gait/balance problems. One of the interventions included for staff to anticipate needs and to make sure the call light was within reach and encourage to use it to call for assistance as needed. Observation and interview on 5/12/26 at 3:07 PM with Resident #3 and the DON revealed Resident #3 was lying in bed with quarter side rails up on both sides of the bed. Resident #3 stated he was doing well. He presented as being alert with confusion. Further observation revealed the call light was placed on top of chair next to Resident #3's bed behind his line of sight. The bedside table was pushed over the chair and then there was a wheelchair in front of the bedside table. Resident #3 stated he would use the call button to call staff for help but stated he did not know where it was. Interview with the DON revealed the call light was on top of the chair and she stated staff probably did not put it back on the bed, but staff should make sure the call light was within Resident #3's reach so he could ask for help as needed. Interview on 5/13/26 at 11:31 AM with the DOR revealed she had worked in her position since 2021/2022. The DOR stated the rehabilitation staff should ensure the call light was within reach after providing services in the resident's room. Otherwise, the residents would not be able to ask for assistance as needed. The DOR stated Resident #3 was new to the facility, had ADL deficits and was considered to be a fall risk; therefore, it was important that he had access to the call light so he could ask for help and to help prevent falls. Review of facility policy, Policy/Procedure - Nursing Clinical, subject: call light/bell read It is the policy of this facility to provide the resident a means of communication with nursing staff. 5. Leave the resident comfortable. Place the call device within resident's reach before leaving the room.

Based on interview and record review the facility failed to treat the decisions of a resident representative as the decisions of the resident to the extent delegated by the resident for 1 of 1 Resident (Resident #1) whose records were reviewed. The facility failed to provide Resident #1's representative with Resident #1's medical records per oral and written request. This deficient practice could result in the residents or family members not having access to medical records. The findings were:Record Review of Resident #1's face sheet, dated 5/14/26, revealed she was admitted to the facility on [DATE] with diagnoses including orthostatic hypotension (when blood pressure drops significantly upon standing from a sitting or lying position), personal history of malignant neoplasm of breast (code applies to patients who have been previously diagnosed with breast cancer, but are currently in remission or cancer free and it is not considered a current illness or injury) and acquired absence of right breast and nipple. Further review revealed a family member was identified as emergency contact #1. Resident #1 was discharged from the facility on 5/4/26. Record Review of Resident #1's entry MDS assessment, dated 5/1/26, revealed her BIMS score was 5 of 15 reflective of severe cognitive impairment and participation in assessment and goal setting included the resident and a family member. Record Review of Resident #1's Authorization for Disclosure of Medical Information, dated 4/30/26, revealed Resident #1's family member was designated as the representative and Resident #1 preferred a family member to sign the document. Record Review of Resident #1's Resident admission Agreement, dated 4/30/26, revealed Resident #1 elected a family member as her family representative. Record Review of an email, dated 5/5/26, and addressed to the DON revealed Resident #1's family member requested the following documents:A copy of any incident report (s) related to this eventAll nursing and clinical notes from the date of the incidentThe names and titles of all staff involved, including the third party lab company, and technicianYour facility's written policies regarding limb alert restrictions and blood drawsAny internal documentation or timeline of when this incident was first recognized and addressedCT scan results of right arm, requested by family on 05/03/26. Record Review of an email, dated 5/11/26, written by the ADM and addressed to Resident #1's family member read With respect to records, the facility can provide copies of the resident's medical records in accordance with applicable state and federal privacy laws. To do so, we must receive a completed medical records authorization from the legally authorized representative. Once that authorization is received, we will process the requested medical records promptly. Much of the clinical information you are requesting, including test results, will be reflected within those records. Interview on 5/13/26 at 10:05 AM with the DON revealed Resident #1 was in the facility for about a week. She stated Resident #1's family member was very upset with her and the facility in general because Resident #1 had a mastectomy some years back and the lab tech drew blood from Resident #1's restricted arm. The DON stated they had a sign over Resident #1's bed and Resident #1 was wearing a bracelet which indicated the restrictions, but the lab tech stated he missed it. The DON stated she attempted to schedule a meeting with Resident #1's family and other family members to discuss their concerns, but she and the family member did not reach an agreement on a date and time. The DON stated Resident #1's family member requested a copy of Resident #1's entire medical records but would not provide a POA which she stated was requested from onset, Resident #1's admission. The DON stated Corporate advised that Resident #1's family member would have to provide a POA in order for the facility to release any medical records. The DON stated she understood the resident and resident representative had a right to request and obtain medical records but stated she had to follow protocol. Interview on 5/13/26 at 3:44 PM with Resident #1's family member revealed he wrote a letter to the facility case manager and to the DON requesting Resident #1's medical records and he also had a telephone conversation with the DON and requested Resident #1's medical records at that time. Resident #1's family member stated the DON told him they would release Resident #1's medical records once he provided an authorization for release for medical records and a POA to the facility. The family member stated the ADM responded on 5/11/26 to the email requests he submitted and stated the facility would release Resident #1's medical records upon receiving an authorization from Resident #1's legal representative. Resident #1's family member further stated he also left a message for the medical records staff, LVN B, requesting Resident #1's medical records. He stated they never talked. Resident #1's family member stated he believed the facility was not going to release medical records unless he provided a POA. The family member stated he had been Resident #1's primary caregiver for years and he signed all of the admitting documentation upon Resident #1's admission to the facility. He stated he believed that sufficed. Telephone interview on 5/14/26 at 9:35 AM with LVN B, medical records staff, revealed she had been in her position for about 8 to 9 years. She stated when releasing medical records, she would usually talk with the resident if the resident was their own RP and would request permission to release their records. LVN B stated if the resident had an assigned RP or emergency contact, she would be able to release the resident's medical records with an authorization for release of medical records. She stated the legal team would then verify the resident's POA status. LVN B stated usually the turnaround period for getting medical records ready was 48 hours. LVN B stated the receptionist let her know Resident #1's family member left a message requesting medical records and she attempted to call Resident #1's family member on the same date the family member called. She stated the first time she called; she left a message and the second time the family member's phone rang but she was not provided with an option to leave a message. LVN B stated she understood it was the resident's right or family representative's right to receive the resident's medical records upon request; however, she stated she had to follow facility protocol. Interview on 5/14/26 at 8:30 PM with the ADM revealed he talked with the facilities' legal team, and they advised him that he would only be able to release Resident #1's medical records to Resident #1's family member upon the family member providing a POA. The ADM stated in the 20 plus years he had been an administrator, he had always requested a POA. He stated he understood Resident #1 had a right to a copy of her medical records and if the family member wanted a copy of Resident #1's medical records he had to provide an authorization for release of medical records. Once that was completed the request was sent to their legal team and Resident #1's family member would be asked to provide a POA. The ADM further stated he understood Resident #1's family member was active in Resident #1's care, but he also had to follow facility protocol. Review of facility policy, Resident Rights, dated 10/25, read It is the policy of this facility that Our residents have certain rights and protections under federal and state law that help ensure they receive the care and services necessary. One essential job function is to protect and promote our residents' rights. 8. A resident may authorize the release of personal and clinical records as provided by law. Review of facility policy, Medical Records, undated, read It is the policy of this facility to ensure every resident has an accurate record. 9. If records are requested by family, a medical records release form must be completed.

Based on observation, interview and record review the facility failed to ensure residents were able to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for 1 of 4 days (May 12, 2026) observed for survey results. The Administration failed to include the most recent survey results in the survey binder located in the lobby. This deficient practice could result in residents being denied reading the most current survey results. The findings were: Observation on 5/12/26 at 2:30 PM revealed the last survey results in the survey binder located in the lobby were dated 11/14/25. Interview on 5/12/26 at 2:40 PM with the ADM revealed the last survey results in the survey binder located in the lobby were dated 11/14/25. The ADM stated he thought he had included the most recent survey results from December 2025. He stated the residents and family members had the right to read the results and ask questions. The ADM stated it was their right and failure to post violated their right to access the survey results. Review of a facility policy, Resident Rights, dated 10/25, did not include verbiage related to the right for residents to access the most recent survey results.

Based on observation and interview the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers from 1 of 1 nutrition room observed for stored enteral feedings. The facility failed to ensure one box of Glucerna 1.2 containing 6 quart containers of enteral feedings did not exceed the expiration date and were removed from the nutrition room. This deficient practice could lead to residents receiving expired feedings and result in health complications. The findings were:Observation and interview on [DATE] at 3:40 PM in the nutrition room revealed 6 quarts of Glucerna 1.2 dated [DATE]; they were expired. The DON stated the Glucerna feedings were expired. The DON stated the staff in charge of central supply or any nursing staff member should have removed to formula because it could lead to residents receiving expired feedings and the residents could get sick. The DON stated she did not believe they had any residents who received Glucerna feedings but stated there was always the possibility nursing staff could grab the wrong feeding and give it to the wrong resident. Interview on [DATE] at 3:50 PM with the DON revealed they did not have any residents who received Glucerna 1.2 cal feedings. Interview on [DATE] at 3:30 PM with the DON revealed the facility did not have a policy on expired enteral feedings.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #13 and #126) of 3 residents reviewed for incontinence care. 1. CNA-B did not clean Resident #13's pubic area and did not open the labia and thoroughly clean the vaginal area for Resident #13 during incontinence care. 2. CNA-C did not clean Resident #126's pubic area during incontinence care. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections. The findings included: 1. Record review of Resident #13's face sheet, dated 12/04/2025, revealed the resident was [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition (a nutrition status in which reduced availability of nutrients leads to changes in body composition and function), dementia (loss of memory and thinking ability), and osteoporosis (bones become weak and are likely to fracture). Record review of Resident #13's quarterly MDS assessment, dated 11/05/2025, revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment, and the resident was always incontinent of bladder and bowel. Record review of Resident #13's comprehensive care plan, dated 02/24/2025, revealed [Resident #13] has bowel and bladder incontinence related to dementia and impaired mobility. For intervention - incontinent: check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Observation on 12/03/2025 at 9:59 a.m., revealed CNA-B removed the soiled brief from Resident #13, cleaned the resident's left groin area and right groin areas. When CNA-B cleaned the vaginal area of Resident #13, CNA-B did not separate the resident's labia and thoroughly clean the area and then rolled the resident to her left side and cleaned the resident's buttock area without cleaning the resident's pubic area. During an interview on 12/03/2025 at 10:20 a.m., CNA-B stated when she cleaned Resident #13's vaginal area, she did not open or separate the resident's labia area. Further interview with CNA-B said she did not clean Resident #13's pubic area also. CNA-B said she should have cleaned Resident #13's pubic area and separated the resident's labia area to prevent possible infection, but CNA-B was nervous and forgot cleaning those areas. CNA-B said she received skill check for peri care of female resident every year. During an interview on 12/03/2025 at 3:52 p.m., DON stated CNA-B should have cleaned Resident #13's pubic area and should have separated the resident's labia area to clean the base of the labia to prevent possible infection or skin breakdown. 2. Record review of Resident #126's face sheet, dated 12/04/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE] and readmitted to the facility 11/26/2025 with diagnoses of orthopedic aftercare (following rehabilitation program after musculoskeletal treatment), hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body), and malignant neoplasms of colon (cancer of large intestine). Record review of Resident #126's admission MDS assessment revealed In Progress because the resident was admitted to the facility on [DATE]. - Record review of Resident #126's baseline care plan, dated 12/02/2025, revealed [Resident #126] has urinary catheter and bowel incontinence related to activity intolerance. For intervention - incontinent: check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Observation on 12/03/2025 at 3:12 p.m., revealed CNA-C removed Resident #126's soiled brief, and CNA-C started cleaning the resident's left groin, right groin, penis, and urinary catheter, and then rolled the resident to his left side and cleaned the resident's buttock area without cleaning the resident's pubic area. During an interview on 12/03/2025 at 3:35 p.m., CNA-C stated when she cleaned Resident #126's perineal area and urinary catheter, she did not clean the resident's pubic area, and she said she should have cleaned the resident's pubic area to prevent possible infection. CNA-C said she was checked-off regarding male peri and catheter care every year. During an interview on 12/03/2025 at 3:52 p.m., the DON stated CNA-C should have cleaned Resident #126's pubic area to prevent possible infection. Record review of the facility's policy, titled Perineal Care, revised 05/2007, revealed Female-without catheter.4. Wash pubic area, including upper, inner aspect of both thighs and frontal portion of perineum. 9. Wash perennial area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttock. Male - 1. Wash pubic area, including upper inner aspect of thighs as well as the penis and scrotum.

Based on observation, interview, 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 observed for puree diet preparation.The facility failed to ensure dietary staff preparing the puree diets used sanitary preparation procedures.These failures could place residents who received meals and/or snacks from the kitchen at risk of food born illness.The findings included: Observation on 12/03/2025 at 10:46 a.m. revealed the [NAME] using a processor to prepare the pureed pork loin. The [NAME] had the processor sitting on one side of the counter near the 2-compartment sink with a pot of pork loin next to it. The [NAME] was observed scooping out the pork loin with a large cooking spoon and placing it in the processor to puree it. After blending the pork loin, the [NAME] reached across the 2-compartment sink grabbing the plastic liquid measuring cup which was sitting on the metal counter with liquid droplets around and near it. The [NAME] then placed the measuring cup into the pot of pork loin and gathered the broth from the pork loin then poured it into the processor and proceeded to blend the pureed pork loin. The [NAME] left the measuring cup in the pot with the pork loin while pureeing the pork loin. The [NAME] again pressed the measuring cup down in the pot to gather broth and poured it into the processor, continuing to puree the pork loin. This time the [NAME] placed the measuring cup on a piece of tin foil that had been placed behind the food processor. The [NAME] once finished pureeing the pork loin scooped it out of the processor into a metal pan and covered it to be placed on the steam table. During an interview on 12/03/2025 at 11:09 a.m. the [NAME] stated when she took the measuring cup from the other counter, she risked cross contamination by using it after it had been setting on the counter due to it touching the surface and it having not been sanitized before. The [NAME] further stated by not using the spoon and dipping the measuring cup in the pork loin for the broth risked cross contamination. The [NAME] stated this could have made people get sick. During an interview on 12/03/2025 at 11:12 a.m. the DS stated the [NAME] should have used the ladle instead of grabbing a cup from the counter and sticking it in the pork loin for the broth. The DS further stated this could cause cross contamination and could get people sick. The DS instructed the cook to throw out the pork loin she had prepared and make more. Review of facility's policy, Infection Control Policy/Procedure, revised 05/2007, read Section: Departmental, Subject: Dietary Services: Policy: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedures: 6. Proper Food Handling, N. Utensils, cups, glasses, and dishes must be handled in such a way as to avoid touching surfaces with which food or drink will come in contact.

Based on observations, interviews, and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #86) of 29 residents reviewed the privacy of medical records. LVN-A left her computer open and unattended with Resident #86's personal and medical information on the nursing cart at the 300-hallway on 12/03/2025. This failure could place residents at risk of resident identifiable and medical information being accessed by unauthorized persons. The findings were: Record review of Resident #86's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year old female, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), osteoporosis (bones become weak and are likely to fracture), hypothyroidism (abnormally low activity of the thyroid gland), and neuropathy (happens when the nerves that are located outside of the brain and spinal cord are damaged). Record review of Resident #86's quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 7 out of 15, which indicated the resident had severe cognitive impairment, and the resident had insulin injections that were received during the last 7 days. Observation on 12/03/2025 at 11:10 a.m. revealed LVN-A opened her computer located on the cart and looked at Resident #86's electronic MAR. LVN-A took out Resident #86's glucometer, lancet, alcohol swap, and gauze from the cart and put them inside a basket. LVN-A knocked on the door of Resident #86's room and entered the room without closing or logging off the computer. Resident #86's electronic MAR on the screen of the computer, including the resident's face photo, date of birth , and medications to be provided, was opened. During an interview on 12/03/2025 at 11:26 a.m. with LVN-A stated the nurse did not close or log off the computer when the nurse entered Resident 86's room to check the resident's blood sugar, so the computer screen on the cart was opened with Resident #86's face photo, date of birth , and medications to be provided. LVN-A said she left her computer open with Resident #86's personal and medical information on the nursing cart at the 300-hallway, and it was Resident #86's privacy violation because anybody could see Resident #86's personal and medical information. During an interview on 12/03/2025 at 3:52 p.m. with DON said LVN-A should have closed or logged off her computer when she left her nursing cart at the 300-hallway to protect Resident #86's personal and medical information, and it was the nurse's mistake and HIPAA violation. Record review of the facility policy, titled HIPAA, undated, revealed It is the policy of this facility to protect the privacy of patient/resident health information - 1. Protected health information that identifies patient/resident or contains information that can be used to identify the patient/resident must be kept safe, confidential, and protected. This include: electronic, written, and paper and/or verbal formats.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 27 residents (Residents #130 and #81) reviewed for storage. 1. Resident #130's insulin Degludec Flex Pen for diabetes had no open date, found inside 100-wing nursing cart on 12/02/2025. 2. Resident #81's insulin Glargine Flex Pen for diabetes had no open date, found inside 100-wing nursing cart on 12/02/2025. These failures could place residents at risk of having no therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #130's face sheet, dated 12/04/2025, revealed Resident #130 was a [AGE] year-old male and admitted to the facility 11/19/2025 with diagnoses of sepsis (the body responded improperly to an infection), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and hypertension (high blood pressures). Record review of Resident #130's admission MDS, dated [DATE], revealed the MDS was In Progress. Record review of Resident #130's physician's order, dated 11/20/2025, revealed the resident had the order of Insulin Degludec Subcutaneous Solution 100 UNIT/ML (Insulin Degludec) Inject 10 unit subcutaneously at bedtime for Diabetes Hold if blood sugar is less than 100. Record review of Resident #130's medication administration record, dated from 12/01/2025 to 12/31/2025, revealed the resident was receiving Insulin Degludec Subcutaneous Solution 100 UNIT/ML (Insulin Degludec) Inject 10 unit subcutaneously at bedtime for Diabetes at 8:00 pm. Observation on 12/02/2025 at 3:08 p.m. revealed Resident #130's insulin Degludec Subcutaneous Solution 100 UNIT/ML Pen for diabetes with no open date was found inside the 100-wing nursing cart. Further observation on the box of the insulin indicated after first use store at room temperature for up to 56 days. Interview on 12/02/2025 at 3:22 p.m. with LVN-F stated Resident #130's insulin Degludec Subcutaneous Solution 100 UNIT/ML Pen for diabetes with no open date was found inside the 100-wing nursing cart, and the insulin pen should have been discarded 56 days after opening it. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen. LVN-F said she did not know if she should discard the insulin pen because the insulin pen did not have open date, and the nurse did not know when the facility nurses opened Resident #130's insulin pen. 2. Record review of Resident #81's face sheet, dated 12/04/2025, revealed Resident #81 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses of encephalopathy (serious neurological change), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), protein-calorie malnutrition (a nutrition status in which reduced availability of nutrients leads to changes in body composition and function), and hypertension (high blood pressures). Record review of Resident #81's admission MDS, dated [DATE], revealed the resident's BIMS was 4 out of 15 which indicated the resident had severe cognitive impairment and received insulin injection. Record review of Resident #81's physician's order, dated 12/02/2025, revealed the resident had the order of Insulin Glargine-yfgn Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 10 unit subcutaneously at bedtime for diabetes Hold insulin if Blood Sugars less than 70. Record review of Resident #81's medication administration record, dated from 12/01/2025 to 12/31/2025, revealed the resident was receiving Insulin Glargine-yfgn Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 10 unit subcutaneously at bedtime for diabetes at 8:00 pm. Observation on 12/02/2025 at 3:08 p.m. revealed Resident #81's insulin Glargine-yfgn Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Pen for diabetes with no open date was found inside the 100-wing nursing cart. Further observation on the box of the insulin indicated discard after 28 days. Interview on 12/02/2025 at 3:22 p.m. with LVN-F stated Resident #81's insulin Glargine-yfgn Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Pen for diabetes with no open date was found inside the 100-wing nursing cart, and the insulin pen should have been discarded 28 days after opening it. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen. LVN-F said she did not know if she should discard the insulin pen because the insulin pen did not have open date, and the nurse did not know when the facility nurses opened Resident #81's insulin pen. Interview on 12/03/2025 at 3:52 p.m. with DON said the facility nurses should have written open dates on insulins when they opened them to discard them after the insulins were opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. DON said that it was nurse's responsibility, and DON sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. Record review of the facility policy, titled Medication Access and Storage, revised 05/2007, revealed that The provider pharmacy dispense medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved two residents (Residents #57 and #18) of five residents reviewed for medication errors. 1. MA-D gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident administered two sprays to each nostril by himself, but the physician order said, Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies. 2. MA-D administered 15 ml of Resident #18's Enulose Solution 10 gm/15 ml to the resident on 12/03/2025. However, the physician order indicated Enulose Solution 10 gm/15 ml, Give 30 ml by mouth two times a day for constipation. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, according to physician orders. Findings include: 1. Record review of Resident #57's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of sepsis (the body responds improperly to an infection), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), hypertension (high blood pressures), and malignant neoplasm of colon (cancer of the large intestine). Record review of Resident #57's admission MDS assessment, dated 11/28/2025, revealed the resident's BIMS was 15 out of 15 which indicated the resident's cognitive was intact and required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating and required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand and toilet transfer. Record review of Resident #57's physician order, dated 11/15/2025, revealed the resident had the order of Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies. Record review of Resident #57's medication administration record, from 12/01/2025 to 12/31/2025, revealed Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies was scheduled at morning time every day. Observation on 12/03/2025 at 8:38 a.m. revealed MA-D entered Resident #57's room and gave the resident's Fluticasone Propionate Nasal Suspension to the resident, and Resident #57 administered two sprays to each nostril by himself and returned the medication to MA-D. During an interview on 12/03/2025 at 12:49 p.m. with MA-D stated she gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident administered two sprays to each nostril by himself, but the physician order said, one spray to each nostril. The MA-D said she did not say one-spray to each nostril to Resident #57 when giving it to the resident on 12/03/2025 because the resident already knew it, but the resident sometimes made two sprays to each nostril. MA-D said she would report it to the nurse. During an interview on 12/03/2025 at 12:50 p.m. with LVN-E stated she would report to the physician regarding Resident #57 administered two sprays of Fluticasone Propionate Nasal Suspension to each nostril because the physician order said, one spray to each nostril. During an interview on 12/04/2025 at 3:52 p.m. with Resident #57 refused interviewing with the surveyor by saying, I am busy now. During an interview on 12/04/2025 at 3:52 p.m. with DON said it was medication error that Resident #57 administered two sprays of his Fluticasone to each nostril, and MA-D did not say one spray to each nostril to the resident before giving it to the resident, but the physician indicated one spray to each nostril. MA-D should have reeducated the resident whenever giving the medication to the resident. 2. Record review of Resident #18's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year-old male and originally admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), severe protein-calorie malnutrition (a nutrition status in which reduced availability of nutrients leads to changes in body composition and function), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #18's admission MDS assessment, dated 11/06/2025, revealed the resident's BIMS was 13 out of 15 which indicated the resident's cognitive was intact and required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) to eating and required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand. Record review of Resident #18's physician order, dated 10/24/2025, revealed the resident had the order of Enulose solution 10 gm/ml (Lactulose Encephalopathy) Give 30 ml by mouth two times a day for constipation. Record review of Resident #18's medication administration record, from 12/01/2025 to 12/31/2025, revealed Enulose solution 10 gm/15 ml (Lactulose Encephalopathy) Give 30 ml by mouth two times a day for constipation was scheduled at morning time and hours of sleep every day. Observation on 12/03/2025 at 8:30 a.m. revealed MA-D entered Resident #18's room and gave 15 ml of Enulose solution 10 gm/15 ml to Resident #18, and the resident took 15 ml of Enulose solution. During an interview on 12/03/2025 at 12:49 p.m. with MA-D stated she administered 15 ml of Enulose solution 10 gm/15 ml to Resident #18, and the resident took 15 ml of Enulose solution, but the physician's order indicated Enulose solution 10 gm/ml (Lactulose Encephalopathy) Give 30 ml by mouth two times a day for constipation. MA-D said she should have administered 30 ml of Enulose solution to Resident #18 as ordered, but she was confused about the dosage, and it was medication error. During an interview on 12/04/2025 at 3:52 p.m. with DON said it was medication error that Resident #18 should have received 30 ml of Enulose solution for constipation, but the resident took 15 ml of Enulose solution, and it might affect not receiving the intended therapeutic benefits of the medication. Record review of the facility policy, titled Medication Administration, revised 05/2007, revealed verify medication cards with medication orders and read the label on the bottle as it is removed from the shelf and check label with mediation orders.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 resident (Resident #11) of 8 residents reviewed for MDS assessments.The facility failed to ensure Resident #11's admission 5-day MDS and Significant change MDS were coded accurately for Preadmission Screening and Resident Review (PASRR). These deficient practices could affect residents who receive care and could result in missed or inappropriate care. The findings included: Record review of Resident #11's face sheet dated 12/03/2025, revealed Resident #11 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses that included: schizophrenia unspecified, bipolar disorder unspecified, and unspecified intellectual disabilities. Record review of Resident #11's admission 5-day MDS assessment, dated 02/07/2025 Section A1500 Preadmission Screening and Resident Review (PASRR) coded 0 (No) for was the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident #11's Significant Change MDS assessment, dated 09/28/2025 Section A1500 Preadmission Screening and Resident Review (PASRR) coded 0 (No) for is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident #11's care plan, revision date of 11/13/2025, revealed Resident #11 had a focus of PASRR positive and currently only receives Habilitation Coordination. Record review of Resident #11's PASRR Level 1 Screening, dated 02/03/2025, revealed, Section C PASRR Screening coded yes for Mental Illness, Intellectual Disability and Developmental Disability. Record review of Resident #11's PASRR Evaluation, dated 03/06/2025, read, Section B0200 coded yes for To your knowledge, does the individual have a Developmental Disability other than an Intellectual Disability that manifested before the age of 22? During an interview on 12/04/2025 at 2:09 p.m. the MDS Nurse stated Resident #11was PASRR positive and received habilitative services. The MDS Nurse further stated Resident #11's MDS assessments should have been coded yes for PASRR. The MDS Nurse stated she was responsible for the coding of the section and guessed she had overlooked it. The MDS Nurse stated it was important to accurately code the MDS assessments because they were sent to HHSC, and they were signing off they were being truthful. During an interview on 12/04/2025 at 3:52 p.m. the DON stated the MDS Nurse was responsible for MDS assessments accuracy. The DON stated the MDS assessments being coded accurately was important to make sure the services needed were triggered. The DON further stated by miscoding the MDS assessments could have the potential to cause services not to be provided. Record review of facility's policy titled Resident Assessment and Associated Processes, revised date 12/2023, read, Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident.Procedure: Comprehensive Assessment: Includes the completion of the MDS (Minimum Data Set) as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change.An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. Section A: Identification Information Intent: The intent of this section is to obtain the reasons for assessment, administrative information, and key demographic information to uniquely identify each resident.Coding instructions for A1550 Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on observations, interviews, and record reviews, the facility failed to ensure residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 1 of 5 residents (Residents #57) reviewed for medications. MA-D gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident sprayed the medication to each nostril by himself. However, the facility did not assess and evaluate Resident #57's ability to self-administer medications and did not obtain a physician's order for self-administration of medications. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #57's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of sepsis (the body responds improperly to an infection), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), hypertension (high blood pressures), and malignant neoplasm of colon (cancer of the large intestine). Record review of Resident #57's admission MDS assessment, dated 11/28/2025, revealed the resident's BIMS was 15 out of 15 which indicated the resident's cognitive was intact and required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating and required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand and toilet transfer. Record review of Resident #57's comprehensive care plan, dated 11/16/2025, revealed there was no care plan related to self-administration of medications for the resident's Fluticasone Propionate Nasal Suspension. Record review of Resident #57's physician order, dated 11/16/2025, revealed there was no physician order related to self-administration of medications for the resident's Fluticasone Propionate Nasal Suspension. Further record review of the resident's physician order, dated 11/15/2025, revealed the resident had the order of Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies. Record review of Resident #57's medication administration record, from 12/01/2025 to 12/31/2025, revealed Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies was scheduled at morning time every day. Observation on 12/03/2025 at 8:38 a.m. revealed MA-D entered Resident #57's room and gave the resident's Fluticasone Propionate Nasal Suspension to the resident, and Resident #57 sprayed the medication to each nostril by himself and returned the medication to MA-D. During an interview on 12/03/2025 at 12:49 p.m. with MA-D stated she gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident sprayed the medication to each nostril by himself because the resident wanted to administer the medication by himself and had no cognitive impairment. Further interview with MA-D said she notified nurses regarding Resident #57's self-administration of the medication, but MA-D said she did not receive any direction, so she thought it was fine to give this medication to the resident for self-administration by the resident. During an interview on 12/03/2025 at 12:50 p.m. with LVN-E stated she knew Resident #57 sprayed his Fluticasone Propionate Nasal Suspension to each nostril by himself because the resident was able to do it by himself, but there was no physician's order related to self-administration of the medication by the resident and did not know what reason the facility did not obtain the order from the resident's physician. During an interview on 12/04/2025 at 3:52 p.m. with Resident #57 refused interviewing with the surveyor by saying, I am busy now. During an interview on 12/04/2025 at 3:52 p.m. with DON said according to the facility policy regarding self-administration of medication, the facility IDT should have assessed the resident's ability to self-administer medications, and the resident's cognitive, communication, visual, and physical ability to carry out this responsibility should have been evaluated. DON said Resident #57 was able to self-administer his Fluticasone nasal spray by himself without any problem, but the facility should have obtained a physician's order. DON said the facility might miss the procedures related to obtaining self-administration order of the medication by the resident. Record review of the facility policy, titled Self-Administration of Medications, revised 05/2016, revealed To determine the ability of alert residents to participate in self-administration of medications. To maintain the safety and accuracy of medication administration. 1. Upon admission, alert residents will be informed of their right to self-administer medications. 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess the resident's ability to self-administer medications. 3. The resident's cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. 4. If the resident is a candidate for self-administration of medications, a physician's order will be obtained.

Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) out of 27 residents reviewed for medical records. Facility nurses did not document their initials when they administered Resident #16's oxygen via a nasal cannula as ordered on the resident's medication administration record. This failure placed residents at risk for missed treatment regarding oxygen therapy as ordered which could result in decline in healing and well-being.Findings included: Record review of Resident #16's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), protein-calorie malnutrition (a nutrition status in which reduced availability of nutrients leads to changes in body composition and function), heart failure (heart not pumping enough blood to the body), and peripheral vascular disease (slow and progressive disorder of the blood vessels). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 7 out of 15, which indicated the resident had severe cognitive impairment, required Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) such as sit to stand, chair to bed, and toilet transfer, and receiving oxygen therapy on Section O (Special Treatments and Programs). Record review of Resident #16's comprehensive care plan, dated 12/02/2025, revealed Oxygen therapy related to ineffective gas exchange. For intervention - Oxygen per medical doctor orders. Record review of Resident #16's physician order, dated 11/03/2025, revealed the resident had the orders of O2 (oxygen) AT 2 LPM (liter per minute) CONTINUOUS PER Nasal Cannula as needed for Short of breathing / WHEEZING. Record review of Resident #16's medication administration record from 12/01/2025 to 12/31/2025 revealed the order of O2 (oxygen) AT 2 LPM (liter per minutes) CONTINUOUS PER Nasal Cannula as needed for Short of breathing / WHEEZIN was scheduled as needed, and the dates of 12/01/2025, 12/02/2025, and 12/03/2025 were all left blank. Observation on 12/01/2025 at 10:54 a.m. revealed Resident #16 was sitting on the wheelchair in her room, and the resident had oxygen 2 liter per minute via nasal cannula, and the oxygen tubing and nasal cannula had label for change, and the label indicated they were changed on 12/01/2025. Interview on 12/04/2025 at 10:55 a.m. with LVN-A stated the nurses administered oxygen 2 liter per nasal cannula to Resident #16 as ordered on 12/1/2025, 12/02/2025, and 12/03/2025, but they did not document on the resident's medication administration record. The facility nurses should have documented on Resident #16's medication administration record after administering the resident's oxygen per nasal cannula to keep accurate medical records and communicate with other nurses with the documentation. Interview on 12/04/2025 at 3:52 p.m. with DON stated the facility nurses should have documented on Resident #16's medication administration record after administering the resident's oxygen per nasal cannular to keep accurate medical record and communicate with other nurses with the documentation. Record review of the facility policy, titled Oxygen Administration, revised 05/2007, revealed that . 17. Document all appropriate information in medical record for Oxygen therapy.

Based on observation, interview, 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, in that: 1. The facility failed to ensure an opened bag of shredded cheese was stored in a sealed container in the reach-in cooler. 2. The facility failed to ensure a storage bag of cooked pork was sealed and labeled with a use-by date in the reach in cooler. 3. The facility failed to store a mop in the equipment storage closet in a position that allowed air drying. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 09/24/2024 at 9:26 AM revealed there was a 5-lb. bag of shredded cheddar cheese in the reach-in cooler. The cheese was in its original package and placed in a clear, gallon-sized storage bag with a zipper-seal. The package of cheese had been opened and the zipper-sealed bag was also open. During an interview on 09/24/2024 at 9:27 AM the DS stated the zipper-sealed bag should have been closed. The DS further stated any staff member who stored food in the cooler was responsible for ensuring all foods were properly labeled, dated, and stored in sealed containers or bags to prevent cross contamination and spoilage. 2. Observation on 09/24/2024 at 9:29 AM revealed leftover cooked pork in a gallon-sized storage bag with a zipper-seal. The bag was unsealed, and there was no prepared or use-by date on the bag. During an interview on 09/24/2024 at 9:30 AM the DS stated the storage bag of pork should have been sealed and labeled with a use-by date, and it was facility policy to use leftover food within seven days. The DS further stated all dietary staff knew they were supposed to store all leftover food sealed bags or containers and label and date the bags and containers with a use-by date to prevent cross contamination and spoilage. Staff was trained upon hire and all dietary staff had valid and current food handler certificates. 3. Observation on 09/26/2024 at 11:50 AM in the equipment storage closet revealed a mop stored with the mop head on the ground in a manner that did not allow for air drying. Further observation revealed the mop head was not completely dry to the touch. During an interview on 09/26/2024 at 11:50 AM, the DS stated the mop head was damp, the mop should have been stored on a hook in the closet, and dietary staff knew how it was supposed to be stored. When asked on 09/24/2024 at 9:45 AM for the facility's dietary policies, the DS stated the facility used the Texas Food Establishment Rules (TFER) as their policy manual. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the of the Texas Food Establishment Rules (TFER), October 2015, S228.69(a)(1)(A) & (B) revealed it was the same verbiage as the U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11(A)(1) and (2), Food Storage. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the Texas Food Establishment Rules (TFER), October 2015, S228.75 (g) (1) revealed it was the same verbiage as the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-501.17(A), Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment or supplies. Record review of the Texas Food Establishment Rules (TFER), October 2015, S228.186(f) revealed it was the same verbiage the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 501.16, Drying Mops.

Based on observation, interview and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 residents of 9 residents (Resident #226, Resident #221, and Resident #320) reviewed for use of side or bed rails in that: 1. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #226 and failed to assess Resident #226 for risk of entrapment from bed rails before they were installed. 2. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #221 and failed to assess Resident #221 for risk of entrapment from bed rails before they were installed. 3. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #320 and failed to assess Resident #320 for risk of entrapment from bed rails before they were installed. This failure could affect residents who use bed or side rails as enablers and could result in entrapment. The findings included: 1. Record review of Resident #226's face sheet, dated 9/26/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included legal blindness (severe vision impairment), and hemiplegia (total paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction (also known as a stroke; occurs when blood flow to a part of the brain is blocked) affecting unspecified side. Record review of Resident #226's most recent MDS assessment, dated 9/14/24 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #226's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/12/24 revealed the resident's representative signed the document and was fully informed of the potential dangers in the usage of hand rails and bed side rails. Record review of Resident #226's Restraint/Enabling Device /Safety Device Evaluation, dated 9/22/24 revealed the resident had Associated Health issues/diagnoses which contribute to potential for falls or need for Safety/Enabling Devices related to weakness. Further review of the document revealed, Indicate below, ALL measures you have tried Before Implementing Recommended Device. Check ALL that Apply was left blank. During an observation and interview on 09/25/24 8:12 a.m., Resident #226 stated he was completely blind, could not walk and needed help with transfers. Resident #226 was observed in the bed with quarter bed rails up on both sides of the bed. Resident #226 stated he had never tried to use the quarter rails. Observation on 09/26/24 at 2:08 p.m. revealed Resident #226 sleeping in bed and the quarter bed rails were up on both sides of the bed. 2. Record review of Resident #221's face sheet, dated 9/26/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy and lack of coordination. Record review of Resident #221's baseline care plan, dated 9/13/24 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes. Record review of Resident #221's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/13/24 revealed the resident signed the document and was fully informed of the potential dangers in the usage of hand rails and bed side rails. Record review of Resident #221's Restraint/Enabling Device /Safety Device Evaluation dated 9/14/24 revealed the resident had Associated Health issues/diagnoses which contribute to potential for falls or need for Safety/Enabling Devices related to weakness. Further review of the document revealed, Indicate below, ALL measures you have tried Before Implementing Recommended Device. Check ALL that Apply was marked 1/4 side rails right and 1/4 side rails left. During an observation on 9/24/24 at 10:26 a.m., Resident #221 was sitting up in bed with quarter rails on both sides of the bed in the up position. During an observation and interview on 9/26/24 at 8:30 a.m., Resident #221 was sitting up in bed with quarter rails on both sides of the bed in the up position. Resident #221 stated the bed rails were always up and did not know how to put them down. Resident #221 stated she used the bed rails to reposition herself. During an interview on 9/26/24 at 4:29 p.m., the DON revealed Resident #226 and Resident #221 had bed rails used as enablers and were affixed to the bed. The DON stated the facility obtained a consent at the time of admission for the use of enablers. The DON stated to have the bed rails it was required to have physician orders, a consent and the bed rails needed to be care planned. The DON further stated, we do an assessment to make sure they are able to use it, and it is not a restraint. The DON stated, the use of bed rails should be care planned to make sure the staff are aware the bed rails are used as mobility bars to enhance mobility and not as a restraint. 3.Record review of Resident #320's face sheet, dated 9/26/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), Parkinson's disease (a movement disorder that affects the nervous system and worsens over time) without dyskinesia without mention of fluctuations, and adult failure to thrive. Record review of Resident #320's initial admission record, dated 9/19/24 revealed the resident was sometimes understood and sometimes understood others. Record review of Resident #320's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/19/24 revealed the resident representative signed the document and was fully informed of the potential dangers in the usage of hand rails and bed side rails. Record review of Resident #320's assessments, on 9/26/24, revealed they did not contain a Restraint/Enabling Device /Safety Device Evaluation. Record review of Resident #320's Order Summary Report, dated 9/26/24 revealed an order for bolsters placed on bed with a start date of 9/20/24, and no end date. Another order for MAY USE MOBILITY BARS TO AIDE IN EASY TURNING &REPOSITIONING WHILE IN BED every evening and night shift, with a start date of 9/19/24, and no end date. Record review of Resident #320's baseline care plan, dated 9/20/24 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes and did not have the use of bed rails included in the baseline care plan. During an observation on 9/27/24 at 11:25 a.m. revealed Resident #320 was sitting in his bed with 1/8th rails in the upright position on either side of the bed. The resident was not able to answer questions when asked. The resident also appeared to have a mattress with side bolsters. Record review of the facility policy and procedure titled, Mobility Bars, with revision date 5/2007 revealed in part, .It is the policy of this facility to use mobility bars .1. Based on resident's assessed medical needs .2. Used for treatment of medical symptoms or condition .3. Used for resident's mobility and/or transfer .Informed Consent . 45857

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #226, Resident #221 and Resident #320) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #226's use of bed rails was care planned. 2. The facility failed to ensure Resident #221's use of bed rails was care planned. 3. The facility failed to ensure Resident #320's use of bed rails was care planned. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: 1. Record review of Resident #226's face sheet, dated 9/26/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included legal blindness (severe vision impairment), and hemiplegia (total paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction (also known as a stroke; occurs when blood flow to a part of the brain is blocked) affecting unspecified side. Record review of Resident #226's most recent MDS assessment, dated 9/14/24 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #226's baseline care plan, dated 9/12/24 revealed the use of bed rails was not included in the care plan. Record review of Resident #226's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/12/24 revealed the resident's representative signed the document and was fully informed of the potential dangers in the usage of handrails and bed side rails. During an observation and interview on 09/25/24 8:12 a.m., Resident #226 stated he was completely blind, could not walk and needed help with transfers. Resident #226 was observed in the bed with quarter bed rails up on both sides of the bed. Resident #226 stated he had never tried to use the quarter rails. Observation on 09/26/24 at 2:08 p.m. revealed Resident #226 sleeping in bed and the quarter bed rails were up on both sides of the bed. 2. Record review of Resident #221's face sheet, dated 9/26/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy and lack of coordination. Record review of Resident #221's baseline care plan, dated 9/13/24 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes and did not have the use of bed rails included in the baseline care plan. Record review of Resident #221's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/13/24 revealed the resident signed the document and was fully informed of the potential dangers in the usage of handrails and bed side rails. During an observation on 9/24/24 at 10:26 a.m., Resident #221 was sitting up in bed with quarter rails on both sides of the bed in the up position. During an observation and interview on 9/26/24 at 8:30 a.m., Resident #221 was sitting up in bed with quarter rails on both sides of the bed in the up position. Resident #221 stated the bed rails were always up and did not know how to put them down. Resident #221 stated she used the bed rails to reposition herself. 3. Record review of Resident #320's face sheet, dated 9/26/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), Parkinson's disease (a movement disorder that affects the nervous system and worsens over time) without dyskinesia without mention of fluctuations, and adult failure to thrive. Record review of Resident #320's initial admission record, dated 9/19/24 revealed the resident was sometimes understood and sometimes understood others. Record review of Resident #320's Enabling Device/Safety Device/Restraint Informed Consent, dated 9/19/24 revealed the resident representative signed the document and was fully informed of the potential dangers in the usage of hand rails and bed side rails. Record review of Resident #320's assessments, on 9/26/24, revealed they did not contain a Restraint/Enabling Device /Safety Device Evaluation. Record review of Resident #320's Order Summary Report, dated 9/26/24 revealed an order for bolsters placed on bed with a start date of 9/20/24, and no end date. Another order for MAY USE MOBILITY BARS TO AIDE IN EASY TURNING &REPOSITIONING WHILE IN BED every evening and night shift, with a start date of 9/19/24, and no end date. Record review of Resident #320's baseline care plan, dated 9/20/24 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes and did not have the use of bed rails included in the baseline care plan. During an observation on 9/27/24 at 11:25 a.m. revealed Resident #320 was sitting in his bed with 1/8th rails in the upright position on either side of the bed. During an interview on 9/26/24 at 4:29 p.m., the DON revealed Resident #226, Resident #221, and Resident #320 had bed rails used as enablers and were affixed to the bed. The DON stated to have the bed rails it was required to have physician orders, a consent and the bed rails needed to be care planned. The DON stated, the use of bed rails should be care planned to make sure the staff are aware the bed rails are used as mobility bars to enhance mobility and not as a restraint. A careplan policy was requested and provided for comprehensive care plans, no baseline care plan policy was provided.

45857 Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 6 residents (Resident #320) reviewed for advanced directives, in that: The facility failed to ensure Resident #320's Out-of-Hospital Do Not Resuscitate (OOH DNR) was included in the medical record and correctly completed. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #320's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), Parkinson's disease (a movement disorder that affects the nervous system and worsens over time) without dyskinesia (uncontrolled, involuntary movements of the face, arms, and legs) without mention of fluctuations, and adult failure to thrive. Record review of Resident #320's initial admission record, dated [DATE] revealed the resident was sometimes understood and sometimes understood others. Record review of Resident #2's comprehensive care plan, initiated on [DATE] revealed the resident was a DNR. Record review of Resident #320's Order Summary Report, dated [DATE] revealed an order for DNR, with a start date of [DATE], and no end date. Record review Resident #320's DNR, dated [DATE], revealed it contained Resident #320's RP's signature and name in section C. The DNR was signed by two witnesses and two physicians. There were two physicians' signatures at the bottom of the document but no witness or RP signature at the bottom where any person who had signed above must sign below. During an interview on [DATE] at 2:20 p.m. the SW stated he was unsure if there were any pending DNR's and had just started at the facility. The SW was unsure if Resident #320 had a DNR or where the DNR was. During an interview on [DATE] at 2:59 p.m. the DON stated clinical staff was helping the SW with DNR paperwork since he was new and in training. The DON stated it took them a while to find the DNR and if Resident #320 had coded, he would have received CPR in the event of an emergency if they had taken that long to locate the DNR. The DON stated the RP's signature was not necessary on the document because they had two provider signatures. During an interview on [DATE] at 11:27 a.m. Resident #320's RP stated they did not complete a DNR form. The RP was shown the DNR form. The RP stated that was not their signature or print and was concerned someone would be forging their name on documents. The RP stated they did wish to execute a DNR but was not asked to fill out paperwork by the facility. The RP stated they only discussed the DNR with hospital staff prior to being admitted to the facility. Record review of the facility policy titled Advanced Directives and Associated Documentation, dated ,d+[DATE], reflected . Procedure: 1. Prior to, upon, or immediately after admission, a facility staff member shall: a. Provide the resident/family or responsible agent written information regarding the right to accept or refuse medical treatment and the right to formulate Advance Directives b. Document in the resident health record that, at the time of admission, the resident/family has been provided with written information regarding advance directives. c. Inquire whether he/she has completed an Advance Directive. 2. If the resident is incapacitated at the time of admission and is unable to receive information or indicate whether or not he/she has executed an advance directive, the facility may give advance directive information to the resident's representative in accordance with existing State law. a. If the resident becomes able to receive information at a later point during his/her admission, the facility will follow its policy relative to the provision of advance directive information to extent permitted by the resident's condition. b. Information will be provided directly to the resident by a member of the care plan team, in a timely manner . 4. If the resident is incapacitated and not-capable of independent decision-making at the time of admission: a. Inform the surrogate decision maker to document his/her desire to initiate an advance directive and his/her knowledge that this decision is in the resident's best interest or is to comply with resident's known desires, when this need arises. b. If the surrogate decision-maker is a family member who is not the attorney-in-fact, conservator or guardian with health care decision power, all members of the immediate family with equal relationship to the resident will need to agree and sign the document. i. In the event opinions differ among family members, the Advance Directives will not be implemented until a resolution is achieved. c. If there is no surrogate decision maker who can act on behalf of an incapacitated resident, an Advance Directive order may be issued when the attending physician determines it is medically appropriate and concurrence is evident in the resident health record by the Interdisciplinary Team. 5. When an Advance Directive is completed: a. Review the Advance Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent . d. Obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record. 6. Obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record. a. It should be noted that a Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is not an advance directive. b. Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #77, and #312) reviewed for indwelling urinary catheter care. 1. The facility failed to ensure Resident #77's indwelling urinary catheter drainage bag was emptied and draining to gravity when provided with urinary catheter care. 2.The facility failed to ensure CNA C cleansed Resident #312 from the meatus (the opening of the urethra where urine exits the penis) outwards and washed the resident's scrotum, inner thighs, and thoroughly cleaned between his buttocks. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #77's face sheet, dated 9/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included need for assistance with personal care, benign prostatic hyperplasia with lower urinary tract symptoms (a benign condition in which the prostate gland is larger than normal causing slow or block the flow of urine from the bladder), and cystitis (inflammation of the bladder or a lower urinary tract infection). Record review of Resident #77's most recent significant change MDS assessment, dated 7/29/24 revealed the resident was severely cognitively impaired for daily decision-making skills and utilized an indwelling urinary catheter. Record Review of Resident #77's comprehensive care plan with revision date 3/13/24 revealed the resident had an indwelling urinary catheter related to obstructive uropathy (urine flow blocked or slowed related to obstruction in any part of the urinary tract) with interventions that included to position the catheter bag and tubing below the level of the bladder and away from entrance room door, provide catheter care every shift and as needed, and a goal for the resident to remain free from catheter related trauma. Observation on 9/26/24 beginning at 5:09 p.m., revealed Resident #77's indwelling urinary catheter bag was filled with approximately 1,200 ml of urine and draining to gravity on the right side of the bed rail. Observation during catheter care revealed, CNA A took the indwelling urinary catheter bag and tubing and placed it on the foot of the bed next to Resident #77's right foot. Observations of the indwelling urinary catheter bag and tubing revealed they remained on Resident #77's bed throughout the catheter care until 5:47 p.m. During an interview on 9/26/24 at 5:57 p.m., CNA A stated she realized Resident #77's indwelling urinary catheter bag was filled with urine and should have emptied the bag prior to catheter care. CNA A further stated, the indwelling urinary catheter bag filled with urine could backflow and could give the resident a urinary tract infection or the catheter could dislodge. CNA A stated she was nervous. During an interview on 9/26/24 at 6:18 p.m., the DON stated, Resident #77's indwelling urinary catheter bag should have been emptied of urine prior to catheter care as it could dislodge and you don't want to push it and the urine could back flow causing an infection. Record review of CNA A's Comprehensive Clinical Competency Review Skills Checklist dated 5/25/24 revealed CNA A had satisfied the requirements for performing catheter care. 2. Record review of Resident #312's face sheet, dated 9/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation and benign prostatic hyperplasia (a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer) without lower urinary tract infection. Record review of Resident #312's admission MDS revealed it was not complete because he was a new admit. Record Review of Resident #312's comprehensive care plan with revision date 9/26/24 revealed the resident had an indwelling urinary catheter with interventions to provide catheter care every shift and as needed. During an observation on 9/27/24 at 11:28 a.m. revealed CNA C and CNA D provided catheter and incontinent care to resident #312. Resident #312 had purulent (thick, milky discharge) continuously dripping from his urethra (urethra is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body). CNA C held Resident #312's penis and wiped in the wrong direction from the base to the tip of the penis. The purulent drainage was on the resident's scrotum and had dripped from the resident's penis onto his scrotum. CNA C did not clean the resident's scrotum or under the scrotum. CNA C then turned the resident to his side and cleaned his buttocks. CNA C did not fully sperate the resident's gluteus folds to reach the intergluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum). During an interview on 9/27/24 at 11:59 a.m. CNA C stated he thought he wiped the right direction when he cleaned the resident's penis. CNA C stated if he wiped towards to meatus it could cause infection. CNA C stated he forgot to clean the resident's scrotum and under the scrotum because he focused on the catheter care and forgot. CNA C stated he thought he separated the resident's buttocks enough to clean between the folds because he observed fecal matter on the wipe. CNA C stated he had received training for catheter and peri care but did not have any male residents on his assigned hallway who received catheter care. CNA C stated he was asked to help with the catheter care for Resident #312 but was not familiar with the resident. During an interview on 9/27/24 at 12:09 p.m. the DON stated if staff did not clean the resident's penis the right direction or provide full peri care to include cleaning the scrotum and buttocks the resident could get an infection. The DON stated the resident was sent to the hospital the day prior and returned with a diagnosis of a UTI. The DON stated the resident was having a PICC line inserted to receive IV antibiotics. The DON stated they had no hospital paperwork but had requested it. Record review of CNA C's skills check list, dated 2/27/24, showed CNA C was trained and met standards for catheter care and perineal care. The check off stated with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position .Wash and rinse the tip of penis using circular motion beginning at urethra. Continue washing down the penis to the scrotum and inner thighs .Clean the rectal area, wiping in strokes from the base of the scrotum and over the buttocks. Record review of the facility policy and procedure titled, Infection Control Policy/Procedure, Section: Quality of Care, Subject: Catheter Care, Indwelling, review date 12/2019 revealed in part, .It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling .Purpose: to Promote hygiene, comfort and decrease risk of infection for catheterized residents .Keep tubing below level of bladder . 41095 45857

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 residents (Resident #1) reviewed for quality of care in that: RN E and LVN C failed to notify Resident #1's provider, NP A, of Resident #1's abnormal radiology results after resident had experienced nausea and vomiting and been administered anti-nausea medication for 3 days. As a result, Resident #1 was eventually transported to an acute care hospital and expired. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE]. While the immediacy was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR (plan of removal). This failure could affect all residents and place them at risk of not receiving the necessary care and a decline in health and/or death. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 was initially admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of Resident #1's Order Summary Report from [DATE] - [DATE], printed [DATE], revealed Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MAR and TAR for [DATE], printed [DATE], revealed Resident #1 had not received a dose of [MEDICATION(S)] PRN during the entire month of [DATE]. Record review of Resident #1's MAR and TAR for [DATE], printed [DATE], revealed Resident #1 received two doses of [MEDICATION(S)] on [DATE], administered by RN E at 5:59 a.m. and by GVN X at 4:38 p.m. and two more doses of [MEDICATION(S)] on [DATE], administered by LVN I at 6:32 p.m. and by RN E at 10:46 p.m. The record review did not reveal that the physician or NP was notified. Record review of Nursing Progress Note, written by LVN I on [DATE] at 6:28 p.m., revealed during a visitation with the family, Resident #1 threw up moderate amt [amount] of brown emesis. The record did not reveal that the physician or NP was notified. Record review of Nursing Progress Note, written by RN E on [DATE] at 5:45 a.m., revealed Resident #1 had an episode of emesis. [emesis is the action or process of vomiting]. Record review of Daily Skilled Note, written by LVN C on [DATE] at 6:44 p.m., revealed the following documentation emesis x2. Record review of Nursing Progress Note, written by RN E on [DATE] at 2:53 a.m., revealed upon arrival to the unit resident c/o [complained of] nausea and light vomiting. I gave [Resident #1] an [MEDICATION(S)] tab at 11pm a few minutes after resident had an episode of emesis measuring 200 mls [milliliters] in color yellow. Record review of Resident #1's KUB results, dated [DATE], revealed the following impression, mild small bowel ileus, which indicated a temporary arrest in intestinal movement. Record review of Resident #1's Order Recap report for the order dates [DATE]-[DATE], printed on [DATE] revealed the KUB was ordered on [DATE] by NP A for pain of the abdomen and emesis. [emesis is the action or process of vomiting]. Record review of facility's in-service training report, dated [DATE], revealed education was done on notifying providers of critical labs and x-rays. Further record review of this in-service training revealed only 12 nurses attended this training. Record review of Resident #1's Emergency Department Document, dated [DATE] and written by Hospital Physician B, revealed Resident #1 was admitted to a local acute care hospital on [DATE]. Further record review of Resident #1's hospital paperwork revealed Resident #1's abdomen was severely distended. [very serious swelling in the belly/stomach area]. Record review of Resident #1's CT Angiogram [a type of medical imaging testing that may or may not use a special contrast dye]), with and without contrast [a substance injected or taken orally to help improve CT studies] of the abdomen and pelvis, dated [DATE], revealed the following: findings highly suspicious for bowel ischemia [lack of blood supply] and developing bowel breakdown, without frank perforation. Specifically, the proximal [upper-left quadrant of the small bowel] and mid [midsection] small bowel, stomach, and distal esophagus [a muscular tube that carries food and liquids from the mouth to the stomach, the distal portion of the esophagus is closest to the stomach] are involved. Record review of Resident #1's Emergency Department Document Addendum, dated [DATE] and written at 10:39 p.m. by Hospital Physician B, revealed Resident #1 became unresponsive while in the Emergency Department and CPR was started. Hospital Physician B wrote the following, the etiology [cause] this code was due to ischemic [lack of blood supply] bowel causing perforation. [ .] It became clear after copious [plentiful amount] blood noted in the oropharynx [the back of the mouth] and on suction, that the patient's radiology of cardiac arrest was not reversible. Time of death called at 22:07 [10:07 p.m.]. Record review of facility's staff roster, printed [DATE], revealed the facility has 39 nurses employed. During an interview on [DATE] at 3:26 p.m., NP A confirmed she saw Resident #1 on [DATE]. NP A confirmed Resident #1's nausea was reported, by the nursing staff, as resolved during her visit [DATE] visit with Resident #1. NP A stated upon assessment she found Resident #1's abdomen to be rock hard. NP A stated she was not notified of Resident #1's abnormal KUB results from [DATE]. NP A stated she ordered a STAT KUB and an enema at first, but then changed her mind and ordered for Resident #1 to be sent to the hospital instead. During an interview on [DATE] at 4:01 p.m., Resident #1's family member stated she was on the phone with Resident #1 on [DATE] and Resident #1 stated, I'm in so much pain, and was screaming for help. Family member stated she saw Resident #1 on [DATE]. Family member described Resident #1's stomach as being very tight, [swollen] and Resident #1 was sweating. Family member stated she had brought Resident #1 food to eat and Resident #1 did not want the food. Family member discussed her concerns with LVN C and LVN C revealed to the family member that she had administered [MEDICATION(S)] to Resident #1 earlier and she would attempt to give Resident #1 a [MEDICATION(S)]. During an interview on [DATE] at 6:48 p.m., LVN C stated she never reviewed the results of Resident #1's abnormal KUB, dated [DATE], because RN E told her the KUB results were fine. LVN C stated, I never seen the results. LVN C explained when a nurse receives any results, regardless if the results are normal or abnormal, the nurse would inform the provider. LVN C confirmed the results and notification to the provider would require documentation in the medical record, which was not completed. During an interview on [DATE] at 7:10 a.m., LVN C confirmed she should have reviewed Resident #1's abnormal KUB results herself. LVN C stated she also gave a copy of Resident #1's abnormal KUB, dated [DATE], results to ADON I. LVN C confirmed nausea or emesis was not normal for Resident #1 but did not believe it was an issue because no one said anything. I never saw her throw up. I didn't even know if the nurses documented that she had thrown up. During an interview with a representative from X-Ray Company Y on [DATE] at 8:08 a.m., (the facility's X-ray vendor), representative confirmed the X-ray results for Resident #1 was faxed on [DATE] at 2:00 p.m. to 3 different facility fax numbers. During an interview on [DATE] at 8:56 a.m., Administrator M stated he briefly remembered something GI-related that was discussed in a past clinical meeting on [DATE]. Administrator M could not recall specific details discussed. Administrator M could not recall any specific details regarding Resident #1's discharge on [DATE]. Administrator M could not recall hearing of any concerns from providers. Administrator M confirmed that when there is a change in condition, the nursing staff should contact the provider for orders, then the provider will make a decision whether the condition can be managed in the facility or needs hospitalization . During an interview on [DATE] at 9:36 a.m., ADON J stated abnormal lab results should be reported to the resident's primary care provider. ADON J confirmed the facility has a clinical meeting every morning where clinical issues (including new orders or results) are discussed. ADON J elaborated, we educated staff to not go by ear and report everything and document everything. If a doctor is not answering your text you need to call them. ADON J stated the facility educated their nursing staff on promptly notifying the provider of abnormal labs. ADON J confirmed Resident #1 had no history of chronic nausea or emesis. ADON J recalled Resident #1's change of condition on [DATE] and elaborated on [DATE] Resident #1 was fine, but on [DATE] Resident #1 vomited. ADON J stated NP A visited Resident #1 on [DATE], reviewed Resident #1's radiology results, gave orders and left the building. ADON J elaborated NP A later called back a couple hours later and gave orders to send Resident #1 out to an acute care hospital. ADON J stated an educational in-service about notifying providers of abnormal lab results was done on [DATE], not on [DATE] as dated on the facility's educational in-service document. ADON J stated the date on the educational in-service was wrong. ADON J could not recall why the educational in-service was started, just that it was about Resident #1's radiology results. During an interview on [DATE] at 10:36 a.m., CNA K stated she cared for Resident #1 on [DATE]. CNA K recalled Resident #1 was complaining of a lot of stomach pain. CNA K stated she observed Resident #1 vomit once during her shift. CNA K stated she reported the issue to LVN O. During an interview on [DATE] at 11:32 a.m., RN E stated Resident #1 had episodes of nausea and vomiting the last few days before discharge. RN E recalled Resident #1's KUB ordered on [DATE] showed a small obstruction in the colon. RN E stated because the obstruction was small and Resident #1 was going to the restroom, she did not report it to the provider. RN E elaborated, I did not consider it urgent because [Resident #1] was having [bowel movements.] RN E confirmed she gave Resident #1 [MEDICATION(S)], then Resident #1 vomited, and Resident #1 reported feeling better. RN E stated she gave a copy of Resident #1's KUB, dated [DATE], to LVN C. RN E elaborated she told LVN C that Resident #1 had a small bowel obstruction and Resident #1 was having bowel movements. When asked if there was anything further, she should have done, RN E stated, No, I treated the signs and symptoms and [Resident #1] was fine. During an interview on [DATE] at 1:04 p.m., LVN I confirmed Resident #1 vomited on [DATE] while Resident #1 was in a family visitation. LVN I stated nausea or vomiting was not normal for Resident #1, but felt it was a one-time thing because the day before, [DATE], Resident #1 left the facility for a family outing and ate a lot of food according to the family member. LVN I explained Resident #1 did not have a fever at the time and did not complain of any pain. LVN I stated if Resident #1 had vomited more than 3 times she would have become suspicious of an issue . During an interview on [DATE] at 1:28 p.m., NP A stated she would have preferred to be notified if a resident was receiving [MEDICATION(S)] more consistently than usual. NP A stated she was supposed to be notified of any abnormal results. NP A stated if she had known Resident #1's abnormal KUB results showed a small bowel ileus earlier she would have ordered for Resident #1 to be sent out immediately. NP A stated a small bowel ileus is life-threatening and elaborated, a nursing home would not have been equipped. [Resident #1] would need to be NPO, an NG tube, decompress her stomach, daily KUB. And none of that could be done in the SNF setting. During an interview on [DATE] at 2:49 p.m., NP A confirmed if she had sent Resident #1 to an acute care hospital sooner, it would have prevented any negative outcomes. During an interview on [DATE] at 4:55 p.m., DON L stated the facility provided in-services on assessing gastrointestinal issues and notifying providers of any change of conditions on [DATE]. DON L explained the nurses should assess the abdomen for distension, ask the resident about bowel movements, and ask the resident about stomach issues. DON L stated the facility had daily meetings, including a clinical meeting in the morning which involved the direct-care staff. DON L stated issues regarding a new onset of vomiting and new utilization of PRN [MEDICATION(S)] would be discussed in the clinical meeting. DON L recalled Resident #1 was discussed in the facility's clinical meeting on [DATE] but was unaware of any other medical issues with Resident #1 after [DATE]. DON L was also unaware Resident #1 received [MEDICATION(S)] on [DATE]. DON L was aware Resident #1 had an episode of emesis after a family outing on [DATE] and elaborated it wasn't an unusual amount. [Resident #1] had nausea, she threw up, but it was not like she was throwing up repeatedly. DON L did not see the vomit. DON L explained the nurse did perform a change of condition assessment on [DATE] because Resident #1 was reporting a stomachache, but at the time it was believed the issue was related to Resident #1's recent family outing. DON L recalled on [DATE] she received report NP A was upset about not being notified of a result. DON L stated she was on her way out of town when she was made aware of NP A's concerns, but she wrote up an in-service on notifying providers on that day and delegated the in-servicing to the ADONs. DON L confirmed providers should be notified if there is an abnormal result. DON L explained, what happened with [Resident #1's] KUB was there was a normal finding [at the top of the paper], but then the findings [at the bottom] says the mild ileus. So initially [the nurse] saw no evidence at the top portion, so that's what [RN E] told [LVN C]. DON L confirmed the expectation was for nurses to read the entire radiology result. When asked about the nursing staff's response to Resident #1's symptoms, DON L replied, I feel they did respond as far as treating the symptoms. They did give the PRN medication. The patient, from what I was told, has no pain or issues until the day she went out. During an interview on [DATE] at 11:50 a.m., ADON F stated during NP A's visit on [DATE], NP A had come to their office to request Resident #1's KUB results. ADON F confirmed she and LVN G provided the results to NP A. ADON F stated she, LVN G and NP A reviewed the KUB result together. ADON F stated At first, I seen the top of the x-ray results and said that looks good. [NP A] asked me to continue reading to the bottom of the paper. I verified the result, that [Resident #1] had a small bowel ileus. ADON F stated DON L was not notified of the abnormal x-ray results because DON L was not in the building. ADON F confirmed that it would have been LVN C's responsibility [current nurse on duty] to notify DON L or the ADON's F or J, but LVN C did not . ADON F stated the process for receiving and reporting abnormal results was to document the issue on the 24-hour report, notify the provider, and follow up. ADON F confirmed that a small bowel ileus was considered an urgent result. ADON F confirmed the KUB was ordered on the [DATE] and was able to recall that ADON J printed the result out and gave it to the charge nurse, LVN C, to report at the clinical meeting the next day, [DATE]. ADON J stated, My understanding the results came in - in the afternoon- no results available at shift change. ADON J confirmed LVN C had documented the results were normal, and LVN reported Resident #1 was stable. ADON F revealed was she unaware if LVN C had reviewed the results, and reiterated LVN C had the results with her at the clinical meeting on [DATE]. ADON F stated, I guess [LVN C] missed the lower part that was on the result page. ADON F confirmed that the provider was not notified same day regarding Resident #1's x-ray result, and further confirmed that she believed the bottom part of the x-ray results was missed or not read thoroughly. ADON F stated that even I did not read it (x-ray results) fully and providers should be notified immediately after results are received in hand. Record review of facility policy titled Change of Condition Reporting, not dated, revealed the following verbiage, all symptoms of unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life-threatening. Administrator M was notified of an IJ for the above failures on [DATE] at 6:03 p.m. A copy of the IJ Template was given to Administrator M and a Plan of Removal was requested. The Plan of Removal accepted on [DATE] included the following: A. Immediate Actions Taken: Education started by Clinical Resource/DON on the following topics: - Notification to Physician regarding all results for X-rays, diagnostic results, KUB, and Change of Conditions must be communicated immediately to the physician/NP and appropriate assessment of residents. In-service started [DATE] to be completed by [DATE] anyone not receiving education will not be allowed to work until in-serviced. - Licensed nurses to receive education prior to accepting shift - Audit performed on residents with orders for KUB, Chest x-ray, and diagnostics to ensure proper notification to physician of all results, audit was started [DATE] and will be completed by [DATE]. - Resident number one is no longer in the facility. B. Identification of Others Affected: - Currently there are 9 residents as of [DATE] with KUB and Chest X-ray orders who could be at risk once results are received if not communicated to MD/NP. C. Systemic Change Taken to Prevent Reoccurrence: - DON, or designee, will review all new orders and current orders for X-ray, KUB and diagnostics to identify any abnormal results and ensure they are communicated to the MD timely. Starting [DATE]. - A tracking log for KUB, Chest X-rays, and diagnostics will be initiated [DATE] and reviewed at the clinical meeting which will be held 7 days a week and will be initialed once all results are communicated to the MD/NP. - DON/Designee started in-service on [DATE] with licensed clinical staff on proper shift reporting to include review of the 24 hour report for resident change of condition, staff will also be in-serviced on what to do for a change of condition to include notification to MD/NP and RP and follow any orders received due to change of condition and notify DON of change of condition. Licensed staff will not be allowed to take a shift until they have received the in-service. Starting [DATE]. - DON, or designee, will monitor education, notifications, tracking and share summary of actions taken with QAPI weekly for additional review or recommendations on timely notification of all KUB, diagnostics, X-ray and change of condition. D. Monitoring: - Daily review of orders for KUB, diagnostics, Chest X-ray and all change of conditions to ensure all results are communicated to MD/NP. Starting [DATE]. - DON/Designee will monitor notifications to physician for all Chest X-ray, KUB, diagnostic results, and change in conditions. Starting [DATE]. - Summary of IJ and corrective action to be reviewed by QAPI until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include review of resident all results for KUB, Chest X-ray, all diagnostics and change of conditions. The surveyors' verification of the Plan of Removal from [DATE] through [DATE] was as follows: A. Immediate Actions Taken: Observation on [DATE] at 6:13 a.m. revealed, during overnight-to-day shift change, nurses were observed conducting room-to-room report. Nurses were discussing resident status, pending labs, pending medications, pending appointments, and any change of condition. During an interview on [DATE] at 3:20 p.m., Administrator M and DON L stated only 6 licensed nursing staff have not received education, all of which are PRN staff. Per DON L, they have attempted to call these 6 licensed nursing staff with no answer. Per Administrator M and DON L, these 6 remaining licensed nursing staff will not be placed on-schedule until they receive education. Per Administrator M and DON L, the Staffing Department was aware not to put the 6 remaining licensed nursing staff on-schedule until they have received the education. From [DATE] to [DATE], 26 licensed nursing staff were interviewed. Nursing staff interviews included day shift, evening shift, night shift, and weekend shift nurses. All nursing staff interviewed verbalized they received education on: - All change of condition should be documented in PCC. Provider, RP, and resident should be notified. - All lab results (abnormal and normal) will be reported to order physician upon receiving the results. If order physician is not available or unresponsive, medical director and DON will be notified immediately. Notification will be documented in a nursing progress note. - 24-hr shift report will be conducted with walking rounds. On-coming nurses verbalized they will verify lab results given by the off-going nurse. Nurses have verbalized a resident with new onset nausea would be reported to provider. Record review of facility document titled, Diagnostic Test & Lab Tracking, revealed: audit has been completed as of [DATE]. Further record review of Diagnostic Test & Lab Tracking log revealed audit reviewed labs ordered from [DATE] to [DATE]. Record review of In-Service Training Reports, dated [DATE] at 6:00 p.m., revealed education began on [DATE] and included the following: reporting change of conditions of the provider, notification to MD/NP of all KUB, X-rays, and diagnostic normal and abnormal results, and walking, room-to-room reporting at change-of-shift which will include communication of change of conditions and all diagnostic lab results. Second record review of In-Service Training Reports on [DATE] revealed 33 of 39 licensed nursing staff have been educated (85%.) B. Identification of Others Affected: Record review of all 9 residents with KUB and Chest X-ray orders revealed the following: all 9 residents' lab results were reported to ordering providers within 1 business day of lab result and physician's response was documented in a Nursing Progress Note. Each Nursing Progress Notes' date was compared with the date of creation in order to identify any possible back-dating of Nursing Progress notes. No back-dating of progress notes was identified. C. Systemic Change Taken to Prevent Reoccurrence: During an interview on [DATE] at 1:09 p.m., DON L stated timely meant immediately upon receiving the results. If the MD is unresponsive, then Medical Director and DON are to be notified. Per DON L, a process was in place for reviewing diagnostic testing and lab results 7 days a week. DON L was to be the primary reviewing of diagnostic lab results, and ADONs were to be the secondary reviewers if DON L became unavailable. Observation on [DATE] at 6:13 a.m. revealed, during overnight-to-day shift change, nurses were observed conducting room-to-room report. Nurses were discussing resident status, pending labs, pending medications, pending appointments, and any change of condition. From [DATE] to [DATE], 26 licensed nursing staff were interviewed. Nursing staff interviews included day shift, evening shift, night shift, and weekend shift nurses. All nursing staff interviewed verbalized they received education on: - All change of condition should be documented in PCC. Provider, RP, and resident should be notified. - All lab results (abnormal and normal) will be reported to order physician upon receiving the results. If order physician is not available or unresponsive, medical director and DON will be notified immediately. Notification will be documented in a nursing progress note. - 24-hr shift report will be conducted with walking rounds. On-coming nurses verbalized they will verify lab results given by the off-going nurse. Nurses have verbalized a resident with new onset nausea would be reported to provider. Record review of facility document titled, Diagnostic Test & Lab Tracking, revealed: audit has been completed as of [DATE]. Further record review of Diagnostic Test & Lab Tracking log revealed audit reviewed labs ordered from [DATE] to [DATE]. Record review of the facility's next QAPI agenda revealed: next QAPI meeting includes summary of IJ and corrective actions is on QAPI agenda. D. Monitoring: During an interview on [DATE] at 1:09 p.m., DON L confirmed a process was in place for reviewing diagnostic testing and lab results 7 days a week. DON L was to be the primary reviewing of diagnostic lab results, and ADONs were to be the secondary reviewers if DON L became unavailable. Record review of facility document titled, Diagnostic Test & Lab Tracking, revealed: diagnostic testing log was up to date and in place. Record review of the facility's next QAPI agenda revealed: next QAPI meeting includes summary of IJ and corrective actions is on QAPI agenda. On [DATE] at 5:37 p.m. the Administrator was notified the immediacy was lifted. The facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. Plan of Correction (POC) Verification On [DATE] licensed clinical staff was in-serviced on: Notification to physician regarding all results for X rays, diagnostic results, KUB, change of condition, proper shift reporting walking rounds, to include review of the 24 hour report for resident change of condition, assessing gastrointestinal issues and proper assessment must be communicated to the physician/NP. [DATE] - In-service sign in sheets revealed all licensed staff have signed off on all trainings listed above. Audit performed on residents with orders for KUB, chest X ray, and diagnostics to ensure proper notification to physician of all results was started [DATE] and completed on [DATE]. [DATE] - Audit logs for KUB, chest X rays, and diagnostics were examined and revealed audit was started and completed [DATE]. A tracking log for KUB, chest X rays, and diagnostics will be initiated [DATE] and reveiwed at teh clinincal meeting which will be held 7 days a week and will be initialed once all results are communicated to the MD/NP. [DATE] - Tracking log was verified and revealed start date of [DATE] ongoing to [DATE] DON/designee will review of orders for KUB, diagnostics, chest X ray and all change of conditions to ensure all resutls are communicated to MD/NP and will monitor notifications to physician for all chest X ray, KUB, diagnostic results and change of conditions. [DATE] - Tracking log was verified and revealed review of orders was ongoing to [DATE] Summary of IJ and corrective action to be reviewed by QAPI until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [DATE] - QAPI sign in sheet verified and content regarding IJ summary and corrective action confirmed Montly QAPI meeting will include review of resident all results for KUB, chest X ray, all diagnostics and change of conditions. [DATE] - QAPI sign in sheets revealed monthly meeting has been completed up until this date [DATE].

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 21 residents (Resident #12) reviewed for neglect in that; 1. LVN F & LVN M were treating Resident #12's Stage III pressure ulcer with [MEDICATION NAME] swabs without an order. 2. Nursing staff failed to identify and correct the assessment and documentation of location of pressure ulcer (Pressure ulcer was on left trochanter and was being documented on as on the right hip). 3. Nursing staff failed to acquire an order to treat the left trochanter pressure ulcer. 4. Nursing staff did not accurately implement Resident # 12's skin integrity care plan. Resident #12's Stage III pressure ulcer to the left trochanter increased in size and did not improve. These deficient practice could affect 5 residents who received wound care in May 2017 and could result in worsening of pressure ulcer, and/or infection. The findings were: Record review of the facility's policy/procedure Nursing Administration for Abuse and Neglect with a revision date of 05/2007 revealed the following definition of neglect: Action or inaction that avoids or prevents physical, mental harm, pain demonstrates disregard or consequences that may constitute a clear and present danger. Record review of the facility's policy/procedure wound care policy dated 05/2017 revealed for stage II seek orders for appropriate wound care treatment. Measure weekly and evaluate for effectiveness of treatment. Resident will be reviewed weekly in High Risk Clinic. Document with each dressing change and with weekly measuring for clinic and as needed. Record review of the Admission Face Sheet dated 06/01/2017 revealed Resident # 12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's History & Physical dated on 04/05/2017 revealed Resident # 12 was admitted with a Stage III decubitus (pressure sore that extends into the tissue beneath the skin) to the Right trochanter. Record review of -Initial Admission Record (Licensed Nurse Initial Assessment Record) dated 04/05/2017 revealed open areas to the Right Ischial (hip/buttocks area), beefy red. Record review of Licensed Nurse-Skin pressure ulcer weekly (initial wound care assessment) dated 04/05/2017 revealed a Stage II (pressure sore where skin breaks open) to Right trochanter-Right ischial wound beefy red scant serosanguinous (yellowish with small amounts of blood) drainage 1.6 x 0.6 cm. Further review of the skin pressure ulcer weekly assessment revealed an order to cleanse with normal saline (NS) pat dry apply zinc oxide daily. Record review of Resident # 12's initial MDS dated [DATE] revealed short and long term memory loss with severely impaired decision making skills. Further review of the same document revealed Resident #12 was admitted with 3 Stage II pressure ulcers. Record review of Resident #12's skin integrity care plan dated 05/02/2017 revealed interventions included: Monitor/ document location, size, and treatment of [REDACTED]. Record review of Resident #12's pressure ulcer care plan dated 04/13/2017 revealed he was admitted with Stage II- Right Trochanter, Stage II- Sacrum, Stage II- Left Buttock. Further review of the same document revealed the interventions included: Assess/record/monitor wound healing. Report improvements and declines to the physician. Further review of the -Skin pressure ulcer weekly assessments revealed the following: -.04/12/2017 and 04/19/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.6 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -04/26/2017 and 05/03/2017 -Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/10/2017, 05/17/2017, and 05/24/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/31/2017 Stage II Right trochanter-Right ischial wound beefy red scant serous drainage 1.1 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily Observation on 05/31/2017 at 08:20 a.m. revealed a Stage III pressure ulcer to the left hip with beefy red granulation tissue with minimal amount of yellowish green slough (yellowish fibronous tissue) in the center with no dressing in place. Further observation revealed Licensed Vocational Nurse (LVN) F applied a new dressing to Resident #12's left hip. She cleaned the stage III to the left hip with NS, applied [MEDICATION NAME] with swabs and covered with a dry dressing. Record review of Medication Review Report for the month of June dated 06/01/2017 revealed orders for the following: Cleanse with NS, paint with [MEDICATION NAME] (no site specified), and cover with dry dressing every shift. Cleanse bilateral buttocks with NS pat dry and apply zinc oxide daily. Leave open to air daily. Interview with the DON and Regional Nurse on 06/02/2017 at 4:10 p.m. revealed there was no evidence regarding skin assessment or a treatment order for pressure ulcer treatment to Resident #12's left hip area and believed the pressure ulcer was on Resident's #12's right hip. Record Review of Resident # 12's Medication Review Report (consolidated physician orders) dated Jun 1, 2017, revealed orders to Cleanse with NS, paint with [MEDICATION NAME], and covered with a dry dressing. Every shift (no site documented) with a start date of 05/01/2017 at 10:57 p.m. Record review of Resident#12's Medication Administration Record [REDACTED]. Interview with LVN F on 06/02/2017 at 9:35 a.m. confirmed the written order for [MEDICATION NAME] did not specify where to apply the [MEDICATION NAME]. LVN F indicated she applied the [MEDICATION NAME] to Resident #12's stage III located on the left hip, as she had been told that was where the [MEDICATION NAME] was supposed to be applied. Interview with LVN M on 06/02/2017 at 3:35 p.m. confirmed she had been applying the [MEDICATION NAME] to the left hip pressure ulcer every shift she worked for the month of May 2017. Interview with ADON G on 06/02/2017 at 4:10 p.m., confirmed there was no site on the order for [MEDICATION NAME]. ADON G also confirmed there was no order for treatment of [REDACTED]. Interview with the Wound Care Nurse on 06/02/2017 at 4:12 p.m.,revealed that he had been applying zinc oxide to the Stage III pressure ulcer to the left hip and that [MEDICATION NAME] was supposed to be applied to the Left Great Toe for an abrasion. The wound care nurse could not find an order for [REDACTED]. Observation on 06/01/2017 at 04:20 p.m. of Resident #12's skin with ADON G, the Wound Care Nurse and the Regional Nurse revealed Resident #12 had a pressure ulcer to the left hip area. The wound care nurse confirmed the pressure ulcer could be a stage III since it had minimal amount of slough. After surveyor intervention, record review of the -Skin pressure ulcer weekly assessment dated [DATE] revealed a Stage III to the Left Trochanter - 1.5 x 2.4 cm Depth 0.1 cm. with scant serous drainage, slough and granulation tissue. Record review of Medication Review Report (consolidated physician orders) dated 06/02/2017 revealed an order to clean pressure ulcer to left trochanter with NS, pat dry and apply duoderm every 7 days and as needed. Interview with the wound care nurse on 06/02/2017 at 11:45 a.m. the wound care nurse confirmed the wound size had not improved and he should have reviewed the treatment. Review of information provided by facility on 06/02/2017 revealed there was 5 residents with pressure ulcers.

Based on observation, interview and record review the facility failed to implement written policy to ensure residents have the right to be free from neglect for 1 of 21 residents (Resident #12) reviewed for neglect in that; 1. LVN F & LVN M were treating Resident #12's Stage III pressure ulcer with [MEDICATION NAME] swabs without an order. 2. Nursing staff failed to identify and correct the assessment and documentation of location of pressure ulcer (Pressure ulcer was on left trochanter and was being documented on as on the right hip). 3. Nursing staff failed to acquire an order to treat the left trochanter pressure ulcer. 4. Nursing staff did not accurately implement Resident # 12's skin integrity care plan. Resident #12's Stage III pressure ulcer to the left trochanter increased in size and did not improve. These deficient practice could affect 5 residents who received wound care in May 2017 and could result in worsening of pressure ulcer, and/or infection. The findings were: Record review of the Admission Face Sheet dated 06/01/2017 revealed Resident # 12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's History & Physical dated on 04/05/2017 revealed Resident # 12 was admitted with a Stage III decubitus (pressure sore that extends into the tissue beneath the skin) to the Right trochanter. Record review of -Initial Admission Record (Licensed Nurse Initial Assessment Record) dated 04/05/2017 revealed open areas to the Right Ischial (hip/buttocks area), beefy red. Record review of Licensed Nurse-Skin pressure ulcer weekly (initial wound care assessment) dated 04/05/2017 revealed a Stage II (pressure sore where skin breaks open) to Right trochanter-Right ischial wound beefy red scant serosanguinous (yellowish with small amounts of blood) drainage 1.6 x 0.6 cm. Further review of the skin pressure ulcer weekly assessment revealed an order to cleanse with normal saline (NS) pat dry apply zinc oxide daily. Record review of Resident # 12's initial MDS dated [DATE] revealed short and long term memory loss with severely impaired decision making skills. Further review of the same document revealed Resident #12 was admitted with 3 Stage II pressure ulcers. Record review of Resident #12's skin integrity care plan dated 05/02/2017 revealed interventions included: Monitor/ document location, size, and treatment of [REDACTED]. Record review of Resident #12's pressure ulcer care plan dated 04/13/2017 revealed he was admitted with Stage II- Right Trochanter, Stage II- Sacrum, Stage II- Left Buttock. Further review of the same document revealed the interventions included: Assess/record/monitor wound healing. Report improvements and declines to the physician. Further review of the -Skin pressure ulcer weekly assessments revealed the following: -.04/12/2017 and 04/19/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.6 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -04/26/2017 and 05/03/2017 -Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/10/2017, 05/17/2017, and 05/24/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/31/2017 Stage II Right trochanter-Right ischial wound beefy red scant serous drainage 1.1 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily Observation on 05/31/2017 at 08:20 a.m. revealed a Stage III pressure ulcer to the left hip with beefy red granulation tissue with minimal amount of yellowish green slough (yellowish fibronous tissue) in the center with no dressing in place. Further observation revealed Licensed Vocational Nurse (LVN) F applied a new dressing to Resident #12's left hip. She cleaned the stage III to the left hip with NS, applied [MEDICATION NAME] with swabs and covered with a dry dressing. Record review of Medication Review Report for the month of June dated 06/01/2017 revealed orders for the following: Cleanse with NS, paint with [MEDICATION NAME] (no site specified), and cover with dry dressing every shift. Cleanse bilateral buttocks with NS pat dry and apply zinc oxide daily. Leave open to air daily. Interview with the DON and Regional Nurse on 06/02/2017 at 4:10 p.m. revealed there was no evidence regarding skin assessment or a treatment order for pressure ulcer treatment to Resident #12's left hip area and believed the pressure ulcer was on Resident's #12's right hip. Record Review of Resident # 12's Medication Review Report (consolidated physician orders) dated Jun 1, 2017, revealed orders to Cleanse with NS, paint with [MEDICATION NAME], and covered with a dry dressing. Every shift (no site documented) with a start date of 05/01/2017 at 10:57 p.m. Record review of Resident#12's Medication Administration Record [REDACTED]. Interview with LVN F on 06/02/2017 at 9:35 a.m. confirmed the written order for [MEDICATION NAME] did not specify where to apply the [MEDICATION NAME]. LVN F indicated she applied the [MEDICATION NAME] to Resident #12's stage III located on the left hip, as she had been told that was where the [MEDICATION NAME] was supposed to be applied. Interview with LVN M on 06/02/2017 at 3:35 p.m. confirmed she had been applying the [MEDICATION NAME] to the left hip pressure ulcer every shift she worked for the month of May 2017. Interview with ADON G on 06/02/2017 at 4:10 p.m., confirmed there was no site on the order for [MEDICATION NAME]. ADON G also confirmed there was no order for treatment of [REDACTED]. Interview with the Wound Care Nurse on 06/02/2017 at 4:12 p.m.,revealed that he had been applying zinc oxide to the Stage III pressure ulcer to the left hip and that [MEDICATION NAME] was supposed to be applied to the Left Great Toe for an abrasion. The wound care nurse could not find an order for [REDACTED]. Observation on 06/01/2017 at 04:20 p.m. of Resident #12's skin with ADON G, the Wound Care Nurse and the Regional Nurse revealed Resident #12 had a pressure ulcer to the left hip area. The wound care nurse confirmed the pressure ulcer could be a stage III since it had minimal amount of slough. After surveyor intervention, record review of the -Skin pressure ulcer weekly assessment dated [DATE] revealed a Stage III to the Left Trochanter - 1.5 x 2.4 cm Depth 0.1 cm. with scant serous drainage, slough and granulation tissue. Record review of Medication Review Report (consolidated physician orders) dated 06/02/2017 revealed an order to clean pressure ulcer to left trochanter with NS, pat dry and apply duoderm every 7 days and as needed. Interview with the wound care nurse on 06/02/2017 at 11:45 a.m. the wound care nurse confirmed the wound size had not improved and he should have reviewed the treatment. Record review of the facility's policy/procedure wound care policy dated 05/2017 revealed for stage II seek orders for appropriate wound care treatment. Measure weekly and evaluate for effectiveness of treatment. Resident will be reviewed weekly in High Risk Clinic. Document with each dressing change and with weekly measuring for clinic and as needed. Record review of the facility's policy/procedure Nursing Administration for Abuse and Neglect with a revision date of 05/2007 revealed the following definition of neglect: Action or inaction that avoids or prevents physical, mental harm, pain demonstrates disregard or consequences that may constitute a clear and present danger. Review of information provided by facility on 06/02/2017 revealed there was 5 residents with pressure ulcers.

Based on observations, interviews, and record review the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 5 residents (Resident #12) who were reviewed for pressure ulcers in that; 1. LVN F & LVN M were treating Resident #12's Stage III pressure ulcer with [MEDICATION NAME] swabs without an order. 2. Nursing staff failed to identify and correct the assessment and documentation of location of pressure ulcer (Pressure ulcer was on left trochanter and was being documented on as on the right hip). 3. Nursing staff failed to acquire an order to treat the left trochanter pressure ulcer. 4. Nursing staff did not accurately implement Resident # 12's skin integrity care plan. Resident #12's Stage III pressure ulcer to the left trochanter increased in size and did not improve. These deficient practice could affect 5 residents who received wound care in May 2017 and could result in worsening of pressure ulcer, and/or infection. The findings were: Record review of the Admission Face Sheet dated 06/01/2017 revealed Resident # 12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's History & Physical dated on 04/05/2017 revealed Resident # 12 was admitted with a Stage III decubitus (pressure sore that extends into the tissue beneath the skin) to the Right trochanter. Record review of -Initial Admission Record (Licensed Nurse Initial Assessment Record) dated 04/05/2017 revealed open areas to the Right Ischial (hip/buttocks area), beefy red. Record review of Licensed Nurse-Skin pressure ulcer weekly (initial wound care assessment) dated 04/05/2017 revealed a Stage II (pressure sore where skin breaks open) to Right trochanter-Right ischial wound beefy red scant serosanguinous (yellowish with small amounts of blood) drainage 1.6 x 0.6 cm. Further review of the skin pressure ulcer weekly assessment revealed an order to cleanse with normal saline (NS) pat dry apply zinc oxide daily. Record review of Resident # 12's initial MDS dated [DATE] revealed short and long term memory loss with severely impaired decision making skills. Further review of the same document revealed Resident #12 was admitted with 3 Stage II pressure ulcers. Record review of Resident #12's skin integrity care plan dated 05/02/2017 revealed interventions included: Monitor/ document location, size, and treatment of [REDACTED]. Record review of Resident #12's pressure ulcer care plan dated 04/13/2017 revealed he was admitted with Stage II- Right Trochanter, Stage II- Sacrum, Stage II- Left Buttock. Further review of the same document revealed the interventions included: Assess/record/monitor wound healing. Report improvements and declines to the physician. Further review of the -Skin pressure ulcer weekly assessments revealed the following: -.04/12/2017 and 04/19/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.6 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -04/26/2017 and 05/03/2017 -Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/10/2017, 05/17/2017, and 05/24/2017- Stage II Right trochanter-Right ischial wound beefy red scant serosanguianous drainage 1.3 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily -05/31/2017 Stage II Right trochanter-Right ischial wound beefy red scant serous drainage 1.1 x 0.8 cm Depth 0.1 cm Order cleanse with NS pat dry apply zinc oxide daily Observation on 05/31/2017 at 08:20 a.m. revealed a Stage III pressure ulcer to the left hip with beefy red granulation tissue with minimal amount of yellowish green slough (yellowish fibronous tissue) in the center with no dressing in place. Further observation revealed Licensed Vocational Nurse (LVN) F applied a new dressing to Resident #12's left hip. She cleaned the stage III to the left hip with NS, applied [MEDICATION NAME] with swabs and covered with a dry dressing. Record review of Medication Review Report for the month of June dated 06/01/2017 revealed orders for the following: Cleanse with NS, paint with [MEDICATION NAME] (no site specified), and cover with dry dressing every shift. Cleanse bilateral buttocks with NS pat dry and apply zinc oxide daily. Leave open to air daily. Interview with the DON and Regional Nurse on 06/02/2017 at 4:10 p.m. revealed there was no evidence regarding skin assessment or a treatment order for pressure ulcer treatment to Resident #12's left hip area and believed the pressure ulcer was on Resident's #12's right hip. Record Review of Resident # 12's Medication Review Report (consolidated physician orders) dated Jun 1, 2017, revealed orders to Cleanse with NS, paint with [MEDICATION NAME], and covered with a dry dressing. Every shift (no site documented) with a start date of 05/01/2017 at 10:57 p.m. Record review of Resident#12's Medication Administration Record [REDACTED]. Interview with LVN F on 06/02/2017 at 9:35 a.m. confirmed the written order for [MEDICATION NAME] did not specify where to apply the [MEDICATION NAME]. LVN F indicated she applied the [MEDICATION NAME] to Resident #12's stage III located on the left hip, as she had been told that was where the [MEDICATION NAME] was supposed to be applied. Interview with LVN M on 06/02/2017 at 3:35 p.m. confirmed she had been applying the [MEDICATION NAME] to the left hip pressure ulcer every shift she worked for the month of May 2017. Interview with ADON G on 06/02/2017 at 4:10 p.m., confirmed there was no site on the order for [MEDICATION NAME]. ADON G also confirmed there was no order for treatment of [REDACTED]. Interview with the Wound Care Nurse on 06/02/2017 at 4:12 p.m.,revealed that he had been applying zinc oxide to the Stage III pressure ulcer to the left hip and that [MEDICATION NAME] was supposed to be applied to the Left Great Toe for an abrasion. The wound care nurse could not find an order for [REDACTED]. Observation on 06/01/2017 at 04:20 p.m. of Resident #12's skin with ADON G, the Wound Care Nurse and the Regional Nurse revealed Resident #12 had a pressure ulcer to the left hip area. The wound care nurse confirmed the pressure ulcer could be a stage III since it had minimal amount of slough. After surveyor intervention, record review of the -Skin pressure ulcer weekly assessment dated [DATE] revealed a Stage III to the Left Trochanter - 1.5 x 2.4 cm Depth 0.1 cm. with scant serous drainage, slough and granulation tissue. Record review of Medication Review Report (consolidated physician orders) dated 06/02/2017 revealed an order to clean pressure ulcer to left trochanter with NS, pat dry and apply duoderm every 7 days and as needed. Interview with the wound care nurse on 06/02/2017 at 11:45 a.m. the wound care nurse confirmed the wound size had not improved and he should have reviewed the treatment. Record review of the facility's policy/procedure wound care policy dated 05/2017 revealed for stage II seek orders for appropriate wound care treatment. Measure weekly and evaluate for effectiveness of treatment. Resident will be reviewed weekly in High Risk Clinic. Document with each dressing change and with weekly measuring for clinic and as needed. Review of information provided by facility on 06/02/2017 revealed there was 5 residents with pressure ulcers.