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

Based on observation, interview, and record review, the facility failed, in accordance with State and Federal laws, to ensure medications and biologicals were stored in a safe and secure manner and were not accessible to residents #17 & #21. 1. The facility failed to ensure Resident #17 did not have access to an open tube of Clear Moisture Barrier Ointment observed on the bedside table in plain view on 4/28/26. 2. The facility failed to ensure Resident #21 did not have access to an unopened packet of Essentials Prevent Ointment observed on the bedside table in plain view on 4/28/26. These failures could place residents at risk for accidental misuse or ingestion of topical medications. Findings include: 1. Record review of Resident #17's admission record dated 4/28/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other cirrhosis of liver (chronic liver damage that may impair healing), thrombocytopenia (low platelet count that may increase risk for bruising and impaired skin integrity), type 2 diabetes mellitus (condition that may impair wound healing), protein-calorie malnutrition (condition that may contribute to impaired skin integrity), cellulitis (bacterial skin infection), irritant contact dermatitis due to fecal or urinary incontinence (skin irritation related to incontinence), neuromuscular dysfunction of bladder, and cognitive communication deficit. Record review of Resident #17's comprehensive Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15 indicating cognitively intact status. Record review of Resident #17's care plan dated 3/28/26 revealed staff were instructed to Observe peri-area during cares for redness or excoriation; notify nurse or physician if present. Record review of Resident #17's active physician's orders dated 4/30/26 revealed no physician's order for self-administration of medications. 2. Record review of Resident #21's face sheet dated 4/29/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified dementia (progressive cognitive impairment affecting judgment and decision-making), cerebral infarction (stroke resulting in neurological impairment), chronic kidney disease stage 4, anemia, peripheral vascular disease with history of vascular intervention (condition affecting circulation and skin integrity), blindness, and immobility placing the resident at risk for skin breakdown. Record review of Resident #21's comprehensive Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 14 indicating cognitively intact status. Record review of Resident #21's care plan dated 3/16/26 revealed staff were instructed to Monitor, document, and report signs and symptoms of immobility including contractures, signs of blood clots, skin breakdown, and fall-related injury to the physician as needed. Observation of Resident #17's room on 4/28/26 at 9:05 AM revealed a barrier cream sitting on the bedside table. Interview with Resident #17 at the time of observation revealed the resident stated the cream was brought from the hospital and had been provided during hospitalization. When questioned why it was sitting out and why the resident had possession of it, the resident did not respond. Observation of Resident #21's room on 4/28/26 at 9:13 AM revealed an unopened package of Essentials Prevent ointment in the resident's room. Resident #21 was not present in the room during the observation. Interview with CNA H on 4/30/26 at 9:49 AM regarding medication storage revealed CNA H had worked at the facility a little over one year. When questioned regarding the barrier cream in Resident #21's room, CNA H stated awareness that the resident had a barrier cream but was unsure what it was used for. CNA H stated nurses applied creams and treatments and residents did not administer them independently. CNA H stated creams and topical treatments are disposed of after use and should not remain in resident rooms. CNA H confirmed routine medication storage audits were conducted by nursing leadership. Interview with LVN I on 4/30/26 at 9:55 AM revealed LVN I had worked at the facility since July 2024. LVN, I stated the resident's skin condition was pretty good. When questioned regarding the ointment observed in the room, LVN I stated no awareness of the cream being in the resident's room. LVN, I stated no residents on the unit were supposed to keep medications at bedside. LVN, I stated medications, including over-the-counter medications, should be stored in the medication cart or designated storage area. LVN, I stated staff were never instructed to leave creams or treatments in resident rooms. LVN I further stated if medication was found in a resident room, staff were expected to report it to the Director of Nursing. Interview with the RN on 4/30/26 at 10:06 AM regarding Residents #17 revealed the RN stated Resident #21 was incontinent, alert with some confusion, and able to make needs known. The RN stated Resident #17 had made progress since admission, remained more active, used oxygen, and had wound care orders in place. When questioned regarding the cream observed in Resident #17's room, the RN stated no prior observation of the cream in the room and stated the cream shown was not what the facility normally used for Resident #17. The RN stated medications should remain on the medication cart and never be left in resident rooms. The RN stated staff normally took only what was needed for application and discarded the remainder after use. The RN further stated if medications were found in resident rooms, staff were expected to remove the medication and report it to the Director of Nursing. Observation on 4/30/26 at 10:15 AM revealed Resident #21 was not present in the room. No visible medications were observed in the room at that time. Interview with the Social Worker on 4/30/26 at 10:26 AM revealed no awareness of medications being left in resident rooms and no personal observations of medications left in rooms. The Social Worker stated if medications were observed in resident rooms, the concern would be reported to nursing staff and the facility administrator. The Social Worker indicated medications should not be left in resident rooms. Interview with the Director of Nursing on 4/30/26 at 10:45 AM revealed medications and treatments should not be left in resident rooms. The Director of Nursing stated no residents currently had assessments or authorizations in place for bedside medication storage or self-administration of medications. The DON stated facility policy required an assessment prior to allowing residents to self-administer medications. The DON stated medications or treatments found in resident rooms were expected to be removed immediately for resident safety and either properly stored or discarded. The DON stated residents on the skilled nursing hall frequently returned from the hospital with medications or treatments, which continued to be an ongoing issue. The DON stated the facility had postings notifying residents not to keep medications in their rooms and staff were expected to remain watchful for such items. The DON further stated responsible parties would be notified to remove medications from the facility when appropriate, or the facility would obtain physician orders and properly store medications per policy. Record review of the facility's undated nursing policy regarding medication storage revealed it was the policy of the facility to store all drugs and biologicals in locked compartments under proper temperature controls. The policy further reflected that medications were accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy indicated medications intended for internal use were to be stored in a medication cart or other designated area and medication carts and supplies were to remain locked or attended by authorized personnel.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twelve residents (Resident #73, and Resident ##81) reviewed for infection control.1. The facility failed to ensure LVN D placed a cap on Resident #73's IV port after disconnecting the resident's IV on 04/28/2026.2. The facility failed to ensure on 04/28/2026 CNA E wore a gown while performing Resident #81's incontinent care, who had a permacath and was undergoing dialysis, and was on enhanced barrier precautions. Findings included:1. Record review of Resident #73's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with overactive bladder (a bladder control problem which leads to a sudden urge to urinate). Record review of Resident #73's Quarterly MDS Assessment, dated 03/26/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident was incontinent of bowel and bladder. Record review of Resident #73's Comprehensive Care Plan, dated 02/12/2026, reflected that the resident had bowel and bladder incontinence and one of the interventions was monitor for signs and symptoms of UTI (infection involving the organs producing urine).Record review of Resident #73's Physician's Order, dated 04/27/2026, reflected Midline (a long and thin tube inserted into a large vein in the upper arm used for medication administration) placement one time only for UTI for 1 Day.During an observation and interview on 04/28/2026 at 10:34 a.m. revealed Resident #73 was in her bed, awake. It was observed that there was an IV pole inside the resident's room. The resident said there was an IV pole inside her room because she was receiving antibiotics for her UTI. She pulled her hand from under her blanket to show her midline. It was observed that the midline port was not covered. She said she was not sure if the nurses were putting a cover on her IV port.During an observation and interview on 04/28/2026 at 11:09 a.m., LVN D said Resident #73 was receiving antibiotics because she had a UTI. He said he administered the antibiotics and was also the one who disconnected it. He said he was not sure if he covered the resident's midline port after disconnecting the IV. He went inside the resident's room and saw the midline port did not have a cover. He said he would get a green cap for the resident's IV. He said the risk of not covering the midline port could be infection.2. Record review of Resident #81's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with end stage renal failure (kidneys no longer effectively filter waste and toxins from the blood).Record review of Resident #81's Quarterly MDS Assessment, dated 04/24/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident was undergoing dialysis (a medical treatment that removes waste products from the blood).Record review of Resident #81's Comprehensive Care Plan, dated 03/26/2026, reflected that the resident needed hemodialysis related to hemodialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function) and one of the interventions was to use enhanced barrier precautions due to central venous catheter to right upper chest (permacath).Record review of Resident #81's Physician's Order, dated 04/27/2026, reflected ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: permacath (flexible tube used for long term dialysis often inserted into the blood vessels of the neck or upper chest) every shift.Record review of Resident #81's Physician's Order, dated 03/30/2026, reflected RESIDENT HAS CENTRAL VENOUS CATHETER (flexible tube inserted into a large vein, used for hemodialysis) TO RIGHT UPPER CHEST .MONITOR SITE Q SHIFT FOR BLEEDING, PAIN, REDNESS, TENDERNESS, SWELLING, & DISLODGEMENT. DOCUMENT ( - ) ABSENT OR ( + ) IF PRESENT. NOTIFY MD & DIALYSIS CENTER every shift.During an observations and interview on 04/28/2026 at 9:13 a.m. revealed Resident #81 was in her bed, awake. The resident said she was waiting for the staff to get her up for her dialysis. She then pulled her permacath from her shirt and said it was what they used during her dialysis. The permacath was observed on the resident's right upper chest.During an observation on 04/28/2026 at 9:18 a.m. revealed CNA E went inside the room and started to do Resident #81's incontinent care. She washed her hands before putting on a pair of gloves and started with incontinent care. She did not wear a gown while performing incontinent care. During an interview on 04/28/2026 at 10:38 a.m., CNA E said it was an oversight on her part because she forgot to wear a gown knowing that Resident #81 had a tube on her upper chest that was used for dialysis. She said a gown was required for residents on EBP to prevent transfer of microorganisms to other residents.During an interview on 04/30/2026 at 7:09 a.m., ADON A said the IV port should be covered after disconnecting the IV bags to prevent any microorganism from going inside the midline. She said the facility had green caps, which was an alcohol-containing cap used to disinfect the IV ports. She said the staff must wear a gown when PPE was required. She said if there was a sign outside a resident's door that the resident was on EBP, then gowns should be worn, in addition to the gloves, for an extra layer of protection from splashes of blood or bodily liquids that could be infected and then could be transferred to other residents. She said the staff might also bring home any infection that adhered to their clothing. She said deviation from the said procedure could result in cross contamination and spread of infection, if there was any. She said the expectation was for the staff to be mindful and compliant with the policy of infection control. She said they would re-educate the staff about EBP and infection control.During an interview on 04/30/2026 at 7:35 a.m., the DON said that when a resident was on EBP, staff should wear a gown and a pair of gloves when handling the resident to prevent any transfer of MDROs (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics). She said these organisms might transfer to the scrub suits and then might be transferred to other residents. She also said that there were signs outside the doors of the residents that were on EBP to remind the staff to wear PPE. She said all the residents with indwelling medical devices, like feeding tube, urinary catheter, and dialysis port, were on EBP. She said the IV port should also be capped to prevent cross contamination. She said the expectation was for the staff to be mindful with what they were doing to protect the residents from all kinds of infections. She said she already initiated an in-service about EBP and infection control and would closely monitor the staff's adherence to the policy.During an interview on 04/30/2026 at 8:08 a.m., the Administrator said he was not a clinician and he would let the DON handle the issue about the IV port and not wearing a gown.Record review of the facility's policy, IPCP Standard and Transmission-Based Precautions Infection Control revised October 2022 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . 3. Enhanced Barrier Protection (EBP}: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROsto staff hands and clothing then indirectly transferred to residents or from resident-to-resident . c. Examples of high-contact resident care activities requiring gown and glove . vi. Changing briefs or assisting with toileting . vii. Device care or use: central vascular line (including hemodialysis catheters).A policy for capping the IV port was requested verbally on 04/30/2026 at 10:02 a.m. to the Administrator. The Administrator said the facility did not have a policy specific to capping the IV port.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of three residents (Resident #29) reviewed for feeding tube management.The facility failed to ensure LVN D flushed Resident #29's g-tube before and after medication administration as ordered on 04/29/2026.This failure could place residents with g-tubes at risk for clogging.Findings included:Record review of Resident #29's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing) and gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support).Record review of Resident #29's Comprehensive MDS Assessment, dated 04/17/2026, reflected the resident had a memory problem. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach).Record review of Resident #29's Quarterly Care Plan, dated 04/22/2026, reflected the resident required tube feeding (delivery of nutrition through a tube inserted in the stomach) and one of the interventions was to see MD orders for current feeding orders.Record review of Resident #29's Physician's Order, dated 08/18/2025, reflected Enteral Feed (delivery of food through feeding tube) Order every shift FLUSH G-TUBE (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) WITH 30-50 ML OF WATER BEFORE AND AFTER MEDICATION ADMINISTRATION.During an observation on 04/29/2026 at 6:41 a.m. revealed LVN D was about to administer Resident #29's medications via g-tube. He sanitized his hands, put the medications in small plastic cups, crushed them, returned the crushed medications to the small plastic cups, and dissolved them with 10 ml of water. He placed the cups of crushed medications on the resident's overbed table that was sanitized prior to medication preparation. He also put some small cups of water with 15 ml each on the overbed table. He then went inside the resident's room, took a 60 ml piston syringe from the resident's bedside table, and placed it on the overbed table. He put on a gown and a pair of gloves, raised the bed, elevated the head of the bed, turned off the g-tube pump, and disconnected the g-tube from the formula. After disconnecting the g-tube, he took the syringe, pulled the plunger halfway, connected it to the gtube, and checked the placement of the g-tube by pushing air into g-tube while listening using a stethoscope (device used to listen to the sounds inside the body). After checking the placement, he pulled the plunger of the syringe and checked for the gastric residual (food, liquid, and secretions remaining in the stomach). After checking the placement and the residuals, he disconnected the syringe, pulled the plunger of the syringe, and connected the barrel of the syringe to the g-tube. After connecting the barrel of the syringe, he started to pour the first medication without flushing the g-tube. After he was done administering the medications, he flushed the g-tube with 15 ml of water.During an observation and interview on 04/29/2026 at 7:36 a.m. LVN D said the g-tube should be flushed in order to make sure that the g-tube was not clogged and patent. He said he prepared the water he needed for flushing in between medications but did not prepare for the water needed to flush before administering the medications. He checked Resident #29's orders and said there was an order to flush the g-tube before and after medication administration with 30 to 50 ml of water. He said he did flush the g-tube after but not with what was ordered.During an interview on 04/30/2026 at 7:09 a.m., ADON A said the g-tube should be flushed before medication administration to prevent clogging that could lead to replacing the g-tube. She said flushing the g-tube was done to make sure the medications would go through without any issues and there was no residues, like medications, that could interact to the medications that would be administered. She said if the order said to flush 30 to 50 cc before and after medication then the staff should have flushed it with 30 to 50 cc before and after medication administration. She said a specific amount of water was ordered to ensure hydration and that the medication was delivered safely. She said they already started an in-service about flushing before medications administration.During an interview on 04/30/2026 at 7:35 a.m., the DON said the g-tube should be flushed before administration of medications to clear the tube and to make sure the tube was patent. She said the expectation was for the staff to understand and follow the procedure. She said they already started an in-service about flushing the g-tube.During an interview on 04/30/2026 at 8:08 a.m., the Administrator said he was not a clinician and would let the DON take the lead on the issue about the g-tube.Record review of the facility's policy Gastrostomy Tube Care and Management revised July 2024 reflected Policy: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes . Procedure . 5. Flush the feeding tube and adapter, if applicable per Physician's order before and after every feeding, and before and after giving any medication by tube .9. Flushing the Tube . a. To reduce the risk of tube clogs . Before and after each administration of medication . b. The amount of water used for tube flushing depends on the individual physician orders.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for one of six residents (Resident #24) reviewed for accident hazards. The facility failed to ensure Resident #24 had physician orders for a scoop mattress to ensure it was not a hazard for the resident. This failure could prevent the residents from having an environment that was free from accidents, and potential injury. Findings included:Record review of Resident #24's Face Sheet, dated 04/29/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #24 had a diagnosis of reduced mobility.Record review of Resident #24's Initial MDS Assessment, dated 03/19/26, reflected the resident had a BIMS score of 5 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of reduced mobility.During an observation on 04/14/26 at 11:35 a.m., revealed Resident #24 was lying in bed on a scoop mattress (a scoop mattress features raised sides and a concave center). Record review of Resident #24's Comprehensive Care Plan, dated 03/20/26, reflected the resident being a fall risk, but there was no intervention including the use of a scoop mattress. Record review of Resident #24's Physician's Order, dated 04/29/26, reflected no physician's orders for a scoop mattress. During an interview and observation on 04/29/26 at 1:30 a.m., ADON A stated Resident #24 was a fall risk. She observed the scoop mattress on the resident's bed and she stated she did not know if the resident had orders for the mattress. She stated the resident needed a physician's order for the mattress because it was part of her care. She did not know the risk of the resident having the mattress without physician orders.During an interview and observation on 04/29/26 at 1:40 a.m., the DON and Clinical Resource Nurse were informed of Resident #24 having a scoop mattress and no physician's order. The DON stated the resident had orders for use of a wedge and assumed that was for the scoop mattress. The DON stated it was used for fall prevention. They stated they would work on getting the resident a physician's order for the scoop mattress. They stated it was the nursing staff's responsibility to ensure the resident had physician orders for the use of the equipment. Record review of the facility's policy, Fall Management System, dated 02/2023, reflected This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.POLICY:It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interview, and record review, the facility failed to ensure provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of three residents (Residents #17) reviewed for quality of care.The facility failed to ensure that Resident #17's open wounds to her left and right buttocks were covered with dressings on 04/28/2026. This failure could place the residents with open wounds at risk for infection.Findings included: Record review of Resident #17's Face Sheet, dated 04/29/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with irritant contact dermatitis due to fecal, urinary or dual incontinence (unable to control).Record review of Resident #17's Comprehensive MDS Assessment, dated 04/02/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had moisture associated skin damage.Record review of Resident #17's Comprehensive Care Plan, dated 04/08/2026, reflected that the resident had an actual impairment to the skin integrity related to shear (downward pressure and friction causing skin damage)/MASD (moisture associated skin damage: inflammation or erosion of the skin caused by prolonged exposure moisture from bodily fluids)) to right and left buttocks and one of the interventions was to administer treatments as ordered.Record review of Resident #17's Physician's Order, dated 03/30/2026, reflected Cleanse: wound to left buttock with NS, pat dry, apply Triad paste, cover with foam dressing and prn for dislodgement/soiling. every day shift every Mon, Wed, Fri for Shear/MASD AND as needed.Record review of Resident #17's Physician's Order, dated 03/30/2026, reflected Cleanse: wound to right buttock with NS, pat dry, apply Triad paste, cover with foam dressing and prn for dislodgement/soiling. every day shift every Mon, Wed, Fri for Shear/MASDAND as needed.During an observation on 04/28/2026 at 11:23 a.m. revealed CNA F and CNA G were about to transfer Resident #17 to her wheelchair. Before transferring the resident, they provided incontinent. After cleaning the perineal (area between the legs) area, they rolled the resident to her side and lowered her brief. It was observed that the resident had loose, unformed stools, scattered on her left and right buttocks. It was also observed that the resident had open wounds on her right and left buttocks that had no dressings and had feces on them. It was also observed that there were no dressings on the resident's brief that was taken off from the resident's bottom. CNA F finished cleaning Resident #17's bottom and then went out of the room to call the nurse.During an interview on 04/28/2026 at 11: 36 a.m., CNA G said she was not sure why Resident #17's wounds did not have dressings.During an interview on 04/28/2026 at 11:40 a.m., CNA F said he went out of the room to call LVN H to see if she needed to put some cream or dressings on Resident #17's wounds before he put on the resident's brief. He said the Treatment Nurse heard what he was telling LVN H and said she would do the resident's wound care. He said he was not sure why the resident's wounds did not have any dressings on them. He said because the wounds had no dressing, they were contaminated with feces that could lead to infection.During an observation on 04/28/2026 at 11:45 a.m., revealed ADON B cleaned Resident #17's wounds and placed some dressings on them.During an interview on 04/28/2026 at 12:01 p.m., ADON B said she was also the Treatment Nurse. She said already cleaned Resident #17's wounds. She said the order for the resident's wound care was M-W-F and PRN if the dressings were soiled or dislodged. She said she had no idea why the resident's wounds did not have dressings on them. She said whoever changed the resident or saw that the wounds did not have any dressings on them should have informed the nurse so that the nurse could have placed some dressings. ADON B said the dressings were needed to keep the wound from having contact with any contaminants such as feces and urine. She said the wounds should be covered to prevent cross contamination and infection. She said she would start an in-service about the matter. She said she had no idea that the resident's wounds were not covered and how long they were uncovered.During an interview on 04/28/2026 at 12:13 p.m., LVN H said nobody notified her earlier that the Resident #17's wound dressings were soiled or dislodged or that the resident's wounds did not have any dressings on them. She said if somebody informed her that the wounds were not covered, then she could have put some dressings on the wounds to keep them clean. She said since the resident was going more often, then the more they need to monitor the dressings of the wounds to prevent infections. She said, even without the feces, the wounds could not have contact with the brief because the brief might be soaking with urine. During an interview on 04/28/2026 at 1:46 p.m., CNA G said was assigned to Resident #17 but she had not changed the resident prior to the incontinent care done at around 11:30 a.m She said if she saw that the wounds did not have dressings, she would notify the nurses so they could do wound care.During an interview on 04/30/2026 at 7:35 a.m., the DON said the CNAs did the right process during incontinent care because they called the nurse when they saw that the wounds did not have any dressings on them and the possible risk would be infection. She said she did not know why the wounds had no dressings on them but already started an in-service that if any dressing was soiled or dislodged, to call the nurse so they could perform wound care. During an interview on 04/30/2026 at 8:08 a.m., the Administrator said he was not a clinician and would let the DON take the lead about the wounds having no dressings.Record review of the facility's policy Skin and Wound Monitoring and Management Quality of Care revised December 2023 reflected Policy: It is the policy of this facility that . 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing . Purpose: The purpose of this policy is that the facility provides care and services to . 3. Prevent the development of additional, avoidable pressure injury . Procedure . g. Ongoing Skin and Wound Assessments . 7) Identifying any possible complications or signs/symptoms consistent with the possibility of Infection . j. Treatments per physician order . 3. Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries . f. If the resident is incontinent, make sure that his/her skin remains clean and dry with regular pericareand toileting when appropriate.from worsening . CNAs will review electronic Kardex to view care plan interventions . f. If the resident is incontinent, make sure that his/her skin remains clean and dry with regular pericare and toileting when appropriate.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two of twenty residents (Resident #93 and Resident #95) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #93 and Resident #95's rooms were in a position that was accessible to the residents on 04/28/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #93Record review of Resident #93's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and anxiety (intense or excessive fear or worry).Record review of Resident #93's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/24/2026, reflected the resident had a memory problem. The Quarterly MDS Assessment indicated the resident was dependent on staff for eating, hygiene, showers, dressing, and bed mobility.Record review of Resident #93's Comprehensive Care Plan, dated 03/13/2026, reflected the resident was at risk for falls related to weakness and one of the interventions was to be sure the resident's call light was within reach.During an observation and interview on 04/28/2026 at 9:13 a.m., revealed Resident #93 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked where her call light was, the resident did not reply.During an observation and interview on 04/28/2026 at 9:20 a.m., the MDS Nurse said call lights should be with the residents at all times in case they needed to call the staff for any assistance. She went to the resident's bedside and took the call light from the floor and placed it where the resident could reach it.Resident #95 Record review of Resident #95's Face Sheet, dated 04/29/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acquired absence of left leg below knee.Record review of Resident #95's Quarterly MDS Assessment, dated 03/20/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident needed assistance for hygiene, shower, dressing, bed mobility, and transfer.Record review of Resident #95's Comprehensive Care Plan, dated 02/03/2026, reflected the resident was at risk for fall and one of the interventions was for the call light to be in reach.During an observation and interview on 04/28/2026 at 9:04 a.m. revealed Resident #95 was in her bed, awake. It was observed that the resident's call light was on the floor. It was also observed that the resident's bed was soaking wet. The resident said she spilled her coffee and that was why she and her bed were wet. She said she did not have her call light and she had no way to call the staff.During an observation and interview on 04/28/2026 at 9:19 a.m., CNA E said call lights were important for the residents because they used them to call for help or assistance. She said they might get mad if they needed the staff and there was no way to call them. She went inside Resident #95's room and saw the call light on the floor. She picked it up and placed it where the resident could reach it. She also saw that the resident's bedding was wet. She said she would change also the resident.During an interview on 04/30/2026 at 7:09 a.m., ADON A said call lights should always be with the residents or within the reach of the residents in cases they needed the staff for anything. She said the residents would call if they needed to be changed, a pain pill, or if they were not feeling well. She said the staff should make sure that the call lights were with the residents before they left the room. She said the call lights had clips on them and the staff could use them to prevent the call lights from falling if the residents moved. She said the call lights were for all residents, regardless of whether they were dependent or independent. She said everybody was responsible for making sure the call lights were with the residents. She said the expectation was for the staff to make sure that all the call lights were within reach of the residents. She said they already started an in-service about call lights. During an interview on 04/30/2026 at 7:35 a.m., the DON said call lights were used by the residents to communicate with the staff if they needed something or needed assistance. She said the expectation was for the staff to make sure the call lights were within reach of the residents before they left the room. She said she already started an in-service about call light placement. During an interview on 04/30/2026 at 8:08 a.m., the Administrator said the expectation was for staff to check if the call lights were within the reach of the residents at all times. He said sometimes the residents would knock them off so another expectation would be for the staff to pick up the call lights and put them where the residents could reach them. He said the DON already started an in-service about call lights.Record review of facility's policy Call Light Policy Procedure - Nursing Clinical revised May 2023 reflected POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff . PROCEDURES . 4. Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Based on interview and record review the facility failed to provide care and services, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for one of seven residents (Resident # 3) reviewed for activities of daily living. The facility failed to ensure Resident #3 was provided with incontinent care in a timely manner. This failure could place residents at risk for poor self-esteem, infection, and diminished quality of life.Findings included: Record review of Resident #3's face sheet, dated 03/06/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #3 had diagnoses that included: chronic obstructive pulmonary disease (inflammatory lung disease), dementia with mood disturbance (emotional shifts such as depression, anxiety, agitation, apathy, or rapid swings), type 2 diabetes mellitus (body resist insulin or fails to produce enough), morbid obesity (chronic, complex disease with body mass index of 40 or higher), urinary tract infection (bacterial infection of the bladder), acute kidney failure anemia in chronic kidney disease (damaged kidneys produce less erythropoietin, a hormone necessary for red blood cell production), acute pyelonephritis (serious bacterial infections of the kidney and renal pelvis), obstructive and reflux uropathy (urine flow is blocked), chronic kidney disease (loss of kidney function), overactive bladder (sudden, uncontrollable urge to urinate), tremor (involuntary, rhythmic muscle contraction causing shaking in hands, head, voice, or legs), obstructive sleep apnea (throat muscles relax excessively during sleep), gastroesophageal reflux disease with esophagitis (inflammation, irradiation, or erosion of the esophageal lining), hyperlipidemia (excessive fat level in the blood), anxiety disorder (persistent, excessive fear or worry), osteoarthritis ( wear-and-tear diseased affecting cartilage in the joints) and absence of left leg below knee. Record review of Resident #3's MDS assessment, dated 02/19/26, reflected BIMS score which indicated moderate cognitive impairment. The MDS, under Section GG-Functional Abilities, reflected Resident #3 needed substantial assistance on most of her ADLs, used a wheelchair and was dependent on all mobility tasks. Further review of the MDS assessment section H-Bowel and Bladder reflected Resident #3 had urinary and bowel incontinence. Record review of Resident #3's care plan, no date, reflected Resident #3 had bowel/bladder incontinence related to decreased mobility, deconditioning, activity intolerance, weakness, unsteady gait, and impaired cognition. Interventions included: brief use: using disposable briefs, incontinent: checking as required for incontinence. Washing, rinsing, and drying perineum. Changing clothing as needed after incontinence episodes, monitoring/documenting for signs and symptoms of UTI, monitoring/documenting/reporting to MD possible medical causes of incontinence and observing peri-area during cares for redness or excoriation and notify nurse/MD if present. In an interview on 03/06/26 at 10:52 AM, Resident #3's RP stated she received a call on 03/04/26 at 11:30 AM from Resident #3 crying because she had waited since 8:00 AM for her soiled brief to be changed. Resident #3's RP stated she called the facility at 11:38 AM but no answer. Resident #3's RP stated she called Resident #3 at 11:58 AM to inform her that she was trying to reach someone to change her. Resident #3's RP stated when she spoke with the resident, she still had not been changed. Resident #3's RP stated she called the facility again at 12:00 PM and was put in contact with a nurse on 400 that transferred her to 500 hall, but no answer. Resident #3 stated she called several family members to find out if someone could go to the facility, but no one was able. Resident #3 RP stated she called Resident #3 back at 12:27 PM and she was informed that staff still had not changed her. She stated Resident #3 told her she had fallen asleep while waiting to be changed. Resident #3's RP stated when Resident #3 called and told her, she attempted to contact the facility but to no avail. She stated when staff returned, they told Resident #3 she was not changed because she was asleep when they returned. Resident #3's RP stated Resident #3 told the staff she did not know why they did not wake here as they do for everything else. Resident #3's RP stated when Resident #3 called her with issues with toileting, she would usually go to the facility to take care of Resident #3 herself. In an interview on 03/06/26 at 12:54 PM, Resident #3 stated she used her call light for assistance with changing her clothes and soiled brief. She stated CNA C came into her room and asked what she needed. Resident #3 stated when she informed CNA C that she needed changing, CNA C told her Not now because she was passing trays but would change her afterwards. Resident #3 stated she waited for over an hour and fell asleep. Resident #3 stated it was on 03/04/26 around 1:00 PM when CNA C returned to change her. Resident #3 stated she was upset because it had taken hours and asked what happened. She stated CNA C told her she returned to change her, but she was asleep and did not want to wake her. Resident #3 stated she told CNA C she wanted her to wake her, so her soiled brief was changed. Resident #3 also stated she was confused because staff constantly woke her for everything else. Resident #3 stated she wanted to be woken to be changed, and staff did not do that. Resident #3 stated staff left her in a urine soiled brief for hours. In an interview on 03/06/26 at 4:41 PM, CNA C stated she worked a double shift on 03/04/26. She stated she worked 6:00 AM-10:00 PM. CNA C stated she worked with Resident #3 on 03/04/26. CNA C stated Resident #3's call light was on and when she answered, Resident #3 told her she wanted her brief changed. CNA C stated when she looked in Resident #3's closet, she noticed Resident #3 only had smaller briefs and not the XXXL that she liked. She stated she informed Resident #3 that she would go to the storage to get the size briefs needed. CNA C stated the storage was on the 500 hall. She stated when she got back to Resident #3's room to change her, she was asleep. CNA C stated she did not wake the resident and at that time did not change Resident #3's brief. CNA C stated he did not want to wake Resident #3 because she had previously done so, and the resident got upset with her. She stated she did not want the resident to get upset with her again. CNA C revealed she made the decision to not change the resident. She stated when Resident #3 woke, she was upset that she did not wake to change her. CNA C stated if she had known Resident #3 would have been upset for not waking her, she would have woken her from her sleep. CNA C stated she was unaware of how long it took to return to Resident #'3 room with the briefs to change her. CNA C stated the expectation was to wake the resident to change, if requested. CNA C stated the risks of leaving Resident #3 in a soiled a brief was the resident could have developed a sore, infection or a rash. In an interview on 03/06/26 at 5:20 PM, the Administrator and DON stated they were made aware of the situation with Resident #3 being soiled on 03/05/26. The DON stated it was the resident's right to decide if he or she wanted to be changed. The DON stated it was the residents' right to be changed, and staff were expected to change the residents. The DON stated if the resident was asleep, then depending on the resident's choice, staff may or may not wake the resident. Both the Administrator and DON stated they did not know about this issue with the resident. The DON stated the risk was a rash or infection if a resident was not changed in a timely manner. Record review of the facility's policy titled Quality of Care, revised July 2015, reflected in part of the following: Policy:It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures:If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, toileting and personal oral hygiene will be provided by qualified staff. Residents will be involved in decision making and given choices related to ADL activities as much as possible. Showers and bed baths will be provided to residents in accordance with the residents shower schedule.Residents will be involved in decision making and given choices related to ADL activities as much as possible. Record review of the facility's policy titled Resident Rights, revised October 2015, reflected in part of the following: Policy: It is the policy of this facility that all residents be treated with kindness, dignity and respect. Procedures: 3. Resident will be appropriately dressed in clean clothes arranged comfortably on their persons and be well groomed.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of seven residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse by Resident #2, who threw an empty plastic bowl at Resident #1. This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings included: Record review of Resident #1's face sheet, dated 03/06/26, reflected an 85- year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: dementia (decline in memory), osteoarthritis (cartilage breakdown causing bones to rub together), type 2 diabetes mellitus (high blood sugar), hypertension (force of blood pushing against artery walls), hypothyroidism (thyroid gland does not make enough thyroid (regulates metabolism) hormones), gastro-esophageal reflux disease with esophagitis (stomach acid flows back to esophagus), hyperlipidemia (excessive fat level in the blood), reduced mobility (reduction in the ability to move, walk, or transfer independently), mood affective disorder (disruptions in emotions), generalized anxiety disorder (persistent, excessive and uncontrollable worry), hemorrhoids (swollen veins in the anus caused by straining), myopathy (muscle fibers causing primary muscle weakness), chronic pain syndrome (pain last for more than 3 to 6 months), synovial cyst of popliteal (fluid-filled lump behind the knee) and cognitive communication deficit (impairment in communication). Record review of Resident #1's MDS assessment, dated 12/1/25, reflected Resident #1 was unable to complete the interview; therefore, there was no BIMS score documented. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed set up to complete assistance with all ADLs, used a wheelchair and was dependent on all her mobility tasks. The MDS assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised 12/03/25, reflected Resident #1 was at risk for cognitive function/dementia or impaired thought process. Interventions included: administering medications as ordered, identifying self at each interaction by facing her when speaking and making eye contact, reducing distractions, giving step by step instructions one at a time as needed, keeping routine consistent by trying to provide consistent care givers as much as possible in order to decrease confusion, monitoring/documenting/reporting any changes in cognitive function to MD and reporting to the nurse any changes in cognitive function.Record review of Resident #1's progress note, dated 03/03/26 at 09:50 AM, reflected the following: Resident to resident incident occurred during dining this morning. [Resident #1] was reportedly struck by a cup that was thrown by [Resident #2] seated nearby. Both residents were separated from one another and monitored. No injuries observed by nurse during assessment. No distress noted, resident reported she was fine. Denied pain. [Resident #'1's] family member notified via VM. Record review of Resident #2's face sheet, dated 03/06/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: nontraumatic intercerebral hemorrhage (severe stroke involving bleeding in the brain), hypertension (blood pushing too hard against artery walls), type 2 diabetes mellitus (body resist insulin or fails to produce enough), morbid obesity (chronic, complex disease with body mass index of 40 or higher), hemiplegia and hemiparesis following cerebral infarction (one-sided motor deficits occurring after a stroke), hyperlipidemia (excessive fat levels in the blood), schizoaffective disorder (combination of schizophrenia symptoms (hallucinations, delusions, disorganized thinking) and mood disorder (mania or depression), lack of coordination (clumsy, unsteady, and uncoordinated muscle movements), muscle weakness (a reduction in physical strength), dysphagia (pain, choking, or food feeling stuck in the throat), age-related nuclear cataract (lens clouding), hypertensive retinopathy (damage to the retinal blood vessels), retinal ischemia (blood flow to the retina is inadequate), bipolar disorder (chronic mental condition characterized by extreme mood swings), generalized anxiety disorder (mental health condition characterized by persistent, excessive and uncontrollable worry), clonic hemifacial spasm (neurological disorder causing involuntary, intermittent twitching of muscles on one side of the face), cerebral infarction (blood flow to the brain blocked), bilateral primary osteoarthritis ( wear-and-tear diseased affecting cartilage in the joints) and facial weakness (loss of muscle control on one or both sides of the face). Record review of Resident #2's MDS assessment, dated 02/26/26, reflected BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 needed setup to dependent or complete assistance with all ADLs, used a wheelchair and needed substantial assistance with all her mobility tasks. The MDS assessment under Section E-Behaviors, reflected Resident #2 did not have any physical or verbal behaviors. Record review of Resident #2's care plan, revised 12/02/25, reflected Resident #2 at risk for impaired cognitive function/dementia or impaired thought processes related to history of CVAM schizophrenia and bipolar disorder. Interventions included: communication: identifying self at each interaction, facing her when speaking and make eye contact, reducing distractions, using simple, directive sentences. Interventions also included: reporting to nurse any changes in cognitive function, attending group activities and for social services to provide psychosocial support as needed. Further review of Resident #2's care plan, reflected Resident #2 had a potential for mood problem related to schizophrenia and bipolar disorder. Interventions included: behavioral health consults as needed, encouraging her to express feelings, monitoring/recording/reporting to MD, and prn acute episode feelings of sadness, loss of pleasure and interests in activities, feelings of worthlessness or guilt, change in appetite or eating habits, change in sleep patterns, diminished ability to concentrate and change in psychomotor skills. Record review of Resident #2's progress note, dated 03/03/26 at 10:32 AM by SW, reflected the following: SW notified [Resident #2] threw cup at another [Resident #1]. SW completed BIMs and PHQ9 assessment with [Resident #2]. BIMs was a 12 (moderate impairment) and PHQ9 was a 0 (none-minimal depression). SW asked [Resident #2] if she was feeling okay. Resident stated yes. SW asked [Resident #2] of situation this morning during breakfast. [Resident 2] reported she understood [that] what she did was wrong and became upset. When [Resident #1] was reaching for her food. SW educated resident on calling staff for help. [Resident #2] voiced understanding. During interview [Resident #2] has good [effect] and did not appear to be in any signs of distress. Follow-ups with [Resident #2] would continue. SW notified psychiatrist of [Resident #2] behavior. SW would continue follow-ups with [Resident #2].In an interview on 03/06/26 at 11:53 AM, CNA A stated she worked Mondays-Fridays from 6:00 AM-2:00 PM on the 200 hall. She stated she worked with Resident #1 and Resident #2 on 03/03/26. She stated she was not a witness to the incident. She stated she went to clear the dining after lunch and a resident pointed out the empty cup on the floor. She stated Resident #2 said she threw the cup at Resident #1 because she had tried to take food off her tray. CNA A stated she immediately separated Resident #1 and Resident #2, then cleared the dining room. She stated she spoke with Resident #2 and informed her that it was not right to throw anything at anyone else. She stated she assessed Resident #1 but there were no marks or bruises. She stated Resident #1 told her that she was okay. She stated after getting the residents separated and assessed, she informed the nurse on the floor. CNA A stated that neither resident had any behavior issues. In an interview on 03/06/26 at 12:21 PM, LVN B stated she worked Mondays, Wednesdays and Fridays from 6:00 AM- 2:00 PM as the charge nurse on halls 200, 300 and partial 400. She stated she worked on 03/03/26 with both Resident #1 and Resident #2. She stated on another hall during the incident but was informed when she got back to 200 hall. She stated CNA A informed her that Resident #1 reached for Resident #2's food items on her tray. She stated CNA A told her Resident #2 apparently told Resident #1 no, but Resident #1 kept reaching to grab her food. LVN B stated Resident #2 tossed a cup at Resident #1 which hit Resident #1's upper body. LVN B revealed staff had separated the residents and monitored them throughout the day. LVN B stated she assessed Resident #1's skin and noted no marks or bruises. She stated she asked Resident #1 about pain, and she did not have any pain. She also revealed Resident #1 and Resident #2 were roommates, so Resident #1 was moved to a new room. LVN B stated she informed management of the incident. In an interview on 03/06/26 at 12:33 PM, the SW stated she was informed that Resident #1 was reaching for something on Resident #2's plated. The SW stated Resident #2 grabbed an empty cup and threw it at Resident #1. The SW stated the residents were separated to deescalate. She stated that was all she knew of the incident. She stated she spoke with both Resident #1 and Resident #2 after the incident. The SW stated Resident #2 told her Resident #1 was reaching for her food. The SW stated Resident #2 told her she did not want Resident #1 to touch her food, so she grabbed her cup and tossed it. The SW stated when she spoke with Resident #1 she was confused and did not remember the incident. Attempted interview on 03/06/26 at 2:17 PM with Resident #1 was unsuccessful. Resident #1 had no recollection of the incident. Resident #1 revealed she did not remember anything. In an interview on 03/06/26 at 3:58 PM, Resident #2 stated she [NAME] an empty salad bowl at Resident #1. Resident #2 stated Resident #1 kept coughing over her food and grabbed her food. She stated she told Resident #1 to stop but she did not. Resident #2 stated when Resident #1 did not stop, she picked up an empty plastic bowl and threw it at her. Resident #2 stated the bowl hit Resident #1 on her shoulder. Resident #2 stated the staff separated them and told her she could not throw anything. Resident #2 stated she apologized to Resident #1. She also stated Resident #1 was moved out of her room. Record review of the facility's policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised October 2022, reflected in part the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, resident representative, families, friends, or other individuals.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Residents #1) of ten residents and for one (Crash Cart) of three carts reviewed for medication storage. The facility failed to ensure the crash cart (cart stocked with medical equipment, supplies, and medications used during medical emergencies) was locked on 12/30/2025. The facility failed to ensure a tube of pain relieving topical (application of medication through the skin) analgesic (painkiller) cream was not inside Resident #1's room on 12/30/2025. These failures could place the residents at risk of accessing/opening the cart, accidental overdose, adverse reactions, misuse of medications.Findings included: 1. An observation on 12/30/2025 at 8:22 AM revealed a crash cart was parked outside the nurse's station unlocked. The cart and its drawers were facing the hallway, the drawers contained emergency supplies and equipment like nasal cannula, syringes, and suction device, and several types of tubing. It was observed that the first drawer had scissors in it and the third drawer had a first aid kit. It was observed that several residents were passing by the crash cart and there was no staff in the nurse's station. An observation on 12/30/2025 at 8:24 AM, a staff called ADON A and ADON A locked the crash cart. In an interview on 12/30/2025 at 10:39 AM, LVN B stated the crash cart should be locked when not in use for the safety of the residents. She said a resident might open it and grab something that would be detrimental for the residents. She said the crash cart had tubings and scissors in it that the resident could use to harm themselves if they were able to get hold of them. She said crash carts also have medications used for emergencies that when accidentally consumed could result to allergic reactions, overdose, nausea, and stomach upset. She said they were all responsible for locking the crash carts. In an interview on 12/30/2025 at 11:06 AM, LVN C stated all the carts should be kept locked when not in use or was left unattended, including the crash cart. She said the things inside the crash cart should not be assessable to the residents because the resident might use them inappropriate like wrap the tubes around their neck or poke their eyes with the syringe. She said there were scissors inside the crash cart and the resident might accident cut themselves. She said the crash carts also have medications used for emergencies and residents, staff, and visitors might open the drawers and get some medications from the cart. 2. Record review of Resident #1's Face Sheet, dated 12/30/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason), depression (persistent feeling of sadness or loss of interest), and low back pain. Record review of Resident #1's Comprehensive MDS Assessment, dated 11/13/2025, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment with a BIMS score of 02. The Comprehensive MDS Assessment indicated the resident had dementia, depression, and low back pain. Record review of Resident #1's Comprehensive Care Plan, dated 11/20/2025, reflected the resident had potential for injury related to family bringing medications and one of the goals was the resident would have no injuries related to family bringing medications and for the staff to scan the room for any medications. Record review of Resident #1's Physician Orders on 12/30/2025, reflected the resident did not have an order for the analgesic cream. Record review of Resident #1's Assessment Notes on 12/30/2025, reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. In an observation and interview on 12/30/2025 at 8:29 AM revealed Resident #1 was in her wheelchair, awake. It was observed that there was a tube of topical analgesic cream on top of her overbed table that was beside her wheelchair. The tube of analgesic cream was in plain view. The resident nodded her head when asked if the analgesic cream was hers. The resident nodded her head when asked if the analgesic cream had always been on her table. In an interview on 12/30/2025 at 11:06 AM, LVN C stated she was not aware there was a tube of topical analgesic cream inside Resident #1. She said she did not notice it when she did her morning round. She said the resident had dementia and might use it inappropriately like applying it to her eyes or mouth. She said the resident did not even have an order for the analgesic cream. She said the analgesic cream should be inside the nurse's carts and the nurses should be the one applying it if the resident needed it. She said she would go to the resident's room and talk to the resident regarding removing the analgesic cream. She said she would re-educate the family member about letting the nurses about any medication being brought to the facility. She said since there was already an issue about a family member bringing medications, the more staff should be mindful of checking for any medications. In an interview on 12/30/2025 at 11:27 PM, the Administrator stated the expectation was for all the carts, nurses' carts, medication aide carts, and the wound care carts, crash carts would always be locked to protect the residents from getting any supplies and medications that they might be allergic to or used inappropriately. he said another expectation was for no medications were inside the residents' room to prevent accidental consumption that could result to adverse reactions like allergy, stomach upset, and irritations. He said he would coordinate with the ADONs to educate the staff about the matter. In an interview on 12/30/2025 at 12:44 PM, ADON A stated the carts should be locked every time they were left unattended. She said the staff should lock the carts before leaving them to prevent unauthorized individuals from opening them. She said confused residents might open the cart and ingest something to which they were allergic or use something inappropriately that could result to harm. She said there was no emergency the night prior, so she did not know why and how long the crash cart was not locked. She said another issue was if somebody got hold of the supplies and medications, staff might not have something to use in case of emergencies. She said she would try to find out who left it open so she could remind the staff to always lock the crash cart. She said all the nurses were responsible in making sure the crash cart was locked. She said there should be no medication inside the rooms of the residents because of the danger of inappropriate use or overdose, especially if they had confusion or fading eyesight. She said the topical analgesic cream was a medication for pain. She said if the staff knew that family members were bringing medications, the more they should scan the room for any medications. She said the expectation was for the staff to be observant to see if there were medications inside the residents' rooms and always lock the carts when not in use. She said she initiate an in-service about the importance of the locking the carts and about scanning the residents' room for any medications. Record review of the facility's policy titled Medication Access and Storage Policy/ Procedure - Nursing Clinical revised May 2007 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . PROCEDURES . 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's sleep apnea mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nebulizer mask was properly stored in a bag when not in use on 09/30/25. The facility failed to ensure Resident #1's nasal canula attached to the oxygen tank on his wheelchair was properly stored in a bag when not in use on 09/30/25. These failures could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 09/30/25, reflected she was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included chronic respiratory failure (severe lack of oxygen). Record review of Resident #1's Quarterly MDS assessment, dated 8/18/25, reflected he had a BIMS score of 13 (intact cognitive response). The resident had an active diagnosis of chronic respiratory failure. Record review of Resident #1's Comprehensive Care Plan, dated 8/11/25, reflected a plan of care for oxygen therapy. Record Review of Resident #1's physician orders, dated 9/30/25, reflected O2 at 4l/Min continuous per NC, Albuterol Sulfate Nebulization Solution 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath, and BiPAP/CPAP nightly In an observation on 09/30/25 at 8:27 AM, Resident #1 had a sleep apnea mask unbagged, a nebulizer mask unbagged, and a nasal canula attached to the oxygen tank connected to his wheelchair unbagged. In an observation and interview on 09/30/25 at 8:35 AM, the DON and RN G were shown Resident #1's sleep apnea mask unbagged, his nebulizer mask unbagged, and his nasal canula attached to the oxygen tank connected to his wheelchair unbagged. They stated all the breathing devices should have been bagged when not in use to avoid infection. The DON stated the nurses should be re-bagging equipment when they make their rounds. She stated they were completing in-services on re-bagging nasal cannulas and mask when not in use. Review of the facility's policy Oxygen Administration (Mask, Canula, Catheter), 05/2007, reflected It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency until the order was obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure that food items past there expiration date were discarded. This failure could place residents at risk of exposure to food borne illnesses. Findings included: In an observation and interview on 02/18/2025 at 9:41 AM two 48-ounce plastic jars of opened Spaghetti Sauce were observed on a shelf in the walk-in refrigerator in the kitchen of the facility. Both jars were found to have no dates of when they were opened or a discard date. The Dietary Manager stated all food in the walk-in refrigerator should have an open and discard date. She stated foods that are past their discard dates could become spoiled and possibly expose residents to possible food-related illness. She stated because there were no dates on the containers, she was unable to determine when they were opened or when they should be discarded. In an interview on 2/18/2025 at 10:09 AM [NAME] F revealed that it was important to make sure all leftover foods in the refrigerator have an opened and discard date. She stated that it could make residents ill if they are exposed to possibly spoiled foods. She stated that she had received training on how to properly store foods. Record review of all dietary aides and Cooks food safety certificates found that all certificates were up to date. In an interview on 2/20/2025 at 2:32 PM the DON revealed that if residents ingested spoiled foods or foods that were past their respective discard dates it could cause food-borne illnesses or discomfort to residents. Review of the facility's policy Frozen and Refrigerated Foods Storage, revised November 2017, reflected, 9. Items stored in the refrigerator must be dated upon receipts, unless they contain a manufacturer use by, sell by, best by date, or a date delivered . The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage (B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded.

Based on observation, interview, 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 13.33% based on four errors out of 30 opportunities, which involved three (Resident #28, Resident #74, and Resident #89) of six residents reviewed for medication errors. 1. The facility failed to ensure Resident #28's Glipizide (lowered blood sugar) and Benzonatate (treats cough) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00 a.m. 2. The facility failed to ensure Resident #74's Carvedilol (treats high blood pressure) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. 3. The facility failed to ensure Resident #89's Metformin (lowers blood sugar) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or not receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #28's Quarterly MDS dated [DATE] revealed Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes and chronic respiratory failure. The MDS also revealed the BIMS score was 15 (no cognitive impairment). Record review of Resident #28's care plan with a revision date of 11/22/2024 revealed Resident #28 had diabetes that was managed with oral medication and included interventions such as administering medications as ordered. The care plan also revealed Resident #28 had chronic respiratory failure and included interventions such as administering medications as ordered. Record review of Resident #28's physician order dated 3/11/2024 revealed Resident #28 was to receive one tablet of glipizide 5mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. Record review of Resident #28's physician order dated 2/03/2025 revealed Resident #28 was to receive one capsule of Benzonatate 200mg three times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m., 12:00 p.m. to 2:00 p.m., and 4:00 p.m. to 8:00 p.m. In an observation on 2/18/2025 at 11:27 a.m., MA A administered eight medications to Resident #28 including Glipizide and Benzonatate that was ordered to be administered between 7:00 a.m. to 10:00 a.m. The glipizide and Benzonatate on the MAR was red on the computer screen. 2. Record review of Resident #74's Annual MDS dated [DATE] revealed Resident #74 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and coronary artery disease (heart disease). The MDS also revealed a BIMS score of 07 (suggested severe cognitive impairment). Record review of Resident #74's care plan with a revision date of 12/23/2024 revealed Resident #74 had an altered cardiovascular status related to hypertension and the goal was to remain free from cardiac complications. Record review of Resident #74's physician order dated 1/13/2025 revealed Resident #74 was to receive one tablet of carvedilol 6.25mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. In an observation on 2/18/2025 at 11:47 a.m., MA A administered 11 medications to Resident #74 including carvedilol that was ordered to be administered between 7:00 a.m. to 10:00 a.m. The carvedilol on the MAR was red on the computer screen. 3. Record review of Resident #89's Comprehensive MDS dated [DATE] revealed Resident #89 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis of diabetes. The MDS also revealed a BIMS score of 09 (suggested moderate cognitive impairment). Record review of Resident #89's care plan with a revision date of 1/27/2025 revealed Resident #89 had diabetes and included interventions such as administering medications as ordered. Record review of Resident #89's physician order dated 2/10/2025 revealed Resident #89 was to receive one tablet of Metformin 850mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. In an observation on 2/18/2025 at 12:13 p.m., MA A administered eight medications to Resident #89 including Metformin that was ordered to be administered between 7:00 a.m. to 10:00 a.m. The Metformin on the MAR was red on the computer screen. In an interview on 2/19/2025 at 12:32 p.m., MA A stated that he administered medications as scheduled on the MAR and that the medications on the MAR turned red when late. MA A stated he tried to make sure medications were administered during those times. MA A stated it was not right to give those medications too close together. In an interview on 2/20/2025 at 10:05 a.m., MA A stated he did not intentionally give medications late to Resident #28, Resident #74, and Resident #89 on 2/18/2025. MA A stated he was running behind and that did not usually happen. MA A stated he was not sure what the risks to the residents were but that he would not like it if he did not get his medications correctly. In an interview on 2/19/2025 at 12:36 p.m., ADON B stated there was a window on the MAR that indicated medications should have been given between 7:00 a.m. and 10:00 a.m. ADON B stated the medications should be given between those times or the doctor should be called to change the time. ADON B stated that it was possible that if medications were given late that it could affect the resident. Clinical Resource Nurse C was in the room and stated she was responsible for checking the MARs once a week when she was in the building. Clinical Resource Nurse C stated the risk to the residents was that they could experience health problems and the expectation was that medications were administered on time. In an interview on 2/19/2025 at 12:48 p.m., the DON stated staff that administered medications should give medications within the window scheduled. The DON stated the staff had an hour before and an hour after the scheduled times to administer the medications. The DON stated the risks to the residents were that the medications could be given too close together or lead to an adverse event. The DON reported that the nurse management team was responsible for monitoring that medications were administered correctly. In an interview on 2/20/2025 at 1:05 p.m., the MD stated that the medications that were administered late on 2/18/2025 would not cause harm but that he would like them to be administered spaced out. The MD stated his expectation was that the medications were ideally administered as ordered within the window they were scheduled. In an interview on 2/20/2025 at 12:30 p.m., the medication administration and medication error policies were requested from the DON. At the time of exit, the medication error policy was not received. Review of facility policy titled, Medication Administration, with a revision date of 07/2015, revealed It is the policy of this facility that medications shall be administered as prescribed by the attending physician.

Based on observations, interviews and record reviews, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of his or her own personal medical records for 1 (Resident #94) of 2 residents investigated for privacy of medical records. The facility failed to ensure when Resident #93 discharged from the facility Resident #94's Personal Private Information was not handed to Resident #93's Resident's representative. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information. Findings included: Review of an attachment to the complaint intake revealed two pictures of a document that was discerned to be Resident #94's Face Sheet which contained Resident #94's name, birthdate, social security number and all diagnosis. In an interview on 02/14/2025 at 10:21 AM with the resident representative for Resident #93 the resident representative stated that she had been at the facility to assist with the discharge of Resident #93 when she was handed Resident #93's medical/personal records by an unknown staff member. She stated it was not until a few days later that she discovered that the facility had also included Resident #94's face sheet. In an interview on 02/20/2025 at 2:12 PM , the DON stated after reviewing the pictures of the documents in the possession of Resident #93's resident representative that the documents were the Face Sheet for Resident #94. She stated that the incident must have happened two years ago, but that all staff should always be aware of protecting resident information. She stated that they have not had any other similar incidents in the past 12 months that she had been working as the DON at the facility. She stated it was important to protect resident private/medical information or residents could be at risk of psychological or financial harm. Record Review of facility provided policy, Labeled, Protected Health Information (PHI) Management and Protection, date Revised on April 2023, stated: Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. Policy Interpretation and Implementation: 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. Record Review of HIPAA Privacy Laws listed on the Texas Health and Human Services, dated 04/11/2024, online website, at: http://www.hhs.texas.gov/regulations/legal-information/hipaa-privacy-laws, date not listed. Stated: Privacy Rule: The HIPAA privacy rule establishes national standards protecting medical records and other personal health information.

Based observation, interview, and record review, the facility failed to ensure that four (Resident #3, Resident #12, Resident #56, and Resident #58) of fifteen residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure CMA B and LVN N re-ordered medications on a timely manner for Resident #3 (Clopidogrel Bisulfate 75 mg), Resident #12 (Gabapentin capsule 100 mg), Resident #56 (Oxcarbazepine 300 mg) and Resident #58 (Levothyroxine Sodium 25 mcg). This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident # 3 Review of Resident #3's Face Sheet dated 01/19/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non-dominant side and cerebral infarction due to thrombosis (formation of blood clot) of basilar artery (one of the arteries that supplies oxygen to the brain). Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected resident was had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment also indicated cerebral infarction due to thrombosis as one of Resident #3's primary medical condition. Review of Resident #3's Physician Order for clopidogrel bisulfate oral tablet 75 mg dated 06/16/2023 reflected Give 1 tablet by mouth one time a day for CVA related to HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE; CEREBRAL INFARCTION DUE TO THROMBOSIS OF BASILAR ARTERY. Resident #12 Review of Resident #12's Face Sheet dated 01/19/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included low back pain and pain in right upper arm. Review of Resident #12's Quarterly MDS assessment dated [DATE] reflected resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment also indicated neuropathy as one of the additional active diagnosis. Review of Resident #12's Comprehensive Care Plan dated 12/26/2023 reflected resident had chronic pain related to osteoporosis and neuropathy (nerve pain) and one of the interventions was administer analgesia as per order. Review of Resident #12's Physician's Order for gabapentin capsule 100 mg dated 05/25/2023 reflected, Give 1 capsule by mouth one time a day for nerve pain. Resident #56 Review of Resident #56's Face Sheet dated 01/18/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included major depressive disorder and bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows). Review of Resident #56's Quarterly MDS assessment dated [DATE] reflected resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated bipolar disorder as one of Resident #56's primary medical condition. Review of Resident 56's Comprehensive Care Plan dated 12/03/2023 reflected resident had potential for mood problem related to bipolar and one of the interventions was administered medication as ordered. Review of Resident #76's Physician Order for Trileptal Tablet 300 mg (Oxcarbazepine) dated 12/29/2022 reflected Give 1 tablet by mouth three times a day for Bipolar d/o (disorder) related to BIPOLAR DISORDER, UNSPECIFIED. Resident #58 Review of Resident #58's Face Sheet dated 01/18/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic (an illness persisting for a long time or constantly recurring) kidney disease and hypothyroidism (decreased production of thyroid hormones). Review of Resident #58's Quarterly MDS assessment dated [DATE] reflected resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated hypothyroidism as one of Resident #58's primary medical condition. Review of Resident 58's Comprehensive Care Plan dated 01/18/2024 reflected resident potential for complications related to dx of hypothyroidism and one of the interventions was give thyroid replacement therapy as ordered. Review of Resident #58's Physician Order for Levothyroxine Sodium Oral Tablet 25 MCG (Levothyroxine Sodium) dated 09/17/2023 reflected Give 1 tablet by mouth in the morning for hypothyroidism. Observation and interview on 01/18/2024 at starting at 7:44 AM revealed CMA B was preparing the medications of Resident #3. It was noted Resident #3's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for clopidogrel bisulfate oral tablet 75 mg was completely out after CMA B put the last tablet in a small plastic cup. CMA B finished preparing the medications and gave the medications to Resident #3. After giving Resident #3's medication, she started to prepare Resident #12's medication. It was noted Resident #12's blister pack for gabapentin capsule 100 mg only had 3 capsules left. CMA B finished preparing the medications and gave the medications to Resident #12. After giving Resident #12's medication, CMA B started to prepare Resident #56's medication. Resident #56's blister pack for oxcarbazepine 300 mg only had one tablet. CMA B finished preparing the medications and gave the medications to Resident #56. CMA B said she was responsible in re-ordering medication that were running low. CMA B stated the medication should be re-ordered when the medication reached the blue portion of the blister pack. CMA C stated she did not notice the said blister packs were running low. CMA said sometimes she would wait until the medications were midway the blue portion of the blister pack before she would re-order. CMA B said some medications would be automatically re-ordered but said she still need to follow-up if the blister packs were not yet on the cart. CMA B said if medications were not re-ordered on a timely manner, the residents might run out of medications and their present medical situations might worsen. CMA B stated she would re-order the blister packs that were running low. Observation and interview with LVN N on 01/18/2024 starting at 3:21 PM revealed Resident #58's blister pack for levothyroxine 25 mcg only had two tablets. LVN N stated medications should be re-ordered as soon as medications reached the blue portion of the blister pack. LVN N said medications should not be re-ordered on the last minute because the residents will not have sufficient supply of medication in situations that the delivery was delayed. LVN N further added that this could worsen the residents' medical situation. LVN N said she should had checked the cart if there were medications that need to be re-ordered. LVN N said she would re-order Resident #58's medication. Interview with the DON on 01/19/2024 at 7:25 AM, the DON stated the staff must make sure the medications were re-ordered on a timely manner to make certain the residents have the medications they needed. It was not acceptable that residents did not have their medications because the medications were not re-ordered when it was supposed to be re-ordered. The DON said the staff should also follow-up with pharmacy why the needed medications were not yet in the facility. The DON said the expectation was all staff would follow the procedure in re-ordering medications so the residents would not run out of medications that was detrimental to their health. The DON concluded they would make an audit of the carts to see what medications needed re-ordering. Interview with ADON R on 01/19/2024 at 11:50 AM, ADON R stated it was not right that the medications were not re-ordered. ADON R said the nurses and the CMAs were responsible in re-ordering medications when the medications reached the dedicated area. ADON R stated that the medications should be re-ordered in a timely manner to make sure that the residents have enough supply of medications. ADON R said the facility had an e-kit (emergency kit) but the e-kit must be used for emergencies and not because the medications were not re-ordered. ADON R added the residents were taking those medications for a reason and if the residents would not be able to take those medications, it could cause adverse effects to the health of the residents. ADON R concluded she would in-service the staff to remind them the importance of re-ordering medications in a timely manner. Record review of facility policy, Ordering and Receiving Medications FAC19 rev. 11.13.18 revealed Policy: Medications and related products are received . on a timely basis . Procedures . 2. Repeat medications . ordered as follows: . a. Re-order medications (seven) days in advance of need to assure an adequate supply is on hand.

Based on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #14, #15, #55, and #67) of 6 residents reviewed for respiratory care. The facility failed to ensure Resident #14's tubing on his Nebulizer machine was changed within the facility policy of 7 days. The Facility failed to ensure Resident #15's mask and tubing for his BiPAP machine was cleaned and sanitized. The facility failed to ensure Resident #55's nebulizer mask was properly stored and dated. The facility failed to ensure Resident #67's humidifier had water in it. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #14 Record review of Resident #14's face sheet dated 01/18/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnoses included palpitations (irregular heartbeat), and bifascicular block (blockage in heart valve) Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 15 (cognitively intact). The assessment also indicated the resident had an active diagnosis for palpitations and bifascicular block. Record review of Resident #14's Comprehensive Care Plan dated 12/05/23 revealed the resident was care planned for shortness of breath and an intervention included the use of a nebulizer machine. Record review of Resident #14's Physician orders dated 01/18/24 revealed the resident had an active order dated 01/11/2024 to Change Nebulizer Tubing/Mask/Mouthpiece every night shift every Wednesday. In an observation on 01/17/24 at 11:21 AM Resident #14's nebulizer machine reflected the tubing on the machine had no date of when the last change occurred. Resident #15 Record review of Resident #15's face sheet dated 01/18/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included severe obesity, and Obstructive Sleep Apnea (airflow blockage while sleeping) Record review of Resident #15's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 15 (cognitively intact). The assessment also indicated the resident had an active diagnosis for obstructive sleep apnea. Record review of Resident #15's Comprehensive Care Plan dated 11/06/23 revealed the resident was care planned for difficulty breathing and obstructive sleep apnea. Record review of Resident #15's Physician orders dated 01/18/24 revealed the resident had an active order dated 11/2/23 the following active physician order: BiPAP at HS and PRN Setting IPAP AT 12, EPAP at 6 every evening and night shift. Remove in AM Cleanse BiPAP Tubing and Mask every night shift, every Monday In an observation on 01/17/24 at 11:29 AM, Resident #15's BiPAP machine reflected the mask and the tubing on the machine had no date of when the last cleaning occurred. In an observation and interview on 01/18/24 at 09:05 AM with LVN S, she stated she was the day nurse for Resident #15. She stated the Resident did use a Sleep Apnea machine and she stated that the night nurse services the machine, which include cleaning the tubing and ensuring water was in the humidifier. She stated could tell of the machine had been serviced because it would have a date on around the tubing or mask. She looked for a date and could not find one. She stated she could not find a date and was not sure when was the last time it was serviced and had not checked. She stated the risk of the machine not being properly serviced could result in an infection. In an interview on 01/18/24 at 09:10 AM with Resident #15's family member, she stated she just had a care plan meeting with the facility on 01/17/24 to discuss her concerns regarding the resident. She stated she had complained to the Administrator and the DON about his Sleep Apnea machine not being properly serviced. She stated she had concerns about the tubing and his mask not being cleaned at all and she had observed the humidifier empty, and they are not refilling it with distilled water. In an interview on 01/19/24 at 09:59 AM with ADON H, she stated she was the ADON for Resident #14 and Resident #15. She was advised of Resident #14's Nebulizer tubing not being dated and of Resident #15's Sleep Apnea machine not being sanitized. She stated all tubing for respiratory machines are scheduled to be changed out on Wednesday nights by the night nurse and all the nursing staff should be checking for this on Thursday. She stated she thought that all of the Respiratory machines were serviced but they may had missed a few. She stated the risk of the tubing not being changed out could result in an infection. She stated Resident #15 eats a lot of food and used his sleep apnea machine a lot so it gets dirty faster. She stated they had increased his cleaning to be done daily when the machine is not in use. She stated not ensuring the resident mask and tubing are thoroughly clean could result in an infection control. Resident #55 Review of Resident #55's Face Sheet dated 01/18/2024 reflected the resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included mild intermittent asthma and anemia. Review of Resident #55's Quarterly MDS assessment dated [DATE] reflected resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated Resident #55 had asthma as one of the primary medical conditions. Review of Resident #55's Comprehensive Care Plan dated 12/07/2023 reflected resident had asthma and one of the interventions was give medications as ordered. Review of Resident #55's Physician Order dated 11/16/2023 reflected Budesonide 0.5 MG/2ML Suspension. Give 3 ml by mouth two times a day for SOB. Give1 vial via nebulizer. Observation and interview with Resident #55 on 01/17/2024 at 9:46 AM revealed Resident #55 was on her bed with family at bedside. Resident #55's nebulizer was noted sitting on top of the nebulizer machine. The part of the nebulizer mask that touches the face when in use was in contact with the top of the nebulizer machine. Resident #55 said she was on breathing treatment for the longest time because of her breathing problem. Resident #55 said the nurse would put a solution on the container connected to the mask, would turn it on, and put the mask on her. Resident #55 continued the nurse would go out of the room and would sometimes come back to take off the mask and put it on the table. Resident #55 said she was not sure if the nurse was putting it on a bag but she never saw a bag for her nebulizer. The resident said sometimes the nurse would not come back when it was done so she would put the mask on the table. In an interview with RN P on 01/17/2024 at 9:56 AM, RN P said she was familiar with the care of Resident #55. She added Resident #55 had respiratory problems that was why she used a breathing treatment twice a day. RN P said the breathing mask should had been cleaned and bagged after every use to prevent respiratory issues. RN P continued the breathing mask was bagged to prevent contamination. She added the tubing and the mask should be dated to know when they were last changed and when they were supposed to be changed. RN P said she was not aware the mask for the breathing treatment was on the top of the nebulizer machine. She said she would get a new breathing mask and a plastic bag to store it. In an interview with ADON R on 01/18/2024 at 10:29 AM, ADON R said it was not right that the breathing mask was just laying on top of the machine because the top of the breathing machine is not always clean. ADON R said it should not be on top of the nebulizer machine, said it should be bagged, and said it should be dated. ADON R said her expectation was staff would be vigilant in monitoring if the breathing apparatus because they use it to breath in. said this was an infection control issue because the resident might breathe in dirt acquired from the top of the nebulizer machine. ADON R said she would make sure the breathing mask would be changed, bagged, and dated. ADON R stated the nurses were responsible for ensuring the masks were bagged. She said the DON and ADONs were responsible in ensuring the nurses were doing the best practice regarding respiratory care. ADON R said she would do an in-service about respiratory care. Resident #67 Review of Resident #67's Face Sheet dated 01/18/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #67's Quarterly MDS assessment dated [DATE] reflected resident had a moderate cognitive impairment with a BIMS score of 12. The Quarterly MDS Assessment indicated Resident #55 had asthma. Review of Resident #67's Comprehensive Care Plan dated 01/18/2024 reflected the resident had altered respiratory status related to chronic respiratory failure with hypoxia and one of the interventions was provide oxygen as ordered. Review of Resident #67's Physician Order reflected Change & Date All Oxygen Tubing, N/C, Mask, DuoNeb, Humidifier Bottles (If Needed & PRN Through Out Week; Also Remove Concentrator Filter to Clean Then Replace Once Completed. Every night shift every Wed for maintenance related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA. Observation and interview with Resident #67 on 01/18/2024 at 10:32 AM, Resident #67 was on his bed with supplemental oxygen via nasal cannula at 2 liters per minute. The nasal cannula was attached to the humidifier bottle of the oxygen concentrator. The humidifier bottle did not have water on it. Resident #67 said he was feeling just a faint flow of oxygen. Observation and interview with DON on 01/18/2024 at 10:37 AM, the DON went inside Resident #67's room when advised that the humidifier bottle did not have water in it. The DON stated he would get somebody to get some water for the humidifier. The DON said there should water on the humidifier to prevent nasal irritation. The DON said the purpose of the humidifier was to moisten the nasal linings and prevent dryness of the nose, throat, and lips. The DON said the staff should had make sure there was water on the humidifier. Observation and interview with ADON R on 01/18/2024 at 10:44 AM, ADON R entered Resident #67's room with a gallon of distilled water. ADON R detached the humidifier bottle and put some distilled water and attached the humidifier to the oxygen concentrator. ADON R stated the humidifier should had water on it to moisten the nose to prevent nasal dryness and irritation. ADON R said the staff should monitor if the humidifier had water on it. ADON R said she would in-service the staff about respiratory care. In an interview with the DON on 01/19/2024 at 7:25 AM, the DON stated they always make rounds in the morning to check on the rooms of the residents. The DON said the staff must had missed the breathing mask being not bagged and dated. The DON said if the nebulizer mask was just laying around, it could cause infection and the breathing could be compromised. The DON said it should be bagged to prevent the mask being dirty. The DON added it should be dated to monitor when it was last changed. The DON said the expectation was the staff would make sure the breathing apparatus being used were clean to prevent exacerbation of any respiratory issues. The DON said the expectation was the staff to monitor the breathing mask if bagged and dated. Record review of facility's policy, Oxygen Administration, Policy/Procedure - Nursing Services rev. 07/2022 revealed POLICY: It is the policy of this facility that oxygen therapy is administered by licensed nurse as ordered by the physician . PURPOSE: The purpose of the oxygen therapy is to provide sufficient oxygen . will include: 1. That oxygen is to be administered; 2. When and how often oxygen is to be administered; 3. The type of oxygen device to use (i.e., mask, nasal).

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 11 (Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's) of 27 resident rooms observed for housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility failed to ensure that Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Resident #1 and #56's room on 01/17/24 at 10:55 AM revealed the air-condition unit had black dirt stains on the top of the unit and in between the vents. The filter in the unit had a thick dust built-up. The inside main door had white and brown splash stains going down the door. In an interview on 01/17/24 at 10:57 AM with Resident #56, she stated her room had not been cleaned in at least a couple of days, and she stated that housekeeping never cleaned the air-condition unit and she had never observed them cleaning the air filters. She stated she had sinus and allergy problems and the lack of cleanliness of the unit did not help. Observation of Resident #48 and 52's room on 01/17/24 at 11:14 AM revealed the air-condition unit had black dirt stains on the top of the unit and in between the vents. The filter in the unit had a thick dust built-up. Observation of Resident #14 and 23's room on 01/17/24 at 11:19 AM revealed the minifridge in the room had a dark black stain on the outside of the lower bottom door. The inside of the freezer had a brownish stain on the lower shelf of the unit. Observation of Resident #15 and 80's room on 01/17/24 at 11:30 AM revealed the air-condition unit had dark dirt stains on the top of the unit and in between the vents. Resident #15's linen was heavily soiled with reddish stains near the headed the bed and in the middle and lower portion of the bed, the linen was dingy and had dark stains all over the linen. In an interview on 01/17/24 at 11:31 AM with Resident #15, he stated that the facility did not do a good job changing out his linen and they do not do a good job cleaning his sleep apnea machine. He stated his mother had complained to the DON about this before. Observation of Resident #70's room on 01/17/24 at 11:35 AM revealed the air-conditioned unit had dirt particles between the vents and both air filters were missing from unit. Observation of Resident #36 and 51's room on 01/17/24 at 11:59 AM revealed the air-condition unit had dark dirt stains on the top of the unit and in between the vents. Resident #51's living area had over 50 opened sugar packets all over the floor. The wall near Resident #36's bed had a long thin brownish stain. In an interview on 01/19/24 at 02:00 PM with Housekeeping A, she stated had been at the facility for 4 months and she stated she was the housekeeper for Resident #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, and 80's room. She stated they were trained to clean the room from top to bottom to include the walls, floors, refrigerators, bathrooms, the air-conditioned units, and change the linen. She stated the area identified in the observations may had been overlooked. She stated Resident # had an issue with hoarding things like sugar packets and they had a challenging time getting cleaning his area because he always got aggressive and fought with them. She stated anytime she tried to clean his area, she would have to get the nursing staff involved to distract him. She stated not cleaning the areas mentioned could result in an infection. In an interview on 01/19/24 at 02:17 PM with the Housekeeping Supervisor, he stated he had been at the facility almost 7 years. He stated he trained the new housekeeping staff by having them shadow a more experienced worker for three days, and then he placed them on a schedule for specific areas. He stated staff was supposed to clean the air condition filters, which he also serviced every three months. He stated housekeeping was responsible for general cleaning of the air condition unit. He stated housekeeping was supposed to clean the mini fridge in the room and they also threw away any food more than three days old. He stated he was familiar with Resident #51 room and he stated they had to get other nursing staff involved when cleaning his room. He stated he walked around and checked the rooms, especially when he does his Angel rounds, which was supposed to be done daily. He stated Angel rounds consisted of members of the Inter-disciplinary team being assigned rooms to observe daily. He stated they had to check for things like the resident's care and the condition of their environment. He stated if resident rooms are not thoroughly clean, it was an infection control concern. Review of the facility's policy on Environmental Services - Housekeeping (2022) revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 6 (Resident #14, #49, and #63) residents reviewed for restraints. The facility failed to ensure Residents #14 and Resident #63 had physician orders or a physician assessment for a scoop mattress. The facility failed to ensure Resident #49 had physician orders or a physician assessment for a large positioning wedge to be added to her bed. These failures could unnecessarily inhibit the residents' freedom of movement or activity. Findings included: Resident #14 Record review of Resident #14's face sheet dated 01/18/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnosis included Quadriplegia (paralysis of lower extremities) Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 15 (cognitively intact). The resident was totally dependent upon the facility to assist with ADL care. Record review of Resident #14's Comprehensive Care Plan dated 01/13/24 revealed the resident was care planned for having a history of falls, with an unwitnessed fall occurring as recently as 01/07/24. One of the interventions included 1/7/24 Scoop mattress in a place to assist resident in defining the edges. Record review of Resident #14's Physician orders dated 01/18/24 revealed the resident had no active orders for a scoop mattress. Record review of Resident #14's medical record from 02/21/23 to 01/18/24 revealed there was not a physician assessment for a scoop mattress. In an observation on 01/17/24 at 11:21 AM of Resident #14 was observed to have a scoop mattress, which had raised edges. In an interview and observation on 01/18/24 at 09:05 AM with LVN S, she stated that Resident #14 did have a scoop mattress she was unsure of when the resident was supplied the scoop mattress. She stated the resident did have a history of falls, but she was unsure of when the resident has his last fall. She stated she did not know if a physician assessment was completed, and she stated that she did not think physician orders were needed for a scoop mattress. She stated the risk of not completing an assessment to determine if the scoop mattress would pose a risk to the resident, could result in the resident harming himself. Resident #63 Record review of Resident #63's face sheet dated 01/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included Alzheimer (mental function decline) Record review of Resident #63's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 99 (severe cognitive impairment). The resident was totally dependent upon the facility to provide ADL care. Record review of Resident #63's Comprehensive Care Plan dated 01/15/24 revealed the resident was care planned for having a history of falls, and one of the interventions included Bed in lowest position. dtr wants a scoop mattress if avail. Record review of Resident #63's Physician orders from 07/01/22 to 01/18/24 revealed there was not a physician assessment for a scoop mattress. In an observation on 01/17/24 at 11:29 AM Resident #63 was observed to have a scoop mattress, which had raised edges. Resident #49 Record review of Resident #49's face sheet dated 01/18/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included repeated falls, and abnormal posture. Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 00 (severe cognitive impairment). The resident was totally dependent upon the facility to provide ADL care. Record review of Resident #49's Comprehensive Care Plan dated 12/15/23 revealed the resident was care planned for having a risk of pressure ulcers, and one of the interventions included assistance with turning and repositioning the resident to avoid pressure ulcers. Record review of Resident #49's Physician orders from 09/02/20 to 01/18/24 revealed there was not a physician assessment for a scoop mattress. In an observation on 01/17/24 at 11:32 AM Resident #49 was observed to have a positioning wedge on the left side of her body while she was laying on the bed. In an interview and observation on 01/18/24 at 09:05 AM with LVN T, she stated that Resident #63 did have a scoop mattress and she thought that Hospice may had provided the mattress. She stated she was aware that the resident had falls but she was not sure how recently the last fall occurred, and she did not know when the resident first received the mattress. She stated she was unsure if there were physician orders, or an assessment completed prior to the mattress being installed. She stated she thought the resident's family member may had requested the scoop mattress after the resident's last fall. She stated the risk of the resident not having an assessment or physician order could result in the resident injuring herself. In an interview on 01/19/24 at 09:26 AM with ADON R, she stated she was the ADON for the long-term care unit and she was somewhat familiar with Resident #63, but she was unsure if she had a scoop mattress or not. She was advised that the resident was observed laying on a scoop mattress. She stated she was unsure if the resident had orders for the scoop mattress. She went and retrieved her laptop to check, and she stated she could not find any orders for the scoop mattress, but she did see in the resident's care plan where the family had requested a scoop mattress, so they did so at the family's request. She stated she did not think that orders were needed for the scoop mattress, so she did not understand the risk to the resident. She stated there was no assessment completed prior to the scoop mattress being provided to the resident. She stated she was new to the facility and was still learning the facility's process. In an interview on 01/19/24 at 09:59 AM with ADON H, she stated she was the ADON for Resident #14 and Resident #49. She stated both residents did require the equipment and it was care planned. She stated the residents did not have physician orders for the equipment and thought that if it was care planned, it was okay. She stated she thought assessments were done but was not sure. She stated the risk of an assessment not being done could result in the resident getting injured because the proper assessment was not completed. In an interview on 01/19/24 at 11:50 AM with the DON, he stated he did not think physician orders were needed for scoop mattresses or a positioning wedge. He stated he was made aware of the concerns regarding Resident #14 and#63 having scoop mattresses and Resident #49 having a positioning wedge. He stated they discuss adding these types of equipment usage during their Interdisciplinary Team meetings. He stated any assessments should be in the facility's system of records, but he was unsure if any of these residents had one on file. He stated the risk of the residents not having a proper assessment could result in the resident injuring themselves. Record review of facility policy on Restraint/Seclusion, revised March 30. 2022, revealed Chemical/Physical restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, WITH THE EXCEPTION OF TEMPORARY BEHAVIORAL EMERGENCY.

Based on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 3 residents (Residents #1, and #36) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Resident #1, and #36 received showers consistently based on records reviewed for January 2024 and December 2023. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 01/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included amputation below left and right knee. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 14 (cognitively intact). The resident was totally dependent upon the facility to assist with ADL care. Record review of Resident #1's Comprehensive Care Plan dated 01/15/24 revealed the resident was care planned for having ADL self-care performance deficit and the goal for the resident was to maintain current levels function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Records review of Resident #1's Bath/Shower Sheets from 01/01/24 to 01/18/24, revealed the resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. The facility was only able to provide shower sheets for the following dates: 01/06/24: Bed bath 01/10/24: Bed bath 01/14/24: Bed bath In an interview on 01/17/24 at 10:55 AM with Resident #1, she stated she did not receive proper care at the facility and had not had a shower in nearly two weeks and they mainly only gave her bed baths. She stated she had not complained about this because she was scared of retaliation. In an interview on 01/19/24 at 01:11 PM with CNA C, she stated she had been at the facility for four years. She stated she was just filling in for the CNA that normally works the hall. She stated she asked the resident if she wanted showers the two days she worked, and Resident #1 had refused. She stated the first time she did not feel like it and yesterday she had refused and she think she told a nurse. She stated she documented in the PCC that the resident had refused a shower. She stated she thought she was to fill out shower sheet when showers are not given, but she was unsure. She stated that if the resident refused a shower, she notified the nurse. She stated she thought the nurse would go and speak with the resident to try to talk her into getting a shower. She stated she had told the nurse the nurse on Tuesday, 01/17/24, that the resident had refused her shower, but she was unsure if the nurse did anything. She stated if the resident was not getting her showers it could lead to infection and discomfort. In an interview on 01/19/24 at 01:18 PM with LVN D, he stated he had been at the facility for nearly three weeks. He stated he was familiar with Resident #1 and usually worked her hall on Fridays. He stated he was not aware the resident was not receiving her showers, but he saw on her care plan to ensure that she received her showers. He stated there should not be any reason that she did not receive her showers. He stated he did not know her showers days and would have to look it up. He stated the CNAs are required to complete a shower sheet and then turn it into the nurses. He stated if the resident refuses the nurse attempts to persuade the resident and include family to intervene. He stated if residents did not receive her scheduled showers, she could have a skin breakdown. In an interview on 01/19/24 at 02:09 PM with ADON R, she stated she was charge of the hall where Resident #1 resided. She stated the resident was scheduled to receive her showers on Tuesday, Thursdays, and Saturdays. She stated the resident did receive showers and often refuse showers. She stated the CNAs are supposed to complete shower sheets for all residents, whether they received a shower or refused one. She stated if a resident refused a shower, the CNA must notify their hall nurse and the nurse would then try to persuade the resident to take a shower and if the resident still refused, the nurse would notify family member and the resident's physician. She stated she is unsure why the resident had not been receiving her three showers a week. She stated the risk of the resident not getting her scheduled showers could result in skin breakdown. Resident #36 Record review of Resident #36's face sheet dated 01/18/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnosis included acute chronic respiratory failure with hypoxia (heart and lung failure). Record review of Resident #36's Quarterly MDS assessment dated [DATE] revealed the resident had a BIM score of 00 (severe cognitive impairment). The resident was totally dependent upon the facility to assist with ADL care. Record review of Resident #36's Comprehensive Care Plan dated 12/20/23 revealed the resident was care planned for ADL care and was totally dependent upon the facility to assist with needs, including showers. Record review of Resident #36's Physician Orders dated 01/18/24 revealed the resident had physician orders for Hospice care effective 12/18/23. Records review of Resident #36's Bath/Shower Sheets from 01/01/24 to 01/18/24, revealed the resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. The facility was only able to provide shower sheets for the following dates: 01/02/24: Bed bath 01/03/24: Bed bath 01/08/24: Bed bath 01/10/24: Bed bath 01/12/24: Bed bath In an interview on 01/17/24 at 01:20 AM with Resident #36's family members stated they had been trying to get the resident a shower for the past two weeks and had been advised by Hospice that they had to special order a shower chair. They advised they would like for the resident to receive showers and not just bed baths. In an interview and observation on 01/18/24 at 09:05 AM with LVN S, she stated that Resident #36 received hospice services and the showers for the resident were completed by the Hospice Aide. She stated she was unsure why the resident was not receiving his showers when scheduled. She stated if the resident did not receive their scheduled showers, they could have skin breakdown. In an interview with Hospice Executive Director, she stated she was not familiar with Resident #36, but she has spoken with the RN and the aide that provided care to the resident. She stated the aide stated that the correct form was not being completed for the resident every time the aide was visiting the resident, but they had a meeting with the DON on 01/18/24 and was advised that there were no signed forms in the resident's binder. She stated she thought there was a breakdown in communication because the Resident's family members are not on the same page. She was advised that both family members were interviewed, and they had expressed concerns about the resident not receiving any showers and was told that they were waiting for a special chair. She stated she was not aware of any special chair being ordered. She stated she will follow up with the family and the facility. In an interview on 01/19/24 at 11:10 AM with ADON H, she stated that Resident #36 did receive Hospice care and he should have been receiving three showers a week, which was being provided by the Hospice Aide. She was advised that the family and hospice reported that no showers had been given to the resident since he had been at the facility. She stated she was unaware of this and would address the issue. She stated they had shower chairs at the facility, so she is unsure why the family was being told that a specific chair was being required because they had them. She stated the facility was overall responsible for ensuring Hospice care was being provided to the resident. She stated the risk of the resident not getting his showers could result in him developing wound and skin integrity. In an interview on 01/19/24 at 11:50 AM with the DON, he stated Resident #36 received hospice care, but everyone should be involved in the care of the resident. He stated he met with the family weekly and with different family members. He stated he had advised the family member that the resident was a risk for falling out of the shower chair because he moved a lot, so they thought for the time being, a bed bath was the safest way. He stated they also had a shower bed, but the family member did not want to do that. He stated the risk of the resident not getting his shower when scheduled could result in skin breakdown. Record Review of facility policy on Showers, dated 05/2007, revealed It is the policy of the facility to promote cleanliness, stimulate circulation and assist in relaxation. Tasks commonly completed during the bathing process: o Inspect skin, especially those that are showing redness or signs of breakdown o Observe Range of Motion during the bathing process o If discomfort is present, ask the resident to describe and rate the discomfort o Record the procedure in the record

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the freezer was not exposed from air-borne contaminants. The facility failed to ensure the ice machine, located in the facility's kitchen, was thoroughly cleaned. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 01/19/24 from 09:17 AM to 09:21 AM in the facility's only kitchen revealed: o The ice machine, in the facility kitchen revealed the inside door hinges having rust on and inside the hinges. o One gallon container of dill pickle relish, located in the walk-in refrigerator, was dated 9-14 and there was no visible expiration date. o One large box of frozen chicken nuggets, located in the walk-in freezer, was not sealed and was exposed to air-borne contaminants. In an Interview on 01/18/24 at 11:10 AM with the Dietary Manager and Dietician, they stated they both managed the kitchen in the facility. They were both shown the ice machine and the rust along the door hinges, and she stated the cleaning of the ice machine was the responsibility of maintenance and they would notify the Maintenance Director. The Dietitian stated she had observed these concerns earlier in the day and had resolved the issues. She stated the kitchen staff had failed to date the item with the entire date and she discarded the food. The Dietician stated she had corrected the concerns by ensuring the bag of frozen chicken nuggets was sealed. They stated the risk of the concerns not being addressed could result in food-borne illnesses. In an interview on 01/19/24 at 02:17 PM with the Housekeeping Supervisor, he stated that he was responsible for managing both housekeeping and maintenance responsibilities. He stated that maintenance was responsible for cleaning the ice machine in the kitchen. He stated they clean the inside of the ice machine thoroughly once a month with a cleaning agent. He was shown a picture of the inside door hinges having rust on and inside the hinges, and he stated he had observed this and was not sure how to remove it and would have to see if it could be cleaned or need to be replaced. He stated the risk of the concern not being addressed could result in contamination. Record Review of the Facility's policy on Food Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on interview and record review the facility failed to ensure residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 6 residents (Resident #28) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #28 prior to administering Lamictal (medicine to treat seizures and bipolar disorder). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the risk of the medications prescribed. Findings included: Record review of Resident #28's quarterly MDS assessment, dated 12/14/23, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. The resident was understood and able to understand others. The resident's diagnoses included Alzheimer's disease. Record review of the care plans for Resident #33, not dated, revealed no focus areas for the medication Lamictal. Record review of Resident #28's order summary, dated 02/01/23, reflected: Lamictal Tablet 25 MG by mouth at bedtime for bipolar disorder. Record review of Resident #28's Pharmacist Recommendations, dated 10/16/23, reflected: Please ensure informed consent has been obtained and is available in the chart for the following orders: Lamictal - requires consent due to psych diagnosis of bipolar. Record review of Resident #28's electronic medical record on 01/18/24 reflected there was not a consent for Lamictal. An interview on 01/19/24 at 9:52 AM with Resident #28 revealed she was alert and oriented to person, place, and time. She said that she did not know she was taking Lamictal and did not realize the Lamictal was being used to treat bipolar disorder. She said she did not know she had bipolar disorder. An interview on 01/19/24 at 11:28 AM with ADON A revealed she was responsible for reviewing pharmacy recommendations. She said she must have overlooked the pharmacist recommendation to obtain consent for Lamictal for Resident #28. ADON A said there was a risk to the resident's rights if she was not informed about the medication, because she might not want to take the medication. An interview on 01/19/24 at 11:47 AM with the DON for Resident #28 revealed residents were supposed to give consent to receive medications and the ADONs were responsible for ensuring consents were obtained. Record review of the facility policy for Psychoactive Medications Consent, dated July 2014, reflected: .2. The use of psychoactive medication must first be explained to the resident, family member, or legal representative. A consent is to be obtained either from the resident or responsible party if resident unable to give. A verbal consent may be obtained if no responsible person is available. The person obtaining the consent is to sign the consent once obtained.

Based on observation, interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, to include corporal punishment, involuntary seclusion for one (Resident #1) of 7 residents reviewed for resident rights. Facility staff failed to provide necessary care and services for Resident #1 to avoid a preventable injury. CNA C was not competent of Resident #1's ADL limitations and supervision requirements. Resident #1 had diagnoses including one sided paralysis, unsteady gait and severe cognitive impairment with a history of documented falls at the facility. Resident #1 required extensive assistance with bathing and was left alone in the shower room to shower. The resident fell in the shower room when left alone and sustained a fracture of the distal femur requiring hospitalization for further evaluation and treatment. On 05/12/23 at 12:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/14/23, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for not providing necessary care and services to prevent falls with injuries, which could result in severe harm, hospitalization or death. Findings included: Record review of the facility policy, Abuse: Prevention of and Prohibition Against, date revised 10/2022, revealed, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which include, but not limited to the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Record review of Resident #1's Annual MDS Assessment, dated 03/09/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia, atrial fibrillation, hypertension, hyponatremia, hip fracture, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, and hemiplegia. Her BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. Her functional status revealed her self-performance was total dependence and required one-person physical assistance with bathing. Record review of Resident #1's care plan, revised 05/10/23, revealed Has had an actual fall with no injury due to poor balance, unsteady gait on 08/28/21. Fall due to resident trying to get up without help on 11/12/21. Falls on 01/06/22 and 03/05/22 with no injuries. Unwitnessed fall without injury on 09/03/22. Unwitnessed fall with right hip pain and left upper extremity pain on 09/07/22. Unwitnessed fall with right hip pain without injury on 10/14/22. Unwitnessed fall with no known injuries on 12/26/22. Unwitnessed fall with no known injuries on 03/13/23. Unwitnessed fall with a fracture of the distal femur on 05/02/23. Her goal was to resume usual activities without further incident. Her interventions were evaluated in the emergency roiagnom on [DATE] and referral to therapy made upon her return. Her bed in lowest position. Continue interventions on the at-risk plan. Monitor/document /report to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. Her scoop mattress in place. Therapy consults for strength and mobility. 3/7/22 - Therapy consult s/p fall 3/5/22. Review of Resident #1's occupational therapy evaluation and plan of treatment, dated 04/11/23, reflected she required max assistance with bathing. Review of CNA C's trainings revealed she completed Alzheimer's disease and related disorders: behavior and ADL management on 04/13/23. She completed documentation of ADLs training on 04/15/23. She completed abuse, neglect, and exploitation training on 04/16/23. Review of Resident #1's occupation therapy discharge summary, dated 05/02/23, revealed she was not provided services regarding bathing. Review of Resident #1's shower schedule, undated, reflected her shower days were Tuesday, Thursday, and Saturday during the 2:00 PM - 10:00 PM shift. CNA C was responsible for bathing Resident #1 on 05/02/23. Record review of Resident #1's Therapy Consultation/Screen, dated 05/02/23, revealed Patient triggered decline in locomotion on unit and off unit as documented in ADL significant change analysis report on 05/01/23. Patient was currently in physical therapy services under skilled maintenance program. Patient to increase duration of treatment to address decline. Record review of Resident #1's nursing notes, dated 05/02/23, written by LVN A revealed The nurse was called to the shower room by CNA. Upon entering room resident was observed to be lying on the floor in the shower stall in a supine position. Neuros within normal limits. Moves all extremities well. Denies pain. Resident assessed for injuries with no apparent injuries. DON and physician notified of fall. Left message with RP. No acute distress noted. Resident complained of pain in right knee. Right knee edema noted. Physician contacted and x-ray was ordered. Record review of Resident #1's nursing notes, dated 05/02/23 written by RN B, revealed X-ray competed and result shows acute fracture of the distal femur. Physician was notified and gave order to send resident to emergency room . RP was notified. Record review of Resident #1's right knee x-ray, dated 05/02/23, revealed she had a fracture of the distal femur. Record review of Resident #1's Change in Condition note, dated 05/03/23 written by RN B, revealed Fall with fracture to right distal femur. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1 to sustain a fall with fracture, and they reported the incident to HHSC on 05/03/23. The facility also identified measures to prevent a similar occurrence, including in-servicing staff on proper abuse and neglect protocols, update Resident #1's care plan, install new grip tape in shower rooms, the Director of rehab will update special instructions weekly according to current ADL assist status, and DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service staff on proper abuse and neglect protocols. - installed grip tape in all public shower rooms. - Director of rehab will update special instructions weekly according to current ADL assist status. - DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. Interview with DON on 05/10/23 at 7:04 PM revealed CNA C left Resident #1 unattended in the shower room. She sated CNA C needed to remove Resident#1's bed linens. She stated Resident #1 was able to bathe herself but required supervision. She stated CNA's returned to the shower room and found Resident #1 on the ground. She stated Resident #1 was assessed by the nurse. She stated Resident #1 later complained of pain and received an x-ray. She stated the x-ray revealed a fracture of the distal femur. She stated the RP and physician were notified. She stated Resident #1 was sent to the hospital and will not be returning to the facility. She stated after the incident staff were in-serviced regarding residents' bathing needs. She stated CNA C received one-on-one coaching regarding where to find ADL information for residents. She stated she was unaware Resident #1's MDS assessment reflected she was total dependent and required one-person assist with bathing. She stated she refers to occupational therapy ADL notes to determine a resident's bathing needs. She stated she uses each resident's occupational therapy notes to complete the ADL forms. She stated the residents' ADL status was in their EMR dashboard. She stated CNAs were able to access residents' ADL status in the EMR dashboard. She stated the CNAs also had access to ADL forms regarding the residents' ADL status. She stated the CNAs were responsible for reviewing residents' EMR dashboard and ADL forms prior to providing service to the residents. She stated Resident #1's fall was preventable had she received adequate supervision by CNA C. She stated CNA C should have reviewed Resident #1's ADL status prior to providing care. Observation of shower rooms located in the public areas at the facility on 05/10/23 at 8:40 PM revealed a shower stall in shower room Bath 2 did not have grip strips. There was grip strips in shower rooms labeled Bath 1 and Bath 3. Record Review of CNA binder located at the nurse's station near the 100, 200, and 300 halls revealed the 100 hall ADL form for all residents was not in the binder. The ADL forms for the 200, 300, 400, and 500 halls were inaccurate; did not reflect ADL status for all residents at the facility. Interview with CNA C on 05/10/23 at 9:30 PM revealed she and CNA D provided Resident #1 with two-person assistance into a shower chair. She stated CNA D informed her Resident #1 could bath unsupervised in the shower room with the door cracked. She stated she did not have knowledge to check the ADL status in the EMR dashboard or CNA binder. She stated she knew residents were supposed to be supervised while bathing. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she always supervised residents' bathing and did not know why she allowed Resident #1 to bath unsupervised. She stated residents' were supervised during bathing to prevent accidents from happening. She stated once Resident #1 was in the shower room set up help was provided. She stated the shower was turned on for the resident, soap provided, and a towel was provided. She stated she left Resident #1 unsupervised in a shower chair, in the public shower room. She stated she needed to change Resident #1's linens. She stated Resident #1's linens were changed on shower days. She stated when she went back to the shower room the resident was on the floor. She stated she informed LVN A and the resident was assessed. She stated Resident #1 did not complain of pain. She stated Resident #1 was transferred from the floor back to the shower chair and taken to her room. She stated she noticed Resident #1's knee was swollen while lying in bed. She stated she informed LVN A. Interview with CNA D on 05/11/23 at 6:50 AM revealed residents' ADL status was in the CNA binder at both nurse's station. She stated Resident #1 required assistance and supervision with bathing. She stated Resident #1 was not safe when she was left in the shower room unsupervised. She stated Resident #1 was only able to wash her hair and chest without CNA assistance. She stated all residents at the facility require supervision during bathing. She stated on 05/02/23 she assisted CNA C with transferring Resident #1 into a shower chair. She stated she and CNA C took Resident #1 to the shower room. She stated she turned the shower on, provided Resident #1 with soap, and towel. She stated she advised CNA C to stay in the shower room and supervise Resident #1 bathing. She stated she was in-serviced by the ADON regarding residents' ADL needs after the incident regarding Resident #1. She stated she had not previously been in-serviced regarding residents' bathing needs. Interview with Administrator 0n 05/11/23 at 9:07 AM revealed Resident #1 was found on the floor in the shower room by CNA C on 05/02/23. She stated LVN A and DON were immediately notified. She stated LVN A assessed the resident. She stated Resident #1 was transferred back to the shower chair and taken to her room. She stated there was no immediate harm. She stated the physician and RP were notified. She stated 20 minutes after the fall Resident #1 complained of pain and an x-ray was received. She stated the results were not received until 05/03/23. She stated the physician and RP were notified regarding the x-ray results. She stated Resident #1 was sent to the hospital. She stated Resident #1's care plan was updated. She stated after receiving the x-ray results, she investigated the incident to determine if there was immediate danger. She stated staff were in-serviced regarding abuse and neglect. She stated the DON provided one-on-one coaching to CNA C on where to locate ADL assistance information in EMR and the importance of checking ADL status even if familiar with the resident. She stated a shower book was created to include residents' ADL needs. She stated the DON educated staff how to access the special instructions and ADL sheets for the residents. She stated rounds were completed to ensure CNAs were following proper shower procedures. She stated a monitoring tool was created to check staff competency regarding proper shower procedures. She stated herself, DON, and Rehab Director review and updated the residents' special instructions regarding ADL assistance weekly in their EMR. She stated the facility ordered grip strips and placed them in the public showers labeled Bath 1, 2, and 3. She stated grip strips were not added to the private showers in residents' rooms. Interview with the Rehab Director on 05/11/23 at 10:05 AM revealed Resident #1 received occupational therapy from 04/11/23 to 05/03/23. She stated her occupational therapy evaluation revealed Resident #1 required max assistance with bathing. She stated she reviewed the residents' special instructions weekly for skilled residents and when there has been a change regarding non-skilled residents. Interview with Occupational Therapist on 05/11/23 at 11:19 AM revealed she provided occupational services to Resident #1 from 04/11/23 to 05/02/23. She stated Resident #1 needed assistance from staff with bathing. She stated Resident #1 should not have been left alone in the shower from to bathe herself. She stated Resident #1 had good sitting balance but not standing balance. She stated the fall with injury could have been prevented had staff provided adequate supervision to Resident #1. Interview with Maintenance supervisor on 05/11/23 at 11:39 AM revealed grip strips were ordered on 05/04/23. He stated he added the grip strips to the public shower stall floors as a fall protocol. Interview with CNA C on 05/11/23 at 2:15 PM revealed she had provided care to Resident #1 prior to the incident on 05/02/23. She did not specify the type of care provided to Resident #1 in the past. She stated 05/02/23 was the first time she provided bathing assistance to Resident #1. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she was re-educated regarding accessing residents' ADL status using the CNA binder and supervising residents while bathing on 05/02/23. Interview with RP on 05/12/23 at 5:25 PM revealed Resident #1 had been in the hospital since 05/03/23 due to an injury acquired from a fall at the facility. He stated the hospital had not provided a discharge date for Resident #1. He stated the facility informed him she fell in the shower room. He stated Resident #1 informed him a staff member was helping her shower then left her alone in the shower room. He stated Resident #1's injuries could have been prevented had the staff member stayed in the shower room. He stated Resident #1 would not be safe at the facility and not returning to the facility after discharge from the hospital. Record review of the facility policy, Abuse: Prevention of and Prohibition Against, date revised 10/2022, revealed, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This was determined to be an Immediate Jeopardy (IJ) on 05/12/23 at 12:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 12:42 PM. The Facility Plan of Removal was accepted on 05/14/23. The plan of removal reflected: The facility failed to ensure Resident #1 was free of accident hazards. The Resident was left in the shower room unsupervised, fell and sustained a fracture. The facility failed to implement corrective measure identified in the self-report to prevent recurrence. 1. Resident #1 was assessed by the nurse and transferred back to the shower chair. Medical Director was notified of the fall and complaint of pain to right knee. The x-ray showed a fracture to the right distal femur. Medical Director was notified and gave orders to transfer to the hospital. The resident's responsible party was notified, and the resident was sent to the hospital. The resident did not return to the facility as of 5/12/2023, per the family she will transferring from the hospital to another skilled nursing facility. 2. Post investigation the following measures were initiated and included on the self-report. o Self report made to HHSC o Staff training initiated on shower assistance levels, abuse/neglect. o Grip tape was ordered to place on the shower floors. o Documentation was created for the CNA binders for each unit that identifies the level of assistance needed for showers. o Director of Rehab to update special instructions weekly. 3. The Medical Director was notified of IJ on 5/12/2023 at 1:00pm. 4. Training and knowledge checks on abuse and neglect; ADL care in regard to shower assistance levels and supervision; and preventing accidents and hazards was initiated with all staff on 5/12/2023 and will be completed on 5/13/2023 by the DON; ADON; MDS; RN J; RN L; RN M; RN N; RN P; or RN O. The trainings included abuse & neglect; shower supervision / assistance levels; and preventing accidents and used facility policy on abuse and neglect; facility shower policy; and incident and accident policy. 5. This training and knowledge check may be in-person or over the phone with non-clinical staff, in person training will be completed with all nursing staff prior to starting their next shift. Nursing staff will not be allowed to work until they have completed the training and knowledge checks to ascertain competency with DON; ADON; MDS; RN N; RN P; or RN O. This training and knowledge check will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. See attached check forms. 6. An ad hoc meeting regarding items in the IJ template was completed on 5/12/2023 at 2:15pm. Attendees included Administrator; DON; ADON; Medical Director; RN P; RN N. The Plan of removal items and interventions were developed, reviewed, and agreed upon. 7. The bath/shower policy was updated and implemented by DON on 5/3/2023 to include the addition of the CNA binder's documentation that includes shower assistance levels. The CNA Binders , which contains information on all residents, are made accessible to nursing staff on both nursing stations by DON and ADON. The policy was implemented 5/3/2023. Facility policy on abuse/neglect, incident and accidents and bath/showers were reviewed by DON ; Administrator and RN Clinical Resource on 5/12/2023, there were no changes at that time. 8. Grip tape installation was complete and verified on 5/12/2023. 9. All residents could have been affected by the alleged deficient practice. Currently there are 71 residents living in the facility. An audit of shower assistance levels was completed for all residents. The shower assistance sheets and OT evaluation documentation in EMR were compared by DON and Rehab Director. There were no additional residents identified, all were found to have the appropriate shower assistance levels documented in the CNA Binders. This information was added to the Care Profile and all care plans updated. Fall assessments were completed for all residents and their care plans updated as necessary. 10. DON; ADON; MDS or RN Clinical Resource will monitor 5 nursing staff weekly for shower assistance level knowledge. 11. Shower assistance levels are updated in the CNA binder by DON; ADON; or RN N twice weekly and with change in condition. Shower assistance levels were added to the resident Care Profile 5/12/2023 and will be reviewed during the weekly clinical meeting. 12. Residents at risk for falls and resident shower assistance levels will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Knowledge checks will be completed with 10 staff weekly by DON; ADON; MDS or RN N; RN P; or RN O, beginning 5/12/2023 with initial knowledge check and again on 5/13/2023 and will be on-going throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect.The clinical knowledge checkincludes questions onabuse and neglect definitions,abuse coordinator, when should incidents be reported, examples of abuse and neglect,shower assistance needed, CNA Binder. If competency via the knowledge check form cannot be ascertained, the staff member will be removed from their work duties immediately and retrained and/or receive disciplinary action accordingly. 13. Daily review of incidents and accidents will be completed by DON; ADON; and Administrator, beginning 5/13/2023. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Administrator will monitor CNA shower binders weekly to ensure accurate levels of assistance are documented. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Weekly clinical meetings will include review of residents at risk of falls and shower assistance levels/CNA Binders and review of the Care Profile. Meeting attendees will include DON; ADON; MDS and Administrator. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 16. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 17. Follow up on IJ Plan of Removal and monitoring will be verified by DON and Administrator by review of residents at risk of falls and shower assistance levels during the weekly clinical meeting, review of staff knowledge checks obtained throughout the week, and the weekly QAPI meeting. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports from 05/12/23 and 05/13/23 revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff were in-serviced regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Record review of facility competency test, undated, revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff completed quizzes regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Observation of the facility's public shower rooms on 05/13/23 at 3:32 PM revealed grip tape was placed in the showers located in Bath 1, 2, and 3. Record review of the CNA Binders located at the nurse's station for halls 100, 200, and 300 revealed shower ADLs had been updated for all residents. Record review of the CNA Binders located at the nurse's station for halls 400, 500, and 600 revealed shower ADLs had been updated for all residents. Interviews were conducted on 05/12/23 through 05/14/23 with CNA F, CNA G, CNA H, LVN I, and RN K across all three shifts, the weekend, PRN staff, and agency staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Interview with the Director of Rehab on 05/14/23 at 3:26 PM revealed her responsibilities regarding the plan of removal was the special instructions and ADL care instructions. She stated she did a review of all the charts. She stated she updated any instructions that needed to be updated. She stated she will complete weekly audits. Interview with the Director of Rehab on 05/14/23 at 3:30 PM revealed her responsibilities regarding the plan of removal were weekly knowledge checks, observing showers, following ADLs listed in CNA binder. She stated she must complete five observations a week and ten knowledge check a week. She stated if the staff do not pass the knowledge checks, they cannot work with the resident. Interview with RN J on 05/14/23 at 3:34 PM revealed her responsibilities regarding the plan of removal was providing education and in-servicing. She stated the task would be ongoing. She stated she did abuse, neglect, shower supervision, assistance levels, preventing accidents, and using facility policies in-servicing with staff. Interview with RN L on 05/14/23 at 3:45 PM revealed her responsibilities regarding the plan of removal was in-servicing staff. Interview with RN M on 05/14/23 at 3:47 PM revealed her responsibilities regarding the plan of removal was completing training with staff. She stated she was the companies educator. She stated training will continuously be done. Interview with RN N on 05/14/23 at 3:50 PM revealed her responsibilities regarding the plan of removal was education; abuse, neglect, incident/accident, showers/ADLs. He stated he educated non-clinical staff too. He stated training will be on-going. Interview with RN J on 05/14/23 at 4:08 PM revealed her responsibilities regarding the plan of removal was knowledge checks and will be ongoing. Interview with DON on 05/14/23 at 4:20 PM revealed her responsibilities regarding the plan of removal was to check CNA binders every new admission, every Monday, and Friday with the Rehab Director to see if any occupational therapy ADLs changed, ten knowledge checks, 5 visual checks a week to ensure competency, and continue to educate new agency staff. Interview with Administrator on 05/13/23 at 5:12 PM revealed the IJ occurred due to the information provided in the IJ template and per the plan of removal. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. She stated the DON monitored their staff. She stated she monitored the Don to ensure they had completed their tasks per plan of removal, incident and accident report monitored, overseeing the in-servicing and check offs, weekly QAPI updated, and made sure there were weekly meetings and daily meetings. Interview with the DON on 5/14/23 at 5:02 PM revealed, she supervised her staff by watching them complete the showers in person. She stated she was going to complete five random audits to ensure appropriate ADL levels were completed. She stated the IJ occurred due to the facility failing to ensure accurate safety measures for the dependent resident in the shower room. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. Interview with Medical Director on 05/17/22 at 9:20 AM revealed, he was notified on 05/02/23 regarding Resident #1's fall and injury. He stated he was informed the facility received an IJ due to Resident #1 not being supervised in the shower, lack of training with staff, and Resident #1's needs were not communicated. He stated his expectation for staff was to be better trained and to communicate better with residents due to language barriers. He stated there would be more QAPI meetings. He stated the facility needed to train staff. The facility's Administrator was informed the Immediate Jeopardy was removed on 05/14/23 at 6:06 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for accidents and supervision. CNA A failed to provide supervision for Resident #1, who was identified in her MDS Assessment as being totally dependent upon staff with one person assist, while Resident #1 was in the shower. Resident #1 subsequently fell and was found alone on the floor in the shower room. X rays were completed and indicated Resident #1 sustained injury including a fracture of the distal femur(thighbone fracture). She was sent to the hospital for further evaluation and treatment; she did not return to the facility . On 05/12/23 at 12:30 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/14/23, the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for inadequate supervision and assistance from staff which may cause falls with injuries resulting in severe harm, hospitalization and/or death. Findings included: Record review of Resident #1's Annual MDS Assessment, dated 03/09/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia, atrial fibrillation, hypertension, hyponatremia, hip fracture, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, and hemiplegia. Her BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. Her functional status revealed her self-performance was total dependance and required one-person physical assistance with bathing. Record review of Resident #1's care plan, revised 05/10/23, revealed Has had an actual fall with no injury due to poor balance, unsteady gait on 08/28/21. Fall due to resident trying to get up without help on 11/12/21. Falls on 01/06/22 and 03/05/22 with no injuries. Unwitnessed fall without injury on 09/03/22. Unwitnessed fall with right hip pain and left upper extremity pain on 09/07/22. Unwitnessed fall with right hip pain without injury on 10/14/22. Unwitnessed fall with no known injuries on 12/26/22. Unwitnessed fall with no known injuries on 03/13/23. Unwitnessed fall with a fracture of the distal femur on 05/02/23. Her goal was to resume usual activities without further incident. Her interventions were evaluation in the emergency roiagnom on [DATE] and referral to therapy made upon her return. Her bed in lowest position. Continue interventions on the at-risk plan. Monitor/document /report to MD for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks as ordered. Her scoop mattress in place. Therapy consults for strength and mobility. 3/7/22 - Therapy consult s/p fall 3/5/22. Review of Resident #1's occupational therapy evaluation and plan of treatment, dated 04/11/23, reflected she required max assistance with bathing. Review of CNA C's trainings revealed she completed Alzheimer's disease and related disorders: behavior and ADL management on 04/13/23. She completed documentation of ADLs training on 04/15/23. She completed abuse, neglect, and exploitation training on 04/16/23. Review of Resident #1's occupation therapy discharge summary, dated 05/02/23, revealed she was not provided services regarding bathing. Review of Resident #1's shower schedule, undated, reflected her shower days were Tuesday, Thursday, and Saturday during the 2:00 PM - 10:00 PM shift. CNA C was responsible for bathing Resident #1 on 05/02/23. Record review of Resident #1's Therapy Consultation/Screen, dated 05/02/23, revealed Patient triggered decline in locomotion on unit and off unit as documented in ADL significant change analysis report on 05/01/23. Patient was currently in physical therapy services under skilled maintenance program. Patient to increase duration of treatment to address decline. Record review of Resident #1's nursing notes, dated 05/02/23, revealed The nurse was called to the shower room by CNA. Upon entering room resident was observed to be lying on the floor in the shower stall in a supine position. Neuros within normal limits. Moves all extremities well. Denies pain. Resident assessed for injuries with no apparent injuries. DON and physician notified of fall. Left message with RP. No acute distress noted. Resident complained of pain in right knee. Right knee edema noted. Physician contacted and x-ray was ordered. The nurse's note was written by LVN A. Record review of Resident #1's nursing notes, dated 05/02/23, revealed X-ray competed and result shows acute fracture of the distal femur. Physician was notified and gave order to send resident to emergency room . RP was notified. The nurse's note was written by RN B. Record review of Resident #1's right knee x-ray, dated 05/02/23, revealed she had a fracture of the distal femur. Record review of Resident #1's Change in Condition note, dated 05/03/23, revealed Fall with fracture to right distal femur. The nurse's note was written by RN B. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1 to sustain a fall with fracture, and they reported the incident to HHSC on 05/03/23. The facility also identified measures to prevent a similar occurrence, including in-servicing staff on proper abuse and neglect protocols, update Resident #1's care plan, install new grip tape in shower rooms, the Director of rehab will update special instructions weekly according to current ADL assist status, and DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service staff on proper abuse and neglect protocols. - installed grip tape in all public shower rooms. - Director of rehab will update special instructions weekly according to current ADL assist status. - DON/designee will monitor proper shower procedures and documentation of ADLs on three residents weekly for 4 weeks. Interview with DON on 05/10/23 at 7:04 PM revealed CNA C left Resident #1 unattended in the shower room. She sated CNA C needed to remove Resident#1's bed linens. She stated Resident #1 was able to bathe herself but required supervision. She stated CNA's returned to the shower room and found Resident #1 on the ground. She stated Resident #1 was assessed by the nurse. She stated Resident #1 later complained of pain and received an x-ray. She stated the x-ray revealed a fracture of the distal femur. She stated the RP and physician were notified. She stated Resident #1 was sent to the hospital and will not be returning to the facility. She stated after the incident staff were in-serviced regarding residents' bathing needs. She stated CNA C received one-on-one coaching regarding where to find ADL information for residents. She stated she was unaware Resident #1's MDS assessment reflected she was total dependent and required one-person assist with bathing. She stated she refers to occupational therapy ADL notes to determine a resident's bathing needs. She stated she uses each resident's occupational therapy notes to complete the ADL forms. She stated the residents' ADL status was in their EMR dashboard. She stated CNAs were able to access residents' ADL status in the EMR dashboard. She stated the CNAs also had access to ADL forms regarding the residents' ADL status. She stated the CNAs were responsible for reviewing residents' EMR dashboard and ADL forms prior to providing service to the residents. She stated Resident #1's fall was preventable had she received adequate supervision by CNA C. She stated CNA C should have reviewed Resident #1's ADL status prior to providing care. Observation of shower rooms located in the public areas at the facility on 05/10/23 at 8:40 PM revealed a shower stall in shower room Bath 2 did not have grip strips. Record Review of CNA binder located at the nurse's station near the 100, 200, and 300 halls revealed the 100 hall ADL form was not in the binder. The ADL forms for the 200, 300, 400, and 500 halls were inaccurate; did not reflect ADL status for all residents at the facility. Interview with CNA C on 05/10/23 at 9:30 PM revealed she and CNA D provided Resident #1 with two-person assistance into a shower chair. She stated CNA D informed her Resident #1 could bath unsupervised in the shower room with the door cracked. She stated she did not have knowledge to check the ADL status in the EMR dashboard or CNA binder. She stated she knew residents were supposed to be supervised while bathing. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she always supervised residents' bathing and did not know why she allowed Resident #1 to bath unsupervised. She stated residents' were supervised during bathing to prevent accidents from happening. She stated once Resident #1 was in the shower room set up help was provided. She stated the shower was turned on for the resident, soap provided, and a towel was provided. She stated she left Resident #1 unsupervised in a shower chair, in the public shower room. She stated she needed to change Resident #1's linens. She stated Resident #1's linens were changed on shower days. She stated when she went back to the shower room the resident was on the floor. She stated she informed LVN A and the resident was assessed. She stated Resident #1 did not complain of pain. She stated Resident #1 was transferred from the floor back to the shower chair and taken to her room. She stated she noticed Resident #1's knee was swollen while lying in bed. She stated she informed LVN A. Interview with CNA D on 05/11/23 at 6:50 AM revealed residents' ADL status was in the CNA binder at both nurse's station. She stated Resident #1 required assistance and supervision with bathing. She stated Resident #1 was not safe when she was left in the shower room unsupervised. She stated Resident #1 was only able to wash her hair and chest without CNA assistance. She stated all residents at the facility require supervision during bathing. She stated on 05/02/23 she assisted CNA C with transferring Resident #1 into a shower chair. She stated she and CNA C took Resident #1 to the shower room. She stated she turned the shower on, provided Resident #1 with soap, and towel. She stated she advised CNA C to stay in the shower room and supervise Resident #1 bathing. She stated she was in-serviced by the ADON regarding residents' ADL needs after the incident regarding Resident #1. She stated she had not previously been in-serviced regarding residents' bathing needs. Interview with Administrator 0n 05/11/23 at 9:07 AM revealed Resident #1 was found on the ground in the shower room by CNA C on 05/02/23. She stated LVN A and DON were immediately notified. She stated LVN A assessed the resident. She stated Resident #1 was transferred back to the shower chair and taken to her room. She stated there was no immediate harm. She stated the physician and RP were notified. She stated 20 minutes after the fall Resident #1 complained of pain and an x-ray was received. She stated the results were not received until 05/03/23. She stated the physician were and RP were notified regarding the x-ray results. She stated Resident #1 was sent to the hospital. She stated Resident #1's care plan was updated. She stated after receiving the x-ray results, she investigated the incident to determine if there was immediate danger. She stated staff were in-serviced regarding abuse and neglect. She stated the DON provided one-on-one coaching to CNA C on where to locate ADL assistance information in EMR and the importance of checking ADL status even if familiar with the resident. She stated a shower book was created to include residents' ADL needs. She stated the DON educated staff how to access the special instructions and ADL sheets for the residents. She stated rounds were completed to ensure CNAs were following proper shower procedures. She stated a monitoring tool was created to check staff competency regarding proper shower procedures. She stated herself, DON, and Rehab Director review and updated the residents' special instructions regarding ADL assistance weekly in their EMR. She stated the facility ordered grip strips and placed them in the public showers labeled Bath 1, 2, and 3. She stated grip strips were not added to the private showers in residents' rooms. Interview with the Rehab Director on 05/11/23 at 10:05 AM revealed Resident #1 received occupational therapy from 04/11/23 to 05/03/23. She stated her occupational therapy evaluation revealed Resident #1 required max assistance with bathing. She stated she reviewed the residents' special instructions weekly for skilled residents and when there has been a change regarding non-skilled residents. Interview with Occupational Therapist on 05/11/23 at 11:19 AM revealed she provided occupational services to Resident #1 from 04/11/23 to 05/02/23. She stated Resident #1 needed assistance from staff with bathing. She stated Resident #1 should not have been left alone in the shower from to bathe herself. She stated Resident #1 had good sitting balance but not standing balance. She stated the fall with injury could have been prevented had staff provided adequate supervision to Resident #1. Interview with Maintenance supervisor on 05/11/23 at 11:39 AM revealed grip strips were ordered on 05/04/23. He stated he added the grip strips to the public shower stall floors as a fall protocol. Interview with CNA C on 05/11/23 at 2:15 PM revealed she had provided care to Resident #1 prior to the incident on 05/02/23. She did not specify the type of care provided to Resident #1 in the past. She stated 05/02/23 was the first time she provided bathing assistance to Resident #1. She stated she was in-serviced during new hire orientation regarding accessing the EMR for resident ADL requirements. She stated she was re-educated regarding accessing residents' ADL status using the CNA binder and supervising residents while bathing on 05/02/23. Interview with RP on 05/12/23 at 5:25 PM revealed Resident #1 had been in the hospital since 05/03/23 due to an injury acquired from a fall at the facility. He stated the hospital had not provided a discharge date for Resident #1. He stated the facility informed him she fell in the shower room. He stated Resident #1 informed him a staff member was helping her shower then left her alone in the shower room. He stated Resident #1's injuries could have been prevented had the staff member stayed in the shower room. He stated Resident #1 would not be safe at the facility and not returning to the facility after discharge from the hospital. Record review of the facility policy, Change of Condition Notification, dated 06/2020, revealed, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to: an injury/accident; a significant change in the resident's physical, cognitive, behavioral or functional status; a significant change in treatment; and/or a decision to transfer or discharge the resident from the facility. This was determined to be an Immediate Jeopardy (IJ) on 05/12/23 at 12:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/28/22 at 12:42 PM. The Facility Plan of Removal was accepted on 05/14/23. The plan of removal reflected: The facility failed to ensure Resident #1 was free of accident hazards. The Resident was left in the shower room unsupervised, fell and sustained a fracture. The facility failed to implement corrective measure identified in the self-report to prevent recurrence. 1. Resident #1 was assessed by the nurse and transferred back to the shower chair. Medical Director was notified of the fall and complaint of pain to right knee. The x-ray showed a fracture to the right distal femur. Medical Director was notified and gave orders to transfer to the hospital. The resident's responsible party was notified, and the resident was sent to the hospital. The resident did not return to the facility as of 5/12/2023, per the family she will transferring from the hospital to another skilled nursing facility. 2. Post investigation the following measures were initiated and included on the self-report. o Self report made to HHSC o Staff training initiated on shower assistance levels, abuse/neglect. o Grip tape was ordered to place on the shower floors. o Documentation was created for the CNA binders for each unit that identifies the level of assistance needed for showers. o Director of Rehab to update special instructions weekly. 3. The Medical Director was notified of IJ on 5/12/2023 at 1:00pm. 4. Training and knowledge checks on abuse and neglect; ADL care in regard to shower assistance levels and supervision; and preventing accidents and hazards was initiated with all staff on 5/12/2023 and will be completed on 5/13/2023 by the DON; ADON; MDS; RN J; RN L; RN M; RN N; RN P; or RN O. The trainings included abuse & neglect; shower supervision / assistance levels; and preventing accidents and used facility policy on abuse and neglect; facility shower policy; and incident and accident policy. 5. This training and knowledge check may be in-person or over the phone with non-clinical staff, in person training will be completed with all nursing staff prior to starting their next shift. Nursing staff will not be allowed to work until they have completed the training and knowledge checks to ascertain competency with DON; ADON; MDS; RN N; RN P; or RN O. This training and knowledge check will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. See attached check forms. 6. An ad hoc meeting regarding items in the IJ template was completed on 5/12/2023 at 2:15pm. Attendees included Administrator; DON; ADON; Medical Director; RN P; RN N. The Plan of removal items and interventions were developed, reviewed, and agreed upon. 7. The bath/shower policy was updated and implemented by DON on 5/3/2023 to include the addition of the CNA binder's documentation that includes shower assistance levels. The CNA Binders , which contains information on all residents, are made accessible to nursing staff on both nursing stations by DON and ADON. The policy was implemented 5/3/2023. Facility policy on abuse/neglect, incident and accidents and bath/showers were reviewed by DON ; Administrator and RN Clinical Resource on 5/12/2023, there were no changes at that time. 8. Grip tape installation was complete and verified on 5/12/2023. 9. All residents could have been affected by the alleged deficient practice. Currently there are 71 residents living in the facility. An audit of shower assistance levels was completed for all residents. The shower assistance sheets and OT evaluation documentation in EMR were compared by DON and Rehab Director. There were no additional residents identified, all were found to have the appropriate shower assistance levels documented in the CNA Binders. This information was added to the Care Profile and all care plans updated. Fall assessments were completed for all residents and their care plans updated as necessary. 10. DON; ADON; MDS or RN Clinical Resource will monitor 5 nursing staff weekly for shower assistance level knowledge. 11. Shower assistance levels are updated in the CNA binder by DON; ADON; or RN N twice weekly and with change in condition. Shower assistance levels were added to the resident Care Profile 5/12/2023 and will be reviewed during the weekly clinical meeting. 12. Residents at risk for falls and resident shower assistance levels will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Knowledge checks will be completed with 10 staff weekly by DON; ADON; MDS or RN N; RN P; or RN O, beginning 5/12/2023 with initial knowledge check and again on 5/13/2023 and will be on-going throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. The knowledge checks for non-clinical includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect. The clinical knowledge check includes questions on abuse and neglect definitions, abuse coordinator, when should incidents be reported, examples of abuse and neglect, shower assistance needed, CNA Binder. If competency via the knowledge check form cannot be ascertained, the staff member will be removed from their work duties immediately and retrained and/or receive disciplinary action accordingly. 13. Daily review of incidents and accidents will be completed by DON; ADON; and Administrator, beginning 5/13/2023. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Administrator will monitor CNA shower binders weekly to ensure accurate levels of assistance are documented. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Weekly clinical meetings will include review of residents at risk of falls and shower assistance levels/CNA Binders and review of the Care Profile. Meeting attendees will include DON; ADON; MDS and Administrator. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 16. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 17. Follow up on IJ Plan of Removal and monitoring will be verified by DON and Administrator by review of residents at risk of falls and shower assistance levels during the weekly clinical meeting, review of staff knowledge checks obtained throughout the week, and the weekly QAPI meeting. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports from 05/12/23 and 05/13/23 revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff were in-serviced regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Record review of facility competency test, undated, revealed CNA F, CNA G, CNA H, LVN I, RN k and staff across all three shifts, the weekend, PRN staff, and agency staff completed quizzes regarding incident prevention, abuse and neglect, incident/accident, and ADL care. Observation of the facility's public shower rooms on 05/13/23 at 3:32 PM revealed grip tape was placed in the showers located in Bath 1, 2, and 3. Record review of the CNA Binders located at the nurse's station for halls 100, 200, and 300 revealed shower ADLs had been updated for all residents. Record review of the CNA Binders located at the nurse's station for halls 400, 500, and 600 revealed shower ADLs had been updated for all residents. Interview with the Director of Rehab on 05/14/23 at 3:26 PM revealed her responsibilities regarding the plan of removal was the special instructions and ADL care instructions. She stated she did a review of all the charts. She stated she updated any instructions that needed to be updated. She stated she will complete weekly audits. Interview with the Director of Rehab on 05/14/23 at 3:30 PM revealed her responsibilities regarding the plan of removal were weekly knowledge checks, observing showers, following ADLs listed in CNA binder. She stated she must complete five observations a week and ten knowledge check a week. She stated if the staff do not pass the knowledge checks, they cannot work with the resident. Interview with RN J on 05/14/23 at 3:34 PM revealed her responsibilities regarding the plan of removal was providing education and in-servicing. She stated the task would be ongoing. She stated she did abuse, neglect, shower supervision, assistance levels, preventing accidents, and using facility policies in-servicing with staff. Interview with RN L on 05/14/23 at 3:45 PM revealed her responsibilities regarding the plan of removal was in-servicing staff. She stated she did not know what the plan was going forward. Interview with RN M on 05/14/23 at 3:47 PM revealed her responsibilities regarding the plan of removal was completing training with staff. She stated she was the companies educator. She stated training will continuously be done. Interview with RN N on 05/14/23 at 3:50 PM revealed her responsibilities regarding the plan of removal was education; abuse, neglect, incident/accident, showers/ADLs. He stated he educated non-clinical staff too. He stated training will be on-going. Interview with RN J on 05/14/23 at 4:08 PM revealed her responsibilities regarding the plan of removal was knowledge checks and will be ongoing. Interview with DON on 05/14/23 at 4:20 PM revealed her responsibilities regarding the plan of removal was to check CNA binders every new admission, every Monday, and Friday with the Rehab Director to see if any occupational therapy ADLs changed, ten knowledge checks, 5 visual checks a week to ensure competency, and continue to educate new agency staff. Interview with Administrator on 05/13/23 at 5:12 PM revealed the IJ occurred due to the information provided in the IJ template per the plan of removal. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. She stated the DON monitored their staff. She stated she monitored the Don to ensure they had completed their tasks per plan of removal, incident and accident report monitored, overseeing the in-servicing and check offs, weekly QAPI updated, and made sure there were weekly meetings and daily meetings. Interview with the DON on 5/14/23 at 5:02 PM revealed, she supervised her staff by watching them complete the showers in person. She stated she was going to complete five random audits to ensure appropriate ADL levels were completed. She stated the IJ occurred due to the facility failing to ensure accurate safety measures for the dependent resident in the shower room. She stated the acceptance of the plan of removal will prevent the reoccurrence of the IJ; such as completing trainings and knowledge checks with staff, ad hoc meeting regarding IJ templates with Medical Director, following the Medical Directors recommendations, keep ADL sheets updated, ensure ADL sheets were in the CNA binder, grip tape installed and verified in shower rooms, audit shower ADL sheets to ensure currency, DON/ADON/MDS nurse/Clinical Resource Nurse provide shower ADL knowledge to staff, review fall risk residents and ADLs weekly, daily review of the incident and accidents, weekly QAPI meetings, weekly clinical meetings, summary of IJ reviewed weekly by QAPI, herself and DON will follow up regarding Plan of removal weekly. She stated she supervises her staff to ensure policies/procedures are being followed. She stated she make sure she has staff to train them. She stated she made her number accessible for staff to report. She stated as the abuse coordinator she educated staff. She stated she would have the DON train staff regarding supervision and ADLs. She stated observations and interviews, resident council regarding grievances, reviewing incidents, and high-risk clinical meeting weekly. Interview with Medical Director on 05/17/22 at 9:20 AM revealed, he was notified on 05/02/23 regarding Resident #1's fall and injury. He stated he was informed the facility received an IJ due to Resident #1 not being supervised in the shower, lack of training with staff, and Resident #1's needs were not communicated. He stated his expectation for staff was to be better trained and to communicate better with residents due to language barriers. He stated there would be more QAPI meetings. He stated the facility needed to train staff. The facility's Administrator was informed the Immediate Jeopardy was removed on 05/14/23 at 6:06 PM. The facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to honor the resident's right to refuse treatment for 1 (Resident #100) of 18 residents reviewed for advanced directives. The facility failed to ensure Resident #100's updated code status was documented in her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #100 and witnessed by facility staff. The facility uploaded the form into the electronic charting system but failed to ensure her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #100 experienced a change in condition and was sent to the hospital via 911 EMS. The paramedics were provided with Resident #100's incorrect orders which stated she was Full Code status. On the way to the hospital, Resident #100 went into [CONDITION(S)]. She received treatment from EMS and the hospital including CPR, AED, and intubation/ventilation. This continued until Resident #100's family member advised hospital staff of her DNR status; she was then pronounced deceased . An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be a past noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure placed residents with a DNR status at risk of not having their wishes known, respected, and implemented in an emergency. Findings included: Review of Resident #100's MDS Assessment, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #100's MDS Assessment reflected she had severely impaired cognition. Review of Resident #100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was listed as active with a start date of [DATE]. Review of Resident #100's Out of Hospital Do Not Resuscitate (OOH-DNR) Order form, dated [DATE], reflected Resident #100's family member completed the form. The form was signed by witnesses Receptionist L and Receptionist M, and it was also signed by Resident #100's physician. Review of Resident #100's Progress Notes, dated [DATE] at 4:48AM and signed by LVN D, reflected, .Resident noted awake but unresponsive during routine rounds. SpO2 at 73%. MD notified and order received to send resident to hospital. 911 called while another nurse administers oxygen at 3 lpm per n/c, and city paramedics arrive within 4 minutes. Resident's [family member] notified and states she will wait for resident at the hospital. Resident transferred on stretcher to [hospital] . Review of Fire Department EMS records, dated [DATE], reflected Resident #100 received the following care and treatments: .Applied BVM to [patient] to assist respirations ., .Inserted [NAME] 4 [a supraglottic airway device] and continued bagging ., .placed I/O in [left] humerus and gave NS ., .while enroute, we were unable to find [patient] pulse and began CPR ., .Passed resuscitation efforts to ER staff. Found that [patient's family member] was in ER waiting room and she told staff [patient] was DNR. Efforts were stopped . Review of Resident #100's hospital records, dated [DATE], reflected, .Per EMS, patient was short of breath but upon arrival at the facility, patient was noted to have agonal respirations [an abnormal breathing pattern originating from lower brainstem neurons and characterized by labored breaths, gasping, and, often, [CONDITION(S)] and grunting] with a faint pulse. No bystander intervention was initiated. Patient was in PEA [pulseless electrical activity, which was a clinical condition characterized by unresponsiveness and the lack of a palpable pulse in the presence of organized cardiac electrical activity] and asystole [no electricity or movement in her heart, i.e. flatline] very soon after arrival at the facility and CPR was initiated by EMS . Resident #100's hospital records also reflected, .CPR in progress upon arrival to the ED. Patient given 2 rounds of [MEDICATION(S)] and 1 dose of [MEDICATION(S)] with response. After intubation, patient's [family member] stated that the patient was DNR status . Resident #100's family member notified the hospital of Resident #100's DNR status on [DATE] at 5:22AM, and Resident #100's time of death was pronounced on [DATE] at 5:23AM. Review of the facility's Provider Investigation Report, dated [DATE], reflected Resident #100's family member contacted the facility and voiced concern regarding Resident #100's listed code status at the time of her death on [DATE]. Resident #100's family member stated she remembered signing an Out of Hospital DNR form for Resident #100, but the facility had Resident #100 listed as Full Code on her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Out of Hospital DNR form was scanned into the facility's electronic charting system; however, Resident #100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She remained listed as Full Code. Because of this, Resident #100 was provided with life-saving measures following being sent out to the hospital for a change in condition. Upon being made aware of the allegation by Resident #100's family member, the facility initiated a self-report to HHSC and notified both the Ombudsman and the Medical Director. The facility completed an audit of all residents' code statuses with no additional discrepancies noted. The facility initiated their Quality Assurance process. Staff members were in-serviced on abuse/neglect and code status protocol. During an interview with the Administrator on [DATE] at 2:21PM, he stated he investigated the incident involving Resident #100. He said Resident #100's family member reached out to the facility in late August or early September of 2021 and requested medical records regarding Resident #100's death on [DATE]. Resident #100's family member voiced that Resident #100 had a DNR status in place, but Full Code protocol was initiated on her. The Administrator said he looked into the concern and found that Resident #100 was sent out to the hospital following a change in condition on [DATE]. At the time she was sent out, she was breathing on her own and no life-saving interventions were put in place by facility staff. Resident #100's family and the Medical Director were notified of the transfer to the hospital. According to Resident #100's family member, when Resident #100 got to the hospital, either EMS staff and/or hospital staff were performing CPR on Resident #100. Resident #100's family member advised of the DNR code status and life-saving measures were stopped; Resident #100 expired. The Administrator stated upon looking into the concern, it was found that Resident #100 initially had a Full Code status at the time of her admission to the facility on [DATE]. On [DATE], Resident #100's family member signed an Out of Hospital DNR form for Resident #100. This paperwork was signed at the facility and witnessed by facility staff. The Administrator stated the Out of Hospital DNR form was scanned into the facility's electronic charting system, but Resident #100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Because of this, when Resident #100 was sent to the hospital on [DATE], EMS were provided with inaccurate physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator said at the time Resident #100's Out of Hospital DNR form was completed, the proper protocol would have been for Medical Records to scan the orders into the facility's electronic charting system and for the previous DON (no longer employed by the facility for an unrelated reason) to ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also notified both the Ombudsman and the Medical Director of their findings. The facility completed an audit of all residents' code statuses with no additional discrepancies noted. The facility also initiated their Quality Assurance process and continued to discuss and audit code statuses during daily morning meetings, weekly Standards of Care meetings, and monthly Quality Assurance meetings. Medical Records was now the designated staff member who was responsible for ensuring all code status changes were updated in the system. Staff members were in-serviced on abuse/neglect and proper code status protocol. The Administrator stated the risk of code statuses not being followed was that the resident and/or family's wishes may not be adhered to during end-of-life situations. During a telephone interview with the Previous DON on [DATE] at 1:55PM, she stated she was the DON at the facility when Resident #100 was sent out to the hospital following a change in condition. She said after Resident #100 was sent to the hospital and ultimately expired. The Previous DON stated she did not recall being present when Resident #100's family member signed the form. She said her understanding was that once the form was completed, Resident #100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated when she worked at the facility, the process would have been for Medical Records to upload the form into the electronic charting system and then for nursing staff to ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview with LVN D on [DATE] at 5:35PM, he stated he was the Charge Nurse for Resident #100 at the time of her change in condition and when she was sent to the hospital for further evaluation on [DATE]. He said Resident #100's oxygen stats were low, but she did not code and was still breathing upon assessment. He said when he looked up her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he notified her physician of her change in condition, and an order was obtained to send her to the hospital for further evaluation. EMS was called via 911, and Resident #100's family member was notified. LVN D stated paramedics arrived at the facility, and he provided them with Resident #100's printed her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said she was transported to the hospital at that time. He stated he was later advised that she coded while in transport to the hospital and, because her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he did not know Resident #100 was a DNR status at the time of her transport to the hospital. He stated he had since been trained on proper code status protocol, and he verbalized the facility's protocol on ensuring code statuses were appropriately reflected in each resident's electronic medical record (including physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview with Resident #100's family member on [DATE] at 5:55PM, she stated Resident #100 was admitted to the facility for skilled nursing services. About a week after being admitted to the facility, Resident #100's family member said she signed an Out of Hospital DNR form for Resident #100 because she knew how painful life-saving measures could be for elderly individuals who stopped breathing. She said the previous DON was present at the time the form was signed but stated she could not be a witness because she was a registered nurse. Two other non-nursing staff members signed the form as witnesses, and the form was left with facility staff. Resident #100's family member stated about a two weeks later on [DATE], she got a call at 4:00AM from LVN D, stating Resident #100 was having a hard time holding her oxygen at an adequate level. It was decided to send Resident #100 to the hospital for further evaluation. Resident #100's family member said she herself arrived at the hospital five minutes later, but Resident #100 was not yet there. She said she continued to wait for Resident #100 for over an hour until a hospital staff member came to the waiting room and asked if Resident #100 had a DNR code status. Resident #100's family member stated she advised that there was a DNR code status in place, and she was then advised that Resident #100 went into [CONDITION(S)] while in transport to the hospital from the facility. Resident #100 received CPR and other life-saving measures, including AED [automated external defibrillator, which was a type of computerized defibrillator that automatically analyzed the heart rhythm in people who were experiencing [CONDITION(S)] and, when appropriate, delivered an electrical shock to the heart to restore its normal rhythm] and intubation/ventilation. Resident #100's family member was emotionally distraught during the telephone conversation and stated she felt as though her Resident #100 had been failed during her end of life care. The Administrator was notified of the past noncompliance Immediate Jeopardy on [DATE] at 12:48PM. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. The facility implemented the following interventions: During an interview with the Administrator on [DATE] at 1:34PM, he stated he was responsible for managing the facility and overseeing the department heads, who managed staff members within their own departments. He said the facility had daily morning meetings, weekly Standards of Care meetings, and monthly Quality Assurance meetings in which he was able to monitor and assess practices being implemented within the facility. He said he was in contact with the DON at least daily but also whenever needed to address any issues that arise. He said at the time the incident regarding Resident #100 occurred, the facility was transitioning between staff and the nursing department did not follow through with adding Resident #100's new DNR order to her chart. During interviews with 13 staff members (Administrator, DON, ADON K, Social Worker, Medical Records, MDS LVN, LVN D, LVN E, LVN F, CMA G, CNA H, CNA I, CMA J) across various departments and assigned shifts from [DATE] at 2:21PM to [DATE] at 10:30AM revealed all staff members reported being recently in-serviced on proper code status protocol. Each of the staff members was aware of what steps to take in situations when they were advised of code status changes, as well as what steps to take (including steps related to code status) when a resident displayed a possible change of condition. The staff members were aware of where the code status book was located on the facility crash cart. No current concerns were noted as a result of these interviews. Review of the facility's Code Status book, located on the facility's crash cart, on [DATE] reflected code statuses were up-to-date and current. Review of facility in-servicing records reflected facility staff across all departments and including department heads were in-serviced on the facility's Code Status protocols on [DATE]. Review of a Code Status Audit, completed on [DATE], reflected the audit was completed with no noted discrepancies for current residents of the facility. Review of a Code Status Audit, completed on [DATE], reflected the audit was completed with no noted discrepancies for current residents of the facility. Review of the facility's Do Not Resuscitate (DNR) Policy and Procedure, revised on [DATE], reflected, .1. A written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record reviews, the facility failed to provide care and treatments, consistent with professional standards, to promote healing of pressure ulcers and to prevent development of new pressure ulcers for one (Resident #87) of one resident reviewed for pressure ulcers. The facility failed to implement wound care as ordered by the physician. Resident #87's stage 2 pressure ulcer to her sacrum/coccyx deteriorated to a stage 3. Resident #87's wounds on left and right arm were not identified, assessed, and treated to promote healing. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:36 PM. The administrator was notified on [DATE] and provided an IJ template. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents with skin integrity issues at risk of [CONDITION(S)], pain, worsening pressure ulcers, decreased quality of life, a potentially life-threatening infection, and death . Findings Included: Review of Resident #87's quarterly MDS Resident Assessment, dated [DATE], revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 87's BIMS score was 15 which indicated she was cognition was intact. She was at risk of developing pressure ulcers and had one pressure ulcer at the time of the assessment, which included one Stage 2 that was present upon entry. She had no other skin issues, ulcers, or wounds. Resident #1's pressure ulcer treatment included application of non-surgical dressings, ointments, and medications. Review of Resident #87's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound care order to her left elbow dated [DATE] revealed cleanse left elbow with normal saline. Pat dry apply TAO and secure with dressing. One time a day for wound. The wound care order to her sacrum dated [DATE] revealed clean stage 3 to sacrum with n/s. Pat to dry. Apply collagen powder and alginate calcium apply daily and as needed, Cover with dry dressing daily and as needed. Every day shift for stage 3 wound to sacrum. Review of Resident #87's TAR revealed she was receiving wound care as ordered. Review of Resident #1's care plan, dated [DATE], revealed she had the potential for pressure ulcer development due to fragile skin, requires assist to reposition. Interventions included: educate resident, family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Monitor/document/report to MD PRN changes in skin status; appearance, color, wound healing, signs of infection, wound size, and stage. Needs monitoring/reminding/assistance to turn/reposition. Weekly head to toe skin at risk assessment. Review of Resident #87's wound care progress note written by Wound care physician, dated[DATE]revealed the following: STAGE 3 PRESSURE WOUND SACRUM- 2.3 x 2.6 x 0.4 cm Surface Area - 5.98 cm2 Exudate - Moderate Serous Slough - 60% Granulation Tissue - 40% Wound progress - deteriorated In an observation on [DATE] at 9:32 AM revealed Resident #87 had a bandage on her left arm dated [DATE] and underneath her arm was a padded sheet. The bandage appeared to be soaked and was wet to touch. In an interview with [DATE] at 9:35 AM Resident #87 revealed she did not know the last time she received wound care. In an observation and interview with LVN T on [DATE] at 10:25 AM revealed she changes the resident's dressings daily when she works. She only works Monday, Tuesday, Wednesday. LVN T stated that she did not know why the 3 dressings to the residents' right arm were saturated with green and yellow drainage and dated [DATE], because this was her first day back working. LVN T removed a pillowcase from under Resident 87's right arm with red, yellow and green saturation. A foul odor was noted coming from residents' dressings and saturated pillowcase. LVN T said, it was for under her arm since it was draining. LVN T stated she didn't know why they put it there. LVN T said she did not know if the dressing should have been left like that, she didn't know because she wasn't here. LVN T changed dressing to buttocks and applied wound gel and dated the dressing to cover. The DON was present during dressing change and stopped the nurse asking her if she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then had LVN discard the dressing and she left the room to call the resident's physician to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with DON on [DATE] at 11:00 AM revealed she felt the wound to sacrum was a stage 4 with eschar to the center. She stated that the nurses should be doing a skin assessment weekly and the residents with pressure ulcers should be seen by the rounding wound care physician weekly. She was unsure if the resident had been seen weekly by the wound care physician. She revealed that any changes in the wound would be reported to the wound care physician when discovered. The DON said if wounds were not being properly cared for then they could get worse or infected. She stated, wound dressings should be changed as ordered by physician. The DON revealed she did not have a wound care nurse at this time but stated she had hired one, but the nurse had an expired license and was unable to start. DON stated she was actively trying to hire a wound care nurse . She stated the ADON C and ADON K were responsible for ensuring all residents received necessary wound care treatments by their charge nurses. In an attempted telephone interview on [DATE] at 11:32AM the wound care physician was unable to be reached and a voicemail was left. Review of the facility's policy titled Policy/Procedure - Nursing, dated [DATE], revealed, It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures taken to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. The Administrator was notified on [DATE] at 3:36 PM, an IJ situation was identified due to the above failures and an IJ template was provided. The Plan of Removal was accepted on [DATE] at 10:54 AM and reflected: Immediate Action o Medical Director, notified of IJ on [DATE] at 3:45pm. o Skin sweep of total census initiated and will be completed [DATE] by , RN N; RN O; RN P; Don [NAME], RN Q; ADON C; ADON K; LVN R o Review of all pressure ulcer treatments orders was initiated and will be completed [DATE] by RN N; RN S; O; RN P; DON; ADON C; ADON K o All resident with identified pressure ulcers / treatments will be assessed by facility nurses. Hospice will be notified of areas, but facility staff nurses are responsible for appropriate identification, assessment, treatment, and monitoring of wounds. Hospice companies contracted with the facility will be notified of this policy. o Wound assessment completed by Physician V and Physician W for resident identified [DATE] Order received to cleanse open areas to left and right upper arms and apply calcium alginate/Purocol and cover with non-adherent dressing and Fourflex q 3 days and PRN for soiling or dislodgement. The coccyx was also assessed, and new orders received for cleanse coccyx and apply Santyl and calcium alginate, cover with bordered dressing daily and PRN. The resident's responsible party was notified. o [DATE] Nurses responsible (LVN T and LVN U) for dressing changes on ,d+[DATE], ,d+[DATE] and ,d+[DATE] will be given counseling for not completing treatment as ordered. Identification of Others Affected Currently there are 92 residents at risk for alterations in skin integrity. The facility conducted a skin sweep on [DATE] and identified pressure ulcers on 10 residents. All were assessed, documented, MD notified, and treatments obtained. Systemic Change to Prevent Re-occurrence o DON, started in-service on [DATE] with facility charge nurses on documentation and monitoring skin integrity system along with competency on wound care and skin assessments. The training includes use of shower sheets by the CNAs, reporting new areas to nurses, nurse documentation / treatment / notification of new areas, new admission assessments to occur once a week for four weeks, quarterly, and with any change of condition. In-services included: documenting skin assessments, timely follow up and notification to RP and MD, wound treatments, until all applicable personnel educated. In-services will be completed prior to accepting assignments. All staff unable to attend training/on leave or PRN will receive a call from DON or designee to address necessary training of wound care and skin assessment competencies will be completed prior to next shift. Staff competency/understand was completed after in-service. o All Agency staff will receive training/in-servicing from DON or designee to address necessary training of wound care and skin assessment competencies will be completed prior to start of shift working at facility. o The Clinical Resource- RN N, will train the DON. DON will train the ADONs. The DON, ADONs or designee will train charge nurses. o Nurses will complete competencies for wound care, aseptic treatment, and skin assessment prior to the start of their next shift. The specific tools are a wound care skills competency and a skin assessment competency. o Staff including agency staff will complete training/in-servicing and competency before working. Staff including agency staff, will not be allowed to work without these trainings/in-services/competencies. o Shower sheets to be completed by CNA and any new areas to be communicated to Charge Nurse. o Skin assessments to be completed by Charge Nurse, document and communicate any new skin changes to physician, responsible party and place on 24 hr. report for DON notification. o Skin assessments documented for total census started on [DATE] and to be completed on [DATE]. o Head to toe skin assessments to be conducted weekly on residents ongoing. o ADON C will be assigned to wound program to assess skin, complete treatments, and round with Wound MD o Hospice companies will be notified of pressure ulcers by the Charge Nurse and / or the ADON. Treatments will be provided by facility nurses. o Administrator, DON, ADON C, ADON K, MDS LVN/Coordinator and/or designees to attend weekly systems meetings to include the skin integrity system to review skin assessment, status and progression/worsening of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring o Daily review of documented head to toe skin assessments, completed and documented shower sheets (CNA communication sheets) by DON/designee. DON/designee will ensure notifications and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . o The DON, will monitor 5 nurses weekly for skin assessments and/or wound assessment competency and report to the weekly QAPI Committee meeting for 4 weeks, then monthly for 90 days. o Summary of IJ and corrective action to be reviewed by QAPI Committee weekly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions such as pressure ulcers. o Follow up on IJ Plan of Removal and monitoring will be verified by, DON and Administrator. Monitoring of the plan of removal revealed: In an interview with the administrator on [DATE] at 1:34 PM revealed he manages the facility; Department heads manage staff members; The facility has weekly Standards of Care meetings; Monitor in QAA/QAPI to see if methods are effective and revise if not. He utilizes his resource team (clinical resource); There is a weekly call that the DON has with clinical resource and as any issues arise, they address the issue; He meets with the DON daily and as needed; He monitors issues through QAA/QAPI and SOC meetings; ADONs: Supervised by DON, but reports/issues are reported to him as needed; He also utilizes QAA/QAPI, SOC, and daily meetings. Pressure Ulcers: System failure in terms of nursing accountability and oversight, lack of appropriate rounding and assessments - Angel Care program was implemented this past Friday and will allow for extra rounding and oversight on residents. Interviews conducted from [DATE] to [DATE] with staff across all shifts revealed LVN X, LVN Y, LVN Z, CNA AA, ADON C, and ADON K were in-serviced on documentation and monitoring skin integrity system along with competency on wound care and skin assessments, use of shower sheets by the CNAs, reporting new areas to nurses, nurse documentation / treatment / notification of new areas, new admission assessments to occur once a week for four weeks, quarterly, and with any change of condition, documenting skin assessments, timely follow up and notification to RP and MD, and wound treatments. The Administrator was notified the IJ was removed on [DATE] at 10:34 AM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services for one (Resident #87) of one residents observed for indwelling urinary catheters. The facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place Resident # 87 at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #87's quarterly MDS Resident Assessment , dated 08/21/21, revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an indwelling catheter . Review of Resident #87's Physician Orders revealed she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #87's Comprehensive Care Plan dated 08/27/21 revealed there was no care plan for her indwelling catheter . Review of Resident #87's urinalysis dated 09/29/21 revealed there was bacteria. In an observation on 09/29/19 at 11:58 a.m. revealed Resident #87 had an indwelling catheter. Resident # 87's catheter bag was laying on the floor on top of a pillowcase. The catheter bag was dated 08/01/21. Resident #87's urine in the bag appeared to be tan in color and there were tan colored particles in the bag. In an interview on 09/26/21 at 11:58 a.m. Resident #87 stated she admitted to the facility on [DATE] with a catheter from the hospital. She stated the last time she received catheter care was in the hospital prior to admitting to the facility on [DATE]. She stated she was not in pain . In an interview on 09/29/21 at 01:53 PM with ADON and DON revealed Resident #87 was supposed to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated the resident admitted the facility on 08/17/21 with a catheter. They stated she had a [CONDITION(S)] upon admission and was receiving antibiotics. They stated Resident #87's catheter bag should have been checked every shift by nurses and CNAs. They stated the resident was at risk of infection and [CONDITION(S)] due to not receiving catheter care . Review of the facility policy titled, Catheter Care, Indwelling, dated December 2019, revealed It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status that was life threatening for one (Resident #13) of nine residents reviewed for notification of changes. LVN L failed to consult with Resident #13's physician, who was the Medical Director of the facility, when her blood pressure was very low on the morning of [DATE]. Resident #13 was sent to theER on the afternoon of [DATE] and was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the scope and severity of actual harm and isolated. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure placed residents at risk for delays in life saving treatments and care which could result in clinical complications and/or death. Findings included: 1. Resident #13's admission record dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's MDS assessment dated [DATE] reflected she was moderately impaired cognitively, required extensive assistance of two plus persons for bed mobility, transfers and personal hygiene. She required limited assistance of one person for locomotion, eating and toilet use. Resident #13 also received [MEDICAL TREATMENT]. Resident #13's nurses note dated [DATE] at 9:57 PM reflected, the resident's B/P was ,[DATE] and her family member wanted her sent to the hospital. The Medical Director and DON were notified and the resident was sent out via ambulance with her family member. Resident #13's nurses note dated [DATE] at 2:15 AM reflected the resident returned from the hospital via stretcher awake, alert and oriented times three, and her B/P was ,[DATE]. She was seen at the hospital for [MEDICAL TREATMENT] related [MEDICAL CONDITION]. Resident #13's Order Summary Report dated [DATE] reflected, [MEDICATION NAME] HCI Tablet 10 MG give one by mouth three times day for [MEDICAL CONDITION]. Give M, W, F 1 PM dose at [MEDICAL TREATMENT]. Review of the web-site: https://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details; on [DATE] reflected the following warning when using [MEDICATION NAME]: WARNINGS: [MEDICATION NAME] should only be used in carefully selected patients. When you are lying on your back, this medication causes a significant increase in blood pressure. Your blood pressure will be monitored carefully during treatment. It further reflected: This medication is used for certain patients who have symptoms of low blood pressure when standing. This condition is also known as orthostatic [MEDICAL CONDITION] This medication can cause your blood pressure to increase, especially when you are lying down (supine hypertension). Resident #13's MAR indicated [REDACTED]. The next recorded B/P was for 1 PM and was ,[DATE]. Resident #13's nurses note dated and signed by LVN L on [DATE] at 9:39 AM reflected the resident's B/P was ,[DATE], P 78, R 18, Temp. 97.8. Resident difficult to wake up. Noted that resident had been given Midodren HCI (used to treat low blood pressure) Tablet 10 MG 1 tablet by (sic) as ordered for [MEDICAL CONDITION] (low blood pressure). (Medical Director) notified. (LVN L took this B/P himself) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 10:24 AM reflected, BP (sic) ,[DATE]. Resident clean and dry. Resident did not eat her breakfast. Attempts made to give resident sips of water, Resident not waking enough to swallow. Head of bed remains elevated. Resident #13's nurse's note dated and signed by LVN L on [DATE] at 11:53 AM reflected, Another dose of [MEDICATION NAME] HCI 10 MG tablet given as scheduled for [MEDICAL CONDITION]. (No B/P taken at this time) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 3:58 PM reflected, B/P ,[DATE], P 74, R 18, Resident slow to respond. Resident's (family member) here. (Medical Director) is contacted again. order (sic) given to send resident to (hospital) for [MEDICAL CONDITION] and altered mental status. (There was no clinical documentation on Resident #13 by LVN L from 11:53 AM until 3:59 PM) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 4:29 PM reflected, Resident sent to (hospital) Per (Medical Director's) orders. Transported by (ambulance) on a stretcher. Resident #13's hospital Emergency Department Record dated [DATE] reflected her differential [DIAGNOSES REDACTED]. Her admitting [DIAGNOSES REDACTED]. Resident #13's hospital discharge summary dated [DATE] reflected her active [DIAGNOSES REDACTED]. She had multiple medical issues, admitted with septic shock, deteriorated quickly and expired on [DATE]. Interview with CNA O on[DATE] at 11:55 AM revealed she had worked at the facility for 3 months, and she worked the hall Resident #13 resided on. She stated she remembered Resident #13. She stated the resident was normally talkative, unable to move herself and required assistance with eating. CNA O stated Resident #13 always had back pain, and would always be screaming unless her family was there. She stated she fed her before and she would normally not eat very much breakfast, she would drink coffee, cranberry juice, but always ate well at lunch. She stated she did not remember if Resident #13 was talkative the morning of [DATE], but she thought the resident only ate ,[DATE] % of breakfast. CNA O revealed Resident #13 did not eat lunch, so CNA O left her tray there. She stated she would normally check Resident #13 every two hours but the resident did not urinate on [DATE]. CNA O revealed the last time she saw Resident #13 she thought the resident was sleeping. She stated she did not try to wake her because the resident's family member was there and he did everything for her. CNA O revealed she did not remember checking on Resident #13 around 2 PM because her family member was there and he did everything for her. An interview with MA M on [DATE] at 2:19 PM revealed she normally took Resident #13's B/P when she got there. She would go in and said hi my friend, and Resident #13 would respond. MA M said the resident was a little bit tired but she did respond. MA M stated the response was a little bit different but that day ([DATE]) the resident complained about her back pain, and did not talk as much. She stated she took the resident's B/P two times that day, before and a little bit later after Resident #13 got her medication. MA M stated the one she charted with her medications ,[DATE] was the first time. She went back a little bit later and it was ,[DATE] which she stated was unusual so MA M went back and checked her a little later and Resident #13 was real sleepy, was not normal and because her B/P had come down prior she became concerned and called the nurse, LVN L, and he went in and checked her B/P again and it was ,[DATE]. She stated Resident #13 was normally very talkative in the morning. Telephone Interview with LVN L on [DATE] at 10:16 AM revealed he worked with Resident #13 but not very often. LVN L thought he worked the 6 AM to 6 PM shift on [DATE]. He stated he called the physician as referenced in the 9:39 AM nurse's note and she told him to keep monitoring Resident #13. He stated he did not consult with Resident #13's physician when he could not get the resident to swallow as mentioned in the 10:43 AM nurse's not. LVN L revealed he did not know what her normal B/P was, and he thought that was the time he sent her to the ER. He stated he remembered her family member came in around 1 PM and she was still responding. LVN L stated he called the physician again and was told to send Resident #13 to the hospital as she was slow to respond and the [MEDICATION NAME] did not change her B/P much. He said he also remembered texting the DON telling her Resident #13's B/P was running low and he had contacted the doctor. LVN L also stated he called the resident's family member to let him know as well. (There were no new physician's orders [REDACTED].>Further interview with LVN L via telephone on [DATE] at 5:02 PM revealed, he contacted the Medical Director at 9:39 AM and was told to monitor the resident her. He also said usually from his experience when somebody had a low B/P, dehydration was the first thing he suspected so he looked at whether they were taking fluids and usually contacted the doctor. LVN L stated that usually 100% of the time he would receive orders to encourage fluid, as he had to make sure they are were hydrated. If their B/P continued to run low, most likely their organs would shut down and they may have kidney issues. He also stated those were the ones he would communicate to the doctor, if they were not taking fluids so the doctor could order IV fluids. LVN L stated the Medical Director knew Resident #13 was on medication to bring her B/P up so monitoring Resident #13 meant if her B/P did not come up he was to call her back. LVN L stated Resident #13 took the medication (to raise her blood pressure) three times a day and the first time he took Resident #13's B/P was about an hour after her first dose of the medication around 9:59 AM because the MA came to him and said she was having difficulty swallowing. LVN L stated he tried to wake Resident #13 up, and checked her B/P which was ,[DATE]. He stated she had awakened but when he tried feeding her she was not awake enough to eat. LVN L also stated he had looked at her first B/P of ,[DATE] and that was one of the reasons he contacted the doctor. LVN L stated they were supposed to take a B/P when administering [MEDICATION NAME]. He also stated he had his own B/P cuff and would take it himself. LVN L revealed he took it before the medication was given but could not recall what it had been. LVN L agreed the B/P charted at the 1:00 PM dose of [MEDICATION NAME] ,[DATE] was not a normal B/P but would not say if that was the one he had taken. Interview with a Resident #13's family member on [DATE] at 1:25 PM revealed a text message he sent to the Administrator on [DATE] at 2:36 PM which reflected that no one had been in to check on Resident #13 from 11:00 AM when he arrived until the time the text was sent three and a half hours later. Interview with LVN L on [DATE] at 1:27 PM revealed he had not actually gone to the Skilled unit where Resident #13 resided until after 10:00 AM on [DATE]. He stated when he worked there he usually worked all over the building and the first thing that happened that morning was the MA came and told him the resident did not look good, did not look like herself, so he went and assessed her. When he came from the room the other charge nurse came and LVN L asked him if they had the doctor's phone number. The other charge nurse called the doctor and handed him the phone. LVN L stated that had to be around 10 something. LVN L provided Resident #13's Blood Pressure Summary dated [DATE] and stated he had gone over that list of Resident #13's B/Ps with the Medical Director. He stated all but the top one of ,[DATE] which was at 12:12 PM. He stated those were all of the B/Ps he had gone over with the Medical Director, and he stated yes. When informed the B/P of ,[DATE] was not on that list he stated he told the Medical Director about the B/P being ,[DATE] something. LVN L stated the physician told him to monitor the resident and let her know if there were changes. He stated he told the CNAs not to feed the resident as he would do it and when he spoke to the CNAs they said Resident #13 did not eat much. LVN L said she ate just a little of her lunch and very little breakfast because she was not up enough to eat. He said the CNAs told him she usually slept late and did not eat breakfast. At lunchtime her husband arrived and LVN L informed him Resident #13's B/P was a little low and he talked with the doctor. LVN L revealed because her B/P came up a little bit, she got the second dose of [MEDICATION NAME] and he waited an hour to check her B/P again. He stated since it had not come up, he called the DON who told him to call the Medical Director. He stated he spent a lot of time with Resident #13 that morning and throughout the day. Resident #13's Blood Pressure Summary dated [DATE] reflected the B/P's LVN L went over with the Medical Director the morning of [DATE] were as follows: [DATE] at 8:39 AM ,[DATE]; [DATE] at 5:39 PM ,[DATE]; [DATE] at 11:10 AM ,[DATE]; [DATE] at 5:37 PM ,[DATE]. Telephone interview with the Medical Director on [DATE] at 4:47 PM, revealed, she did not know if anyone had called her about Resident #13's B/P being ,[DATE] the morning of the ninth. She stated they must not have called her because she would not sit on a B/P (,[DATE]) like that, as she always ordered something. She stated she would have ordered fluids, another dose of medication to raise the B/P or to send her to the ER if they called her with a decreased B/P. She stated of course the staff should call her with any change of condition and she felt the outcome may not have been different if Resident #13 went to the hospital earlier, but of course the sooner she had gotten there the better chance she would have had to survive. Further interview with the Medical Director on [DATE] at 4:47 PM revealed she again stated she had not received a call at 9:30 AM on the [DATE]. She stated if she had she would have acted on a B/P that low. The Medical Director revealed, I would not sit on that. I would have ordered something. Interview with the DON on [DATE] at 1:32 PM revealed, she was contacted on the day Resident #13 was sent out to the hospital. She had a text from LVN L on [DATE] at 2:54 PM that he was sending Resident #13 out for altered mental status and [MEDICAL CONDITION]. She also stated she had talked to him that morning ,[DATE] times. She stated LVN L informed her about Resident #13's B/P, speaking to the Medical Director and doing whatever the Medical Director said to do. The DON also stated the Medical Director told LVN L to give Resident #13 more medication but she did not remember the specifics of the conversations. Interview with Resident #13's family member on [DATE] at 11:23 AM revealed he had initiated the staff sending Resident #13 to the hospital on [DATE] and [DATE]. He also stated he initiated them calling the doctor and initiated everything. He stated the morning of [DATE], she the resident was not eating, was lethargic, nauseous, and he gave her water. He stated there was an issue with her not being herself. He said any nurse, doctor, NP would have noticed. He stated every time Resident #13 went to the hospital, he had initiated it. He stated he talked to everybody all the time and he remembered everything regarding that day ([DATE]). He stated he felt LVN L was slow to react to the situation that day ([DATE]). Interview with LVN P on [DATE] at 4:20 PM revealed she was Resident #13's nurse during the week on the ,[DATE] shift. She stated most of the time Resident #13 was screaming for pain medication, and she would give it to her. She also stated sometimes the resident could feed herself and sometimes they assisted her but most of the time Resident #13 was alert and oriented. LVN P also stated when Resident #13 came back from [MEDICAL TREATMENT], her B/P would be low, and she would give the resident a [MEDICATION NAME] and water. LVN P revealed on non-[MEDICAL TREATMENT] days, the resident's B/P would not run low most of the days. She stated there was a day when they could not get her B/P up and they sent her to the hospital. LVN P also stated after hearing the resident's B/P dropped after receiving the first dose of [MEDICATION NAME] and since she had [MEDICAL TREATMENT] on Friday and it was Sunday, she would have called 911 and gotten another nurse to notify the physician. She stated she would have sent Resident #13 out 911. 6. The facility's policy and procedure for Change of Condition Reporting dated (MONTH) 2007 reflected the following: Acute Medical Change, 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and or acute care evaluation. The facility's policy and procedure Notification, Physician or Responsible Party dated (MONTH) 2007 reflected the following: It is the policy of this facility to promptly notify .his/her attending physician .of changes in the resident's condition and/or status.The nurse supervisor will notify the resident's attending physician when: A .B. There is a significant change in the resident's physical, mental, or psychosocial status. 2. An IJ was identified on [DATE]. On [DATE] at 6:18 PM the Administrator, DON, and Clinical Market Leader were notified of the IJ and a plan of removal to remove the immediacy was requested at that time. 3. Review of the facility's Plan of Removal, dated [DATE], reflected the following: A. Immediate Actions Taken Education was completed with licensed staff and medication aides on [DATE] at 1:30 pm. Education included review of change of condition policy as well as following physician orders [REDACTED]. Education included one on one return demonstration of knowledge via interviews with DON and Clinical Market Leader. 2. Change of condition. 4. LVN L was interviewed by DON, Clinical Market Leader, and Administrator. Nurse's documentation was incomplete and did not include all of his actions and interventions of sampled resident on [DATE] which included his conversations with the physician and family. 5. LVN L was provided education on documenting interactions and assessments of resident in the clinical record. As part of education, change of condition policy including notifications. D. Monitoring to Ensure Ongoing Compliance The DON and or ADON will monitor b/p checks on residents daily to ensure appropriate antihyper/hypo medication administration and ordered parameters are being followed per physician ordersl 4. Interview of the Medical Director with the Clinical Market Leader sitting in, on [DATE] at 2:54 PM revealed the Medical Director had learned of the IJ called on [DATE] at 9:30 PM. She stated as she was the administrator she took this very seriously and at first said she had not gotten a call but went back on her call log and now says the first call was at 10:15 AM, so she made a mistake telling the surveyor, she did not get a call. The Medical Director stated she received a phone call from LVN L on [DATE] around 10:15 AM. The Medical Director could not recall the specifics of the conversation but stated if she had known of the drastic drop in B/P Resident #13 had experienced she would have sent her out to the hospital. The Medical Director said she did not recall telling LVN L to monitor but if she had she would have expected him to re-check her vitals within an hour and if were the same or worse expected a call back. She again stated if the first BP was WNL and then two hours later there was an acute drop she would have sent her to the hospital if she had known. She stated Resident #13's case was not clear cut and maybe that was why LVN L did not pick up on it. She also stated with an altered mental status and low B/P, Resident #13 could have gone out emergency ambulance but it was a judgment call and staff probably thought it was not a new problem because they had been dealing with a low B/P for Resident #13, especially after [MEDICAL TREATMENT] days. The following observations, interviews, and record reviews were conducted to verify the implementation of the pln of removal: 5. Monitoring interviews were completed with staff beginning on [DATE] at 5:42 PM PM and ended on [DATE] at 11:03 AM. Staff were able to communicate: 1. Some signs and symptoms of changes in residents condition that would alert you that something may be wrong with the resident. 2. Who to notify when change of condition. 3. After life threatening situation what actions are taken after change of condition is identified. 5. When to report a change of condition. 8. Identify a life threatening condition. 9. If physician is unavailable who else to contact. On [DATE] from 5:42 PM until 6:11 PM the following staff were interviewed and gave the correct answers: LVN J, ,[DATE] and ,[DATE] shifts; ADON; AD; CNA Q, ,[DATE] shift; CNA R, ,[DATE] shift; MA S, ,[DATE] shift; RN H, ,[DATE] shift, CNA AA, ,[DATE] and ,[DATE] shifts, LVN BB, ,[DATE] shift; and LVN T, ,[DATE] shift. On [DATE] from 8:53 AM until 11:03 AM the following staff were interviewed and gave the correct answers: CNA O, ,[DATE] shift; RA U, ,[DATE] shift; LVN E, ,[DATE] and ,[DATE] shifts; SW ,[DATE] shift; MA V ,[DATE] and ,[DATE] shifts; DON; RN W, ,[DATE] shift; CNA X, ,[DATE] shift; CNA Y, ,[DATE] shift; and CNA Z, ,[DATE] shift. 6. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the plan of removal.

Based on interview and record review the facility failed to identify and provide needed care and services in accordance with professional standards of practice for one (Resident #13) of nine residents reviewed for quality of care. LVN L failed to recognize when Resident #13 had a significant change in condition and inform Resident #1's physician, who was the Medical Director of the facility, about all the changes including her low blood pressure on the morning of [DATE]. LVN L also failed to check on the resident from 11:53 AM until 3:58 PM. Resident #13 was sent to theER on the afternoon of [DATE] and was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the scope and severity of actual harm and pattern. The facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure placed residents at risk for delays in life saving treatments and care which could result in clinical complications and/or death. Findings included: 1. Resident #13's admission record dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's MDS assessment dated [DATE] reflected she was moderately impaired cognitively, required extensive assistance of two plus persons for bed mobility, transfers and personal hygiene. She required limited assistance of one person for locomotion, eating and toilet use. Resident #13 also received [MEDICAL TREATMENT]. Resident #13's nurses note dated [DATE] at 9:57 PM reflected, the resident's B/P was ,[DATE] and her family member wanted her sent to the hospital. The Medical Director and DON were notified and the resident was sent out via ambulance with her family member. Resident #13's nurses note dated [DATE] at 2:15 AM reflected the resident returned from the hospital via stretcher awake, alert and oriented times three, and her B/P was ,[DATE]. She was seen at the hospital for [MEDICAL TREATMENT] related [MEDICAL CONDITION]. Resident #13's Order Summary Report dated [DATE] reflected, [MEDICATION NAME] HCI Tablet 10 MG give one by mouth three times day for [MEDICAL CONDITION]. Give M, W, F 1 PM dose at [MEDICAL TREATMENT]. Review of the web-site: https://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details; on [DATE] reflected the following warning when using [MEDICATION NAME]: WARNINGS: [MEDICATION NAME] should only be used in carefully selected patients. When you are lying on your back, this medication causes a significant increase in blood pressure. Your blood pressure will be monitored carefully during treatment. It further reflected: This medication is used for certain patients who have symptoms of low blood pressure when standing. This condition is also known as orthostatic [MEDICAL CONDITION] This medication can cause your blood pressure to increase, especially when you are lying down (supine hypertension). Resident #13's MAR indicated [REDACTED]. The next recorded B/P was for 1 PM and was ,[DATE]. Resident #13's nurses note dated and signed by LVN L on [DATE] at 9:39 AM reflected the resident's B/P was ,[DATE], P 78, R 18, Temp. 97.8. Resident difficult to wake up. Noted that resident had been given Midodren HCI (used to treat low blood pressure) Tablet 10 MG 1 tablet by (sic) as ordered for [MEDICAL CONDITION] (low blood pressure). (Medical Director) notified. (LVN L took this B/P himself) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 10:24 AM reflected, BP (sic) ,[DATE]. Resident clean and dry. Resident did not eat her breakfast. Attempts made to give resident sips of water, Resident not waking enough to swallow. Head of bed remains elevated. Resident #13's nurse's note dated and signed by LVN L on [DATE] at 11:53 AM reflected, Another dose of [MEDICATION NAME] HCI 10 MG tablet given as scheduled for [MEDICAL CONDITION]. (No B/P taken at this time) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 3:58 PM reflected, B/P ,[DATE], P 74, R 18, Resident slow to respond. Resident's (family member) here. (Medical Director) is contacted again. order (sic) given to send resident to (hospital) for [MEDICAL CONDITION] and altered mental status. (There was no clinical documentation on Resident #13 by LVN L from 11:53 AM until 3:59 PM) Resident #13's nurse's note dated and signed by LVN L on [DATE] at 4:29 PM reflected, Resident sent to (hospital) Per (Medical Director's) orders. Transported by (ambulance) on a stretcher. Resident #13's hospital Emergency Department Record dated [DATE] reflected her differential [DIAGNOSES REDACTED]. Her admitting [DIAGNOSES REDACTED]. Resident #13's hospital discharge summary dated [DATE] reflected her active [DIAGNOSES REDACTED]. She had multiple medical issues, admitted with septic shock, deteriorated quickly and expired on [DATE]. Interview with CNA O on[DATE] at 11:55 AM revealed she had worked at the facility for 3 months, and she worked the hall Resident #13 resided on. She stated she remembered Resident #13. She stated the resident was normally talkative, unable to move herself and required assistance with eating. CNA O stated Resident #13 always had back pain, and would always be screaming unless her family was there. She stated she fed her before and she would normally not eat very much breakfast, she would drink coffee, cranberry juice, but always ate well at lunch. She stated she did not remember if Resident #13 was talkative the morning of [DATE], but she thought the resident only ate ,[DATE] % of breakfast. CNA O revealed Resident #13 did not eat lunch, so CNA O left her tray there. She stated she would normally check Resident #13 every two hours but the resident did not urinate on [DATE]. CNA O revealed the last time she saw Resident #13 she thought the resident was sleeping. She stated she did not try to wake her because the resident's family member was there and he did everything for her. CNA O revealed she did not remember checking on Resident #13 around 2 PM because her family member was there and he did everything for her. An interview with MA M on [DATE] at 2:19 PM revealed she normally took Resident #13's B/P when she got there. She would go in and said hi my friend, and Resident #13 would respond. MA M said the resident was a little bit tired but she did respond. MA M stated the response was a little bit different but that day ([DATE]) the resident complained about her back pain, and did not talk as much. She stated she took the resident's B/P two times that day, before and a little bit later after Resident #13 got her medication. MA M stated the one she charted with her medications ,[DATE] was the first time. She went back a little bit later and it was ,[DATE] which she stated was unusual so MA M went back and checked her a little later and Resident #13 was real sleepy, was not normal and because her B/P had come down prior she became concerned and called the nurse, LVN L, and he went in and checked her B/P again and it was ,[DATE]. She stated Resident #13 was normally very talkative in the morning. Telephone Interview with LVN L on [DATE] at 10:16 AM revealed he worked with Resident #13 but not very often. LVN L thought he worked the 6 AM to 6 PM shift on [DATE]. He stated he called the physician as referenced in the 9:39 AM nurse's note and she told him to keep monitoring Resident #13. He stated he did not consult with Resident #13's physician when he could not get the resident to swallow as mentioned in the 10:43 AM nurse's not. LVN L revealed he did not know what her normal B/P was, and he thought that was the time he sent her to the ER. He stated he remembered her family member came in around 1 PM and she was still responding. LVN L stated he called the physician again and was told to send Resident #13 to the hospital as she was slow to respond and the [MEDICATION NAME] did not change her B/P much. He said he also remembered texting the DON telling her Resident #13's B/P was running low and he had contacted the doctor. LVN L also stated he called the resident's family member to let him know as well. (There were no new physician's orders [REDACTED].>Further interview with LVN L via telephone on [DATE] at 5:02 PM revealed, he contacted the Medical Director at 9:39 AM and was told to monitor the resident her. He also said usually from his experience when somebody had a low B/P, dehydration was the first thing he suspected so he looked at whether they were taking fluids and usually contacted the doctor. LVN L stated that usually 100% of the time he would receive orders to encourage fluid, as he had to make sure they are were hydrated. If their B/P continued to run low, most likely their organs would shut down and they may have kidney issues. He also stated those were the ones he would communicate to the doctor, if they were not taking fluids so the doctor could order IV fluids. LVN L stated the Medical Director knew Resident #13 was on medication to bring her B/P up so monitoring Resident #13 meant if her B/P did not come up he was to call her back. LVN L stated Resident #13 took the medication (to raise her blood pressure) three times a day and the first time he took Resident #13's B/P was about an hour after her first dose of the medication around 9:59 AM because the MA came to him and said she was having difficulty swallowing. LVN L stated he tried to wake Resident #13 up, and checked her B/P which was ,[DATE]. He stated she had awakened but when he tried feeding her she was not awake enough to eat. LVN L also stated he had looked at her first B/P of ,[DATE] and that was one of the reasons he contacted the doctor. LVN L stated they were supposed to take a B/P when administering [MEDICATION NAME]. He also stated he had his own B/P cuff and would take it himself. LVN L revealed he took it before the medication was given but could not recall what it had been. LVN L agreed the B/P charted at the 1:00 PM dose of [MEDICATION NAME] ,[DATE] was not a normal B/P but would not say if that was the one he had taken. Interview with a Resident #13's family member on [DATE] at 1:25 PM revealed a text message he sent to the Administrator on [DATE] at 2:36 PM which reflected that no one had been in to check on Resident #13 from 11:00 AM when he arrived until the time the text was sent three and a half hours later. Interview with LVN L on [DATE] at 1:27 PM revealed he had not actually gone to the Skilled unit where Resident #13 resided until after 10:00 AM on [DATE]. He stated when he worked there he usually worked all over the building and the first thing that happened that morning was the MA came and told him the resident did not look good, did not look like herself, so he went and assessed her. When he came from the room the other charge nurse came and LVN L asked him if they had the doctor's phone number. The other charge nurse called the doctor and handed him the phone. LVN L stated that had to be around 10 something. LVN L provided Resident #13's Blood Pressure Summary dated [DATE] and stated he had gone over that list of Resident #13's B/Ps with the Medical Director. He stated all but the top one of ,[DATE] which was at 12:12 PM. He stated those were all of the B/Ps he had gone over with the Medical Director, and he stated yes. When informed the B/P of ,[DATE] was not on that list he stated he told the Medical Director about the B/P being ,[DATE] something. LVN L stated the physician told him to monitor the resident and let her know if there were changes. He stated he told the CNAs not to feed the resident as he would do it and when he spoke to the CNAs they said Resident #13 did not eat much. LVN L said she ate just a little of her lunch and very little breakfast because she was not up enough to eat. He said the CNAs told him she usually slept late and did not eat breakfast. At lunchtime her husband arrived and LVN L informed him Resident #13's B/P was a little low and he talked with the doctor. LVN L revealed because her B/P came up a little bit, she got the second dose of [MEDICATION NAME] and he waited an hour to check her B/P again. He stated since it had not come up, he called the DON who told him to call the Medical Director. He stated he spent a lot of time with Resident #13 that morning and throughout the day. Resident #13's Blood Pressure Summary dated [DATE] reflected the B/P's LVN L went over with the Medical Director the morning of [DATE] were as follows: [DATE] at 8:39 AM ,[DATE]; [DATE] at 5:39 PM ,[DATE]; [DATE] at 11:10 AM ,[DATE]; [DATE] at 5:37 PM ,[DATE]. Telephone interview with the Medical Director on [DATE] at 4:47 PM, revealed, she did not know if anyone had called her about Resident #13's B/P being ,[DATE] the morning of the ninth. She stated they must not have called her because she would not sit on a B/P (,[DATE]) like that, as she always ordered something. She stated she would have ordered fluids, another dose of medication to raise the B/P or to send her to the ER if they called her with a decreased B/P. She stated of course the staff should call her with any change of condition and she felt the outcome may not have been different if Resident #13 went to the hospital earlier, but of course the sooner she had gotten there the better chance she would have had to survive. Further interview with the Medical Director on [DATE] at 4:47 PM revealed she again stated she had not received a call at 9:30 AM on the [DATE]. She stated if she had she would have acted on a B/P that low. The Medical Director revealed, I would not sit on that. I would have ordered something. Interview with the DON on [DATE] at 1:32 PM revealed, she was contacted on the day Resident #13 was sent out to the hospital. She had a text from LVN L on [DATE] at 2:54 PM that he was sending Resident #13 out for altered mental status and [MEDICAL CONDITION]. She also stated she had talked to him that morning ,[DATE] times. She stated LVN L informed her about Resident #13's B/P, speaking to the Medical Director and doing whatever the Medical Director said to do. The DON also stated the Medical Director told LVN L to give Resident #13 more medication but she did not remember the specifics of the conversations. Interview with Resident #13's family member on [DATE] at 11:23 AM revealed he had initiated the staff sending Resident #13 to the hospital on [DATE] and [DATE]. He also stated he initiated them calling the doctor and initiated everything. He stated the morning of [DATE], she the resident was not eating, was lethargic, nauseous, and he gave her water. He stated there was an issue with her not being herself. He said any nurse, doctor, NP would have noticed. He stated every time Resident #13 went to the hospital, he had initiated it. He stated he talked to everybody all the time and he remembered everything regarding that day ([DATE]). He stated he felt LVN L was slow to react to the situation that day ([DATE]). Interview with LVN P on [DATE] at 4:20 PM revealed she was Resident #13's nurse during the week on the ,[DATE] shift. She stated most of the time Resident #13 was screaming for pain medication, and she would give it to her. She also stated sometimes the resident could feed herself and sometimes they assisted her but most of the time Resident #13 was alert and oriented. LVN P also stated when Resident #13 came back from [MEDICAL TREATMENT], her B/P would be low, and she would give the resident a [MEDICATION NAME] and water. LVN P revealed on non-[MEDICAL TREATMENT] days, the resident's B/P would not run low most of the days. She stated there was a day when they could not get her B/P up and they sent her to the hospital. LVN P also stated after hearing the resident's B/P dropped after receiving the first dose of [MEDICATION NAME] and since she had [MEDICAL TREATMENT] on Friday and it was Sunday, she would have called 911 and gotten another nurse to notify the physician. She stated she would have sent Resident #13 out 911. 6. The facility's policy and procedure for Change of Condition Reporting dated (MONTH) 2007 reflected the following: Acute Medical Change, 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and or acute care evaluation. The facility's policy and procedure Notification, Physician or Responsible Party dated (MONTH) 2007 reflected the following: It is the policy of this facility to promptly notify .his/her attending physician .of changes in the resident's condition and/or status.The nurse supervisor will notify the resident's attending physician when: A .B. There is a significant change in the resident's physical, mental, or psychosocial status. 2. An IJ was identified on [DATE]. On [DATE] at 6:18 PM the Administrator, DON, and Clinical Market Leader were notified of the IJ and a plan of removal to remove the immediacy was requested at that time. 3. Review of the facility's Plan of Removal, dated [DATE], reflected the following: A. Immediate Actions Taken Education was completed with licensed staff and medication aides on [DATE] at 1:30 pm. Education included review of change of condition policy as well as following physician orders [REDACTED]. Education included one on one return demonstration of knowledge via interviews with DON and Clinical Market Leader. 2. Change of condition. 4. LVN L was interviewed by DON, Clinical Market Leader, and Administrator. Nurse's documentation was incomplete and did not include all of his actions and interventions of sampled resident on [DATE] which included his conversations with the physician and family. 5. LVN L was provided education on documenting interactions and assessments of resident in the clinical record. As part of education, change of condition policy including notifications. D. Monitoring to Ensure Ongoing Compliance The DON and or ADON will monitor b/p checks on residents daily to ensure appropriate antihyper/hypo medication administration and ordered parameters are being followed per physician ordersl 4. Interview of the Medical Director with the Clinical Market Leader sitting in, on [DATE] at 2:54 PM revealed the Medical Director had learned of the IJ called on [DATE] at 9:30 PM. She stated as she was the administrator she took this very seriously and at first said she had not gotten a call but went back on her call log and now says the first call was at 10:15 AM, so she made a mistake telling the surveyor, she did not get a call. The Medical Director stated she received a phone call from LVN L on [DATE] around 10:15 AM. The Medical Director could not recall the specifics of the conversation but stated if she had known of the drastic drop in B/P Resident #13 had experienced she would have sent her out to the hospital. The Medical Director said she did not recall telling LVN L to monitor but if she had she would have expected him to re-check her vitals within an hour and if were the same or worse expected a call back. She again stated if the first BP was WNL and then two hours later there was an acute drop she would have sent her to the hospital if she had known. She stated Resident #13's case was not clear cut and maybe that was why LVN L did not pick up on it. She also stated with an altered mental status and low B/P, Resident #13 could have gone out emergency ambulance but it was a judgment call and staff probably thought it was not a new problem because they had been dealing with a low B/P for Resident #13, especially after [MEDICAL TREATMENT] days. The following observations, interviews, and record reviews were conducted to verify the implementation of the pln of removal: 5. Monitoring interviews were completed with staff beginning on [DATE] at 5:42 PM PM and ended on [DATE] at 11:03 AM. Staff were able to communicate: 1. Some signs and symptoms of changes in residents condition that would alert you that something may be wrong with the resident. 2. Who to notify when change of condition. 3. After life threatening situation what actions are taken after change of condition is identified. 5. When to report a change of condition. 8. Identify a life threatening condition. 9. If physician is unavailable who else to contact. On [DATE] from 5:42 PM until 6:11 PM the following staff were interviewed and gave the correct answers: LVN J, ,[DATE] and ,[DATE] shifts; ADON; AD; CNA Q, ,[DATE] shift; CNA R, ,[DATE] shift; MA S, ,[DATE] shift; RN H, ,[DATE] shift, CNA AA, ,[DATE] and ,[DATE] shifts, LVN BB, ,[DATE] shift; and LVN T, ,[DATE] shift. On [DATE] from 8:53 AM until 11:03 AM the following staff were interviewed and gave the correct answers: CNA O, ,[DATE] shift; RA U, ,[DATE] shift; LVN E, ,[DATE] and ,[DATE] shifts; SW ,[DATE] shift; MA V ,[DATE] and ,[DATE] shifts; DON; RN W, ,[DATE] shift; CNA X, ,[DATE] shift; CNA Y, ,[DATE] shift; and CNA Z, ,[DATE] shift. 6. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the plan of removal.