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

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting on 04/22/2026. This failure could place residents who have a mental health diagnosis, developmental disability, or intellectual disability at risk from not receiving specialized equipment identified by the IDT in a timely manner. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses of: seizure disorder (recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), respiratory failure (when the lungs cannot adequately exchange gases, leading to low oxygen or high carbon dioxide levels in the blood), cognitive communication deficit (a condition where a person's ability to communicate effectively is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem), renal failure (when the kidneys can no longer effectively filter waste and toxins from the blood), high blood pressure, and heart failure. Review of Resident #1's comprehensive care plan dated 03/25/2026 reflected Resident #1 was PASRR positive for ID (intellectual disability). The interventions included: IDT meeting to be completed as required, notify local authority of any significant changes, notify physician and responsible party of any changes, PASRR evaluation to be completed by local authority, specialized services will be provided as determined by IDT meeting. Review of a HHSC PASRR spreadsheet titled 'IDT Meetings and NFSS Request data' dated 4/1/26-4/30/26 revealed Resident #1 was on the list for CMWC and DME services. It was indicated that the facility ADM and previous DON's electronic mail were on file for Resident #1 and they were both sent an email on 6/17/26. The follow up notes indicated that the NFSS not submitted/NF did not respond to emails. Review of email communication provided by the ADM from the HHSC PASRR unit revealed an email from 'HHSC PASRR QM PASRRQM@hhs.texas.gov' dated 6/17/26 at 3:02 PM delivered to the facility ADM and previous DON's electronic mail, titled 'PASRR NFSS Compliance Request'. The electronic mail from the PASRR unit reflected: The reason for this email is to notify you that according to our records, an Interdisciplinary Team meeting (IDT) was held and entered into the Long Term Care Online Portal for one or more of your residents. During the IDT meeting nursing facility specialized services were recommended and agreed upon for the resident in your facility. For your facility to be compliant with the 26 Texas Administrative Code {TAC), Chapter 554, Subchapter BB, section S554.2704(i)(7), a nursing facility must initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting. Currently, your nursing facility is out of compliance as per this TAC Rule. As of today, our records show that the HHSC PASRR unit has not received a request for specialized services for the following residents: and Resident #1 was listed by means of a personalized/confidential PCSP number. Review of email communication provided by the ADM between this facility and the LIDDA reflected:The facility informed the LIDDA on 5/1/2026 that the MDSC who opened the CMWC form was no longer with the company, and the facility asked the LIDDA to clarify if Resident #1 requested a CMWC. The LIDDA responded to the facility on 5/1/2026 that Resident #1 did have a CMWC added to her plan. The facility responded to the LIDDA on 5/4/2026 that the previous MDSC did not communicate the need for a CMWC and that business day 20 was 5/1/2026. The facility apologized for asking the LIDDA how to proceed as this was her 1st PASRR experience.The LIDDA responded to the facility on 5/4/2026 confirming that they had 20 days after the IDT meeting to submit services, and that in this case, they needed to plan a meeting soon to re-start the clock. In an interview on 07/24/2026 at 10:23 PM with the MDSC, stated she had been the MDSC at the facility for about a year and half. She stated she was heavily involved in PASRR coordination at the facility. She stated that when new admissions came to the facility, the admissions director would give the MDSC names of PASRR positive residents. She stated that she attended IDT meetings, but she did not attend the 4/2/26 IDT meeting for Resident #1, the previous MDSC was present on that date, and that MDSC no longer worked at the facility. In an interview on 07/24/2026 at 10:55 PM with the ADM, stated that the MDSC who was present for Resident #1's IDT was no longer working for the company. He stated that the second MDSC or DON was responsible for ensuring deadlines were followed when personnel changes occurred. He stated that the MDSC that attended the meeting had gone on personal leave for some time, and then never returned to her role. He stated that LIDDA was responsible for putting in the online request to 'open' the IDT meeting, which would trigger the timelines for certain paperwork to be processed. He stated that when those timelines are not followed it prolongs residents from receiving elected benefits and services. Review of LTC Simple revealed a Form Completed for Resident #1 on 4/2/2026.On 4/3/2026 The system indicated has accepted IDD Specialized Services and Participation Confirmation of Initial/Annual Meeting. Review of the facility's PASRR flow chart, which was provided by the ADM when asked for a PASRR policy reflected if the NF was able to serve the individual (resident), the NF would conduct the IDT within 14 calendar days with required participants. Then the NF requests specialized services using the NFSS within 20 business days of the IDT.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative of the significant change in the resident's physical, mental, or psychosocial status for two residents (Resident #2 and Resident #3) of ten residents reviewed for resident rights. The facility failed to inform Resident #2's RP she was being transferred to another facility on 3/7/2026. The facility failed to ensure Resident #3's RP was notified when she fell on 3/17/2026 or 3/18/2026. The facility failed to ensure Resident #3's Physician was notified when she fell on 3/17/2026 or 3/18/2026. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions or having their Physician make care decisions post fall. Findings included:Resident #2Review of Resident #2's face sheet dated 4/8/2026, reflected a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills), Hypertension (high blood pressure) and atrial fibrillation (irregular heart rhythm). Review of Resident #2's admission MDS dated [DATE], reflected no BIMS score assessment. Review of Resident #2's assessments in the EMR reflected no BIMS assessment listed. Review of Resident #2's Progress note dated 3/6/2026 at 3:57 pm reflected: The resident is newly admitted to facility and moved into a long-term care room today. She has been ambulating around pleasantly confused. Family visited today and upon leaving patient with increased emotional outburst. Patient continued to seek family towards the exit doors. Patient easily redirected to room. Wanderguard (A4525-3140) placed on right ankle. [FM] notified. Review of Resident #2's progress note dated 3/7/2026 at 2:08 pm by Nurse A, reflected; resident discharged to [another nursing facility] memory care; transported by facility transport; resident's family collected all resident's belongings During an interview on 4/8/2026 at 1:22 pm, FM of Resident #2 stated the facility called them the morning of 3/7/2026 and said they were moving Resident #2 to another facility, and they needed to come and get her stuff. FM stated the NF called them an hour or two before they moved her and the family was given no choice where she was being moved. FM stated they did not have time to do anything but go up to the facility and get her belongings. FM stated this was very upsetting to the entire family because they did not get any notice she was being moved and did not have any time to prepare. During an interview on 4/8/2026 at 2:16 pm, admission Director stated she spoke to Resident #2's FM when Resident was leaving on 3/7/2026. She stated she had not called the RP and had not notified them that resident was being moved, she thought another staff had already done that. During an interview on 4/8/2026 at 2:33 pm, Nurse A stated she completed the progress note when Resident #2 left the facility. She stated Resident #2 was transferred over to the hall where she was working on 3/6/2026, late in the afternoon. She stated she had come in the next morning on 3/7/2026 and a staff member said they were discharging her and transferring her to another facility due to her wandering. Nurse A stated she could not remember who told her about the transfer. She stated she had not called the RP about the transfer because she thought it had already been done. She stated in her mind the family was aware of the transfer because later in the day they were in the building getting Resident #2's belongings. During an Interview on 4/8/2026 at 2:48 pm, CNA B stated she had been working as a social worker assistant and did not find out about Resident #2 discharging until she came back to work on 3/9/2026. She stated typically she would contact the RP about a transfer or discharge. She stated she would let them know other facilities that are available for transfer and once the RP chose a facility, they will send the clinical information over to see if the resident will be accepted. She stated she did not speak to the RP for Resident #2 about her being discharged and had not sent any clinical information over to other facilities. She stated she came in on Monday, 3/9/2026 and Resident #2 was gone. During an interview on 4/8/2026 at 3:49 pm, ADM stated his expectations were that staff would have communicated with Resident #2's RP prior to a transfer or discharge. He stated he thought staff had spoken to the family on Friday 3/6/2026, but acknowledged there was no documentation in the EMR. He stated Resident #2 was having exit seeking behaviors and needed a facility with a secure unit, so they transferred Resident #2 to their sister facility. He stated that typically they will notify the RP of the facility options and wait for the RP to make a decision, then they will send the clinical information and follow up to complete the transfer. He stated he was unaware this had not been done for Resident #2. Resident #3 Review of Resident #3's face sheet dated 4/1/2026, reflected a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: acute respiratory failure with hypoxia (condition where the body tissues do not received enough oxygen), type 2 diabetes (blood sugar regulation disorder), cognitive communication deficit, hypertension (high blood pressure) and muscle weakness. Review of Resident #3's BIMS assessment dated [DATE], reflected a score of 1 suggesting severe cognitive impairment. Review of Resident #3's care plan with a closed date of 4/6/2026 reflected: Focus - At risk for falls r/t DEMENTIA, WEAKNESS, FOOT ULCER WITH UNSTEADY GAIT/TRANSFERDate Initiated: 03/14/2026. Goal: Will minimize risk of injury. Review of Resident #3's progress notes from 3/17/2026 to 3/26/2026 when resident discharged reflected no entries from any facility staff about resident's fall. Review of Resident #3's progress notes dated 3/23/2026 at 6:15 am by Nurse F reflected: This nurse did body assessment last night and noticed a bruise on the resident right upper arm and the resident had pain with movement. When asked what happened resident did not know. Writer notified NP and received N/O for x-ray 2V right shoulder, humerus, and elbow to rule out fracture. RP [FM] notified. ADON was in building and notified. Review of Resident #3's progress notes for from 3/17/2026 until 3/27/2026, reflected no notes regarding RP notification of Fall. Review of Resident #3's radiology report dated 3/23/2026 reflected: Impression: The bones are osteoporotic. The acute right humeral head fracture is present (osteoporotic - metabolic disease causing weak, brittle bones, humeral head fracture - broken or cracked upper arm bone) During an interview on 4/1/2026 at 1:27 pm FM of Resident #3 stated they received a call on 3/22/2026 notifying them of the bruising and injury to Resident #3's right arm and that an x-ray had been ordered. FM stated they were unaware that the resident had fallen the previous week until this investigator informed them on this day. They stated if the facility failed to call them about this fall - they would have concerns about other events that may have happened and they were not notified. During an interview on 4/15/2026 at 11:10 am, Nurse F stated she completed a weekly skin assessment on Resident #3 and noticed an injury with bruising. She called the provider and received an order for an x-ray and then called the RP to let them know about the injury and x-ray. Nurse F stated she did not inform family about the fall because she was not aware at that time that Resident #3 had sustained a fall. During an interview on 4/15/2026 at 11:40 am, CNA C stated she found Resident #3 on her floor mat in her room by her bed on either 3/17/2026 or 3/18/2026 in the evening. She stated she went to the nurses station and notified Nurse E of the fall and CNA D was standing there and came down to the room to help. She stated that when a resident falls, she is supposed to report it to her charge nurse and then the charge nurse is responsible from there. CNA C stated CNAs do not notify RPs of falls; they tell the charge nurse, and the charge nurse calls the family. She stated she came back to work several days later and heard about Resident #3's injury so she went to DON and told them about her fall and that is when she found out the fall had not been reported by Nurse E. During an interview on 4/15/2026 at 1:07 pm, Nurse E stated he did not call Resident #3's MD, RP or FM about her fall on 3/17/2026 or 3/18/2026 because the resident never fell and he did not recall CNA C reporting a fall to him for Resident #3. Nurse E stated if a resident fell, the nurse was responsible for notifying the family and medical providers, completing an assessment and doing an incident report. Nurse E reiterated he was unaware that Resident #3 had fallen. During an interview on 4/15/2026 at 1:55 pm, DON stated they found out about Resident #3's fall from CNA C. DON stated she interviewed Nurse E and he initially denied it several times that Resident #3 had a fall and then he said she was found on her fall mat on the floor but he did not count it as a fall, so he did not report it or make any notifications. She stated Nurse E was termed on 3/26/2026. She stated her expectation is that all falls will be reported and that nursing staff will complete incident reports and make appropriate notifications. During an interview on 4/15/2026 at 1:59 pm, CNA D stated she was with CNA C on 3/17/2026 or 3/18/2026 in Resident #3's room and observed resident on the floor. She stated she was in the room when Nurse E came in and saw Resident #3 on her fall mat by her bed. She stated CNA C reported the fall to Nurse E and when a resident has a fall, CNAs are supposed to report it to their charge nurse and that is what she witnessed that night. During an interview on 4/15/2026 at 2:11 pm, NP stated she was never informed Resident #3 had a fall. She stated she had been notified of Resident #3's arm bruising and injury and had ordered x-rays which were completed in the facility. She stated she was notified of the x-ray results and reviewed the results. She stated her expectations on resident falls was that staff would report it and notify them so that if there is any need for imaging, labs, or injuries to be treated, she can provide orders for care. She stated if falls were not reported, potential injuries could not be discovered or treated. She stated that depending on how the injury occurred, injuries that are not treated could result in long term issues. During an interview on 4/15/2026 at 2:54 pm, MD stated he was informed about Resident #3's fall after the fact when nursing staff discovered a fall had occurred the week prior. He stated his expectations were that staff would notify providers of the fall details and any trauma, bruising, pain, or injury discovered during their assessment. He stated his potential concerns around falls not being reported would be delays in care, lack of documentation and not being able to appropriately treat a resident. Record Review of facility policy Resident Rights dated July 13, 2017, reflected: Information and Communication. You have the right to: be immediately informed when there is: a decision to transfer or discharge you from the facility. Record Review of facility policy Fall Management System dated 4.2025, reflected:3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.a. The attending Physician and Resident Representative shall be notified of the fall and the resident status.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of ten residents reviewed for quality of care. The facility failed to remove Resident #1's PICC line before he discharged on 3/12/2026. Nurse E failed to report a fall for Resident #3 on or about 3/17/2026 or 3/18/2026. Nurse E failed to assess Resident #3 for injuries after a fall on or about 3/17/2026 or 3/18/2026 These failures placed Resident at risk of injury, infection, not receiving adequate care and services, and decreased quality of life.Findings include: Review of Resident #1's face sheet dated 4/8/2026, reflected a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: cellulitis of right lower limb (bacterial skin infection) , cellulitis of left lower limb, muscle weakness, hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder), chronic heart failure (chronic heart condition where the heart cannot pump enough blood) and chronic kidney disease. (long term condition where kidneys are damaged and don't work effectively). Review of Resident #1's admission MDS assessment dated [DATE], reflected a BIMS score of 13 suggesting no cognitive impairment. Review of Resident #1's discharge summary progress note dated 3/12/2026 at 3:42 pm by Nurse G reflected: Patient completed IV antibiotics r/t cellulitis. Reason for discharge: The Resident's health has improved sufficiently, resident no longer needs the services of the facility. Review of Resident #1's discharge assessment dated [DATE] at 3:54 pm by Nurse G reflected Patient completed IV antibiotics r/t cellulitis. The assessment indicated there were no skin issues and no special instructions. There was no mention of the PICC line in the assessment. Review of Resident #1's orders on 4/8/2026 reflected there was no order to have the PICC line removed. Review of Resident #1's care plan with a closed date of 3/16/2026 reflected resident was receiving IV antibiotics for cellulitis. During an interview on 4/8/2026 at 11:25 am, MD stated he was not aware that Resident #1 was discharged with the PICC still inserted until later. He stated the resident had completed his antibiotic therapy and it is standard of care to remove PICC lines prior to discharge unless there is a rare circumstance. He stated Resident #1 should have had his PICC line removed prior to discharge. MD stated the PICC was removed by nursing staff the next morning and there were no bad outcomes. He stated a potential concern could be infection and possibly cellulitis if it was left in too long but Resident #1's was only left in overnight. He stated it was an unfortunate situation and they tried to correct it as soon as they found out. MD reiterated he had no immediate concerns since the PICC line was removed the next day. During an interview on 4/8/2026 at 11:58 am, DON 2 stated she was aware that Resident #1 was discharged on 3/12/2026 with his PICC still inserted. She stated she received a telephone order from NP on 3/13/2026 in the morning to remove Resident #1's PICC line. She stated she and another nurse went to Resident #1's house on 3/13/2026 in the morning and she removed his PICC line. She stated she assessed the site and there were no skin issues noted and the PICC was removed completely. She stated a concern for leaving a PICC line in after discharge could be injury at the site, infection or the resident could have pulled it out and started bleeding. She stated she was not able to document any of this in the EMR because resident had already been discharged . During an interview on 4/8/2026 at 12:23 pm, Resident #1's FM stated they noticed that evening the PICC line was still in his arm. They stated they called up to the facility the evening on 3/12/2026 and told the staff, then the next day two nurses came out in the morning and removed the PICC line. FM stated they checked Resident #1 over and he was fine and there were no issues. During an interview on 4/8/2026 at 12:25 pm, Resident #1 stated he discharged on 3/12/2026 and forgot he still had the PICC line in his arm. He stated he was in his bedroom later that evening and then saw it still in his arm. He stated he notified his FM who called the facility and let them know. He stated it did not cause any problem and denied any issues with the site or bleeding. During an interview on 4/8/2026 at 3:49 pm, ADM stated he was aware that Resident #1 was discharged with the PICC line still inserted. He stated his expectation is that PICC lines will be removed prior to discharge unless there is an order to keep it in. He stated staff should have gotten an order to remove Resident #1's PICC line especially since he was done with his antibiotic therapy and discharged shortly after. During an interview on 4/8/2026 at 5:20 pm with Nurse G, she stated she completed the discharge assessment on Resident #1 and did not realize or remember that he had a PICC line. She stated she knew he had been on IV antibiotics, but when she discharged him that morning, she did not see a PICC line. She stated she did not think to look for a PICC line because he had completed his antibiotics. She stated she was not aware he had been discharged with the PICC line and not aware nursing staff had gone to his house to remove the PICC. She staed if a resident has a PICC at discharge they are supposed to notify the RN on duty as only RNs can remove PICC lines. She stated she did not notify the RN because she did not know he still had his PICC line. She stated a potential concern with a resident still having a PICC line in at discharge could be infection or possibly pulling the line out accidentally. Resident #3 Review of Resident #3's face sheet dated 4/1/2026, reflected a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: acute respiratory failure with hypoxia (condition where the body tissues do not received enough oxygen), type 2 diabetes (blood sugar regulation disorder), cognitive communication deficit, hypertension (high blood pressure) and muscle weakness. Review of Resident #3's BIMS assessment dated [DATE], reflected a score of 1 suggesting severe cognitive impairment. Review of Resident #3's care plan with a closed date of 4/6/2026 reflected: Focus - At risk for falls r/t DEMENTIA, WEAKNESS, FOOT ULCER WITH UNSTEADY GAIT/TRANSFERDate Initiated: 03/14/2026. Goal: Will minimize risk of injury. Review of Resident #3's progress notes from 3/17/2026 to 3/26/2026 when resident discharged reflected no entries from any facility staff about resident's fall or post fall assessment. Review of Resident #3's progress notes dated 3/23/2026 at 6:15 am by Nurse F reflected: This nurse did body assessment last night and noticed a bruise on the resident right upper arm and the resident had pain with movement. When asked what happened resident did not know. Writer notified NP and received N/O for x-ray 2V right shoulder, humerus, and elbow to rule out fracture. RP [FM] notified. ADON was in building and notified. Review of Resident #3's skin assessment dated [DATE] by Nurse F reflected resident had bruising on her right upper arm and decreased range of motion. Review of Resident #3's radiology report dated 3/23/2026 reflected: Impression: The bones are osteoporotic. The acute right humeral head fracture is present (osteoporotic - metabolic disease causing weak, brittle bones, humeral head fracture - broken or cracked upper arm bone) During an interview on 4/15/2026 at 11:10 am, Nurse F stated she completed a weekly skin assessment on Resident #3 and noticed an injury with bruising. She called the provider and received an order for an x-ray and then called the RP to let them know about the injury and x-ray. Nurse F stated she was not aware at that time that Resident #3 had sustained a fall. During an interview on 4/15/2026 at 11:40 am, CNA C stated she found Resident #3 on her floor mat in her room by her bed on either 3/17/2026 or 3/18/2026 in the evening. She stated she was in another resident's room and as she was coming out of the room, she heard a thud. She walked into Resident #3's room and she was on the floor mat on the floor. She stated she went to the nurses' station and notified Nurse E of the fall and CNA D was standing there and came down to the room to help. She stated Nurse E came in the room, scooped up the resident under both arms and put her in her wheelchair. Then she and CNA D wheeled Resident #3 down to the nurse's station. She stated she did not see any visible injuries or bleeding, and the resident did no cry our in pain or make any facial expressions of pain. She stated she did not see Nurse E assess resident, did not take vitals signs, and did not check her pupils.She stated that when a resident falls, she is supposed to report it to her charge nurse and then the charge nurse is responsible from there. She stated she came back to work several days later and heard about Resident #3's injury so she went to DON and told them about her fall and that is when she found out the fall had not been reported by Nurse E. During an interview on 4/15/2026 at 1:07 pm, Nurse E stated he did not call Resident #3's MD, RP or FM about her fall on 3/17/2026 or 3/18/2026 because the resident never fell and he did not recall CNA C reporting a fall to him for Resident #3. Nurse E stated if a resident fell, the nurse was responsible for notifying the family and medical providers, completing an assessment and doing an incident report. Nurse E reiterated he was unaware that Resident #3 had fallen, so he did not complete an assessment of the resident because there was no fall. During an interview on 4/15/2026 at 1:55 pm, DON stated they found out about Resident #3's fall from CNA C. DON stated she interviewed Nurse E and he initially denied it several times that Resident #3 had a fall and then he said she was found on her fall mat on the floor but he did not count it as a fall, so he did not report it or make any notifications. She stated Nurse E was termed on 3/26/2026. She stated her expectation is that all falls will be reported and that nursing staff will complete incident reports and make appropriate notifications. During an interview on 4/15/2026 at 1:59 pm, CNA D stated she was with CNA C on 3/17/2026 or 3/18/2026 in Resident #3's room and observed resident on the floor. She stated she was in the room when Nurse E came in and saw Resident #3 on her fall mat by her bed. She stated CNA C reported the fall to Nurse E and when a resident has a fall, CNAs are supposed to report it to their charge nurse and that is what she witnessed that night. She stated she observed Nurse E came in the room and immediately picked up Resident #3 under her arms and put her in the wheelchair. She stated her and CNA C pushed Resident #3 in her wheelchair down to the nurses station. She stated she never saw Nurse E check the resident over or do any vital signs or check her body for any injuries. She stated she did not observe any bleeding from the resident and the resident did not cry out in pain or make any faces when she was moved by Nurse E. During an interview on 4/15/2026 at 2:11 pm, NP stated she was never informed Resident #3 had a fall. She stated she had been notified of Resident #3's arm bruising and injury and had ordered x-rays which were completed in the facility. She stated she was notified of the x-ray results and reviewed the results. She stated her expectations on resident falls was that staff would assess the resident, report it and notify them so that if there is any need for imaging, labs, or injuries to be treated, she can provide orders for care. She stated that if residents were not assessed after a fall, there could be potential injuries that were not discovered or treated. She stated that depending on how the injury occurred, injuries that are not treated could result in long term issues. During an interview on 4/15/2026 at 2:54 pm, MD stated he was informed about Resident #3's fall after the fact when nursing staff discovered a fall had occurred the week prior. MD stated it was possible that the fall contributed to Resident #3's injury, but due to the length of time between when the fall occurred and the injury was discovered he can't say one way or the other. He stated his expectations were that staff would assess the resident, notify providers of the fall details and any trauma, bruising, pain, or injury discovered during their assessment. He stated his potential concerns around residents not being assessed would be delays in care, lack of documentation and not being able to appropriately treat a resident. A facility policy on PICC line removal was requested but not provided prior to exit. Review of the undated facility procedure on PICC Line Removal provided, reflected no instructions/guidance on removal of PICC prior to discharge. A facility Policy on Quality of Care dated revised 7/2020 reflected: 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. Record Review of facility policy Fall Management System dated 4.2025, reflected:3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.a. The attending Physician and Resident Representative shall be notified of the fall and the resident status.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure food was properly labeled and dated.This deficient practice could place residents who ate food served from the kitchen at risk for health complications and foodborne illnesses.Findings included:An observation on 02/10/2026 at 9:18 AM in the facility's walk-in cooler revealed 1 large plastic container of mayonnaise, 1 container of white meat chicken salad with cranberries and pecans, and 1 container of chopped dilled relish that was not labeled or dated. In an interview on 02/12/2026 at 12:33 PM, KW A stated he was trained on labeling and dating recently and that all food should be labeled and dated after they were opened, and if this was not done then residents could become sick.In an interview on 02/12/2026 at 12:41 PM, KW B stated she had been in-serviced recently on food labeling and dating and it should be done on every item that was opened, to ensure residents did not eat expired food.In an interview on 02/12/2026 at 12:45 PM, [NAME] A stated he was recently trained in hand hygiene and food labeling and dating and that all items in the kitchen should be labeled and dated as soon as they were opened to prevent serving expired items to residents.In an interview on 02/12/2026 at 12:52 PM, KM A stated it was his expectation that all items in the kitchen be labeled and dated, and he used the rule 'first in first out'. He stated if food was not labeled correctly, it could be expired and cause harm to a resident like salmonella poisoning. He stated he instructed his staff to use the superior store safe labels to help with labeling and dating in the kitchen.In an interview on 02/12/2026 at 1:24 PM, the ADM stated she expected all staff to follow the food policy on labeling and dating. She stated if the policy was not followed the facility could potentially serve expired food to residents.In an interview on 02/12/2026 at 1:30 PM, the DON stated that all foods items should be labeled and dated as food was received in the kitchen, and if that was not done, they could serve expired food items to residents. She stated she required all staff to check expiration dates on all items.Review of the facility's policy titled, Resident/Personal Food Storage/Rethermalization-Microwaving/Hot Liquids undated, revealed: Food brought to the facility by family members or friends will be handled according to safe food handling guidelines. Designated staff will monitor foods and beverages brought in from outside sources for storage in facility pantries or refrigeration units. 1. Food storage areas shall be clean at all times.5. All perishable foods must be dated, labeled and will be disposed of after 72 hours or by package expiration date. Foods must be in original packaging, sealed and dated from an approved vendor/store.

Based on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility's reviewed for qualifications of a Social Worker. The facility, licensed for 121 beds, did not employ a full-time, qualified social worker. This failure could place residents at risk for unmet social services and psychosocial needs. Findings included: Review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) dated 02/10/2026 reflected the facility had a total licensed capacity of 121 beds. Review of the Key Staff Roster, undated, provided by the ADM on 02/10/2026 to the state surveyor, revealed no personnel named next to the job title Social Services Director. In an interview on 02/12/2026 at 11:14 AM with the ADM, she stated that the facility had been without a qualified social worker since the last week of January 2026. She stated that they had an assistant social worker currently employed, but that individual was not licensed nor had the educational requirements for a nursing facility social worker. She stated that the facility would utilize social workers from their sister facilities, but there was not a full-time social worker employed at the facility since the last one was terminated due to their failure to become a licensed social worker. In an interview on 02/12/2026 at 12:09 PM with the ASW, she stated that she had been working at the facility for 8 years and serving as the ASW for the past 2 years. She stated that the prior 6 years, she served as a CNA, and that her CNA license was still active. She stated she did not have a bachelor's degree, and that her highest level of education was a high school diploma. She stated her role responsibilities included handling discharges, grievances, conducting PHQ-9 assessments, and BIMS assessments. She stated if there were grievances that she could fix right then, she would, but that every grievance she received she took to the DON and/or ADM for them to follow up with the griever and come to a resolution. She stated the qualified social worker left the facility about 2 weeks ago. She stated that when the qualified SW was here, there was no real difference in role responsibilities between the 2 of them. In an interview on 02/12/2026 at 2:39 PM with ADM A, she stated the facility did not, at the time of the annual survey, have a qualified social worker employed at the facility. She stated they were looking for a qualified social worker through job postings. She stated that she was in the process of conducting interviews. She stated that anyone could conduct a PHQ-9 (9 item self-report questionnaire used to screen for depression and assess its severity) and/or BIMS assessment. She stated that she was considered the grievance official, and that the social worker receives them. In an interview on 02/12/2026 at 2:47 PM with ADM B, she stated that she helped the facility with social services assessments and helped answer questions about discharge. She stated that she was usually the person the facility and their other sister facilities could ask social work questions to. She stated that prior to her becoming an ADM at a sister facility, she was the ADM at this facility. She stated that she was at this facility fairly often, and families could reach out to her. She stated that she was not currently a full-time social worker at this facility. She stated that BIMS and PHQ-9's could be conducted by different disciplines.

Based on interview and record review, the facility failed to ensure the proper coordination of PASARR assessments for 1 (Resident #41) of 7 residents reviewed for PASARR screenings and evaluations. The facility failed to refer Resident #41 for a PASARR Level II evaluation despite her PASARR Level 1 indicated a diagnosis of MI. This failure could place residents with no PASARR Level II Evaluation at risk of not receiving specialized care and services to meet their needs or obtain their highest practicable well-being.Findings included: Review of Resident #41's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: aphasia (communication disorder caused by damage to the brain that affects a person's ability to speak, understand, read, or write), malnutrition (imbalance in a person's intake of energy and nutrients, affecting overall health and development), bipolar disorder (extreme mood swings that affects the ability to think clearly), cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes), and senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond normal aging). Resident #41 had a BIMS score of 07-indicating severe cognitive impairment. Review of Resident #41's comprehensive care plan dated 01/03/2025 reflected Resident #41 was care planned for being at risk for impaired cognitive function/dementia or impaired thought processes r/t bipolar disorder. The interventions included social services to provide psychosocial support as needed. She was also care planned for potential for a psychosocial well-being problem r/t report of lack of interest. The interventions included: pastoral care, social services, and psych services. In an interview on 02/12/2026 at 1:09 PM with the MDSC, she stated that she started working at the facility on 9/4/2025. She stated that the person who was in her position before she started there, had 2 PL1's for Resident #41 put into the system. She stated the 1st PL1 was incorrect, and the 2nd PL1, the system did not accept, and no one followed up to ensure the correct PL1 was transmitted. She stated that since the PL1 was not transmitted, it would not have alerted the LMHA to go conduct the PE for Resident #41. The MDSC stated that she would be responsible for filling out a 1012 form, which was a correction to the PL1, and then the LMHA would be notified to go to the facility and conduct the PE. In an interview on 02/12/2026 at 2:33 PM, with the ADM, she stated that she was aware that the 2nd (corrected) PASARR for Resident #41 did not get transmitted through the system. She stated that the previous MDSC had submitted those PASARR's. She stated that the current MDSC she had at the facility was very familiar with PASARR and submission guidelines. She stated that she did not think there would be a negative impact to Resident #41 because she was sure the resident would not qualify for services, but residents could lose out on additional services they qualified for. Review of the 'PASRR in the NF Participant Manual' dated 8.13.2018 provided by the facility revealed under the 'Nursing Facility PASRR Responsibility Checklist' Ensure positive Preadmission PL1's are faxed to the Local Intellectual and Developmental Disability (LIDDA) or Local Mental Health Authority (LMHA) and Monitor the Long-Term Care (LTC) online portal daily for alerts.

Based on observation, interview, and record review the facility failed to establish a system of accurate reconciliation and removal of expired/discontinued medications from nursing med carts for 1 (500-hall med cart) of 4 med carts reviewed for pharmacy services and medication storage. The 500-hall nursing medication cart had a box of lubricant eye drops labeled for Resident #13 with an expiration date of 01/2026. The 500-hall nursing medication cart had two boxes of wound dressing with antibacterial silver with an expiration date of 07/01/2025. These failures had the potential risk of affecting 24 residents on 500-hall receiving medications from 500-hall med cart which could place them at risk for having non-therapeutic levels of medications and delayed healing.Findings included: In an observation on 2/11/2026 at 9:58 a.m. the 500-hall's nursing medication cart revealed a box with lubricant eye drops (for temporary relief from dry, burning, and irritated eyes) labeled for Resident #13 with an expiration date of 01/2026. In an observation on 2/11/2026 at 9:58 a.m., the 500-hall nursing medication cart had two boxes of wound dressing with antibacterial silver with expiration date of 07/01/2025. In an interview on 2/11/2026 at 9:08 a.m. with LVN B, she said she was trained on following medication storage policy a few months ago. She stated that this training included verifying each medication for expiration dates before administering medications to the residents and daily med carts checks when working on medication carts. She stated that charge nurses and medication aides were responsible for checking their medication carts daily for expiration dates and removing expired/discontinued medications from the med carts. She stated that potential risk to residents if they received expired medications could be not receiving the full therapeutic effect of medication. LVN B stated that expired wound dressing could reduce effectiveness of treating wounds. In an interview on 2/12/2026 at 1:36 p.m. with ADON B, he said he was trained on the facility's policy on medication storage annually and periodically throughout the year. He stated that each charge nurse and medication aides were responsible for cleaning each cart, checking for expired/discontinued medications and removing them from medication carts. He stated that DON and ADONs were auditing medication carts once a week. ADON B stated that when administered expired medication, it provided less therapeutic benefits for residents. In an interview on 2/12/2026 at 3:26 p.m. with the DON, she stated that she was trained on the facility's medication storage annually. She stated that staff was in-serviced throughout the year and on 02/11/2026 to check medication carts daily for any expired medications and remove from carts. She stated that expired medications if not administered could not harm residents in example of Systane lubricant eye drops for Resident #13. The DON stated that medications should be removed from the med carts if expired or discontinued to reduce risk of administering expired medication to residents. She stated that potentially if expired medications were administered to residents, it could reduce the therapeutic effect of medication to treat their medical conditions. In an interview on 2/12/2026 at 4:06 p.m. with ADM A, she said she did not have any training on medication storage, but all nursing staff were trained on medication storage and were supposed to verify medication expiration dates before administering medications and remove expired medications from the medication carts. She stated that DON, ADONs, charge nurses and medication aides were responsible for monitoring their medication carts for expiration dates and proper labeling medications. She stated that potentially if not properly labeled and provided expired medication to residents, it would not provide intended therapeutic effect to treat their medical conditions. Record review of Resident #13's face sheet, dated 2/12/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute embolism (clot traveling to block a blood vessel) and thrombosis (clot forming in a blood vessel) of left lower extremity, type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar resulting from insulin resistance), and unspecified glaucoma (a group of eye diseases that damage the optic nerve-often due to high eye pressure-leading to permanent vision loss or blindness if untreated). Record review of Resident #13's None of the above MDS assessment, dated 02/16/2026, revealed Resident #13's BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #13's Care Plan, created on 01/29/2025, reflected Resident #13 was at risk for impaired visual function related to Glaucoma with interventions to monitor/document/report to MD signs and symptoms of acute eye problems including blurred or hazy vision. Record review of Resident #13's active orders, dated 02/12/2026, revealed that Resident #13 did not have an active order for Systane lubricant eye drops. Record review of facility's In-Serviced Training Report, dated 02/11/2026, revealed training on removing expired medications and pills from medication carts. This in-service was reviewed and signed by 11 nurses including LVN B.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the open date for insulin for 1 (300-hall med cart) of 4 med carts reviewed for medication storage. The 300-hall nursing medication cart had an insulin pen labeled for Resident #39 and was not labeled with an open date. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of their medications and a decline in health status.Findings included: In an observation on 2/11/2026 at 10:18 a.m., the 300-hall nursing medication cart revealed an insulin pen with 100 units/ml for Resident #39 without open date information available. Record review of Resident #39's face sheet, dated 2/12/2026, revealed a 79-years-old male admitted on [DATE] and readmitted on [DATE]. Resident's #39's diagnoses included type 2 diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar resulting from insulin resistance), alcoholic fatty liver (the earliest, often asymptomatic, stage of alcohol-related liver disease, caused by fat accumulation in liver cells due to heavy drinking) and cognitive communication deficit. Record review of Resident #39's quarterly MDS assessment, dated 1/30/2026, revealed BIMS score of 13 indicating intact cognition. Record review of Resident #39's care plan, dated 12/12/2023, revealed Resident #39 had Diabetes Mellitus with Diabetes medication administered as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #39's orders, revealed that Resident #39 had an active order, started on 01/09/2024, for Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 1u; 201 - 250 = 2units; 251 - 300 = 3units; 301 - 350 = 4units; 351 - 400 = 5units CALL Medical Doctor IF Blood Sugar OVER 400, subcutaneously before meals and at bedtime for HYPERGLYCEMIA (high blood sugar). In an interview on 2/11/2026 at 10:16 a.m., with LVN A, he said he received the medication storage in-service 2-3 months ago. He stated that each charge nurse or medication aide was responsible for checking their medication carts daily to make sure every medication was labeled correctly and expired medications removed from the cart. LVN A stated he was off for two days and did not clean the cart, but usually he did it every day. He stated that he did not give insulin to Resident #39 this morning as he did not require additional insulin on his sliding scale. He stated that this insulin pen was already on the cart when he started his shift this morning and he was not sure how long this pen was on the 300 Hall med cart. He stated that according to the facility policy insulin must be dated when opened and discarded after 28 days. He stated that unopened insulin was kept in the refrigerator in the medication room and brought to the cart just before it was ready to be opened. In an interview on 2/12/2026 at 1:36 p.m. with ADON B, he said he was trained on the facility's policy on medication storage annually and periodically throughout the year. He stated that each charge nurse and medication aides were responsible for cleaning each cart, checking for expired/discontinued medications and removing them from medication carts. He stated that DON and ADONs were auditing medication carts once a week. He stated that insulin should be dated immediately as it got on the nursing med carts. He stated that if not dated it would be hard to know when it was opened and expired 28 days after opening. ADON B stated that when administered expired medication, it provided less therapeutic benefits for residents. In an interview on 2/12/2026 at 3:26 p.m. with the DON, revealed she was trained in the facility's medication storage annually. She stated that staff was in-serviced throughout the year and on 02/11/2026 to check medication carts daily for any expired medications and remove from carts. She stated that unopened insulin pens should be refrigerated in medication rooms. She stated that once insulin was placed on nursing med carts and before opening, they should be labeled with open date and discarded after 28 days. She stated that potentially if expired medications were administered to residents, it could reduce the therapeutic effect of medication to treat their medical conditions. In an interview on 2/12/2026 at 4:06 p.m. with ADM A, she said she did not have any training on medication storage, but all nursing staff were trained on medication storage and were supposed to verify medication expiration dates before administering medications and remove expired medications from the medication carts. She stated that DON, ADONs, charge nurses and medication aides were responsible for monitoring their medication carts for expiration dates and proper labeling medications. She stated that potentially if not properly labeled and provided expired medication to residents, it would not provide intended therapeutic effect to treat their medical conditions. Record review of facility's Preparation for Medication Administration policy, revised 11/13/2018, indicated that 3. Vials and Ampules of injectable medications. b. The date opened and the initials of the first person to use the vial and recorded on multidose vials) on the vial label or an accessory label affixed to that purpose. Record review of facility's In-Serviced Training Report, dated 02/11/2026, revealed training on removing expired medications and pills from medication carts. This in-service included information on insulin multi vials should be dated and discarded after 28 days reviewed and signed by 11 nurses including LVN A.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for resident records. The facility failed to ensure Resident #1's medication and treatment was documented in PCC for 12/06/2025, 12/09/2025 and 12/11/2025.This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs. Findings included:A record review of Resident #1's face sheet, dated 12/12/2025, reflected an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (body does not make enough insulin), muscle weakness (loss of muscle strength), hypertension (high blood pressure), and congestive heart failure (heart muscle weakens or stiffing failing to pump enough oxygen to meet the body's needs).A record review of Resident #1's care plan, dated 12/12/2025, reflected Resident #1 had diabetes with interventions to give diabetes medication as ordered.A record review of Resident #1's care plan, dated 12/12/2025, reflected Resident #1 had a suprapubic catheter (tube inserted through a small cut in lower abdomen above pubic bone to drain urine directly from the bladder when normal urination is difficult or impossible) with interventions to change catheter bag tubing as ordered and to monitor, record and report symptoms.A record review of Resident #1's care plan, dated 12/12/2025, reflected Resident #1 had acute/chronic pain r/t low back pain with interventions to anticipate the need for pain relief and respond immediately to any complaint of pain.A record review of Resident #1's Quarterly MDS assessment, dated 11/02/2025, reflected Resident #1's BIMS score of 11 indicated moderate cognitive impairment.A record review of Resident #1's physician's order, dated 10/27/2025, reflected Humalog Kwik Pen Subcutaneous Solution Pen-Injector (pre-filled disposable pen delivery rapid-acting insulin to quickly lower blood sugar) 100 unit/ML before meals and at bedtime for diabetes.A record review of Resident #1's physician's order, dated 10/28/2025, reflected Lidocaine external patch (pain reliever that numbed the skin and block nerve signals) be applied to the hip and lower back topically one time a day for pain and remove per schedule.A record review of Resident #1's physician's order, dated 10/28/2025, reflected air mattress check placement and function every shift. A record review of Resident #1's physician's order, dated 10/28/2025, reflected air mattress to bed every shift.A record review of Resident #1's physician's order, dated 10/28/2025, reflected apply barrier cream to coccyx/sacrum and bilateral gluteal (bones at bottom spine connecting to pelvis /hip stabilizer) every shift.A record review of Resident #1's physician's order, dated 10/28/2025, reflected suprapubic catheter care every shift to monitor the S/P insertion site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristics, secretions, and catheter pulling causing tension every shift.A record review of Resident #1's physician's order, dated 10/30/2025, reflected suprapubic catheter care was to apply new spit sponge (disposable oral care swabs)as needed if soiled and apply A & D ointment (a skin protectant to help relieve and heal minor skin irritations and conditions) around stoma site (opening that collected waste) to prevent skin breakdown every shift.A record review of Resident #1's physician's order, dated 11/08/2025, reflected acetaminophen - codeine tablet (pain reliever) 300-30 MG, one tablet by mouth every eight hours for pain.A record review of Resident #1's MAR, dated 12/09/2025, reflected Humalog Kwik Pen Subcutaneous Solution Pen-Injector (pre-filled disposable pen delivering rapid acting insulin to quickly lower blood sugar) 100 unit/ML before meals and at bedtime diabetes was not signed off as given by LVN A at 4:30 p.m. on 12/09/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected suprapubic catheter care every shift monitor S/P insertion site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristics, secretions, and catheter pulling causing tension every shift was not signed off as completed by LVN A the morning shift A record review of Resident #1's MAR, dated 12/06/2025, reflected Lidocaine external patch (pain reliever that numbed the skin and block nerve signals) be applied to the hip topically one time a day for pain and removed per schedule was not signed off as given by Med Tech B at 9:59 PM on 12/06/2025.A record review of Resident #1's MAR, dated 12/06/2025, reflected Lidocaine external patch (pain reliver that numbed the skin and block nerve signals) be applied to the lower back topically one time a day for pain and removed per schedule was not signed of as given by Med Tech B at 9:59 PM on 12/06/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected air mattress check placement and function every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected air mattress check placement and function and air mattress to bed every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025A record review of Resident #1's MAR, dated 12/11/2025, reflected apply barrier cream to coccyx/sacrum and bilateral gluteal (bones at the very bottom of spine, forming the base of the vertebral column and connecting to the pelvis) every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR dated 12/11/2025 reflected suprapubic catheter care was to apply a new spit sponge(disposable oral care swabs) as needed if soiled and apply A & D ointment (a skin protectant to help relieve and heal minor skin irritations and conditions ) around stoma site (opening that collected waste) was not signed off on completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR, dated 12/06/2025, reflected acetaminophen - codeine tablet (pain reliever 300-30 MG, give one tablet by mouth every eight hours for pain was not signed off given by Med Tech B at 10:00 p.m. on 12/06/2025.During an interview on 12/12/2025 at 1:20 p.m., Resident #1 stated he did not have any care concerns and received his medications and treatments timely. Resident # 1 stated he had not missed medications and treatments, and he was safe at the facility.During an interview on 12/12/2025 at 5:31 p.m., LVN A stated on 12/09/2025 he checked Resident #1's blood sugar at 4:30 p.m.PM and administered Humalog Kwik Pen Subcutaneous Solution Pen-Injector (pre-filled disposable pen delivery rapid-acting insulin to quickly lower blood sugar) LVN A did not recall the until amount of insulin given but stated he administered to Resident #1 but did not document in PCC (electronic medical record) given. LVN A stated on 12/11/2025 the morning shift he checked Resident #1's air mattress, catheter care, and placement of barrier cream to the sacrum (bones at bottom spine connecting to pelvis) was completed but the MAR was not signed off on.During an interview on 12/12/2025 at 5:41p.m., Med Tech B stated she administered Resident #1's the acetaminophen - codeine tablet (pain reliever) 300-30 MG on 12/06/2025 at 10:00 p.m. PM. Med Tech B stated she removed the lidocaine external patch from the left hip and lower back at 9:59 PM. Med Tech B stated she was not able to document right then as she was helping with other nursing duties. Med Tech B stated it was important to document medications and treatments were given to confirm it was given. Med Tech B stated it was important to ensure medication was given to prevent pain.During an interview on 12/12/2025 at 2:27 p.m., the DON stated it was expected for Med Tech B and LVN to have signed off on the medication and treatment given. The DON stated the MAR not signed off indicated the medication or treatment was not given and could worsen symptoms.During an interview on 12/12/2025 at 6:40 p.m., the ADM stated it was expected for LVN A and Med Tech B to have signed off on Resident # 1's MAR to ensure documentation was completed. The ADM stated the MAR not signed indicated it was not completed and could cause further complications.Record review of the facility's policy, dated 10/2015, titled Documentation and Charting reflected, It is the policy of this facility to provide:1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.2. Guidance to the physician in prescribing appropriate medications and treatments.3. The Facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.4. Nursing service personnel with a record of the physical and mental status of the resident.5. Assistant in the development of a Plan of Care for each resident.6. The elements of quality medical nursing care.7. A legal record that protects the resident, physician, nurse and the facility.8. A source of all resident charges.Procedures:9. For Charting ErrorsA. Do not erase any error. Erasure of any type may not be made in the medical record.B. Draw a single line through the error and write the correction above the error. For electronic charting, the author of the not can strike out the entry. This will draw a line over the note without deleting it.10. Follow-Up-Notes:Documentation relating to follow-up notes should include:A. A summary of the resident's condition, until the resident is stable.B. Documentation that the resident's condition has stabilizedC. Signature and title of person recording the data.

Based on observation, interviews, and record review, the facility failed to ensure residents were afforded rights, including the right to self-determination, for 1 of 6 residents (Resident #1) reviewed for resident rights.The facility failed to ensure Resident #1's Statutory Durable Power of Attorney (DPOA) was appropriately executed in that its elected agents and witness were facility staff, which posed a conflict of interest and the potential for impropriety, and it was implemented during a time in which the resident's capacity to consent was in question. This failure created a dual relationship between the resident and staff and a conflict of interest which could have placed the resident at risk of harm, fraud, exploitation, and/or other legal and medical complications.Findings include:Record review of Resident #1's face sheet revealed a [AGE] year-old male whose most recent admission to the facility was on [DATE], with an initial admission date of [DATE], and an original admission date of [DATE]. The other contacts listed were for a friend and next of kin. Resident #1's diagnoses include in part: Fracture of unspecified part of neck of right femur (thigh bone), onset date: [DATE], Type 2 Diabetes Mellitus (a condition that happens when the body cannot use insulin correctly and sugar builds up in the blood) with foot ulcer (open sore), onset date: [DATE], Cerebral Infarction, Unspecified (a type of stroke where the specific cause or location is not detailed), onset date: [DATE], and Cognitive Communication Deficit (difficulties in communication stemming from impairments in cognitive processes, impacting daily interactions and effective information exchange), onset date: [DATE]. Resident #1's code status was listed as DNR. Record review of Resident #1's face sheet showed that Resident #1's most recent admission was from an acute care hospital, with the hospital stay lasting from [DATE]-[DATE]. Resident #1 was listed as his own Financial Responsible Party with his niece being listed as Emergency Contact #1, Care Conference Person.Observation of Resident #1 was made on [DATE] at 1:05 PM. The resident was pointed out by staff while sitting in the dining room. The resident was observed to be dressed appropriately with good hygiene. Resident #1 sat in his wheelchair at a dining table . Interview with Resident #1 was attempted but it was apparent that his use of the English language was limited , and he only answered in yes or no phrases . The resident affirmed that he was doing okay, that staff treated him well, and he his needs were met. The resident made these affirmations by saying, Yes and nodding his head. During an interview with ADM and DON on [DATE] at 11:20 AM, ADM revealed that Resident #1 and his family/fictive kin ((individuals who are not biologically related but are considered part of one's family) were Jehovah's Witnesses. ADM stated this created a conflict with the assignment of a POA due to religious beliefs. Per ADM, the family/fictive kin did not believe in blood transfusions or other life saving measures and the resident initially designated his code status to be a full code, a medical status in which all available life-saving treatments are used. ADM stated the resident's cognitive status has fluctuated during his time in the facility and he has been in and out of the state of confusion, but the resident has been able to elect his medical care and procedures. ADM stated that the facility has consulted with their legal department, and it was felt that the appointment of a guardian was in the best interest of the resident. ADM stated that appointments are being sought through the local courts. ADM stated that this is a long process in this county and no appointment has been made yet. ADM stated the application process began in [DATE]. ADM claimed that the lack of a designated POA has not interfered with the resident's care. In an interview on [DATE] at 12:43 PM, SW A with a local hospital, indicated they were involved in the discharge planning of Resident #1 during his most recent hospital stay. SW A stated on or about [DATE], she reviewed the DPOA provided for Resident #1 and questioned its legality as it listed SSA and SSM as the Resident's agents, but Resident #1 had no designated medical decision maker. SW A stated that she spoke to the facility (possibly ADM) and highly suggested they apply for guardianship on behalf of Resident #1. The facility stated they would speak to their liaison. SW A stated Resident #1 was confused throughout his stay, unable to make his own decisions, and lacked family willing to serve as POA. SW A stated this made Resident #1 appropriate for guardianship. SW A stated the hospital was able to secure a valid out of hospital DNR on behalf of Resident #1 prior to his discharge on [DATE]. SW A stated the documentation provided by the facility did not include a valid medical POA.In an interview on [DATE] at 1:05 PM, DON stated that Resident #1 is able to understand English, but his understanding was limited. In an interview on [DATE] at 1:15PM, SSA verified she was an assistant to the facility's SW. SSA stated that she had been employed with the facility for 8.5 years, starting as a CNA, then moving into the transporter role, and then as an SSA. SSA stated Resident #1 was initially homeless and taken in by friends. Resident #1 was assaulted and hospitalized . He was discharged to the facility and is now a LTC resident. SSA stated that Resident #1's emergency contact is listed as the resident's niece , but she really isn't biologically kin to the resident. She was not considered the resident's RP but was included in care plan meetings. SSA stated that the need for a POA came up during a care planning meeting. Resident #1's niece refused to fulfill that role. Resident #1's next emergency contacts also declined to serve in the role of POA as well. SSA stated that Resident #1 chose his code status. SSA stated that Resident #1 is Spanish speaking only, but SSM explained to the resident what a code status was, and the resident elected to a code status of DNR. SSA stated that when the decision-making process was explained to Resident #1's next-of-kin or emergency contacts and the need for a POA, they all said they did not want to be the designator due to possible financial and physical implications. SSA claimed at the time Resident #1 signed the DPOA naming her as his agent, he was clear, sound mind and was alert and oriented. SSA stated that initially Resident #1's code status was full code, but the hospital had DNR paperwork and so the resident's code status was changed. SSA stated that the hospital case manager advised facility staff of the possible conflict regarding the DPOA the resident signed naming SSA and SSM as his agent. SSA stated that she and SSM felt the DPOA was appropriate because no one else wanted to fulfill that role and SSA was close to the resident and cared for him and would purchase items for him that he needed. SSA stated that they consulted with their legal department about this and were told this type of agreement was allowed and legal. SSA stated it was SSM who made the call to their legal department. SSA stated that it was felt that the DPOA signed was in the best interest of the resident and was legally appropriate. SSA claimed that she and SSM only signed as witnesses but the resident signed for themself. SSA denied they were ever designated as POA. SSA stated that typical POA duties would have included relaying the resident's wishes and decisions to others, speaking on the resident's behalf, and moral support. SSA further explained that a POA covered medical related issues. But if the resident was alert and oriented, the resident would make their own decisions. SSA stated if the resident's cognition was off then the agent would make the decisions but not financial decisions. SSA stated that SSM handles these types of issues or designations and SSA takes directive from SSM. SSA stated that she and SSM are neither the POA nor DPOA now. SSA stated there are no other residents that have declared SSA or SSM as their agent or POA. In an interview conducted on [DATE] at 2:30 PM, ADM stated that Resident #1 signed himself in for care at the facility and that Resident #1 was alert and oriented at that time. ADM stated Resident #1 was a full code status upon admission. ADM stated that residents' code status is revisited and discussed at every care planning meeting. ADM confirmed that care planning meetings occur every 3 months. ADM stated that the facility always had a translator available through a language line service if needed. ADM stated SSM spoke Spanish as well. ADM stated Resident #1's first language was Spanish, but he also spoke English. ADM stated that the DPOA that was signed naming staff as Resident #1's agents was never utilized. ADM stated an out of hospital DNR was obtained by the hospital during the resident's most recent admission. ADM stated that Resident #1 has overseen his own finances throughout his time at the facility. ADM stated Resident #1 signed a DNR on [DATE] after the need for such was identified. ADM stated that SSA or SSM never acted outside their legal scope regarding the DPOA. ADM stated that their legal department was consulted and ATY A advised them guardianship should be sought on behalf of Resident #1 and staff should not be listed as the Resident's agents. ADM stated that Resident #1 is listed as their own primary decision maker because the family did not want to act on his behalf. ADM was advised that no filing for guardianship could be located or established. ADM then stated she was unsure of the status of the guardianship application as SSM was handling that. ADM also stated that SSM explained to ADM that the utilization of the DPOA for these purposes was a common practice at her former place of employment and SSM did not think it was considered inappropriate. An interview was attempted on [DATE] at 3:00 PM with ATY A, but contact could not be established. A message was left for ATY A requesting a return telephone call, but none was received.In an interview on [DATE], at 3:00 PM, ADM stated that ATY A was out of the office and could not be reached. ADM stated that she contacted their legal department on this date prior to this interview and was told the directive given by ATY A was all that could and should be provided. Per ADM, their legal department confirmed the DPOA was not the most appropriate course of action and guardianship should have been sought. ADM stated that she also spoke to SSM who stated that SSM was advised to begin the due diligence process for the appointment of a guardian, which she had started by locating 2 additional family members. Per ADM, the legal process had not been initiated because it takes time to complete the due diligence process. In an interview on [DATE] at 3:40PM, SSM stated she began her employment with this facility in February 2025. SSM stated that she is a licensed SW and has experience and knowledge of the geriatric population. SSM stated that she became aware of the need for a POA for Resident #1 at a care planning meeting. SSM stated Resident #1 wanted SSA to be his POA. SSM stated that she did not consult with their legal department prior to implementation of the DPOA. SSM said that ADM did consult with their legal department after the implementation. SSM stated that the hospital SW brought the issue to ADM's attention and ADM then contacted their legal department. SSM stated that she anticipated Resident #1's lack of family would become a problem, so she contacted their OMB on or about [DATE]. SSM stated no response was received from OMB so they proceeded with the POA that was implemented in [DATE]. SSM stated that several care conferences were held between [DATE], and [DATE], discussing the need for a POA; however, SSM admits the documentation is missing from PCC. SSM stated that she has counseled SSA on the importance of inputting these notes. SSM stated that she does have her own notes though and read from them over the phone. SSM stated that on [DATE], SSA made arrangements with Resident #1's niece to come in to sign a POA but the niece did not show. SSM stated that there has been no formal application or legal filing made regarding guardianship for Resident #1 as she needed to get her ducks in a row and became stuck during the process. SSM stated that she had attempted to contact the courts to determine what would be needed but she was unable to establish contact. SSM stated that she anticipated the need for a medical certification, which she obtained, and a possible psychological evaluation. She stated that she planned to seek this evaluation when she returned to the office after the holiday. SSM stated at this time, she and SSA are still the legal agents for Resident #1 and are responsible for the duties listed in the DPOA.An interview with OMB A was attempted on [DATE] at 3:12 PM. Contact was not established at that time but was later established. OMB A stated that under these circumstances, they would have instructed staff to seek guidance from their legal team as the relationship the DPOA established with staff could be considered a conflict of interest. OMB A stated that they were not contacted by facility staff in relation to this issue or this resident.Record review of Resident #1's admission Agreement implemented and signed by the resident on [DATE], revealed in part:The Facility may petition a Court to appoint a Guardian and/or take other legal action if the Facility reasonably believes that the Resident's needs are not being properly met, or the duties imposed by this Agreement are not being fulfilled by the Resident Representative.The admission Agreement was signed by Resident #1. Resident #1 did not identify or elect a Resident Representative in the agreement. Record review of the DPOA signed by Resident #1 on [DATE], revealed SSA (facility staff member) was elected as Resident #1's agent who was able to act for Resident #1 in any lawful way with respect to the following powers: Real Property Transactions Tangible personal property transactions Stock and bond transactions Commodity and option transactions Banking and other financial institution transactions Business operating transactions Insurance and annuity transactions Estate, trust, and other beneficiary transactions Claims and litigation Personal and family maintenance; Benefits from Social Security, Medicare, Medicaid, or other government programs or civil or military service Retirement plan transactions Tax matters Digital assets and the content of electronic communicationThe Special Instructions indicated by Resident #1 entitled SSA to reimbursement of reasonable expenses incurred on [NAME] behalf and to compensation that was reasonable under the circumstances. Resident #1 elected SSM (facility staff member) to be his successor agent in the event SSA died, became incapacitated, resigned, or refused to act, or was removed by court order. The DPOA was witnessed and notarized by another staff member at the facility. Record review of Resident #1's Progress Notes revealed the following: [DATE]: Social Services reviewed once more about signing a POA with niece once more she declined due to her religion. (Resident #1) wishes to be cremated and asked for assistance in securing affordable services. He indicated when it is time to go to let him go. SSD will update a code status change. [DATE]: SSA set up [name] funeral services to come out and meet with resident regarding cremation as resident would like to plan accordingly. [DATE] Social Services Summary written by SSM: met with.funeral director from [name]Funeral Home from [city] assisted in helping (Resident #1) honor his wishes of being cremated. Everything was discussed, completed [and witnessed].[preburial ] arrangements saved, and copy provided to (Resident #1) as well.Record review of the Certificate of Medical Examination for Guardianship revealed DO A personally examined Resident #1 on [DATE] and asserted their medical opinion that Resident #1 was incapacitated. DO A recommended the appointment of a guardian of the person and estate in order to protect Resident #1's health, safety, and financial interests.Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1 had a BIMS score of 2 out of 15, indicating severe cognitive impairment. Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1 had a BIMS score of 7 out of 15, indicating severe problems with thinking.Record review (online search) conducted on [DATE] at 2:55 PM, revealed no application, petition, or legal filing existed in relation to the guardianship of Resident #1 in the local County Court record system.Record review of the facility's policy and procedures regarding Resident Rights dated [DATE], and amended on [DATE], revealed residents have the right to be informed of, and participate in their treatment, the right to self-determination, the right to privacy and confidentiality, the right to a safe environment, the right to file grievances, the right to choose their attending physician, the right to information and communication, and the right to contact with external entities.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident no longer being treated for a yeast infection. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings Included: Review of Resident #1's face sheet dated 04/14/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included essential primary hypertension(a condition characterized by persistently elevated blood pressure without an identifiable underlying cause), unspecified dementia( where the underlying cause or specific type of dementia is not determined , despite a medical evaluation), and depression(sadness). Review of Resident #1's quarterly MDS assessment, dated 03/14/2025, reflected a BIMS score of 1, indicating she had severe cognitive impairment. Review of Resident #1 's care plan dated 04/13/2025 and date initiated 03/11/2025 reflected Resident #1 had an active yeast infection. Review of Resident #1's physician order dated 03/11/2025, reflected that Resident # 1 had order for Terconazole(antifungal medication used to treat yeast infections in the vagina) vaginal suppository 80 MG. Insert vaginally at bedtime for 3 days. Review of Resident #1's MAR revealed Resident # 1 received Terconazole vaginal suppository 80 MG on 03/12/2025, 03/13/2025, and 03/14/2025. During an interview with the ADON on 04/14/2025 at 2:15 PM, the ADON stated she was responsible for making sure the care plan reflected Resident #1 yeast infection had been resolved. The ADON stated she had missed updating Resident # 1 care plan to reflect it resolved. The ADON stated the care plan communicated care that needed to be provided to residents. The ADON stated if the care plan was not updated, the resident's need may not get met or resolved. During an interview with the DON on 04/14/2025 at 1:00 PM, the DON stated that Resident #1 was no longer being treated for a yeast infection. The DON stated that the ADON was responsible for updating the care plan to reflect Resident # 1 was no longer being treated for a yeast infection. The DON stated it was expected for the ADON to have updated the care plan to show Resident # 1's yeast infection had been resolved and was no longer being treated. During an interview with the ADM on 04/14/2025 at 4:01 PM, the ADM stated that the ADON was responsible for making sure Resident # 1's care plan indicated she was no longer being treated for the yeast infection. The ADM stated it was expected for the ADON to update the care plan to reflect Resident # 1 yeast infection had been resolved. Review of the facility policy Comprehensive Person-Centered Care Planning dated 11/2016 revised 12/2023 reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 Residents (Resident #162) reviewed for quality of care. The facility failed to ensure Resident #162 made follow up appointment with a wound care specialist. This failure placed residents at risk of condition exacerbation, psychosocial harm, and infection. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. The complainant alleged Resident #162 required 2 people to transfer her, but only 1 staff member was present. The complainant alleged Resident #162 received a wound, a huge gash to her leg. Resident #162 was rushed to the hospital where she received a blood transfusion. Upon her release, Resident #162 was supposed to have returned to see the wound care doctor on 11/6/2024, but the facility allegedly did not read the discharge papers and did not get her to the appointment. The Responsible parties for Resident #162 were extremely worried about the lack of care. Record review of Resident #162's AR, dated 11/13/2024, reflected a [AGE] year-old-woman who was admitted to the facility on [DATE]. She was diagnosed with muscle weakness, need for assistance with personal care (which was a diagnosed medical classification influenced by health status and needed support with health services), unsteadiness on feet, other reduced mobility, unspecified lack of coordination, other abnormalities of gait (manner of walking) and mobility, unspecified abnormalities of gait and mobility, Parkinson's disease (which was progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), other lack of coordination, body mass index 36.0-36.9-Adult , generalized anxiety disorder (which was a mental heal condition marked by heightened responses (worry) to certain situations and stimuli), and other recurrent depressive disorders (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life). Record review of Resident #162's Quarterly MDS Assessment, dated 8/13/2024, reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand;) Resident had no impairment in either lower extremity (hip, knee, ankle, and foot.) The resident utilized a wheelchair and a walker for mobility. The resident required partial/moderate assistance for eating, oral hygiene, and personal hygiene (which meant the helper provided less than half the effort while the resident completed the greater portion of the activity). The resident was dependent upon staff for toileting hygiene, showering/bathing self, and putting on/taking off shoes (which meant the helper provided all the effort of the activity). The received substantial/maximal assistance with upper body dressing (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Lower body dressing: not applicable, not attempted, and the resident did not perform this activity prior. The resident required substantial/maximum assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Record review of Resident #162's CCP reflected a Focus area for skin tear to left knee, initiated 11/2/2024, R/T transferring. The Goal, initiated on 11/5/2024, indicated the skin tear on the left knee would heal and the resident would be free from skin tears. The Intervention, initiated on 11/2/2024, delegated nursing facility staff to identify potential causative factors, notify Med. Dir., and family, of skin tears occur, prevent skin tears, monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces; a Focus area for potential/actual skin impairment to skin integrity, initiated 11/02/2024, R/T laceration to the left lower leg with sutures in place. Follow up with Physician at hospital on 11/12/2024. Enhanced Barrier Precautions ordered. An addition goal, initiated on 11/8/2024, indicated the resident would not have any complications R/T skin in jury type. The Interventions, initiated on 11/2/2024, delegated nursing facility staff to monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Record review of a facility communication for Resident #162, dated 11/2/2024, indicated Resident #162 experienced a change in condition on 11/2/2022 due to a skin laceration, puncture, or wound. The condition was a new condition and the resident experienced pain at the degree of 8 out of 10. At the time of the assessment, the skin wound, or ulcer, progress was unable to be determined. The resident was on anticoagulant therapy (blood thinner). Record review of a nursing home to hospital; transfer form, dated 11/2/2024, indicated Resident #162 transferred from the nursing home to a local hospital on 1/2/2024 for a skin wound, or ulcer. Blood pressure was 202/104. ADLs, such as bathing, dressing, transfers, toileting, and eating required assistance. Additional relevant information was resident saying laceration was received to the lower left leg during a transfer from the bed to wheelchair. Pressure bandage applied, 911 called, nurse practitioner, notified family, family visiting when accident occurred. (Form Incorrect-Transfer was from the wheelchair to the bed.) Record review of Resident #162's hospital discharge paperwork reflected Resident #162 presented to the emergency department from a local nursing home on 11/2/2024 at 8:50 PM with an acute left lower extremity bleeding from a wound that occurred today just prior to arrival. Height was 5 feet 6 inches; Weight was 183 pounds. Large lower extremity wound oozing blood. [NAME] blood cell counts on 11/2/2024 were first recorded at 5:38 PM results with 7.7 and again at 7:22 PM results 11.7. Principle Problem: Acute blood loss, anemia Secondary to left lower extremity injury. *Presented with acute onset bleeding from left lower extremity wound after injury at nursing home, currently on dual antiplatelet therapy. *Hypotensive with blood pressure in 80s/60s, status post (experienced a medical event) fluid bolus with improvement. *Hemoglobin 11.4 to 10.3 * Status post pressure dressing with Tranexamic Acid (medication to prevent bleeding) and lidocaine with epinephrine impregnated quick clot, achieving adequate hemostasis; status post 1 unit packed red blood cells emergently. *No overt signs of continued blood loss at this time. *Monitor Hereditary Hemochromatosis (a genetic disorder that causes iron to build up in organs) every 12 hours, transfuse if Red Blood Cells are less than 7, or active bleeding *Patient also requested wound care referral to wound care physician on discharge. *Blood pressure low on arrival; hold high blood pressure medications at this time in light of acute bleeding. Monitor blood pressure. *Resident admitted to the hospital from the emergency roiagnom on [DATE] at 7:24 PM for monitoring. *Handwritten, on the last page of the hospital discharge paperwork, dated 11/4/2024 indicated resident received 13 stitches to her left leg below the knee. *1 unit of blood. *Wound care order follow-up clinic on 11/6/2024 at 2:30 PM. *Do not bend knee for 1 week; not to be in wheelchair for more than 4 hours; keep leg straight. *Blood pressure was 150/70 at 11:30 AM 11/4/2024. * Resident discharged from the hospital to the nursing facility on 11/4/2024 at 1:48 PM *Resident was transported by a local transport company to the nursing facility on 11/4/2024. Record review of Resident #162's PN, dated 11/4/2024 at 3:19 PM, reflected Resident #162 had a follow-up visit on 11/6/2024 at 2:30 PM. Entered by LVN O. Record review of Resident #162's Skin Evaluation, dated 11/4/2024 at 4:46 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Entered by ADON Record review of Resident #162's TAR, dated 11/2024, reflected Resident #162 received Wound care treatment described in the resident's order summary report on 11/5/2024, 11/6/2024, 11/8/2024, 11/10/2024, 11/12/2024, and 11/15/2024. Record review of Resident #162's appointment request form. Appointment request form initiated on 11/6/2024 with a scheduled appointment for 11/12/2024 at 1:00 PM with wound care clinic off site from the facility. Record review of Resident #162's infection surveillance assessment, dated 11/10/2024 at 2:21 PM reflected Resident #162 developed an infection to her skin, soft tissue, and mucus membrane. Resident #162 was prescribed Doxycycline 100 MG 2 times a day for 7 days. Started 11/10/2024. Entered by LVN O. Wound care continued per order. Record review of Resident #162's PN, dated 11/10/2024 at 2:16 PM reflected an order for Resident #162 to start Doxycycline 100 MG 2 times a day for 7 days R/T wound infection. Entered by LVN O. Record review of Resident #162's Skin Evaluation, dated 11/10/2024 at 3:57 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Doxycycline 100 MG 2 times a day for 7 days for infection. Entered by LVN C. Record review of Resident #162's MAR, dated 11/2024, reflected Resident #162 received Doxycycline 100 MG 2 times a day for 7 days. The first dose was on 11/10/2024 at 4:00 PM. The medication continued through 11/15/2024 and was due to run the course on 11/17/2024 at 8:00 AM. Record review of the facility's transport schedule, dated 11/12/2024, reflected Resident #162 had an off-site appointment, with the wound care clinic, on 11/12/2024 at 1:00 PM. Record review of the facility's schedule book for 11/12/2024 reflected Resident #162 was transported to an off-site appointment, with the wound care clinic, on 11/12/2024 at 1:00 PM. Record review of a photo revealed the facility's appointment request box. The appointment request box was attached to the wall, just outside of the transporter's office. Record review of a blank appointment request form revealed spaces for a name of person completing form, date, specialty, reason for appointment, date, time, physician, address, city, state, zip code, contact number, required labs/x-rays/medications, resident name, room, and date of birth. Record review of the facility's appointment reminder flier was taped to the wall in the room of Resident #162. The appointment reminder was for an off-site appointment, with the wound care clinic, on 11/19/2024 at 2:00 PM. Observation and interview on 11/12/24 at 4:34 PM with Resident #162 revealed the resident in her room sitting in her wheelchair watching television. The resident was well groomed and in good spirits. She made appropriate eye contact and was easy to engage. The room was free from odors but was slightly cluttered. The interview revealed she was expecting a visit from someone from the complaint department. The resident explained that on 11/2/2024, she was helped in a transfer from her wheelchair to her bed by CNA P. During the transfer, the CNA was not able to hold her up and she hit her leg against a part of the bed that caused a tear in her skin. The mobility support bar, which was on the side of the bed where the transfer occurred, was unlocked from the vertical position to the horizontal position. She explained she was rushed to the hospital, where she stayed for about 2 days. While there, she received pain medication, an infusion of blood, and several stitches. She made mention she had just come back from the wound care doctor earlier that same say but was supposed to have seen the wound care doctor on 11/6/2024. When she asked staff why she did not get to her appointment, staff stated something about the transporter not getting the appointment information. Interview, observation, and record review on 11/13/2024 at 4:40 PM with Resident #162 and RP #1000, in Resident #162's room, revealed RP #1000 was concerned about the skin tear Resident #162 suffered, on 11/2/2024, and Resident #162 having missed her follow-up wound care appointment, on 11/6/2024. Record review of photos, provided by RP #1000, reflected the injury to Resident #162's lower left extremity. Looking at the photo, the picture of the left leg was viewed from the vantage point of the resident looking down at their leg. The left kneecap was at the 6 o'clock position, the left outer side of her left kneecap was at the 9 o'clock position, the left shin was at the 12 o'clock position, and the right inner side of her left kneecap was at the 3 o'clock position. The photos reflected a straight tear in the skin beginning just beneath, or at the same level, of Resident #162's left kneecap area (Spot A.) The tear began at the 3 o'clock position of the left kneecap area. The tear extended across the entire left kneecap area towards the 9 o'clock position for an approximate 2-3 inches. At the 2-3-inch mark, the skin tear curved towards the shin in the shape of the letter {C} for 2-3 inches in distance. At the bottom of the C shaped curve, the tear continued at a downward 45-degree angle for 2-3 inches towards the 1 o'clock position of the inner portion of the resident's left shin (Spot B.) The skin was still connected to the resident's lower extremity at Spot A and at Spot B leaving a loose flap of skin. Interview on 11/15/2024 at 11:58 PM with the former VDT revealed she used to be the transporter and had an extensive knowledge of the procedures to learn of, and make, appointments for residents. The current VDT was out on runs and was not available for interview. When a resident returned from the hospital, or an encounter with an off-site entity, the resident usually returned with some form of documentation. The nursing staff were supposed to review the documentation and enter required information into the resident's medical record. Based on the documentation, if a follow up appointment was to be made, the nursing staff were supposed to complete an appointment request for the resident and provide the request form to the VDT. The VDT would make the appointment, added it to the schedule, and placed a reminder in the resident's room. It was not the responsibility for the VDT to review medical records to look for appointment information. The former VDT was not aware Resident #162 missed an appointment on 11/6/2024, but was able to confirm by the schedule, and the appointment request form, there was an appointment for Resident #162 scheduled on 11/6/2024 for 11/12/2024. Record review of the files, or available information, in the VDT office did not reveal an appointment request for an appointment for Resident #162 that was supposed to have occurred on 11/6/2024. A safeguard in place to ensure the residents got appointments scheduled, was the VDT making a convenience copy of the documentation and reviewing it for clarity. Interview on 11/15/24 at 12:56 PM with Resident #162 revealed she knew, on 11/4/2024, she had an appointment on 11/6/2024 for a follow up with the wound care clinic. When 11/6/2024 came, the appointment did not happen. She spoke to a member of the nursing staff (specific name unknown) who was unable to confirm, or deny, the existence of an appointment. The VDT was not at the facility and could not elaborate on the issue with the appointment. She was not in pain on the day of the missed appointment, and she had not developed an infection. She stated she was concerned about her leg and was disappointed the facility did not get her to her appointment. She had moments of anxiety about the condition of her leg and her concern had grown to worry. The next day, 11/7/2024 or 11/8/2024, she learned she had a new follow up appointment on 11/12/2024 with the wound care doctor. The news of the upcoming appointment, which was several days away, did not reduce her worry about the condition of her leg. In fact, her worry intensified. She stated she was irritated and aggravated the facility did not make her appointment. On 11/8/2024 or 11/10/2024, she received wound care from the facility. During wound care, the nurse noticed an odor emitting from the resident's wound. Resident #162 was prescribed an antibiotic. After she learned of the infection, she hypothesized it would not have gotten infected if she had made her appointment on 11/6/2024. Having to wait a few days more for her appointment, on top of a new infection, made her angry. She made it to the doctor on 11/12/2024 for wound care and feels much better now. She has a weekly appointment for wound care, and her next appointment was scheduled for 11/19/2024. Interview on 11/15/2024 at 3:16 PM with LVN Q revealed the nursing staff reviewed the DC papers from the residents and coordinated with the VDT using an appointment request and submission to the appointment request box. The nursing staff could enter a progress note in the resident's medical record, as an option to remember, because papers get lost. If a nursing staff member entered an appointment into the medical record, they should have initiated the appointment request form. Follow up appointments for residents were important because residents obviously needed to have a health care provider follow up for a condition that needed further treatment. A resident's medical condition that needed further treatment but did not get further treatment due to a missed appointment, risked exacerbation, possible infection, or possible pain. Residents who missed an appointment for a medical treatment, were at risk of psychosocial harm, such as depression, anxiety, worry, or anger. A Safeguards in place to make sure residents got to their future appointments was documentation review and communication between nursing staff and the VDT for confirmation. Interview on 11/15/24 at 4:47 PM with the DON revealed the facility followed physician orders that described treatment on any resident's DC order. These recommendations were read by the nursing staff and then the appointment request was provided to the VDT to make the appointment. The orders for Resident #162, upon DC on 11/4/2024, indicated a follow-up appointment for wound care at an off-site entity on 11/6/2024. The resident did not get to her appointment. The DON was unable to confirm if the facility called the doctor for any new orders based on the resident missing her appointment on 11/6/2024. Wound care continued like it was ordered on 11/4/2024. The DON stated the follow-up appointments were important because of continuity of care. The Resident's, who missed appointments, risked interrupted continuity of care and the health risk varied depending upon the medical concern. The DON stated that Resident #162 was ordered [wound care orders] upon her return on 11/4/2024; [Do not bend left knee] and [Follow up appointment 11-6-2024] and [Not to be in wheelchair greater than 4 hours.] The Resident received orders to clean and pat wound dry and orders to treat every other day. On 11/10/2024, which was 4 days later then the missed appointment, the resident developed an infection in the wound. The resident was prescribed Doxycycline 100 MG BID for 7 days. The resident had her rescheduled follow up appointment on 11/12/2014. The DON could not state, as a matter of fact, that the delay in getting the resident to the physician's follow-up appointment caused her leg to get infected. She said the leg could have gotten infected at any point along the way, even if she did make the follow-up appointment on 11/6/2024. The DON stated she spoke to Resident #162 after she returned from the hospital, on 11/4/2024, for the skin tear. She stated Resident #162 had been scared due to the amount of blood, and its loss. She had not heard of any complaints from Resident #162's heightened anxiety for either the skin tear or missing her follow-up appointment. Interview on 11/15/2024 at 6:08 PM with ADM A revealed there was a disciplinary approach in place for residents to get to their follow-up appointments. The approach consisted of medical records review and any appointment requests were provided to the VDT. A safeguard in place, to ensure accurate appointment setting, was that the nursing staff checked the scheduling book to make sure appointments matched the orders, did not conflict with others, and could be provided. The ADONs followed up with the transporter to make sure the appointments were set per the physician order. It was important for residents to attend their follow up appointments because it was the physician request to follow up. Some negative outcomes for a resident missing a follow up appointment depended on the details for the appointment. Record review of the facility's Physician Orders policy, dated 7/2022, reflected it was the policy of the facility to accurately implement orders upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Record review of the facility's Transportation to Appointment Policy, dated 05/2027, reflected it was the policy of the facility to assist residents in arranging transportation to and from appointments when necessary. Record review of the facility's ADL policy, in the Quality-of-Care Section; dated 7/2020, reflected it was the policy of the facility that residents were 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.

Based on observations, interviews, and record review, the facility failed to ensure residents' environments remained as free from accident hazards as possible for 1 of 9 Residents (Resident #162) reviewed for environmental accidents. The facility failed to ensure Resident #162 was free from environmental hazards and accidents during a 1 person transfer from a wheelchair to a bed. This failure placed residents at risk of physical and psychosocial harm. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. The complainant alleged Resident #162 required 2 people to transfer her, but only 1 staff member was present. The complainant alleged Resident #162 received a wound, a huge gash to her leg. Resident #162 was rushed to the hospital where she received a blood transfusion. Upon her release, Resident #162 was supposed to have returned to see the wound care doctor on 11/6/2024, but the facility allegedly did not read the discharge papers and did not get her to the appointment. The Responsible parties for Resident #162 were extremely worried about the lack of care. Record review of Resident #162's AR, dated 11/13/2024, reflected a [AGE] year-old-woman who was admitted to the facility on [DATE]. She was diagnosed with muscle weakness, need for assistance with personal care (which was a diagnosed medical classification influenced by health status and needed support with health services), unsteadiness on feet, other reduced mobility, unspecified lack of coordination, other abnormalities of gait (manner of walking) and mobility, unspecified abnormalities of gait and mobility, Parkinson's disease (which was progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), other lack of coordination, body mass index 36.0-36.9- adult , generalized anxiety disorder (which was a mental heal condition marked by heightened responses (worry) to certain situations and stimuli), and other recurrent depressive disorders (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life). Record review of Resident #162's Quarterly MDS Assessment, dated 8/13/2024, reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand;) Resident had no impairment in either lower extremity (hip, knee, ankle, and foot.) The resident utilized a wheelchair and a walker for mobility. The resident required partial/moderate assistance for eating, oral hygiene, and personal hygiene (which meant the helper provided less than half the effort while the resident completed the greater portion of the activity). The resident was dependent upon staff for toileting hygiene, showering/bathing self, and putting on/taking off shoes (which meant the helper provided all the effort of the activity). The received substantial/maximal assistance with upper body dressing (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Lower body dressing: not applicable, not attempted, and the resident did not perform this activity prior. The resident required substantial/maximum assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Record review of Resident #162's CCP reflected a Focus area for Parkinson's Disease, created on 8/20/2022. The Goal, created on 8/20/2022, indicated the resident would be free from complications related to Parkinson's Disease. The Intervention, initiated 8/20/2022, delegated nursing facility staff to monitor and report resident's poor balance, poor coordination, gait disturbance, muscle cramps or rigidity, decline in range of motion, and changes in mood; a Focus area for ADL Self Care performance deficit, revised on 3/29/2024, R/T limited mobility for Parkinson's Disease. The Goal, revised on 7/11/2024, indicated resident would maintain current level in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. The Intervention, created on 8/1/2022, delegated nursing facility staff to provide 1 staff limited assist for toilet use and 1 person contact guard for transfers; a Focus are for falls, revised on 10/10/2023, R/T weakness, Parkinson's Disease, and Anxiety. The Goal, revised on 7/11/2024, indicated the resident would not sustain serious injury. The Intervention, initiated on 9/27/2023, delegated nursing facility staff to educated resident on locking wheelchair wheels before transfers and have bed in the lowest position; a Focus area for antidepressant medication use, initiated on 12/24/2021, /T depression. The Goal, initiated on 12/24/2021, indicated the resident would show decreased episodes of depression. The Intervention, initiated 12/24/2024, delegated nursing facility staff to give antidepressant medications as ordered and to monitor for muscle tremor, agitation, depression, sadness, irritability, anger, crying, worthlessness, slowed movements, lethargy, fear of being alone, concern with body functions, anxiety, and the need for constant reassurances; a Fosus area for anti-anxiety medication, initiated on 12/24/2021, R/T anxiety. The Goal, initiated on 12/24/2021, indicated the resident would show decreased anxiety. The Intervention, initiated on 12/24/2024, delegated nursing facility staff to give anti-anxiety medications as ordered. Monitor for clumsiness, slow reflexes, confusion, disorientation, depression, dizziness, light-headedness; a Focus are for skin tear to left knee, initiated 11/2/2024, R/T transferring. The Goal, initiated on 11/5/2024, indicated the skin tear on the left knee would heal and the resident would be free from skin tears. The Intervention, initiated on 11/2/2024, delegated nursing facility staff to identify potential causative factors, notify Med. Dir., and family, of skin tears occur, prevent skin tears, monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces; a Focus area for potential/actual skin impairment to skin integrity, initiated 11/02/2024, R/T laceration to the left lower leg with sutures in place. Follow up with Physician at hospital on 11/12/2024. Enhanced Barrier Precautions ordered. An addition goal, initiated on 11/8/2024, indicated the resident would not have any complications R/T skin in jury type. The Interventions, initiated on 11/2/2024, delegated nursing facility staff to monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Record review of Resident #162's Order Summary Report reflected orders for: 1. Change of condition for: (add what the Change of Condition) Provider notified: Med. Dir.; resident sent to emergency room for laceration to lower left extremity; family visiting at time of incident. Every shift for 3 Days, started 11/3/2024. 2. Clean left knee with wound cleanser pat dry then use xeroform gauze on stiches line to keep moist, cover with 4-inch x4 inch gauze and (dressing) pad and wrap with kerlix (gauze) and ace once a day and as needed. Left knee should not be bend for at least a week and patient should not be in a wheelchair for more than 4 hours a day. Each day shift for secondary to trauma, started 11/5/2024. Record review of a facility communication for Resident #162, dated 11/2/2024, indicated Resident #162 experienced a change in condition on 11/2/2022 due to a skin laceration, puncture, or wound. The condition was a new condition and the resident experienced pain at the degree of 8 out of 10. At the time of the assessment, the skin wound, or ulcer, progress was unable to be determined. The resident was on anticoagulant therapy (blood thinner). Record review of a nursing home to hospital; transfer form, dated 11/2/2024, indicated Resident #162 transferred from the nursing home to a local hospital on 1/2/2024 for a skin wound, or ulcer. Blood pressure was 202/104. ADLs, such as bathing, dressing, transfers, toileting, and eating required assistance. Additional relevant information was resident saying laceration was received to the lower left leg during a transfer from the bed to wheelchair. Pressure bandage applied, 911 called, nurse practitioner, notified family, family visiting when accident occurred. (Form Incorrect-Transfer was from the wheelchair to the bed.) Record review of Resident #162's medication order reflected Resident #162 received 50 Micrograms/Milliliters Fentanyl injection (pain medication) once on 11/2/2024 at 10:23 PM. Record review of Resident #162's hospital discharge paperwork reflected Resident #162 presented to the emergency department from a local nursing home on 11/2/2024 at 8:50 PM with an acute left lower extremity bleeding from a wound that occurred today just prior to arrival. Height was 5 feet 6 inches; Weight was 183 pounds. Large lower extremity wound oozing blood. [NAME] blood cell counts on 11/2/2024 were first recorded at 5:38 PM results with 7.7 and again at 7:22 PM results 11.7. Principle Problem: Acute blood loss, anemia Secondary to left lower extremity injury. *Presented with acute onset bleeding from left lower extremity wound after injury at nursing home, currently on dual antiplatelet therapy. *Hypotensive with blood pressure in 80s/60s, status post (experienced a medical event) fluid bolus with improvement. *Hemoglobin 11.4 to 10.3 * Status post pressure dressing with Tranexamic Acid (medication to prevent bleeding) and lidocaine with epinephrine impregnated quick clot, achieving adequate hemostasis; status post 1 unit packed red blood cells emergently. *No overt signs of continued blood loss at this time. *Monitor Hereditary Hemochromatosis (a genetic disorder that causes iron to build up in organs) every 12 hours, transfuse if Red Blood Cells are less than 7, or active bleeding *Patient also requested wound care referral to wound care physician on discharge. *Blood pressure low on arrival; hold high blood pressure medications at this time in light of acute bleeding. Monitor blood pressure. *Resident admitted to the hospital from the emergency roiagnom on [DATE] at 7:24 PM for monitoring. *Handwritten, on the last page of the hospital discharge paperwork, dated 11/4/2024 indicated resident received 13 stitches to her left leg below the knee. *1 unit of blood. *Wound care order follow-up clinic on 11/6/2024 at 2:30 PM. *Do not bend knee for 1 week; not to be in wheelchair for more than 4 hours; keep leg straight. *Blood pressure was 150/70 at 11:30 AM 11/4/2024. * Resident discharged from the hospital to the nursing facility on 11/4/2024 at 1:48 PM *Resident was transported by a local transport company to the nursing facility on 11/4/2024. Record review of Resident #162's Skin Evaluation, dated 11/4/2024 at 4:46 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Entered by ADON Record review of Resident #162's TAR, dated 11/2024, reflected Resident #162 received Wound care treatment described in the resident's order summary report on 11/5/2024, 11/6/2024, 11/8/2024, 11/10/2024, 11/12/2024, and 11/15/2024. Record review of Resident #162's infection surveillance assessment, dated 11/10/2024 at 2:21 PM reflected Resident #162 developed an infection to her skin, soft tissue, and mucus membrane. Resident #162 was prescribed Doxycycline 100 MG 2 times a day for 7 days. Started 11/10/2024. Entered by LVN O. Wound care continued per order. Record review of Resident #162's PN, dated 11/10/2024 at 2:16 PM reflected an order for Resident #162 to start Doxycycline 100 MG 2 times a day for 7 days R/T wound infection. Entered by LVN O. Record review of Resident #162's Skin Evaluation, dated 11/10/2024 at 3:57 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Doxycycline 100 MG 2 times a day for 7 days for infection. Entered by LVN C. Record review of Resident #162's MAR, dated 11/2024, reflected Resident #162 received Doxycycline 100 MG 2 times a day for 7 days. The first dose was on 11/10/2024 at 4:00 PM. The medication continued through 11/15/2024 and was due to run the course on 11/17/2024 at 8:00 AM. Record review or Resident #162's PN, dated 11/12/2024 at 4:27 PM, reflected Resident #162 reported a pain level at a severity of a 3 out of 10. Pain medication administered as needed/ effective. Entered by LVN C. Observation and interview on 11/12/24 at 4:34 PM with Resident #162 revealed the resident in her room sitting in her wheelchair watching television. The resident was well groomed and in good spirits. She made appropriate eye contact and was easy to engage. The room was free from odors but was slightly cluttered. The interview revealed she was expecting a visit from someone from the complaint department. The resident explained that on 11/2/2024, she was helped in a transfer from her wheelchair to her bed by CNA P. During the transfer, the CNA was not able to hold her up and she hit her leg against a part of the bed that caused a tear in her skin. The mobility support bar, which was on the side of the bed where the transfer occurred, was unlocked from the vertical position to the horizontal position. She explained she was rushed to the hospital, where she stayed for about 2 days. While there, she received pain medication, an infusion of blood, and several stitches. She made mention she had just come back from the wound care doctor earlier that same say but was supposed to have seen the wound care doctor on 11/6/2024. When she asked staff why she did not get to her appointment, staff stated something about the transporter not getting the appointment information. Interview and observation on 11/13/24 at 3:03 PM with the MNTD revealed Resident #162's bed mobility support bars were attached to the bed, on each side, with three bolts. The mobility bar was a slender, upside-down U-shaped bar, about 36 to 42 inches long. The top end of the slender upside-down U-shaped bar extended in the direction of the ceiling. The bottom of the slender upside-down U-shaped bar extended in the direction of the floor. The bottom 6-8 inches of the slender upside-down U-shaped bar had a welded junction box. The welded junction box was the location of the mobility bar where the three attachment bolts were housed. The 6-8-inch welded junction box section was the point where the slender upside-down U-shaped bar was attached to the bed. The slender upside-down U-shaped bar was hollow and each of the hollow ends, at the bottom of the welded junction box, were covered with smooth ended round black safety caps. Slightly higher than the center point of the welded junction box, was a black knob. To change the slender upside-down U-shaped bar from the vertical to horizontal position, the black knob was pulled outwards to release a stabilizing pin. When the stabilizing pin was disengaged, the slender upside-down U-shaped bar rotated from the vertical to horizontal position. When rotated, the top of the slender upside-down U-shaped bar pivoted 90 degrees towards the head of the bed; the bottom of the slender upside-down U-shaped bar, which was welded junction box and the two plastic capped ends, rotated 90 degrees towards the foot of the bed. The MNTD touted years of experience with the facility's mobility bars and did not know how the resident could have torn her skin on any part, or configuration, of the bed's mobility bar. The MNTD stated there were no sharp edges on the mobility bar; no sharp edges on the sides on the rounded bar; no sharp edges on the welded junction box; and no sharp edges on the smooth ended round black safety caps. Observations of the MNTD in Resident #162's room, revealed the MNTD running his fingers along the curved bar that extended vertically from the side of the bed, the welded junction box, and the 2 smooth ended round black safety caps. His inspection revealed no edges that could have contributed to Resident #162's skin tear. He said there was no way the resident hurt herself on the mobility bar. Group interview, observation, and record review on 11/13/2024 at 4:40 PM with Resident #162 and RP #1000, in Resident #162's room, revealed RP #1000 was concerned about the skin tear Resident #162 suffered, on 11/2/2024.RP #1000 was not present at the time of the accident. RP #1000 pointed out a bouquet of flowers CNA P sent the resident. RP #1000 did not think the CNA P meant to hurt the resident; furthermore, RP #1000 felt the accident was just that, an accident. RP #1000 did question the size, height, and weight of CNA P, who performed the transfer, and described how her Resident #162 towered over CNA P. Observations of the room revealed Resident #162's bed. The foot of the bed was at the 6 o'clock position, the head of the bed was at the 12 o'clock position, the side of the bed closest to the window was at the 3 o'clock position, and the side of the bed closest to the bathroom was at the 9 o'clock position. Resident #162 described the wheelchair to bed transfer at the time of the accident. Resident #162 stated CNA P came to the room to help her from the wheelchair to the bed. Resident #162 was at the 4 o'clock position in her wheelchair facing the bed at a 45-degree angle (the portion of the left armrest, where the left hand of the resident would have been, was closest to the bed.) CNA P locked the wheels on the wheelchair and started to perform the transfer. At the beginning of the transfer, Resident #162 asked CNA P to stop because her legs were not in the correct position. CNA P continued with the transfer. During the transfer, the resident was lifted and shifted to their left slightly more than 90 degrees to place her buttocks on the side of the bed at the 3 o'clock position. During the transfer, and before Resident #162 realized what was happening, the accident had occurred. She stated her left leg struck something hard and the accident occurred. Measurements were taken from the top height of the mattress (6 inches in thickness) at the 3 o'clock position to the floor. The distance was 25 inches. Three hard surfaces existed between the mattress and the floor. One hard surface between the top of the mattress and the floor was a metal mattress support structure (Surface A.) Surface A was at 2 inches in vertical length and located just beneath the mattress. A second hard surface was a middle metal support rail with an information plate on it (Surface B.) Surface B was at 2 inches beneath Surface A and Surface B was at 3 inches in vertical length. A third hard surface was the lowest metal support rail closest to the floor (Surface C.) Surface C was at 2 inches in vertical length and directly beneath Surface B; Surface C was recessed inwards under the bed. When rubbing a finger against the bottom edge of Surface B, there was a straight and prominent 90-degree edge. There was a dark circular stain on the floor. The stain was 8-12 inches in distance from the outline of the bed, just to the left, while facing the window at the 3 o'clock position (2:45 position.) The stain was described by Resident #162 as a blood stain left by the accident. The size of the stain was slightly larger than the diameter of a softball. Measurements were taken of the distance between Resident #162's left knee to left ankle. The distance was 15 inches. The resident's left leg and left ankle were thickly wrapped with ace bandages at the time of the interview, so the distance from the ankle to the bottom of the foot was estimated to be an additional 2 inches. At the time of the transfer on 11/2/2024, the resident was not wearing any shoes. The bed's mobility bar, the slender upside-down U-shaped bar, was attached to the bed at the 1:45 position of the bed. It was attached by 3 bolts on the welded junction box, 6-8 inches in vertical length, at the height of Surface B. After disengaging the stabilizing pin by pulling the black knob, the slender upside-down U-shaped bar rotated 90 degrees; the curved end at the top rotated towards the head of the bed; and the welded junction box rotated in the direction of the foot of the bed. The welded junction box, which was at the bottom of the slender upside-down U-shaped bar, had no parts extending its length, but the 2 smooth ended round black safety caps. The welded junction box was the point of a 90-degree rotation. Since there were no parts extending its length downward, except the smooth ended round black safety caps, the rotation did not extend any of its parts towards the foot of the bed, but the smooth ended round safety caps. The mobility bar, in the horizontal position, was parallel in direction, and the same heights of Surface B. RP #1000 observed the inspection of Resident #162's bed and mobility bar and stated, there was no way Resident #162 could have hurt her leg on the mobility bar in the horizontal position. Record review of photos, provided by RP #1000, reflected the injury to Resident #162's lower left extremity. Looking at the photo, the picture of the left leg was viewed from the vantage point of the resident looking down at their leg. The left kneecap was at the 6 o'clock position, the left outer side of her left kneecap was at the 9 o'clock position, the left shin was at the 12 o'clock position, and the right inner side of her left kneecap was at the 3 o'clock position. The photos reflected a straight tear in the skin beginning just beneath, or at the same level, of Resident #162's left kneecap area (Spot A.) The tear began at the 3 o'clock position of the left kneecap area. The tear extended across the entire left kneecap area towards the 9 o'clock position for an approximate 2-3 inches. At the 2-3-inch mark, the skin tear curved towards the shin in the shape of the letter {C} for 2-3 inches in distance. At the bottom of the C shaped curve, the tear continued at a downward 45-degree angle for 2-3 inches towards the 1 o'clock position of the inner portion of the resident's left shin (Spot B.) The skin was still connected to the resident's lower extremity at Spot A and at Spot B leaving a loose flap of skin. Based on the measurements of the resident's knee to ankle, plus an estimation of 2 inches from ankle to the bottom of foot, the distance from the knee to the bottom of foot was @ 17 inches. The injury on Resident #162's kneecap began at the point of the kneecap or just under (17 inches from the floor.) Her skin was torn for 2-3 inches below that mark in the direction of her shin. The resident's left kneecap was at 17 inches up from the bottom of the foot. The skin tear started at 17 inches up the left leg and continued downward 2-3 inches in the direction of the shin. The skin tear stopped at 14 inches from the resident's foot. The level in inches at the top of mattress was at 25 inches from the floor. Standard hospital mattresses were at 6 vertical inches in depth. Surface A was at 2 vertical inches; the gap between Surface A and Surface B was at 2 vertical inches; and Surface B was at 3 vertical inches. Based on the measurements from the hospital bed, the lower edge of Surface B, which had the straight and prominent 90-degree edge, was at 12 inches from the floor. If the resident's left knee met the bottom edge of Surface B while being lifted and rotated to their left, the tear would have been vertical across the knee (resembling the bottom shape of Surface B) and extended downward on the left outside of the lower extremity. Interview and observation 11/13/24 at 5:16 PM with RP #3000 revealed she was at the facility on 11/2/2024 at the time Resident #162 had the injury to her left lower leg. Just before the injury occurred, CNA P came to the room to transfer Resident #162 from her wheelchair to her bed. RP #3000 was asked to leave the room, by the resident, while she was being transferred. While outside of the room, the door was open; curtain was not drawn. RP #3000 was standing across the hall from the resident's door; the door was at RP #3000's 11:00 position; and the resident's bed was 20 feet away, to her front. In RP #3000's line of sight to her the resident, was staff with a medication cart. The medication cart staff had her back to the inside of the resident's room with objects in their hands. The medication staff was not making any noises. After a span of 1-2 minutes, RP #3000 heard Resident #162 protesting the method CNA P was attempting to transfer her (exact words not remembered.) About a minute after the protest, Resident #162 was heard emitting a cry out in pain. After the cry of pain, she clearly heard CNA P cry out, oh no. After the CNA cried out oh no, the staff member at the medication cart turned around and went in to assess the situation. RP #3000 stated the facility responded, called 911, and got her to the hospital. RP #3000 did not observe, nor had she looked for, the resident with a gait belt (a cloth strap used to help life a resident) around her waist. She did not think the size, height, and weight of CNA P was appropriate to transfer someone with the size, height, and weight of Resident #162, since she was transferring Resident #162 alone. Interview on 11/13/24 at 6:04 PM with CNA P revealed she was the CNA who transferred Resident #162 from her wheelchair to her bed on 11/2/2024. She explained how she transferred the resident by placing the wheelchair next to the bed. The foot of the bed was at the 6 o'clock position, the head of the bed was at the 12 o'clock position, the side of the bed closest to the window was at the 3 o'clock position, and the side of the bed closest to the bathroom was at the 9 o'clock position. The resident's wheelchair was at about a 45-degree angle to the bed close to the 4 o'clock position. The opening of the wheelchair was facing towards the bed. The resident was seated in the wheelchair with her legs stretched outwards to the front. The wheels were locked; the bed was in the lowest position. CNA P was standing in front of the resident, facing her, with her legs inside of the positioning of the resident's legs. The resident wrapped her arms around the CNA's waist. The CNA put her arms under the resident's armpits (inside the resident's grip around the CNA's waist) and laced her left hand over right wrist; her right hand was in a fist. Before they started the transfer, the CNA stated Resident #162's legs were pointed straight out. She stated she moved the resident's legs in a manner to move them away from the bed, so she did not hit them during the transfer. When trying to move the resident's legs prior to performing the transfer, the resident stopped her and stated, No No No , don't do that, watch my legs. The CNA stated she stopped at that moment thinking she needed more support. She stated she grabbed a gait belt and wrapped it around the resident's upper abdomen area, just under her breasts. CNA P was standing in front of the resident, facing her, with her legs inside of the positioning of the resident's legs. The resident wrapped her arms around the CNA's waist. The CNA put her arms under the resident's armpits (inside the resident's grip around the CNA's waist) and grabbed onto the gait belt. The resident's legs were still straight out. She stated the resident would not let the CNA bend them. When the CNA lifted and turned the resident, the CNA pivoted to her right; while the resident pivoted to her left to be placed on the bed. At the time of the lifting, CNA P stated the resident's legs were at an approximate 45-degree angle from the resident's hips to the ground; both legs were on the outside of the CNA's legs. Resident #162's legs were angled downwards and away from the bed pointing towards the 3 o'clock position. When Resident #162's buttocks came to rest on the mattress, her legs were straight at a downward 45-degree towards the floor still directed towards the 3 o'clock position. It was at that moment when the resident stated ouch, ouch, my leg. CNA and the resident looked down at the same time and noticed the tear of the skin on her lower left leg, two or three inches under the knee. CNA stated she stated, OMG, I am so sorry, and yelled out for help. The resident handed the CNA a brief, and she applied direct pressure. The nursing staff arrived and called 911. Resident #162 went to the hospital. When asked how CNA P thought the injury occurred, she mentioned it could have been the bottom of the mobility bar and the two black buttons on the bottom. When asked, she stated she was not sure if the resident's legs were as straight as they were described earlier; furthermore, it was possible the resident's side of her left shin was up against the bed frame during the transfer. Interview and observation on 11/13/2024 at 6:55 PM with ADM B revealed the possible source of Resident #162's left lower leg injury could have been Surface B's prominent edge on her bed. ADM B was observed looking at a bed, which was not being used. She stated she would look at the bed in further detail with the maintenance director. Interview and observation on 11/14/2024 at 2:30 PM with CNA P revealed the use of a gait belt had not been discussed in any interview prior to her interview on 11/13/2024 at 6:04 PM. When asked for clarity, CNA P stated she did stop the transfer and apply a gait belt to continue the transfer. CNA P's size, height, and weight were observed as petite. Interview on 11/15/24 at 4:47 PM with the DON revealed Resident #162's skin tear was not reported to the state because the resident, who had a high BIMS Score, was able to explain what happened during the transfer. The facility did not feel the skin tear was the result of neglect or mistreatment; therefore, it did not meet the criteria for reporting. The DON stated that Resident #162 was ordered [wound care orders] upon her return on 11/4/2024; [Do not bend left knee] and [Follow up appointment 11-6-2024] and [Not to be in wheelchair greater than 4 hours.] The Resident received orders to clean and pat wound dry and orders to treat every other day. The DON stated she spoke to Resident #162 after she returned from the hospital, on 11/4/2024, for the skin tear. She stated Resident #162 had been scared due to the amount of blood, and its loss. She had not heard of any complaints from Resident #162's heightened anxiety for either the skin tear. Interview on 11/20/2024 at 11:13 AM with Resident #162 revealed the initial objection, where she cautioned the way CNA P was transferring her, was at the start of the transfer. Resident #162 told CNA P that her leg was caught on the bed. CNA P did not pause. CNA P did not stop and apply a gait belt. CNA P continued with the transfer. The resident stated the portion of her left leg, which was caught on the bed, was the area just beneath her kneecap on the outside left portion of the upper shin area. After the injury occurred, CNA P got Resident #162 to the bed, seated outward from the bed at the 3 o'clock position facing the window. The resident confirmed the blood stain on the floor was 8-12 inches from the outline of the bed at the 3'oclock position. Record review of the facility's Incident and Accident Policy, dated 5/2018, reflected any accident that required reporting would be completed to the state's standard. Record review of the facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment Policy, dated 10/2022, reflected it was the right of each resident be free from neglect and mistreatment. Neglect was the failure of the facility to have provided

Based on observations, interviews, and record review, the facility failed to ensure residents could receive services with reasonable accommodation of resident's needs and preferences for 1 of 9 Residents (Resident #23) reviewed for accommodation of needs. The facility failed to place Resident #23's call light paddle (which was a white, 0.5 inch by 2.5-inch diameter plastic circular paddle, used to call staff for resident assistance) in a place the resident could reach or activate. This failure placed the residents at risk of having their medical needs unmet and to have experienced psychosocial harm. Findings included: Record review or Resident #23's AR, dated 11/15/2024, reflected an [AGE] year-old-man who admitted to the facility on [DATE]. He was diagnosed with Parkinson's Disease (which was progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), need for assistance with personal care (which was a diagnosed medical classification influenced by health status and needed support with health services), and other lack of coordination. Record review of Resident #23's Quarterly MDS Assessment, dated 7/21/2024, reflected the resident had a BIMS Score of 11. A BIMS Score of 11 indicated the resident had moderate cognitive impairment. The resident had impairment on both sides of their upper extremities (shoulder, elbow, wrist, and hand). The resident had impairment on both sides of their lower extremities (hip, knee, ankle, and foot). The resident utilized a wheelchair, and a geriatric-chair (a large padded reclining chair with wheels that people with limited mobility) for mobility. The resident was dependent upon staff (which meant the helper provided all the effort of the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off shoes, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, walking 50 feet (with 2 turns), and walking 150 feet. The resident was always incontinence of bowel and bladder. Record review of Resident #23's CCP reflected an area of Focus area of risk of falls, initiated on revised on 12/12/2022, R/T weakness and balance. The Goal, initiated on 12/12/2022, indicated the resident would not sustain serious injury. The Intervention, initiated on 12/12/2022, delegated nursing facility staff to ensure the resident's call light was within reach and encourage resident to use it to call for assistance as needed; and, a Focus area of pressure ulcer development, initiated on revised on 3/5/2024, R/T disease process and immobility. The Goal, revised on 2/6/2024, indicated the resident would have intact skin and show no signs of pressure ulcer progression of infection. The Intervention, initiated on 2/6/2024, delegated nursing facility staff to ensure the resident's call light was within reach. Record review of Resident #23's Order Summary Report reflected an order, started on 1/24/2024, for Tramadol Oral Tablet, 5 MG, by mouth 3 times a day for pain; an order for Morphine Sulfate Oral Solution 20 MG, .25 ML to 1 ML, every hour as needed for pain. Observations and interview on 11/12/24 at 10:17 AM revealed Resident #23 was in his bed resting. The head of the resident's bed was at a 45-degree angle. Both resident's arms were beneath his top sheet. The resident had a call paddle instead of a call light button (which was a white, life saver sized, handheld mechanism with a red button at one end used to call staff for help). The call paddle was placed near the top outer edge of his right shoulder, and it was not touching his body. He tried to demonstrate, with his right arm, how he could activate the call system in place to call for staff. He did not know the location of the call light paddle; he was told it was located near the top of his right shoulder. He could not free his right arm from the covers to reach, or activate, the call light paddle. He was unable to reach across his body, with his left arm, to reach or activate the call light paddle either. Observations revealed the resident had a limited range of motion in both left and right arms. He stated he could not call for help when he needed it and was at the mercy of staff checking on him. Since he could not reach the call paddle, he felt helpless. Observations and interview on 11/13/24 at 10:05 AM revealed Resident #23 was in his bed watching the television. The head of the resident's bed was at a 45-degree angle. The call paddle was placed near the top outer edge of his right shoulder, and it was not touching his body. He tried to demonstrate, with his right arm, how he could activate the call system in place to call for staff. He did not know the location of the call light paddle; he was told it was located near the top of his right shoulder. He tried to activate the call paddle with his right arm but was unable to raise his right arm to reach to his shoulder area. He was unable to reach across with his left arm to activate the call light paddle either. Again, he felt like he was at the mercy of staff to come and check on him and he still felt helpless. Interview on 11/15/24 at 2:55 PM with LVN N revealed the residents use their call light to get staff help with emergencies, assistance with eating, help being changed, to drink water, or help with a general care concern. To use a call light button, a resident must have the physical ability to move an extremity to reach it. The resident must have the ability to grasp the call light button in their hand and use a digit to press the red button. For residents, who did not have the physical ability to use a call light button, there was the option of a call light paddle. A call light paddle was a small flat round device a resident could touch, or move, to call for staff. A resident could use any extremity to call for help. Residents, who were given a call light paddle based on their physical limitations, should have had the call light paddle positioned near their body in an accessible spot, and educated how to use it. Some negative outcomes for a resident, who could not call for help, were toileting accidents, falls, linen entanglements, issues with dignity, anxiety, or fear. Safeguards to ensure residents had access to their call lights were regular room rounds, as needed room rounds, and confirmation the call light was in the correct place for the resident upon having left the room. Interview on 11/15/24 at 4:33 PM with CNA M revealed call lights were provided to residents to use to get help from staff with their needs. One of the call light devices, a call light button, was a lifesaver sized device, the handle, with a red button at the end. The other was a round paddle that was activated by movement. To use the button, you had to be physically able to hold the device and press the button. The paddle required only to be moved or bumped. Some residents did not have the ability to use the call light button, because of contractures and had to use the paddle. CNA M stated Resident #23 utilized a call light paddle. She stated, I place the call light paddle on his chest, described as the sweet spot. The resident could not move their arms much and the paddle needed to be close. Negative outcomes for residents who could not call for help were thirst, hunger, sat in wet clothes, anger, or felt ignored. The staff were trained to make sure the call light buttons, or paddles, were always in the resident's reach. Safeguards in place to ensure residents always had access to their call lights consisted of room checks every 2 hours and to make sure the call light was within reach upon leaving the room. Observation and interview on 11/15/2024 at 5:15 PM with RP #4000 revealed him, and Resident #23 , moving throughout the facility in a geriatric-chair (a large padded reclining chair with wheels that people with limited mobility.) RP #4000 stated he was not that impressed with the care the facility provided. He explained how he visited Resident #23 recently and the resident was very thirsty. He explained the resident consumed a large cup of water in one act of consumption. When RP #4000 was informed about the call light paddle inaccessibility, he voiced frustration and mentioned the resident did not have the physical ability to call for help. He did not like having heard Resident #23 was unable to call for help and at the mercy of staff coming to his room to check on him. Interview on 11/15/24 at 5:46 PM with the DON revealed residents who could not use the traditional call light button were provided with a call paddle. The resident's ability to use the traditional call light button required a physical grasp and the ability to press the red button on top. Resident #23, who had contractures, was provided a paddle. The call light paddle was sensitive, as long as they could touch or move it, the paddle would initiate a call for help to staff. Safeguards in place to make sure the call light paddle was close enough to a resident to activate were clipped, to ensure proximity, angel rounds, and spot checks. Negative outcomes for a resident, who was not able to call staff for help, would having resulted in the resident's need not being met. A resident, who could not call staff for help, would be at the mercy of a staff member making a room round. Interview on 11/15/24 at 6:01 PM with ADM A revealed she had her staff trained to follow the call light policy. Staff were trained to determine which was the best call light apparatus to provide for the resident and to make sure it was always in reach. Residents that were not able to call for help risked the opportunity to receive staff's help. Record review of the facility's Call Light Policy, dated 8/3/2021, reflected instruction to answer the call light/bell within a reasonable time; listen to the resident's request; responds to the request; and leave the resident comfortable having placed the call device within the resident's reach before leaving the room. Record review of the facility's Rounds, Licensed and Certified Staff Policy, dated 05/2007, reflected instruction to place all call lights within the resident's reach.

Based on observations, interviews, and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment to the state agency within 2 hours for 1 of 9 Residents (Resident #162) reviewed for required reporting. The facility failed to report an incident of neglect after a failed resident transfer, which resulted in an injury and a 2 day hospitalization . This failure placed residents at risk of continued incidents of neglect. Findings included: Record review of an intake, dated 11/7/2024 at 8:21 AM, reflected a complaint made by a responsible party on behalf of Resident #162. The intake alleged on 11/2/2024 a staff attempted to transfer Resident #162 from her wheelchair to her bed. The complainant alleged Resident #162 required 2 people to transfer her, but only 1 staff member was present. The complainant alleged Resident #162 received a wound, a huge gash to her leg. Resident #162 was rushed to the hospital where she received a blood transfusion. Upon her release, Resident #162 was supposed to have returned to see the wound care doctor on 11/6/2024, but the facility allegedly did not read the discharge papers and did not get her to the appointment. The Responsible parties for Resident #162 were extremely worried about the lack of care. Record review of Resident #162's AR, dated 11/13/2024, reflected a [AGE] year-old-woman who was admitted to the facility on [DATE]. She was diagnosed with muscle weakness, need for assistance with personal care (which was a diagnosed medical classification influenced by health status and needed support with health services), unsteadiness on feet, other reduced mobility, unspecified lack of coordination, other abnormalities of gait (manner of walking) and mobility, unspecified abnormalities of gait and mobility, Parkinson's disease (which was progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), other lack of coordination, body mass index 36.0-36.9- adult , generalized anxiety disorder (which was a mental heal condition marked by heightened responses (worry) to certain situations and stimuli), and other recurrent depressive disorders (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life). Record review of Resident #162's Quarterly MDS Assessment, dated 8/13/2024, reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand;) Resident had no impairment in either lower extremity (hip, knee, ankle, and foot.) The resident utilized a wheelchair and a walker for mobility. The resident required partial/moderate assistance for eating, oral hygiene, and personal hygiene (which meant the helper provided less than half the effort while the resident completed the greater portion of the activity). The resident was dependent upon staff for toileting hygiene, showering/bathing self, and putting on/taking off shoes (which meant the helper provided all the effort of the activity). The received substantial/maximal assistance with upper body dressing (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Lower body dressing: not applicable, not attempted, and the resident did not perform this activity prior. The resident required substantial/maximum assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer (which meant the helper provided more than half the effort while the resident completed the lesser portion of the activity). Record review of Resident #162's CCP reflected a Focus area for ADL Self Care performance deficit, revised on 3/29/2024, R/T limited mobility for Parkinson's Disease. The Goal, revised on 7/11/2024, indicated resident would maintain current level in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. The Intervention, created on 8/1/2022, delegated nursing facility staff to provide 1 staff limited assist for toilet use and 1 person contact guard for transfers; a Focus area for skin tear to left knee, initiated 11/2/2024, R/T transferring. The Goal, initiated on 11/5/2024, indicated the skin tear on the left knee would heal and the resident would be free from skin tears. The Intervention, initiated on 11/2/2024, delegated nursing facility staff to identify potential causative factors, notify Med. Dir., and family, of skin tears occur, prevent skin tears, monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces; a Focus area for potential/actual skin impairment to skin integrity, initiated 11/02/2024, R/T laceration to the left lower leg with sutures in place. Follow up with Physician at hospital on 11/12/2024. Enhanced Barrier Precautions ordered. An addition goal, initiated on 11/8/2024, indicated the resident would not have any complications R/T skin in jury type. The Interventions, initiated on 11/2/2024, delegated nursing facility staff to monitor location, size, and treatment of skin tear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Record review of Resident #162's Order Summary Report reflected orders for: 1. Change of condition for: (add what the Change of Condition) Provider notified: Med. Dir.; resident sent to emergency room for laceration to lower left extremity; family visiting at time of incident. Every shift for 3 Days, started 11/3/2024. 2. Clean left knee with wound cleanser pat dry then use xeroform gauze on stiches line to keep moist, cover with 4-inch x4 inch gauze and (dressing) pad and wrap with kerlix (gauze) and ace once a day and as needed. Left knee should not be bend for at least a week and patient should not be in a wheelchair for more than 4 hours a day. Each day shift for secondary to trauma, started 11/5/2024. Record review of a facility communication for Resident #162, dated 11/2/2024, indicated Resident #162 experienced a change in condition on 11/2/2022 due to a skin laceration, puncture, or wound. The condition was a new condition and the resident experienced pain at the degree of 8 out of 10. At the time of the assessment, the skin wound, or ulcer, progress was unable to be determined. The resident was on anticoagulant therapy (blood thinner). Record review of a nursing home to hospital; transfer form, dated 11/2/2024, indicated Resident #162 transferred from the nursing home to a local hospital on 11/2/2024 for a skin wound, or ulcer. Blood pressure was 202/104. ADLs, such as bathing, dressing, transfers, toileting, and eating required assistance. Additional relevant information was resident saying laceration was received to the lower left leg during a transfer from the bed to wheelchair. Pressure bandage applied, 911 called, nurse practitioner, notified family, family visiting when accident occurred. (Form Incorrect-Transfer was from the wheelchair to the bed.) Record review of Resident #162's hospital discharge paperwork reflected Resident #162 presented to the emergency department from a local nursing home on 11/2/2024 at 8:50 PM with an acute left lower extremity bleeding from a wound that occurred today just prior to arrival. Height was 5 feet 6 inches; Weight was 183 pounds. Large lower extremity wound oozing blood. [NAME] blood cell counts on 11/2/2024 were first recorded at 5:38 PM results with 7.7 and again at 7:22 PM results 11.7. Principle Problem: Acute blood loss, anemia Secondary to left lower extremity injury. *Presented with acute onset bleeding from left lower extremity wound after injury at nursing home, currently on dual antiplatelet therapy. *Hypotensive with blood pressure in 80s/60s, status post (experienced a medical event) fluid bolus with improvement. *Hemoglobin 11.4 to 10.3 * Status post pressure dressing with Tranexamic Acid (medication to prevent bleeding) and lidocaine with epinephrine impregnated quick clot, achieving adequate hemostasis; status post 1 unit packed red blood cells emergently. *No overt signs of continued blood loss at this time. *Monitor Hereditary Hemochromatosis (a genetic disorder that causes iron to build up in organs) every 12 hours, transfuse if Red Blood Cells are less than 7, or active bleeding *Patient also requested wound care referral to wound care physician on discharge. *Blood pressure low on arrival; hold high blood pressure medications at this time in light of acute bleeding. Monitor blood pressure. *Resident admitted to the hospital from the emergency roiagnom on [DATE] at 7:24 PM for monitoring. *Written by hand, on the last page of the hospital discharge paperwork, dated 11/4/2024 indicated resident received 13 stitches to her left leg below the knee. *1 unit of blood. *Wound care order follow-up clinic on 11/6/2024 at 2:30 PM. *Do not bend knee for 1 week; not to be in wheelchair for more than 4 hours; keep leg straight. *Blood pressure was 150/70 at 11:30 AM 11/4/2024. * Resident discharged from the hospital to the nursing facility on 11/4/2024 at 1:48 PM *Resident was transported by a local transport company to the nursing facility on 11/4/2024. Record review of Resident #162's Skin Evaluation, dated 11/4/2024 at 4:46 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Entered by ADON Record review of Resident #162's TAR, dated 11/2024, reflected Resident #162 received Wound care treatment described in the resident's order summary report on 11/5/2024, 11/6/2024, 11/8/2024, 11/10/2024, 11/12/2024, and 11/15/2024. Record review of Resident #162's infection surveillance assessment, dated 11/10/2024 at 2:21 PM reflected Resident #162 developed an infection to her skin, soft tissue, and mucus membrane. Resident #162 was prescribed Doxycycline 100 MG 2 times a day for 7 days. Started 11/10/2024. Entered by LVN O. Wound care continued per order. Record review of Resident #162's PN, dated 11/10/2024 at 2:16 PM reflected an order for Resident #162 to start Doxycycline 100 MG 2 times a day for 7 days R/T wound infection. Entered by LVN O. Record review of Resident #162's Skin Evaluation, dated 11/10/2024 at 3:57 PM, reflected the Resident had a laceration to the left lower leg at 8 CM x2.5 CM x0.5 CM with sutures in place. Left and right leg with some swelling observed with a moderate indention left in the skin after applying pressure to both legs. Doxycycline 100 MG 2 times a day for 7 days for infection. Entered by LVN C. Record review of Resident #162's MAR, dated 11/2024, reflected Resident #162 received Doxycycline 100 MG 2 times a day for 7 days. The first dose was on 11/10/2024 at 4:00 PM. The medication continued through 11/15/2024 and was due to run the course on 11/17/2024 at 8:00 AM. Record review or Resident #162's PN, dated 11/12/2024 at 4:27 PM, reflected Resident #162 reported a pain level at a severity of a 3 out of 10. Pain medication administered as needed/ effective. Entered by LVN C. Observation and interview on 11/12/24 at 4:34 PM with Resident #162 revealed the resident in her room sitting in her wheelchair watching television. The resident was well groomed and in good spirits. She made appropriate eye contact and was easy to engage. The room was free from odors but was slightly cluttered. The interview revealed she was expecting a visit from someone from the complaint department. The resident explained that on 11/2/2024, she was helped in a transfer from her wheelchair to her bed by CNA P. During the transfer, the CNA was not able to hold her up and she hit her leg against a part of the bed that caused a tear in her skin. The mobility support bar, which was on the side of the bed where the transfer occurred, was unlocked from the vertical position to the horizontal position. She explained she was rushed to the hospital, where she stayed for about 2 days. While there, she received pain medication, an infusion of blood, and several stitches. She made mention she had just come back from the wound care doctor earlier that same say. Interview and observation on 11/13/24 at 3:03 PM with the MNTD revealed Resident #162's bed mobility support bars were attached to the bed, on each side, with three bolts. The mobility bar was a slender, upside-down U-shaped bar, about 36 to 42 inches long. The top end of the slender upside-down U-shaped bar extended in the direction of the ceiling. The bottom of the slender upside-down U-shaped bar extended in the direction of the floor. The bottom 6-8 inches of the slender upside-down U-shaped bar had a welded junction box. The welded junction box was the location of the mobility bar where the three attachment bolts were housed. The 6-8-inch welded junction box section was the point where the slender upside-down U-shaped bar was attached to the bed. The slender upside-down U-shaped bar was hollow and each of the hollow ends, at the bottom of the welded junction box, were covered with smooth ended round black safety caps. Slightly higher than the center point of the welded junction box, was a black knob. To change the slender upside-down U-shaped bar from the vertical to horizontal position, the black knob was pulled outwards to release a stabilizing pin. When the stabilizing pin was disengaged, the slender upside-down U-shaped bar rotated from the vertical to horizontal position. When rotated, the top of the slender upside-down U-shaped bar pivoted 90 degrees towards the head of the bed; the bottom of the slender upside-down U-shaped bar, which was welded junction box and the two plastic capped ends, rotated 90 degrees towards the foot of the bed. The MNTD touted years of experience with the facility's mobility bars and did not know how the resident could have torn her skin on any part, or configuration, of the bed's mobility bar. The MNTD stated there were no sharp edges on the mobility bar; no sharp edges on the sides on the rounded bar; no sharp edges on the welded junction box; and no sharp edges on the smooth ended round black safety caps. Observations of the MNTD in Resident #162's room, revealed the MNTD running his fingers along the curved bar that extended vertically from the side of the bed, the welded junction box, and the 2 smooth ended round black safety caps. His inspection revealed no edges that could have contributed to Resident #162's skin tear. He said there was no way the resident hurt herself on the mobility bar. Group interview, observation, and record review on 11/13/2024 at 4:40 PM with Resident #162 and RP #1000, in Resident #162's room, revealed RP #1000 was concerned about the skin tear Resident #162 suffered, on 11/2/2024. RP #1000 was not present at the time of the accident. RP #1000 pointed out a bouquet of flowers CNA P sent the resident. RP #1000 did not think the CNA P meant to hurt the resident; furthermore, RP #1000 felt the accident was just that, an accident. RP #1000 did question the size, height, and weight of CNA P, who performed the transfer, and described how her Resident #162 towered over CNA P. Observations of the room revealed Resident #162's bed. The foot of the bed was at the 6 o'clock position, the head of the bed was at the 12 o'clock position, the side of the bed closest to the window was at the 3 o'clock position, and the side of the bed closest to the bathroom was at the 9 o'clock position. Resident #162 described the wheelchair to bed transfer at the time of the accident. Resident #162 stated CNA P came to the room to help her from the wheelchair to the bed. Resident #162 was at the 4 o'clock position in her wheelchair facing the bed at a 45-degree angle (the portion of the left armrest, where the left hand of the resident would have been, was closest to the bed.) CNA P locked the wheels on the wheelchair and started to perform the transfer. At the beginning of the transfer, Resident #162 asked CNA P to stop because her legs were not in the correct position. CNA P continued with the transfer. During the transfer, the resident was lifted and shifted to their left slightly more than 90 degrees to place her buttocks on the side of the bed at the 3 o'clock position. During the transfer, and before Resident #162 realized what was happening, the accident had occurred. She stated her left leg struck something hard and the accident occurred. Measurements were taken from the top height of the mattress (6 inches in thickness) at the 3 o'clock position to the floor. The distance was 25 inches. Three hard surfaces existed between the mattress and the floor. One hard surface between the top of the mattress and the floor was a metal mattress support structure (Surface A.) Surface A was at 2 inches in vertical length and located just beneath the mattress. A second hard surface was a middle metal support rail with an information plate on it (Surface B.) Surface B was at 2 inches beneath Surface A and Surface B was at 3 inches in vertical length. A third hard surface was the lowest metal support rail closest to the floor (Surface C.) Surface C was at 2 inches in vertical length and directly beneath Surface B; Surface C was recessed inwards under the bed. When rubbing a finger against the bottom edge of Surface B, there was a straight and prominent 90-degree edge. There was a dark circular stain on the floor. The stain was 8-12 inches in distance from the outline of the bed, just to the left, while facing the window at the 3 o'clock position (2:45 position.) The stain was described by Resident #162 as a blood stain left by the accident. The size of the stain was slightly larger than the diameter of a softball. Measurements were taken of the distance between Resident #162's left knee to left ankle. The distance was 15 inches. The resident's left leg and left ankle were thickly wrapped with ace bandages at the time of the interview, so the distance from the ankle to the bottom of the foot was estimated to be an additional 2 inches. At the time of the transfer on 11/2/2024, the resident was not wearing any shoes. The bed's mobility bar, the slender upside-down U-shaped bar, was attached to the bed at the 1:45 position of the bed. It was attached by 3 bolts on the welded junction box, 6-8 inches in vertical length, at the height of Surface B. After disengaging the stabilizing pin by pulling the black knob, the slender upside-down U-shaped bar rotated 90 degrees; the curved end at the top rotated towards the head of the bed; and the welded junction box rotated in the direction of the foot of the bed. The welded junction box, which was at the bottom of the slender upside-down U-shaped bar, had no parts extending its length, but the 2 smooth ended round black safety caps. The welded junction box was the point of a 90-degree rotation. Since there were no parts extending its length downward, except the smooth ended round black safety caps, the rotation did not extend any of its parts towards the foot of the bed, but the smooth ended round safety caps. The mobility bar, in the horizontal position, was parallel in direction, and the same heights of Surface B. RP #1000 observed the inspection of Resident #162's bed and mobility bar and stated, there was no way Resident #162 could have hurt her leg on the mobility bar in the horizontal position. Record review of photos, provided by RP #1000, reflected the injury to Resident #162's lower left extremity. Looking at the photo, the picture of the left leg was viewed from the vantage point of the resident looking down at their leg. The left kneecap was at the 6 o'clock position, the left outer side of her left kneecap was at the 9 o'clock position, the left shin was at the 12 o'clock position, and the right inner side of her left kneecap was at the 3 o'clock position. The photos reflected a straight tear in the skin beginning just beneath, or at the same level, of Resident #162's left kneecap area (Spot A.) The tear began at the 3 o'clock position of the left kneecap area. The tear extended across the entire left kneecap area towards the 9 o'clock position for an approximate 2-3 inches. At the 2-3-inch mark, the skin tear curved towards the shin in the shape of the letter {C} for 2-3 inches in distance. At the bottom of the C shaped curve, the tear continued at a downward 45-degree angle for 2-3 inches towards the 1 o'clock position of the inner portion of the resident's left shin (Spot B.) The skin was still connected to the resident's lower extremity at Spot A and at Spot B leaving a loose flap of skin. Based on the measurements of the resident's knee to ankle, plus an estimation of 2 inches from ankle to the bottom of foot, the distance from the knee to the bottom of foot was @ 17 inches. The injury on Resident #162's kneecap began at the point of the kneecap or just under (17 inches from the floor.) Her skin was torn for 2-3 inches below that mark in the direction of her shin. The resident's left kneecap was at 17 inches up from the bottom of the foot. The skin tear started at 17 inches up the left leg and continued downward 2-3 inches in the direction of the shin. The skin tear stopped at 14 inches from the resident's foot. The level in inches at the top of mattress was at 25 inches from the floor. Standard hospital mattresses were at 6 vertical inches in depth. Surface A was at 2 vertical inches; the gap between Surface A and Surface B was at 2 vertical inches; and Surface B was at 3 vertical inches. Based on the measurements from the hospital bed, the lower edge of Surface B, which had the straight and prominent 90-degree edge, was at 12 inches from the floor. If the resident's left knee met the bottom edge of Surface B while being lifted and rotated to their left, the tear would have been vertical across the knee (resembling the bottom shape of Surface B) and extended downward on the left outside of the lower extremity. Interview and observation 11/13/24 at 5:16 PM with RP #3000 revealed she was at the facility on 11/2/2024 at the time Resident #162 had the injury to her left lower leg. Just before the injury occurred, CNA P came to the room to transfer Resident #162 from her wheelchair to her bed. RP #3000 was asked to leave the room, by the resident, while she was being transferred. While outside of the room, the door was open; curtain was not drawn. RP #3000 was standing across the hall from the resident's door; the door was at RP #3000's 11:00 position; and the resident's bed was 20 feet away, to her front. In RP #3000's line of sight to her the resident, was staff with a medication cart. The medication cart staff had her back to the inside of the resident's room with objects in their hands. The medication staff was not making any noises. After a span of 1-2 minutes, RP #3000 heard Resident #162 protesting the method CNA P was attempting to transfer her (exact words not remembered.) About a minute after the protest, Resident #162 was heard emitting a cry out in pain. After the cry of pain, she clearly heard CNA P cry out, oh no. After the CNA cried out oh no, the staff member at the medication cart turned around and went in to assess the situation. RP #3000 stated the facility responded, called 911, and got her to the hospital. RP #3000 did not observe, nor had she looked for, the resident with a gait belt (a cloth strap used to help life a resident) around her waist. She did not think the size, height, and weight of CNA P was appropriate to transfer someone with the size, height, and weight of Resident #162, since she was transferring Resident #162 alone. Interview on 11/13/24 at 6:04 PM with CNA P revealed she was the CNA who transferred Resident #162 from her wheelchair to her bed on 11/2/2024. She explained how she transferred the resident by placing the wheelchair next to the bed. The foot of the bed was at the 6 o'clock position, the head of the bed was at the 12 o'clock position, the side of the bed closest to the window was at the 3 o'clock position, and the side of the bed closest to the bathroom was at the 9 o'clock position. The resident's wheelchair was at about a 45-degree angle to the bed close to the 4 o'clock position. The opening of the wheelchair was facing towards the bed. The resident was seated in the wheelchair with her legs stretched outwards to the front. The wheels were locked; the bed was in the lowest position. CNA P was standing in front of the resident, facing her, with her legs inside of the positioning of the resident's legs. The resident wrapped her arms around the CNA's waist. The CNA put her arms under the resident's armpits (inside the resident's grip around the CNA's waist) and laced her left hand over right wrist; her right hand was in a fist. Before they started the transfer, the CNA stated Resident #162's legs were pointed straight out. She stated she moved the resident's legs in a manner to move them away from the bed, so she did not hit them during the transfer. When trying to move the resident's legs prior to performing the transfer, the resident stopped her and stated, No No No , don't do that, watch my legs. The CNA stated she stopped at that moment thinking she needed more support. She stated she grabbed a gait belt and wrapped it around the resident's upper abdomen area, just under her breasts. CNA P was standing in front of the resident, facing her, with her legs inside of the positioning of the resident's legs. The resident wrapped her arms around the CNA's waist. The CNA put her arms under the resident's armpits (inside the resident's grip around the CNA's waist) and grabbed onto the gait belt. The resident's legs were still straight out. She stated the resident would not let the CNA bend them. When the CNA lifted and turned the resident, the CNA pivoted to her right; while the resident pivoted to her left to be placed on the bed. At the time of the lifting, CNA P stated the resident's legs were at an approximate 45-degree angle from the resident's hips to the ground; both legs were on the outside of the CNA's legs. Resident #162's legs were angled downwards and away from the bed pointing towards the 3 o'clock position. When Resident #162's buttocks came to rest on the mattress, her legs were straight at a downward 45-degree towards the floor still directed towards the 3 o'clock position. It was at that moment when the resident stated ouch, ouch, my leg. CNA and the resident looked down at the same time and noticed the tear of the skin on her lower left leg, two or three inches under the knee. CNA stated she stated, OMG, I am so sorry, and yelled out for help. The resident handed the CNA a brief, and she applied direct pressure. The nursing staff arrived and called 911. Resident #162 went to the hospital. When asked how CNA P thought the injury occurred, she mentioned it could have been the bottom of the mobility bar and the two black buttons on the bottom. When asked, she stated she was not sure if the resident's legs were as straight as they were described earlier; furthermore, it was possible the resident's side of her left shin was up against the bed frame during the transfer. Interview and observation on 11/13/2024 at 6:55 PM with ADM B revealed the possible source of Resident #162's left lower leg injury could have been Surface B's prominent edge on her bed. ADM B was observed looking at a bed, which was not being used. She stated she would look at the bed in further detail with the maintenance director. Interview and observation on 11/14/2024 at 2:30 PM with CNA P revealed the use of a gait belt had not been discussed in any interview prior to her interview on 11/13/2024 at 6:04 PM. When asked for clarity, CNA P stated she did stop the transfer and apply a gait belt to continue the transfer. CNA P's size, height, and weight were observed as petite. Interview on 11/15/24 at 4:47 PM with the DON revealed Resident #162's skin tear was not reported to the state because the resident, who had a high BIMS Score, was able to explain what happened during the transfer. The facility did not feel the skin tear was the result of neglect or mistreatment; therefore, it did not meet the criteria for reporting. Interview on 11/20/2024 at 11:13 AM with Resident #162 revealed the initial objection, where she cautioned the way CNA P was transferring her, was at the start of the transfer. Resident #162 told CNA P that her leg was caught on the bed. CNA P did not pause. CNA P did not stop and apply a gait belt. CNA P continued with the transfer. The resident stated the portion of her left leg, which was caught on the bed, was the area just beneath her kneecap on the outside left portion of the upper shin area. After the injury occurred, CNA P got Resident #162 to the bed, seated outward from the bed at the 3 o'clock position facing the window. The resident confirmed the blood stain on the floor was 8-12 inches from the outline of the bed at the 3'oclock position. Record review of the facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment Policy, dated 10/2022, reflected it was the right of each resident be free from neglect and mistreatment. Neglect was the failure of the facility to have provided goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment was inappropriate treatment of a resident. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility was supposed to have reported to the state agency immediately, but no later than 2 hours after the allegations was made.

Based on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 6 residents (Resident #18 and Resident #58) who were reviewed for accuracy of assessments. Resident #18's most recent MDS was coded as resident having clear speech, when observations revealed the resident was only able to make sounds and did not have the ability to carry a conversation. Resident #58's most recent MDS was coded as resident having clear speech, when observations revealed the resident was unable to move her mouth in order to speak. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #18's undated face sheet indicated Resident #18 was a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Parkinson's Disease (a movement disorder of the nervous system that worsens over time), epilepsy with status epilepticus (continuous seizure or multiple seizures without enough time to recover between them), personal history of transient ischemic attack (minor stroke), cerebral infarction without residual deficits (temporary disruption of blood flow to the brain), aphasia (inability to speak well), and dysphagia (difficulty swallowing). Record review of Resident #18's Quarterly MDS, dated [DATE], reflected in Section B Speech Clarity that Resident #18 had unclear speech-slurred or mumbled words. Record review of Resident #18's Quarterly MDS, dated [DATE], reflected in Section B Speech Clarity that Resident #18 had clear speech-distinct intelligible words. Record review of Resident #18's care plan dated 09/22/2024 reflected resident has alteration in communication related to aphasia, impaired ability to make self-understood. The interventions listed included for staff to anticipate and meet needs, monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed, refer to speech therapy for evaluation and treatment as ordered, and validate messages by repeating aloud. Observation on 11/12/2024 at 10:07 a.m., revealed resident #18 sitting in her wheelchair in her room watching television. When the resident was being asked by the state surveyor about her stay at the facility, the food, and her daily activities, she responded with unarticulated sounds, and was unable to form words. She enhanced her communication with hand movements, head nods, and other gestures. Observation on 11/13/2024 at 9:15 a.m., revealed resident #18 in the same position as the previous observation. When asked if she had already eaten breakfast Resident #18 shook her head in a yes motion and then used her hand to motion to the window and made unarticulated sounds to try and communicate back to the state surveyor. Interview on 11/14/2024 at 09:31 a.m., with the LVN E revealed she had worked at the facility off and on for roughly three months. The LVN E stated that the way in which Resident #18 communicated was by rolling up to staff in her wheelchair and would tug on their clothes if she needed their attention, knock on the medicine cart if she needed pain medication, tap the water cart if she needed assistance with water, and used other gestures to communicate her needs. The resident also utilized her call light, shook her head yes or no, and attended activities when they interested her. Interview on 11/14/2024 at 10:03 a.m., with the ST revealed she had worked at the facility since 04/2018. The ST stated that Resident #18 was last evaluated on 01/25/2024 for speech therapy services. The resident was on speech therapy services three times a week from June to October of 2020 when she first admitted to the facility. The resident only showed a little bit of improvement in speech at that time, she already had her own ways of communicating and did not want to continue speech therapy, and she refused a communication board or other devices at that time due to her already formed coping strategies. Record review of Resident #58's undated face sheet indicated Resident #58 was a [AGE] year-old female, who admitted to the facility on [DATE]. She was diagnosed with dementia (decline in mental ability that interferes with daily life), cognitive communication deficit, dysphagia (difficulty swallowing, aphasia (inability to speak well), Parkinson's Disease (a movement disorder of the nervous system that worsens over time), cerebral infarction (lack of blood flow to the brain), dysarthria (motor-speech disorder that makes it difficult to form and pronounce words), and anarthria (a severe form of dysarthria). Record review of Resident #58's Quarterly MDS, significant change dated 05/01/2022 reflected in Section B Speech Clarity that Resident #58 had unclear speech-unclear or mumbled words. Record review of Resident #58's Quarterly MDS, dated [DATE] reflected in Section B Speech Clarity that Resident #58 had clear speech-distinct intelligible words. Record review of Resident #58's care plan dated revised on 09/24/2023 reflected resident has Parkinson's Disease and was at risk for decline in all aspects due to her natural disease process. The interventions listed included to allow sufficient time for speech/communication. Follow ST recommendations to assist resident with communication. The care plan also reflected that the resident was at risk for communication problems related to aphasia. The interventions listed include to anticipate and meet residents needs and to validate the message by repeating aloud, dated revised on 04/22/2024. Observation on 11/12/2024 at 10:25 AM revealed Resident #58 lying in bed with her mouth open wide, eyes half open with gaze towards the ceiling, and her hands contracted in her lap. When the state surveyor introduced themselves to the resident, she did not respond with words, sounds, or a gaze in their direction. Observation on 11/13/2024 at 09:22 AM revealed Resident #58 in the same position as the previous observation with headphones on her ears. When prompted with questions from the state surveyor, the resident gave no response and did not look in their direction. Interview on 11/13/2024 at 09:22 AM with LVN D revealed she had worked at the facility since 06/2019. LVN D stated that hospice came in the mornings between the hours of 6 AM and 8 AM to visit with Resident #58. She further explained that Resident #58 was changed positions every 2 hours, her tube feedings were changed every 24 hours, and to alleviate Resident 58's contractures she was given a towel for comfort. Interview on 11/14/2024 at 01:04 p.m., with ADM B revealed that around 2 years ago she was the Social Worker for the facility and was familiar with Resident #58. The Social Worker is responsible for completing Section B-Hearing, Speech, and Vision of the MDS assessment. She stated that Resident #58 was aphasic, has not recently been on therapy services, and she cannot speak due to her progression in diagnosis. Interview on 11/14/2024 at 02:13 PM with ST revealed she had worked at the facility since 04/2018. The ST stated that Resident #58 was admitted to the facility in 2020 and had some speaking impairments but was able to communicate. The most recent SLUMS assessment conducted by the ST was conducted on Resident #58 on 09/18/2023 in which the resident scored 0's (meaning severe impairment). Resident #58 was discharged from speech therapy services on 02/28/2024 due to transferring to hospice care . The assessments conducted would lead to therapies residents received to maintain their highest practicable standard of life. Record review on 11/15/2024 of the facility's Resident Assessment and Associated Processes Policy, dated 12.2023 indicated, It is the policy of this facility that resident's will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. Procedure: Comprehensive Assessment: includes the completion of the MDS (Minimum Data Set} as well as the CAA (Care Area Assessment} process, followed by development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment, and Significant Correction to Prior Comprehensive Assessment. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI and will include at least the following: Cognitive patterns Communication Mood and behavior patterns Physical functioning and structural problems Disease diagnosis and health conditions Special Treatments and procedures Documentation of summary information regarding additional assessment performed on the care areas triggered by the completion of the MDS Documentation of resident participation in the assessment process. 3. Comprehensive assessments will be conducted within 14 days of admission, when there is a significant change in the resident's status and not less than once every 12 months (within 366 days of the previous comprehensive assessment). a. Significant Change: is a major decline or improvement in a resident's status that: i. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered self-limiting (note: self limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.) b. Significant Change in Status Assessment: is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a residents meets the significant change guidelines for either major improvement or decline. The assessment will be completed within 14 days of identification and the clinical health record will contain information related to when the determination was made.

Based on observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 2 (Resident #34 and Resident #82) of eleven residents reviewed for care plans. The facility failed to update the comprehensive person-centered care plan for Resident #34's transfer status for use of the Mechanical lift. The facility failed to implement a comprehensive person-centered care plan for Resident #82 that included Enhanced Barrier Precautions as ordered. These failures could place residents at risk for not receiving appropriate care and treatment. Findings included: Resident #34 Record review of Resident #34's Face Sheet reflected an [AGE] year-old male who was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus (elevated blood sugars), spastic hemiplegia affecting unspecified side (paralysis with muscle spasms of an arm or leg), muscle weakness, and cognitive communication deficit. Record review of Resident #34's care plan initiated 10/10/2024 reflected Resident #34 had an ADL self-care performance deficit related to hemiplegia, reduced mobility, weakness, and generalized pain., Resident #34's goal was to safely perform bed mobility, transfers, eating, and grooming through the review date. Interventions included on the care plan were staff to perform ADLs as needed. Interventions on the care plans did not indicate how much assistance was needed. The care plan did not indicate the use of the mechanical lift for transfers. Record review of Resident #34's Admission MDS dated [DATE], reflected a BIMs score of 04 indicating resident #34 was cognitively impaired. The MDS also reflected that Resident #34 had lower extremity impairments, used a wheelchair for mobility, and had a goal to be substantial maximal assistance with transfers. Record review of Resident #34's Visual Bedside Kardex (a smaller version of the comprehensive care plan indicating ADL needs) report dated 11/13/24 reflected staff were to assist with ADLs as needed. Interventions on the Kardex did not indicate how much assistance was needed or the use of the Mechanical Lift. Record review of Resident #34's Documentation Survey Report (a detailed report of how much staff assistance the resident required within a period of time) dated 11/15/2024 reflected Resident #34 was total dependence for transfers with assistance of 1-2 staff members. In an observation on 11/12/24 at 12:36 PM Resident #34 was sitting up in his wheelchair with a blue lift sling behind him. He was dressed, groomed, and did not appear in any distress. He did not answer questions just nodded his head up and down when asked if he was ok. In an interview and observation on 11/15/24 at 11:11 AM CNA B stated transfer status could be found on the plan of care. CNA B was able to pull up the plan of care for Resident #34 but was unable to verify mechanical lift transfer status. She stated if she were unsure of how to transfer a resident, she would ask the nurse for clarification. CNA B stated she had been educated on transferring a resident safely using a mechanical lift. She stated the risk for not transferring a resident correctly could be injury or falls possibly. In an interview on 11/15/24 at 12:15 PM ADM Stated mechanical lift should be within the care plan. She stated therapy would do initial evaluation and establish transfer status. The interdisciplinary team were responsible for adding transfer status to the care plan. ADM A stated the risk for not care planning mechanical lifts could be that the resident could get improperly transferred. In an interview on 11/15/24 at 12:50 PM LVN C stated Resident #34 was new to her hall. She stated if she were unclear about a transfer, she would refer to the therapy department. She stated the CNAs needed to see transfer status. LVN C stated not having a transfer status clear on the plan of care could lead to unsafe transfers and falls. LVN C stated it was the responsibility of the nurse to make sure Resident #34's transfer status was correct to ensure safety. In an interview on 11/15/24 at 12:56 PM the DON stated if the nurse aides were unsure of transfer status, they were to use the safest mechanism of transfer and that would be a mechanical lift with the assistance of two staff members. She stated if staff were not sure of transfer status, they couldn ' t ' t always talk to the nurse or therapist. If the staff used the mechanical lift, there would not be a risk to the resident because it was the safest route of transferring a resident. Record review of facility undated policy titled Mechanical Lift and Slings reflected the facility will provide for the safety needs of a resident requiring the use of a mechanical lift for transfers. Transfer status / mechanical lift will be maintained in the resident's medical record. Review of Resident #82's admission record on November 15, 2024, revealed that Resident #82 was a [AGE] year-old male resident who was admitted and re-entered the facility on September 2, 2022, with diagnoses that included: acute kidney failure, personal history of COVID-19, muscle weakness (generalized), need for assistance with personal care, and elevated white blood cell count. Resident #82's advanced directive was Full Code. Enhanced Barrier Precautions (EBP) were required for for high resident contact care activities. Indication: wounds, indwelling medical device, infection and/or MDRO status. Review of Resident #82's Comprehensive Minimum Data Set (MDS) Resident Care and Screening assessment dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score to be twelve out of a possible 15, thus indicating the resident was cognitive and able to make decisions. The same MDS indicated that the resident required set-up or clean-up assistance with most of the resident's functional abilities and goals, except the resident required supervision or touching assistance with tub/shower transfers, and partial/moderate assistance with walking ten feet. The MDS revealed the resident had an indwelling catheter. The MDS revealed the resident had a skin condition that required the application of ointments/medications other than to feet . Review of Resident #82's Order Summary Report as of 11/15/2024 revealed an active order which read, ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds, indwelling medical device, infection and/or MDRO status every shift. The order status was active, order date: 4/17/2024, and start date: 4/17/2024. Review of Resident #82's care plan did not indicate the need to use Enhanced Barrier Precautions during high contact care activities, although this was ordered. In an interview with the DON on November 15, 2024, at 1 PM, the DON stated that she ensured EBP were implemented and communicated with all staff by making rounds and doing spot checks. The DON stated that staff were educated on which residents required the utilization of EBP, but also there was a gold star or flower [sticker] on the name of each resident who required EBP. The DON stated there was no set determination by the facility as to where PPE was to be placed. The DON stated that staff should always refer to the care plan for an indication such as EBP . In an interview with LVN D on November 15, 2024, at approximately 1:45 PM, it was stated that LVN D learned of residents' conditions through shift reports and referencing treatment records and care plans, as changes occur regularly and often . Record review of facility policy titled Comprehensive Person-Centered Care Planning dated 11/2016 and revised 12/2023 reflected It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment .

Based on interviews and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #96) of 6 residents reviewed for pharmacy services. The facility failed to monitor Resident #96 for side effects/adverse reactions for the use of Apixaban (an anticoagulant medication- blood thinner). These failures could place residents at risk of bruising, and bleeding. Findings included: Resident #96 Record review of undated face sheet reflected Resident #96 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #96 had the following diagnoses of muscle weakness, hyperlipidemia (elevated cholesterol), abnormalities of gait, and hypertension (elevated blood pressure). Record review of the Quarterly MDS dated [DATE] reflected Resident #96 was given an Anticoagulant (blood thinner) medication during the prior 7 days to the MDS assessment reference date of 09/18/2024. Record review of Physicians Order Summary Report dated 11/13/2024 for Resident #96 reflected an order for Apixaban (a blood thinner) to be given daily. Record review of the Order Summary also reflected there was no order for side effect monitoring of the Apixaban. Record review of Medication Administration Record (MAR) for the month of November reflected resident #96 had received Apixaban twice daily routinely. The MAR also reflected there was no monitoring for side effects in place related to the use of the Apixaban. In an interview 11/12/24 at 09:48 AM Resident #96 stated she would like to have more choices with her food. She had no complaints related to care. In an interview on 11/15/24 at 12:15 PM ADM A stated she would have to refer to policy, but yes blood thinner side effects should have been monitored. She stated the interdisciplinary team (a team of department heads within the nursing home) review treatment records to ensure monitoring for side effects of medications such as a blood thinner were in place. ADM A stated she was not familiar with what the general risk to a resident would have been for not monitoring for side effects of a blood thinner. She stated she would have to refer to policy . In an interview on 11/15/24 at 12:56 PM the DON stated when the floor nurse gets an order for a blood thinner, they should also put in the order to monitor for side effects at the same time of that medication. The ADON's monitor the charts and follow up after the floor nurses to ensure the anticoagulant (blood thinner) monitoring was in place. The DON stated risk for residents receiving blood thinners that were not monitored would be bleeding or bruising that was unnoticed. Record review of facility policy titled Pharmacy Services dated 08/2017 and revised 01/2022 reflected The MRR includes identification of irregularities, medications-related errors, adverse consequences, and use of unnecessary drugs. Unnecessary drug is defined as medication ordered: Without adequate monitoring.

Based on observations and interviews, the facility failed to prepare food that was at an appetizing temperature for one of five residents sampled: 1. The facility served Resident #13 cold or lukewarm food throughout the resident's stay and refused the resident's requests to reheat food items, stating that federal and state regulations did not allow for this. This failure could have placed residents at risk of not being satisfied with their food, decreased food intake, unintended weight loss, hunger, poor nutrition, impeded recovery from illness and injury, and diminished quality of life. Findings included: Record review of Resident #13's admission record revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses that included: neuromyelitis optica [devic], need for assistance with personal care, paraplegia, legal blindness, gastro-esophageal reflux disease without esophagitis, and irritable bowel syndrome with diarrhea. The resident's advance directive was full code: use AED with CPR during sudden cardiac arrest . In an interview with Resident #13 on [DATE], at 10:02 AM, the resident stated that often her meals were served cold. The resident stated that she was served all meals in her room and by the time they get to her, they were not at a preferred temperature. The resident stated that requests for food items to be reheated were met with reluctance or denial. For example, the resident stated that scrambled eggs were served lukewarm or cold on the inside. The resident stated that toast was often served cold, and butter cannot be spread because of the temperature of the toast. The resident stated that staff's response to food temperature complaints was that they could not control the temperature of the food served on hall trays. The resident stated that staff have also refused to reheat outside food items brought in by the resident's family. In a follow up interview with Resident #13 on [DATE], at approximately 2:30 PM, the resident stated the temperature of the food has improved this week while state surveyors have been in the building. The resident stated that staff would refuse to reheat food items to her preference often during the early days of her admission,. but recently their refusal was less often. The resident stated that she estimated staff's current refusal to be ,d+[DATE] times a week. The resident stated that this concern was reported to the facility and the ombudsman with little but some improvement. The resident stated that she has spent $478.23 on outside food and delivery service due to the quality, taste, and temperature of the food being served at the facility. In an interview with LVN D on [DATE], at approximately 1:45 PM, regarding reheating food items at the request of the resident, LVN D stated staff do not reheat food. LVN D stated their procedure was to get the resident a whole new tray. LVN D stated if a resident had a complaint regarding the temperature of the food, staff would do what they needed to resolve the resident's complaint . Record review of the facility's policy/procedure titled Resident/Personal Food Storage/Rethermalization-Microwaving/Hot Liquids revised on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE], stated the following in part: If rethermalization/microwaving is needed, all rethermalization/microwaving will be done in the kitchen, by kitchen staff only during kitchen hours .For time and temperature control for safety foods (perishables), cook to a temperature of 165F. Food will remain above 135F prior to serving .

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #52 and Resident #82) of eleven residents reviewed for infection control. 1. CNA #A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief for Resident #52. 2. The facility failed to ensure staff and others were aware that Resident #82 required the use of Enhanced Barrier Precautions. 3. The facility failed to ensure Personal Protective Equipment (PPE) was readily accessible for the care and treatment of Resident #82, who was on Enhanced Barrier Precautions. 4. The facility failed to provide proper environmental cleaning and disinfection of Resident #82's room. This failure could place residents at risk for healthcare associated cross contamination which could result in infections or illness. Findings included: Resident #52 Record review of Resident #52's Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (a group of diseases affecting the lungs and breathing), atrial fibrillation (an irregular heart rate and rhythm), pneumonia, shortness of breath, and unsteadiness on feet. Record review of Resident #52's care plan initiated 05/21/2024 reflected a care plan for bladder incontinence. Resident #52s goal was to remain free from skin breakdown due to use of incontinence briefs through the review date. The care plan included interventions to check as required for incontinence. Wash, rinse, and dry perineum. Monitor/document for signs and symptoms of UTI (Urinary Tract Infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #52's Quarterly MDS dated [DATE], reflected she was always incontinent of bowel and bladder. The MDS reflected Resident #52 was not assessed for her ADL assistance needed or her cognitive function. In an interview and observation on 11/12/2204 at 09:42 AM Resident#52 was observed in her bed. She has no complaints related to care, stated she was receiving her showers and staff were kind. Observation of Perineal Care for Resident #52 on 11/13/2024 at 1:24PM revealed CNA A performed peri care cleansing from front to back, using new wet wipe with each pass across the perineal area. Resident #52 was rolled over and the backside cleansed again using clean wipes with each pass from the front to back. CNA A removed a soiled brief and did not wash hands or use alcohol-based hand sanitizer between gloving from dirty to clean brief. CNA A completed peri care, covered resident up, and gave her the call light. In an interview with CNA A on 11/13/2024 at 1:45 PM she stated staff were instructed to wash hands between all glove changes. CNA A stated she just forgot to wash her hands. She stated the negative effects on the residents for not washing hands would be spreading bacteria. In an Interview on 11/15/2024 at 12:15 PM ADM A stated it was expected that staff follow policy protocols for infection control. She stated the staff were instructed on infection control upon hire, annually, and with any concerns for infection control. ADM A stated the risk to the resident for not cleaning hands between glove changes would be urinary tract infections or bacterial infections. In an interview on 11/15/2024 at 12:56 PM the DON stated staff were expected to wash their hands before and after putting on gloves. The DON stated staff were instructed on infection control at least monthly and as needed. She stated she was responsible for training the staff. The DON stated the risk for residents for staff not washing their hands included spreading of infections. Record review of the facility's Policy and procedure titled Hand Hygiene dated 05/2007 and updated in 10/2022 reflected: Use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations -after removing gloves. Review of Resident #82's admission record on November 15, 2024, revealed that Resident #82 was a [AGE] year-old male resident who was admitted and re-entered the facility on September 2, 2022, with diagnoses that included: acute kidney failure, personal history of COVID-19, muscle weakness (generalized), need for assistance with personal care, and elevated white blood cell count. Resident #82's advanced directive was Full Code. Review of Resident #82's Comprehensive Minimum Data Set (MDS) Resident Care and Screening assessment dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score to be twelve out of a possible 15, thus indicating the resident was cognitive and able to make decisions. The same MDS indicated that the resident required set-up or clean-up assistance with most of the resident's functional abilities and goals, except the resident required supervision or touching assistance with tub/shower transfers, and partial/moderate assistance with walking ten feet. The MDS revealed the resident had an indwelling catheter. The MDS revealed the resident had a skin condition that required the application of ointments/medications other than to feet. Review of Resident #82's Order Summary Report as of 11/15/2024 revealed an active order which read, ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds, indwelling medical device, infection and/or MDRO status every shift. The order status was active, order date: 4/17/2024, and start date: 4/17/2024. Review of Resident #82's care plan initiated on July 23, 2024, and created on September 23, 2024, revealed the resident was resistive to care and treatments and refused to allow staff to remove dirty linens, insisting on washing and drying it himself. However, no goals or interventions were indicated for this focus area that would appropriately address the dangers this would present . Observation of Resident #82's room on November 12, 2024, at 12:04 PM, revealed no Enhanced Barrier Precautions signage or indication outside of the resident's room in reference to Enhanced Barrier Precautions that should be utilized. Observation of Resident #82's room on November 12, 2024, revealed no PPE immediately available outside or inside of the resident's room. Observation of Resident #82's room on November 12, 2024, revealed a foul odor emitting inside of the room, and at least 10-12 soiled towels draped along furniture and other items in the room and piled behind the door of the resident's room. The towels were soiled with a yellowish substance. As were the bed and linens in the resident's room. In an interview with Resident #82 on November 12, 2024, at 12:04 PM, the resident revealed that his legs were leaking fluid which required his use of multiple towels to soak up and clean up the leaked fluid. The resident stated that he was afraid that he would not be provided with enough towels needed to clean up the fluid, so he preferred to rinse the dirty towels himself and hang them to dry throughout his room, so they were readily available. Observation of Resident #82's room on November 13, 2024, at 10:07 AM, revealed no Enhanced Barrier Precautions signage or indication outside of the resident's room to indicate Enhanced Barrier Precautions should be utilized. Also, on this date and time, no available PPE was observed immediately outside of the resident's room . In an interview with the DON on November 15, 2024, at 1 PM, the DON stated that she ensured EBP were implemented and communicated with all staff by making rounds and doing spot checks. The DON stated that staff were educated on which residents required the utilization of EBP, but also there was a gold star or flower [sticker] on the name of each resident who require EBP. The DON stated there was no set determination by the facility as to where PPE was to be placed. The DON stated that staff should always refer to the care plan for an indication such as EBP . In an interview with LVN D on November 15, 2024, at approximately 1:45 PM, it was stated that LVN D learned of residents' conditions through shift reports and referencing treatment records and care plans, as changes occur regularly and often . Observation of Resident #82's room on November 15, 2024, at approximately 2 PM, revealed no Enhanced Barrier Precautions signage or indication outside of the resident's room, including the presence of a gold star or flower [sticker]. Record review the facility's policy titled Infection Prevention and Control Program-Linens dated 8/29/2017 states, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen, Record review of the facility's policy titled IPCP Standard and Transmission-Based Precautions, which originated on 6/2021 and revised on 7/2022 and 10/2022, states in part the following: 3. Enhanced Barrier Precautions (EBP): expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities . 6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and require PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident room.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to assist and monitor Resident #1 during meal service on 02/20/24 when she was served dinner despite a hospice order dated 02/11/24 stating that she should be assisted with meals and not left alone with food, and Resident #1 choked and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized until 02/25/24. An Immediate Jeopardy (IJ) was identified on 03/05/24. While the IJ was removed on 03/06/24, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of choking, aspiration pneumonia, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that gets worse over time), heart failure, dysphasia (difficulty with swallowing), and the need for assistance with personal care. Review of Resident #1's significant change in condition MDS assessment, dated 02/13/24, reflected a BIMS of 9, indicating she was moderately cognitively impaired. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance while eating. Section K (Swallowing/Nutritional Status) reflected she required a mechanically altered diet. Review of Resident #1's quarterly care plan, revised 02/05/24, reflected she had an ADL self-care performance deficit with an intervention of staffing assisting with ADLs as needed. Review of Resident #1's ER records, dated 02/09/24, reflected she was admitted due to aspirating while eating cake at the facility. Review of Resident #1's undated hospice binder revealed a narrative note dated 02/11/24 starting at 3:42 pm until 7:10 pm and the note stated Resident #1 was on mechanical soft diet with comfort food and thickened liquids. It further revealed she needed to be fed or at least assisted with feeding. She was not to be left in room alone with food due to the threat of choking. Review of Resident #1's hospice orders dated 02/11/24 reflected an order that stated assist patient with feeding, do not leave alone while eating. Review of Resident #1's hospice notes documented by HN A, dated 02/13/24, reflected the following: . Discussed [HN A]'s observation of [Resident #1] coughing with fluid intake this morning during RNV. Advised to continue with mechanical soft diet and honey thickened liquids as well as aspiration teaching/precautions to be followed with all po intake. [Resident #1] to have 1:1 assistance with all meals . Review of Resident #1's progress notes, dated 02/20/24 at 6:33 PM and documented by NURSE B, reflected the following: This nurse along with another nurse observed [Resident #1] had excess phlegm and coughing; [Resident #1] suctioned by nursing staff for excess phlegm . FM #1 states they do not want [Resident #1] to have any bread at mealtime . Review of Resident #1's progress notes, dated 02/20/24 at 8:01 PM and documented by NURSE B, reflected the following: [Resident #1] vomiting and in respiratory distress. Hospice Nurse A was called and came to evaluate the resident. FM #1 also at bedside. Transfer to (hospital) . During an interview and observation on 03/05/24 at 8:16 am with FM #1 he stated Resident #1 was on a mechanical soft diet and that she choked on a piece of cake on 02/09/24 and went to the emergency room and was hospitalized . At this time, FM #1 decided to have Resident #1 admitted to hospice services on return to the facility. He stated that he told the DON that he did not want Resident #1 to have bread any more due to the choking incident. He reiterated this at a meeting on 02/19/24 with the FM #1, FM #2, FM #3, FM #4, the Hospice Nurse, the DON and ADM because on the camera footage he could see Resident #1 had bread on her tray and was concerned about her choking. He stated on 02/20/24 around 5:00 pm FM #2 checked the camera and saw Resident #1 eating alone with bread on her plate. He also showed a picture dated 02/14/24 at 8:26 am that showed Resident #1 unsupervised while eating a meal. In addition, on 02/26/24, the day after she returned from the hospital, she was brought a tray with a sandwich on it and the FM #1 stated a family member called the facility about the concern. He also showed a picture dated 02/29/24 that had a meal ticket that stated, No Bread and Do Not Give Bread and the meal had 2 slices of wheat bread. During an interview and observation on 03/05/24 at 4:00 pm with FM #2 she stated that on 02/19/24 she was part of a meeting with the Hospice Nurse, the DON, the ADM and FM #1, FM #3, and FM #4 during which she voiced her concerns related to Resident #1 choking and reiterated that the family did not want Resident #1 to have bread. FM #2 the stated that on 02/20/24 at 5:00 pm she saw Resident #1 eating alone in her room and she saw bread on the plate. She showed her phone with a text message dated 02/20/24 at 5:04 pm with the DON in which she said she was worried because Resident #1 was alone in her room with her meal and had bread on her tray and FM #2 stated she was concerned about Resident #1 choking. The DON responded on 02/20/24 at 5:27 pm and apologized and said she informed the aides and let them know again. She stated Resident #1 was sent to the ER that evening. She showed a video dated 02/20/24 at 4:59 pm that showed Resident #1 alone in her room with bread on her meal tray. During an interview on 03/05/24 at 4:00 pm with FM #3 and FM #4 they both stated they attended the meeting on 02/19/24 with the DON, the ADM, the Hospice Nurse, FM #1 and FM #2 and the family voiced their concerns about assistance with meals and ensuring Resident #1 was not provided any bread due to their concern about choking. During an interview 03/05/24 at 12:11 pm with Hospice Director she stated that Resident #1 was admitted to hospice services on 02/11/24 and the original hospice orders dated on admission were to give Resident #1 a mechanical soft diet with thickened liquids and to assist Resident #1 with all meals and not to leave her alone while she was eating. Review of hospital progress notes printed 02/26/24 for Resident #1 revealed the results of a chest x-ray dated 02/20/24 at 9:03 pm that stated new patchy airspace opacities compatible with aspiration or pneumonia. Further review of the hospital notes revealed a progress note by the physician dated 02/24/24 at 2:09 pm and revealed Resident #1 was admitted with an episode of choking on bread leading to aspiration pneumonia (inflammation causing infection in the lungs) Review of the facility policy dated January 2022 titled end of life care; hospice and/or palliative care revealed an interdisciplinary assessment would be utilized to develop an individualized plan that would be implemented to prevent and relieve symptoms and family would be an integral part of the plan .assessment should include Preferences and goals of care of the resident and family . resident's functional status and what help was required . family members will be an active part of the care planning team . hospice services would be integrated into the care plan. Review of the facility policy dated 10/2022 titled Physician Orders revealed that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. During an interview on 03/05/24 at 3:45 pm with Nurse C she stated hospice orders should be handed to the nurse on duty and that nurse should contact hospice physician and verify the orders, then contact the facility physician to inform him/her of the hospice orders, then the nurse should input the orders from hospice in the EHR. During an interview with the DON and ADM on 03/05/24 at 2:26 pm the DON stated that tickets should be checked by dietary staff in the kitchen and the nurse in the hall before food was given to a resident. The DON stated she was not aware the family did not want the resident to have bread until dinner on 02/20/24. The also stated she was not aware of the order for assistance with meals from hospice because it was not in the EHR. This was determined to be an Immediate Jeopardy (IJ) on 03/05/2024 3:11 PM. The ADM and DON were notified and provided with the IJ template on 03/05/24 at 5:15 PM. The following POR was accepted 03/06/24 at 9:05 am an the IJ was lifted on 03/06/24 at 12:17 pm: Plan of Removal F689 : 03/05/24 Per the information provided in the IJ Template given on 3/5/2024, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevents accidents. 1. The Medical Director was notified of the Immediate Jeopardy on 3/5/2024 at 7:21pm. 2. Resident #1 was reassessed for assistance level needed while eating, however the physician and hospice were notified of resident's decline in condition and the family's request for pleasure feeds. The physician gave orders for pleasure feeding based on the family's request and her plan of care was updated with those orders accordingly. This reassessment was completed by the ADON on 3/5/2024. The DON notified physician and hospice of decline and obtained the pleasure feed orders and updated the care plan on 3/5/2024. 3. All 107 residents have the potential to be affected by this practice. All residents were reassessed via the Nutrition / Hydration Risk Evaluation by the DON or designee on 3/5/2024. The DON or designee reviewed the medical record, spoke to staff, observed residents eating/drinking, and spoke to residents to complete the assessment for each resident. Care profiles and care plans were updated with the resident eating assistance level by the DON or designees on 3/5/2024. All resident diets and assistive devices were also reviewed and compared with dietary tray card system by the Dietary Manager and the DON on 3/5/2024. 4. Train the trainer in-service was given by the Clinical Resource RN and was completed with DON, ADONs, Cluster Partners, Staffing Coordinators and Executive Director on 3/5/24 related to diet orders, adequate supervision with eating and assistive devices. 5. Training and knowledge checks were initiated on 3/5/24 on diet orders, adequate supervision with eating and assistive devices. Nursing staff, Dietary Staff and Therapy Staff will complete this training and knowledge check. This training and knowledge checks were initiated on 3/5/24 and will be completed 3/6/24 with all nursing staff, dietary staff and therapy staff prior to the start of their next shift. This training and knowledge check will be provided by the DON or designee. The DON or designee will be at the facility at each change of shift to ensure all get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and knowledge check. The ED and DON will ensure that this was completed by: staff posting at time clock to see management for training/knowledge check prior to start of their shift; calls and messages to staff that they cannot work until they complete the training/knowledge check. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 6. An ad hoc (Latin for this/unplanned) meeting regarding items in the IJ template will be completed on 3/5/24. Attendees will include the DON, Medical Director, ADONs, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 7. The DON or designee will verify staff knowledge with 10 nursing, dietary and therapy staff weekly using diet knowledge check form. This will be completed weekly after the initial training/knowledge check began on 3/5/24 and will be ongoing for 90 days or until substantial compliance was achieved. 8. Resident eating assistance levels for new admissions, readmissions, and changes in condition will be reviewed during weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meeting attendees to include but not limited to DON, ADONs, Rehab Director, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting was held weekly beginning 3/6/2024 and residents are reviewed for 90 days or until substantial compliance was achieved. 9. 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. Monitoring the POR In an interview on 03/07/24 at 10:10 AM, MD stated that he was informed of the IJ by the facility administration on 03/05/24. In an interview on 03/06/24 at 8:27 AM DON and ADM stated that Resident #1's family had decided to change her to no food by mouth on 03/06/24 as her end of life was imminent. In an interview on 03/07/24 1:42 PM Clinical Resource RN stated that she had completed an in-service with the DON, ADON, Cluster DON on the ensuring diet orders were current and accurate, that residents who required supervision receive the supervision that they required and resident who required assistive devices for meals had those assistive devices. Clinical Resource RN stated that she reviewed all competency checks that were administered to ensure staff passed prior to allowing them to work the floor. In an interview on 03/07/24 at 1:50 PM DON stated that she had received training from Clinical Resource RN ensuring diet orders were current and accurate, that residents who required supervision receive the supervision that they required and resident who required assistive devices for meals had those assistive devices. DON stated that she along with the ADONs and Cluster DONs educated all facility staff via telephone and in-person in-services on the importance of ensuring that residents were being served meals according to their meal ticket, that when a meal cart was received from the kitchen that the nurse on duty completes a quality assurance check to ensure that meal served aligns with meal ticket and then when the aide passes the meal out the aide was also verifying accuracy. DON stated that Cluster DON and ADON's completed all nutritional assessment on all residents in the facility, revised care plans to be more specific for all residents. DON stated that she administered competency checks to all nursing staff and those who were they were unable to reach would be educated prior to working their next shift. Interviews were conducted with staff across multiple shifts on 03/07/24 from 8:03 AM through 1:21 pm Dietary Manager, 3 CNA's, 2 RN's and LVN, ST had all been in-serviced by either the DON or ADON. Staff stated they were educated on the importance of ensuring that residents were being served meals according to their meal ticket, that when a meal cart was received from the kitchen that the nurse on duty completes a quality assurance check to ensure that meal served aligns with meal ticket and then when the aide passes the meal out the aide was also verifying accuracy. In an interview on 03/06/24 at 12:05 PM with Cluster DON revealed that she had assisted DON with nutrition assessments, revised care plan, in-serviced staff on the importance of ensuring that residents were being served meals according to their meal ticket, that when a meal cart was received from the kitchen that the nurse on duty completes a quality assurance check to ensure that meal served aligns with meal ticket and then when the aide passes the meal out the aide was also verifying accuracy. On 03/07/24 at 12:20 PM revealed lunch was being served to residents. Dietary staff was observed taking the meal cart to the nurses station, Charge Nurse was observed verifying meal served with meal tray ticket and CNA was observed passing the meals to the residents. Observation of the assisted dining room revealed 5 residents were seated at their table. Staff were observed sitting eye level, feeding residents. Review of LN-Nutrition/Hydration Risk Evaluation dated 03/06/24 revealed the facility had completed 107 nutritional risk, 6 residents identified as High Risk. Review of Resident #1's nurses note for 03/06/24 at 10:25 AM and 11:54 AM revealed that family had refused the resident's meal tray. Review of Resident #1's nurses note for 03/05/24 at 5:22 PM reflected: Note Text: Notified family at bedside that hospice had given order for pleasure feeds only due to their request of resident not receiving any foods unless she requests it. Explained that pleasure feeds would only be given upon request. Family voiced understanding and stated that the resident was not wet at this time, and they did not want resident disturbed and that they request pudding ad thickened fluids if needed. MD notified of new hospice orders. Review of a train-the-trainer in-service dated 03/05/24 revealed the corporate nurse trained DON, ADONs, Cluster Partners, Staffing Coordinators and Executive Director on Diets, Tray Cards, Adequate Supervision, and Assistive Devices. Further review revealed all staff trained passed the post-training knowledge check. Review of in-service training record revealed an in-service on 03/05/24 related to Diets, Tray Cards, Adequate Supervision and Assistive devices. Further review revealed post-test knowledge checks for all in-serviced staff. Separate in-services were reviewed for CNAs, Therapy, Nurses, and Medication Aides; it was documented if the staff member was in-serviced in person or over the telephone. Review of a signed document revealed that the medical director was notified of the IJ 03/05/24 at 7:21 pm by the DON and was signed by the DON. Review of resident roster revealed every resident in the facility was assessed for dietary needs by DON. Review of report titled assessment history: nutrition/hydration risk evaluation revealed the evaluation was completed for every resident in the facility on 03/05/24. Review of facility report titled care plan item/task listing report printed 03/06/24 revealed that every care plan for every resident care was updated based on nutrition assessment by DON for dietary needs. Review of an in-service on physical assist and supervision dated 03/05/24 revealed that staff were educated that all residents that require physical assist or supervision were required to eat in the dining room and nurses were required to check all meal trays before they were given to a resident. The ADM was informed the Immediate Jeopardy was removed on 03/06/2024 at 12:17 p.m. The facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 18 Residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 received microwaved food, from an outside source, at a temperature for safe elderly consumption which resulted in a second-degree burn. 2. The facility failed to ensure Resident # 2 had total assistance while consuming a cup of hot coffee resulting in medical attention for skin irritation. On 2-5-2024 at 7:54 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2-7-2024 at 2:40 PM, the facility remained out of compliance at a scope of isolated with a severity level of potential of more than minimal harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: 1. Record review of the facilities investigation report, dated 1-24-2024, indicated Resident #1 asked CNA A for assistance with heating up a bowl of soup on 1-16-2024. CNA A heated the soup and returned it to Resident #1 on his bedside table. Resident #1 accidently knocked the soup from the bedside table onto his right lower torso area having yelled out in pain. CNA A returned shortly to render aid, where she cleaned him, and provided clean linen and clothing. CNA A left the room. On the next day, 1-17-2024, CNA B was assisting Resident #1 with a bed bath and noticed Resident #1's right lower torso area was red. CNA B asked LVN C for help, where it was discovered that Resident # 1's right lower torso area was red with blisters. CNA A was suspended pending investigation, subject to discharge, for having known of the spilled soup and having not reported the incident to the charge nurse. In-service educations for hot beverages and food temperature proceeded. Record review of Resident #1 AR, dated 2-6-2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with orthostatic hypotension (which was lightheadedness or dizziness when standing after sitting or lying down); unspecified lack of coordination; need for assistance with personal care; and mild cognitive impairment. Record review of Resident #1's Quarterly MDS assessment, dated 12-8-2023, indicated Section C- Cognitive Patterns, BIMS Score Summary reflected Resident #1 had a BIMS Score of 6. A BIMS Score of 6 indicated Resident #1 had severe cognitive impairment. Acute Onset Mental Status Change indicated Resident #1 continuously presented with inattention, disorganized thinking, and an altered level of consciousness described as vigilant, meaning he startled easily to any touch or sound. Section GG- Functional Abilities and Goals, Self-Care, indicated Resident #1 required set-up or clean-up assistance (which meant the helper sets up or cleaned up after the resident completed the activity) for eating. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated CNA B was changing resident when it was observed that the resident had a burn with a thick blister to the lateral right thigh. Aide alerted nurse. The resident stated that he spilled a container of soup, brought from home, on him last night. The resident stated he did not tell anyone at the time of incident. Wound care performed per NP: cleanse with NS, pat dry, apply Silvadene cream, and dress with dry dressing. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated burn incident to the right-side hip area. This NP notified today by nurse of incident. Resident reported accidentally hitting the bedside table and knocked over the soup that was brought to him by family. Assessment of site completed with redness noted to right side hip area, non-tender to touch, denies pain at this time, able to move extremities with no limitations. Stable at baseline in good spirits with intermittent confusion. Care discussed with nursing, new orders noted for Silvadene cream, dress with dry dressing. Nursing and wound care to monitor closely for delayed complications. Record review of Resident #1's Progress Notes, dated 1-22-2024 indicated Resident was seen by wound doctor for burn to the right side (flank). Area was cleaned with n/s and anesthesia was achieved using topical benzocaine. Then with surgical technique, 15 blade was used to surgically excise 21.00 cm of devitalized tissue and necrotic subcutaneous level tissues along with sought and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 35%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of the skin and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 1-29-2024 indicated the resident was seen by wound doctor for burn to the right flank and wound with improvement observed on this visit by evidenced by decreased surface area and decreased necrotic tissue increased granulation. Wound was cleaned with normal saline and anesthesia was achieved using topical benzocaine. Then with surgical technique 15 blade was used to surgically excise 12.6cm of devitalized tissue and necrotic subcutaneous level tissues along with slough, biofilm was removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing was applied. The resident has been made aware of the condition of burn and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 2-5-2024 the resident was seen by wound md for burn to the right flank area with improvement observed on this visit evidenced by decreased surface area. Wound was cleaned with n/s and anesthesia was achieved using topical benzocaine and resident has no complaint of pain or discomfort during this assessment. Then with clean surgical technique, 15 blade was used to surgically excise 9.00cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.1cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30% to 5%. Hemostasis was achieved and a clean dressing was applied. The resident has been made aware of the condition of the wound and the treatment that is in place. Record review of Resident #1's skin evaluation, dated 1-18-2024, reflected a fluid filled blister to the upper right side of the torso area with surrounding skin red in color and blister intact, the right lower side of torso area had fluid filled blister with redness to surrounding skin. Record review of Resident #1's skin evaluation, dated 1-23-2024, reflected a burn to the resident's right flank. It was 6 centimeters by 10 centimeters and 1 centimeter deep. The resident would continue to receive wound care on wound rounds. Record review of Resident #1's skin evaluation, dated 1-25-2024, reflected burns to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-1-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-5-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's Order Summary Report indicated an order, dated 1-29-2024, to clean right flank, pat dry, and apply alginate calcium and collagen powder, and cover with gauze island dressing every 24 hours as needed for burn. Record review of Resident #1's Order Summary Report indicated an order, dated 2-6-2024, to clean right flank, pat dry, and apply xeroform and apply gauze island on day shift for burn. Record review of Resident # 1's IDT BIMS Assessment, administered on 1-18-2024, indicated Resident # 1 had a BIMS Score of 11. A BIMS Score of 11 indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's CP indicated a [Focus Area] created 1-18-2024 and evidenced by actual impairment to skin integrity R/T burn to right side hip from soup and treatment was documented. Resident was seen by wound physician on 1-22-2024, 1-29-2024, and 2-5-2024. The [Intervention] initiated on 1-18-2024 was to follow facility protocols for treatment of injury. A second [Focus Area] created 6-2-2023 evidenced by risk of impaired cognitive function/dementia or impaired thought was documented. The [Intervention] created on 6-2-2023 was to give step-by-step instructions one at a time as needed to support cognitive functions and report any changes in cognitive function, specifically in decision making ability, memory, recall, awareness of surroundings and other, difficulty expressing self, difficulty understanding others, sleepiness, or confusion. A third [Focus Area] created 6-2-2023 evidenced by risk of visual function R/T aging was documented. The [Intervention} created 6-2-2023 was to monitor, document and report to the physician any signs of acute eye problems; changes in ability to perform ADLs, decline in mobility, second visual loss, double vision, tunnel vision, blurred vision, or hazy vision. Interview and observation on 2-5-2024 at 10:30 AM with Resident #1 revealed Resident #1 was lying in bed relaxing. His tray side table had two thin rectangular non-slip pads. He stated he just got the non-stick pads today, and they were there to help things from slipping off his table. On the evening of 1-16-2024 he asked CNA A to heat up some soup for him. When CNA A brought the soup back, he stated she placed it on the bed side table and left. He sat up in bed and knocked the soup over by accident onto his right-side lower torso area, which caused him to holler out in pain. He gauged the pain on a pain scale of 1-10, with 0 being no pain and 10 being the worst. Resident #1 stated the pain he felt after spilling his soup on his right-side lower torso area was an 8 out of a possible 10. When he called for help after he spilled his soup, he stated CNA A came back to his room, who changed his clothes and his bedding. He did not remember if CNA A asked him if he was in any pain. No other staff member came to his room to look at his skin or to see if he needed medical attention. During the interview, CNA E came to the room and moved back Resident #1's covers to expose his right-side lower torso area. His right-side lower torso area was covered with two light pink bandages. Record review of CNA A's counseling and disciplinary notice dated 1-18-2024 having pertained to Resident #1, indicated CNA A was suspended, pending investigation, subject to discharge. Employee knew that a resident spilled hot food on them and failed to notify the charge nurse of the incident / change of condition. Record review or Resistant #1's SBAR Communication form, dated 1-17-2024, indicated Resident#1 had a change in condition, due to a burn, which occurred on 1-16-2024. Record review of the in-service training dated 1-18-2024, on [Hot Beverages and Food Temperature,] provided by the facility, indicated that [Coffee and Hot Water for all Residents Cannot Exceed 135 degrees Fahrenheit.] The training consisted of 5 instructions: (1) dietary staff will log copy temperatures daily to ensure that the temperature does not exceed 135 degrees Fahrenheit; (2) canned soup should be warmed up to 130 degrees Fahrenheit unless it is leftover and then you reheat it to 165 degrees Fahrenheit for 15 seconds; (3) recommendations for the elderly safe consumption were 135 to 150 degrees Fahrenheit; (4) when we reheat resident's food, the preference is for the kitchen to reheat the food. If the kitchen is closed, we must test food temperatures with a food thermometer before giving the resident the item for safe consumption, and; (5) the thermometers were located in the drawer by microwave. Please ensure you clean before and after use with alcohol swab. Record review of the facility's [Significant [NAME] in Condition, Response Policy] dated January 2022 indicated: if, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. 2. Record review of the facilities investigation report, dated 2-6-2024, indicated Resident #2 asked CNA J for a cup of coffee on 2-3-20 at 7:30 AM. CNA J retrieved a cup of coffee from the coffee dispenser and returned the cup of coffee to Resident #2. CNA J asked Resident #2 if he was ok to drink the coffee and Resident #2 stated he was. After a couple of minutes, CNA J stated she heard Resident #2 having yelled for help. When CNA J reported to Resident #2's room, she witnessed his coffee was spilled on the upper side of his left leg at the groin area. CNA J stated she immediately retrieved the nurse. LVN D assessed Resident #2 and noted redness to the area of the skin where the coffee was spilled. CNA J was educated, one on one, for safety with warm liquids. In-services for ANE and hot beverages and food temperatures proceeded. Record review of Resident #2's AR, dated 2-6-2024, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Parkinson's Disease, with fluctuations (which was a progressive disorder that affected the nervous system and parts of the body controlled by nerves, along with fluctuations in the ability to move); cognitive communication deficit; Unspecified lack of coordination; and the need for assistance with personal care. Record review of Resident #2's Quarterly MDS, dated [DATE], indicated Section C- Cognitive Patterns, BIMS Score Summary reflected Resident #2 had a BIMS Score of 11. A BIMS Score of 6 indicated Resident #2 had moderate cognitive impairment. Acute Onset Mental Status Change indicated Resident #2 continuously presented with inattention. Section GG- Functional Abilities and Goals, Functional Limitation in Range of Motion indicated Resident #2 had impairment on both shoulders, elbows, wrists, and hands. Self-Care indicated Resident #2 substantial/maximal assistance (which meant the helper did more than half of the effort) for eating. Record review of Resident #2 CP indicated a [Focus Area] created 1-11-2024 evidenced by the resident having Arthritis. The [Intervention] initiated on 1-11-2024 was to monitor and report to nurse any change in level of activity or ability to perform; monitoring, document, and report to physician complications related to arthritis such as pain, joint stiffness, swelling, decline in mobility, decline in self-care ability, contracture formation, and joint shape changes. A second [Focus Area] created on 12-12-2022 was evidenced by ADL self-care performance deficit R/T weakness. The [Intervention] created on 2-5-2024 was all staff to assist with ADLs. Record review or Resistant #2's SBAR Communication form, dated 2-3-2024, indicated Resident #2 had a change in condition, due to a skin discoloration, which occurred on 2-3-2024. Record review of Resident #2's skin evaluation, dated 2-3-2024, reflected skin irritation to the resident's left inner thigh. Record review of Resident #2's skin evaluation, dated 2-5-2024, reflected to continue treatment to the resident's left inner thigh. Record review of Resident #2's Progress Notes, dated 2-3-2024, reflected this nurse heard resident yelling, proceeded to resident's room, prior to arriving in resident room saw CNA J exit resident's room, and told this nurse that the resident had spilled coffee on himself. This nurse and CNA J entered the resident's room to see that the resident had spilled coffee on the sheet that was covering him from the waist down. The sheet was removed; the resident was assessed. The resident's left inner and bottom of left buttock had some skin irritation and redness, skin intact. Asked the resident what happened, and the resident stated that he spilled the coffee on himself, and it was hot. The resident cleaned up by can x 2, clean brief applied to resident, and bed linen changed. The NP, the DON, and the administrator were notified. Cleanse resident left inner thigh and left buttocks with NS, pat dry, and apply Silver Sulfadiazine Cream 1% BID. The resident's wife was notified. The ordered treatment was initiated. The coffee temperature was taken and was within normal limits. The resident denied pain. The resident stated that it was hot when it happened but now, he feels better, and he will be okay. The CNA was educated on the importance observing food and/or beverages for steam and notifying the nurse, prior to giving the resident food and/or beverages if the CNA thinks that the food and/or beverages was too hot. CNA verbalized understanding. Record review of Resident #2's Order Summary Report indicated an order, 2-3-2024, to cleanse left inner thigh with NS, pat dry, and then apply silver sulfadiazine external cream 1% until healed. Leave open to air. Two times a day for skin irritation. Record review of the in-service training dated 2-3-2024, on [Abuse and Neglect] provided by the facility, indicated that [abuse is prohibited. Every resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation] The training indicated residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, resident representatives, family, friends, or other individuals. Abuse must be reported to the abuse coordinator immediately. The abuse coordinator is the ADM. Types of abuse are, but not limited to our physical, mental, financial, restraints, verbal, and misappropriation of funds. Record review of the facility's [Abuse Prevention Policy,] dated September 2017. Record review of the facility's [reporting alleged violations of abuse, neglect, exploitation, or mistreatment,] dated October 2022. Record review of the in-service training dated 2-3-2024 on [Hot Beverages and Food Temperature,] provided by the facility, indicated that [Coffee and Hot Water for all Residents Cannot Exceed 135 degrees Fahrenheit.] The training consisted of 5 instructions: (1) dietary staff will log copy temperatures daily to ensure that the temperature does not exceed 135 degrees Fahrenheit; (2) canned soup should be warmed up to 130 degrees Fahrenheit unless it is leftover and then you reheat it to 165 degrees Fahrenheit for 15 seconds; (3) recommendations for the elderly safe consumption were 135 to 150 degrees Fahrenheit; (4) when we reheat resident's food, the preference is for the kitchen to reheat the food. If the kitchen is closed, we must test food temperatures with a food thermometer before giving the resident the item for safe consumption, and; Please see nurse before giving any liquids/food for verification of safe consumption. (5) the thermometers were located in the drawer by microwave. Please ensure you clean before and after use with alcohol swab. Interview, observation, and record review on 2-5-2024 at 10:55 AM with CNA E revealed that residents have asked her to heat their food for them in the past. She said there was a microwave in the nutrition room at the nurse's station. Having reheated resident's food before, she admitted that she had not used a thermometer to check for the food's temperature until the incident with Resident #1's soup on the evening of 1-16-2024. Since then, she stated that the staff had been trained to check the resident's food with a thermometer prior to returning it to the resident. CNA E demonstrated her knowledge of training provided by the facility having attempted to heat a cup of water in a plastic coffee cup in the microwave. The observation reflected CNA E having entered the nutrition room, near the 300 hall, where she looked for a thermometer. CNA E opened the drawer under the microwave, where the thermometer was visible, but she could not locate it. She opened and shut the drawer 3 times before she finally located the thermometer. There were no alcohol swabs. CNA E had to leave the nutrition room and locate alcohol swabs, which were located on the medication cart. When she returned to the nutrition room, she placed the cup of water in the microwave. CNA E did not know a guesstimated time to put the cup of water in the microwave. When the timer went off, she wiped the thermometer and placed it in the cup, the temperature was 145 degrees Fahrenheit. CNA E then stated that she would wait for the coffee, or whatever the item was, to cool to 135 degrees Fahrenheit before having given it to the resident. CNA E stated having known a start point to put a particular item in the microwave to heat to 135 degrees Fahrenheit would help, because having to wait for it to cool risked bringing something to a resident that was too hot. She also stated that alcohol swabs should have been located in the drawer next to the thermometer because not having one handy risked using a thermometer that was not clean. The only written guidance in the nutrition room for reference, near the 300 hall, was a square sticker on the refrigerator with a picture of a thermometer. The sticker indicated the proper holding temperatures for foods were above 135 degrees Fahrenheit or below 41 degrees Fahrenheit. This sticker informed the reader of safe holding temperatures to avoid food borne pathogens, not to designate safe temperatures for elderly consumption. CNA E reviewed the in-service training, and her name was not recorded to mark attendance. Interview, observation, and record review on 2-5-2024 at 11:20 AM with CNA F revealed she had heard Resident #1 spilled soup on himself on 1-16-2024. If she had been the CNA on duty, she stated she would have wanted to see where the soup was spilled and get the nurse to check for injuries. According to CNA F, CNA A failed in her duties having not reported the spill to the nurse. CNA F entered the nutrition room, near the 700 hall, and demonstrated her knowledge from the in-service training, called [Hot Beverages and Food Temperature,] dated 1-18-2024. CNA F stated that the coffee was supposed to be reheated between 135-150 degrees Fahrenheit. She said that coffee was safe to serve to residents at 145 degrees Fahrenheit. CNA F correctly demonstrated the process to heat an item, but she was incorrect about the coffee temperature being safe to serve at 145 degrees Fahrenheit. CNA F was provided a copy of the in-service training for [Hot Beverages and Food Temperature,] dated 1-18-2024. When she reviewed the in-service training, she became confused because the in-service training indicated more than one example of safe temperatures that were safe for elderly consumption. She noted the heading of the in-service training stated coffee and hot water for residents cannot exceed 135 degrees Fahrenheit, but (3) recommended elderly safe consumption was 135-150 degrees Fahrenheit. She was also confused because the instructions for soup (2) stated soup should be warmed up to 135 F unless it is left over and then you reheat it to 165 F for 15 seconds. The only written guidance in the nutrition room for reference, near the 700 hall, was a square sticker on the refrigerator with a picture of a thermometer. The sticker indicated the proper holding temperatures for foods was 135 F or 41 F; this sticker informed the reader of safe holding temperatures to avoid food borne pathogens, not to designate safe temperatures for elderly consumption. CNA F reviewed the in-service training, and her name was recorded marking attendance. Interview, observation, and record review on 2-5-2024 at 11:45 AM with CNA B revealed she was in Resident #1's room on the evening of 1-17-2024 to give Resident #1 a bed bath. When she was about to begin, Resident #1 pointed to his right lower torso area, referring to the area he spilled his soup, and asked if she was going to do anything about it, because [it was uncomfortable.] She pulled back Resident #1's covers and clothing to reveal a big bubble blister. She immediately got LVN C for a medical assessment. Both CNA B and LVN C returned to the room where she observed LVN C assess the injury. CNA B observed the big bubble blister was seeping clear liquid. After the wound was dressed by LVN C, CNA B continued with Resident #1's bed bath. If she were on duty the night of 1-16-2024, when Resident #1 spilled his soup, she stated she would have asked the nurse to check his skin. CNA B stated CNA A neglected Resident #1 by not reporting the matter to the nurse. Prior to the incident with Resident #1 having spilled his soup, CNA B stated there was no direction given to CNAs that pertained to food and beverage temperatures for elderly safe consumption. CNA B entered the nutrition room, near the 300 hall, to demonstrate her knowledge of the in-service training for [Hot Beverages and Food Temperature,] dated 1-18-2024. At this time, the thermometer was located in the same location as before, but the thermometer was placed it in a 1-gallon size plastic bag and had used a black magic marker to indicate a temperature range of 135-145 degrees Fahrenheit, which was not congruent with the in-service training and safe consumption for the elderly. However, CNA B correctly demonstrated the process of heating up a plastic cup of water not to exceed 135 degrees Fahrenheit. She started at 30 second intervals and brought the temperature up gradually so it did not exceed 135 degrees Fahrenheit. CNA B reviewed the in-service training, and her name was recorded marking attendance. Interview, observation, and record review on 2-5-2024 at 12:40 PM with CNA A revealed Resident #1 asked her to heat up some soup for him on the evening of 1-16-2024. The soup was a single serve microwavable soup. She did what she was asked and returned the soup to Resident #1's bedside table. She stated she placed it on the bed side table and told Resident #1 to wait until it cooled off, because she stated it was steaming. CNA A left the room to address other duties. CNA A guesstimated 5-10 minutes passed when she noticed his call light was activated. After an additional 2-3 minutes, she stated she entered the room for the call. When she entered the room, she learned that Resident #1 had spilled his soup on his right lower torso area. She removed Resident #1's clothing and bedding then provided clean replacements. After, she left the room to address her duties. She did not report the incident of Resident # 1 having spilled soup, which she referred to as steaming on his right lower torso area. Prior to the incident on 1-16-2024, CNA A stated she had not received any formal training on food temperatures for elderly safe consumption. However, after the incident on 1-16-2024, the facility began to train staff on hot beverages and food temperature. CNA A entered the nutrition room, near the 700 hall, to demonstrate the training she received for [Hot Beverages and Food Temperature] on 1-18-2024. CNA A filled a plastic coffee cup with water and placed it in the microwave and heated the water with an increments of 30 seconds. She took the liquids temperature for two intervals of heating but did not use an alcohol wipe before inserting the thermometer. She stopped at 117 degrees Fahrenheit and said she would have provided it to the resident. CNA A reviewed the in-service training and was unable to determine the safe temperature for elderly consumption for a can of soup. The training initially stated that 135 degrees Fahrenheit was the safe temperature for soup, but the training also said it could be heated to 135 is it was considered a left over. CNA A reviewed the in-service training, and her name was recorded marking attendance. Interview and record review on 2-5-2024 at 1:31 PM with the DM and the [Hot Beverages and Food Temperature] in-service on 1-18-2024 revealed she was not consulted by the ADM with the information contained in the training. According to the DM, the different temperatures in the trainings were not consistent. Temperature logs for coffee in the month of January 2023 and February 2023 indicated all 3 coffee station areas, Shawnee, Express, and Activity, ranged between 130-135 degrees Fahrenheit. Interview on 2-5-2024 at 1:49 PM with LVN C revealed she was on duty the evening of 1-17-2024, around 5:00 PM, when CNA B reported Resident #1 needed medical attention. When LVN C entered the room, she noticed Resident #1's right lower torso area was red. LVN C pulled back the sheet and discovered two blistered areas, one of which one had popped exposing raw skin. She informed the nurse practitioner, applied Silvadene cream, and dressed the wound. LVN C stated Resident #1 told her [it hurt at the time it happened.] LVN C had been a nurse for [AGE] years with experience treating burns and characterized Resident #1's injury either a 1st degree or a 2nd degree burn. Furthermore, she stated the skin would have continued to burn until the burn stopped on its own, or if something were applied like cold water, ice, or Silvadene cream. Had the burn been treated sooner, it might have had a better outcome. LVN C stated CNA A should have told the nurse after she learned Resident #1 spilled hot soup on himself. Also, neglect did not have to be a willful act. LVN C completed a SBAR form, to note a Change in Condition, for Resident #1's burn on 1-17-2024 at 5:00 PM. The wound care was assigned to the wound care nurse, LVN G, because raw skin was exposed and there was a greater risk of infection. According to WebMD at [https://www.webmd.com/drugs/2/drug-4910silvadene-topical/details] Silvadene cream was a medication used with other treatments to help prevent and treat wound infections in patients with serious burns. Group interview on 2-5-2024 at 2:10 PM with LVN G (wound nurse), Physician H (wound doctor), and Physician I (wound doctor) revealed a consensus that the wound on Resident #1 was classified as a 2nd degree burn. LVN G stated that CNA A should have reported the soup spill to the nurse for a medical assessment. Interview and record review on 2-5-2024 at 3:00 PM with the ADM revealed the CNA staff who demonstrated heating items in the microwave were confused after they were interviewed. The ADM was shown the in-service for [Hot Beverages and Food Temperature] on 1-18-2024 and was informed that the demonstration and the interview questions came directly from the in-service [Hot Beverages and Food Temperature] on 1-18-2024. The ADM stated that the information on the in-service for [Hot Beverages and Food Temperature] on 1-18-2024 was taught differently. However, she understood the actual words and temperature ranges contradicted each other. Staff were being re-trained. Interview and observation on 2-5-2024 at 5:24 PM with Resident #2 revealed he asked CNA J to bring him a cup of coffee on 2-3-2024 around 7:30 AM. CNA J brought him a cup of coffee and put it in his right hand then left the room. After a brief few moment, he stated he dropped the coffee in his crotch and yelled out in pain because it hurt a lot when it happened. He stated he was in pain for about 30 seconds. He was asked to demonstrate how he held a plastic coffee cup, the same kind used by the facility. Before he could accept the coffee cup, he needed to put down his call-light button, which was in his right hand. Observations reflected his right arm, right forearm, and his right hand moved very slowly. Resident #2 displayed difficulty manipulating his fingers to release his grasp of the call-light button and his arm moved unsteadily when he reached out to grab the plastic cup. Resident #2 did not have use of his left arm, left forearm, or his left hand. Interview on 2-5-2024 at 5:32 PM with CNA K revealed she has provided care for Resident #2 many times. She stated he did not have proficient use with his right hand sometimes it moved in a jerking motion. She stated she would not have given Resident #2 a cup of hot coffee and left him alone because he required supervision with hot liquids because he could pill it and[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care with professional standards of practice for 1 of 19 Residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received immediate medical care after he spilled a bowl of [steaming] soup on his right lower torso area, which caused a 2nd degree burn. The incident went unreported and undetected for 1 calendar day. This failure placed residents at the facility at risk for unmet medical attention. Findings included: Record review of the facilities investigation report, dated 1-24-2024, indicated Resident #1 asked CNA A for assistance with heating up a bowl of soup on 1-16-2024. CNA A heated the soup and returned it to Resident #1 on his bedside table. Resident #1 accidently knocked the soup from the bedside table onto his right lower torso area having yelled out in pain. CNA A returned shortly to render aid, where she cleaned him, and provided clean linen and clothing. CNA A left the room. On the next day, 1-17-2024, CNA B was assisting Resident #1 with a bed bath and noticed Resident #1's right lower torso area was red. CNA B asked LVN C for help, where it was discovered that Resident # 1's right lower torso area was red with blisters. CNA A was suspended pending investigation, subject to discharge, for having known of the spilled soup and having not reported the incident to the charge nurse. Record review of Resident #1 AR, dated 2-6-2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with orthostatic hypotension (which was lightheadedness or dizziness when standing after sitting or lying down); unspecified lack of coordination; need for assistance with personal care; and mild cognitive impairment. Record review of Resident #1's Quarterly MDS, dated [DATE], indicated Section C- Cognitive Patterns, Sub-Section C 0500., BIMS Score Summary reflected Resident #1 had a BIMS Score of 6. A BIMS Score of 6 indicated Resident #1 had severe cognitive impairment. Sub Section C1310., Acute Onset Mental Status Change indicated Resident #1 continuously presented with inattention, disorganized thinking, and an altered level of consciousness described as vigilant, meaning he startled easily to any touch or sound. Section GG- Functional Abilities and Goals, Sub-Section GG 0130., Self-Care, indicated Resident #1 required set-up or clean-up assistance (which meant the helper sets up or cleaned up after the resident completed the activity) for eating. Record review of an IDT BIMS Assessment, administered on 1-18-2024, indicated Resident # 1 had a BIMS Score of 11. A BIMS Score of 11 indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's CP indicated a [Focus Area] created 1-18-2024 and evidenced by actual impairment to skin integrity R/T burn to right side hip from soup and treatment was documented. Resident was seen by wound physician on 1-22-2024, 1-29-2024, and 2-5-2024. The [Intervention] initiated on 1-18-2024 was to follow facility protocols for treatment of injury. A second [Focus Area] created 6-2-2023 evidenced by risk of impaired cognitive function/dementia or impaired thought was documented. The [Intervention] created on 6-2-2023 was to give step-by-step instructions one at a time as needed to support cognitive functions and report any changes in cognitive function, specifically in decision making ability, memory, recall, awareness of surroundings and other, difficulty expressing self, difficulty understanding others, sleepiness, or confusion. A third [Focus Area] created 6-2-2023 evidenced by risk of visual function R/T aging was documented. The [Intervention} created 6-2-2023 was to monitor, document and report to the physician any signs of acute eye problems; changes in ability to perform ADLs, decline in mobility, second visual loss, double vision, tunnel vision, blurred vision, or hazy vision. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated a CNA B was changing the resident when it was observed that resident had a burn with a thick blister to lateral right thigh. Aide alerted nurse. Resident stated that he spilled a container of soup, brought from home, on him last night. Resident stated he did not tell anyone at the time of incident. Wound care performed per NP: cleanse with normal saline, pat dry, apply Silvadene cream, and dress with dry dressing. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated burn incident to right side hip area. This NP notified today by nurse of incident. Resident reported accidentally hitting bedside table and knocked over soup that was brought to him by family. Assessment of site completed with redness noted to right side hip area, non-tender to touch, denies pain at this time, and able to move extremities with no limitations. Stable at baseline in good spirits with intermittent confusion. Care discussed with nursing, new orders noted for Silvadene cream, and dress with dry dressing. Nursing and wound care to monitor closely for delayed complications. Record review of Resident #1's Progress Notes, dated 1-22-2024 indicated Resident was seen by wound doctor for burn to the right side (flank). Area was cleaned with normal saline and anesthesia was achieved using topical benzocaine. Then with surgical technique, 15 blade was used to surgically excise 21.00 cm of devitalized tissue and necrotic subcutaneous level tissues along with sought and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 35%. Hemostasis was achieved and a clean dressing was applied, Resident has been made aware of the condition of the skin and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 1-29-2024 indicated Resident was seen by wound doctor for burn to the right flank and wound with improvement observed on this visit by evidenced by decreased surface area and decreased necrotic tissue increased granulation. Wound was cleaned with n/sand anesthesia was achieved using topical benzocaine. Then with surgical technique 15 blade was used to surgically excise 12.6cmof devitalized tissue and necrotic subcutaneous level tissues along with slough, and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of burn and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 2-5-2024Resident was seen by wound md for burn to the right flank area with improvement observed on this visit evidenced by decreased surface area. Wound was cleaned with normal saline and anesthesia was achieved using topical benzocaine and resident has no complaint of pain or discomfort during this assessment. Then with clean surgical technique, 15 blade was used to surgically excise 9.00cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.1cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30% to 5%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of the wound and the treatment that is in place. Record review of Resident #1's skin evaluation, dated 1-18-2024, reflected a fluid filled blister to the upper right side of the torso area with surrounding skin red in color and blister intact, right lower side of torso area had fluid filled blister with redness to surrounding skin. Record review of Resident #1's skin evaluation, dated 1-23-2024, reflected a burn to the resident's right flank. It was 6 centimeters by 10 centimeters and 1 centimeter deep. Resident would continue to receive wound care on wound rounds. Record review of Resident #1's skin evaluation, dated 1-25-2024, reflected burns to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-1-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-5-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's Order Summary Report indicated an order, dated 1-29-2024, to clean right flank, pat dry, and apply alginate calcium and collagen powder and cover with gauze island dressing every 24 hours as needed for burn. Record review of Resident #1's Order Summary Report indicated an order, dated 2-6-2024, to clean right flank, pat dry, and apply xeroform and apply gauze island on day shift for burn. Interview and observation on 2-5-2024 at 10:30 AM with Resident #1 revealed Resident #1 was lying in bed relaxing. His tray side table had two thin rectangular non-slip pads. He stated he just got the non-stick pads today, and they were there to help things from slipping off his table. On the evening of 1-16-2024 he asked CNA A to heat up some soup for him. When CNA A [NAME] the soup back, he stated she placed it on the bed side table and left. He sat up in bed and knocked the soup over by accident onto his right-side lower torso area, which caused him to holler out in pain. He gauged the pain on a pain scale of 1-10, with 0 being no pain and 10 being the worst. Resident #1 stated the pain he felt after spilling his soup on his right-side lower torso area was an 8 out of a possible 10. When he called for help after he spilled his soup, he stated CNA A came back to his room, who changed his clothes and his bedding. He did not remember if CNA A asked him if he was in any pain. No other staff member came to his room to look at his skin or to see if he needed medical attention. During the interview, CNA E came to the room and moved back Resident #1's covers to expose his right-side lower torso area. His right-side lower torso area was covered with two light pink bandages. Interview on 2-5-2024 at 11:20 AM with CNA F revealed she had heard Resident #1 spilled soup on himself on 1-16-2024. If she had been the CNA on duty, she stated she would have wanted to see where the soup was spilled and get the nurse to check for injuries. According to CNA F, CNA A failed in her duties having not reported the spill to the nurse for medical assessment and treatment. Interview on 2-5-2024 at 11:45 AM with CNA B revealed she was in Resident #1's room on the evening of 1-17-2024 to give Resident #1 a bed bath. When she was about to begin, Resident #1 pointed to his right lower torso area, referring to the area he spilled his soup, and asked if she was going to do anything about it, because [it was uncomfortable.] She pulled back Resident #1's covers and clothing to reveal a big bubble blister. She immediately got LVN C for a medical assessment. Both CNA B and LVN C returned to the room where she observed LVN C assess the injury. CNA B observed the big bubble blister was seeping clear liquid. After the wound was dressed by LVN C, CNA B continued with Resident #1's bed bath. If she were on duty the night of 1-16-2024, when Resident #1 spilled his soup, she stated she would have asked the nurse to check his skin. CNA B stated CNA A neglected Resident #1 by not reporting the matter to the nurse for medical assessment and treatment. Interview on 2-5-2024 at 12:40 PM with CNA A revealed Resident #1 asked her to heat up some soup for him on the evening of 1-16-2024. The soup was a single serve microwavable soup. She did what she was asked and returned the soup to Resident #1's bedside table. She stated she placed it on the bed side table and told Resident #1 to wait until it cooled off, because she stated it was steaming. CNA A left the room to address other duties. CNA A guesstimated 5-10 minutes passed when she noticed his call light was activated. After an additional 2-3 minutes, she stated she entered the room for the call. When she entered the room, she learned that Resident #1 had spilled his soup on his right lower torso area. She removed Resident #1's clothing and bedding then provided clean replacements. After, she left the room to address her duties. She did not report the incident of Resident # 1 having spilled soup, which she referred to as steaming on his right lower torso area. Interview on 2-5-2024 at 1:49 PM with LVN C revealed she was on duty the evening of 1-17-2024, around 5:00 PM, when CNA B reported Resident #1 needed medical attention. When LVN C entered the room, she noticed Resident #1's right lower torso area was red. LVN C pulled back the sheet and discovered two blistered areas, one of which one had popped exposing raw skin. She informed the nurse practitioner, applied Silvadene cream, and dressed the wound. LVN C stated Resident #1 told her [it hurt at the time it happened.] LVN C had been a nurse for [AGE] years with experience treating burns and characterized Resident #1's injury either a 1st degree or a 2nd degree burn. Furthermore, she stated the skin would have continued to burn until the burn stopped on its own, or if something were applied like cold water, ice, or Silvadene cream. Had the burn been treated sooner, it might have had a better outcome. LVN C stated CNA A should have told the nurse after she learned Resident #1 spilled hot soup on himself. Also, neglect did not have to be a willful act. LVN C completed a SBAR form, to note a Change in Condition, for Resident #1's burn on 1-17-2024 at 5:00 PM. The wound care was assigned to the wound care nurse, LVN G, because raw skin was exposed and there was a greater risk of infection. According to WebMD at [https://www.webmd.com/drugs/2/drug-4910silvadene-topical/details] Silvadene cream was a medication used with other treatments to help prevent and treat wound infections in patients with serious burns. Group interview on 2-5-2024 at 2:10 PM with LVN G (wound nurse), Physician H (wound doctor), and Physician I (wound doctor) revealed a consensus that the wound on Resident #1 was classified as a 2nd degree burn. LVN G stated that CNA A should have reported the soup spill to the nurse for a medical assessment. Interview and Observation on 2-6-2024 at 10:25 PM revealed resident # 1 in bed resting comfortably, alert, and responded to questions appropriately. He recalled the night of 1-16-2024 when he spilled his soup. He stated he was in pain and discomfort after the soup spill, was in continued pain and discomfort throughout the night, and into the next day until he received treatment. He denied current pain and discomfort. Interview on 2-6-2024 at 4:35 PM with the ADON revealed she had been working at the facility for about 1.5 years. She was in charge of the Express Side of the facility that encompassed halls 200, 300, and 400. CNA A was under her supervision. On the evening of 1-16-2024, which was the day Resident #1 spilled his soup, hollered out in pain, and sustained 2nd degree burns to his right lower torso area. CNA A did not report the incident to the nursing staff for a medical assessment. Having heated the soup, delivered it [steaming,] and having told Resident #1 to let it cool, CNA A should have reported the accident to nursing staff after the spill. The failure of Resident #1 not receiving immediate medical care was CNA A did not report the spill to the nurse. The ADON stated that CNA A was trained in the facility's [Change in Condition, Response] policy and that the incident should have been reported to the nurse for a medical assessment and treatment. Interview on 2-6-2024 at 5:00 PM with the DON revealed that CNA A was trained to report all incidents and accidents to the charge nurse for a medical assessment. CNA A failed in her duties when she left the steaming soup in Resident #1's room and failed to inform nursing staff of the accident for a medical assessment and treatment. Interview on 2-6-2024 at 5:30 PM with the ADM revealed Resident #1's soup burn prompted a change in Resident #1's condition and the incident met the criteria for the facility's Change in Condition, Response Policy. CNA A was suspended for a day, while the facility investigated the matter. The ADM stated that CNA A failed in her duties to report the incident to the nurse for a medical assessment and medical treatment. Record review of CNA A's counseling and disciplinary notice, dated 1-18-2024, indicated CNA A was suspended, pending investigation, subject to discharge. Employee knew that a resident spilled hot food on them and failed to notify the charge nurse of the incident / change of condition. Record review or Resistant #1's SBAR Communication form, dated 1-17-2024, indicated Resident#1 had a change in condition, due to a burn, which occurred on 1-16-2024. Record review of the facility's [reporting alleged violations of abuse, neglect, exploitation, or mistreatment,] dated October 2022. Record review of the facility's [Significant [NAME] in Condition, Response Policy] dated January 2022 indicated: if, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to develop a comprehensive fall prevention care plan that addressed resident-specific risk factors for falls for 2 (Resident #11 and Resident #20) of 4 sampled residents reviewed for falls. The facility also failed to ensure comprehensive care plans addressed the necessary care and monitoring related to: - chronic diarrhea for 1 (Resident #83) of 1 sampled resident reviewed for constipation/diarrhea. - pre and post-dialysis care for 1 (Resident #48) of 1 sampled resident reviewed for dialysis. - rehabilitation (rehab) services for 1 (Resident #90) of 2 sampled residents reviewed for rehab. - wound care for 1 (Resident #76) of 4 sampled residents reviewed for wound care. The failed practices affected a total of 6 of 28 sampled residents whose care plans were reviewed. Resident #11 experienced 27 falls in a 12.5-month period and multiple fall-related injuries, including right rib fractures on 11/15/2021, a left hand fracture on 11/25/2021, right pubic rami fracture on 04/01/2022, and closed head injuries on 12/25/2021, 03/16/2022, and 07/19/2022. Resident #20 experienced 20 falls in a 12-month period and two trips to the emergency room (one on 11/21/2021 for a fall-related subdural hematoma and one on 06/23/2022 to replace the resident's feeding tube, which was dislodged during a fall). It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to Residents #11 and #20. The immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21(b) Comprehensive Care Plans. The IJ began on 07/01/2021, when Resident #11 sustained a fall, and no measures were put in place to prevent additional falls and injuries. Resident #11 fell an additional 26 times and sustained multiple serious fall-related injuries. On 07/22/2022 at 8:45 PM, the survey team notified the facility Administrator of the IJ situation related to comprehensive care plans and provided the completed IJ template. The Administrator signed the template and returned the original to the survey team. On 07/24/2022 at 1:53 PM, the facility's removal plan was accepted by the Texas Health and Human Services Commission. The IJ was removed on 07/24/2022 at 4:31 PM, after the survey team verified the elements of the removal plan had been implemented. Noncompliance remained at the lower scope and severity of a pattern of harm that was not immediate jeopardy for F656. Findings included: A review of the facility policy titled, Comprehensive Person-Centered Planning, revised 08/2017, revealed, Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The policy also indicated the following procedures: - 4. The comprehensive care plan will be developed by the IDT within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR [Pre-Admission Screening and Resident Review] recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plans. - 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment. - 7. The facility IDT includes but is not limited to the following professionals: A. Attending Physician or Non-Physician Practitioner (NPP) designee involvd [sic] in resident's care; B. Registered nurse responsible for the resident; C. Nurse Aide responsible for the resident; D. Member of the Food and Nutrition Services staff; E. To the extent practicable, resident and/or resident representative; F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. A review of the facility policy titled, Fall Management System, revised 06/2021, revealed, 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. The policy also indicated the following procedures: - 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. - 4. Review of the fall incident will include investigation to determine probable casual factors. 5. The investigation will be reviewed by the Inter Disciplinary Team. A Summary of the investigation and recommendations will be documented in the resident's clinical record. 6. Resident's care plan will be updated. 1. A review of an Admission Record revealed Resident #11 had diagnoses including muscle weakness, need of assistance with personal care, insomnia, dementia without behavioral disturbance, unsteadiness on feet, and unspecified fall. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 scored 6 on a Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The resident required extensive assistance of one person for bed mobility and toilet use and limited assistance with transfer. The MDS indicated the resident used a wheelchair for mobility and had no falls since admission/entry/reentry or prior assessment. A review of the current care plan, dated as created 09/05/2018, revealed Resident #11 was at risk for falls related to a history of fracture from a fall prior to admission, pain, poor balance and weakness. Interventions included: - Anticipate and meet needs, initiated 01/12/2021. - Avoid rearranging furniture, initiated 09/05/2018. - Be sure the call light is within reach and encourage to use it to call for assistance as needed, initiated 09/05/2018. - Bed in lowest position, initiated 09/05/2018. - Keep needed items, water, et cetera (etc.) in reach, initiated 01/21/2021. - Provide bed and chair alarm as ordered, initiated 01/12/2021. Further review of the care plan revealed a focus statement dated as initiated 05/19/2021 which indicated the resident had a history of actual falls related to poor balance, unsteady gait, and poor decision making. Interventions, which were all dated as initiated on 05/19/2021, included: - Bed in lowest position. - Continue interventions on the at-risk plan. - Monitor/document/report to MD (Medical Doctor) for signs/symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, or agitation. - Neurological (neuro) checks as ordered. - Vital signs as ordered. The most recent revision or new intervention on either of the fall-related care plans for Resident #11 was dated 05/19/2021, over one year prior to the survey date. A review of incident reports and related Progress Notes, dated from 07/01/2021 through 07/20/2022 revealed Resident #11 had repeated falls, as follows: - Resident #11 had an unwitnessed fall on 07/01/2021 at 11:33 PM. The incident report indicated the resident was found sitting on the floor, next to the toilet in the bathroom. The resident was assessed by the nurse to have no injuries and was instructed to use the call light for assistance. There was no reference to any new interventions on the incident report. The care plan did not address that the resident had experienced an actual fall in the facility. - Resident #11 had an unwitnessed fall on 08/01/2022 at 9:45 PM. The incident report indicated the resident fell in his/her room. The bed was in the low position and was free from disarray. The resident was assessed by the nurse and was found to have an abrasion to the right knee, smaller abrasions to lateral side of the right knee, and a small puncture wound to the center of the top of his/her head. Resident #11 received first aid and was instructed to use the call light for assistance. No other fall prevention interventions were addressed on the incident report or in the related progress note, and the care plan did not address that the resident had experienced two actual falls in the facility. - Resident #11 had an unwitnessed fall on 08/20/2021 at 12:30 AM. The incident report indicated the resident was found on the floor near the bed, with the wheelchair tipped over on its side. The resident was assessed by the nurse and was found to have an abrasion to the right ear, a bruise and small indentation on the right cheek bone, and redness to the right acromion process (bony prominence on the shoulder blade). First aid was provided and neuro checks were initiated. The resident was reminded to use the call light for assistance. No fall prevention interventions were addressed on the incident report, nor the related progress note. The care plan did not address that the resident had now experienced three falls in the facility. Resident #11 had an unwitnessed fall on 08/22/2021 at 7:28 PM. The incident report indicated the resident was found on the floor. The resident was assessed by the nurse and found to have a wound to the left arm and an abrasion to the left knee. First aid was provided. There was no evidence any new fall prevention interventions were initiated. - Resident #11 had an unwitnessed fall on 08/27/2021 at 1:15 PM. The incident report indicated a family member of the resident's roommate reported to staff that Resident #11 was on the floor. The report indicated the nurse questioned Resident #11 about the fall, and the resident responded that he/she tried to stand up by holding onto the bedside table, lost his/her balance and fell . The resident was assessed by the nurse and was noted to have a skin tear to the right arm. The resident received treatment to the wound. The incident report indicated a chair alarm was on the resident's chair and functioning, and the resident was instructed not to pull up on the table and to use the call light for assistance. The care plan continued to have no reference to Resident #11 having any falls occur in the facility. No interventions were added to the care plan. - Resident #11 had an incident on 09/28/2021 at 2:30 PM. The incident report indicated the nurse was called to the activity room by another staff member, and the resident was assisted back to the chair. The report did not specifically indicate that the resident fell . The resident was assessed by the nurse and was found to have no injuries. No fall prevention interventions were addressed on the report. - Resident #11 had an unwitnessed fall on 11/15/2021 at 5:47 PM. The incident report indicated the resident was found on the bathroom floor. The resident was assessed by the nurse and found to have rib pain. Resident #11 was sent by ambulance to the emergency room . Medical records from the acute care hospital indicated computed tomography (CT) scan results revealed acute nondisplaced fractures of the right eighth, ninth and tenth ribs and bilateral (both sides) nonacute (older) fractures. The care plan continued to reflect no actual falls within the facility. Review of a, Fall Risk Assessment-Prevention and Management, form indicated an entry was added on 11/15/2021 which indicated frequent toileting was initiated; however, this intervention was not addressed on the care plan. During an interview on 07/19/2022 at 10:35 AM, the DON stated the Fall Risk Assessment- Prevention and Management tool was utilized to add approaches and interventions for fall prevention. The DON stated the binder with these forms was maintained in her office, but all staff had access to the forms. During a follow-up interview with the Director of Nursing (DON) on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 was placed on frequent toileting after the fall on 11/15/2021. The DON acknowledged this intervention was not addressed on the care plan in the resident's electronic medical record (EMR). During an interview on 07/20/2022 at 5:01 PM, Licensed Vocational Nurse (LVN) #7 stated all care plans were maintained in the EMR. During an interview on 07/20/2022 at 5:03 PM, Registered Nurse (RN) #2 stated all care plans were maintained in the computer, and there were no paper care plans. During an interview on 07/20/2022 at 5:07 PM, LVN #2 revealed care plans were maintained within the computer charting. LVN #2 denied having any knowledge of a binder containing paper care plans. Review of Certified Nursing Assistant (CNA) documentation revealed Resident #11 was taken to the bathroom three times on 11/15/2021, two times on 11/16/2021, three times on 11/17/2021, four times on 11/18/2021, two times on 11/19/2021, two times on 11/20/2021, two times on 11/21/2021, two times on 11/22/2021, three times on 11/23/2021, and four times on 11/24/2021. A review of the CNA Kardex (a communication form used by CNA staff to identify care tasks), revealed as of 07/20/2022, the safety interventions included that Resident #11's bed was to be in the lowest position. The other category indicated to provide bed and chair alarm as ordered. There was no reference to the need for frequent toileting on the CNA Kardex for Resident #11. During an interview on 07/20/2022 at 7:52 PM, CNA #2 revealed Resident #11 was usually in bed when her shift started at 2:00 PM. CNA #2 stated the interventions in place to prevent falls for Resident #11 included having the bed in the low position, a floor mat, the door to the room remaining open, and the light above the bed being left on. CNA #2 confirmed that CNA staff utilized the Kardex for special instructions. During an interview on 07/23/2022 at 11:45 AM, the DON stated the CNAs documented the times they assisted the resident for toileting in the CNA computer documentation. The DON stated frequent toileting would be every two to three hours and acknowledged that the three to four times daily that was documented in the CNAs' computer documentation would not constitute frequent toileting. The DON stated the CNAs did not always document every time they assisted the resident to the bathroom. Continued review of incident reports and related Progress Notes, revealed Resident #11 had an unwitnessed fall on 11/25/2021 at 7:30 PM. The incident report indicated the resident was found on the bathroom floor. The resident was assisted to bed, after which he/she complained of pain. While the nurse left the area to get pain medicine, the nurse heard the resident yelling for help. The report revealed the nurse found Resident #11 on the floor again, by the wheelchair. The wheelchair was noted to have two seat cushions and two blankets in place. The resident was assessed, and no injury was found. A review of medical records revealed an x-ray of the left hand was obtained the next day, on 11/26/2021. The x-ray revealed Resident #11 sustained an acute fracture of the fourth digit of the left hand. A review of the Fall Risk Assessment-Prevention and Management, tool indicated physical therapy was to evaluate. The resident's care plan still did not address any actual falls within the facility. During an interview on 07/23/2022 at 11:45 AM, the DON stated Resident #11 did not have any complaints of pain on the night of the incident, but the next day complained of pain and swelling in the left hand and was sent for an x-ray. The DON confirmed the x-ray revealed a fractured finger on the left hand. The DON stated Resident #11 was already receiving physical therapy and that the intervention was not added to the care plan located in the EMR. Review of a Physical Therapy (PT) Evaluation & (and) Plan of Treatment, dated 11/18/2021, revealed the resident was assessed for therapy services on 11/18/2021. Therapy was initiated on 11/18/2021, with a plan to continue through 12/15/2021. Continued review of incident reports and related Progress Notes, revealed the following: - Resident #11 had an unwitnessed fall on 12/25/2021 at 8:25 PM. The incident report indicated the nurse was called to the resident's room and found the resident on his/her knees with his/her head resting on the wall. The resident was assessed by the nurse and found to have a bruise/abrasion to the head. The resident was transported to the emergency room . A review of hospital records indicated the resident was diagnosed with a closed head injury, scalp abrasion, abrasion to the left knee, and contusion to the left knee. This fall was not addressed on the resident's care plan and there was no evidence of any new interventions. This fall was also not addressed on the paper Fall Risk Assessment - Prevention & Management tool. - Resident #11 had an unwitnessed fall on 01/27/2022 at 10:55 PM. The incident report indicated the nurse was called to the resident's room and found the resident on the floor. The resident was assessed by the nurse and found to have abrasions to the right knee, lateral right thigh, and top of the right hand. First aid was provided. There was no evidence any new fall prevention interventions were initiated. The fall was referenced on the Fall Risk Assessment - Prevention & Management sheet as, on floor in room. No associated interventions were noted on the form. The resident's care plan still did not address any actual falls in the facility. - Resident #11 had an unwitnessed fall on 02/07/2022 at 6:45 AM. The incident report indicated the resident was found on the floor in the bathroom. The resident was assessed by the nurse and found to have no injuries. The resident received instruction to use the call light for assistance. The Fall Risk Assessment-Prevention & Management sheet was updated with an intervention to add Dycem (non-slip material) to the resident's chair. The resident's care plan did not address this fall, nor any of the resident's multiple other falls in the facility. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 had the intervention of Dycem added to the Fall Risk-Prevention & Management sheet on 02/14/2022 after the resident's fall on 02/07/2022. The DON acknowledged the intervention was not added to the care plan in Resident #11's EMR. Continued review of incident reports and related Progress Notes, revealed Resident #11 had an unwitnessed fall on 03/16/2022 at 1:35 AM. The incident report indicated the resident was found on the floor in the bathroom and stated the resident hit his/her head. The resident was assessed by the nurse and found to have a bruise to the back of the head and a small bruise to the anterior part of the left lower leg. Resident #11 was sent to the emergency room . The resident was treated for closed head injury, contusion to the occipital (back) region of the scalp, and a scalp abrasion. The fall was addressed on the Fall Risk Assessment-Prevention & Management sheet and included an intervention to have the pharmacist review the resident's medications. Neither the fall, nor the intervention were addressed on the care plan in the resident's EMR. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 had the intervention of pharmacist to review medication added through the Fall-Risk-Prevention and Management after the fall sustained on 03/16/2022. There was no evidence that this review was completed. The DON confirmed the intervention was not added to the care plan located in the EMR for Resident #11. Continued review of incident reports and related Progress Notes, revealed Resident #11 suffered an unwitnessed fall on 04/01/2022 at 6:00 PM. The incident report indicated the resident was found on the floor in the bathroom after someone heard the resident yelling for help. The resident was assessed and sent to the emergency room . The resident was treated for multiple pubic rami (components of the pelvis) fractures after undergoing x-rays and CT scans of the head and pelvis. The fall was addressed on the Fall Risk Assessment-Prevention & Management, sheet with an intervention to have PT evaluate the resident. Neither the fall, nor the intervention were addressed on the resident's care plan. Continued review of incident reports and related Progress Notes, revealed Resident #11 had an unwitnessed fall on 04/28/2022 at 4:08 AM. The incident report indicated the resident was found on the floor in the bathroom. The report documented a CNA heard the resident yelling for help. The resident was assessed by the nurse and was sent to the emergency room . Progress notes indicated the resident was diagnosed with a head injury. The hospital records were not available, and the facility was unable to obtain them during the survey. The fall was addressed on the Fall Risk Assessment-Prevention & Management, sheet, with an intervention to reorient the resident to the call light. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed the intervention to reorient the resident to the call light was added to the Fall Risk Assessment-Prevention & Management tool after the fall on 04/28/2022. The DON acknowledged the intervention to encourage call light use had been on the resident's care plan since 09/05/2018. Continued review of incident reports and related Progress Notes, revealed the following: - Resident #11 had an unwitnessed fall on 05/28/2022 at 4:22 PM. The incident report indicated the nurse was called to the resident's room and found the resident on the floor beside the bed and wheelchair. The resident was assessed by the nurse and found to have no injuries. The fall was not addressed on the resident's care plan. The Fall Risk Assessment-Prevention & Management sheet did address this fall and included an intervention dated 05/28/2022 to keep the resident in a common area as much as possible. This intervention was not added to the resident's care plan. - Resident #11 had an unwitnessed fall on 05/31/2022 at 3:28 PM. The incident report indicated the resident was observed sitting on the dining room floor. The report indicated the resident stated he/she fell from the wheelchair. The report did not indicate whether Dycem was present in the resident's wheelchair seat at the time of the fall. The resident was assessed by the nurse and was found to have a small bruise to the right knee. This fall was not addressed on the resident's care plan, nor on the Fall Risk Assessment-Prevention & Management tool. - Resident #11 had an unwitnessed fall on 06/04/2022 at 4:22 PM. The incident report indicated the nurse found the resident on the floor in his/her room next to the wall. The resident stated he/she hit his/her head on the wall. The resident was sent to the emergency room . Hospital records were not available, and the facility was unable to obtain them during the survey. This fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 06/17/2022 at 1:31 AM. The incident report indicated the resident had turned on the call light and, when staff arrived, they found the resident on the floor next to the bed. The resident reported he/she tried to get on the chair and missed. The nurse was called to the resident's room and found the resident on the floor beside the bed and wheelchair. The resident was assessed by the nurse and was found to have no injuries. This fall was addressed on the Fall Risk Assessment-Prevention and Management, and included a new intervention for a night light in the resident's room. Neither the fall, nor the intervention for a night light were addressed on the resident's care plan. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed the intervention for a night light was added to the Fall Risk Assessment-Prevention and Management sheet after the fall on 06/17/2022. The DON acknowledged the intervention was not addressed on the care plan in Resident #11's EMR. Continued review of incident reports and related Progress Notes, revealed the following: - Resident #11 had an unwitnessed fall on 06/18/2022 at 8:00 AM. The incident report indicated the CNA found the resident on the floor mat next to the bed, which was in the lowest position. The resident stated he/she had tried to get up. The resident was assessed by the nurse and was found to have no injuries. This fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 06/28/2022 at 5:13 AM. The incident report indicated a CNA found the resident on the floor mat next to the bed, which was in the lowest position. The resident stated he/she had tried to get up. The resident was assessed by the nurse and was found to have no injuries. The resident was instructed to use the call light for assistance. The fall was not addressed on the resident's care plan, and there was no evidence of any fall prevention interventions that were implemented other than reminding the cognitively impaired resident to use the call light. - Resident #11 had an unwitnessed fall on 07/06/2022 at 12:20 AM. The incident report revealed staff found the resident wrapped in bedding on the floor next to the bed. The resident stated he/she rolled out of bed and complained of rib pain. The resident was assessed by the nurse and was found to have red, scraped areas to the right rib cage area and a red area to the right shoulder. No treatment, nor fall prevention interventions were documented as initiated. The fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 07/07/2022 at 2:11 AM. The incident report revealed staff found the resident on the floor next to the bed. The resident was not able to tell staff what happened. The resident was assessed by the nurse and found to have no injuries. The fall was referenced on the Fall Risk Assessment-Prevention & Management, form, with an intervention for a scoop mattress added. Neither the fall, nor the intervention were addressed on the resident's care plan. During an interview with the Director of Nursing (DON) on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 had the intervention of scoop mattress added to the Fall Risk Assessment-Prevention & Management sheet after the fall on 07/07/2022. The DON acknowledged the intervention was not addressed on the care plan in Resident' #11's EMR. Continued review of incident reports and related Progress Notes, revealed the following: - Resident #11 had an unwitnessed fall on 07/08/2022 at 6:09 AM. The incident report revealed a CNA found the resident on the floor next to the bed, covered in stool. The resident was taken to the shower and, while in the shower, the resident became combative and fell from the shower chair, hitting his/her head. The resident was assessed by the nurse and was found to have a large bruise to the forehead. The resident was sent to the emergency room and was admitted with a diagnosis of acute encephalopathy (a term indicating a disease of the brain which alters brain function or structure). The resident was also diagnosed with a urinary tract infection and was treated with intravenous antibiotics. A CT scan of the head revealed right front scalp swelling. The resident was released from the hospital on 07/12/2022. The 07/08/2022 fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 07/17/2022 at 9:35 PM. The incident report revealed a CNA found the resident on the floor in the bathroom. The resident was assessed by the nurse and was found to have a bruise on the left knee and left back. No treatment was provided. The resident was instructed to call for assistance. The document indicated the bed was in the low position and the call light was in reach. This fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 07/19/2022 at 4:08 AM. The incident report revealed the staff found the resident on the floor on his/her back. The resident was assessed by the nurse and was found to have a one-inch-long hematoma on the left side of the temple (flat area on the side of the forehead) and a one-inch-long skin tear to the left forearm. The resident requested to go to the hospital. The resident was transferred to the hospital as requested. The hospital record indicated the resident was diagnosed with a closed head injury. The hospital assessment indicated the resident had a contusion to the right side of the forehead and contusions to both elbows. The fall was not addressed on the resident's care plan. - Resident #11 had an unwitnessed fall on 07/20/2022 at 2:45 AM. The incident report revealed staff heard a noise, and a CNA found the resident on his/her knees on the floor between the wall and the bed. The resident was assessed by the nurse and was found to have a skin tear to the right outer arm near the elbow and a scrape to the right knee. There was no treatment documented. Additional red, scraped areas were identified to the right rib cage area and a red area to the right shoulder. No treatment was provided. This fall was not addressed on the resident's care plan. As of 07/20/2022, the resident had experienced 27 falls in a 12.5-month period and multiple fall-related injuries, including right rib fractures on 11/15/2021, a left hand fracture on 11/25/2021, right pubic rami fracture on 04/01/2022, closed head injuries on 12/25/2021, 03/16/2022, and 07/19/2022, and numerous bruises, abrasions, and skin tears. The resident's care plan did not address the numerous falls the resident had experienced in the facility since admission. Observation on 07/18/2022 at 3:25 PM revealed Resident #11 sitting in a wheelchair in his/her room. The resident was sleeping. There was a folded fall mat at the foot of the bed. There was no Dycem or other non-slip material in the seat of the wheelchair. Observation on 07/19/2022 at 10:09 AM revealed the resident sitting in a wheelchair in his/her room. There was no Dycem or other non-slip material in the wheelchair. There was a fall mat folded at the foot of the bed. Observation on 07/20/2022 at 7:51 PM revealed Resident #11 lying on his/her back in bed. The bed was in a low position. There was a fall mat at the bedside and a scoop mattress was on the bed. An interview was conducted on 07/23/2022 at 11:41 AM with Licensed Vocational Nurse (LVN) #3, who stated he was aware that Resident #11 had multiple falls with injury. LVN #3 stated all care plans were maintained in the EMR and he was unaware of any paper documentation. LVN #3 denied any knowledge of a form titled, Fall Risk Assessment-Prevention and Management. LVN #3 stated all interventions should be appropriate for each resident and educating Resident #11 on call light use was not effective because of the resident's mental ability. LVN #3 stated care plans were updated quarterly and as changes occurred, and that all nurses could update the care plans. LVN #3 confirmed interventions such as neuro checks did not prevent falls; they were just an assessment performed after an unwitnessed fall. 2. A review of an Admission Record revealed the facility admitted Resident #20 on 05/15/2021 with diagnoses including muscle weakness, nontraumatic intercranial hemorrhage, repeated falls, and need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 scored 3 on a Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The resident required extensive assistance of two or more people for bed mobility and toileting and used a wheelchair for locomotion. Per the MDS, the resident had experienced two falls without injury since admission/reentry or prior assessment. A review of the current care plan, dated as initiated 05/18/2021, revealed Resident #20 was at risk for falls related to confusion, weakness, the need for assistance to t[TRUNCATED]

Based on observations, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents for 2 (Resident #11 and Resident #20) of 4 sampled residents reviewed for falls. Specifically, the facility failed to: - investigate falls to determine causal factors and develop and implement fall prevention interventions that were specific, resident-appropriate, and based on causal factors for Resident #11 and Resident #20. - consistently implement planned interventions to prevent further falls for Resident #11 and Resident #20. Resident #11 experienced 27 falls in a 12.5-month period and multiple fall-related injuries, including right rib fractures on 11/15/2021, a left hand fracture on 11/25/2021, right pubic rami fracture on 04/01/2022, and closed head injuries on 12/25/2021, 03/16/2022, and 07/19/2022. Resident #20 experienced 20 falls in a 12-month period and two trips to the emergency room (one on 11/21/2021 for a fall-related subdural hematoma and one on 06/23/2022 to replace the resident's feeding tube, which was dislodged during a fall). It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to Residents #11 and #20. The immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d)(1)-(2) Accident Hazards/Supervision. The IJ began on 07/01/2021, when Resident #11 sustained a fall, and the facility did not investigate for causal factors and develop appropriate, resident-specific fall prevention interventions. Resident #11 fell an additional 26 times and sustained multiple serious fall-related injuries. On 07/22/2022 at 8:45 PM, the survey team notified the facility Administrator of the IJ situation related to supervision to prevent accidents and provided the completed IJ template. The Administrator signed the template and returned the original to the survey team. On 07/24/2022 at 1:53 PM, the facility's removal plan was accepted by the Texas Health and Human Services Commission. The IJ was removed on 07/24/2022 at 4:31 PM, after the survey team verified the elements of the removal plan had been implemented. Noncompliance remained at the lower scope and severity of a pattern of harm that was not immediate jeopardy for F689. Findings included: A review of the facility policy titled, Fall Management System, revised 06/2021, revealed, 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. The policy also indicated the following procedures: - 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. - 4. Review of the fall incident will include investigation to determine probable casual factors. 5. The investigation will be reviewed by the Inter Disciplinary Team. A Summary of the investigation and recommendations will be documented in the resident's clinical record. 6. Resident's care plan will be updated. 1. A review of the Admission Record for Resident #11 revealed the facility admitted Resident #11 with diagnoses that included muscle weakness, need of assistance with personal care, insomnia, dementia without behavioral disturbance, unsteadiness on feet, and unspecified fall. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. Further review of the MDS revealed Resident #11 required the extensive assistance of one person for bed mobility and toileting. The MDS indicated the resident used a wheelchair for locomotion and had not had any falls since admission/reentry or the prior assessment. A review of the current care plan for Resident #11, dated as created 09/05/2018, revealed the resident was at risk for falls related to a history of a fracture from a fall prior to admission, pain, poor balance, weakness, frequent attempts to stand/transfer by him/herself, confusion, and psychoactive medications. Interventions included anticipating needs (01/12/2021), avoid rearranging the furniture (09/05/2018), be sure the call light is within reach and encourage to use it to call for assistance as needed (09/05/2018), bed locked and in lowest position (09/05/2018), keep needed items, water, et cetera (etc.) in reach (01/21/2021), and provide bed and chair alarm as ordered (01/12/2021). Continued review of the current care plan for Resident #11 revealed a focus of history of actual falls related to poor balance, unsteady gait and poor decision making. Interventions included bed in lowest position, monitor/document/report to Medical Doctor (MD) for signs and symptoms: pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation, neurological (neuro) checks as ordered, vital signs as ordered, and continue the interventions listed on the at-risk plan. All interventions for this care plan problem were dated 05/19/2021. No additional interventions had been added to either of the fall/fall risk care plans for Resident #11 since 05/19/2021. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/01/2021 at 11:33 PM. The incident report indicated the resident was found sitting on the floor, next to the toilet in the bathroom. The resident was assessed by the nurse to have no injuries and was instructed to use the call light for assistance. There was no evidence of an effort to determine the causal factors of the fall and no fall prevention interventions put in place other than reminding the cognitively impaired resident to use the call light. A review of an incident report revealed Resident #11 had an unwitnessed fall on 08/01/2021 at 9:45 PM. The incident report indicated that the resident fell in his/her room. The report revealed the bed was in low position and the bed was free from disarray. The resident was assessed by the nurse and was found to have an abrasion to the right knee, smaller abrasions to the lateral side of the right knee, and a small puncture wound to the center top of his/her head. Resident #11 received first aid and was instructed to use the call light for assistance. There was no record that an investigation was completed to attempt to determine causative factors of the fall, nor of any fall prevention interventions put in place other than instructing the cognitively impaired resident to use the call light. A review of an incident report revealed Resident #11 had an unwitnessed fall on 08/20/2021 at 12:30 AM. The incident report indicated the resident was found on the floor near the bed with the wheelchair tipped over on its side. The resident was assessed by the nurse and was found to have an abrasion to the right ear, a bruise and a small indentation on the right cheek bone, and redness to the right acromion process (bony prominence on the shoulder blade). First aid was provided and neurological checks were initiated. The resident was reminded to use the call light for assistance. There was no record that an investigation was completed, nor of any fall prevention interventions implemented other than reminding the resident to use the call light. A review of an incident report revealed Resident #11 had an unwitnessed fall on 08/22/2021 at 7:28 PM. The incident report indicated the resident was found on the floor. The resident was assessed by the nurse and found to have a wound to the left arm and an abrasion to the left knee. First aid was provided. There was no record that an investigation was completed, nor that any fall prevention interventions were put in place after this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 08/27/2021 at 1:15 PM. The incident report indicated the roommate's family member reported to staff that Resident #11 was on the floor. The report indicated the nurse questioned Resident #11 about the fall, and the resident responded, Tried to stand up by holding onto the bedside table, lost balance and fell . The resident was assessed by the nurse and was noted to have a skin tear to the right arm. The resident received treatment to the wound. The incident report indicated the chair alarm was on the chair and functioning, and the resident was instructed to not pull up on the table and to use the call light for assistance. There was no record that an investigation was completed, nor of any new interventions that were implemented to prevent further falls, other than verbal instructions provided to the cognitively impaired resident. A review of an incident report revealed Resident #11 had an unwitnessed fall on 09/28/2021 at 2:30 PM. The incident report indicated the nurse was called to the activity room by another staff member, and the resident was assisted back to the chair. The report did not specifically indicate that the resident had fallen. The resident was assessed by the nurse and was found to have no injuries. There was no record that an investigation was completed. A review of an incident report revealed Resident #11 had an unwitnessed fall on 11/15/2021 at 5:47 PM. The incident report indicated the resident was found on the bathroom floor. The resident was assessed by the nurse and found to have pain of the ribs. Resident #11 was sent by ambulance to the emergency room . Medical records from the acute care hospital indicated the reason for the emergency room visit was fall, and computed tomography (CT) scan results indicated acute nondisplaced fractures of the right eighth, ninth and tenth ribs. Additional bilateral [both sides] nonacute [older] fractures. There was no record that an investigation was completed. Review of a paper document titled Fall Risk Assessment-Prevention and Management indicated an intervention of frequent toileting was added; however, this document was not available in the resident's medical record, and this intervention was not included on the resident's care plan, nor on the Kardex utilized by Certified Nursing Assistant (CNA) staff to inform them of what care was needed for each resident. Review of Certified Nursing Assistant (CNA) documentation revealed Resident #11 was taken to the bathroom three times on 11/15/2021, two times on 11/16/2021, three times on 11/17/2021, four times on 11/18/2021, two times on 11/19/2021, two times on 11/20/2021, two times on 11/21/2021, two times on 11/22/2021, three times on 11/23/2021, and four times on 11/24/2021. A review of the CNA Kardex (a communication form used by CNA staff to identify care tasks), revealed as of 07/20/2022, the safety interventions included that Resident #11's bed was to be in the lowest position. The other category indicated to provide bed and chair alarm as ordered. There was no reference to the need for frequent toileting on the CNA Kardex for Resident #11. During an interview on 07/20/2022 at 7:52 PM, CNA #2 revealed Resident #11 was usually in bed when her shift started at 2:00 PM. CNA #2 stated the interventions in place to prevent falls for Resident #11 included having the bed in the low position, a floor mat, the door to the room remaining open, and the light above the bed being left on. CNA #2 confirmed that CNA staff utilized the Kardex for special instructions. During an interview on 07/23/2022 at 11:45 AM, the DON stated the CNAs documented the times they assisted the resident for toileting in the CNA computer documentation. The DON stated frequent toileting would be every two to three hours and acknowledged that the three to four times daily that was documented in the CNAs' computer documentation would not constitute frequent toileting. The DON stated the CNAs did not always document every time they assisted the resident to the bathroom. The DON confirmed the frequent toileting intervention was not added to the care plan located in the electronic medical record (EMR) for Resident #11. A review of an incident report revealed Resident #11 had an unwitnessed fall on 11/25/2021 at 7:30 PM. The incident report indicated the resident was found on the bathroom floor. The resident was assisted to bed, after which he/she complained of pain. The report indicated that while the nurse left the area to get the resident pain medicine, the nurse heard the resident yelling for help. The report revealed the nurse found Resident #11 on the floor by the wheelchair, and the wheelchair was noted to have two seat cushions and two blankets in place. The resident was assessed, and no injury was found. Review of the medical records revealed an x-ray was obtained on 11/26/2021 of the left hand. The x-ray indicated Resident #11 sustained an acute fracture of the fourth digit of the left hand. There was no record of an investigation to determine causative factors and no evidence in the medical record of any fall prevention interventions that were initiated at this time. Review of the Fall Risk Assessment-Prevention and Management sheet revealed an intervention for physical therapy to evaluate was added; however, this intervention was not addressed on the resident's care plan. A review of Physical Therapy notes indicated the resident was assessed for therapy services on 11/18/2021. The therapy notes indicated therapy started on 11/18/2021 (prior to the 11/25/2021 fall) and would continue through 12/15/2021. During an interview on 07/23/2022 at 11:45 AM, the DON stated Resident #11 did not have any complaints of pain on the night of the incident, but the next day complained of pain and swelling in the left hand and was sent for an x-ray. The DON confirmed the x-ray revealed a fractured finger on the left hand. The DON confirmed Resident #11 was already receiving physical therapy at that time, and that the intervention for therapy was not addressed on the resident's care plan. A review of an incident report revealed Resident #11 had an unwitnessed fall on 12/25/2021 at 8:25 PM. The incident report indicated the nurse was called to the resident's room and found the resident on his/her knees with head resting on the wall. The resident was assessed by the nurse and was found to have a bruise/abrasion to the head and was transported to the emergency room . Review of hospital records indicated the resident was diagnosed with a closed head injury, scalp abrasion, abrasion to the left knee, and contusion to the left knee. There was no record that an investigation was completed and no documentation of any fall prevention interventions that were put in place at this time. A review of an incident report revealed Resident #11 had an unwitnessed fall on 01/27/2022 at 10:55 PM. The incident report indicated the nurse was called to the resident's room and found the resident on the floor. The resident was assessed by the nurse and was found to have an abrasion to the right knee, lateral right thigh, and top of the right hand. First aid was provided. There was no record that an investigation was completed or that any new fall prevention interventions were discussed or implemented. Review of an incident report revealed Resident #11 had an unwitnessed fall on 02/07/2022 at 6:45 AM. The incident report indicated the resident was found on the floor in the bathroom. The resident was assessed by the nurse and found to have no injuries. The resident received instruction to use the call light for assistance. There was no record that an investigation was completed. Review of a document titled Fall Risk Assessment-Prevention and Management indicated an intervention of Dycem (non-slip material) for the resident's chair was added to this form on 02/14/2022. This intervention was not included on the resident's care plan to ensure staff who provided care for the resident would be aware this intervention was needed. Observation on 07/18/2022 at 3:25 PM revealed Resident #11 was sitting in a wheelchair in his/her room. The resident was sleeping. There was a folded fall mat at the foot of the bed and no Dycem in the wheelchair. Observation on 07/19/2022 at 10:09 AM revealed the resident was sitting in a wheelchair in his/her room. There was no Dycem in the chair, and there was a fall mat folded at the foot of the bed. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 had the intervention of Dycem to the chair added to the Fall Risk Assessment-Prevention and Management tool on 02/14/2022 after the fall sustained on 02/07/2022. The DON acknowledged the intervention was not added to the care plan. A review of an incident report revealed Resident #11 had an unwitnessed fall on 03/16/2022 at 1:35 AM. The incident report indicated the resident was found on the floor in the bathroom. The resident stated he/she hit his/her head. The resident was assessed by the nurse and found to have a bruise to the back of the head and a small bruise to the anterior part of the left lower leg. Resident #11 was sent to the emergency room . The resident was treated for closed head injury, contusion to the occipital (back) region of the scalp, and scalp abrasion. There was no record an investigation was completed. Review of the document titled Fall Risk Assessment-Prevention and Management indicated an intervention for the pharmacist to review the resident's medications was added; however, this intervention was not addressed on the care plan, and there was no documentation in the medical record of the review, nor the results of the review. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed the intervention of a medication review by the pharmacist added to the Fall Risk Assessment-Prevention and Management form after the fall on 03/16/2022. The DON confirmed the intervention was not added to the care plan located in the EMR for Resident #11 and was unable to provide evidence that the review was completed. A review of an incident report revealed Resident #11 had an unwitnessed fall on 04/01/2022 at 6:00 PM. The report indicated the resident was found on the floor in the bathroom after someone heard the resident yelling for help. The resident was assessed and was then sent to the emergency room . The resident was treated for closed fracture of multiple pubic rami (sections of the pelvis), after undergoing multiple x-ray imaging and CT scans of the head and pelvis. There was no record of an investigation for causal factors of the fall. Review of the Fall Risk Assessment-Prevention and Management form indicated an intervention for physical therapy to evaluate was added. A review of an incident report revealed Resident #11 had an unwitnessed fall on 04/28/2022 at 4:08 AM. The report indicated the resident was found on the floor in the bathroom. The report indicated a CNA heard the resident yelling for help. The resident was assessed by the nurse and was sent to the emergency room . Progress notes indicated the resident was diagnosed with a head injury. The facility was unable to obtain hospital records during the survey. There was no record of an investigation for causal factors. Review of the Fall Risk Assessment-Prevention and Management form indicated an intervention to reorient the resident to the call light was added. An intervention to encourage call light use was already on the resident's care plan and had been since 09/05/2018. No other fall prevention interventions were initiated at this time. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed Resident #11 had the intervention of reorient to call light added to the Fall Risk Assessment-Prevention and Management form after the fall on 04/28/2022 and acknowledged that the resident's care plan already had an intervention dated 09/05/2018 to encourage the resident to use the call light. Review of an incident report revealed Resident #11 had an unwitnessed fall on 05/28/2022 at 4:22 PM. The incident report indicated the nurse was called to the resident's room and found the resident on the floor beside the bed and wheelchair. The resident was assessed by the nurse and was found to have no injuries. There was no record of an investigation for causal factors or of any fall prevention interventions that were put in place at this time. A review of an incident report revealed Resident #11 had an unwitnessed fall on 05/31/2022 at 3:28 PM. The incident report indicated the resident was observed to be sitting on the dining room floor. The resident stated he/she fell from the wheelchair. The report did not indicate whether Dycem was in place in the wheelchair at the time of the fall. The resident was assessed by the nurse and was found to have a small bruise to the right knee. There was no record of an investigation for causal factors or of any fall prevention interventions that were put in place at this time. A review of an incident report revealed Resident #11 had an unwitnessed fall on 06/04/2022 at 4:22 PM. The incident report indicated the nurse noted the resident was on the floor in his/her room next to the wall. The report indicated the resident stated he/she hit his/her head on the wall. The resident was sent to the emergency room . Hospital records were not available, and the facility was unable to obtain them during the survey. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 06/17/2022 at 1:31 AM. The incident report indicated the resident had turned the call light on and when staff arrived, they found the resident on the floor next to the bed. The resident stated he/she tried to get on the chair and missed. The resident was assessed by the nurse and was found to have no injuries. There was no record of an investigation for causal factors. Review of the Fall Risk Assessment-Prevention and Management form indicated an intervention for night light in the resident's room was added. During an interview on 07/23/2022 at 11:45 AM, the DON confirmed the intervention for a night light was added to the Fall Risk Assessment-Prevention and Management form after the fall sustained on 07/23/2022. The DON confirmed the intervention was not added to the care plan. A review of an incident report revealed Resident #11 had an unwitnessed fall on 06/18/2022 at 8:00 AM. The incident report indicated the CNA found the resident on the floor mat next to the bed. The bed was in the lowest position. The resident stated he/she had tried to get up. The resident was assessed by the nurse and was found to have no injuries. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 06/28/2022 at 5:13 AM. The incident report indicated the CNA found the resident on the floor mat next to the bed. The bed was found in the lowest position. The resident stated he/she tried to get up. The resident was assessed by the nurse and was found to have no injuries. The resident was instructed to use the call light for assistance. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall, other than reminding the cognitively impaired resident to use the call light. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/06/2022 at 12:20 AM. The report indicated the staff found the resident on the floor next to the bed with bedding wrapped around him/her. The resident stated he/she rolled out of bed and complained of rib pain. The resident was assessed by the nurse and was found to have red, scraped areas to the right rib cage area and a red area to the right shoulder. No treatment was provided. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/07/2022 at 2:11 AM. The incident report indicated that staff found the resident on the floor next to the bed. The resident was not able to tell staff what had happened. The resident was assessed by the nurse and was found to have no injuries. There was no record of an investigation for causal factors. Review of the Fall Risk Assessment-Prevention and Management form indicated an intervention of scoop mattress was added. During an interview with the DON on 07/23/2022 at 11:45 AM, the DON confirmed the scoop mattress was added to the Fall Risk Assessment-Prevention and Management form after the fall on 07/07/2022. The DON confirmed the intervention was not added to the care plan located in the EMR for Resident #11. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/08/2022 at 6:09 AM. The incident report indicated the CNA found the resident on the floor next to the bed covered in stool. The resident was taken to the shower and in the shower, the resident became combative and fell from the shower chair, hitting his/her head. The resident was assessed by the nurse and was found to have a large bruise to the forehead. The resident was sent to the emergency room and was admitted with a diagnosis of acute encephalopathy (a term indicating a disease of the brain which alters brain function or structure). The resident was also diagnosed with a urinary tract infection and was treated for this with intravenous antibiotics. A CT scan of the head indicated right front scalp swelling. The resident was released from the hospital on 07/12/2022. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/17/2022 at 9:35 PM. The incident report indicated the CNA found the resident on the floor in the bathroom. The resident was assessed by the nurse and was found to have a bruise on the left knee and left back. No treatment was provided. The resident was instructed to call for assistance. The document indicated the bed was in the low position and call light was in reach. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall, other than instructing the resident to use the call light. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/19/2022 at 4:08 AM. The incident report indicated the staff found the resident on the floor on his/her back. The resident was assessed by the nurse and was found to have a one-inch-long hematoma on the left side of the temple and a one-inch-long skin tear to the left forearm. The resident requested to go to the hospital. Per the hospital record, the resident was diagnosed with a closed head injury. The hospital assessment indicated the resident had a contusion to the right side of the forehead and contusions to both elbows. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. A review of an incident report revealed Resident #11 had an unwitnessed fall on 07/20/2022 at 2:45 AM. The incident report indicated the staff heard a noise and the CNA found the resident on his/her knees on the floor between the wall and the bed. The resident was assessed by the nurse and was found to have a skin tear to the right outer arm near the elbow and a scrape to the right knee. No treatment was provided. There was no record of an investigation for causal factors or of any fall prevention interventions that were implemented in response to this fall. Observation on 07/20/2022 at 7:51 PM revealed Resident #11 was lying on his/her back in bed. The bed was observed to be in low position. There was a fall mat at the bedside and a scoop mattress was on the bed. During an interview on 07/19/2022 at 10:35 AM, the DON stated she conducted investigations of falls, utilizing the Fall Risk Assessment-Prevention and Management tool. The DON confirmed this form had no documentation of investigations for causal factors of the falls. She stated the form was utilized to add approaches and interventions for fall prevention. The DON stated these forms were kept in a binder, which was maintained in her office, but that all staff had access to the forms. The DON stated she conducted interviews with staff after falls and educated the staff on fall prevention and updated approaches. The DON confirmed she did not document this education, nor the interviews. During an interview on 07/20/2022 at 5:01 PM, Licensed Vocational Nurse (LVN) #7 stated all care plans were maintained in the EMR. During an interview on 07/20/2022 at 5:03 PM, Registered Nurse (RN) #2 stated all care plans were maintained in the computer, and there were no paper care plans. During an interview on 07/20/2022 at 5:07 PM, LVN #2 revealed care plans were maintained within the computer charting. LVN #2 denied having any knowledge of a binder containing paper care plans. An interview was conducted on 07/23/2022 at 11:41 AM with Licensed Vocational Nurse (LVN) #3, who stated he was aware that Resident #11 had multiple falls with injury. LVN #3 stated all care plans were maintained in the EMR and he was unaware of any paper documentation. LVN #3 denied any knowledge of a form titled, Fall Risk Assessment-Prevention and Management. LVN #3 stated all interventions should be appropriate for each resident and educating Resident #11 on call light use was not effective because of the resident's mental ability. LVN #3 confirmed interventions such as neuro checks did not prevent falls; they were just an assessment performed after an unwitnessed fall. 2. Review of Admission Record revealed the facility admitted Resident #20 with diagnoses including muscle weakness, nontraumatic intercranial hemorrhage, repeated falls, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS indicated the resident required extensive assistance of two people for bed mobility and toileting. The resident used a wheelchair for locomotion and had experienced two falls without injury during the review period. Review of the current care plan, dated as created 05/18/2021, revealed Resident #20 was at risk for falls related to confusion, weakness, requiring assistance to transfer, a family member who raised the head of the bed, and the resident's use of antihypertensive and diuretic medications. Interventions included therapy evaluation and treatment per physician order; avoid rearranging furniture; be sure call light is within reach and encourage to use to call for assistance as needed; educate resident and family members about safety reminders and what to do if fall occurs; ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair; keep needed items, water, et cetera in reach; maintain clear pathway, free from obstacles; need a safe environment: floors free from spills and clutter, adequate, glare free light, a workable and reachable call light, the bed in low position at night, side rails as ordered, hand rails on walls, and personal items in reach. All interventions were dated as initiated on 05/18/2021. There was no care plan for any actual falls that occurred in the facility. Observation on 07/20/2022 at 1:10 PM during medication administration revealed Resident #20 was on the bed, and the bed appeared to be in the lowest position. There was a fall mat next to the bed. A review of progress notes revealed Resident #20 had an unwitnessed fall[TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance to prevent falls/ injuries for one (Resident#1) of six residents reviewed for accidents. The facility failed to provide two-person assistance during incontinent care. The resident rolled and fell to the floor which resulted in left shoulder pain, and limited range of motion in left arm. This deficient practice placed resident at risk for neglect, harm, pain, and emotional distress. Findings included: Review of Resident #1's undated face sheet reflected a 79- year-old male who was admitted to the facility on [DATE] with a diagnosis of chronic [CONDITION(S)] with [CONDITION(S)] (the absence of enough oxygen in the tissues to sustain bodily function), personal history of COVID -19, other recurrent depressive disorders, unsteadiness on feet, unspecified abnormalities of gait and mobility. Self -Care performance deficit r/t limited mobility, weakness and history of [CONDITION(S)] with Hem affecting the left side. Prior stroke causing limited range of motion in left arm. Review of Resident #1's MDS, dated [DATE], reflected a BIMS (Brief Interview of Mental Status a score of 13 to 15 suggests the person is cognitively intact) of 15. It further reflected the resident requires extensive assistance with transfers and bed mobility. Review of Resident #1's care plan revised on 4/30/22, reflected he was at risk for falls related to weakness on his left side. The care plan also reflected, an ADL self- care performance deficit with right limited mobility weakness, and history of weakness affecting the left side requiring extensive assistance with transfers and bed mobility. The care plan did not specify a one-person or two-person assist, only extensive assistance. Observation of Resident #1's room on 7/8/22, revealed two signs posted by the facility reflecting the resident is a two-person assist when changing at all times, and a two-person assist when transferring. Record review of Residents #1's nursing progress notes of incident, written 7/4/2022 by LVN-A, reflected the following: LVN description: Aide called this nurse to residents # 1's room d/t resident sliding off bed during transfer. The action witnessed by aide who then immediately sought help. Resident # 1 denied pain but was distressed about the situation. This nurse reminded resident that staff is here to help and to not feel bad when it is needed. Immediate Action Taken: Description: Resident was assessed by this LVN nurse then assisted back into bed with the assistance of a couple of CNAs and a nursing student. Per LVN, the resident denied any pain at this time. Contacted the doctor, family, and DON. Please put all this together with the quotes. During a phone interview on 7/8/22 at 11:52am with Resident # 1's family reported, the incident took place on 7/3/22 and the facility attempted to contact another one of resident's #1 family members. She stated when she spoke with the facility, she was advised that Resident # 1, slid out of bed and there were no injuries. She stated staff believes CNA- A hurt his feeling, by something that he said. She stated when she visited the next day 7/4/22, Resident # 1 stated, CNA-A, flipped when he was changing his brief and he hurt his shoulder from trying to grab the rail when he was falling. Resident #1's FAM reported, on the following day when she visited 7/5/22, Resident #1 was still complaining of his shoulder hurting and she requested that they send him out to the emergency room to have x-rays completed. She stated LVN-A told her that when they came in the room Resident # 1 was on the floor crying stating he didn't do anything and that he kept saying that he was sorry. She stated Resident # 1 has stated to her that he is afraid and feels that CNA-A is going to come in his room and shoot him. During a phone interview on 7/8/22 at 1:30pm with CNA- A, indicated he had worked with Resident #1 many times providing his care. He reported the events of the incident as follows: when he was transferring the resident down for bed, he grabbed the pee pad pulled it and Resident #1's legs were sliding. He stated he then grabbed Resident #'1 under both arms, but he was not strong enough to pull him up, so he helped him to the ground and went and got help. He stated Resident #1 denied any pain at that time, but later was observed crying. He stated, I guess he was crying because he fell . During an interview on 7/8/22 at 2:00pm with Resident #1, stated he was lying in bed and CNA-A was changing him. He stated CNA-A asked him to rollover, he was not able to rollover fast enough and that's when he pulled the pad and he rolled out the bed hitting the floor. Resident # 1 stated he tried to catch himself when he was falling by grabbing the side rail of the bed and that's when he hurt his shoulder. Resident # 1 stated CNA-A said, see what happens when you don't help, he stated he fell to the left side of his bed hurting his left shoulder. Resident # 1 stated he does not know why he did that to him and doesn't want it to happen again. He reported he felt afraid because he didn't know if CNA-A was going to come back in his room and do something else to him. He stated he spoke with the administrator and told him the same thing. Resident # 1 stated he was crying because he didn't want anyone to ever do that to him again. Resident #1 stated that he hurt his shoulder, but stated he didn't want any medication. He did not indicate the extent of the pain that he had. During an interview on 7/8/22 at 2:24 pm with Staff Coordinator, she stated she is the immediate supervisor for CNA-A. According to her, she had already gotten off work for the day at the time of the incident, however learned of the incident when she returned on 7/5/22. She stated this is the reason they have the signs on the wall in the room for staff to use 2-people when transferring and changing. She stated she believes that CNA-A assumed that he could do it by himself because sometimes Resident # 1 is able to help with re-positioning when changing. According to her, she always used two-people with resident # 1 because it's for the safety of the resident, you never know what might happen, and you need someone on both sides. During an interview on 7/8/22 at 3:00pm with CNA-B, she stated she was working the day of the incident, however she was working on the other side and just heard about what happened. According to CNA-B, she was told that CNA-A had pulled the pad and caused Resident # 1 to fall out of bed. CNA-B stated she does not ever work with CNA-A because he works on the other side. According to CNA-B, she has been trained on transfers and two-person assist, she stated the nurse will let them know if a person is a two-person assist. During an interview on 7/8/22 at 3:30pm with CNA-C, she stated she has worked with Resident #1 before and provided care. She stated she always has two people because he is a large man. CNA-A stated the nurse let them know if a person is a two-person assist, she stated she has been trained on two-person assist, transfers, [NAME] lift and sit to stand lift. CNA-C stated Resident# 1 is a sit to stand lift (to assist a person from a sitting position to a standing position or [NAME] versa) and requires two people. CNA-C stated when she spoke with Resident # 1, he was crying and sad stating he didn't want to bother anyone. She stated she didn't know if it was because he fell or if because he thought CNA-A wasn't taking it seriously, she indicated she had never seen him like that before in the time that she has been employed there. During an interview on 7/8/22 at 4:00pm with CNA-D, she stated she has provided care for Resident # 1, she stated she always has two people assisting because he is a large man, and he is a two-person assist. She stated this is protect her and the resident from getting hurt. CNA-D stated she has been trained on transfers and lifts. During a phone interview on 7/8/2022 at 4:43pm with LVN, she reported she was the nurse in charge the night of the incident. According to her, she was in another resident's room working with a student, when CNA-A came and got her stating Resident #1 was on the floor he also reported the resident did not indicate that he was in any pain. LVN stated, she observed Resident #1 on the floor when she went into the room, he did not state that he was in pain. She indicated a couple of the other aides who were there assisted in getting Resident #1 off the floor and back into his bed. LVN, stated during the time the staff were assisting Resident #1 off the floor, CNA-A made the comment, I can't pick him up myself, he doesn't do anything. LVN, reported later when she went back to check on Resident #1, he was crying stating he did not mean to be a bother to anyone and that he was sorry to be so much trouble, she stated she advised resident #1 that he was not any trouble and that it was their job to help him. LVN stated she did not ask CNA-A why he didn't get another person to assist him when he is a two-person as During a phone interview on 7/8/22 at 6:34pm with SOWK, she stated she met with Resident # 1on 7/5/2022 and stated he explained, that when CNA-A was changing him, CNA-A pulled the pad that he was lying on in the bed. She stated once he pulled the pad, Resident # 1 became to roll and stated he helped lower him to the ground. SOWK, stated Resident #1 felt like CNA-A may have been upset with him because he was not able to help more. During an interview on 7/8/22 at 6:00pm with DON, she stated she was not working at the time of the incident and was notified via text message the night of the incident, so she didn't get the information until the next day. She stated if a resident is a two-person assist they verbally let the staff know and they post the signs up in the resident's room. She stated Resident # 1 is a sit to stand lift and has the signs posted in his room are for transfer and changing. She stated sometimes the resident can assist with rolling over when changing, she stated after this incident they made him all the time two-person assist. During an interview on 7/8/22 at 6:19pm with ADM, he stated he learned of the incident on 7/4/22 from the DON. He stated on 7/3/22, there was no allegations made regarding the incident. He stated on 7/4/22 when Resident# 1's FAM, made allegations he immediately suspended CNA-A from his next shift for the morning on 7/5/22 pending an investigation. ADM reported he spoke with resident # 1, FAM, Resident # 1, CNA-A, the LVN on duty at the time, completed safe assessments for four of the residents on hall 400. According to him, he concluded that it did not meet the definition of abuse/neglect and lifted CNA-A suspension that evening @ 6:00pm allowing him to return to work. The ADM stated Resident # 1 is not always a two-person assist, he stated it is up to the staff who is providing care at that time to determine if the resident will be a two-person assist at that time. He stated he was not aware of any signs up in the resident's one room he stated, they must be old as this is an old building. He stated because the MDS and Care plan indicate extensive assistance, this does not mean two-people, he stated again the staff are to determine when two-people are needed. He stated Resident t # 1 is able to assist some so when he does not assist or is able to assist is when the staff will get two people to assist. ADM later stated the signs were placed in resident # 1 room when the incident happened on 7/5/22. He stated on 7/4/22 when FAM was visiting resident # 1, she made the allegation the CNA-A intentionally pulled the pad causing Resident #1 to fall and would be filing charges. ADM stated at that he then contacted CNA-A via phone and advised him that he was suspended pending the investigation. He stated after speaking with Resident t # 1, CNA-A, SOWK, and completing safe surveys for other residents that he concluded that this did not meet the definition of abuse and lifted CNA-A's suspension that evening allowing him to return to work on 7/6/22. Review of the facility's in-services from 4/1/22- 7/6/22 reflected, falls, customer service, CNA tasks, [NAME] transfer, Nurse assessments, abuse/ neglect, turning /repositioning, and infection control. Review revealed there was no training provided on 2-person assist/transfer or assessing when a resident requires a one person or two- person assist. Review of the discharge summary dated 7/6/22, from local hospital revealed, Resident # 1 presented with left shoulder pain, caused from a fall at the nursing facility. The report indicated Resident # 1 was alert and oriented able to communicate clearly and appears to have capacity to making own decisions. X-rays show negative for acute fracture. The report further indicates Resident # 1 noted bruising to ball and joint region of the left arm where the muscle connects to the rest of the body. The report also stated, the resident exhibited decreased range of motion and tenderness. According to the hosital notes Resident #1 was re-evaluated again at 3:30pm and he indicated that he did not want anything for pain, the report did not give the level of pain. Final Diagnosis indicates Fall, initial encounter, contusion of left shoulder, initial encounter, and acute pain of left shoulder. The Resident # 1 was not prescribed any medication for pain, discharged in stable condition. Reviewed Disciplinary actions taken by facility dated 7/5/22, reflected the following: A. Written warning for CNA-A - For making an inappropriate comment that hurt the resident's feeling. B. Suspension pending investigation 7/5722, suspension lifted staffed returned to work on 7/6/22. C. Staff assigned to different hall Review of the facility's Abuse and Neglect Policy, dated 11/28/2017, reflected the following: The facility will take action to protect and prevent abuse/neglect from occurring within the facility by: A. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs which might lead to neglect, such as: 1. Residents that require extensive care and or totally dependent on staff for the provision of care. B. Protection: The facility will provide emotional support and counseling to the resident during and after the investigation as needed. C. Neglect: is the failure of the facility, its employees or services providers to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress a. Based on ADM interview, staff are expected to be aware or expected to assess the residents needs at the time they are proving care to ensure that they are providing the services required but fails to provide that service.

Based on observation, interview, and record review, the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #2) of 4 residents review for pressure ulcers. The facility failed to identify, treat, document, and monitor Resident #2's facility acquired pressure injury which was acquired in the facility. The facility failed to develop and implement an accurate care plan with ongoing assessments, interventions and approaches to improve tissue breakdown and to provide treatments for newly acquired pressure injury. These failures could place residents at risk for developing pressure injuries and/or deterioration of existing pressure injuries. Findings include : Review of Resident #2's EMR care plan reflected Resident #2 had a pressure ulcer or potential for pressure ulcer development with approach to include monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size and stage. Review of Resident #2's handwritten care plan for skin integrity, dated 9/3/21 and provided to surveyor on 10/19/21 reflected Resident #2 had an actual pressure ulcer to her left heel and right heel, surgical wound to left leg and skin tear to right leg. The handwritten care plan included the approach to elevate legs to decrease stasis/[CONDITION(S)], Dietary consult as needed, Wound care as ordered, Vitamin C, protein supplement added 10/18/21, and pressure relieving mattress added 10/18/21 . Review of Resident #2's Daily skilled nursing note, dated 9/12/21 reflected, skin injury/ulcer. Skin injury is located left heel, resident response to treatment is notify wound nurse, continue to elevate and offload. Skin condition is a new onset. Other observations and interventions include notify wound nurse. Review of Resident #2's Nurse Practitioner progress note, dated 9/13/21, reflected extremities no [CONDITION(S)], left lower extremity immobilizer, +left knee surgical wound and skin: warm/dry and continues rehab efforts, no concerns . Review of Resident #2's Nurse Practitioner progress note, dated 9/15/21, reflected documentation of a surgical site wound but did not reflect presence of pressure injury/injuries to Resident #2's heels. Review of facility provided weekly skin report, dated 10/3/21-10/9/21, reflected Resident #2 had a surgical wound on the left knee, wound on the distal right lower extremity, and trauma wound on the right lateral extremity . Review of facility provided non-pressure weekly report for Resident #2, dated 10/5/21, reflected Resident #2 had a surgical wound to her left proximal anterior shin, a surgical wound to her left distal anterior shin measuring, and a trauma wound to her right lateral calf. Review of facility provided weekly skin report, dated 10/10/21 to 10/16/21, reflected Resident #2 to have a surgical wound to her left knee measuring 3.0 cm x 6.0 cm, a surgical wound to her right lower extremity measuring 1.9 x 0.5, and a trauma wound to her right leg measuring 1.0 x 1.3 cm . The report did not reflect Resident #2 to have a pressure injury to her left heel. Review of facility provided non-pressure weekly report for Resident #2, dated 10/12/21, reflected Resident #2 had a surgical wound to her left proximal anterior shin measuring 3.0 cm x 6.0 cm, a surgical wound to her left distal anterior shin measuring 1.9 cm x 0.5 cm, and a trauma wound to her right lateral shin measuring 1.0 cm x 1.3 cm. The report reflected surgical wounds were on the left and the trauma wound was on the right which varied from the weekly skin reports provided by the facility. Review of undated document, provided 10/18/21 that listed all residents who as of 10/18/21 had a pressure injury reflected 3 residents. Resident #2 was not included on the facility provided list of residents with a pressure injury. On 10/18/21 at 12:25 p.m. Resident #2 was observed sitting in a wheelchair with her feet dangling in a dependent position with her left heel resting on the front wheel of her wheelchair. Resident #2 was wearing cloth ballet type house shoes with coverage including running over her mid heel area. Resident #2 stated she came to the facility after having surgery on her leg so she could get stronger. She stated she needed help moving around because of pain in her leg and back of her feet. She stated she injured her right leg when she was trying to get in bed. She stated she did not know why the back of her heels hurt but related it to her house shoes being too tight or feet swelling from sitting up in the wheelchair. On 10/18/21 around 12:25 p.m. Visitor C stated Resident #2 required help to ambulate and to change positions in bed because Resident #2 had surgery on her left leg. Visitor #1 stated she has been at the facility and witnessed times where Resident #2 had to wait over an hour for assistance. The visitor stated on one occasion Resident #2 was told she would have to wait for assistance with incontinent care because dinner trays were on the floor and staff could not do incontinent care with trays on the floor. The visitor stated when she complained about Resident #2 having to wait for assistance until after trays were picked up the facility apologized for the misunderstanding and stated that was not true. Visitor C also stated Resident #2 was told on at least one occasion to urinate in her brief due to staff not being readily available to assist the resident . In an interview on 10/18/21 at 12:52 p.m. Visitor D stated she had witnessed wait times for Resident #2 to get the help that she needs that exceeded an hour or more waiting. In an interview on 10/18/21 at 1:50 p.m. Family D stated Resident #2 frequently had to wait 45 minutes or more to go to the restroom. She stated on one occasion Resident #2 had to urinate in bed because she could not get help from the staff. She stated the surgeon caring for Resident #2 was not happy with how the surgical wound was healing so he ordered a wound vacuum on 10/8/21 but it had not been placed yet. Review of facility provided grievance log, for 09/2021 and 10/2021, provided on 10/18/21 reflected Resident #2 voiced a concern regarding toileting on 9/14/21, a concern with an appointment on 10/8/21, a concern with showers on 10/15/21 and a concern with call light placement /bandage change on 10/17/21 . On 10/18/21 at 2:25 p.m. LVN A stated Resident #2 received dressing changes daily on the left leg which is the surgical site. LVN A stated Resident #2 only received dressing changes to the skin tear on the right leg as needed. LVN A did not include any concerns regarding Resident #2's heels and/or planned treatment. She stated she had reached out to the surgeon for Resident #2 to request clarification on the order for the wound vacuum but had not heard from the surgeon yet. On 10/18/21 at 4:15 p.m. Resident #2 was observed to still be sitting in her wheelchair with feet in dependent position resting on the metal footrest of the wheelchair . The resident stated she had been sitting up since she previously spoke with the surveyor (3 hours and 50 minutes prior). She stated her foot was hurting so she asked for the footrest to be placed on her wheelchair which helped her foot not hurt as bad. Resident #2's heel was exposed and revealed a large blackened area that covered most of the left heel. On 10/18/21 at 4:28 p.m. LVN A was interviewed over the phone regarding the finding of a large purple/black wound to Resident #2's heel that was not identified on any of the wound reports. LVN A stated her reports were only to include surgical wounds. She stated the nurses were to follow pressure injuries. When questioned why the report she provided had other residents on the list with pressure injuries that were not related to surgery she stated it depended on the area and if the wound care doctor is following the wound or not. She stated the wound care doctor was not following Resident #2's wounds so her pressure injuries would not be on her report. She stated Resident #2 had previously been followed by the wound care doctor but the surgical doctor had requested a wound vacuum to be placed on Resident #2's surgical wound. The wound care nurse stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned why Resident #2 was not included on the list that she provided on the first day of the investigation of all residents in the facility with a pressure injury, she stated she forgot . Review of Resident #2's Nurse Practitioner progress note late entry note with creation date of 10/18/21 at 7:38 p.m. to link to note on 9/13/21 at 1:20 p.m. reflected, Addendum Assessment: Left heel DTI, no change in DTI, continue monitoring & floating of heels per facility protocol Review of Resident #2's progress note documented by the wound care nurse with creation date of 10/18/21 at 8:01 p.m. for date of 9/14/21 at 8:41 a.m. reflected Late Entry: This nurse informed by CN that res noted to have wound to left heel. Wound assessed to be SDTI unstageable. Provider informed and obtained n/o to float heels q shift . Orders carried out. Input order for weekly skin assessment to be completed. On 10/19/21 at 12:00 p.m. the Administrator stated an air mattress was ordered for Resident #2 to assist with pressure relief on her heels. He stated the facility completed a skin assessment on all residents in the facility over-night and there were no additional skin issues identified from the skin assessments. He stated Resident #2 has been added to the list of residents with pressure injuries and will be followed by the wound care nurse. The Administrator stated he has determined the pressure injury was identified on 9/12/21 which was a Sunday. He stated the nurse working sent a text message to the wound care nurse to inform her of the pressure injury. He stated on 9/13/21 (Monday), the nurse practitioner and a physician assessed the pressure injury. He stated on 9/14/21, the wound care nurse placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the daily nurse's notes did not require a measurement and that the pressure injuries were not followed by the wound care nurse . He stated the facility did fail to add the resident to the list of pressure injuries, but he felt the staff did an accurate job of assessing the pressure injuries by noting the presence of the injury on the heel. He stated the wound care nurse forgot to place the order for offloading, the nurse practitioner forgot to place the progress note regarding the pressure injury, and the wound care nurse forgot to add Resident #2's pressure injury to the facility's list of pressure injuries . Review of facility provided undated document, provided on 10/19/21, of all residents who have a pressure injury after completing a skin assessment on all residents in the facility the night of 10/18/21 reflected 4 residents had pressure injuries. The list included Resident #2 who had not previously been identified on the list of 10/18/21 of residents with a pressure injury. On 10/19/21 at 12:49 p.m. Resident #2 was observed sitting in a wheelchair with her feet dangling in a dependent position. Resident #2 was wearing the same type of cloth ballet type house shoes with coverage including running over her mid heel area that she had worn on the previous day. Resident #2 stated she slept much better after getting the new mattress last night. She stated the back of her foot did not hurt as bad at the moment because she had not been sitting up to long, so her feet were not swollen. In an interview on 10/19/21 at approximately 1:30 p.m. LVN A stated the list of residents with pressure injuries provided on 10/19/21 was the same as the list of residents with pressure injuries provided on 10/18/21 with the exception of adding Resident #2 to the list. LVN A also stated the protocol for wound care was already provided to the surveyor which would be the skin care policy. She stated there was no additional protocols or policies relating to pressure injuries. In an interview on 10/19/21 at 2:20 p.m. CNA A stated she had been assigned to the hall where Resident #2 was located, and she had consistently cared for Resident #2 for the past 3 weeks. She stated Resident #2 received her shower on the second shift, so she did not help her with showers. CNA A was unaware of any skin breakdown on Resident #2's heels. She stated she thought she was offloading Resident #2's legs to assist with swelling of the legs because Resident #2 had surgery on her left leg. She stated if she had been aware of any skin breakdown to Resident #2's heels she would have been more careful to not touch the area and she would not put shoes with a back on Resident #2's feet . In an interview on 10/19/21 at 2:35 p.m. Family #1 stated he was not informed by the facility of the pressure injury to Resident #2's heel until the morning of 10/19/21. She stated she was the emergency contact for Resident #2. She stated she was already aware of the wound to the resident's heel because a visitor had sent her a picture of the heel on 10/8/2021 . She stated the picture of the heel on 10/8/2021 had a large dark purple/black area that completely covered the back of the heel . In an interview on 10/19/21 at 3:15 p.m. Nurse Practitioner A stated she was aware of the pressure injury to Resident #2 which was why she ordered the facility to implement the facility's protocol for monitoring and floating of Resident #2's heels. She stated she was informed about the pressure injury to Resident #2's heel on 9/13/21 . She stated she would expect the facility staff to assess the heels every shift and report change in condition such as wound size, color, drainage, etc. She stated she would expect to implement strategies such as using heel protective devices to assist with improving the injury and/or prevent deterioration of the injury. She stated Resident #2 should not be wearing house shoes with a backing that adds additional pressure to the heel area . 10/19/21 at 4:05 pm, attempted to contact and left message for Doctor B regarding questions related to Resident #2. In a phone interview on 10/20/21 at 1:20 p.m. Doctor B stated he was not aware of any pressure injuries on Resident #2. The doctor stated Resident #2 had poor wound healing potential due to her age and severity of the injury that she received on her left leg from a fall at home. He stated he would expect the facility to notify him of a pressure injury on the leg had required surgery because the treatment plan and healing of the surgical wound could be impaired from the additional complications with perfusion and circulation that can occur with the addition of a pressure injury. Doctor B stated he would expect the facility to be assessing the resident's skin for signs of breakdown due to her co-morbidities. He stated he would expect the assessment to include documenting the size and character of the wound. He stated he would also expect the facility to implement preventive measure such as frequent turning, off-loading with the heel elevated, and pressure relieving boots that have heel opening to prevent additional pressure on the heel. He stated the resident should not be wearing house shoes that have a band putting pressure on the back of the heel. Doctor B also stated he would expect Resident #2 to be followed by a dietician to support nutritional needs for wound healing . Review of Policy and Procedure-Skin management System, dated January 2020, revealed: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventive 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 policy also reflects that a treatment order will be obtained from the Attending Physician for areas requiring treatment. i.e. pressure injury, surgical wounds, open skin tears, abrasions, lacerations etc . The Registered Dietitian will provide nutritional support when appropriate . The Medical Records designee shall conduct treatment record reviews to ensure administration of treatments as prescribed and documentation of ongoing assessment on the resident's clinical record.