Every finding on record at McAllen Transitional Care Center

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan reflected refusals of medications (on 05/16/26, 05/17/26, 05/25/26, 05/29/26, 05/30/26, 05/31/26, 06/03/26, 06/04/26, 06/08/26, 06/09/26, 06/12/26, 06/13/26, 06/14/26, 06/17/26, 06/18/26, 06/22/26, 06/26/26, 06/27/26, 06/28/26, 07/01/26, 07/02/26, 07/06/26, 07/07/26, and 07/15/26) and skin assessments (on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26). This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #2's face sheet, dated 07/14/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: chronic obstructive pulmonary disease (incurable lung disease that cause s restricted airflow and severe breathing difficulties), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), hemiplegia/hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, mood disorder due to physiological condition (mental health disorder where depressive or manic symptoms arise directly from a medical or neurological condition affecting brain function), and major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems). Record review of Resident #2's quarterly MDS assessment, dated 06/12/26, reflected a BIMS score of 15, which indicated intact cognition. The MDS reflected Resident #2 had impairment on one upper extremity and no impairment to lower extremities. Record review of Resident #2's care plan, dated 07/14/26, reflected [Resident #2] had cerebral accident (stroke) with hemiplegia affecting left non-dominant side. Date initiated: 02/16/26. Interventions included: give medications as ordered by the physician, monitor/document/report to MD, and provide assistance. [Resident #2] had a self-care performance deficit. Date initiated: 02/09/26. Interventions included: required partial/moderate assistance with bathing/showering. [Resident #2 had bowel/bladder incontinence. Interventions included: licensed nurse will monitor skin at least weekly and report any changes to MD. Care plan did not reflect refusals of medications and skin assessments. Record review of Resident #2's progress notes, dated 05/13/26-07/15/26, reflected Resident #2 refused all medications on 05/16/26, 05/17/26, 05/25/26, 05/29/26, 05/30/26, 05/31/26, 06/03/26, 06/04/26, 06/08/26, 06/09/26, 06/12/26, 06/13/26, 06/14/26, 06/17/26, 06/18/26, 06/22/26, 06/26/26, 06/27/26, 06/28/26, 07/01/26, 07/02/26, 07/06/26, 07/07/26, and 07/15/26.During an interview and observation, on 07/14/26 at 12:30 PM, Resident #2 stated she was doing well. Resident #2 stated she took her medications when she wanted. Resident #2 stated the nurses checked her skin when she let them. Resident #2 stated there were times she told them no to everything because she was fine. Resident #2 was observed with no visible injury. During an interview, on 07/14/26 at 1:40 PM, LVN A stated Resident #2 refused medications, the PA was made aware, and the PA gave no new orders. LVN A stated they educated and encouraged Resident #2 to take her medications but it was her right to refuse. During an interview, on 07/14/26 at 1:55 PM, the PA stated she was notified when Resident #2 refused medications. The PA stated the staff explained the importance of taking her medications but Resident #2 had the right to refuse. The PA stated the staff monitored Resident #2 and she had no changes resulting from medication refusals. During an interview, on 07/15/26 at 8:50 AM, MA B stated Resident #2 refused medications a lot of the time. MA B stated when Resident #2 refused medications, she attempted to explain the importance of taking her medications but Resident #2 still refused. MA B stated she told the nurse on shift and they tried to convince Resident #2 but she still refused. MA B stated she did not remember what days Resident #2 refused but she documented a progress note each time. During an interview, on 07/15/26 at 9:20 AM, LVN C stated Resident #2 refused skin assessments. LVN C stated they cannot force Resident #2 to allow them to check her skin and she had the right to refuse. During an interview, on 07/15/26 at 10:30 AM, the MDS Nurse stated if Resident #2 refused care, that should have been included in her care plan. The MDS Nurse stated she was aware that Resident #2 refused medications, but it was not included in her care plan because she missed adding it. The MDS Nurse stated she was not aware that Resident #2 refused skin assessments, but that should have also been added to her care plan. The MDS Nurse stated the team communicated changes that needed to be added to the care plan, but Resident #2's skin assessments refusals were not been reported to her. The MDS Nurse stated any refusals of care should have been added to the care plan. The MDS Nurse stated there was no negative outcome for Resident #2 as staff encouraged, explained, and educated her on the importance of allowing for care, but it was her right to refuse. The MDS Nurse stated it was important for the care plan to be developed accurately to ensure all staff were aware of Resident #2's refusals and what interventions to attempt. During an interview, on 07/15/26 at 11:00 AM, the ADON stated Resident #2 refused medications, but she was not sure what days. The ADON stated she was made aware today (07/15/26) that Resident #2 refused skin assessments. The ADON stated the refusals of care should have been in Resident #2's care plan. The ADON stated the MDS Nurse developed and updated the care plans, but it was a team effort to communicate changes to the MDS Nurse and ensure the care plan was accurate. The ADON stated for refusals of care, interventions were to educate the resident, encourage, and notify the MD. The ADON stated the staff had already implemented those interventions for Resident #2's refusals of medications and skin assessments. The ADON stated there was no negative outcome for Resident #2 but it was important to include behaviors, such as refusals, in the care plan so everyone was aware of the plan of care. During an interview, on 07/15/26 at 11:45 AM, the PA stated she was notified that Resident #2 refused skin assessments. The PA stated Resident #2 had the right to refuse and the staff respected her wishes. During an interview, on 07/15/26 at 3:00 PM, the DON stated care plans were developed and updated by the MDS Nurse. The DON stated Resident #2 refused medications and skin assessments. The DON stated the refusals of care should have been included in the care plan. The DON stated there was no negative outcome or risk of injury for Resident #2 as staff notified the PA, the PA gave no new orders, and the staff implemented interventions to address her refusals such as educating and explaining the importance of taking her medications and allowing the skin assessments. The DON stated it was important for the care plan to be developed accurately to ensure everyone was aware of the resident's needs and behaviors. Record review of the facility's Comprehensive Person-Centered Care Planning policy, dated November 2016 and revised April 2025, reflected - Policy: It is the policy of this facility that the 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 psychological needs that are identified in the comprehensive assessment.

Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for accuracy of records.LVN C failed to document progress notes for skin assessment refusals on Resident #2's electronic medical record on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26.This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.Findings included:Record review of Resident #2's face sheet, dated 07/14/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: chronic obstructive pulmonary disease (incurable lung disease that cause s restricted airflow and severe breathing difficulties), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), hemiplegia/hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, mood disorder due to physiological condition (mental health disorder where depressive or manic symptoms arise directly from a medical or neurological condition affecting brain function), and major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems). Record review of Resident #2's quarterly MDS assessment, dated 06/12/26, reflected a BIMS score of 15, which indicated intact cognition. The MDS reflected Resident #2 had impairment on one upper extremity and no impairment to lower extremities. Record review of Resident #2's care plan, dated 07/14/26, reflected [Resident #2] had cerebral accident (stroke) with hemiplegia affecting left non-dominant side. Date initiated: 02/16/26. Interventions included: give medications as ordered by the physician, monitor/document/report to MD, and provide assistance. [Resident #2] had a self-care performance deficit. Date initiated: 02/09/26. Interventions included: required partial/moderate assistance with bathing/showering. [Resident #2 had bowel/bladder incontinence. Interventions included: licensed nurse will monitor skin at least weekly and report any changes to MD. Record review of Resident #2's Braden scale (tool) for predicting pressure ulcer risk evaluation, dated 05/11/26, reflected a low risk with no need for treatment at this time. Record review of Resident #2's skin checks reviewed on 07/15/26 at 4:00 PM, reflected a skin check on 05/13/26 with no new skin issues. There were no other skin checks completed until 07/15/26 at 2:19 PM. Resident #2 had a rash to the left lower quadrant midline. Record review of Resident #2's progress notes, dated 05/13/26-07/15/26, reviewed on 07/15/26 at 4:05 PM, reflected Resident #2 had a scattered rash on 07/13/26, the PA was notified, and Resident #2 was seen by the PA who prescribed her a topical ointment and oral medication. There was no documentation found for Resident #2's refusals of skin assessments on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26. Record review of Resident #2's nurse aide skin identification form (shower sheet), dated 05/15/26-07/10/26, reflected no new skin site or change. During an interview and observation, on 07/14/26 at 12:30 PM, Resident #2 stated she was doing well. Resident #2 stated the nurses checked her skin when she let them. Resident #2 stated there were times she told them no to everything because she was fine. Resident #2 was observed with no visible injury. During an interview, on 07/15/26 at 9:20 AM, LVN C stated Resident #2 refused skin assessments. LVN C stated they cannot force Resident #2 to allow them to check her skin and she had the right to refuse. LVN C stated he did not recall when the last time was Resident #2 allowed him to do the skin assessment. LVN C stated he was unsure if he documented Resident #2's refusals. LVN C stated he explained to Resident #2 why he needed to do the skin check but she told him that there was nothing wrong with her skin and refused. LVN C stated he notified the PA when Resident #2 refused skin checks, but there was no other intervention or order, and they continued to monitor. LVN C stated it was important to do the skin checks or attempt to, to see if there were any skin changes. LVN C stated the ADON checked his work and ensured the weekly skin assessments were done. LVN C stated it was important to document so staff were aware of skin changes or the refusals. During an interview, on 07/15/26 at 11:00 AM, the ADON stated she reviewed the skin system and ensured the assessments were done. The ADON stated LVN C completed weekly skin assessments on all the residents. The ADON stated today (07/15/26) LVN C informed her that Resident #2 refused weekly skin checks, but there was no documentation of her refusals. The ADON stated she reviewed Resident #2's file and the last skin check was completed on 05/13/26, with no skin issues. The ADON stated Resident #2 should have had weekly skin assessments or a note on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26. The ADON stated Resident #2's weekly skin assessment was scheduled for today (07/15/26) and they were going to attempt. The ADON stated she did not know why Resident #2 refused skin checks or why LVN C had not documented the refusals. The ADON stated she was told by LVN C that he notified the PA of the refusals and there were no new orders. The ADON stated there was no documentation to show LVN C's actions. The ADON stated there was no negative outcome for Resident #2 and Resident #2 was vocal, able to voice needs or issues. The ADON stated the floor staff would have reported any skin changes noted during brief/clothing changes or showers. The ADON stated it was important that the weekly skin assessments were completed or attempted to capture any skin changes, and it was important to document to show the staff's efforts. During an interview, on 07/15/26 at 11:45 AM, the PA stated she was notified that Resident #2 refused skin assessments and she gave no new orders. The PA stated Resident #2 had the right to refuse, and the staff respected her wishes. During an interview, on 07/15/26 at 3:00 PM, the DON stated the skin system was overseen by the ADON and LVN C. The DON stated LVN C completed weekly skin assessments on all the residents. The DON stated if the resident refused a skin check, LVN C should have notified the doctor and documented a progress note about the refusal. The DON stated he reviewed Resident #2's file and there was no documentation for refusals regarding skin checks on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26. The DON stated the ADON completed audits and ensured the weekly skin assessments were done. The DON stated the last skin check, before today (07/15/26), was on 05/13/26 when Resident #2 was noted with no skin issues. The DON stated the floor staff completed skin checks during showers and had not reported any skin changes. The DON stated Resident #2 was very particular, so LVN C probably attempted the skin check and she refused, but there was no documentation to show LVN C's actions. The DON stated the policy for skin and wounds was to assess the residents weekly and to document the assessment, document a note, or document the refusal. The DON stated there was no negative outcome to Resident #2 as she did not have wounds or major skin issues, and she was at low risk of developing pressure wounds since she was still able to wheel herself around, move around in bed, and voice her needs, wants, or dislikes. The DON stated it was important for the weekly skin assessments to be completed or attempted with follow up documentation as a preventative measure to avoid any skin integrity issues. During an interview, on 07/15/26 at 4:45 PM, the DON stated there was no risk of injury for Resident #2 as skin changes would not go unnoticed since CNAs completed skin checks during showers and noted skin changes on shower sheets. The DON stated even if there was no skin change noted by the CNAs, LVN C was the licensed staff to assess and say there was an actual skin change or abnormality that could lead to further issues. Record review of the facility's Skin and Wound Monitoring and Management policy, dated March 2015 and revised April 2025, reflected, Policy: It is the policy of this facility that: A resident who enters the facility without pressure injury does not develop pressure injury. and receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.1.g. Ongoing skin and wound assessments: A licensed nurse will assess/evaluate a resident's skin at least weekly.4.b. Weekly skin check: Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessments/evaluation weekly and as needed.8.a. if the resident is not able to or chooses not to participate in the care plan relative to prevention of skin breakdown.the nursing staff shall communicate with the resident's physician to discuss an appropriate intervention or response.

:Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1-refrigerator (1 of 1 facility refrigerator) and 1 of 1 freezer (1 of 1 resident freezer reviewed for storage, preparation and sanitation and failed to keep residents room free from pests. -The facility failed to ensure food items in the resident's refrigerator were dated and sealed properly. -The facility failed to ensure food items in the resident's freezer were sealed properly. -These failures could place residents at risk of complications from food contamination. Findings included: Observations during the initial tour of the kitchen on 03/09/26 at 10:30 am revealed one block of sliced cheese wrapped in clear plastic undated, a box of tomatoes of uncovered, cucumbers uncovered exposed to air possibly coming contaminated that were stored in the facility refrigerator. Observation of the freezer revealed a box of raw biscuits open and exposed to the air. Observation of Resident and interview revealed Resident #42 and Resident #79stated they both saw large roaches in their rooms for a couple of days In an interview with DA A on 03/09/26 at 10:30 a.m. said all kitchen staff were responsible for cleaning the refrigerator and made sure that all food was labeled, had not expired, and had a use by date. DA #A stated the fridge was cleaned and all expired food was thrown out daily. DA A could not explain why the cheese did not have a date of when the cheese was placed in the refrigerator. DA A stated she did not know the tomatoes and cucumbers were not stored properly, or she would have stored them properly. DA A stated she did not know of the biscuits that were left open in the freezer. DA A stated she knew that all items in the freezer should be sealed to prevent freezer burn and could become contaminated making residents sick. In an interview on 03/11/06with DA B at 10:41 a.m. he stated he could not recall when the cheese was placed in the refrigerator but knew that all items put in the refrigerator were to have a use by date. DA B stated the staff throw away all expired food daily and clean the refrigerator weekly. DA B said he was not aware of the cheese not being dated but knows that all food in the refrigerator must be dated so the expired food is not used for cooking for the residents. DA B stated the biscuits must have been left open recently and the person must have been in a rush because all food is sealed and dated. DA B stated he knew it was important to keep all open items in the freezer must be resealed so that it does not become contaminated and make residents ill. In an interview with the DM on 03/11/26 at 10:13 a.m. she stated she and the staff clean out the refrigerator daily and the cheese was not dated correctly and if should have been stored with a date when it was put in the refrigerator. The DM said the cheese had not been used for cooking recently, and that could be why the cheese was not noticed with no use by date. The DM stated she did not know why they did not have a date on the cheese or when the cheese was put in the refrigerator as all other items had a date. The DM stated the cheese gets used quite often so could not say who did not date the cheese when it was put in the facility refrigerator. The DM stated she will do a retraining on dating items and making sure they are all covered or in a container sealed correctly and throwing out all expired foods for all forms of storage. Record review of the facility's policy dated 11/2016, titled, Infection Control Policy /Procedure Dietary Services and stated, It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, Ready-to eat, Time/Temperature Control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #12) of 6 residents reviewed for comprehensive care plans. The facility failed to include Resident #12 diagnosis of paranoid schizophrenia in his care plan. This failure could place residents at risk for their mental and psychosocial needs not being met.The findings included:Record review of Resident #12's admission record dated 03/11/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] and an original admission date of 01/04/2025. Resident #12's pertinent diagnosis was paranoid Schizophrenia (mental disorder characterized by intense suspicions and false beliefs that others were plotting against or trying to harm them). This diagnosis had an onset date of 02/23/2026.Record review of Resident #12's MDS revealed a completion date of 03/02/2026. Section C-Cognitive Pattern revealed a BIMS score of 5 which indicated severely impaired cognition. Section I-Active Diagnoses revealed a diagnosis of Schizophrenia.Record review of Resident #12's care plan completed on 02/24/2026 revealed no mention of paranoid Schizophrenia except in the diagnoses list on the bottom of the last page of the care plan.In an interview on 03/11/2026 at 2:14 p.m., LVN C stated that she was responsible for completing Resident #12's care plan. She verified that Resident #12 did not have the diagnosis of paranoid Schizophrenia care planned. LVN C stated that she missed it because Resident #12 was a readmission. She stated that she has 14 days from the admission date to complete the care plan. If the doctor gives orders, then she would enter the care plan the next day. LVN C stated that the negative outcome of not having the diagnosis of paranoid Schizophrenia care planned would be that Resident #12 could be a risk for behaviors or other delusions. She stated that having it care planned was important to make sure that he was receiving the appropriate treatment.In an interview on 03/11/2026 at 2:30 p.m., the DON stated that LVN C was responsible for updating and completing the care plan once it was reopened. He stated that he was not sure if an acute or comprehensive care plan needed to be completed within one week. The DON stated that there was no negative outcome of not having the diagnosis of paranoid Schizophrenia care planned. He stated that it was important for the diagnosis to be in the care plan so that staff were familiar with it and ensure the correct diagnosis was documented in the chart. The DON stated that having it part of the care plan helps guide the proper care and treatment. Record review of the facility's policy titled Comprehensive Care Planning with a revision/review date of April 2025 revealed the following:Policy: It is the policy of this facility that the interdisciplinary team 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 interdisciplinary 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 of care.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #24) of 4 residents who was observed for medication administration.CMA A failed to inform Resident #24 the names of the medications and the indications for the medications that were being administered.This failure could lead to inaccurate administration of medications and ineffective therapeutic effects.Finding included: Record review of Resident #24's face sheet, dated 03/11/26, revealed resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #24's diagnoses included: Mild protein-calorie malnutrition, muscle weakness, blindness right eye, hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), gastritis (inflammation of the lining of the stomach), osteoarthritis (arthritis affecting joints in hands, knees, hips and spine), GERD (when stomach acid flows back up into the esophagus and causes heartburn) and hyperlipidemia (high cholesterol).Record review of Resident #24's BIMS evaluation dated 02/26/26 revealed the resident had a BIMS of 15 which indicated intact cognition. Record review of Resident #24's care plan dated 02/25/26 revealed there was not a focus, goal, or intervention that indicated resident was not to receive indications regarding the medication she was taking. Record review of Resident #24's current order summary dated March 2026 revealed resident was receiving the following medications:*amiodarone hydrochloride 200 mg 1 tablet my mouth twice a day for atrial fibrillation,*furosemide 40 mg 1 tablet by mouth daily for edema,*metoprolol tartrate 25 mg 1 tablet by mouth daily for hypertension,*losartan potassium 50 mg 1 tablet by mouth daily for hypertension,*famotidine 20 mg 1 tablet by mouth daily for GERD,*diltiazem hydrochloride 180 mg 1 tablet by mouth daily for hypertension,*clopidogrel 75 mg 1 tablet by mouth daily for blood clot prevention,*atorvastatin 80 mg 1 tablet by mouth daily for hyperlipidemia,*apixaban 2.5 mg 1 tablet by mouth twice a day for DVT (a blood clot in a vein located deep withing your body, usually in the leg),*iron 325 mg 1 tablet by mouth three times a day for low iron,*docusate sodium 100 mg 1 capsule by mouth daily for constipation,*multivitamin with minerals 1 tablet by mouth daily for risk of malnutrition, and*senokot 8.6 mg tablet by mouth daily in the morning for constipation.Observation on 03/11/26 at 9:02 am revealed CMA A proceeded to administer Resident #24 morning medications: amiodarone hydrochloride, furosemide, metoprolol tartrate, losartan potassium, famotidine, diltiazem hydrochloride, clopidogrel, atorvastatin, apixaban, iron, docusate sodium, multivitamin with minerals, and senokot. All medications were placed in a clear, medication cup and were given to Resident #24 to take. CMA A did not identify medications to the resident, nor did she indicate what medications were for. Resident #24 swallowed all medications with water and handed the medicine cup back to CMA A. In an interview on 03/11/26 at 9:09 am, CMA A stated she did not identify medications nor did she tell Resident #24 what the medications were for because the resident already knew what the medications were for. CMA A stated the resident had been transferred from another facility and had arrived with the same medications. CMA A stated, She already knows what they are for; I don't need to tell her over and over again. CMA A stated it was also offensive to tell Resident #24 what the medications are for because Resident #24 was all there (cognitively) and already knew that information. CMA A stated there was not a need to tell residents the indications of medications stating, I never tell them [residents] what the medications are for. CMA A stated there was no harm in not telling residents what the medications were for. In an interview on 03/11/26 at 9:31 am, RN B stated that when she administered medications, she gave one medication at a time telling the resident what each medication was for. RN B stated she administered medications in that manner as to educate the resident on the medications they were taking. RN B stated it was important for the residents to know what medications they are taking because it involved the residents in their care. RN B stated that telling what the medications were for was part of the Rights of Medication Administration (set of safety checks designed to prevent errors and ensure patient safety).In an interview on 3/11/26 at 4:15 pm, the DON stated he was not aware that CMA A had not informed Resident #24 of the indications for the medications administered. DON stated he expected all CMAs or nurses that administered medications would provide all the information to the residents about the medications they received. DON stated he taught his staff accurate medication administration with return demonstration. Record review of the facility policy and procedure titles Medication Administration dated revised 05/2024 revealed:Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 1 (Resident #47) of 4 residents reviewed for infection control.The facility failed to ensure that LVN B changed her gloves and performed hand hygiene during Resident #47's medication administration.These failures could place residents at risk for contamination and infection.The findings included:Record review of Resident #47's face sheet, dated 07/07/2025, revealed an [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 diagnoses included: Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), chronic respiratory failure with hypoxia (the body or a region of the body is deprived of an adequate oxygen supply), gastrostomy status (indicates the presence of a gastrostomy tube, also known as a g-tube or peg tube, for nutritional support), dysphagia (difficulty swallowing), vascular dementia (dementia caused by reduced blood flow to the brain), and cognitive communication deficit.Record review of Resident #47's BIMs assessment dated [DATE] revealed a score of 3 which indicated severe impairment.Record review of Resident #47's care plan dated 07/09/24 revealed [Resident #47] requires tube feeding. Goal: Feeding tube insertion site will be free of s/sx of infection. Interventions: Provide local care to feeding tube site as ordered and monitor for s/sx of infectionDuring an observation on 03/10/26 at 7:49 am, While inside of Resident #47's room, LVN B donned gown and gloves. LVN B had bedside table with medications and water prepared as ordered. LVN B walked over to Resident 47's bedside. LVN B pushed the pause button on resident's feeding pump. LVN B disconnected the pump tubing from Resident #47 peg tube site and hung it over the feeding bottle on the feeding pump pole. LVN B checked for peg tube placement (verification that the feeding tube remains correctly positioned in the stomach by using a stethoscope) and residuals (to check for gastric content). LVN B administered medications via peg tube. After all medications had been administered, LVN B reconnected feeding tubing and pressed the start button. LVN changed gloves but did not perform hand hygiene between change. LVN B rinsed feeding syringe in the sink, dried and placed the syringe back in its original plastic bag. LVN B cleaned up the trash on the bedside table and threw it in the trash bin. LVN removed her gown, threw it in the trash bin, then removed her gloves and threw it in the trash bin as well. LVN B washed her hands and exited the room.During an interview on 03/10/26 at 8:30 am, LVN B stated she did not have to change gloves after pushing the pause button on the feeding pump and prior to feeding. LVN B stated she felt that the feeding pump is not a contaminated surface. LVN B stated she did not have to perform hand hygiene between glove changes because she had not done incontinent care. LVN B stated she removed gloves and washed her hands before rinsing the syringe because she was going to store the syringe. LVN B stated poor hand hygiene could spread germs and cause infections.During an interview on 03/11/26 at 4:15 pm the DON stated he did not feel there was a reason to change gloves during the medication administration. DON stated he felt the feeding pump was not a contaminated surface therefore LVN B did not have to change gloves nor perform hand hygiene. DON stated he felt LVN B had done the medication administration task correctly. DON stated he taught his staff accurate medication administration with return demonstration.Record review of the facility's Hand Hygiene Policy with original date of 05.2007 and last revised on 12.2003 revealed:2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:o Before and after direct contact with residents;o Before performing any non-surgical invasive procedures;o Before and after handling an invasive device (e.g., urinary catheter, IV access sites);o After touching contaminated surfaces;o After changing gloves;Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers updated on 02/27/2024 revealed Know when to clean your hands,- Immediately before touching a patient.- After touching a patient or patient's surroundings- After contact with blood, body fluids, or contaminated surfaces- Immediately after glove removal.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests for Resident #42, Resident #79' s rooms and 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. The facility failed to ensure Resident #42 and #79s room were free from roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of lifeFindings included: Observation and initial tour of the kitchen with the DM on 03/09/26 at 10:35 am revealed there were pest droppings in the dry storge room floor. During the dry storage observation, the right back corner of the storage room had numerous pests dropping and a small dead roach on the floor. The DM stated the rodents could carry diseases and could make the residents sick. In an interview with the DM on 03/09/25 at 10:15 AM, she said pest control comes twice a month and sprays for pest. The DM stated she has not seen a roach while she has been in the kitchen. The only sighting of roaches she knew of was the one that had just been found and pest control was requested to come in and spray. The DM stated the kitchen is kept as clean as possible to keep pests and rodents down. The kitchen staff know to report any sighting immediately so the pest control company can come in and take care of the problem. Record review of Resident #42's face sheet dated 02/26/26 revealed a 77year old male initially admitted on [DATE] with a diagnosis of Diabetes Mellitus(a chronic metabolic disorder characterized by high blood sugar due to insufficient insulin production or cellular resistance to insulin) , Hypertension(a chronic condition where blood force against artery walls is to high) and Unspecified Mood disorder (A diagnostic category used when a person experiences significant mood disturbances that do not meet the full criteria for any other specific mood disorder)and Muscle wasting and Atrophy, not elsewhere classified. In an interview on 03/10/26 At 3:46 with Resident #42 he stated he and a family member that was visiting last week saw two large roaches in the room. Resident #42 stated the family member tried to kill the roaches but they were fast and went into the closet and could not be found. Resident #42 stated he let the CNA know and has not seen any roaches since that day. Record review of Resident #79's face sheet dated 03/09/26 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with a diagnosis of Peripheral Vascular Disease Peripheral Vascular disease (a slow progressive circulation disorder characterized by the narrowing or blockage of blood vessels out side the heart), Hypertension(a chronic condition where blood force against artery walls is to high), Diabetes Mellitus(a chronic metabolic disorder characterized by high blood sugar due to insufficient insulin production or cellular resistance to insulin) ,and Depression (a group of conditions associated with the elevation or lowering of a person's mood). In an interview on 03/10/26 at 4:00 pm with Resident #79 he stated he saw two big roaches in his room sometime last week and the roaches went toward the closet but had not been seen any roaches since then. Resident #79 stated he let the CNA know and had not seen any since then. In a second interview on 03/11/26 10:30 AM the DM stated the pest control company was called to come in on 03/09/26 to come in immediately and spray in and out of the facility and look for the area they might be coming in from. The DM stated maintenance will be and fixing any areas that might be where the pests come in. The DM stated she and the staff will make extra efforts to keep the dry pantry clean and the floor free of fallen food items. In an Interview on 03/11/2025 3:42 PM with the maintenance man he stated the pest control company had been contacted to come in and treat for pests by spaying for pests indoors and outdoors. The maintenance man also stated the facility was increasing their visits from the pest control company to keep the pest problem under control. The maintenance man stated maintenance man will do repairs to any walls and closets that have holes to prevent any rodents from outside to be able to enter the facility. The maintenance man stated the kitchen staff was going to keep the kitchen clean to avoid any pests from trying to enter the facility. The administrator stated it was of importance that the facility combats the problem of the pests as the pests can make residents sick. The administrator stated he, housekeeping, the kitchen staff, and DM will be monitoring the facility for pest in any other areas in the kitchen and in the facility. The maintenance man stated all staff is responsible for reporting any kind of pest throughout the facility and the residents are to tell the staff the CNA and then the CNA reports it to him and a work order will be made so the pest control company can come in a spray as needed. In an interview on 03/11/26 at 4:02 PM The administrator stated it was of importance that the facility combats the problem of the pests as the pests can make residents sick. The administrator stated he, housekeeping, the kitchen staff, and DM will be monitoring the facility for pests in any other areas in the kitchen and in the facility. The maintenance man stated all staff is responsible for reporting any kind of pest throughout the facility and the residents are to tell the staff the CNA and then the CNA reports it to him and a work order will be made so the pest control company can come in a spray as needed. In record review of the Venibra Pest Control company receipts for Pest Control dated 01/05/26,01/26/2026, 2/02/26, and the last pest control monthly visit was on 03/03/26 and sprays for gnats, roaches and silverfish. There were no extra dates added for additional visits. In record review of the Pest control Policy the state surveyor asked twice for the policy, and it was not provided. The Dietary Manager and the Maintenance Man were asked for the policy, and it was not provided to the surveyor.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity.The facility failed to ensure CNA A did not stand while assisting Resident #1 with lunch on 01/27/26.This failure could place the residents at risk of not having the right to a dignified existence maintained.The findings included:Record review of Resident #1's face sheet dated 01/27/26 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive mental deterioration), chronic kidney disease (kidney failure), generalized muscle weakness, dysphagia (difficulty swallowing), cognitive communication deficit, and need for assistance with personal care. Record review of Resident #1's care plan dated 01/27/26 reflected [Resident #1] had an ADL self-care performance deficit related to diagnosis. Interventions: for eating - required total assistance by 1 staff to eat. Date initiated: 10/07/25.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 2, which indicated her cognition was severely impaired. Resident #1's functional ability for eating (the ability to use utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal is placed before the resident) was partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort).During an observation on 01/27/26 at 12:30 PM, CNA A was observed feeding Resident #1 while CNA A stood to the left of Resident #1. CNA A stood on Resident #1's left side until ADON C moved a chair behind CNA A, then CNA A sat down next to Resident #1 at about 12:34 PM.In an interview and observation on 01/27/26 at 1:00 PM with Resident #1, she was not interviewable. Resident #1 was not injured or in distress. In an interview on 01/27/26 at 1:30 PM, CNA A said the facility's protocol when assisting a resident with their meals was for the CNA to be sitting at the resident's level while feeding them. CNA A said she fed Resident #1 lunch today, 01/27/26, and had a chair behind her but did not have a chance to sit down before she started feeding Resident #1. CNA A said she was trained in feeding the residents and that it was important for them to sit down when feeding them, not stand. In an interview on 01/27/26 at 4:00 PM, ADON C said Resident #1 required assistance with all her meals. ADON C said staff were required to sit at the resident's level when feeding them. ADON C said staff should not be standing next to the resident while feeding them to prevent aspiration and to maintain their dignity. ADON C said she saw CNA A standing next to Resident #1 while feeding her lunch today, 01/27/26. ADON C said the chair was behind CNA A, so she reminded her to sit down. ADON C said there was no incident or negative outcome for Resident #1. ADON C said Resident #1 required assistance for eating, but not because she was at risk of aspiration, rather so that staff could cue her and to promote protein intake. ADON C said staff should have been sitting at Resident #1's level while assisting with feeding to promote and maintain her dignity. ADON C said staff were in-serviced on resident rights and to sit while feeding residents. In an interview on 01/29/26 at 10:55 AM, the DON said residents that required assistance with their meals were fed by CNAs/nursing staff. The DON said there was no negative outcome or incident with Resident #1 on 01/27/26 as a result of CNA A feeding Resident #1 while standing during lunch. The DON said if a CNA fed a resident while standing next to them, it was a dignity issue as part of their resident rights. The DON said Resident #1 was not at risk of injury, but she might have felt uncomfortable or rushed. The DON said the staff were in-serviced on resident rights and how to feed the residents sitting down. Record review of the facility's Resident Rights, Dignity and Respect policy, dated 10/2015 reflected:Policy: It is the policy of this facility that all residents be treated with kindness, dignity and respect. Procedures: 1. The staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident # 2) reviewed for care plans.1. The facility failed to implement the care plan to ensure Resident #2 required assistance with feeding. 2. The facility failed to update Resident #2's Kardex (ADLs: eating and transfer). This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings include:Record review of Resident #2's admission record dated 10/06/25, reflected a [AGE] year-old male with an admit date of 09/18/25 and an original admission date of 01/14/24. His relevant diagnoses included quadriplegia (a condition characterized by paralysis or loss of movement and sensation in all four limbs (arms and legs), lack of coordination (a neurological symptom characterized by clumsy, uncoordinated movements that can affect walking, speaking, or using hands), need for assistance with person care, muscle wasting and atrophy (a condition where muscles lose mass and strength).Record review of Resident #2's quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated his cognition was intact. Further review reflected Resident #2 had limited range of motion to his upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. His functional abilities for eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer were coded as being dependent ( helper does all of the effort) Resident #2's diagnosis of quadriplegia was listed as an active neurological disorder. Resident #2's quarterly care plan dated 05/19/25 reflected:Problem: [Resident #2] ADL self-care performance.may need 1-2-person extensive assist with bed mobility, toileting, personal hygiene, dressing and set up encouragement/limited assist (date initiated 01/15/24, revised on 05/19/25). Interventions: Transfer (chair/bed to chair transfer, toilet transfer) requires 2 person assist with staff participation with transfers (date created 01/15/24 and revised on 05/19/25). Bed mobility (roll left and right, sit to lying, lying to sitting on side of bed): Requires 1-2 person assist/staff participation to reposition and turn in bed (date initiated 01/15/24) Dressing (lower and upper body dressing, putting on/taking off footwear): requires 1-2 person assist/staff participation to dress (date initiated 01/15/24) Transfer (chair/bed to chair transfer, toiler transfer): requires Hoyer lift x2 staff assistance with transferring (date initiated 01/15/24 and revised 05/19/25)Resident #2's ADL for eating was not included as an intervention on Resident #2's care plan.Record review of Resident #2's Kardex dated 10/06/25 reflected:Transfers: Transfer (chair/bed to chair transfer, toiler transfer): requires 1-2 person asst/staff participation with transfers. Transfer (chair/bed to chair transfer, toiler transfer): Requires 2 person assist with staff participation with transfers. Transfer (chair/bed to chair transfer, toiler transfer): Requires Hoyer lift x2 staff assistance with transferring.Eating: Dietary: avoid food or beverages that tend to irritate esophageal lining, i.e., alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods. Monitor and record food intake at each meal. Monitor intake to assure an adequate fluid intake to prevent dehydration. OT to screen and provide adaptive equipment for feeding as needed.There was no mention Resident #2 required the assistance of 1 person for feeding.In an observation and interview on 10/06/25 at 3:54 pm, Resident #2 was observed lying in bed. Resident #2 said he was quadriplegic and had no feeling or movement from his neck down. He said he required assistance with all his ADLs as he was not able to assist. Resident #2 said he would get assistance with eating all three meals. In an interview on 10/07/25 at 10:00 am, CNA E, said Resident #2 was quadriplegic and required a 1 person assist for eating and a 2 person assist for all other ADLs. CNA E said Resident #2 only had movement from his neck up. CNA E said if she needed to verify a resident's level of assistance, she would check Kardex on their electronic medical record. She said Kardex was a tool for CNAs used to assist in determining the resident's level of care.In an interview on 10/07/25 at 12:42 pm, CNA F, said Resident #2 was quadriplegic and required a 1 person assist for eating and a 2 person assist for all other ADLs. CNA F said Resident #2 was not able to move from his neck down. She said if she needed to verify if a resident required a 1 or 2 person assist, she would check Kardex in their electronic medical record.In an observation and interview on 10/06/25 at 5:15 pm, LVN G, said Resident #2 was quadriplegic and was a was a two-person transfer with a mechanical lift. She said Resident #2 required 1 person to assist for feeding. She said Resident #2 only had movement from his neck up. LVN G said if a CNA needed to verify the level of assistance for a resident, they could ask their charge nurse or look in Kardex which was found in the resident's electronic medical record. She reviewed Resident #2's Kardex and said CNAs knew Resident #2 was a 2 person assist with mechanical lift for all transfers and a 1 person assist for feeding. She said there were no negative outcome to Resident #2 because he was being assisted with his feeding and was being transferred by 2 persons with a mechanical lift. In an interview on 10/06/25 at 5:30 pm, the DON said Resident #2 was quadriplegic, which meant he was paralyzed from his chest down. The DON reviewed Resident #2's Kardex in his electronic medical record and said under transfer the statement read 1-2-person assist, he stated that was incorrect. He said the reason the level of care needed for feeding was omitted was because it had not been checked off on his baseline care plan when he re-admitted . The DON said there were no negative outcome to Resident #2 for having his Kardex indicate he was a 1-2 person assist for transfer because CNAs knew he was a quadriplegic and he was being assisted with feeding. In an interview on 10/07/25 at 10:55 am, MDS-LVN H said Resident #2 was quadriplegic which meant he was paralyzed from his neck down. He was observed as her reviewed Resident #2's Kardex and care plan in his electronic medical record and said eating had been left out because that task had not been checked off on his baseline care plan. He said Resident #2's care plan should have indicated he was a 2 person assist for all ADLs except feeding which he only required 1 person to feed him. He said Resident #2's Kardex should have only read he was a 2 person assist for transfer with a mechanical lift and for feeding he required assistance. Record review of the facility's Comprehensive Person-Centered Care Planning dated 11/2016 and most recent revision on 04/2025 reflected: 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. Procedure:4. The facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven 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 recommendation, and resident's goals and desired outcomes, preference for future discharge plan. 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #3) reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #3's order for a house supplement included the route of administration and dosage and order for liquid protein included the route of administration.This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. he findings include:Record review of Resident #3's admission record dated 10/13/25, reflected a [AGE] year-old female with an admit date of 06/03/25, an original admission date of 12/04/24 and a discharge date of 06/27/25. Her relevant diagnoses included sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), mild protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their nutritional needs), cognitive communication deficit (difficulty with communication caused by problems with the brain's thinking abilities, rather than a physical speech or language impairment), dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment, severe enough to interfere with daily life), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other substances in the body), and dependence on renal dialysis (a chronic condition where the kidneys have lost their ability to adequately filter waste products from the blood, requiring regular treatments to remove these toxins and maintain overall health).Record review of Resident #3's quarterly MDS assessment dated [DATE], reflected a BIMS score of 3, which indicated her cognition was severely impaired. Further reviewed indicated Resident #3 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.Record review of Resident #3's quarterly care plan dated 03/13/25 reflected the following:focus of has risk of malnutrition (date initiated 06/04/25). The interventions in part included give supplements as ordered (date initiated 05/29/25). Focus of has actual impairment to skin integrity r/t sacral wound PU stage 3 sacrum. The interventions in part included encourage good nutrition and hydration in order to promote healthier skin (date initiated 06/04/25). Record review of Resident #3's order summary dated 10/14/25 the following: House supplement, two times a day for supplement effective 06/06/25 and discontinue date of 07/03/25. Liquid protein, two times a day for aide in wound healing, administer 30 ml effective 06/09/25 and a discontinue date of 07/03/25. Record review of Resident #3's eMAR for the month of 06/25 reflected both the house supplement and liquid protein were administered as orderedIn an interview on 10/13/25 at 3:45 pm, LVN C said that for an order to be considered valid it must include the resident's name, the dosage, the frequency, the diagnosis, and the route. LVN C said if an order did not include any of the above, it would be considered an incomplete order. She said if she were to discover an order that was incomplete, she would call the doctor to obtain the missing information. LVN C said, liquid protein is a general name is ordered to residents who suffer from malnutrition and or have wounds. She said Resident #3's order for liquid protein was missing the route. She said Resident #3's order for house supplement was missing the route and the amount. She said house supplement was ordered to residents as a supplement. LVN C said both orders would be considered incomplete. She said there were no negative outcome as Resident #2 was administered the medication as ordered. In an interview on 10/13/25 at 4:00 pm, LVN D said an order must include the resident's name, dosage, frequency, route, and diagnoses to be considered complete. He said if an order was missing any of the above, it would be considered invalid. LVN D said if he discovered an order was not complete, he would have reached out to the resident's doctor to obtain the missing information. In an observation and interview on 10/13/25 at 5:06 pm, The DON said an order must include the resident's name, route of administration, frequency, dosage, and diagnosis to be considered a complete order. The DON was observed reviewing Resident #3's electronic medical record and said Resident #3's order for a liquid protein and house supplement were missing route of administration. The DON said it was the responsibility of the nurse that received the order to ensure it was complete. The DON said the ADON facility had the responsibility of ensuring all orders received were complete.In an observation and interview on 10/14/25 at 9:20 am, the ADON-LVN said part of her responsibilities included to ensure all orders received were complete. She said an order must include the resident's name, route of administration, frequency, dosage, and diagnoses to be considered a complete order. She reviewed Resident #3's electronic medical record and said Resident #3 order for liquid protein was missing the route of administration and brand name. She said Resident #3's order for house supplement was missing the route of administration, amount, and brand name. She said there were no negative outcomes to Resident #3 not having a complete order for house supplement and liquid protein because, she it was administered as ordered.Record review of the facility's Physician's Orders policy revised on 08/2022 reflected:Policy: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Procedure:7. Orders for medications must include:A. Name and strength of the drug.B. quantity or specific duration of therapy.C. Dosage and frequency of administration.D. Route of administration if other than oral; andE. Reason or problem for which given.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) residents reviewed for EBP. The facility failed to post EBP signage and for Resident #1 when she had a permcath (a flexible tube used for dialysis treatment) to right chest. This failure could place residents at risk of MDRO contamination.The findings include:The findings include:Record review of Resident #1's admission record dated 10/06/25, reflected a [AGE] year-old female with an admit date of 09/22/25 and initial admission date of 09/10/25. Her relevant diagnoses included type 2 diabetes (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels), hypertension (a condition where the force of blood against the artery walls is consistently too high), irritable bowel syndrome (a chronic condition that affects the large intestine, causing abdominal discomfort, bloating, and changes in bowel habits), and need for assistance with personal care.Record review of Resident #1's 5-day Medicare MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact. Resident #1 was also noted to have an indwelling catheter.Record review of Resident #1's comprehensive care plan dated 09/23/25 reflected a problem of has indwelling catheter (date initiated 09/11/25). Her interventions in part included, change catheter bag and tubing as ordered, Monitor/record/report to MD for signs and symptoms of UTI, and position catheter bag and tubing below the level of the bladder and away from entrance room door. In an observation and interview on 10/06/25 at 2:45 pm, Resident #1 was observed with an indwelling foley catheter. There was no EBP signage posted on her door/room and no PPE cart outside the door. In an interview on 10/06/25 at 3:00 pm, CNA A said Resident #1 had an indwelling catheter and was supposed to have EBP signage and a PPE cart outside her door. She said CNAs were only allowed to empty the indwelling catheters. CNA A said even though there was no signage or PPE cart outside the door, she ensured she wore gloves when emptying Resident #1's catheter. CNA A said a negative outcome to Resident #1 not having EBP signage and a PPE cart outside her door could be infection control.In an interview and observation on 10/06/25 at 3:30 pm, LVN B reviewed Resident #1's electronic medical record and said she had an indwelling catheter. LVN B said, all residents who had an indwelling catheter required to be under EBP. He walked into Resident #1's room and said he did not see an EBP signage or PPE cart by her door. LVN B said he was not sure why Resident #1 did not have the required signage or PPE cart by her door. LVN B said a negative outcome of Resident #1 not having the EBP signage and PPE cart by her door would be that staff who would enter her room would not know how to protect themselves. In an observation and interview on 10/06/25 at 3:45 pm, the DON said a resident who had an indwelling catheter required to be under EBP. He entered Resident #1's room and said he did not see the EBP signage or PPE cart outside her door. The DON said Resident #1 had recently transferred to that room and maybe that's where the miscommunication occurred. The DON said a negative outcome for not having EBP signage and supplies readily available could possibly be the spreading an infection. Record review of the facility's Infection Control policy revised on 04/25 reflected:Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.Procedure:3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloved during hi-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to resident or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).A. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with:i. wounds and/or indwelling medical devices regardless of known MDRO infection or colonization.indwelling medical devices include, but not limited to central lines, peripherally inserted central catheter lines, urinary catheters, feeding tubes, and tracheostomies.

Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 1 resident (Resident #1) observed for infection control issues in that: CNA A did not follow infection control procedures while providing incontinent care to Resident #1 when she failed to apply a PPE gown prior to providing incontinent care, reused wipes when providing care to the perineal area, and did not sanitize hands between glove changes. This deficient practice could place residents at-risk for infection due to improper PPE, sanitizing hands, and incontinent care practices.The findings included: Record review of Resident #1's electronic face sheet dated 11/5/25 revealed the resident was a [AGE] year-old female with an initial admit date to the facility on 7/16/25. Her diagnosis included dementia (a medical condition characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, language, and judgement), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), dysphagia (a medical condition characterized by difficulty or discomfort in swallowing), cognitive communication deficit (an impairment in a person's ability to communicate effectively due to underlying problems with cognitive functions like memory, attention, reasoning, and problem-solving), nontraumatic intracerebral hemorrhage (a type of stroke involving bleeding within the brain's tissue that was not caused by a physical injury), unspecified convulsions (sudden, involuntary muscle contractions or spasms where the exact type or cause was not identified), muscle weakness, muscle wasting and atrophy (decrease in size or wasting away of muscle). Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident # 1 had a BIMS score of 10 which indicated moderate cognitive impairment and was dependent for all ADL care. Record review of Resident #1's undated comprehensive person-centered care plan, reflected Resident #1 had:ADL Self Care Performance Deficit r/t Weakness. Dx. CVA w/Lt. Hemiplegia. intracranialhemorrhage, dementia. TOILET USE (TOILET TRANSFER, TOILET HYGIENE): requires assistance to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet. Date Initiated: 07/17/2025.Had Indwelling Catheter. Catheter type: FR # 18 mL _ to closed urinary drainage system - diagnosis for use: neurogenic bladder Date Initiated: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 07/24/2025.Requires tube feeding Glucerna 1.5 AT 50 ML/HR X 22 hr, 200ml water q 4 hours Date Initiated: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 10/07/2025Had pressure ulcer or potential for pressure ulcer development r/t Risk for skin integrity. Weakness. Dx. CVA w/Lt. Hemiplegia. intracranial hemorrhage, dementia, DMII. malnutrition,Actual pressure ulcer: stage 3 pressure ulcer to sacrum Date Initiated: 09/09/2025 Created on: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 08/31/2025EBP PPE Risk for infection related to High contact care activity Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: indwelling catheter, PEG tube, wounds. Date Initiated: 11/05/2025. Record review of Resident #1's Order Summary Report dated 11/5/25 reflected orders for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Indwelling catheter, PEG Tube, wounds every shift Active 10/7/2025. During an incontinent care observation for Resident #1 on 11/4/25 at 5:45 PM., CNA A performed incontinent care on Resident #1, LVN B was already in the room and later assisted with repositioning and providing safety for Resident #1, and ADON C was already in the room at the time the need for a brief change was identified and remained in the room. CNA A appropriately washed her hands and donned gloves prior to starting incontinent care. CNA began incontinent care when unfasted the tabs on the brief, opened the diaper forward, when noted Resident #1 had a large BM that entered the vaginal area. CNA A wiped the vaginal area using one wipe per swipe. CNA A did not apply a gown prior to starting incontinent care. CNA A removed her gloves after swiping with the second wipe, then washed her hands with soap and water in the bathroom sink. CNA A returned wearing a gown and clean gloves. CNA A continued to wipe the vaginal area using one wipe per swipe until the vaginal area was cleaned. CNA A would wash her hands with soap and water after every second glove change. CNA A did not sanitize her hands between the other glove changes. CNA began using one wipe per swipe when she cleaned the buttocks area, but after the third wipe CNA folded over each wipe and reused each wipe throughout the remainder of the incontinent care. In an interview on 11/4/25 at 6:20 pm., CNA A stated they received skills check-off and/or training on incontinent care every couple of weeks. She said they also cover this information during monthly meetings. She said the DON was very good at providing training and keeping staff up to date with everything. CNA A said she was supposed to use gloves and a gown when providing incontinent care to Resident #1 because she had a foley catheter, but she forgot to place it on at first because she was so nervous. CNA A said it was also the largest BM Resident #1 had. CNA A said that was why she washed her hands when she completed her first wipe, and she applied the gown at that time. CNA A said she should be using hand sanitizer to sanitize hands every second glove change. She should use hand sanitizer or wash hands. When this surveyor asked CNA A if she should be using hand sanitizer in between each glove change, CNA A said no, it was never the second glove change. CNA A said while providing incontinent care, she could reuse a wipe as long as she folded it over and used a clean part of the wipe. CNA A then changed her response and said she remembered she could hand sanitize every glove change and wash hands every 2nd or 3rd glove change. She said she only remembered using hand sanitizer once between glove changes during incontinent care, but then did not use hand sanitizer again between glove changes for the remainder of the incontinent care. She said she was very nervous. She said if she did not provide incontinent care correctly, it could cause infections. In an interview on 11/4/25 at 6:35 pm, LVN B stated she recalled receiving training, and skills check offs for incontinent care and infection control upon hire and usually had trainings weekly or monthly. She said she recalled having one a couple of weeks ago. She said they trained both CNAs and nurses. She said they must wear gloves and a gown during incontinent care for Resident #1 because she was EBP due to having a foley and a PEG tube. LVN B said that was why she placed the gown on when she was asked to assist with the incontinent care for Resident #1. LVN B said they must perform hand hygiene before and after care and when hands were visibly soiled. LVN B said hand sanitizer should be used between glove changes and that they changed gloves and sanitize or wash hands at the beginning and end or when visibly soiled. She said if appropriate hand hygiene and PPE were not used, they could break infection and possible spread of germs. In an interview on 11/4/25 at 6:55 pm, ADON C said she assisted with incontinent care and infection control training and the DON oversaw. She said they had a station with mannequins where they could practice when needed. ADON C said they went over information during huddles one or twice a month and had videos available to review. ADON C said the DON completed the skills training and check-offs for the staff. ADON C said they go over PPE, and get them to understand when they should be utilized and the reason residents had them. ADON C said Resident #1 was on EBP due to having a foley and peg tube. ADON C said staff must wear gowns and gloves when providing incontinent care with Resident #1. ADON C agreed that CNA A had not put on a gown when she began providing incontinent care to Resident #1. She said CNA A applied the gown after she recalled. ADON C said staff must change gloves when they were visibly dirty, and when touching residents. ADON C said hands should be sanitized in between glove changes. ADON C said hand washing must be done after every third time they sanitized hands and/or change gloves, before starting care and after finishing care. ADON C said wipes were supposed to be used by swiping once then tossing them in trash. ADON C said if proper hand hygiene and PPE were not utilized it would break infection control. In an interview on 11/5/25 at 10:06 am, the DON said infection control was included in monthly meetings. The DON said they had nursing huddles twice a month. He stated huddles were like in-services, so they received signatures, and he also provides power points. He said during the training, he goes over hand hygiene, EBP, different types of isolations, proper handling of linen, dos, and don'ts of breaking infection control. The DON said he completes check-offs on skills annually. The DON said he also reinforces it during open window for survey. He said they had their internal audit in September and part of what they completed was the skills check-offs. The DON said they go over hand washing monthly, and he had a list he keeps track. The DON said he also monitored EBP and PPE usage. The DON said hand hygiene must be done before incontinent care with soap and water for at least 20 seconds. He said in between, they can use hand sanitizer or wash hands if they feel their hands were soiled. He said staff were told that they must hand sanitize between glove changes. The DON said staff must also perform hand hygiene after incontinent care was done. The DON said regarding wipes, staff were told to clean from clean to dirty, preferably with enough supplies to use the one wipe technique. The DON said if the wipes were not dirty, they can fold and use a clean area of the wipe, but not more than two folds per wipe, then staff must dispose of the wipe. The DON said he did not feel it was a break in infection control if it was used in the same area. The DON said they used larger wipes that had a larger surface area. The DON said if heavy soiled during peri care and used the wipes then yes should dispose of the wipes after use. The DON said Resident #1 was on EBP because of her PEG tube, foley catheter, and pressure ulcer. The DON said PPE for EBP was only for direct contact of care not for other tasks, such as combing hair or providing water. The DON said for incontinent care they must wear gloves and a gown prior to starting care for Resident #1. The DON said the whole purpose was to stop the spread of infection, prevent it from getting and spreading, or minimize the spread of infection. The DON said the CNA not placing the appropriate PPE prior to starting incontinent care on Resident #1 could start a mode of transmission of anything Resident #1 could have had. Record review of Resident Nurse Assistant Skill Inventory Checklist for CNA A dated 6/17/25 Perineal indicated CNA met skills for:Standard Precautions, Isolation Precautions / Use of PPE, Glove Use (Donning (put on) / Doffing (remove)), Hand Hygiene, Perineal Care for the incontinent female, and Indwelling Urinary Catheter Care and was signed and dated by the DON. Record review of the facility's IPCP Standard and Transmission-Based Precautions with most recent revision/review date October 2022 revealed:PolicyIt is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with:i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents.c. Examples of high-contract resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: vi. Changing briefs or assisting with toileting viii. Wound care: any skin opening requiring a dressingix. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Record review of the facility's Hand Hygiene policy with the most recent revision/review date April 2025, revealed:PolicyIt is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Procedure1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled (e.g., blood, body fluids) .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; . e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; . m. After removing gloves; . r. After removing and disposing of personal protective equipment Record review of the facility's Incontinent Care policy with most recent revision/review date 4.2025, revealed:PolicyIt is the policy of this facility that each resident receive perineum cleansing after incontinent episode daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Procedure1. Gather equipment and supplies. a. Soap or cleanserb. Basin with water (disposable wipes may be used as a substitute for soap and water)c. Glovesd. Two clean washcloths(more if needed and trash bag .FEMALE - WITHOUT CATHETER11. Cleanse pubic area, including upper, inner aspect of both thighs and frontal portion of perineum. a. Use long strokes from the most anterior down to the base of the labia. (Wash from the cleanest area to the dirtiest area.) b. After each stroke, Use a clean portion of the disposable wipe for one cleansing motion.14. Wash perineal area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttocks. a. Use a clean portion of the disposable wipe for one cleansing motion.FEMALE - WITH CATHETER16. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag). Use a clean portion of the disposable wipe for one cleansing motion.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 1 resident (Resident#66) reviewed for indwelling catheters. The facility failed to prevent Resident#66's urinary catheter bag/tubing from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#66's face sheet dated 12/12/24 revealed a [AGE] year-old male originally admitted on [DATE]. Resident#66 had primary/admitting diagnoses of Anemia, Unspecified (a condition where the number of red blood cells is below normal, but the type or cause of the anemia is not specified), and Neurogenic bladder (a condition that affects bladder control due to damage to the nervous system). Record review of Resident #66's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #66 did not had a BIMS score indicated. Section H- Bladder and bowel revealed Resident #66 had not had an indwelling catheter. Record review of Resident #66's care plan dated 3/13/24 revealed Resident #66 had a Foley catheter Neurogenic Bladder Date initiated 11/22/24 and revised on 11/22/24 Intervention/tasks listed Provide catheter care every shift and Position catheter bag and tubing below the level of the bladder and away from entrance room door initiated and revised on 11/22/24. Record review of the Order Summary of Resident's #66 order printed 12/20/24 revealed order to Change Foley Catheter French 20 with 30 milliliters balloon every month and if accidental removal, dislodgement or obstruction as needed. Order Foley catheter check every shift and as needed start dated 11/22/24. During an observation on 12/10/24 at 10:32 AM, revealed Resident #66 Foley catheter bag was noted lying on the floor under Resident #66's bed. Resident #66 was non interviewable. During an interview with CNA C on 12/10/24 at 10:40 AM, CNA C was informed and shown the catheter bag laying on the floor. She said that she noted that the privacy bag that was attached to the bed was torn. She stated that she checked earlier around 9:00 AM and the Foley catheter bag was not touching the floor at that time. CNA C stated if Resident's #66 foley bag was on the floor, the bag could get contaminated, and the resident could get an infection. CNA C said that she would replace the privacy bag for a new one and would put the foley catheter bag inside it. CNA C said that the last in-service on foley catheters and infection control was done last week. During an interview with CNA A on 12/11/24 at 1:05 PM CNA A said that it was important for the bag not to touch the floor because the resident could be at risk for getting an infection. CNA A said that if bag was on the floor staff could step on it. CNA A said that the last in-service on infection control was last week but could not recall the exact date. During an interview with CNA B on 12/11/24 at 1:10 PM CNA B said she checked the Foley bags on residents every time she went into the resident's room. CNA B said it was important to keep foley bags in the privacy bags to prevent the bags touching the floor because the resident could get an infection. CNA B said that the last in-service on infection control was last week. During an interview with CNA D on 12/12/24 at 9:30 AM CNA D said that the Foley bags should be on the sides inside the privacy bag that was attached to the bed. CNA D said that if the foley bag was in the floor, someone could step on it. CNA D said that foley bag was not supposed to be on the floor because the resident could be at risk of getting an infection. During an interview with LVN E on 12/12/24 at 1:40 PM LVN E said that Foley bags should be below the bladder level and the foley bag inside a privacy bag. LVN E said that the foley bags should not be on the floor because the bag could tear, and the resident could get an infection. LVN E said that the last in-service on infection control was last month. During an interview with RN F on 12/12/24 at 2:15 PM RN F said she checks during her shift that was placed correctly and not touching the floor. RN F stated that foley bag should never be touching the floor because it could get pinched, or it could cause a leakage if the foley bag was on the floor. RN F said that the last in-service on infection control was yesterday. During an interview with the ADON on 12/12/24 at 3:05 PM the ADON said that nurses were in charge on checking the Foley bags every shift and that managers made rounds every morning. The ADON said that she educated staff to make sure everything complied. The ADON said that the bag should not be touching the floor to prevent any infections. The ADON said that the last in-service was last Friday, 12/6/2024. During an interview with the DON on 12/12/24 at 3:10 PM the DON said all staff were responsible to check that the Foley catheters had a privacy bag. The DON said that he provided 3 privacy bags for each resident that had a foley catheter. He said that 2 bags were attached to the bed and the third one was attached to wheelchair or walker depending on each resident needs. The DON said that if a foley bag was touching the floor, the bag could get contaminated and could introduce and infection or bag could get a leak. The DON said that the last in-service was last week. Record Review of a policy titled, Infection Prevention and Control Program with revision and review date 12/2023, reflected, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Goal is to decrease the risk of infection to residents and personnel. Record Review of a policy titled, Catheter Drainage Bag with the revision and review dated 12/2023, reflected, Position the drainage bag below the level of the resident's bladder and without resting on the floor.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident's #234) reviewed for respiratory care. 1. The facility failed to ensure Resident #234's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: 1.Record review of Resident #234's face sheet, dated 12/10/24 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #234's quarterly MDS assessment was in process. Record review of Resident #234's physician's order dated 12/6/24 indicated Oxygen at 2 liters per minute continuous via nasal cannula every shift for COPD. Record review of Resident #234's comprehensive care plan, dated 12/06/24, indicates Resident #234 required oxygen therapy related to ineffective gas exchange. The intervention of the care plan was for staff to give medications as ordered by physician. Monitor/document side effects and effectiveness. During an observation on 12/10/24 at 9:23 a.m., Resident #234 was lying in her bed with oxygen set at 2.5 liters per minute via nasal cannula. During an observation on 12/12/24 at 9:35 am Resident #234 was lying in her bed with oxygen set at 2 liters per minute via nasal cannula. During an interview on 12/10/24 at 2:40 p.m., LVN G looked at Resident #234's oxygen rate and said it was at 2.5 liters per minute per nasal cannula. He said he thought she was supposed to run at 2 liters per minute. He looked in the electronic medical records for Resident #234 and read her order for oxygen at 2 liters per nasal continuously for COPD. LVN G said that he checked the setting this morning when he started his shift. LVN G said that he thought the humidifier bottle moved the settings and LVN G put the setting at the correct rate. LVN G said that if resident receiving the incorrect order, the resident could be harm. LVN G said that the inservice were done frequently but could not remember the exact date. During an interview on 12/12/24 at 9:22 a.m., LVN E said that nurses were responsible to check every shift the oxygen settings at the beginning of the shift and at the end of the shift. LVN E said that if not administered the correct order the resident could be harm. LVN E could not remember when was the last inservice. During an interview on 12/12/24 at 10:20 am, RN F said that the floor nurses were in charge to check the oxygen settings when starting the shift, during shift, and at the end of the shift. RN F said that if not giving the correct order to the resident, the resident could be hyper-oxygenated (too much oxygen). RN F said that the last inservice was yesterday. During an interview on 12/12/24 at 2:00 pm with ADON said that the nurses were responsible to check the oxygen settings every shift, specially when was a continuous oxygen, ADON said that management made morning rounds each morning. the ADON said that an adverse reaction to the resident was that the oxygen level could drop if not administer the appropriate oxygen ordered by the physician. ADON said that the last inservice was last Friday. During an interview on 12/12/24 at 3:06 p.m., the DON said the charge nurses were responsible for following the physician's orders and to check oxygen settings at the beginning of the shift and as needed during the shift and at the end of the shift. He said that if given less than the oxygen order the Resident's oxygen level could need more oxygen, and if given more than what was prescribed by the doctor, DON said that would not affect the resident if it was only increase by 0.5 liters per minute than the order. DON said that inservices were done weekly for the past few months and monthly. Record review of facility policy titled, Oxygen Administration revision date as of April 2016, revealed it is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtain.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents (R #6) reviewed for supervision. The facility failed to ensure R #6 received adequate supervision as R #6 eloped from the facility without anyone's knowledge on 07/08/24 at around 3:16 AM and went to a corner store approximately 0.5 miles away. R #6 experienced a change of condition (UTI), had increased confusion, and was unsupervised for approximately 1 hour and 15 minutes before the facility became aware that he had eloped. An Immediate Jeopardy was identified on 07/08/24. The Immediate Jeopardy template was provided to the facility Administrator on 07/30/24 at 11:20 AM. While the Immediate Jeopardy was removed on 07/31/24 at 10:30 AM, the facility remained out of compliance pending approval of Plan of Correction. This failure could lead to residents exiting the facility unattended which could result in injuries, hospitalization , or death. The findings included: Record review of R #6's face sheet dated 06/10/24 reflected an [AGE] year-old male, with an original admitted [DATE]. Diagnoses included: unspecified dementia, chronic obstructive pulmonary disease (progressive lung disease that results in breathlessness and cough), depression, anxiety disorder, insomnia, and osteoarthritis (arthritis that affects any joint, causes pain, stiffness, and loss of mobility). Record review of R #6's MDS assessment dated [DATE] reflected R #6 had a BIMS score of 11 (moderate cognitive impairment), required setup or clean-up assistance (helper sets up or cleans up, resident completes activity, helper assists only prior to or following the activity) with sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. R #6 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for walking 10 feet. The MDS also reflected R #6 used a wheelchair. Record review of R #6's Care Plan dated 07/10/24 reflected the following care areas: *R #6 had a UTI. Interventions included to monitor/document/report to MD for signs/symptoms of UTI: Frequency, Urgency, Malaise (ill, fatigued), foul smelling urine, dysuria (painful urination), fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria (blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes. Date initiated: 07/05/24. *R #6 reflected an elopement: at risk for delirium or an acute confused episode related to UTI, change in condition. At risk for elopement related to disoriented to place. On 07/08/24, R #6 was found outside facility grounds. R #6 was placed on 30-minute checks. Hospice would visit R #6 more frequently. Family wish to transition to standard wheelchair and not use the power wheelchair for now. Pharmacy to evaluated medications. Date initiated: 07/08/24. Record review of R #6's elopement assessment dated [DATE] reflected score of 3, low risk. Record review of R #6's BIMS assessment dated [DATE] reflected BIMS score of 3, severely cognitively impaired. Record review of R #6's elopement assessment dated [DATE] reflected score of 15, high risk. Record review of R#6's BIMS assessment dated [DATE] reflected BIMS score of 11, moderately cognitively impaired. Record Review of R #6's progress notes for July 2024 reflected the following: - 07/08/24 at 5:00 AM, documented by LVN A indicated the facility received call from LE stating R #6 was at a local corner store and left building without informing staff. LVN A assisted in bringing R #6 back into building. R #6 had motorized wheelchair and was very mobile with it. Last noted in room at 3:30 AM. At this time, R #6 appeared to be in stable condition, some confusion noted, more than baseline. R #6 was able to tell LVN A his name and location but did not recall date or time. Head to toe assessment completed and all within normal limits. Vitals signs were stable, and skin was intact. Per R #6, he wanted to smoke but needed a lighter and decided to go to store to buy one. R #6 stated that he forgot what way to come back so he asked the store clerk to call for directions. The RP, DON, Administrator and MD called to inform of elopement. At this time, R #6 was safe in the room. LVN A assigned 1:1 staff with R #6 until further directions from DON. - 07/08/24 at 7:15 AM, documented by the DON indicated R #6 was noted outside facility grounds this morning. Assessment followed up by this RN. R #6 was currently in bed, awake/alert confused, with RP at bedside. As per R #6, stated he felt the urge to smoke but did not have a lighter and decided to leave facility with his power wheelchair to the corner store without advising staff. Once R #6 arrived at the store, he stated he did not take his money and asked for directions back to facility which at that time the store clerk assisted him by calling local LE. LE then called the facility to inform of R #6's whereabouts and he was safely transferred to facility with assistance of LVN A and RNA B. Head to toe assessment conducted by LVN A and followed up by this RN at this time. The assessment was within normal limits, vital signs were within normal limits. As per the RP, who was at bedside, she stated she believed his acute confusion was noted by her yesterday morning and thought his UTI was not resolved. R #6 was currently on antibiotics for a UTI and was started on a patch for pain by hospice. The RP wished to discontinue the patch for now as his pain was better controlled by Morphine. The DON spoke with the hospice nurse who would stop by today to assess R #6. The Medical Director was made aware of the occurrence. He advised to consult with psych for re-evaluation and do a urine analysis (UA) for UTI follow up. The RP was aware and agreed with the recommendation. - 07/08/24 at 10:40 AM, documented by the DON indicated the hospice nurse was at bedside and assessed R #6. Discussion occurred about R #6 leaving facility without notifying staff this morning. The hospice nurse talked to R #6 and education was provided about leaving the facility which R #6 verbalized understanding. Plan was to discontinue the pain patch per family request. The hospice nurse agreed with the UA and psych evaluation per the Medical Director recommendation. At this time R #6 was frequently monitored by the licensed nurse every 30 minutes, visual checks for the next 72 hours. All doors in the facility were checked by maintenance for proper functioning of fire alarm when opening. As per hospice nurse, the RP wanted R #6 to be transitioned to a regular wheelchair for now. Therapy to evaluate. A discussion occurred with R #6 about the RP's requests, and he agreed to them. Resident rights, out on pass, and smoking policy/procedure were discussed with the RP and R #6. Both parties verbalized understanding. - 07/08/24 at 2:30 PM, documented by an RN indicated: Hospice nurse gave new order for UA which was collected. Results were pending. - 07/12/24 at 2:42 PM, documented by RN C indicated: Relayed UA results to hospice nurse. R #6 continued to take prophylactic antibiotics for recurrent UTI. No new orders given. - progress notes from 07/08/24 to 07/16/24 reflected staff continued to monitor R #6 and R #6 did not exhibit elopement or exit seeking behaviors. Record review of the Provider Investigation Report dated 07/13/24 reflected the incident on 07/08/24 at 4:48 AM was reported on 07/08/24 at 5:20 PM. At 4:48 AM, the ADM received a call from the night nurse to inform them that R #6 was identified outside of facility grounds. R #6 was located and returned safely to the facility. R #6 stated he left to go to the corner store to buy cigarettes. Head-to-toe inspected, no injuries noted, and R #6 was noted to be more confused than baseline. Provider Response: monitor closely, 1:1 to care for remainder of shift, and do visual checks often, and hospice to visit. Investigation attached. Conclusion: The facility completed a thorough investigation that included the review of the resident's clinical record, interviews with the staff and resident, and the resident's responsible party, consultation with the primary care provider and hospice services, review of the facility's policies and processes, and physical plant elopement risk points. During the facility investigation, it was evident that R #6 exited the front lobby door while staff were working in other hallways and were not able to witness the resident exit. The resident exited his hall at 2:14 AM (3:14 AM, video footage timestamp incorrect) and exited the facility front door at 2:15 AM (3:15 AM). It took the resident approximately one (1) minute to exit the facility in his wheelchair after leaving his room. R #6 exited the front door of the facility on 07/08/24 at approximately 2:15 AM (3:15 AM). R #6 was found safe at the corner store approximately 1 block (0.5 mile away according to a web search) from the facility with LE, who contacted facility staff for pick up. The resident was returned to the facility without injury or adverse effects to his health. Again, to repeat, there were no signs or symptoms of abuse, neglect, distress, or bodily injury noted. The facility felt confident the investigation revealed this was an unpredictable and isolated event which was unavoidable and not related to neglect. The resident never demonstrated behavior, voiced desire, or had assessment results that would have indicated he was a risk for elopement. The facility took all measures possible to ensure this does not re-occur with R #6 or any other resident in the facility. Investigation findings: Unconfirmed. Provider Action Taken Post-Investigation: Staff in-service conducted regarding abuse/neglect/exploitation, reporting incidents, elopement, change of conditions, 100% in-service for all staff on elopement and facility investigation conducted regarding allegation of abuse/neglect with findings unconfirmed. Signed by the ADM on 07/13/24. Interview with R #6 on 07/10/24 at 11:30 AM. R #6 said he left the other night. R #6 could not provide details of where he went. R #6 said he did not tell anyone he was leaving. R #6 said the police brought him back. R #6 appeared confused and did not continue the interview. Interview with R #6's RP on 07/10/24 at 11:45 AM. The RP said she had no concerns with the care provided to R #6 at the facility. The RP said she was aware of R #6 eloping. The RP said she received a call from the nurse on 07/08/24 at around 4:48 AM to let her know about the situation. The RP said when she arrived at around 6 AM, the DON and ADM were already at the facility. The RP said she did not believe the staff failed to do something, but she just thought about all the worst-case scenarios and she just worried. The RP said she did not want to think about all the things that could have happened. The RP said R #6 did not have a history of leaving like he did. The RP said R #6 did not say he wanted to go home or show any sign of wanting to leave. RP said R #6 had been doing well. The RP said R #6 had a UTI, but he got UTIs frequently, and never tried to leave. Interview with corner store Manager on 07/10/24 at 8:20 AM. The Manager did not have any knowledge or information regarding the incident involving R #6. The Manager reassured her staff would have notified her of such incident but did not mention that they called LE for R #6. The Manager did not wish to provide the contact information for the clerk that worked at the time of incident. Interview with LE attempted on 07/10/24 at 9:40 AM. LE was not working, and a message was left requesting a callback. Interview with RNA A on 07/10/24 at 10:25 PM. RNA A worked the 10 PM-6 AM shift. RNA A said she worked on 07/07/24-07/08/24 with R #6. RNA A said she was assigned to R #6's room in the 700 hall, but she and the other RNA would help each other out as needed for all residents on the north side. RNA A said they rounded on the residents every 2 hours and as call lights were turned on. RNA A said R #6 was very independent and he was known to get up in the middle of the night. RNA A said R #6 would self-transfer to his wheelchair, go down the hall to the south side, and go back to his room. RNA A said R #6 had never left the facility. RNA A said he always went back to his room. RNA A said R #6 did not say he wanted to go home or to the store. RNA A said R #6 did not exhibit different behaviors, it was like any other night. RNA A said nobody knew that R #6 was going to elope. RNA A said the last time she saw R #6 was around 2 AM during their rounds. RNA A said she saw him in the motorized wheelchair in the hall. RNA A said after that she did not remember seeing him. RNA A said she continued answering lights and helping the other RNA. RNA A said they did help in all 3 halls as needed on the north side. RNA A said around 4 AM, she had started rounds in the 800 hall and LVN A informed her that R #6 was at the corner store. RNA A said LVN A and RNA B left to bring R #6 back. RNA A said she continued with the rounds in the meantime. RNA A said they brought R #6 back and he was not injured or in distress. RNA A said R #6 did not tell her anything about where he went or why, he just went to his room and laid down. RNA A said she knew to look for signs or symptoms of UTIs and would report it to the nurse. RNA A said she could not remember if R #6 had a UTI, but he did not appear confused that night. RNA A said he conversed with them, looked out for his roommate, and had no signs of confusion when she worked with him. RNA A said they completed their rounds like usual that night like they always did. RNA A said she did not fail to complete the rounds every 2 hours. RNA A said they did rounds, answered call lights, and got busy at times. RNA A said R #6 had never done what he did, and they had no reason to monitor him for elopement. Interview with RNA B on 07/10/24 at 10:50 PM. RNA B worked the 10 PM-6 AM shift. RNA B said she worked on 07/07/24-07/08/24 with R #6. RNA B said she had seen R #6 around 2 AM. RNA B said she had seen him in his room and in the hallway in his wheelchair. RNA B said she believed she might have been in another resident's room at the time when LVN A informed them that R #6 was gone around 4 AM. RNA B said R #6 was very independent and had never tried to leave. RNA B said R #6 went to the restroom, got coffee down the hall on the south side, and went back to his room. RNA B said R #6 never appeared confused, at least not during their shift. RNA B said R #6 was able to self-transfer from the bed to the wheelchair and from the wheelchair to the bed. RNA B said R #6 did not like for them to assist him much. RNA B said it was normal for R #6 to be awake at that hour of the night. RNA B said they rounded on the residents every 2 hours. RNA B said she and RNA A helped each other out to care for the residents in the 600, 700, and 800 halls (north side). RNA B said R #6 never said he wanted to leave or that he wanted to go to store. RNA B said R #6 smoked a lot but understood that there were smoke breaks, and he never tried to go outside during the overnight hours to go smoke. RNA B said LVN A asked her to help him bring R #6 back. RNA B said they went in her car so R #6's wheelchair would fit in the back of her car. RNA B said when she arrived at the corner store, LE was outside with R #6. RNA B said R #6 recognized her and LVN A. RNA B said R #6 did not appear confused. RNA B said the corner store clerk said that R #6 had asked for cigarettes. RNA B said the clerk spoke more to LVN A. RNA B said LE said he wanted to make sure that R #6 was safe and LE followed them to the facility. RNA B said LE spoke to RN A, then left. RNA B said LVN A assessed R #6 and RNA B continued with rounds and assisted other residents. RNA B said R #6 did not tell her anything on the way back to the facility such as where he went or how he left. RNA B said R #6 told LVN A that he went to the store. RNA B said LVN A continued to interview and assess R #6 but she continued with rounds so she was not sure what else he said. RNA B said if the resident had a UTI, they did inform them during the report or shift change. RNA B said she did not know if R #6 had a UTI, but he was known to have UTIs. RNA B said sometimes they did have to monitor the residents more when they had a UTI because they were very confused. RNA B said R #6 was not confused, at least it did not appear like that to her. RNA B said R #6 always had a staff with him for now and they were checking on him more frequently. RNA B said she did not know which door R #6 exited through. RNA B said the doors at the end of the halls would sound when they opened them, but the door alarms never sounded that night. RNA B said the front door was not locked before. RNA B said she was not sure if it was locked when she arrived for her shift today, she did not pay attention. RNA B said she had been in-serviced on elopements before the current incident and a similar incident had never happened before. RNA B said they completed the rounds on time, rounded at 2 AM and then again at 4 AM but they were in other residents' rooms around that time. RNA B said especially around the 4 AM shift, the residents usually started waking up and pressed the call lights more frequently. Interview with RN A on 07/10/24 at 11:45 PM. RN A said he worked on 07/07/24-07/08/24 with R #6. RN A said he worked on the south side of the building but that night he was in/out of another resident's room that had declined. RN A said he might have been in that resident's room when R #6 was on the south side or exited the building. RN A said he was informed by LVN A that LE called the facility to inform them that R #6 was at the corner store. RN A said LVN A and RNA B left to bring R #6 back. RN A said R #6 arrived with RNA B and LE had escorted them. RN A said LE asked him for R #6's DOB and wanted to make sure he was a resident of the facility. RN A said LE left, and he assisted R #6 into his wheelchair. RN A said LVN A assessed R #6. RN A said he assisted a bit but then returned to his residents. RN A said R #6 was not injured. RN A said R #6 was known to get up throughout the night. RN A said R #6 was self-sufficient, went to the restroom, got coffee by the kitchen area, and went back to his room. RN A said that was his normal routine. RN A said R #6 did seem confused this night. RN A said R #6 had a diagnosis of dementia and his cognition fluctuated. RN A said R #6 had recurrent UTIs, but he did not know if R #6 was being treated for that. RN A said UTIs were reported in the shift change, as well as medication changes. RN A said LVN A was assigned to R #6 that night. RN A said if there was a change of condition, the RNAs would also be informed so they ensured to monitor them for any changes. RN A said he kept track of the residents that might have a change of condition and if they had a UTI, that might cause confusion. RN A said he was not sure if R #6 was being treated for a UTI or if the staff were informed that night. RN A said even if R #6 was confused, he had never tried to leave like this. RN A said the most R #6 would do was get up, get coffee, and go back to his room. RN A said the nurses did rounds, the RNAs did rounds, every 2 hours or as needed. RN A said before the incident happened, the front door was not locked. RN A said he was not sure if the door would be kept locked. RN A said LVN A completed the cognitive and body assessment for R #6. RN A said they notified the DON, ADM, RP, and MD. RN A said R #6 did not say anything like where he went or really talk. RN A said LVN A might have gotten more information from him. Interview with LVN A on 07/11/24 at 8:20 AM. LVN A said he worked on 07/07/24-07/08/24 with R #6 in the 700 hall. LVN A said he was assigned to the 600, 700, and 800 halls (north side). LVN A said when he arrived for his shift, he got report, did his round, and made sure everyone was accounted for with the call light nearby, like usual. LVN A said LE called him on the phone at around 4 AM, to inform him that R #6 was at the corner store. LVN A said that was when he was aware that R #6 was missing. LVN A said he had seen R #6 around 2 AM, down the hallway and in his bed. LVN A said R #6 was able to transfer himself in and out of bed and it was not unusual for him to get up around that time. LVN A said R #6 would go to the restroom, go down the hall to the south side, get coffee, but he would always go back to his room. LVN A said R #6 had never tried to leave before. LVN A said R #6 was a smoker and there were no smoke breaks during the overnight hours, but R #6 never tried to go outside to smoke during the night. LVN A said if the residents went out on pass, there was a binder in the front to sign in and out, but R #6 would never try to go out in the middle of the night like that. LVN A said R #6 never said he wanted to go home or that he wanted to go to the store. LVN A said R #6 did not exhibit any indications that he would elope. LVN A said R #6 was sometimes confused, probably because of the UTI he kept getting and his diagnosis of dementia. LVN A said R #6 had recurrent UTIs, so it was hard to say if he was confused because of the UTIs or the dementia. LVN A said other times that he had UTIs, he never tried to leave. LVN A said if a resident had a UTI, the staff were informed. LVN A said the RNAs knew to report any changes such as behavioral changes or altered mental status. LVN A said even if they did not have a UTI, the staff knew to report any changes. LVN A said the staff knew R #6 had a UTI. LVN A said it was around maybe 4 AM when LE called. LVN A said he and RNA B took off right away to the store in their vehicles. LVN A said they did not use the facility van because they did not have the keys, plus they did not want to waste time. LVN A said when they arrived, R #6 was sitting outside with LE. LVN A said the store clerk asked him for the facility's phone number to have just in case. LVN A said the clerk did not mention anything else. LVN A said he did not know how they figured out if that was that facility. LVN A said maybe they just called different locations. LVN A said LE wanted to know his name and DOB to release R #6 to him. LVN A said they brought R #6 back to the facility in RNA B's vehicle. LVN A said LE helped to put R #6 in the car, ensured he was buckled, and brought him back safely to the facility. LVN A said LE followed them to the facility. LVN A said R #6 said he wanted to purchase a lighter but was not able to get one. LVN A said he completed the head-to-toe assessments and the other assessments for R #6. LVN A said he was not injured. LVN A said he was confused but the confusion was normal to his baseline. LVN A said he completed the BIMS and the elopement assessment. LVN A said he did not remember how he scored but it should be documented in his file. LVN A said the RNAs conducted their rounds appropriately and he did not believe they failed to do something. LVN A said sometimes the RNAs went into rooms together to help each other out or maybe help the nurses too. LVN A said he also completed his rounds that night and might have been busy with other residents when R #6 left the facility. LVN A said they brought him back safely, notified all parties, doctor, family, hospice, DON, administrator, and followed the protocol. LVN A said R #6 was at the corner store on the intersection about 0.5 mile away. LVN A said even before the incident happened, they had in-services in the past for elopements and this was not something new that they were learning or trained them on. Interview with the DON on 07/10/24 at 8:50 AM. The DON said he was aware of the incident regarding R #6 eloping on 07/08/24. The DON said the staff had just seen him and checked on R #6 around 3:30 AM, and he was doing fine. The DON said the facility got a call around 4:50 AM that R #6 was at the corner store. The DON said LVN A and RNA B went to pick him up and brought him back. The DON said R #6 was not injured. The DON said the staff had already called him and so he and the ADM showed up to the facility. The DON said he called the corner store and spoke to the store clerk. The DON said the clerk said that R #6 went into the store, asked for cigarettes and a lighter, but then R #6 said he forgot his money. The DON said that R #6 did not remember which way to get back to the facility. The DON said the clerk said he called LE and LE called the facility to see if R #6 was a resident there. The DON said they reviewed the cameras and noted that R #6 left through the front door which was not locked and did not have any chime or alarm. The DON said after R #6's elopement, they installed a chime at the front door so every time the door was opened a chime sounds. The DON said he explained to staff that the chime was to alert them that there was someone at the door. The DON said during the nighttime, nobody came in and out, so staff knew that the chime came from the front door. The DON said the other doors had an alarm that would go off but that was a different alarm system and made a different noise. The DON said the doors were checked and all the door alarms functioned properly. The DON said there was nobody at the front desk when R #6 exited the front door. The DON said nobody knew he had left. The DON said R #6 had not exhibited exit seeking behaviors or said he wanted to go home/store. The DON said there were no indications that he would leave. The DON said R #6 had never eloped before. The DON said R #6's last BIMS was 11 (moderately cognitively impaired), but then when they brought him back, they conducted the BIMS and it was a 3 (severely cognitively impaired). The DON said then when R #6 was assessed again, hours later or the next day, his BIMS was at 11 again. The DON said R #6 was confused and they had been treating him for a UTI. The DON said R #6 was on hospice due to COPD and the hospice nurse had said to put him on antibiotics prophylactically (preventative measure) without labs because since he was on hospice, they usually did not take blood or do labs. The DON said the doctor said to do a urine test to see if they needed to change the antibiotics after the incident happened. The DON said they placed R #6 on 30-minute checks for 3 days, and he had been doing well. The DON said they discussed with the RP that if he had more behaviors or began to exit seek, that they would maybe need to move him to a memory care unit, but the RP did not want that. The DON said R #6 was a smoker, but he understood there were certain times to smoke. The DON said R #6 had a motorized wheelchair, but the RP requested for him to only use the regular wheelchair to prevent any further incidents in the meantime. The DON said R #6 was known to be awake and up in his wheelchair during the night, but he would never try to elope. The DON said that same day on 07/08/24, they initiated elopement assessments on every resident and no other resident triggered for high risk. The DON said there were 3 ambulatory residents, but they were not at risk of elopement according to the assessments. The DON said they also completed in-services for all staff, checked all doors/alarms, installed the front door chime, and began elopement drills. Interview with the ADM on 07/10/24 at 9:05 AM. The ADM said when R #6 eloped through the front door, the front door was not locked, there was nobody assigned to the front desk, and there was no alarm. The ADM said that was how the facility had always done things and no elopement incident had occurred. Interview with the DON on 07/10/24 at 1:55 PM. The DON said R #6's care plan indicated to monitor for symptoms regarding UTIs. The DON said a UTI could cause confusion and he was also on antibiotics so they would monitor daily for altered mental status which meant alertness, cognition, and responsiveness. The DON said R #6 had intermittent confusion, so it was hard to say if the confusion resulted from the UTI or his dementia. The DON said at night, nobody was at the front desk, and it had always been like that. The DON said all the doors opened and had an alarm to alert except the front door. The DON said the front door did not have an alarm or chime until now. The DON said there had never been an issue regarding the front door. The DON said R #6 was able self-transfer to the wheelchair. The DON said some days he required more assistance than other days, depending on his day. The DON said R #6 had been declining a lot the past few weeks which was why he got admitted to hospice. The DON said R #6 had COPD and his lungs were very poor, but he continued to smoke. The DON said RP did not want to take away that joy of smoking and it was his right to smoke. The DON said he believed it was around 3:30 AM that the staff last saw R #6 and he left around 3:37 AM, but the time stamps on the video footage were not correct so he was not sure on the times. The DON said LE called the facility around 4-4:30 AM. The DON said the staff called the ADM, the nurse called the DON, then ADM called the DON to make sure he knew. The DON said he got the call at 4:45 AM from the nurse, and R #6 was already back in the building when they called him. The DON said he arrived at the facility around 5-5:15 AM. The DON said the staff rounded every 2 hours and the staff had rounded with R #6 within the 2-hour period. The DON said R #6 got up during the night, got coffee, or roamed around inside the building but never tried to leave. The DON said that was what the night staff told him. The DON said the staff would check he got coffee and went back to his room. The DON said during the rounds, the staff had to make sure they saw each resident, even if they did not require assistance, make sure they put eyes on them. The DON said the staff would have noticed during the next round that R #6 was missing. The DON said at night, the building was very quiet so the chime installed would echo throughout the building and alert someone was at the front door. Observation/review on 07/10/24 at 4:30 PM revealed the ADM showed the Investigator the video footage of R #6 leaving the facility. The video footage timestamps were incorrect by about 3 hours ahead of actual time. At around 3:16 AM, R #6 exited the building through the front door, which was not locked, and he left the facility grounds on his motorized wheelchair. At around 4:25 AM, LVN A and RNA B left in their cars. At around 4:38 AM, staff returned with R #6 in RNA B's vehicle. LE followed them to the facility. LE spoke to RN A and left. RN A and RNA B assisted R #6 into his wheelchair and back into the facility. Interview with LE attempted on 07/10/24 at 9:50 PM. LE was not working on this night, and a message was left requesting a callback. Interview with the DON on 07/15/24 at 4:10 PM. The DON said they did not know R #6 would elope as he did not have any history or behaviors. The DON said R #6 was not injured and did not have a negative outcome from the incident. The DON said he did not believe R #6 would have been injured from the incident as he was aware of what he was doing. The DON said R #6 told him that se fue por el caminito (followed the sidewalk) and he arrived at the store safely. The DON said R #6 got a little confused and did not know how to come back and knew to ask for help. Record review of a Google.com search conducted on 07/16/24 reflected the corner store was approximately 0.5 mile away from the facility. Record review of a Weather.com search reflected the temperature for 07/08/24 at around 3-4 AM was approximately 80 degrees Fahrenheit. Record review of the Elopement/Unsafe Wandering Policy dated June 2018 Revised on: December 2023 Policy: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Elopement occurs when a resident leaves the facility premises or a safe area without the facility's knowledge, authorization (examples: an order for discharge, appointment, or leave

Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for one (resident #1) of 2 residents reviewed. Facility staff failed to notify administration when Resident #1 contacted the police notifying them that facility staff was not responding to his call light when he was calling for help because he had fallen from his bed. This failure could place residents at risk of injury or neglect. Findings included: Record review of Resident #1's Admission Record dated 2/8/24 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness (generalized), Difficulty in walking, not elsewhere classified, Paraplegia (paralysis of the legs and lower body, unspecified, Need for assistance with personal care, Colostomy status (opening for the colon, or large intestine, through the abdomen). Record review of Resident #1's MDS dated [DATE] revealed a BIM score of 15 which indicated his cognition was intact. Record review of Resident #1's MDS Section G dated 9/7/23 revealed; Bed Mobility resident required extensive assistance, 2-person physical assist and for dressing the resident required extensive assistance, 1 person physical assist. Record review of Resident #1's Progress Note dated 9/22/23 revealed a discharge summary. The summary indicated he had been discharged from the facility. Record review of a local Police Department Summary Report revealed an incident called in to the police department on 9/17/23. The report reflected that on 9/17/23 Resident #1 called the police department because he had fallen from his bed and was not able to get assistance from facility staff. The report also reflected that a police officer was sent to investigate and spoke with both Resident #1 and the charge nurse on duty. The report reflected there were no injuries to Resident #1 and he refused medical attention. Record review of Resident #1's progress notes dated 9/17/23, 9/18/23, 9/19/23, revealed no documentation of this incident. Record review of facility's grievance log dated September 2023 indicated a grievance filed on 9/18/23 by Resident #1 on call lights not being answered at the time of incident. During an interview on 2/7/24 at 2:41 pm the local Police Officer said he followed up on an incident that occurred on 9/17/23. He said he reviewed the case and made a referral to HHSC. He said the police were called into the facility by a resident who had fallen from his bed. The Police Officer said there were no injuries reported at the time. The Police Officer said he spoke to the nurse on duty but did not ask him why they did not answer Resident #1's call. Resident #1 was on floor at the time and staff were able to assess and place him in bed. Resident #1 did not want medical attention according to the Police Officer. During an interview on 2/7/24 at 3:28 pm Community Liaison said Resident #1 filed a grievance on 9/18/23 regarding call lights not being answered at night. She said Resident #1 only brought up the issue on call lights, he did not mention anything else. During an interview on 2/8/24 at 1:17 pm the DON said he was never informed by staff that a police officer had gone into the facility on that day. He said nurses were supposed to notify him if the police department was called in to the facility or if a resident had a fall or change in condition. He said staff had been in-serviced on that before. The DON said Resident #1 never mentioned to him that he called police. He said he would have to assess the incident to decide if it was a reportable incident. During an interview on 2/8/24 at 2:09 pm CNA T said she had just started working at the facility and was taking her lunch break when she saw the police in the building. She said she did not know why they were there. During an interview on 2/8/24 at 2:35 pm the Administrator said he was not informed by staff that a police officer had been called to the facility. He said he did not know about the incident. The Administrator said staff were supposed to notify him when the police are called into the facility. Attempts to contact LVN B on 2/7/24 at 2:00pm and on 2/8/24 at 11:00am were unsuccessful. Attempts also made to contact CNA P on 2/7/24 at 2:03pm and again on 2/8/24 at 11:05 am were unsuccessful. Record review of facility's Abuse: Prevention of and Prohibition Against states; Policy & Procedure Freedom from Abuse, Neglect, Exploitation dated; original date: 11/2017, Revision/Review Date(s): 4/2019, 1/2021, 1/2022, 10/2022, 12/2023 states; The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy. H. Reporting/Response 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator.

Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for one of one facility. The facility did not have a designated seven-day food supply for emergencies for their census of 80 residents who were served from the facility kitchen and 35 staff. The facility's failure could place the resident population at risk for not having resources identified and available to provide the necessary care and services the residents required. The findings included: Record review of the facility assessment tool dated 08/31/23 reflected no documentation that addressed the emergency food supply. Interview and observation in the facility kitchen on 09/26/23 at 9:15 am with the Dietary Supervisor revealed he had been the Dietary Supervisor since November 2022. The Dietary Manager said he had no designated food supply for residents or staff for emergencies. The Dietary Supervisor Manager said he knew the facility had a contract with a local food supplier to order in case of emergencies. The Dietary Supervisor said he had not calculated the amount of food supply for seven-day emergency supply, and he did not know how much food to designate as the seven-day food supply. Interview on 09/26/23 at 10:30 am with the Administrator revealed he did not have policy or procedure to calculate how much food to designate as the seven-day food supply for emergencies. The Administrator said the facility had a storage room for emergency food supplies for seven days for residents only. The Administrator said he did not know how to calculate how much food was needed for the seven-day food supply. The Administrator said the assumed the food needed for seven-day supply for emergencies included the amount for residents only and not for staff on duty. The Administrator said the Dietary Cook was responsible for ensuring food was designated in a different storage room for seven-day emergencies. The Administrator said the Dietary Supervisor was not aware the Dietary Cook had the emergency food designated in a separate storage room. Interview on 09/28/23 at 10:50 am with the Dietary Cook revealed she would always make sure there was enough food for a seven-day food supply for emergencies that were stored in a storage room outside the kitchen. The Dietary Cook said she did not know how to calculate how much food was needed for a seven-day food supply for emergencies for the facility. The Dietary Cook said she did not have an inventory on the storage of food for the seven-day food supply. Observation on 09/26/23 at 11:00 am with the Administrator revealed a storage room outside the kitchen had 20 one-gallon cans of vegetables, fruit, beans, and paper goods. Record review of the facility policy titled Disaster Preparedness Guide 2023 updated January 2023 reflected Ensure uninterrupted operation of food service to residents/patients. Stock a 7-day supply of non-perishable food supplies. Stock a two-day supply of perishable food supplies. Stock a supply of disposable items-recommendation of at least 3 days of disposable items.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #38) reviewed for call lights in that: The facility failed to ensure Resident #38's call light was within reach and was positioned where she could use it and was appropriate for her needs. This failure could place residents at risk of being unable to call for assistance. The findings included: Record review of the admission record dated 09/27/23 for Resident #38 reflected resident was admitted to the facility on [DATE],was a [AGE] year-old female with diagnosis that included dementia (decline in cognitive abilities), need for assistance with personal care, diabetes (high blood sugar levels), and carpal tunnel syndrome (neurological disorder on median nerve on hands) and pain in the right knee. Record review of Resident #38's quarterly MDS dated [DATE] reflected Resident #38's cognitive skills for daily decision making were independent, required two-person assistance for bed mobility and dressing, required total dependence on two staff for toilet use and bathing. Record review of Resident #38's care plans dated 08/23/23 reflected resident was at risk for falls related to weakness. Interventions included to be sure the call light was within reach and to encourage to use it to call for assistance as needed, date initiated, 08/23/23. Observation and interview with Resident #38 on 09/27/23 at 9:26 am revealed Resident #38 was in bed, she stated she had fallen on 09/26/23 from her bed and was feeling pain in her right shoulder/ hand and she could not move her left arm. Resident #38's call light was a push button device that was clipped to resident's pillow on her left side out of sight and out of reach. Resident #38 voiced she could not see or reach her call light. At 9:35 am LVN K was called into Resident #38's room. LVN K said Resident #38 had been assessed for pain after the fall the day before and Resident #38 had not voiced any pain to her shoulders or hands. LVN K said Resident #38 had been asleep earlier in the morning when he did his rounds with her. Resident #38 usually slept late. LVN K placed Resident #38's call light on her right hand and asked Resident if she could see it and use the call light. Resident #38 attempted to push the button on the call light with her right hand and demonstrated she could not press on the push button call light. LVN K said he would come and place a touch pad call light for Resident #38. Interview on 09/27/23 at 9:35 am with CNA L revealed he had gone into Resident #38's rooms earlier in the day and had not seen that her call light was clipped where she could not see it or was not able to reach. CNA L said Resident #38 could use the call light to ask for help if it was placed within her reach and within her sight. Observation and interview on 09/28/23 at 1:42 pm revealed Resident #38 in her bed and her touch pad call light was placed on her bed below her left outstretched arm and elbow. Resident #38 said she could see the touch pad call light and she could not move her upper body to see where the call light was placed. CNA M was called into the room and placed the touch pad call light on Resident #38's right hand that was placed on her stomach. CNA M said she had placed the call light on Resident #38's left lower elbow beside her body where Resident #38 could not see or reach. CNA M said she had been in a hurry when she had come in to check on Resident #38 and had not ensured Resident #38 could see or reach her call light. Interview on 09/28/23 at 3:40 pm with the DON revealed Resident #38 had been assessed on 09/27/23 and she was able to show she could use both arms and hands without any pain or discomfort. Resident #38 was able to show she could use her both her hands to reach and push the call light button. The DON said the call light for Resident #38 should be placed where the resident could see it and be able to use to ask for help. The DON if the call light was not placed within sight and reach, the resident would not be able to call for help as needed. Record review of the facility policy revised May 2017 and titled Call Light/Bell reflected It is the policy of this facility to provide the resident a means of communication with nursing staff. Place the call device within resident's reach before leaving the room.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident, for 1 resident (Resident #88) of 8 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #88's comprehensive person-centered care plan to address the initiation of Aricept, a medication for dementia/Alzheimer's disease, started on 09/13/23. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. The findings were: Review of Resident #88's Progress Notes, dated 09/01/23, revealed he was a [AGE] year-old male, admitted to the facility on [DATE]. Review of Resident #88's admission MDS assessment dated [DATE] (signed on 09/12/23), revealed Resident #88 with diagnoses of infection of the skin and subcutaneous tissue, stroke, burn of second degree of unspecified lower limb, acute kidney failure, rhabdomyolysis (the breakdown of muscle tissue that releases a damaging protein into the blood that can damage the kidneys), cellulitis, type 2 diabetes mellitus, heart disease, and anxiety disorder. Resident #88 had a BIMS of 10 which indicated his cognition was moderately impaired. Resident #88 had adequate hearing and staff could understand him and he usually was able to understand. Resident #88 required extensive assistance with two+ person assist for bed mobility, dressing, toileting, required extensive assistance with 1-person physical assistance for eating and personal hygiene, and activity only occurred once or twice with two+ person physical assist for transfers, and locomotion Resident #88 was always incontinent of bowel and bladder. MDS did not have diagnosis of bipolar disorder or Alzheimer's Disease/dementia. Review of Resident #88's Care Plan dated 09/12/23, revealed Aricept, a medication for dementia, was not addressed in the Care Plan. Review of Resident #88's Physician Order dated 09/12/23 reflected Aricept Oral Tablet 5 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for dementia with a start date of 09/13/23. Review of September 2023 eMAR revealed Aricept Oral Tablet 5 mg was given to Resident #88 by mouth at bedtime for dementia, 09/13/23 through 09/20/23, and 09/22/23 through 09/28/23. In an interview on 09/29/23 at 11:47 a.m., LVN A stated if a resident were admitted with orders for the hospital, he called the physician to reconcile the medications to find out what to continue and what to discontinue. LVN A stated nurses and MDS can put the diagnosis in the computer on admission. LVN A stated the admitting nurse will put in medications in the computer. LVN A stated the ADON will do a check on medications that are put in the computer. LVN A stated if verbal orders are given, it was documented in Progress Notes or on the form. LVN A stated the nurses and ADON are responsible for checking medications to diagnosis. In an interview on 09/29/23 at 12:03 p.m., ADON B stated the charge nurse was the one who does the initial admission of a resident. ADON B stated the charge nurse does the medications. ADON B stated proper diagnosis with medication, route, etc. are checked by the charge, the ADON, and the DON. ADON B stated that he did not input the antipsychotics or that type of medication for residents. ADON B stated the other ADON (ADON C) would have put the medication in for Resident #88, and she would have done the check (for the order with diagnosis). In an interview on 09/29/23 at 02:07 p.m., ADON C stated the admitting nurse will reconcile orders with MD on admission. ADON C stated ADONs will check admission medications with admission paperwork from hospital. ADON C stated the MDS also checked medications. ADON C stated the admitting nurse, LVN D (LVN D was not reachable for interview), was the nurse who took the written note from NP K for the Aricept. ADON C stated NP K gave a diagnosis of dementia. ADON C stated NP K would bring her notes to the facility the following month after seeing a resident. ADON C stated she would sometimes ask for them if she thought it was taking too long to get the records and NP K would fax them to her and then bring her notes next time she comes. ADON C stated NP K came in on 09/12/23 to reconcile medications and started the Aricept for dementia for Resident #88. ADON C stated there was no uploaded paperwork from NP K for the visit. ADON C stated she could try to get surveyor a copy of the paperwork from NP K's visit and notes. In an interview on 09/29/23 at 02:43 p.m., DON stated when a resident is admitted , they get the transfer paperwork from the hospital, and they reconcile the medications with the doctor (name, dosage, frequency). DON stated the psychiatrist (NP K) made a note Resident #88 had dementia on 09/12/23. DON stated it probably had not been uploaded in the computer yet. DON stated change of condition needed to be in the computer within 24 hours. DON stated he does not think there would be a negative effect from giving a resident a medication they did not have a diagnosis for. He said they try to treat a symptom and if the resident was having a symptom and getting a medication to treat that symptom, there would not be a negative effect. Record review of facility's Comprehensive Person-Centered Care 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. 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 recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plans.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #89) reviewed for comprehensive care plans, in that: Resident #89's hospice care was not reflected in his comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services. The findings were: Record review of the admission record for Resident #89 reflected resident was admitted to the facility on [DATE],was a [AGE] year-old male with diagnosis that included epilepsy (neurological condition that causes unprovoked, recurrent seizures), anxiety disorder (excessive unrealistic worry and tension), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness of one entire side of the body). Record review of the physician orders for Resident #89 dated 09/26/23 reflected Resident #89 had orders to admit resident to hospice care, start date 09/02/23. Record review of the admission MDS dated [DATE] for Resident #89 reflected Resident #89 had severe cognitive impairment and was receiving hospice care. Record review of the care plans for Resident #89 last revised on 09/05/23 reflected there was no evidence a care plan to address hospice care was included. Interview and observation on revealed Resident #89 in his bed, alert to self and unable to respond to surveyor greeting due to cognitive impairment. Interview on 09/26/23 at 3:00 pm with MDS /LVN Coordinator I revealed she was responsible for developing a care plan for Resident #89's focus care area of hospice as ordered by his physician. MDS /LVN Coordinator said she had overlooked the development of a care plan for Resident #89 due to the overload of admissions of residents during the month when Resident #89 received his orders for hospice care. Interview on 09/29/23 at 3:25 pm with LVN K revealed he would use the care plans developed to get information such as interventions to provide care to the residents. LVN K said he would make sure that CNAs received the information on the care plans to provide the care that was required. LVN K said he did not see a care developed for Resident #89's hospice care. Interview on 09/29/23 at 3:40 pm with the DON revealed the care plans were reviewed by staff to apply the interventions that were developed for each resident. The DON said if a care plan for a specific focused area was not developed, the resident might not review the necessary care as developed. Record review of the facility policy titled Comprehensive Person-Centered Care Planning revised on August 2017 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 included measurable objectives and timeframes to meet a resident's medical, nursing, 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 interview, and record review, the facility failed to ensure that residents with pressue ulcesres received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent the development of new ulcers for 1 of 4 residents (Resident #1) reviewed for pressure ulcers, in that: Resident#1 was admitted [DATE] and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/07/22 wound assessed by physician as stage IV and [CONDITION(S)] positive. This failure resulted in an identification of an Immediate Jeopardy at 5:05 p.m. on 07/21/22. While the IJ was removed on 07/22/22, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced. This failure could place residents at risk for developing pressure ulcers, a decline in existing pressure ulcers, and pain. Findings included: Record review of Resident #1s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Ointment 10 % Apply to Sacrum topically every day shift for skin condition apply to sacrum q (daily) day. Record review of Resident #1's progress notes dated 07/08/22 revealed: Notified by CNA of Resident #1 abnormal vitals. Upon assessment Resident #1 Oxygen was 61 with 5 liters of continuous oxygen. Noted with labored mouth breathing. At 00:54 at time of EMS arrival. Report given to ER charge nurse at hospital. Signed by LVN H. Record review revealed resident did not return to facility. Record review of Resident #1's Admission Minimum Data Set, dated dated dated [DATE] revealed she had a Brief Interview for Mental Status score of 2 out of 15 which indicated she was severely cognitively impaired. She required extensive assistance with activities of daily living including bed mobility. She was at risk for pressure ulcers and had one unhealed stage 2 pressure ulcer. Record review of Resident #1's initial care plan dated 06/23/22 and signed by DON revealed: Resident #1 required assistance for toilet use, transfer, bed mobility, bathing, personal hygiene, routine oral care , and dressing. Resident #1 Had potential for pressure ulcer development r/t Sacrum PU stage II. Record review of Resident #1's original care plan dated 06/26/22 revealed: Resident #1 had a potential for pressure ulcer development due a sacrum pressure ulcer stage ll. Record review of Resident #1'a comprehensive care plan date initiated 06/26/22 and revised 07/19/22 revealed: Resident #1 has a pressure ulcer stage IV to sacrum. Record review of Resident #1's admission assessment dated [DATE] revealed: Section 12: Skin integrity: Site: Sacrum. Length: was left unanswered. Width: was left unanswered. Depth: was left unanswered. Type: Pressure. Stage: ll. Record review of Resident #1's Braden Scale for Predicting Pressure sore risk dated 06/23/22 revealed Resident had a score of 10 which indicated a high risk. Record review of Resident #1's weekly skin assessments revealed there was no weekly skin assessments or pressure ulcer assessments done from 06/23/22 to 07/08/22. Record review of Resident #1's Treatment Administration Record for June 2022 revealed: [MEDICATION(S)] Ointment 10 %. Apply to Sacrum topically. Every day shift for skin condition apply to sacrum q (daily) day. Order Date 06/23/2022. D/C Date 07/07/22. Record review revealed that Resident #1 received [MEDICATION(S)] Ointment from 06/24/22 to 06/30/22. Record review of Resident #1's Medication Administration Record for July 2022 revealed: [MEDICATION(S)] Ointment 10 %. Apply to Sacrum topically, every day shift for skin condition apply to sacrum daily. Order Date 06/23/2022. D/C Date 07/07/22. Record review revealed that Resident #1 received [MEDICATION(S)] Ointment from 07/01/22 to 07/07/22. Record review of Resident #1's progress notes dated 06/24/22 revealed: Overall skin description is: warm/moist/continues with [MEDICATION(S)] daily to sacrum for pressure ulcer. Signed LVN H. Record review of Resident #1's progress notes dated 06/27/22 revealed: Overall skin description is: warm/moist/continues with [MEDICATION(S)] daily to sacrum for pressure ulcer. Signed LVN H Record review of Resident #1's progress notes dated 06/28/22 revealed: Overall skin description is: warm/moist/continues with [MEDICATION(S)] daily to sacrum for pressure ulcer. Signed LVN H Record review of Resident #1's hospital admission records dated 07/08/22 revealed: History and Present illness: nursing home resident, who was brought into the ER due to worsening confusion and altered mental status over the past couple of days at facility. Patient has been progressively getting worse, weaker reason for which she was brought to into the ER. Your work-up showed patient had findings concerning for severe [CONDITION(S)] (An infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) with septic shock (A widespread infection causing organ failure and dangerously low blood pressure), present at arrival with [CONDITION(S)] (A heart rhythm disorder with heartbeats faster than usual, greater than 100 beats per minute), tachypnea (Rapid and shallow breathing), [CONDITION(S)] (urinary infection), elevated lactic acid (Lactic acid is produced when oxygen levels, become low in cells within the areas of the body where metabolism takes place), she did not respond to aggressive IV fluids hydration per [CONDITION(S)] bolus. Patient also noted with decubitus ulcer with packing (bed sore). Record review of Resident #1's hospital history and physcial dated 07/10/22 revealed; Resident #1 passed away from Plueral Effusion (An excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs.) Record review of Resident #1's nursing home laboratory work dated 07/15/22 revealed: Culture routine: Specimen comment: sacrum stage IV Source: wound Identification: 07/13/22; [CONDITION(S)] In an interview on 07/19/22 at 12:59 p.m., LVN C said he did the admission assessment for Resident #1 on 06/23/22 and noted the pressure ulcer stage ll on the admission assessment. He said after the information was placed in the facility's system, the treatment nurse would have access to it, and proceed with a pressure ulcer assessment. He said sometimes nurses would verbally tell the treatment nurse, however he did not remember if he spoke to treatment nurse about Resident #1 pressure ulcer. He said if a pressure ulcer was not treated appropriately the ulcer could get worse or infected. In an interview on 07/19/22 at 11:45 a.m., LVN B said she had worked the weekend of 07/02/22 and 07/03/22 and provided [MEDICATION(S)] treatment to Resident #1. She said she worked the holiday of 07/04/22 and when she was to provide treatment to Resident #1, she noted that her skin condition appeared to be bigger and wider and the color was different like a pressure injury. She said she called Treatment Nurse A who said to apply Santyl Ointment to area. She said did not remember if she had documented the one-time treatment in Resident #1's progress notes, MARS, or TARS. LVN B said however she followed the orders given by Treatment Nurse A. She said did not document her findings on the progress notes or in any other parts of Resident #1 chart. Record review of Resident #'1 clinical record for 07/04/22 revealed there was no skin assessment documentaion, or progress notes for the description of the wound. In an interview on 07/20/22 at 3:52 p.m., LVN B said after she received the order from Treatment Nurse A she got the Santyl Ointment from the treatment cart and provided treatment to Resident #1. In an interview on 07/19/22 at 2:40 p.m., Treatment Nurse A said he received a phone a call from LVN B on 07/04/22. He said LVN B described Resident #1's as having in her sacrum a yellow necrotic tissue and redness, no smell. He said he called Wound Doctor Specialist D, who gave an order over the phone for a one-time treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he had not documented any skin or pressure ulcer assessment for Resident #1 in the facility's system. He said he provided some of the [MEDICATION(S)] treatments, and as per his observations, Resident #1 did not have a stage II pressure ulcer on the sacrum. He said his observations indicated that it appeared to be a rash. He said he did not document his observations or talk to DON or wound specialist for a second opinion. He said if his observations revealed anything different from a skin condition/rash, he would have called a specialist wound doctor. He said pressure ulcers could go bad in a matter of hours. When he was asked about any other type of documentation for skin assessment for Resident #1, he said he did not have any hard copies of skin assessments. Record review of Resident #1's Medication Administration record and Treatment Administration Record for the month of July 2022 revealed there was no documentation of the one-time Santyl Ointment ([MEDICATION(S)]) given by nurse on 07/04/22 given by LVN B. In an interview on 07/20/22 at 4:09 p.m., Treatment Nurse A said on 07/04/22 there was Santyl Ointment in the treatment cart and most probably LVN B got it from the treatment cart. He said you did not need an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 07/19/22 at 3:13 p.m., DON said Resident #1 was treated with [MEDICATION(S)] for a skin condition. She said [MEDICATION(S)] could be used for a skin condition or a pressure ulcer. She said LVN B noted on 07/04/22 a change on Resident #'1 skin, and called Treatment Nurse A, who called wound specialist and specialist gave order according to Treatment Nurse A description. She said Resident #1's skin was being seen daily by nurses with no reported changes and nurses were following physician orders. She said Resident #1 was no longer at facility as Resident #1 had been discharged to hospital on 07/08/22 so an assessment of avoidable or unavoidable pressure ulcer could not be done. She said the one-time treatment given to Resident #1 on 07/04/22 for Santyl Ointment was not documented on the MARS or TARS or in the progress notes or assessments as given. She said all medications and treatment should be documented. DON said Treatment Nurse A had a certification on wound care and she trusted his judgment when he did skin assessments. In an interview on 07/19/22 at 3:21 p.m., Treatment nurse A said the wound specialist went to see Resident #1 on 07/07/22 and he said it was an unstageable pressure ulcer, however later on he said stage IV. He said wound specialist had not signed the avoidable or unavoidable pressure ulcer assessment for Resident #1. In an interview on 07/19/22 at 3:48 p.m., LVN H said was Resident #1's charge nurse. She said had a pressure ulcer to sacrum, however she did not provide treatment because Treatment Nurse A oversaw the wound treatment. She said she never saw the pressure ulcer. In an interview on 07/20/22 at 10:15 a.m., Treatment Nurse A said he considered Resident #1's skin condition as a rash, however, did not clarify the stage ll pressure ulcer documentation written by other nurses at facility. He said he thought Resident #1's rash got worse and tore her skin. He said called wound specialist after the wound got worse and he got an appointment for Resident #1 for 07/07/22. In an interview over the phone on 07/20/22 at t 10:48 a.m., Wound Specialist physician F said he went to see Resident #1 at facility and did not remember the exact date. He said Resident #1 had a wound that had pus and appeared to be infected. He said talked to family members to request authorization to debride the wound. He said before the debridement he saw the wound as an unstageable, however after the procedure Resident #1 had a stage IV pressure ulcer. He said stage IV pressure ulcer was the worst type. He said he called Resident #1 primary physician to consult about antibiotics and he also ordered a wound culture. Record review of Resident #'1's wound specialist doctor F dated 07/07/22 revealed: Wound care consult: Patient seen today for pressure ulcer to sacral region unstageable. Patient seen today as requested by Nursing facility for: wound #1 (sacral pressure ulcer unstageable) present with 40% slough (part of [CONDITION(S)] process), foul odor, edges defined, attached with mild purulent discharge, [CONDITION(S)] (redness to the skin) peri wound, tender to touch, no other complications at this time. Wound will benefit from debridement. Debridement was performed today for wound #1 down to necrotic muscle and healthy fascia (a system of connective tissue that encases our body parts and binds them together.) Record review of Resident #'1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [ok for wound culture of the sacrum d/t increased purulent drainage STAT for increased purulent Drainage] order date 07/07/222. In an interview on 07/20/22 at 10:57 a.m., wound doctor D said he did not remember if Treatment Nurse A had called him on 07/04/22 about Resident #1. He said he saw too many patients to remember. He said a rash could become a pressure ulcer if it was not treated. In an interview on 07/20/22 at 11:08 a.m., the DON said Treatment Nurse A did not clarify with her or anyone else the skin condition of Resident #1. She said Treatment Nurse A was in-serviced on documentation. She said the facility did a 100% skin assessment for all the residents at facility with no new pressure ulcers. In an interview on 07/20/22 at 12:43 a.m., DON said pressure ulcers were discussed during the weekly meetings. She said remember Resident #1 rash was discussed, however because she was receiving treatment the team did not suggest additional assessments or treatments for the skin condition. She said did not have any documentation on weekly skin meetings after Resident #1 arrived at facility. In an interview on 07/20/22 at 5:05 p.m., DON said nurses that noted a change on the resident's skin condition were responsible for documenting their findings. She said in the case of Resident #1, there was no documentation on 07/04/22 that there were new findings on her skin, and also the treatment that was given. She said the DON was responsible for ensuring documentation was up to date. DON said she and the ADONs were responsible for making sure that nurses were documenting. She said if there was no documentation then there was information that could be missed. In an interview on 07/20/22 at 5:28 p.m., DON said [NAME] ointment did required a physician order. Record review of facility's policy on Quality of care; Skin Management System revised 12/2019 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 infections, unless the resident's clinical condition make the development unavoidable. Residents will have a head to toe skin assessment by a licensed nurse at the time of admission. Any skin [CONDITION(S)] will be documented on the nursing admission assessment. A treatment order will be obtained for the attending physician for areas requiring treatment. Example; pressure injury, surgical wounds open skin tears, abrasions, lacerations, etc. Residents will have ongoing head to toe assessments done weekly, incorporated into the LN weekly summary review by the licensed nursing staff. 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 records The Administrator was notified on 07/21/22 at 4:43 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. The IJ template was provided to the Administrator on 07/21/22 at 5:45 p.m. A Plan of Removal was first submitted by the Administrator on 07/21/22 at 8:22 a.m., and the POR was accepted on 07/22/21 at 11:23 a.m. and indicated the following: Immediate Action -The Medical Director was notified of IJ 7/21/22 at 5:45pm. -Skin sweep of total census initiated 7/19/22 and completed 7/21/2022 by Clinical Resource, ADON and DON. -Two Resident with a new skin issue were identified through the above Facility-wide assessment; both Resident's physician and Responsible Parties were timely notified of the finding. New orders were received for and implemented on both residents, and the skin issue was the subject of a care plan revision with appropriate interventions. -Notification made to Physician and RP on 7/19/21 of new skin issues noted during head to toe skin assessments of current census. -Review of all pressure ulcer treatments orders was initiated and completed 7/19/22 with 2 order changes and additional review of treatment orders 7/20-7/21 for new patients admitted post 7/19/22 with no new changes identified by the DON. -Education initiated 7/19/21 to be completed by 7/22/22 with Nurses and CNAs that include communicating changes in condition related to wounds (pressure injury/pressure ulcers), procedures for wounds, notification of changes in condition, wound identification and documentation and educated on the Skin Management System. Prn nurses will be educated prior to next assigned shift. This education will be included in our new hire orientation. -Licensed Nurses received education completed by outside wound care Clinical Care Representative, on 7-21-22 and will be completed by 7/22/22 on proper documentation and staging of pressure ulcers. PRN nurses will be educated prior to next assigned shift. -Education on Skin Management system was complete for working Nurses and CNAs on 7/19/2022 and 7/21/22 and will continue with all newly hired staff and PRN staff prior to the start of their next shift. -7/21/22 Clinical Resource verified Wound Care Certification/Education for DON, renewed with National wound care Alliance certified on 10/16/20 expiring on 10/16/2025 and Treatment Nurse A certified thru [Wound care company name] Wounds Physicians effective 4/25/22 -Treatment nurse was re-educated on responsibilities of Treatment Nurse role by DON and Administrator on 7-20-2022. Identification of Others Affected Currently there are 73 residents residing in the facility. The facility initiated and completed a skin sweep on 7/19/2022. Systemic Change to Prevent Re-occurrence -DON initiated in-service on 7/19/22 and to be completed by 7/22/22 with facility charge nurses and CNAs relative to the topics of assessing and monitoring resident skin, and documenting the results of these assessments, with the goal of promoting skin integrity and preventing avoidable skin breakdown. The training includes the use of shower sheets by the CNAs and communicating any new skin changes to ADON/charge nurses and or Treatment nurse verbally and by the use of the shower sheets, the charge nurse/ADON/Treatment nurse will perform a clinical assessment of the reported skin change, initiate communication to the physician and responsible party and implement any new orders received. The charge Nurse or ADON will also be responsible to communicate the identified change in skin condition to the DON. -Nurse documentation, treatments, notification of new areas, new admission assessments will be reviewed by DON/ADON daily. Braden Scale assessments will occur at admission then once a week for four weeks, quarterly, and with any change of condition. In-services included: documenting skin assessments, wound treatments, until all applicable personnel educated. In-services will be completed prior to accepting assignments for all charge nurses, nursing assistants, , new hires and PRN staff. This education will be included in the new hire orientation. - Nurses will complete education for skin assessment prior to the start of their next shift. CNAs will also receive education on shower sheets prior to the start of their shift. -Shower sheets to be completed by C.N.A daily in accordance with the patients shower schedule, communicating new skin conditions Charge Nurse/ADON. -Skin assessments to be completed by Charge Nurse at admission, document and communicate any new skin changes to physician, responsible party and place on 24 hr. report for DON notification. Treatment Nurse will verify accuracy of orders daily with skin conditions. -Skin assessments are documented in each resident's electronic chart under assessments tab (LN-Skin Evaluation PRN/Weekly) for total census started on 7/19/22 and completed on 7/19/2022. Skin sweep was completed on 7/19/22. -Head to toe skin assessments to be conducted upon admission and then weekly on residents ongoing. -The ADON and Treatment Nurse will be assigned to wound program to assess skin, complete treatments, and round with the Wound Physician weekly and as needed. -The ADON and Treatment Nurse to review daily Nurse Aide Shower Sheets at the end of work day to ensure follow up on any new identified skin integrity issues or change in skin. - DON to review Wound Care assessments and Treatment Administration Record daily to ensure assessments and treatments occur per physician orders. -The Administrator, DON, ADON, MDS and/or designees to attend weekly systems meetings starting 7/22/22 to include the skin integrity system to review skin assessment, status and progression/worsening of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring -Daily review of documented head to toe skin assessments, completed and documented shower sheets (CNA communication sheets) by DON/designee. DON/designee will ensure notifications and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Summary of IJ and corrective action to be reviewed by QAPI Committee daily until IJ is lifted, weekly until substantial compliance is achieved, and continue monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions such as pressure ulcers. -Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator. -Clinical Resource will monitor weekly to ensure skin assessments are being assessed correctly and will report to QAPI committee on the effectiveness of corrective actions. The survey team monitored the plan of removal on 07/22/22 as follows: Survey team reviewed: Record review revealed 37 out of 44 (full time staff) received the in-service revealed training regarding wound care, assessing, documenting, and reporting. Record review revealed new resident admissions were assessed (head to toe skin assessments, braden assessments), as of 07/22/22. Record review of sampled residents showing, the skin sweep was completed. On 07/22/22 beginning at 1:38 p.m., nursing staff and CNAs in all different shifts were interviewed on skin assessment, identification, documentation, and reporting skin conditions. There was a total of 19 nursing staff and CNAs interviews from all different shifts: 11 Nurses 8 Certified Nursing Assistants. On 07/22/2022 at 7:15 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced.