Every finding on record at Paradigm at the Oak

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Residents #1, #2 and #3) of 7 residents reviewed for activities. The facility failed to provide activities for Resident #1 and Resident #2 to meet their psycho-social and mental well-being for the months of April 2026 and from May 1, 2026, through May 27, 2026.The facility failed to provide activities for Resident #3 to meet his psycho-social and mental well-being for the month of April 2026.This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function. Findings included:1. Record review of Resident #1's face sheet, dated 05/28/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of major depressive disorder (a serious mood disorder- causes persistent feelings of profound sadness, and hopelessness. It is much more than just a passing bad mood and significantly interferes with daily functioning), anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry in everyday situations), and alcohol abuse with alcohol-induced mood disorder (a person's harmful use of alcohol directly causes severe, mental health symptoms such as severe depression or anxiety). Record review reflected Resident # 1 was discharged [DATE] to another facility.Record review of Resident # 1's admission MDS Assessment, dated 08/12/2025, reflected Resident #1 had a BIMS score of 15 indicating his cognition was intact. Record review reflected Resident #1 felt depressed. Further record review reflected Resident #1's activity preferences included the following:Have books, newspapers, and magazines to read.Listening to music.Be around animals such as pets.Keep up with the news.Do favorite activities.Go outside to get fresh air when the weather was good.Participate in religious services or practices.Record review of Resident #1's Quarterly MDS Assessment, dated 04/13/2026, reflected Resident #1 had a BIMS score of 9 indicating his cognition was moderately impaired. Record review reflected he felt down, depressed, or hopeless.Record review of Resident #1's Comprehensive Care Plan, revised on 04/16/2026, reflected Resident #1 (date initiated on 11/19/2025) had a potential for complications related to facility activity involvement as evidence by: Resident #1 required in-room activities. His activity preferences were the following: bingo, outside social, card games, music and dominos. Interventions: (initiated on 11/19/2025) Provide in-room activities as needed. Remind and encourage Resident #1 to attend activities of preference.Record review of Resident #1's Activity Progress Note, dated 05/26/2026 and signed by the Activity Director, reflected Resident #1 was doing well at this time; he required assistance from staff with transfers. He did require to be reminded of activities such as bingo, outside social, party games, cooking class, and other activities. Activity Director will monitor his needs and place a calendar in his room.Record review of the Activity Participation Records for Resident #1 indicated he did not receive in-room activities or attend any group activities for the months of April 2026 and from 05/01/2026 through 05/272026.During an observation on 05/28/2026 Resident #1 was not in the facility. He was discharged to another facility on 05/27/2026 per record review.During an interview on 05/28/2026 at 3:43 p.m., the Activity Director stated Resident #1 did not have any documentation of him attending group or being provided in-room activities during the months of April 2026 and May 2026. She stated she did not have an excuse of not documenting his activity participation on the participation records. The Activity Director stated it was her responsibility when she provided any type of activity to document on the day of the activity on participation records. She stated Resident #1 had a lot of behaviors of yelling, cussing, making false accusations about staff almost on a daily basis. She stated he did have episodes of depression and anxiety. The Activity Director stated if received his preferred activities there was a possibility it would prevent him from being less depressed and anxious. She stated any resident, including Resident #1, exhibiting behaviors needed to have a routine activity program to help with behaviors.2. Record review of Resident # 2's face sheet, dated 05/28/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of Alzheimer's disease with early onset (a disease identified at a much younger age than typically expected usually before age of 50 or 65. A progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks.), bi-polar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels), major depressive disorder (a serious mood disorder- causes persistent feelings of profound sadness, and hopelessness. It is much more than just a passing bad mood and significantly interferes with daily functioning), and anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry in everyday situations).Record review of Resident #2's Annual MDS Assessment, dated 05/12/2026, reflected Resident #2 had a BIMS score of 2, indicating severely impaired cognition. Resident #2's activity preference that was very important to him was the following:Have books, newspapers, and magazines to read.Lisen to music.Being around animals such as pets.Keep up with the news.Do things with groups of people.Do favorite activities.Go outside to get fresh air when the weather was good.Participate in religious services and practices.Record review of Resident #2's Comprehensive Care Plan, revised on 05/24/2026 and initiated 04/18/2025, reflected Resident #2 required assistance with activities. Intervention: (initiated on 04/18/2025) Provide in-room activities as needed. Remind and encourage Resident #2 to attend and assist to activities of his preferences.Record review of Resident #2's Activity Participation record reflected he did not receive in-room activities or group activities during the months of April 2026 and from 05/01/2026 through 05/272026.During an observation and interview on 05/28/2026 at 8:55 a.m., Resident #2 was sitting in his wheelchair across from the nurses desk. He was not interacting with other residents. Resident #2 stated he felt fine. He did not respond to any other questions or conversation.During an observation and interview on 05/28/2025 at 1:10 p.m., Resident #2 was sitting in his wheelchair in the hallway near nurses desk. He was not interacting with other residents. Resident #2 stated he was going to town. He did not respond to any other questions or conversation. During an interview on 05/28/2026 at 3:43 p.m., the Activity Director stated Resident #2 did not always do well in group activities. The Activity Director stated Resident #2 sometimes becomes easily agitated with certain residents. She stated she did not realize Resident #2 had in room activities on his care plan. The Activity Director reviewed the in-room list she provided the morning of 05/28/2026 and Resident #2's name was not on the in-room activity list. She stated Resident #2 should have been receiving in-room activities according to Resident #2's care plan. The Activity Director stated she attended care plans on a weekly basis, and she discussed the activities each resident preferred or needed. She stated Resident #2 could benefit from in-room activities due to his cognition and his behaviors. The Activity Director stated sometimes he could become disruptive in group activities and distracted other residents. She stated she did not have an excuse or know why she did not have any participation records for Resident #2 for the months of April 2026 and May 2026. She stated she was expected to document all residents' activities they participated in on the participation records. The Activity Director stated she would begin providing in-room activities with Resident #2. 3. Record review of Resident #3's face sheet, dated 05/28/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance (indicates that a person is not only experiencing memory decline but also drastic, unpredictable changes in their mood, personality, or actions), depression (a serious mood disorder that causes persistent feelings of sadness), and other lack of coordination (the inability to produce smooth, precise, and controlled physical movements).Record review of Resident #3's admission MDS Assessment, dated 2/16/2026, reflected Resident #3 had a BIMS score of 1 indicating his cognition was severely impaired. Resident #3 had physical and verbal behaviors. His activity preference very important to him was the following:Listening to music.Being around animals such as petsKeeping up with the news.Doing things with groups of people.Participating in favorite activities.Spending time outdoors.Participating in religious activities or practices.Record review of Resident #3's Quarterly MDS Assessment, dated 03/12/2026, reflected Resident #3 had a BIMS score of 1 indicating severely impaired cognition.Record review of Resident #3's Comprehensive Care Plan, revised on 03/19/2026, reflected (date initiated on 02/15/2026) Resident #3 had behaviors. He was at risk for further increased episodes and injury. Interventions: (date initiated 02/15/2026) Encourage to attend social activities of preferences. Resident #3 required to reside in the secure unit related to dementia ( initiated on 02/15/2026). Interventions: Resident #3 needs activities that are meaningful and appropriate for the resident's cognitive (the mental processes involved in acquiring, processing, and understanding information), and physical abilities. Resident #3 needs a consistent daily routine and structure. Resident #3 had a potential for complications related to facility activity involvement as evidence by activities of Resident #3 choice/ preference (1:1). Resident #3 required in-room activities. Interventions: (initiated on 02/17/2026) Provide Resident #3 with in-room activities as needed. Post a month calendar in Resident #3's room.Record review of the facility's admission and discharge report, printed on 05/28/2026, reflected Resident #3 was discharged from the facility to a behavioral health center on 05/02/2026 and readmitted to the facility on [DATE].Record review of the Activity Participation records on 05/28/2026 reflected Resident #3 did not receive in room activities or attend group activities for the month of April 2026.Record review of the Activity Department's list of residents who needed in room (1:1) activities reflected Resident #3 was not on the list.During an observation and interview on 05/28/2026 at 9:00 a.m., Resident #3 was sitting in the hallway away from other residents. He was not interacting with other residents or staff. He stated he felt good today and stated he did like to talk to people by himself. He stated he did not like to be in a crowd. Resident #3 did not respond to any other questions or conversations.During an interview on 05/28/2026 at 3:43 p.m., the Activity Director stated Resident #3 was not on the in- room (1:1) activity list. She stated she forgot he was required to receive in room (1:1) activities. The Activity Director stated Resident #3 did have behaviors and he had a lot of guilt from his past actions when he was younger. She stated he frequently did not appropriately interact with other residents in group activities and outside of group activities. She stated he would make racial remarks and say inappropriate things to other residents. The Activity Director stated Resident #3 would do better if he received in-room activities ( 1:1) activities. She stated she did not know why he did not receive activities during the month of April 2026 and he was in the behavioral hospital during the majority of the month of May 2026. The Activity Director stated Resident #3 may become depressed, have more behaviors, and feel isolated if he did not receive some type of activities. She stated he needed a routine schedule. The Activity Director stated she attended care plans on a weekly basis, and she was the one who reported during care plans of what each resident activity preference or needs were for the next quarter. During an interview on 5/29/2026 at 2:50 p.m., the Administrator stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. He stated the Activity Director was over the activity department and he was her supervisor. He stated there was a possibility that a resident may become lonely, have behaviors, depression and have a decline in their quality of life if they were not receiving some type of activities. He stated his expectation was every resident's activity participation to be documented on the participation records every day. The Administrator stated the Activity Director was expected to document what she did during in room (1:1) activity and the resident's response to the activity every time she visited a resident. He stated all group activities was expected to be documented after the group activity to reflect if the resident was active or passive during the group activity. He stated, I have plans to do a complete change in the activity programming in the facility especially on the secure unit. I want all staff to be involved in the activity plans of the residents on secure unit to ensure the residents are receiving the activities to promote their cognition, socialization or overall psychosocial needs.Record review of the Facility's Activities Policy, revised 05/2024, revealed, The Facility's activity program shall provide meaningful, person-centered activities to meet each resident's physical, mental, and psychosocial well-being, per their comprehensive care plan. Collaborate with the interdisciplinary team to develop an activities section in the care plan. Include goals and interventions tailored to the resident's interests, abilities, and care needs. Identify barriers to participation and adjust activities or approaches as needed. Ensure activities are adaptable for residents with physical or cognitive limitations. Record review of the facility's job description of the Activity Director, signed by Activity Director on 10/03/2024, revealed, In keeping with our organizations goals, this position is responsible for planning, implementing, and evaluating activities and programs for residents. The Activity Director designs programs to encourage socialization, entertainment, relaxation, and fulfillment, as well as improve daily living skills.Job Duties:Plan, create, and implement meaningful and engaging facility activities for the residents.Design programs to encourage socialization, entertainment, relaxation, and fulfillment, as well as improve daily living skills.Engage in one-on-one visits, care plan meetings, and assessments as needed.Keep accurate records of activities attendance and calendar.Ensure that responsibilities are performed consistent with all applicable federal, state, and local rules and regulations as well as facility policies and procedures.Record review of the facility's policy titled, Activity Documentation-General Guidelines, dated 05/26/2025, revealed, A qualified Activity professional will complete all required medical record documentation per state and federal regulations. The Activity Director shall coordinate and supervise all documentation and be responsible for all areas of documentation, according to required time limits and practice guidelines. The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner .1. Interdisciplinary team will assess the need for activities and reflect on the resident care: Problems, Goals and Appropriate approaches to related problems.2. Progress Notes at least quarterly.3. Resident Participation records.General guideline when completing any of the above areas of required documentation include:1. Documentation is maintained in the residents' clinical medical records.2. Only approved medically related abbreviations are used.3. All entries in the medical record are to be signed (including the author's signature and title) and dated by a qualified Activity professional.4. All documentation is completed consistent with health care center policy and applicable state and federal laws.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization. Findings included:During an observation on 05/28/2026 at 10:30 a.m., Housekeeping Cart #1 was located at the end of west hall. The compartment where chemicals were stored was not locked. The compartment had disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper A was not on west hall, and no other staff was near the unlocked housekeeping cart. Housekeeper A entered the west hall from near the nurses desk located beside the west hall. He was unable to view Housekeeping Cart #1.During an interview on 05/28/2026 at 10:40 a.m., Housekeeper A stated the housekeeping cart was expected to be locked anytime the housekeeper walked away from the cart. Housekeeper A stated he could not see Housekeeping Cart #1 from where he was standing near the nurses desk. He stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. He stated it was possible a resident may need to be evaluated at the hospital. Housekeeper A stated he was in-serviced to lock the chemicals in the housekeeping cart. He did not recall the date or the time of the in-service. During an interview on 05/28/2026 at 10:50 a.m., the Housekeeping Supervisor stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. He stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. He stated all housekeeping staff were in-serviced on locking housekeeping carts. He stated there was a possibility that if a resident spilled chemical on their skin it may cause irritation to the skin. During an interview on 5/29/2026 at 2:50 p.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The Administrator stated all housekeeping staff was in-serviced on locking the housekeeping carts. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. He stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Record review of the facility's policy titled, Chemical Usage, not dated, reflected, Secure Chemical Storage: Each housekeeping cart is equipped with a lockbox for storing chemicals. Employees must ensure that all chemicals are securely stored in the lockbox and never leave their cart unattended, especially during breaks.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two residents (Resident #7) reviewed for infection control. The facility failed to ensure RN F followed standard precautions during wound care for Resident #7's unstageable right heel pressure ulcer on 04/01/2026 when she failed to perform hand hygiene during wound care. This failure placed residents at risk for developing wound infections, and at risk for healthcare associated cross-contamination and infection.Findings included: Review of Resident #7's face sheet dated 04/01/2026 reflected at [AGE] year-old male admitted to the facility 04/23/2024 with the following diagnoses diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), chronic obstructive pulmonary disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs.). Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #7 was further assessed to have an unstageable pressure injury Review of Resident #7's comprehensive care plan reflected a focus area 04/24/2024 Enhanced barrier precautions: Resident requires enhanced barrier precautions AEB (as evidence by) open wounds. Further review reflected a focus area dated 10/17/2024 .Resident has the following wounds.2. Pressure ulcer. Interventions included 1. Cleanse with Dakins 0.25%, Primary Dressing Blue Foam Three Times weekly and PRN (as Needed). Apply Betadine to the peri wound where scabbing is present. An observation on 04/01/2026 at 9:35 AM revealed RN F outside of Resident #7's room to prepare supplies for wound care. RN F sanitized her hands using hand sanitizer outside of Resident #7's room and put on gloves. RN F then entered the room. RN F touched the door, the table, and donned her gown. Without changing her gloves, she cut off the old dressing, cleaned the wound, applied the new dressing using the same gloves without hand hygiene. In an interview on 04/01/2026 at 10:45 AM, RN F stated she did sanitize her hands before going into room but did not change her gloves or sanitize her hands during the wound care process. RN F did not answer why she did not sanitize her hands and stated by not performing hand hygiene during wound care, it could cause cross contamination and infection. In an interview on 04/01/2026 at 1:20 PM, the DON stated he expected nursing staff to sanitize their hands prior to wound care and to perform hand hygiene after removing the old dressing, after cleaning the wound, and before putting on the new dressing. The DON further stated, of course, when staff are done providing care to prevent cross contamination or wound infection. Review of the facility's policy Hand Hygiene dated December 2024 reflected It is the policy of The Facility to prioritize hand hygiene as a fundamental practice in preventing the spread of infections. All staff must perform hand hygiene. When to Utilize Hand Hygiene Before/after resident contact, after removing gloves or PPE, After contact with bodily uids, surface, or contaminated equipment. Review of the facility's policy Dressing Change: Wound dated 06/2025 Procedures: NOTE: (Perform Hand Hygiene before and after donning gloves, Hand Wash every 3rd Glove Exchange. 1. Put on gloves; 2. Remove old dressing and packing (if present)3. Remove gloves and perform Hand Hygiene; 4. Put on clean gloves; 5. Cleanse the wound of drainage, debris or dressing/filler residue; 6. Remove gloves and perform Hand Hygiene; 7. Assess the wound (measuring done here according to measuring schedule8. Remove gloves and perform hand hygiene; 9. Put on clean gloves; 10. Pack the dead space of large wounds (if physician order prescribes it); 11. Apply cover dressing-date and initial cover dressing; 12. Remove gloves, discard waste; 13. Perform Hand Hygiene.

Based on observations, interviews, and record review, the facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility reviewed for resident rights in that: The required documents were not posted in a location readily accessible and visible to all residents, their legal representatives, or family members as required.This failure placed residents of the facility at risk of knowing past and present citations of the facility, and potentially being negatively affected by an area of citation.An observation conducted throughout facility on 03/31/26 at 1:12 PM revealed the survey results were not posted in the lobby or any common areas of the facility nor a sign indicating where the survey results were posted. An observation conducted throughout facility on 04/01/2026 at 8:15 AM revealed that survey results were not posted in the lobby or any common areas of the facility nor a sign indicating where the survey results were posted. During a confidential group interview conducted on an undisclosed date and time of 5 of 12 residents revealed they did not know where or how to access the survey results in the facility. Several of the residents stated they would have liked access to that information. They had not understood or been aware that the survey book existed or that they were able to review the results. In an interview and observation conducted 4/1/2026, at 3:07 PM, the Administrator stated he was unsure of the location of the survey results within the facility, as he had only been in his position for three weeks, and indicated he would need to ask the DON. He acknowledged that the survey results were required to be available. The Administrator led this surveyor to the DON's office to verify the location of the survey results binder, and the DON confirmed it was on the Administrator's desk. The RNC and another staff member then returned to the Administrator's office, where the binder was located on his desk. It was subsequently discussed among those facility staff that the binder would be relocated to the table outside the Administrator's office, with signage posted to notify residents, family members, and visitors of its availability. When asked if the binder was accessible to residents while located on his desk, the Administrator stated it was not, and indicated he was unaware it had been placed there. He stated it had been placed on his desk without his knowledge. The Administrator acknowledged that residents, family members, and visitors should have access to review the survey results. When asked about the potential impact of the binder not being readily accessible, he stated he had not considered the potential harm but acknowledged that access to the survey results could provide residents with assurance that reported complaints are investigated by the state.Interview conducted 4/02/2026, at 10:15 AM, the ACTD stated she worked at the facility for a year and a half. The ACTD was asked about the location of the state survey results binder. She stated that she believed it was located in the administrator's office and was not accessible to everyone. She further stated that she was unaware the survey results binder was required to be accessible to all individuals. She indicated that if a resident or visitor requested the binder, she would have to ask the administrator to retrieve it. The ACTD stated she did not know of any potential harm to residents that could result from not having the survey results binder readily accessible. Review of the facility's Required Posting of Survey Results and Regulatory Notices policy with revision date of January 2026 reflected: Policy The facility will ensure that all required survey results, regulatory notices, and enforcement actions are posted in a conspicuous and accessible location for residents, visitors, and the public, in accordance with federal and state regulations. Postings will be current, legible, and maintained for the required timeframes. Procedure Required Documents to be Posted The facility will post the following, as applicable: Most recent standard survey results Complaint survey results (as required) Plans of Correction (POCs) for cited deficiencies Notices of enforcement actions, including: Civil Money Penalties (CMPs) Denial of Payment for New Admissions (DPNA) Directed Plans of Correction State-required notices (if applicable) Posting Location All required postings will be placed in a prominent and accessible location, such as: Main lobby Near reception desk The location must: Be easily visible to the public Not require staff assistance to access Be maintained free of obstruction Timeliness of Posting Survey results and related documents will be posted: Within 72 hours of receipt from the regulatory agency (or per state requirement) Updates (e.g., revised POCs or enforcement notices) will be posted promptly upon receipt. Duration of Posting Survey results and POCs will remain posted for a minimum of: 12 months, or As otherwise required by state regulation.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 19 residents (Resident #56 and Resident #59) reviewed for resident rights. The facility failed to ensure Resident #56 and Resident #59's room temperatures were maintained at comfortable temperatures (between 71 to 81 degrees) on 03/31/2026 when the temperatures were found to be 67 to 68 degrees. These failures could place residents at risk of being cold, living in an uncomfortable environment, and a diminished quality of life.Findings included: Review of Resident #56's face sheet dated 04/02/2026 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body) and macular degeneration (an eye disease that affects central vision). Review of Resident #56's quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating his cognition was intact. Review of Resident #56's comprehensive care plan dated 02/23/2026 reflected a focus area of Resident does not like to get out of bed. Review of Resident #59's face sheet dated 03/25/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses, hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body), diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.) and major depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Review of Resident #59's admission MDS dated [DATE] reflected that he was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. An observation and interview on 03/31/2026 at 8:57 AM revealed Resident #56 was in his room in bed. He stated his room was cold. Resident #56 was in bed with multiple covers on. An observation and interview on 03/31/2026 at 9:15 AM revealed Resident #59 was in his room in bed. He stated his room was cold. Resident #59 was in bed with multiple covers on. An observation on 03/31/2026 at 9:28 AM revealed Resident #56's room temperature was 68 degrees and was measured using a PDT650 (Digital folding pocket thermometer (designed for professionals who need accurate, portable temperature readings in demanding environments such as HVAC.) An observation on 03/31/2026 at 9:30 AM revealed Resident #56's room temperature was 67 degrees and was measured using the PDT650 thermometer. An observation on 03/31/2026 at 9:32 AM revealed the air conditioning control box in the hall outside of Residents #56 (room [ROOM NUMBER]) and #59's room (room [ROOM NUMBER]) was set at 68 degrees. The plastic box that covered the control box was missing. An observation and interview on 03/31/2026 at 10:00 am, the DOSS went to the air conditioner control box and stated it should have a cover on it. He stated he did not know who was messing with the air conditioner box, but he would look into it. In an interview on 03/31/2026 at 2:30 PM, the DOSS stated the facility temperatures should be maintained between 72-82 degrees. He stated that the staff must have changed it. He stated he fixed the temperature and put a new cover box on the thermostat and stated he would be monitoring it daily to make sure the thermostats were set to the right temperatures to make sure the residents were comfortable. In an interview on 04/02/2026 at 10:45 AM, the Administrator stated he expected the facility's temperatures to be maintained at the proper range of 71 to 81 degrees to ensure residents' comfort. Review of the facility's policy Dignity: Resident's rights dated June 2019 reflected It is the policy of this facility that the Facility staff will provide the resident with the right to an environment that preserves dignity and contributes to a positive self-image.7) Create a home-like environment for the resident that includes: e. Proper temperature and ventilation.h. Comfortable and safe temperature levels.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for food and nutrition services.1. The facility failed to date food and beverages found within the facility's freezers and refrigerator on 03/31/2026.2. The facility failed to date and properly seal food products in facility's freezers and refrigerator on 03/31/2026.These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness.Findings included:In an observation on 03/31/2026 at 6:49 AM, the facility's three door refrigerator was found to contain three trays of red juice and water that were not covered, labeled or dated. On a shelf was an open, uncovered, and undated can of soda. On two trays, fruit was cut and in bowls that was covered but not labeled or dated. In an observation on 03/31/2026 at 6:52 AM, the facility's three door freezer was found to contain an open undated box, partially opened bag of frozen fish filets that were exposed to air. There was also a partially opened, undated box of green beans that were exposed to the air. In the freezer, there was also an undated, unlabeled, and uncovered bowl of ice cream with a disposable spoon in it. In an interview on 04/02/2026 at 9:53 AM, Dietary Aide C stated that all items in the kitchen were required to be dated and labeled. The dietary aide stated frozen items were supposed to be covered when opened and that if frozen food was exposed to air in the freezer, it could be exposed to airborne issues or cross contamination. She stated employees' personal food should not be in the refrigerator or freezer. In an interview on 04/02/2026, at 9:56 AM, [NAME] A stated that everything in the kitchen was required to be dated and labeled. She stated frozen items were to be sealed when opened, and frozen food that was exposed to air in the freezer could lead to freezer burn. She also said personal food items were not allowed to be kept in kitchen refrigerators according to dietary policy. In an interview on 04/01/2026 at 10:15 AM, the Dietary Manager stated that their policy was to label and date items placed in the refrigerator and freezer. The Dietary Manager stated the trays containing glasses with juice and the cut fruit were placed in the refrigerator just prior to inspection and were dated after observation. The Dietary Manager stated that the plastic bag containing the green beans and the fish fillets should have been dated and sealed after it was opened. The Dietary Manager stated the failure to properly seal bags containing food in the freezers could lead to frost bite and that food could be ruined if not closed and sealed. Review of the facility's policy entitled Nutrition Services Policies and Procedures Revised February 2022, Subject: Safe Food Handling, General Statements: 6. Follow all local, State, and Federal Regulations when handling food. Food / Beverage Prepared and Served by Facility Staff for Patients / Residents: 5. Refrigerated Time / Temperature Control for Safety (TCS) leftover foods are properly covered, labeled and dated and marked with use by date. Foods are placed in shallow containers and immediately put in refrigerator or freezer for rapid cooling. TCS leftovers are discarded after 3 days unless otherwise indicated. Items that cannot be used within 3 days may be placed in the freezer. Leftover pureed food is discarded. Food / Beverage Prepared with Patients / Residents Individually or Groups: 3. All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened. Food/Beverages for Employee Consumption: 1. All foods and beverages in the facility that belong to employees are stored in employee refrigerators or other designated areas and labeled with the employee's name and the date the item was placed in the facility storge area. 2/ All foods are wrapped or covered to prevent contamination from outside sources. 4. Food and beverages are consumed by employees/contract personnel in designated areas such as breakrooms. Eating and drinking is not permitted in the kitchen, at nursing stations or rehab areas, etc., unless approved for therapeutic intervention.

Based on observations, interviews, and record reviews, the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #38) of five residents reviewed for resident rights.The facility failed to ensure Resident #38's call light was within reach on 03/31/2026 and 04/02/2026.This failure could place residents at risk of needs and accommodation being unmet.Record Review of Resident #38's quarterly MDS assessment dated [DATE] indicated Resident #38 was a [AGE] year-old male who was last admitted to facility on 02/10/2026 with multiple diagnoses to include Schizoaffective Disorder, Bipolar Type(mental health condition combining psychotic symptoms (hallucinations, delusions) with manic and depressive episodes, blindness right and left eye, Type 2 Diabetes(body resist insulin and fail to maintain normal blood sugars), and depression(sadness, loss of interest). MDS also indicated Resident #38 had a BIMS score of 00 indicating severe cognitive function. Review of Resident #38's care plan dated 03/19/2026 revealed focus Call bell will be attached to a stuff animal, so [Resident #38] can feel for it and ring for help when needed, initiated 02/23/2026 and revised 03/31/2026. Observation and interview conducted 3/31/2026 at 9:23 AM, revealed Resident #38 was on his bed, awake. It was observed that resident's call light was hanging on the wall clamped together, not within reach of Resident #38. When asked if he could reach the call light, Resident #38 responded he had to reach to get the light, and the resident was observed struggling to sit up. Observation and interview conducted 4/02/2026 at 9:03 AM, revealed Resident #38 was on his bed, awake. It was observed that resident's call light was still hanging on the wall clamped together, not within reach of Resident #38. Resident #38 said he could not reach the call light on the wall. He told the surveyor to ask the staff how to press the light. Surveyor pressed the call light, CNA B responded in less than a minute. In an interview conducted 04/02/2026 at 9:04 AM, CNA B reported she had worked at the facility for 15 years. She stated that call lights should always be within reach of residents. However, she explained that Resident #38 was blind and unable to visually locate the call light. She further stated that the call light cord was currently positioned on the wall because the resident frequently twists and turns, creating a risk of becoming entangled in the cord. CNA B reported that Resident#38 yelled out frequently throughout the day, and staff responded by checking on him regularly. She stated she had not observed a stuffed animal attached to the call light with the current system, noting that the call light system was relatively new (implemented approximately one week ago). She indicated that the resident may have had a stuffed animal attached to the previous call light system. CNA B stated she had not reviewed the resident's care plan. She stated a potential risk of harm, was that the resident could be harmed if he does not have access to a functional call light. During a demonstration of the call light, the CNA explained that the new call light system operated via a push-button and would not function if a stuffed animal was attached. She noted that the previous system used a pull-cord design, which may have been compatible with such an adaptation. The CNA concluded that the facility would need to figure out an appropriate solution to ensure the resident has safe and effective access to the call light under the new system. In an interview conducted 04/02/2026 at 12:30 PM, LVN D stated she had been employed at the facility for one month and has received training regarding call light use. She stated call lights should be kept within reach of the resident. LVN D reported she was unaware why Resident #38's call light was hanging on the wall. She further stated she was assigned to the locked unit that day of the interview. LVN D stated she would need to review the resident's care plan to determine if there was a specific reason for the call light placement. She reported awareness that Resident #38 crawls on the floor and acknowledged that having the call light positioned by Resident #38 could present a safety risk because Resident #38 may get tangled in the cord. She reiterated that she would need to verify this information in the care plan. LVN D stated the potential risk of a resident not having access to a call light includes the inability to call for assistance, which could result in falls or unmet needs. In an interview conducted 04/02/2026 at 12:45 PM, The MDS Coordinator stated she has been employed at the facility for seven years. She acknowledged concern regarding Resident #38's call light placement and stated the call light should be within reach of the resident. She reported that the facility recently implemented a new call light system, and the new system would require an adaptive attachment for Resident#38. She stated she felt bad for not addressing it sooner. The MDS Coordinator explained that with the previous call light system, the resident utilized a stuffed animal attachment, which served as a more accessible target for the resident to locate when needing assistance. She stated this adaptation had not yet been implemented with the new system. The MDS Coordinator reported that the interdisciplinary team will need to meet to assess the situation and develop an appropriate solution to ensure the resident has access to the call light. She stated she would follow up with the interdisciplinary team promptly to address the issue. The MDS Coordinator stated the potential risk of not having access to a call light is that the resident may be unable to obtain assistance in a timely manner when needed. In an interview conducted 04/02/2026 at 1:04 PM, the DON stated that during the installation of the new call light system, staff conducted routine rounds on Resident #38. He reported that the resident was monitored with hourly checks, and the resident's room was located next to the nurses' station to allow for frequent observation. The DON stated that as of 03/ 21/2026, staff discontinued documenting rounds on a paper check sheet, but continued documentation in the electronic medical record. He further stated the new call light system was fully installed on 03/26/2026. The DON reported that Resident #38 does not actively search for the call light and instead typically knocked on the wall to gain staff attention. He stated that behavior is the reason the resident's room is located near the nurses' station to facilitate frequent monitoring. The DON stated that they are working on a solution for the light at this moment.In an interview conducted 04/02/2026 at 1:55 PM, the Administrator stated that call lights should always be within reach of all residents and accessible. He acknowledged that failure to provide access to a call light presents a potential risk, as residents may be unable to notify nursing staff of their needs or concerns. The Administrator reported that the facility contacted another facility to obtain an adaptive tap device for the call light. He stated the attachment is expected to arrive today and will be installed on the wall at a lower, more accessible level for Resident #38. In an interview and observation conducted 04/02/2026 at 2:25 PM, the RNC and DON advised the tap call light had arrived at facility and was installed to wall well within reach of Resident #38. The call light was observed in reach by a surveyor, and it worked properly.Review of facility's policy titled Resident Rights revised April 2024 reflected, Policy The facility protects and promotes the rights of each resident. The facility staff will uphold the resident's dignity and individuality, providing care that fosters their quality of life in a respectful environment. ProcedureThe facility provides a clean, safe, comfortable, and home-like environment. The facility provides equal access to quality of care regardless of diagnosis, severity of condition, or payment source. Record review of the facility's policy Dignity: Resident Rights, Revision date June 2019, stated: Policy: .7) Create a home-like environment for the resident that includes a. Sufficient space with access to personal living space; b. Appropriate furnishings and equipment, including access to telephones; f. Appropriate environmental adaptations to help residents with dementia or confusion; and g. Appropriate environment adaptations to help residents with other specific/special needs when indicated and if able to provide.

Based on observations, interviews, and record review, the facility failed to ensure resident was treated with respect and dignity for 1 (Resident #26) of 10 residents reviewed for resident rights.1. The facility failed to ensure Maintenance Tech E knocked on Resident #26's door prior to entry and explained the purpose of the visit before performing work in the room on 03/31/2026.2. The facility failed to ensure HSKP G knocked on Resident #26's door prior to entry on 03/31/2026.The deficient practice could place residents at risk of feeling uncomfortable, embarrassment, and a decreased quality of life.Record Review of Resident #26's MDS Assessment, dated 01/19/2026, reflected he was a [AGE] year-old male, admitted [DATE] with a BIMS score of 01, which indicated severe cognitive impairment. The resident's diagnoses included Generalized Anxiety Disorder (excessive worry about daily events), Other Paraphilias (intense, recurrent sexual interest that causes distress and impairment), Hyperlipidemia (elevated fat levels in blood), and Depression (mood disorder, loss of interest).Observation on 3/31/2026 at 9:28 AM revealed Maintenance Tech E entered Resident #26's room without knocking nor announcing who he was and what task he was going to complete in the room.Observation on 3/31/2026 at 9:34 AM revealed Maintenance Tech E re-entered Resident #26's room without knocking.Observation on 3/31/2026 at 9:36 AM revealed HSKP G entered Resident #26's room without knocking, nor spoke to the resident, and started talking to Maintenance Tech E.Interview conducted on 04/02/2026 at 9:16 AM, with HSKP G revealed she worked at the facility for 1 year. HSKP G stated she was trained on resident rights and dignity. HSKP G acknowledged that she did not knock before entering Resident #26 's room on the morning of 03/31/2026, explaining that she was not thinking at the time. She stated that staff should knock on a resident's door before entering, identify themselves, and explain the purpose of their visit. The housekeeper further stated that failing to knock before entering a resident's room could have a negative effect, as it may cause the residents to feel uncomfortable or that their privacy has been violated.Interview conducted on 04/02/2026 at 12:19 PM, with Maintenance Tech E revealed he worked at the facility for 2 years. Maintenance Tech E stated he was trained on dignity and resident rights. He stated he did not recall failing to knock on Resident 26's door. He stated, I do not like being accused of things. After being advised of each observation in which he did not knock, the maintenance tech stated that nine times out of ten he knocks before entering rooms. He stated, in a defensive and rude tone, apparently I was in a rush . He further stated he entered the room to repair a curtain and thought he told the resident what he was going to do. When asked about the potential effect on a resident when staff do not knock before entering, Maintenance Tech E stated, most residents are thankful that I am doing something for them.Record review of the facility's policy Dignity: Resident Rights, Revision date June 2019, stated: Policy: .7) Create a home-like environment for the resident that includes: a. Sufficient space with access to personal living space. d. Staff knock prior to entering room.

Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for one (Resident #4) of four residents reviewed for resident assessments. Resident #4's PASARR Level l was not updated to reflect his new diagnoses of PTSD (post-traumatic stress disorder) on 07/09/2025 after he was admitted on [DATE]. This failure could place residents who had a mental illness and/or intellectual or development disabilities at risk for not receiving the appropriate care, and services to meet their needs.Findings included: Review of Resident #4's face sheet dated 04/01/2026 reflected a [AGE] year-old male admitted on [DATE] with the following diagnoses diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall.), and heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.). Review of Resident #4's annual MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 12 indicating he had moderate cognitive impairment. Resident #4 was assessed to have PTSD. Review of Resident #4's comprehensive care plan dated 03/03/2026 reflected a focus area of Resident has PTSD and is at risk for violence directed towards self or others. Review of Resident #4's PASRR level 1 screening dated 03/28/2025 reflected Resident #4 was assessed to not have mental illness. In an interview on 04/01/2026 at 1:12 PM, the MDS Coordinator stated she was in charge of doing PASRR assessments. She stated Resident #4 had a diagnosis of PTSD added after he was admitted . The MDS Coordinator stated that she should have redone his PASARR level one so he could get a level two evaluation done to determine if he qualified for benefits. She stated that she would update Resident #4's level one PASARR to include mental illness so he can get a PASARR level two completed. In an interview on 04/01/2026 at 1:20 PM, the DON stated he expected residents to have PASARRs done correctly and if they had a change in diagnoses or an addition of a mental health diagnosis, the Residents PASARRs are updated to ensure they are getting the services they need. Review of the facility's policies and procedures PASRR dated 01/2025 reflected This policy ensures compliance with federal and Texas Health and Human Services Commission (HHSC) regulations regarding the Preadmission Screening and Resident Review (PASRR) process. The goal is to identify individuals with Mental Illness (Ml}, Intellectual Disability (ID}, or Developmental Disability/Related Conditions (DD/RC) and ensure appropriate placement and specialized services. The PASRR Level I (Pll) Screening Form is designed to identify individuals who are suspected of having mental illness (Ml), intellectual disability {ID), or a developmental disability (DD).

Based on observations, interviews, and record reviews, the facility failed to provide bedrooms that measured at least 80 square feet per resident in multiple resident bedrooms for 3 of 7 resident rooms (rooms [ROOM NUMBER]) reviewed for environment.The facility failed to ensure resident bedrooms rooms, 25, 26, and 27 measured at least 80 square feet per resident.This failure could place residents at risk by limiting the amount of resident care equipment and personal belongings that could be accommodated in the resident's room. This may restrict the resident's' ability to move about the room freely and could negatively affect the residents' quality of life.Observations conducted on 3/31/26 during the initial pool screening beginning at 6:00 AM revealed 3 resident rooms did not have the required amount of living space for each resident.An observation conducted 4/02/2026 at 8:45 AM revealed the following measurements of resident room dimensions for the room size waiver:1. room [ROOM NUMBER] (2-person room - 2 residents in room) -144 sq ft./ 2 residents = 72 sq ft./resident2. room [ROOM NUMBER] (2-person room - 2 residents in room) -144 sq ft./ 2 residents = 72 sq ft./resident3. room [ROOM NUMBER] (2-person room - 2 residents in room) -144 sq ft./ 2 residents = 72 sq ft./residentAn interview conducted with the DOSS on 4/02/2026 at 10:04 AM, revealed he was not aware of the specific square footage requirements for residents' rooms. He stated he was recently been informed on 3/31/2026 that a waiver was previously granted for the rooms. The DOSS indicated that he believed several rooms may not meet the required square footage. He further stated the room-related issues had typically been handled by the administrator. He reported that he was not aware of any potential harm unless a resident were to voice a complaint.An interview conducted with the ADM on 4/02/2026 at 1:52 PM, revealed he had been at the facility for approximately three weeks, and was not aware the resident rooms did not meet the regulatory room size requirements. The Administrator stated he located documentation that indicated a request for a room size waiver was submitted previously; however, he was unable to determine the status of that request. The Administrator stated he would request a room size waiver again. Record review of the room roster provided by the facility on 03/31/2026 revealed 6 residents lived in rooms [ROOM NUMBER].A facility policy was requested for room sizes. It was not provided before exit.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1wing (1Upstairs wing) of 2 facility wings observed for environment. The facility failed to ensure the upstairs restrooms and shower rooms had hot water readily available. This deficient practice could place residents at risk of a decreased quality of life. During an observation on 3/4/26 at 11:30 a.m. restroom D revealed that the hot water faucet turned on but no water came out of faucet. During an observation on 3/4/26 at 11:35 a.m. restroom C revealed that the hot water after running for 2 minutes reached temperature of 74.4 degrees Fahrenheit. During an observation on 3/4/26 at 1:00 p.m. staff/visitor restroom F revealed that the hot water after running for 2 minutes reached temperature of 73.6 degrees Fahrenheit. During an observation on 3/4/26 at 1:30 p.m. of restroom/shower room A revealed that the hand sink hot water after running for 2 minutes reached temperature of 78.2 degrees Fahrenheit. Observation of shower hot water after running for 2 minutes reached temperature of 78.4 degrees Fahrenheit. During an observation on 3/4/26 at 2:00 p.m. of restroom/shower room B revealed that the hand sink hot water after running for 2 minutes reached temperature of 74.6 degrees Fahrenheit. Observation of shower hot water after running for 2 minutes reached temperature of 73.8 degrees Fahrenheit. During an observation on 3/5/26 at 11:26 a.m. of restroom/shower room B revealed that the hand sink hot water after running for 2 minutes reached temperature of 74.8 degrees Fahrenheit with low water pressure observed. Observation of shower hot water after running for 2 minutes reached temperature of 73.9 degrees Fahrenheit. During an observation on 3/5/26 at 11:33 a.m. of restroom C revealed that the hand sink hot water after running for 2 minutes reached temperature of 74.7 degrees Fahrenheit. During an observation on 3/5/26 at 11:36 a.m. restroom D revealed that the hot water faucet turned on but no water came out of faucet. During an observation on 3/5/26 at 11:50 a.m. of restroom/shower room A revealed that the hand sink water after running for 2 minutes reached temperature of 78.3 degrees Fahrenheit. Observation of shower hot water after running for 2 minutes reached temperature of 78.1 degrees Fahrenheit. During an observation on 3/5/26 at 12:00 p.m. of visitor/staff restroom F revealed that the hand sink hot water after running for 2 minutes reached a temperature of 74.3 degrees Fahrenheit. During an observation on 3/5/26 at 4:16 p.m. of restroom/shower room B revealed that the MS turned the hot water on to heat up. Observation on 3/5/26 at 4:45 pm revealed that the hot water temperature reached 95.3 degrees Fahrenheit. During an interview on 3/5/26 at 10:00 a.m. with CR#1 revealed that CR#1 said there has not been any hot water upstairs for months and that the residents are taken downstairs to receive showers unless they want a cold shower. CR#1 said that the administration and all the staff are aware of the lack of hot water. CR#1 said that he had been told repairs are being made but no completion date is ever provided. During an interview on 3/5/26 at 12:44 p.m. with CNA C revealed CNA C said the restroom and shower rooms hot water takes a very long time to heat up and shower room A never really heats up but shower room B heats up after a long time. CNA C said sometimes the residents are showered upstairs but that most of the time the residents do not want to wait as long as it takes the water to heat so they are taken downstairs to receive their showers. CNA C said he felt that not having hot water could possibly be a Resident Rights concern for the residents since they must go downstairs to receive a shower. During an interview on 3/5/26 at 1:08 p.m. with CNA D revealed CNA D said the upstairs does not really have access to hot water for the restrooms and the showers and that repairs have been occurring for a while now, at least the entire 4 months that I have worked at the facility. CNA D said that she takes her residents downstairs to receive showers so they will have access to hot water. CNA D said she comes in early to shower her residents since the entire facility was sharing one shower and sometimes it was difficult to get all the showers completed on their assigned day. CNA D said she has spoken with the charge nurses, ADON, and DON, about the hot water issue and has received the same response from everyone that repairs are being made. CNA D said she felt that not having access to hot water upstairs could be a Resident Right violation because the residents do have this right and currently it is not honored. During an interview on 3/5/26 at 1:22 p.m. with HK revealed HK said there has not been hot water upstairs for the entire year she has worked at the facility. HK said there have been repairs occurring, but she was unsure when repairs were to be completed. HK stated she had not brought the lack of hot water concern to administration because all the staff at the facility are aware of the problem. HK stated the upstairs resident receive their showers downstairs. HK stated that the housekeeping staff all get their hot water needed for mopping and cleaning resident rooms from the downstairs supply closet sink. HK stated that she feels not having hot water could be a Resident Right violation. During an interview on 3/5/26 at 1:34 p.m. with LVN A revealed LVN A said she was unsure if the restrooms and shower rooms upstairs had hot water currently. LNV A said she knew there had been issues but she was unsure if repairs had been completed. LVN A said that some residents are taken downstairs to receive showers if they want hot water. LVN A said she did not feel there was any concern with residents receiving timely care with the entire facility sharing one shower because all the staff work together. When asked LVN A said that yes not having hot water could potentially be a Resident Rights concern because it is their right to have access to hot water. During an interview on 3/5/26 at 1:45 p.m. with LVN B revealed LVN B said the upstairs restrooms and shower rooms currently do not have hot water. LVN B said she was unsure of the timeframe of how long the upstairs restrooms and shower rooms had been without hot water. LVN B said there have been repair people out for the last couple of weeks making repairs, but she was also unsure of a completion date for the repairs. LVN B said the residents are currently receiving showers downstairs and the staff are just working together to ensure resident care was not impacted. LVN B said not having hot water could be a Resident Rights concern since they do have the same rights as everybody else. During an interview on 3/5/26 at 1:56 p.m. with CNA E revealed CNA E said she was unsure if the upstairs had hot water, but she suspected that they did not since they brought the residents downstairs to be showered. CNA E said the upstairs residents have been receiving showers downstairs for over a month. CNA E said that she felt not having hot water could potentially be a Resident Rights concern. During an interview on 3/5/26 at 2:10 p.m. with CNA F revealed CNA F said that the upstairs had not had hot water for at least the last 6 months. CNA F stated the resident are taken downstairs to receive showers and that there is only one shower downstairs. CNA F stated the entire facility shares one shower room and sometimes that impacts resident care because everyone is taking turns to use the shower and sometimes residents must wait and that can be a struggle for the staff and an inconvenience for the resident. CNA F stated she felt like not having hot water could be a Resident Rights violation. CNA F stated all the staff and administration are aware that there is no hot water, but no response has been received as to when repairs will be completed. During an interview on 3/5/26 at 2:30 p.m. with MS revealed MS said that upstairs currently did not have hot water and that the system had been under repairs for the last 2 months. MS stated it takes over 10 minutes for the water to heat up to be warm enough to shower. MS said he was unsure if this was impacting resident care by all residents having to share the one downstairs shower, but he did not think it was since he had not heard anything from the nursing staff saying it was. MS said by not having hot water upstairs it could potentially be a Resident Rights concern. MS said he had received several different quotes from different companies about having repair work completed. When asked MS was unable to provide a date that repairs had been completed. During an interview on 3/5/26 at 4:20 p.m. with DON revealed DON said ideally the shower rooms and restrooms upstairs should have hot water but currently there was an issue, and repairs are being made. DON said he was unaware of the completion date for the repairs he would have to speak to MS and to his RDO for this information. DON said there had been a problem with the hot water upstairs since January of 2026. During an interview on 3/5/26 at 4:46 p.m. with DON revealed DON said that all the current work order quotes that the facility had for the hot water repair had been completed but since the hot water was still taking so long to heat up that repair people were scheduled to come back to the facility on 3/6/25 to investigate to see why the delay in temperature rise is still occurring. Record review of grievance log reflected no grievances regarding hot water of lack of filed for 6 months reviewed. Record review of hot water repair quote from mechanical repair company dated 2/5/26 reflected needed repair to tankless water heater scope of work as follows installation of 2 return lines at the property to get hot water to the plumbing fixtures sooner. Record review of hot water repair quote from mechanical repair company dated 3/3/26 reflected needed repairs of remove and replace a set of twinned furnaces and replace with new furnaces. Record review of email communication from mechanical repair company dated 3/5/26 reflected the current work that was quoted has been completed. Unfortunately, one of the systems are still offline due to a faulty control board. I am being told there is hot water just takes a few minutes due to system only running at 50%. Good news is the board is under factory warranty. This is an issue that was not caused by the hot water loop installation. The board was ordered and as to expedite shipping. We should be online no later than Monday. But with that said we are at the mercy of the shipping company. I will update you with any new information I receive. Record review of facility Resident Rights with a revision date of 4/2024 reflected under heading policy: The facility protects and promotes the rights of each resident. The facility staff will uphold the residents' dignity and individuality, providing care that fosters their quality of life in a respectful environment. Under heading procedure:-The facility provides a clean, safe, comfortable, and home-like environment

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when on 02/07/2026 at approximately 10:00 AM LVN A told Resident #1 to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up. LVN A pushed Resident #1's head forward in the dining room which humiliated him, and LVN A continued to be Resident #1's nurse after the incident and a the day after the incident. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This failure could place the residents in the facility at risk for abuse and neglect. Finding included: Record review of Resident #1's face sheet, dated 02/19/2026, revealed a fifty-one-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His admitting diagnoses included bipolar disorder, current episode hypomanic (a distinct period of abnormally elevated, energetic, or irritable mood lasting at least four consecutive days), thrombotic microangiopathy (a life-threatening, rare syndrome characterized by damage to the lining of small blood vessels (endothelial injury), and systemic lupus erythematosus (a chronic, multi-system autoimmune disease where the immune system attacks healthy tissue). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 12/16/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 12 indicating moderate cognitive issues. Record review of Resident #1's care plan revealed a focus dated 11/05/2025 of Resident #1 is depended on staff for meeting emotional, intellectual, physical, and social needs. Record review of a text message dated 02/07/2026 at 10:00 AM from MT A to the Administrator reflected MT A said she would be writing a grievance about LVN A due to an incident that occurred at breakfast. The Administrator asked what happened. MT A responded that LVN A was arguing with Resident #1 about him going to his room then made a threat that, she couldnt [sic]wait till he was off of parole so she could show him what a nurse about. Resident #1 told MT A that LVN A tapped him on the back of the head in the dining room. MT A wrote that she knew LVN A was mad because Resident #1 told LVN A quit talking to herself. The Administrator said okay, and thanks for letting her know.Record review of employment document for LVN A reflected employment termination date 02/12/2026 for disciplinary action. During an interview on 02/18/2026 at 1:26 PM MT A said she reported the incident that occurred on 02/07/2026 between LVN A and Resident #1 by text to the Administrator. MT A said she heard LVN A ask Resident #1 where he was going and told him she was tired of him going back and forth. MT A said she heard Resident #1 tell LVN A that she had whole conversations by herself. MT A said she heard LVN A tell Resident #1, I cannot wait until your parole release because then I can show you what a nurse is about. MT A said Resident #1 told her that LVN A popped him on the back of the head. MT A said that LVN A worked the rest of her shift that day. MT A said that Resident #1 told her he was scared to ask LVN A for anything for the rest of the day. MT A said she reported the incident to the Administrator between 9:30 AM and 10:00 AM on 02/07/2026. MT A said that the Administrator replied to MT A's text message that notified the Administrator about the incident that she would take care of it. MT A said the Administrator did not come to the facility that day. MT A said that LVN A worked the rest of her shift on Saturday 02/07/2026 and her shift on 02/08/2026. During an interview on 02/18/2026 at 3:25 PM Resident #1 said he had a problem with LVN A. He said she was, very opened mouthed. Resident #1 said LVN A would tell him she was tired of giving him his 2:00 PM pill all the time. He said he was in the dining room and LVN A told him to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up; and then she hit the back of his head. He said it did not hurt but made him feel like, she could take over him and made him feel stupid. Resident #1 said other residents saw LVN A hit him, but he did not remember their names. Resident #1 said LVN A did not hit him hard, but it made his head go forward. During an interview on 02/18/2026 at 4:34 PM the DON said LVN A could be argumentative and that LVN A was on the clock and worked for 2 days after the allegations between Resident #1 and LVN A were reported to the Administrator. He said that because LVN A continued to work after the allegation of abuse and neglect this could have put residents at risk of abuse and neglect. During an interview on 02/18/2026 at 5:16 PM CNA A said she was in the dining room with Resident #1 and LVN A and she saw LVN A touch the back of his Resident #1's head and his head went forward. CNA A said she looked at CNA C and asked her Did you see that? and CNA C said Yes. CNA A asked Resident #1 if LVN A pushed the back of his head and Resident #1 told her yes. CNA A said she did not hear LVN A say anything to Resident #1. CNA A said it was never okay to touch a resident in that manner, to push their head. She said LVN A did not tell Resident #1 excuse me or that she was sorry. CNA A said LVN A intentionally pushed his head. CNA A said that LVN A pushed Resident #1's head and kept on walking. CNA A said she was trained in abuse and neglect and that the Administrator was the abuse and neglect coordinator. She said MT A told her she reported the incident to the Administrator and that was why she did not report it. CNA A said LVN A disregarded Resident #1. CNA A said she asked Resident #1 if LVN A pushed his head and Resident #1 told her yes. CNA A said that Resident #1 came to her later in the day and said he did not know why LVN A was still at the facility. CNA A said she told Resident #1 it would be handled. During an interview on 02/19/2026 at 8:12 AM with the ADON, she said she learned about Resident #1's allegation with LVN A on Monday, 02/09/2026. The ADON said she did not know who witnessed the incident. The ADON said she assessed Resident #1 from head to toe and there were no findings of visible discoloration. Prior to the incident, the ADON said she heard from the staff that LVN A was easily agitated. The ADON said the incident was an allegation of abuse and neglect and allegations of abuse and neglect should be reported immediately. She said LVN A was not suspended at the time of the incident. The ADON said a possible negative effect of not suspending LVN A was that residents were subject to the same thing happening to them, either to Resident #1 again or another resident. She said the Administrator was the abuse and neglect coordinator. The ADON said when she spoke with Resident #1 when she assessed him on 02/09/2026 he said he did not want to say anything because he did not want to get anyone in trouble, but he confirmed that LVN A did push the back of his head. Resident #1 said it was not a hard slap but like a little pop. The ADON said Resident #1 told her that during the weekend he did not feel safe and was afraid to ask LVN A for his PRN medication. During an interview on 02/19/2026 at 8:42 AM Resident #1 said after the incident with LVN A he stayed out of her way and avoided her because he did not want to deal with her. Resident #1 said she made him feel uncomfortable and he was worried she might be verbally inappropriate to him again. During an interview on 02/19/2026 at 8:47 AM with CNA C, she said LVN A was behind Resident #1 and she saw LVN A push Resident #1's head forward. She said it was not a full force push, but they should not play with residents by pushing their heads. She said she had been trained in abuse and neglect a million times. She said the Administrator was the abuse and neglect coordinator and abuse and neglect should be reported immediately. CNA C said MT A reported the incident to the Administrator. CNA C said LVN A continued to work that weekend and LVN A was Resident #1's nurse that weekend. During an interview on 02/19/2026 at 12:00 PM Resident #1 said he did not feel comfortable asking for his pain medications from LVN A and he said he was in pain. He said he did not have anyone else to get his pills from because LVN A was his nurse that weekend. He said he felt very very uncomfortable, like he had to beg for his pills and did not want to put up with her crap when he asked for his pills. Resident #1 said when LVN A hit his head in front of people in the dining room it humiliated him. He said he was not fearful, but he did isolate himself a little bit that weekend and was psychologically a little uncomfortable. During an interview on 02/19/2026 at 12:40 PM with the Administrator, she said she received a report of an allegation of abuse and neglect on 02/07/2026 and she did not report it to HHS until Monday 02/09/2026. The Administrator said it was an error on her part not to have reported the incident. She did not report the incident because she thought it was a personal issue between MT A and LVN A and she misjudged. The Administrator said she wanted to investigate the incident to find out what it was before she reported it. The Administrator said she now knew that they were to report the incident and not try to get the facts first. She said she now knew she should have immediately suspended LVN A and reported to HHS immediately. She said the possible negative effect of not immediately suspending LVN A immediately was that the residents could have been subjected to additional abuse. During an interview on 02/19/2026 at 12:40 PM with the RDO, he said he received a call on Monday 02/09/2026 about a text that was sent to the Administrator of the facility on 02/07/2026 involving allegations of abuse and neglect. The RDO said matters of personal relationships between staff could not be taken into consideration when the allegation involved resident abuse or neglect. The RDO said the event should have been immediately reported to HHS in accordance with the facility and state guidelines. The RDO said the facility had a responsibility to protect the residents and remove a possible threat of abuse and neglect and in this case, LVN A was the threat, and she should have been removed by suspending her employment. During an interview on 02/20/2026 at 8:05 AM the ADON said she was not aware of the incident that involved Resident #1 or LVN A until Monday, 02/09/2026. She said both she and the DON should have been contacted about the incident by the Administrator when the Administrator learned of the incident from MT A. The ADON said LVN A should have been suspended that day, immediately pending investigation. She said because there was an allegation of abuse LVN A needed to be removed from the facility to protect the residents from possible further abuse. She said the facility policy was that for any possible allegation of abuse by a staff member, that staff member should be suspended until the investigation was completed. She said she had no doubt that Resident #1 was telling the truth about LVN A putting her hand on his head and pushing his head forward. She said she did not know why the Administrator did not take the steps and report the incident. The ADON said they should not make assumptions about what happened when abuse was reported. She said they were supposed to report incidents of abuse and neglect within two hours of learning about it. She said the facility was the residents' home and they needed to be kept from abuse and neglect. The ADON said the facility abuse and neglect policies were not implemented. During an interview on 02/20/2026 at 9:13 AM the Administrator said allegations of abuse and neglect were supposed to be reported to HHS immediately. The Administrator said the facility policies on reporting and investigating abuse and neglect were not followed. The Administrator said on Monday 02/09/2026 she spoke with Resident #1 about the incident with LVN A that occurred on 02/07/2026 and he said what happened made him uncomfortable. The Administrator said she was not aware that Resident #1 told the ADON that he felt uncomfortable asking for his PRN medications because LVN A was his nurse for the rest of her shift on 02/07/2026 and on 02/08/2026. The Administrator said LVN A should not have continued to be his nurse because there could have been potential danger to Resident #1 and maybe other residents for possible further abuse. During an interview on 02/20/2026 at 12:08 PM with the RNC, she said on Monday 02/09/2026 the Administrator called her and told her about the allegation of abuse and neglect that occurred on Saturday 02/07/2026. The RNC said initially she thought that the incident was not reported to the Administrator by the staff then she learned that the incident was reported to the Administrator by the staff and the Administrator did not report it to HHS. The RNC told the Administrator that the allegation should have been reported to HHS immediately. The RNC told her to inform the DON of the incident and to suspend LVN A immediately. The RNC said the Administrator did not report the allegation of abuse and neglect in a timely manner to HHS and she did not follow facility procedures. The RNC said anything that puts resident in harm both mentally and physical should be reported immediately. The RNC said Resident #1 could have had psychosocial harm. She said that Resident #1 could have feared approaching the nurse. The RNC said she understood that the incident humiliated him. The RNC said the Administrator did not report because of lack of experience. The RNC said the Administrator said there was history of MT A and LVN A not getting along so the Administrator thought there was nothing to the alleged allegations. The RNC said the process for any allegation of abuse and neglect was to report the allegation to HHS, suspend any staff who might be involved in allegations of abuse, and then investigate. Record review of facility policy and procedure on Abuse, Neglect and Exploitation dated October 2024 reflected definition abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled by technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Record review on 02/18/2026 of an in-service dated 02/09/2026 by the ROD to the Administrator regarding the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying, disclosing, and investigating alleged allegations of abuse and neglect. The in-service included the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying and disclosing alleged allegations of abuse and neglect. The in-service included the suspension of any employees alleged to have been involved in the abuse, neglect, or exploitation of residents. The in-service discussed when to report any and all allegations of suspected abuse, neglect, or exploitation, when to suspend any staff member(s) involved in allegations of abuse, neglect, or exploitation and when to begin and how to investigate allegations of abuse, neglect, or exploitation. Record review on 02/18/2026 of an in-service to all facility staff dated 02/09/2026 through 02/11/2026 revealed staff were educated on the facility policy and procedure on Abuse, Neglect and Exploitation including the elements of training, prevention, identification, investigation, protection, and reporting/response. Record review on 02/18/2026 of Resident #1's skin observation dated 02/09/2026 by the ADON revealed no redness, discoloration, or skin tears noted. Record review on 02/18/2026 of Resident #1's pain assessment dated [DATE] by DON of pain assessment revealed pain assessment was secondary to Lupus, no headache noted. Record review on 02/18/2026 of Resident #1's neurological assessments every 30 minutes dated 02/09/2026 through 02/11/2026. Record review on 02/18/2026 of an in-service dated 02/09/2026 through 02/11/2026 revealed all staff were educated on the expectations for maintaining professional boundaries, preserving resident dignity, and preventing behaviors that may be perceived as disrespectful, demeaning, or emotionally harmful. Record review on 02/18/2026 of the Resident Safe Survey Questionnaire Alert/Oriented dated 02/10/2026. Record review of statements from MT A dated 02/09/2026, LVN A dated 02/09/2026, CNA A dated 02/10/2026, and Resident #1 dated 02/09/2026. During an interview on 02/19/2026 at 4:39 PM with LVN B, she said she attended an in-service on 02/10/2026 on abuse and neglect and gave an example of hitting a resident or cursing at a resident as examples of abuse and neglect. She said allegations of abuse and neglect should be reported immediately. She said allegations of abuse and neglect should be reported to the Administrator who was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:43 PM with CNA F, she said she received training on 02/10/2026 on abuse and neglect. She said abuse could be physical, verbal, sexual and mental. She said exploiting residents was also abuse. She said abuse should be immediately reported to the facility Administrator. She said the Administrator was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:45 PM with CNA G, she said she was trained in abuse and neglect on 02/10/2026. She said abuse could be physical, mental, or sexual. She said taking a call light away from a resident was a form of abuse. She said abuse should be reported to the Administrator because the Administrator was the abuse and neglect coordinator.

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to remove LVN A from duty and she continued to work with Resident #1 after witnessed abuse was reported to the administrator. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This failure could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of timely reporting of incidents.Finding included: Record review of Resident #1's face sheet, dated 02/19/2026, revealed a fifty-one-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His admitting diagnoses included bipolar disorder, current episode hypomanic (a distinct period of abnormally elevated, energetic, or irritable mood lasting at least four consecutive days), thrombotic microangiopathy (a life-threatening, rare syndrome characterized by damage to the lining of small blood vessels (endothelial injury), and systemic lupus erythematosus (a chronic, multi-system autoimmune disease where the immune system attacks healthy tissue). Record review of Resident #1's care plan revealed a focus dated 11/05/2025 of Resident #1 is depended on staff for meeting emotional, intellectual, physical, and social needs. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 12/16/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 12 indicating moderate cognitive issues. Record review of text message dated 02/07/2026 at 10:00 AM from MT A to the Administrator reflected MT A said she would be writing a grievance on LVN A due to an incident that occurred at breakfast. The Administrator asked what happened. MT A responded LVN A was arguing with Resident #1 about him going to his room then made a threat that, she couldnt [sic] wait till he was off of parole so she could show him what a nurse about. Resident #1 told MT A that LVN A tapped him in the back of the head in the dining room. MT A wrote that she knew LVN A was mad because Resident #1 told LVN A quit talking to herself. The Administrator said okay, thanks for letting me know.Record review of employment document for LVN A reflected employment termination date 02/12/2026 for disciplinary action. During an interview on 02/18/2026 at 1:26 PM MT A said she reported the incident that occurred on 02/07/2026 between LVN A and Resident #1 by text to the Administrator. MT A said she heard LVN A ask Resident #1 where he was going and told him she was tired of him going back and forth. MT A said she heard Resident #1 tell LVN A that she had whole conversations by herself. MT A said she heard LVN A tell Resident #1, I cannot wait until your parole release because then I can show you what a nurse is about. MT A said Resident #1 told her that LVN A popped him in the back of the head. MT A said that LVN A worked the rest of her shift that day. MT A said that Resident #1 told her he was scared to ask LVN A for anything for the rest of the day. MT A said she reported the incident to the Administrator between 9:30 AM and 10:00 AM on 02/07/2026. MT A said that the Administrator replied to MT A's text message that notified the Administrator about the incident that she would take care of it. MT A said the Administrator did not come to the facility that day. MT A said that LVN A worked the rest of her shift on Saturday 02/07/2026 and her shift on 02/08/2026. During an interview on 02/18/2026 at 3:25 PM Resident #1 said he had a problem with LVN A. He said she was, very opened mouthed. Resident #1 said LVN A would tell him she was tired of giving him his 2:00 PM pill all the time. He said he was in the dining room and LVN A told him to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up and then she hit the back of his head. He said it did not hurt but made him feel like, she could take over him and made him feel stupid. Resident #1 said other residents saw LVN A hit him, but he did not remember their names. Resident #1 said LVN A did not hit him hard, but it made his head go forward. During an interview on 02/18/2026 at 4:34 PM the DON said LVN A could be argumentative and that LVN A was on the clock and worked for 2 days after the allegations between Resident #1 and LVN A were reported to the Administrator. He said that because LVN A continued to work after the allegation of abuse and neglect this could have put residents at risk of abuse and neglect. During an interview on 02/18/2026 at 5:16 PM CNA A said she was in the dining room with Resident #1 and LVN A and she saw LVN A touch the back of his Resident #1's head and his head went forward. CNA A said she looked at CNA C and asked her did you see that and CNA C said yes. CNA A asked Resident #1 if LVN A pushed the back of his head and Resident #1 told her yes. CNA A said she did not hear LVN A say anything to Resident #1. CNA A said it was never okay to touch a resident in that manner, to push their head. She said LVN A did not tell Resident #1 excuse me or she was sorry. CNA A said LVN A intentionally pushed his head. CNA A said that LVN A pushed Resident #1's head and kept on walking. CNA A said she was trained in abuse and neglect and that the Administrator was the abuse and neglect coordinator. She said MT A told her she reported the incident to the Administrator and that was why she did not report it. CNA A said LVN A disregarded Resident #1. CNA A said she asked Resident #1 if LVN A pushed his head and Resident #1 told her yes. CNA A said that Resident #1 came to her later in the day and said he did not know why LVN A was still at the facility. CNA A said she told Resident #1 it would be handled. During an interview on 02/19/2026 at 8:12 AM with the ADON she said she learned about Resident #1's allegation with LVN A on Monday, 02/09/2026. The ADON said she did not know who witnessed the incident. The ADON said she assessed Resident #1 from head to toe and there were no findings of visible discoloration. Prior to the incident, the ADON said she heard from the staff that LVN A was easily agitated. The ADON said the incident was an allegation of abuse and neglect and allegations of abuse and neglect should be reported immediately. She said LVN A was not suspended at the time of the incident. The ADON said a possible negative effect of not suspending LVN A was that residents were subject to the same thing happening to them, either to Resident #1 again or another resident. She said the Administrator was the abuse and neglect coordinator. The ADON said when she spoke with Resident #1 when she assessed him on 02/09/2026 he said he did not want to say anything because he did not want to get anyone in trouble, but he confirmed that LVN A did push the back of his head. Resident #1 said it was not a hard slap but like a little pop. The ADON said Resident #1 told her that during the weekend he did not feel safe and was afraid to ask LVN A for his PRN medication. During an interview on 02/19/2026 at 8:42 AM Resident #1 said after the incident with LVN A he stayed out of her way and avoided her because he did not want to deal with her. Resident #1 said she made him feel uncomfortable and he was worried she might be verbally inappropriate to him again. During an interview on 02/19/2026 at 8:47 AM with CNA C she said LVN A was behind Resident #1 and she saw LVN A push Resident #1's head forward. She said it was not a full force push, but you should not play with residents by pushing their heads. She said she had been trained in abuse and neglect a million times. She said the Administrator was the abuse and neglect coordinator and abuse and neglect should be reported immediately. CNA C said MT A reported the incident to the Administrator. CNA C said LVN A continued to work that weekend and LVN A was Resident #1's nurse that weekend. During an interview on 02/19/2026 at 12:00 PM Resident #1 said he did not feel comfortable asking for his pain medications from LVN A and he said he was in pain. He said he did not have anyone else to get his pills from because LVN A was his nurse that weekend. He said he felt very uncomfortable, like he had to beg for his pills and did not want to put up with her crap when he asked for his pills. Resident #1 said when LVN A hit his head in front of people in the dining room it humiliated him. He said he was not fearful, but he did isolate himself a little bit that weekend and was psychologically a little uncomfortable. During an interview on 02/19/2026 at 12:40 PM with the Administrator she said she received a report of an allegation of abuse and neglect on 02/07/2026 and she did not report it to HHS until Monday 02/09/2026. The Administrator said it was an error on her part not to have reported the incident. She did not report the incident because she thought it was a personal issue between MT A and LVN A and she misjudged. The Administrator said she wanted to investigate the incident to find out what it was before she reported it. The Administrator said she now knows that you report the incident and not try to get the facts first. She said she now knows she should have immediately suspended LVN A and reported to HHS immediately. She said the possible negative effect of not immediately suspending LVN A immediately was that the residents could have been subjected to additional abuse. During an interview on 02/19/2026 at 12:40 PM with the RDO he said he received a call on Monday 02/09/2026 about a text that was sent to the Administrator of the facility on 02/07/2026 involving allegations of abuse and neglect. The RDO said matters of personal relationships between staff cannot be taken into consideration when the allegation involved resident abuse or neglect. The RDO said the event should have been immediately reported to HHS in accordance with the facility and state guidelines. The RDO said the facility had a responsibility to protect the residents and remove a possible threat of abuse and neglect and, in this case, LVN A was the threat, and she should have been removed by suspending her employment. During an interview on 02/20/2026 at 8:05 AM the ADON said she was not aware of the incident that involved Resident #1 or LVN A until Monday, 02/09/2026. She said both she and the DON should have been contacted about the incident by the Administrator when the Administrator learned of the incident from MT A. The ADON said LVN A should have been suspended that day, immediately pending investigation. She said because there was an allegation of abuse LVN A needed to be removed from the facility to protect the residents from possible further abuse. She said the facility policy was that for any possible allegation of abuse by a staff member, that staff member should be suspended until the investigation was completed. She said she had no doubt that Resident #1 was telling the truth about LVN A putting her hand on his head and pushing his head forward. She said she did not know why the Administrator did not take the steps and report the incident. The ADON said you do not make assumptions about what happened when abuse was reported. She said you were supposed to report incidents of abuse and neglect within two hours of learning about it. She said the facility was the residents' home and they needed to be kept from abuse and neglect. The ADON said the facility abuse and neglect policies were not implemented. During an interview on 02/20/2026 at 9:13 AM the Administrator said allegations of abuse and neglect are supposed to be reported to HHS immediately. The Administrator said the facility policies on reporting and investigating abuse and neglect were not followed. The Administrator said on Monday 02/09/2026 she spoke with Resident #1 about the incident with LVN A that occurred on 02/07/2026 and he said what happened made him uncomfortable. The Administrator said she was not aware that Resident #1 told the ADON that he felt uncomfortable asking for his PRN medications because LVN A she was his nurse for the rest of her shift on 02/07/2026 and on 02/08/2026. The Administrator said LVN A should not have continued to be his nurse because there could have been potential danger to Resident #1 and maybe other residents for possible further abuse. During an interview on 02/20/2026 at 12:08 PM with the RNC she said on Monday 02/09/2026 the Administrator called her and told her about the allegation of abuse and neglect that occurred on Saturday 02/07/2026. The RNC said initially she thought that the incident was not reported to the Administrator by the staff then she learned that the incident was reported to the Administrator by the staff and the Administrator did not report it to HHS. The RNC told the Administrator that the allegation should have been reported to HHS immediately. The RNC told her to inform the DON of the incident and to suspend LVN A immediately. The RNC said the Administrator did not report the allegation of abuse and neglect in a timely manner to HHS and she did not follow facility procedures. The RNC said anything that puts resident in harm both mentally and physical should be reported immediately. The RNC said Resident #1 could have had psychosocial harm. She said that Resident #1 could have feared approaching the nurse. The RNC said she understood that the incident humiliated him. The RNC said the Administrator did not report because of lack of experience. The RNC said the Administrator said there was history of MT A and LVN A not getting along so the Administrator thought there was nothing to the alleged allegations. The RNC said the process for any allegation of abuse and neglect was to report the allegation to HHS, suspend any staff who might be involved in allegations of abuse, and then investigate. Record review on 02/18/2026 of in-service dated 02/09/2026 by the ROD to the Administrator regarding the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying, disclosing, and investigating alleged allegations of abuse and neglect. The in-service included the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying and disclosing alleged allegations of abuse and neglect. The in-service included the suspension of any employees alleged to have been involved in the abuse, neglect, or exploitation of residents. The in-service discussed when to report any and all allegations of suspected abuse, neglect, or exploitation, when to suspend any staff member(s) involved in allegations of abuse, neglect, or exploitation and when to begin and how to investigate allegations of abuse, neglect, or exploitation. Record review on 02/18/2026 of in-service to all facility staff dated 02/09/2026 through 02/11/2026 on facility policy and procedure on Abuse, Neglect and Exploitation including the elements of training, prevention, identification, investigation, protection, and reporting/response. Record review on 02/18/2026 of Resident #1 skin observation dated 02/09/2026 by ADON that reflected no redness, discoloration, or skin tears noted. Record review on 02/18/2026 of Resident #1 pain assessment dated [DATE] by DON of pain assessment that reflected pain assessment was secondary to Lupus, no headache noted. Record review on 02/18/2026 of Resident #1 neurological assessments every 30 minutes dated 02/09/2026 through 02/11/2026. Record review on 02/18/2026 of in-service dated 02/08/2026 through 02/11/2026 to all staff on reinforcement of expectations for maintain professional boundaries, preserving resident dignity, and preventing behaviors that may be perceived as disrespectful, demeaning, or emotionally harmful. Record review on 02/18/2026 of Resident Safe Survey Questionnaire Alert/Oriented dated 02/10/2026. Record review of statements from MT A dated 02/09/2026, LVN A dated 02/09/2026, CNA A dated 02/10/2026, and Resident #1 dated 02/09/2026.During an interview on 02/19/2026 at 4:39 PM with LVN B she said attended an in-service on 02/10/2026 on abuse and neglect and gave an example of hitting a resident or cursing at a resident as examples of abuse and neglect. She said allegations of abuse and neglect should be reported immediately. She said allegations of abuse and neglect should be reported to the Administrator who was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:43 PM with CNA F she said she received training on 02/10/2026 on abuse and neglect. She said abuse can be physical, verbal, sexual and mental. She said exploiting residents was also abuse. She said abused should be immediately reported to the facility Administrator. She said the Administrator was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:45 PM with CNA G she said she was trained in abuse and neglect on 02/10/2026. She said abuse can be physical, mental, or sexual. She said taking a call light away from a resident was a form of abuse. She said abuse should be reported to the Administrator because the Administrator was the abuse and neglect coordinator. Record review of facility policy and procedure on Abuse, Neglect and Exploitation dated October 2024 reflected - Protection: Immediate response: any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended pending investigation and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated or it is determined that no residents are in danger with the employee's return to work.

Based on interviews and record review, the facility failed to have evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to have evidence that a thorough investigation was conducted following the allegation that on 02/07/2026 LVN A spoke tapped Resident #1 in the back of the head. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk for abuse and neglect by not investigating injuries of unknown origin.Finding included: Record review of Resident #1's face sheet, dated 02/19/2026, revealed a fifty-one-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His admitting diagnoses included bipolar disorder, current episode hypomanic (a distinct period of abnormally elevated, energetic, or irritable mood lasting at least four consecutive days), thrombotic microangiopathy (a life-threatening, rare syndrome characterized by damage to the lining of small blood vessels (endothelial injury), and systemic lupus erythematosus (a chronic, multi-system autoimmune disease where the immune system attacks healthy tissue). Record review of Resident #1's care plan revealed a focus dated 11/05/2025 of Resident #1 is depended on staff for meeting emotional, intellectual, physical, and social needs. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 12/16/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 12 indicating moderate cognitive issues. Record review of text message dated 02/07/2026 at 10:00 AM from MT A to the Administrator reflected MT A said she would be writing a grievance on LVN A due to an incident that occurred at breakfast. The Administrator asked what happened. MT A responded LVN A was arguing with Resident #1 about him going to his room then made a threat that, she couldnt [sic] wait till he was off of parole so she could show him what a nurse about. Resident #1 told MT A that LVN A tapped him in the back of the head in the dining room. MT A wrote that she knew LVN A was mad because Resident #1 told LVN A quit talking to herself. The Administrator said okay, thanks for letting me know.Record review of employment document for LVN A reflected employment termination date 02/12/2026 for disciplinary action. During an interview on 02/18/2026 at 1:26 PM MT A said she reported the incident that occurred on 02/07/2026 between LVN A and Resident #1 by text to the Administrator. MT A said she heard LVN A ask Resident #1 where he was going and told him she was tired of him going back and forth. MT A said she heard Resident #1 tell LVN A that she had whole conversations by herself. MT A said she heard LVN A tell Resident #1, I cannot wait until your parole release because then I can show you what a nurse is about. MT A said Resident #1 told her that LVN A popped him in the back of the head. MT A said that LVN A worked the rest of her shift that day. MT A said that Resident #1 told her he was scared to ask LVN A for anything for the rest of the day. MT A said she reported the incident to the Administrator between 9:30 AM and 10:00 AM on 02/07/2026. MT A said that the Administrator replied to MT A's text message that notified the Administrator about the incident that she would take care of it. MT A said the Administrator did not come to the facility that day. MT A said that LVN A worked the rest of her shift on Saturday 02/07/2026 and her shift on 02/08/2026. During an interview on 02/18/2026 at 3:25 PM Resident #1 said he had a problem with LVN A. He said she was, very opened mouthed. Resident #1 said LVN A would tell him she was tired of giving him his 2:00 PM pill all the time. He said he was in the dining room and LVN A told him to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up and then she hit the back of his head. He said it did not hurt but made him feel like, she could take over him and made him feel stupid. Resident #1 said other residents saw LVN A hit him, but he did not remember their names. Resident #1 said LVN A did not hit him hard, but it made his head go forward. During an interview on 02/18/2026 at 4:34 PM the DON said LVN A could be argumentative and that LVN A was on the clock and worked for 2 days after the allegations between Resident #1 and LVN A were reported to the Administrator. He said that because LVN A continued to work after the allegation of abuse and neglect this could have put residents at risk of abuse and neglect. During an interview on 02/18/2026 at 5:16 PM CNA A said she was in the dining room with Resident #1 and LVN A and she saw LVN A touch the back of his Resident #1's head and his head went forward. CNA A said she looked at CNA C and asked her did you see that and CNA C said yes. CNA A asked Resident #1 if LVN A pushed the back of his head and Resident #1 told her yes. CNA A said she did not hear LVN A say anything to Resident #1. CNA A said it was never okay to touch a resident in that manner, to push thir head. She said LVN A did not tell Resident #1 excuse me or she was sorry. CNA A said LVN A intentionally pushed his head. CNA A said that LVN A pushed Resident #1's head and kept on walking. CNA A said she was trained in abuse and neglect and that the Administrator was the abuse and neglect coordinator. She said MT A told her she reported the incident to the Administrator and that was why she did not report it. CNA A said LVN A disregarded Resident #1. CNA A said she asked Resident #1 if LVN A pushed his head and Resident #1 told her yes. CNA A said that Resident #1 came to her later in the day and said he did not know why LVN A was still at the facility. CNA A said she told Resident #1 it would be handled. During an interview on 02/19/2026 at 8:12 AM with the ADON she said she learned about Resident #1's allegation with LVN A on Monday, 02/09/2026. The ADON said she did not know who witnessed the incident. The ADON said she assessed Resident #1 from head to toe and there were no findings of visible discoloration. Prior to the incident, the ADON said she heard from the staff that LVN A was easily agitated. The ADON said the incident was an allegation of abuse and neglect and allegations of abuse and neglect should be reported immediately. She said LVN A was not suspended at the time of the incident. The ADON said a possible negative effect of not suspending LVN A was that residents were subject to the same thing happening to them, either to Resident #1 again or another resident. She said the Administrator was the abuse and neglect coordinator. The ADON said when she spoke with Resident #1 when she assessed him on 02/09/2026 he said he did not want to say anything because he did not want to get anyone in trouble, but he confirmed that LVN A did push the back of his head. Resident #1 said it was not a hard slap but like a little pop. The ADON said Resident #1 told her that during the weekend he did not feel safe and was afraid to ask LVN A for his PRN medication. During an interview on 02/19/2026 at 8:42 AM Resident #1 said after the incident with LVN A he stayed out of her way and avoided her because he did not want to deal with her. Resident #1 said she made him feel uncomfortable and he was worried she might be verbally inappropriate to him again. During an interview on 02/19/2026 at 8:47 AM with CNA C she said LVN A was behind Resident #1 and she saw LVN A push Resident #1's head forward. She said it was not a full force push, but you should not play with residents by pushing their heads. She said she had been trained in abuse and neglect a million times. She said the Administrator was the abuse and neglect coordinator and abuse and neglect should be reported immediately. CNA C said MT A reported the incident to the Administrator. CNA C said LVN A continued to work that weekend and LVN A was Resident #1's nurse that weekend. During an interview on 02/19/2026 at 12:00 PM Resident #1 said he did not feel comfortable asking for his pain medications from LVN A and he said he was in pain. He said he did not have anyone else to get his pills from because LVN A was his nurse that weekend. He said he felt very uncomfortable, like he had to beg for his pills and did not want to put up with her crap when he asked for his pills. Resident #1 said when LVN A hit his head in front of people in the dining room it humiliated him. He said he was not fearful, but he did isolate himself a little bit that weekend and was psychologically a little uncomfortable. During an interview on 02/19/2026 at 12:40 PM with the Administrator she said she received a report of an allegation of abuse and neglect on 02/07/2026 and she did not report it to HHS until Monday 02/09/2026. The Administrator said it was an error on her part not to have reported the incident. She did not report the incident because she thought it was a personal issue between MT A and LVN A and she misjudged. The Administrator said she wanted to investigate the incident to find out what it was before she reported it. The Administrator said she now knows that you report the incident and not try to get the facts first. She said she now knows she should have immediately suspended LVN A and reported to HHS immediately. She said the possible negative effect of not immediately suspending LVN A immediately was that the residents could have been subjected to additional abuse. During an interview on 02/19/2026 at 12:40 PM with the RDO he said he received a call on Monday 02/09/2026 about a text that was sent to the Administrator of the facility on 02/07/2026 involving allegations of abuse and neglect. The RDO said matters of personal relationships between staff cannot be taken into consideration when the allegation involved resident abuse or neglect. The RDO said the event should have been immediately reported to HHS in accordance with the facility and state guidelines. The RDO said the facility had a responsibility to protect the residents and remove a possible threat of abuse and neglect and, in this case, LVN A was the threat, and she should have been removed by suspending her employment. During an interview on 02/20/2026 at 8:05 AM the ADON said she was not aware of the incident that involved Resident #1 or LVN A until Monday, 02/09/2026. She said both she and the DON should have been contacted about the incident by the Administrator when the Administrator learned of the incident from MT A. The ADON said LVN A should have been suspended that day, immediately pending investigation. She said because there was an allegation of abuse LVN A needed to be removed from the facility to protect the residents from possible further abuse. She said the facility policy was that for any possible allegation of abuse by a staff member, that staff member should be suspended until the investigation was completed. She said she had no doubt that Resident #1 was telling the truth about LVN A putting her hand on his head and pushing his head forward. She said she did not know why the Administrator did not take the steps and report the incident. The ADON said you do not make assumptions about what happened when abuse was reported. She said you were supposed to report incidents of abuse and neglect within two hours of learning about it. She said the facility was the residents' home and they needed to be kept from abuse and neglect. The ADON said the facility abuse and neglect policies were not implemented. During an interview on 02/20/2026 at 9:13 AM the Administrator said allegations of abuse and neglect are supposed to be reported to HHS immediately. The Administrator said the facility policies on reporting and investigating abuse and neglect were not followed. The Administrator said on Monday 02/09/2026 she spoke with Resident #1 about the incident with LVN A that occurred on 02/07/2026 and he said what happened made him uncomfortable. The Administrator said she was not aware that Resident #1 told the ADON that he felt uncomfortable asking for his PRN medications because LVN A she was his nurse for the rest of her shift on 02/07/2026 and on 02/08/2026. The Administrator said LVN A should not have continued to be his nurse because there could have been potential danger to Resident #1 and maybe other residents for possible further abuse. During an interview on 02/20/2026 at 12:08 PM with the RNC she said on Monday 02/09/2026 the Administrator called her and told her about the allegation of abuse and neglect that occurred on Saturday 02/07/2026. The RNC said initially she thought that the incident was not reported to the Administrator by the staff then she learned that the incident was reported to the Administrator by the staff and the Administrator did not report it to HHS. The RNC told the Administrator that the allegation should have been reported to HHS immediately. The RNC told her to inform the DON of the incident and to suspend LVN A immediately. The RNC said the Administrator did not report the allegation of abuse and neglect in a timely manner to HHS and she did not follow facility procedures. The RNC said anything that puts resident in harm both mentally and physical should be reported immediately. The RNC said Resident #1 could have had psychosocial harm. She said that Resident #1 could have feared approaching the nurse. The RNC said she understood that the incident humiliated him. The RNC said the Administrator did not report because of lack of experience. The RNC said the Administrator said there was history of MT A and LVN A not getting along so the Administrator thought there was nothing to the alleged allegations. The RNC said the process for any allegation of abuse and neglect was to report the allegation to HHS, suspend any staff who might be involved in allegations of abuse, and then investigate. Record review on 02/18/2026 of in-service dated 02/09/2026 by the ROD to the Administrator regarding the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying, disclosing, and investigating alleged allegations of abuse and neglect. The in-service included the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying and disclosing alleged allegations of abuse and neglect. The in-service included the suspension of any employees alleged to have been involved in the abuse, neglect, or exploitation of residents. The in-service discussed when to report any and all allegations of suspected abuse, neglect, or exploitation, when to suspend any staff member(s) involved in allegations of abuse, neglect, or exploitation and when to begin and how to investigate allegations of abuse, neglect, or exploitation. Record review on 02/18/2026 of in-service to all facility staff dated 02/09/2026 through 02/11/2026 on facility policy and procedure on Abuse, Neglect and Exploitation including the elements of training, prevention, identification, investigation, protection, and reporting/response. Record review on 02/18/2026 of Resident #1 skin observation dated 02/09/2026 by ADON that reflected no redness, discoloration, or skin tears noted. Record review on 02/18/2026 of Resident #1 pain assessment dated [DATE] by DON of pain assessment that reflected pain assessment was secondary to Lupus, no headache noted. Record review on 02/18/2026 of Resident #1 neurological assessments every 30 minutes dated 02/09/2026 through 02/11/2026. Record review on 02/18/2026 of in-service to all staff dated 02/09/2026 through 02/11/2026 on reinforcement of expectations for maintain professional boundaries, preserving resident dignity, and preventing behaviors that may be perceived as disrespectful, demeaning, or emotionally harmful. Record review 0on 02/18/2026 of Resident Safe Survey Questionnaire Alert/Oriented dated 02/10/2026. Record review of statements from MT A dated 02/09/2026, LVN A dated 02/09/2026, CNA A dated 02/10/2026, and Resident #1 dated 02/09/2026.During an interview on 02/19/2026 at 4:39 PM with LVN B she said attended an in-service on 02/10/2026 on abuse and neglect and gave an example of hitting a resident or cursing at a resident as examples of abuse and neglect. She said allegations of abuse and neglect should be reported immediately. She said allegations of abuse and neglect should be reported to the Administrator who was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:43 PM with CNA F she said she received training on 02/10/2026 on abuse and neglect. She said abuse can be physical, verbal, sexual and mental. She said exploiting residents was also abuse. She said abused should be immediately reported to the facility Administrator. She said the Administrator was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:45 PM with CNA G she said she was trained in abuse and neglect on 02/10/2026. She said abuse can be physical, mental, or sexual. She said taking a call light away from a resident was a form of abuse. She said abuse should be reported to the Administrator because the Administrator was the abuse and neglect coordinator. Record review of facility policy and procedure on Abuse, Neglect and Exploitation dated October 2024 reflected the facility will conduct a timely investigation of any alleged abuse or neglect exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property. The investigation should include gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records, and examining any relevant documentation. The facility will record all investigation findings, interviews, and actions taken. The facility will assess the evidence gathered to review and determine the extent and nature of the allegations. Investigative findings will be documented on appropriate state forms as accessible.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for reporting allegations of abuse. The facility failed to report physical and verbal abuse to the State Agency within 2 hours when, on 02/07/2026, it was reported to Administrator by MT A that LVN A made a threat to Resident #1 and tapped Resident #1 in the back of the head. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Finding included: Record review of Resident #1's face sheet, dated 02/19/2026, revealed a fifty-one-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. His admitting diagnoses included bipolar disorder, current episode hypomanic (a distinct period of abnormally elevated, energetic, or irritable mood lasting at least four consecutive days), thrombotic microangiopathy (a life-threatening, rare syndrome characterized by damage to the lining of small blood vessels (endothelial injury), and systemic lupus erythematosus (a chronic, multi-system autoimmune disease where the immune system attacks healthy tissue). Record review of Resident #1's care plan revealed a focus dated 11/05/2025 of Resident #1 is depended on staff for meeting emotional, intellectual, physical, and social needs. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 12/16/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 12 indicating moderate cognitive issues. Record review of text message dated 02/07/2026 at 10:00 AM from MT A to the Administrator reflected MT A said she would be writing a grievance on LVN A due to an incident that occurred at breakfast. The Administrator asked what happened. MT A responded LVN A was arguing with Resident #1 about him going to his room then made a threat that, she couldnt wait till he was off of parole so she could show him what a nurse about. Resident #1 told MT A that LVN A tapped him in the back of the head in the dining room. MT A wrote that she knew LVN A was mad because Resident #1 told LVN A quit talking to herself. The Administrator said okay, thanks for letting me know.Record review of employment document for LVN A reflected employment termination date 02/12/2026 for disciplinary action. During an interview on 02/18/2026 at 1:26 PM MT A said she reported the incident that occurred on 02/07/2026 between LVN A and Resident #1 by text to the Administrator. MT A said she heard LVN A ask Resident #1 where he was going and told him she was tired of him going back and forth. MT A said she heard Resident #1 tell LVN A that she had whole conversations by herself. MT A said she heard LVN A tell Resident #1, I cannot wait until your parole release because then I can show you what a nurse is about. MT A said Resident #1 told her that LVN A popped him in the back of the head. MT A said that LVN A worked the rest of her shift that day. MT A said that Resident #1 told her he was scared to ask LVN A for anything for the rest of the day. MT A said she reported the incident to the Administrator between 9:30 AM and 10:00 AM on 02/07/2026. MT A said that the Administrator replied to MT A's text message that notified the Administrator about the incident that she would take care of it. MT A said the Administrator did not come to the facility that day. MT A said that LVN A worked the rest of her shift on Saturday 02/07/2026 and her shift on 02/08/2026. During an interview on 02/18/2026 at 3:25 PM Resident #1 said he had a problem with LVN A. He said she was, very opened mouthed. Resident #1 said LVN A would tell him she was tired of giving him his 2:00 PM pill all the time. He said he was in the dining room and LVN A told him to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up and then she hit the back of his head. He said it did not hurt but made him feel like, she could take over him and made him feel stupid. Resident #1 said other residents saw LVN A hit him, but he did not remember their names. Resident #1 said LVN A did not hit him hard, but it made his head go forward. During an interview on 02/18/2026 at 4:34 PM the DON said LVN A could be argumentative and that LVN A was on the clock and worked for 2 days after the allegations between Resident #1 and LVN A were reported to the Administrator. He said that because LVN A continued to work after the allegation of abuse and neglect this could have put residents at risk of abuse and neglect. During an interview on 02/18/2026 at 5:16 PM CNA A said she was in the dining room with Resident #1 and LVN A and she saw LVN A touch the back of his Resident #1's head and his head went forward. CNA A said she looked at CNA C and asked her did you see that and CNA C said yes. CNA A asked Resident #1 if LVN A pushed the back of his head and Resident #1 told her yes. CNA A said she did not hear LVN A say anything to Resident #1. CNA A said it was never okay to touch a resident in that manner, to push their head. She said LVN A did not tell Resident #1 excuse me or she was sorry. CNA A said LVN A intentionally pushed his head. CNA A said that LVN A pushed Resident #1's head and kept on walking. CNA A said she was trained in abuse and neglect and that the Administrator was the abuse and neglect coordinator. She said MT A told her she reported the incident to the Administrator and that was why she did not report it. CNA A said LVN A disregarded Resident #1. CNA A said she asked Resident #1 if LVN A pushed his head and Resident #1 told her yes. CNA A said that Resident #1 came to her later in the day and said he did not know why LVN A was still at the facility. CNA A said she told Resident #1 it would be handled. During an interview on 02/19/2026 at 8:12 AM with the ADON she said she learned about Resident #1's allegation with LVN A on Monday, 02/09/2026. The ADON said she did not know who witnessed the incident. The ADON said she assessed Resident #1 from head to toe and there were no findings of visible discoloration. Prior to the incident, the ADON said she heard from the staff that LVN A was easily agitated. The ADON said the incident was an allegation of abuse and neglect and allegations of abuse and neglect should be reported immediately. She said LVN A was not suspended at the time of the incident. The ADON said a possible negative effect of not suspending LVN A was that residents were subject to the same thing happening to them, either to Resident #1 again or another resident. She said the Administrator was the abuse and neglect coordinator. The ADON said when she spoke with Resident #1 when she assessed him on 02/09/2026 he said he did not want to say anything because he did not want to get anyone in trouble, but he confirmed that LVN A did push the back of his head. Resident #1 said it was not a hard slap but like a little pop. The ADON said Resident #1 told her that during the weekend he did not feel safe and was afraid to ask LVN A for his PRN medication. During an interview on 02/19/2026 at 8:42 AM Resident #1 said after the incident with LVN A he stayed out of her way and avoided her because he did not want to deal with her. Resident #1 said she made him feel uncomfortable and he was worried she might be verbally inappropriate to him again. During an interview on 02/19/2026 at 8:47 AM with CNA C she said LVN A was behind Resident #1 and she saw LVN A push Resident #1's head forward. She said it was not a full force push, but you should not play with residents by pushing their heads. She said she had been trained in abuse and neglect a million times. She said the Administrator was the abuse and neglect coordinator and abuse and neglect should be reported immediately. CNA C said MT A reported the incident to the Administrator. CNA C said LVN A continued to work that weekend and LVN A was Resident #1's nurse that weekend. During an interview on 02/19/2026 at 12:00 PM Resident #1 said he did not feel comfortable asking for his pain medications from LVN A and he said he was in pain. He said he did not have anyone else to get his pills from because LVN A was his nurse that weekend. He said he felt very very uncomfortable, like he had to beg for his pills and did not want to put up with her crap when he asked for his pills. Resident #1 said when LVN A hit his head in front of people in the dining room it humiliated him. He said he was not fearful, but he did isolate himself a little bit that weekend and was psychologically a little uncomfortable. During an interview on 02/19/2026 at 12:40 PM with the Administrator she said she received a report of an allegation of abuse and neglect on 02/07/2026 and she did not report it to HHS until Monday 02/09/2026. The Administrator said it was an error on her part not to have reported the incident. She did not report the incident because she thought it was a personal issue between MT A and LVN A and she misjudged. The Administrator said she wanted to investigate the incident to find out what it was before she reported it. The Administrator said she now knows that you report the incident and not try to get the facts first. She said she now knows she should have immediately suspended LVN A and reported to HHS immediately. She said the possible negative effect of not immediately suspending LVN A immediately was that the residents could have been subjected to additional abuse. During an interview on 02/19/2026 at 12:40 PM with the RDO he said he received a call on Monday 02/09/2026 about a text that was sent to the Administrator of the facility on 02/07/2026 involving allegations of abuse and neglect. The RDO said matters of personal relationships between staff cannot be taken into consideration when the allegation involved resident abuse or neglect. The RDO said the event should have been immediately reported to HHS in accordance with the facility and state guidelines. The RDO said the facility had a responsibility to protect the residents and remove a possible threat of abuse and neglect and, in this case, LVN A was the threat, and she should have been removed by suspending her employment. During an interview on 02/20/2026 at 8:05 AM the ADON said she was not aware of the incident that involved Resident #1 or LVN A until Monday, 02/09/2026. She said both she and the DON should have been contacted about the incident by the Administrator when the Administrator learned of the incident from MT A. The ADON said LVN A should have been suspended that day, immediately pending investigation. She said because there was an allegation of abuse LVN A needed to be removed from the facility to protect the residents from possible further abuse. She said the facility policy was that for any possible allegation of abuse by a staff member, that staff member should be suspended until the investigation was completed. She said she had no doubt that Resident #1 was telling the truth about LVN A putting her hand on his head and pushing his head forward. She said she did not know why the Administrator did not take the steps and report the incident. The ADON said you do not make assumptions about what happened when abuse was reported. She said you were supposed to report incidents of abuse and neglect within two hours of learning about it. She said the facility was the residents' home and they needed to be kept from abuse and neglect. The ADON said the facility abuse and neglect policies were not implemented. During an interview on 02/20/2026 at 9:13 AM the Administrator said allegations of abuse and neglect are supposed to be reported to HHS immediately. The Administrator said the facility policies on reporting and investigating abuse and neglect were not followed. The Administrator said on Monday 02/09/2026 she spoke with Resident #1 about the incident with LVN A that occurred on 02/07/2026 and he said what happened made him uncomfortable. The Administrator said she was not aware that Resident #1 told the ADON that he felt uncomfortable asking for his PRN medications because LVN A she was his nurse for the rest of her shift on 02/07/2026 and on 02/08/2026. The Administrator said LVN A should not have continued to be his nurse because there could have been potential danger to Resident #1 and maybe other residents for possible further abuse. During an interview on 02/20/2026 at 12:08 PM with the RNC she said on Monday 02/09/2026 the Administrator called her and told her about the allegation of abuse and neglect that occurred on Saturday 02/07/2026. The RNC said initially she thought that the incident was not reported to the Administrator by the staff then she learned that the incident was reported to the Administrator by the staff and the Administrator did not report it to HHS. The RNC told the Administrator that the allegation should have been reported to HHS immediately. The RNC told her to inform the DON of the incident and to suspend LVN A immediately. The RNC said the Administrator did not report the allegation of abuse and neglect in a timely manner to HHS and she did not follow facility procedures. The RNC said anything that puts resident in harm both mentally and physical should be reported immediately. The RNC said Resident #1 could have had psychosocial harm. She said that Resident #1 could have feared approaching the nurse. The RNC said she understood that the incident humiliated him. The RNC said the Administrator did not report because of lack of experience. The RNC said the Administrator said there was history of MT A and LVN A not getting along so the Administrator thought there was nothing to the alleged allegations. The RNC said the process for any allegation of abuse and neglect was to report the allegation to HHS, suspend any staff who might be involved in allegations of abuse, and then investigate. Record review on 02/18/2026 of in-service dated 02/09/2026 by the ROD to the Administrator regarding the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying, disclosing, and investigating alleged allegations of abuse and neglect. The in-service included the facility and HHS policies and procedures on self-reporting allegations of abuse and neglect including expectations for promptly identifying and disclosing alleged allegations of abuse and neglect. The in-service included the suspension of any employees alleged to have been involved in the abuse, neglect, or exploitation of residents. The in-service discussed when to report any and all allegations of suspected abuse, neglect, or exploitation, when to suspend any staff member(s) involved in allegations of abuse, neglect, or exploitation and when to begin and how to investigate allegations of abuse, neglect, or exploitation. Record review on 02/18/2026 of in-service to all facility staff dated 02/09/2026 through 02/11/2026 on facility policy and procedure on Abuse, Neglect and Exploitation including the elements of training, prevention, identification, investigation, protection, and reporting/response. Record review on 02/18/2026 of Resident #1 skin observation dated 02/09/2026 by ADON that reflected no redness, discoloration, or skin tears noted. Record review on 02/18/2026 of Resident #1 pain assessment dated [DATE] by DON of pain assessment that reflected pain assessment was secondary to Lupus, no headache noted. Record review on 02/18/2026 of Resident #1 neurological assessments every 30 minutes dated 02/09/2026 through 02/11/2026. Record review on 02/18/2026 of in-service to all staff dated 02/09/2-26 through 02/11/2026 on reinforcement of expectations for maintain professional boundaries, preserving resident dignity, and preventing behaviors that may be perceived as disrespectful, demeaning, or emotionally harmful. Record review 0on 02/18/2026 of Resident Safe Survey Questionnaire Alert/Oriented dated 02/10/2026. Record review of statements from MT A dated 02/09/2026, LVN A dated 02/09/2026, CNA A dated 02/10/2026, and Resident #1 dated 02/09/2026.During an interview on 02/19/2026 at 4:39 PM with LVN D she said attended an in-service on 02/10/2026 on abuse and neglect and gave an example of hitting a resident or cursing at a resident as examples of abuse and neglect. She said allegations of abuse and neglect should be reported immediately. She said allegations of abuse and neglect should be reported to the Administrator who was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:43 PM with CNA F she said she received training on 02/10/2026 on abuse and neglect. She said abuse can be physical, verbal, sexual and mental. She said exploiting residents was also abuse. She said abused should be immediately reported to the facility Administrator. She said the Administrator was the abuse and neglect coordinator. During an interview on 02/19/2026 at 4:45 PM with CNA G she said she was trained in abuse and neglect on 02/10/2026. She said abuse can be physical, mental, or sexual. She said taking a call light away from a resident was a form of abuse. She said abuse should be reported to the Administrator because the Administrator was the abuse and neglect coordinator. Record review of facility policy and procedure on Abuse, Neglect and Exploitation dated October 2024 reflected report abuse (with or without serious bodily injury) immediately, but not later than two hours after the incident occurs or is suspected.

Based on interviews and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 8 residents (Resident #2) reviewed for safety. The facility failed to ensure Resident #2 followed the facility safe smoking policy when on 12/14/2026 and additional unknown dates staff smelled cigarette smoke in Resident #2's room.on 01/31/2026 staff members observed two packages of cigarettes in Resident #2's roomon unknown dates CNAs observed Resident #2 with lighters. These failures could place residents at risk for avoidable accidents and injuries.Findings included: Record review of Resident #2's face sheet, dated 02/19/2026, revealed a thirty-seven-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (impairment or loss of motor and sensory function in the lower extremities), anxiety disorder, and major depressive disorder. Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated 12/14/2025 Quarterly Assessment Section C - Cognitive Patterns revealed a score of 15 indicating no cognitive issues. Record review of Resident #2's care plan revealed a focus dated 11/17/2025 Resident #2 was noncompliant with smoking rules and vapes found in his bed. Record review of Resident #2's signed Resident Smoking Behavior Contract dated 09/12/2025 reflected, The resident agrees to the following terms and conditions: I will follow the objectives set forth in this contract. This Contract has been developed with my input and it reflects my best interests. As a responsible adult, I understand that failure to comply with the obligations of this contract will be dealt with accordingly. If I disregard the facilities smoking safety regulations, I'm aware that the facility will suspend or revoke my smoking privileges. I recognize that continued failure to honor the smoking policy will jeopardize my ability to remain in this facility. Record review of Resident #2's progress note dated 12/14/2025 by the DON reflected, smell of Smoke highly suggestive of Cannabis From his room noted, police confiscated some substance on Voluntary Surrender by Resident Record review of Resident #2's progress note dated 01/31/2026 by LVN B reflected CNA (name of CNA not identified) called LVN B to Resident #2's room and LVN B observed 2 packs of cigarettes in his room and LVN B asked if Resident #2 could give them to her because he was not allowed to have them. Resident #2 brought LVN B a pack of cigarettes. LVN B informed Resident #2 that that was not what she observed, and Resident #2 tried to convince LVN B that was all he had. LVN B informed the DON and ADON. Record review of Resident #2's progress noted dated 02/14/2026 by LVN B reflected it was reported to LVN B that Resident #2 was outside behind laundry building smoking. LVN B went behind the building and Resident #2 was noted smoking cigarettes. Redirected the resident back into the building and reeducated the resident on the smoking The DON was notified. Record review of Resident #2's progress note dated 02/01/2026 by agency nurse reflected Resident #2 came to the nurses' station at approximately 2:00 PM and stated he did not smoke at the 1:00 PM smoke break. Agency nurse asked CNA (name of CNA not identified) if Resident #2 smoked at 1:00 PM. CNA (name of CNA not identified) confirmed that Resident #2 smoked at 1:00 PM and Resident #2pulled a black lighter out of his sock and lit the cigarette and smoked the cigarette. During an interview on 02/19/2026 at 12:18 PM the DON said he thought Resident #2 was smoking in his room because staff have smelled smoke in Resident #2's room. The DON said Resident #2 had a lighter in his possession and when staff entered Resident #2's room and smelled cigarette smoke Resident #2 had the window open. The DON said Resident #2 had a smoking contract. The DON was highly concerned about Resident #2 smoking in his room. During an interview on 02/19/2026 at 12:40 pm with the Administrator she said there was a concern that Resident #2 was smoking in his room. She said the DON told her that about the concern of Resident #2 smoking in his room, but she did not know Resident #2 was seen with a lighter. She said that Resident #2 went to store all the time and could buy whatever he wanted to. During an interview on 02/19/2026 at 4:29 PM with LVN D she said she was told Resident #2 had a lighter and cigarettes and was outside in the laundry room smoking unattended outside of smoking times. She said she told the DON about Resident #2 having the lighter. She said Resident #2 could burn the building down and blow them all up. LVN D said she had not seen Resident #2 smoking in his room, but she was very much concerned that Resident #2 was smoking in his room. During an interview on 02/19/2026 at 4:35 PM with CNA E she said she had smelled cigarette smoke in Resident #2's room but she did not ask him about it. She said she saw a black lighter under Resident #2's wheelchair cushion but did not ask him about it. CNA E said she saw Resident #2 push the lighter under the wheelchair cushion. CNA E said she told the charge nurse about it but did not remember the name of the charge nurse she told. CNA E said that if someone smoked in their room, they could have an accident and something might catch on fire. During an interview on 02/19/2026 at 4:45 PM with CNA G she said she was aware Resident #2 was smoking in his room because he had lighters. CNA G said he was not supposed to have lighters. CNA G said she had smelled cigarette smoke in his room. CNA G said she saw Resident #2 with two different lighters, a black one and a blue one. CNA G said she saw the black lighter about a month ago when he was out on the patio smoking during a non-smoking time. CNA G said she told him the facility did not allow him to have irregular smoke breaks, and he was not supposed to have the lighter. Resident #2 said he was just going to smoke and come right back to the facility. CNA G said she saw Resident #2 with a blue lighter yesterday. CNA G said it was under the cushion in his wheelchair. She said she told an agency nurse that she saw Resident #2 with a lighter, but she did not tell the Administrator or the DON. She said as a CNA she told the nurse if there is an issue and the nurse told the Administrator or the DON. CNA G said if Resident #2 had a lighter he could accidentally burn something while smoking a cigarette or he could burn himself. During an interview on 02/20/2026 at 7:28 AM Resident #2 said he had a smoking contract and he followed it. He said he only smoked during the smoking times and in the allowed smoking space. He said he did not have cigarettes or lighters in his room or on his person. Resident #2 said he realized the facility had smoking rules for the safety of the residents. He said he realized there were residents in his hallway who were on oxygen and it would be dangerous for other residents if he was smoking in his room. During an interview on 02/20/2026 at 8:05 AM with ADON she said she heard that Resident #2 was smoking in his room, but no one has told her they had witnessed Resident #2 smoking in his room. She said she did not see him with a lighter, and no one had reported to her that he had a lighter. She said it was against facility policy for residents to have a lighter in their room. She said it was not okay for residents to have a lighter in their room because they had people who were on oxygen, and it could be a fire hazard. During an interview on 02/20/2026 at 9:41 PM with the PMHNP, she said in her opinion Resident #2 was smoking cigarettes in his room. She said it was dangerous and it could affect more people than him. The PMHNP said if there was a fire she did not know if he could get out of the room without assistance. During an interview on 02/20/2026 at 12:08 PM with the RNC, she said the DON had discussed with her concerns about Resident #2 being non-compliant with the smoking rules. She said Resident #2 was risking other residents if he decided to smoke in the building. She said Resident #2 could burn the building down. She said Resident #2 was not compliant even if they educated him. She said Resident #2 would not cooperate. The RNC said one day he could smoke inside the facility and he could burn the building and Resident #2 was putting residents who were on oxygen at risk. During an interview on 02/20/2026 at 12:47 PM with the DON, he said he was not sure if the Administrator knew that Resident #2 had lighters, but they did discuss the concern about Resident #2 smoking in his room. During an interview on 02/20/206 at 2:34 PM with the NP, she said Resident #2 would not tell the truth if he was smoking in his room. The NP said they were at his mercy. She said Resident #2 had a personality disorder of being non-compliant. She said he would look them in the eyes and tell them he was not smoking in his room when he was smoking in his room. During an interview on 02/20/2026 at 3:28 PM with the DON, he said he tried to get Resident #2 discharged from the facility. During an interview on 02/20/2026 at 5:01 PM with a resident who wanted to be anonymous, said Resident #2 told him that he smoked in his room. Record review of policies and procedures on Safe Smoking dated March 2024 reflected the facility was committed to providing a safe, healthy, and comfortable environment for all residents, staff, and visitors. The facility policy is designed to ensure residents are aware of their privilege when it comes to smoking but also following guidelines in which smoking may occur in our setting. This policy applies to facilities that permit smoking (including the use of e-cigarettes/vape pens). The facility may permit smoking for certain individuals at designated times in designated areas based upon the findings of the resident's Smoking -Safety Screen. The Smoking Policy Notification is outlined in the admission Agreement. Residents who desire to smoke will be assessed using the Smoking- Safety Screen, documented in Point Click Care. Assessments will be conducted at the time of admission, quarterly, and at the time any condition or behavioral change impacts their ability to smoke safely. Areas assessed include: cognitive status, visual status, dexterity, can the resident light their own cigarette, does the roommate use oxygen, and adaptive equipment needed. Staff members maintain all smoking materials as appropriate for the residents. Staff members will distribute smoking materials to residents at designated smoking times in the designated smoking area. Smoking and e-cigarette/vape pen use must occur in designated locations that are environmentally separate from resident care areas. These designated locations should be outdoors, safe, and should be outfitted with required safety equipment including: fire Extinguisher, fire/Smoke Blanket, life Safety Approved Ash Tray life Safety Approved Disposal Can, and signage: No Oxygen Use. Recommended Resident Infractions (the facility has the autonomy to put an alternate plan of action to prevent further Infractions). 1st Offense - the facility will initiate a Behavioral Contract with the resident that outlines expectations of the smoking policy and procedure, 2nd offense notice of Involuntary/Immediate Discharge. Discharge procedures are initiated and pursued to completion. Rationale: endangerment to the health and safety of residents, staff members, and visitors.

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, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 9 residents (Resident #1) observed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 12/11/2025 for Resident #1's wounds when she failed to perform hand hygiene between glove changes. This failure could place residents at risk for healthcare-associated cross-contamination and infections. Findings included: Review of Resident #1's face sheet dated 12/11/2025 revealed Resident #1 is a [AGE] year-old male who was admitted into the facility on [DATE] with the following diagnoses: Multiple Myeloma (a rare blood cancer of plasma cells in the bone marrow), Paraplegia (paralysis affecting the lower half of the body), Generalized muscle weakness, Anxiety disorder and Stage 4 Pressure Ulcer of sacral region. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact with normal thinking and memory. Resident #1 received the following skin treatments: pressure/ulcer injury care, application of nonsurgical dressings. Review of Resident #1's Comprehensive Care Plan dated 5/3/2025 revealed a focus area for Enhanced Barrier Precautions. Interventions included PPE: Gown and Gloves during high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, wound care). Observation on 12/11/2025 at 10:58 AM revealed LVN A sanitized her hands prior to entering the resident's room. She put on a gown and gloves. She used wound cleanser to clean the sacral wound. She applied calcium alginate collagen to the wound and covered it with the bordered gauze dressing. The nurse changed her gloves. She did not sanitize or wash her hands prior to putting on a new pair of gloves. She removed the bordered gauze dressing from the resident's right lower leg. She cleaned the wound with wound cleanser. She applied calcium alginate collagen to the wound and covered it with the bordered gauze dressing. She removed her gloves. She donned new gloves and removed the bordered gauze dressing from the resident's left heel. She did not perform hand hygiene between the glove changes. She discarded the dressing and said this dressing is for protection only. She removed her gloves and discarded them. She did not perform hand hygiene after removing her gloves. In an interview with LVN A on 12/11/12025 at 1:47 PM, she reported that she currently has four residents with wounds. She stated I dispose of my gloves after I take off the old dressing. I change gloves in between the old dressing and new dressing. I sanitize my hands or go straight to the bathroom and wash my hands. But I usually sanitize first and then go wash. LVN A did not acknowledge that she did not perform hand hygiene after removing her gloves during Resident #1's wound care. In an interview with the ADON on 12/11/2025 at 2:40 PM, she said that any time they touch dirty areas with their gloves, they need to change their gloves. She explained that staff should wash their hands between cleaning each wound. She stated they should clean the outside and the wound bed would be last. It's always dirty to clean. She explained that Infection can spread if staff does not wash their hands after changing gloves or after providing care.In an interview with the DON on 12/11/2025 at 2:56 PM, he stated I expect them to change their gloves and do hand hygiene between wounds. He stated that they should follow the rule of clean to dirty. He stated staff should perform hand hygiene before and after changing gloves. He explained there are not sinks in every room. There are only two rooms in the long hall with sinks and one of them is an isolation room. The shorter hall does not have any sinks in the rooms. He stated that the staff should still use hand sanitizer gel. He stated that they should wash their hands as much as they can and reported that there is a lot of access to portable alcohol-based hand gel pumps. Record review of the facility's Hand Hygiene policy with a revision date of 6/2019 reflected 1. Hand hygiene/hand washing is done. After: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds. H. After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident in bed. Further review of page 4 of the Hand Hygiene policy procedures reflected 2. Wash Hands. C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Record review of the facility's Infection Control Program policy with a revision date of 6/2019 reflected the Major activities of the Infection Control Program: Surveillance of Infections with Implementation of Control Measures and Prevention of Infections.Prevention of spread of infections is accomplished by use of hand hygiene, standard precaution, transmission-based precautions and other barriers.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control observed and four (Resident #1, Resident #3, Resident #6, and Resident #7) of seven residents reviewed.The facility failed to keep roaches and rodents out of resident rooms, the facility kitchen, facility common areas, and rest rooms.These failures placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.Findings included:Review of Resident #1's face sheet dated 09/22/25 reflected a 62-year-male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus [HIV] disease (a virus that attacks the body's immune system), type 2 diabetes mellitus with unspecified complications (a chronic condition in which the body does not use insulin effectively and has not developed any specific complications that can be identified), and bipolar disorder, current episode manic without psychotic features, moderate (periods of manic symptoms, including a prolonged elevated or irritable mood, increased energy, and goal-directed activity, lasting at least a week, without the presence of psychotic features such as delusions or hallucinations. The moderate severity suggests the symptoms were causing significant, but not severe, impairment in daily functioning).Review of Resident #1's care plan reflected focus revised 09/19/25 reflected Resident #1 was a diabetic and at risk for fluctuations in blood glucose levels (the amount of sugar (glucose) in the bloodstream), hypo/hyperglycemia (abnormally low or high blood sugar levels) and other complications.Review of Resident #1's Nursing Home Comprehensive MDS, dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment.Review of Resident #3's face sheet, dated 09/11/25, reflected a 36-year-male who was admitted to the facility on [DATE] with diagnoses including paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), displaced fracture of acromial process, right shoulder, initial encounter for closed fracture (a broken bone (acromion) in the right shoulder where the bone fragments have moved from their normal position), displaced fracture of body of scapula, right shoulder, initial encounter for closed fracture (a broken shoulder blade (scapula) on the right side, where the broken pieces have shifted out of their normal alignment), and displaced fracture of acromial process, left shoulder, initial encounter for closed fracture (a broken bone at the acromion (the bony point of the shoulder blade) that is no longer in its normal alignment, on the left side, for which the patient is receiving initial medical care, and the skin is unbroken). Review of Resident #3's care plan focus, dated 08/13/25, reflected [mechanical lift] for transfers with staff to use [mechanical lift] x2 aides for transfers.Review of Resident #3's Entry MDS, dated [DATE] reflected no functional status and no BIMS score.Review of Resident #6's face sheet, dated 09/17/25, reflected a 71-year-male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (nkhhc) (a serious complication of type 2 diabetes characterized by extremely high blood sugar levels (hyperglycemia) without the presence of ketones (molecules produced by the liver from fat, serving as an alternative energy source when glucose is unavailable, and they are a sign of fat breakdown in the body) in the blood) and heart failure (occurs when the heart muscle does not pump blood as well as it should).Review of Resident #6's care plan reflected focus, dated 04/22/25, was a diabetic and at risk for fluctuations in blood glucose levels, hypo/hyperglycemia and other complications. Review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 10 indicating moderate cognitive impairment.Review of Resident #7's face sheet, dated 09/17/25, reflected a 51-year-male who was admitted to the facility on [DATE] with diagnoses including type 1 diabetes mellitus (an autoimmune disorder where the body's immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas) with unspecified diabetic retinopathy with macular edema (medical diagnosis for a person with Type 1 diabetes whose eyesight was affected by a combination of two related eye conditions), major depressive disorder (a common and debilitating mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and malignant neoplasm of bladder (bladder cancer). Review of Resident #7's care plan reflected focus, dated 04/03/25, was a risk for falls and injuries.Review of Resident #7's Quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating no cognitive impairment.Observation on 09/17/2025 at 11:11 am of a live roach in the rest room across from Resident #5 and Resident #6s' room.Observation 09/17/25 at 12:34 pm of dresser drawer in Resident #3's room of what appeared to be rodent droppings. Observation 09/19/25 at 10:03 am of a dead smashed roach in the hallway outside of the facility conference room.Observation 09/19/25 at 10:05 am of a dead roach in the facility conference room next to the conference room table.Record review of pest control service invoice, dated 03/04/25, reflected, American Cockroach activity in Beauty Salon.Record review of pest control service invoice, dated 05/31/25, reflected, Dietary staff reported seeing an American roach. Staff reported sightings of roaches.Record review of pest control service invoice, dated 06/12/2025, reflected, Met with maintenance manager. He stated some roaches in the break room.Record review of pest control service invoice, dated 07/09/25, reflected, Kitchen staff said they're seeing roaches around a heating table.Record review of pest control service invoice, dated 07/31/2025, reflected, [name of pest control service] was on site right now for your emergency call-in regarding roaches in offices and break room. Met with [head of maintenance]. He said it is just one office and the break room. Before I (the exterminator) left I (the exterminator) checked in with the administrator. He said he saw an American roach in the hall bathroom next to his office. Ongoing roaches in breakroom, several offices, and bathrooms.Record review of pest control service invoice, dated 08/14/2025, reflected, A staff member said she saw a roach in the employee break room. During inspection I (the exterminator) found a dead American roach under table. Kitchen staff said they saw a roach by the heating table.Record review of pest control service invoice, dated 08/22/25, reflected, resident was claiming to have been bit by something. I (the exterminator) happened to look up at the ceiling above the bed and found what appears to be a type of blister beetle. The ac window unit has gaps around it. I'm sure this is how the beetle entered the room. Therapy asked if I could treat ants. I did find some odorous house ants by the writing board. Maintenance Director assistant asked if I could treat the breakroom for cockroaches.Record review of pest control service invoice, dated 09/12/2025, reflected, [name of pest control service] is on site to address a concern. On arrival, we met with the maintenance director, [name of maintenance director]. He guided us to room [ROOM NUMBER] where droppings were spotted. The majority of droppings appeared to be American cockroach droppings. There is a hole between the baseboard and the floor that [name of maintenance director] will be sealing to aid in control. Rodent bait stations were filled on the exterior of the facility, and a proposal is being sent for additional bait stations to address rodent pressures. Rat droppings reported and foods being eaten. - RoomInterview on 09/11/2025 at 3:14 pm with the MD revealed the facility had not had a bug infestation problem and the pest control services come every month and if pest control service was needed outside of that time, the facility called them, and the service would come. He said no residents told him about a bug problem. He said Resident #3 told him about rat droppings in his room and he looked at them, but he really was not sure they were rat droppings. He said there were no exposed holes in Resident #3's room that indicated a rodent. Interview on 09/17/2025 at 11:04 am with Resident #6 reflected now there were fewer bugs and the bug problem was getting better, but he saw roaches in the rest room and on the walls of his room. He said he saw roaches run out of the rest room and into the hallway.Interview on 09/17/2025 at 11:27 am with Resident #7 reflected he saw spiders in his room and there were roaches in the bathroom, and the roaches would crawl through the door of his room onto his floor, and it disgusted him, and he believed the place was filthy.Interview on 09/17/2025 at 12:11 pm with Resident #1 reflected he saw a lot of bugs at the facility. He saw bugs in the hallway and in the rooms, mostly roaches, and he said he did not dig it and did not feel good about the bugs. He said the bugs come out at night but he had not complained to anyone about the bugs.Interview on 09/17/2025 at 12:24 pm with Resident #3 reflected the night nurse (he could not recall her name) said she saw a rodent in his room so big she thought it was a possum. He said he saw bugs, roaches, spiders, and mice, which made him feel uncomfortable. He said he heard mice fighting to get to the food in his room and there were rat droppings in his drawer. He said it did not feel sanitary. Interview on 09/17/2025 at 1:36 pm with LVN B reflected she saw tons of roaches at the facility, and she did not pick up night shift because of the roaches with wings. Interview on 09/17/2025 at 2:11 pm with the MD reflected there was a report from a nurse (he did not know the name of the nurse) that she saw a rat in Resident #3's room. He said the nurse reported the rat sighting to the Administrator and the Administrator told him and both he and the Administrator went to Resident #1's room. He said he found a gap on the floorboard where a rodent could have entered, and he plugged the gap. The MD said, after viewing the photo of the dresser drawer in Resident #3's room of what appeared to be rodent droppings, that the photo did depict rat droppings. Interview on 09/17/25 at 4:57 pm with CNA C reflected Resident #3 mentioned there was a mouse in his room and she saw a bag of chips that was nibbled on. She said the Administrator got Resident #3 a bin to put his food in.Interview on 09/17/25 at 6:11 pm with AN LVN reflected she saw a rat, or a mouse run across Resident #3's room and go under the dresser. She said it was big. She said she reported to the oncoming nurse she saw a rodent in Resident #3's room and the oncoming nurse said she would tell the Administrator. She said it concerned her there was a rat in the building because rodents could be detrimental to a resident. She said rodents carry diseases.Interview on 09/19/25 at 4:25 with the Psychiatric NP reflected it was concerning there was a rodent spotted in Resident #3's room. She said a negative effect might be rabies if the resident was bitten because Resident #3 had no sensation from the waist down. She said he was not able to get up and move. She said she was not notified about the rodent situation. She said a review of her progress notes reflected Resident #3 told her the rats were eating his snacks.Interview on 09/19/25 at 4:56 pm with the ADON reflected she saw roaches in the facility every now and then. She said dead pests in the facility would indicate there was a pest problem. The negative effects of having pests in the facility could be infection control and the pests could make the residents feel uncomfortable not knowing if they were going to crawl on them and make the residents feel the facility was not clean. The ADON said she was not aware there was a rodent in Resident #3's room before the nurse witnessed the rodent. She said certain situations could make Resident #3 kind of delusional but a nurse seeing it with their own eyes was the final straw and Resident #3 should have gotten the benefit of the doubt. Because Resident #3 had limited movement, the rodent could have bitten him, and he could have gotten sick. Interview on 09/22/25 at 11:47 pm with the DOR reflected, when asked if she had seen roaches in the facility, she said, oh yea. She said in May, one came out of the secured unit keypad when she was pushing the keypad to get into the secured unit and she saw big water roaches. She said she told the administrator at the time about it, the MD, and the charge nurse. She said it was a big part of her reason she previously left the facility.Interview on 09/22/25 at 7:54 pm with the DON reflected there were bugs in the facility, and it was a problem because it could create skin abrasions and bites. He said roaches could be an infection control issue because they represented a dirty environment. He said he told the Administrator Resident #3 kept food in his room and mice might eat his food, so the Administrator got a plastic container for his food. The DON said Resident #3 should have been moved as soon as it was confirmed there were rat droppings in his room. He said the negative effect of a rodent in a resident's room was the possibility of being bitten by the rodent and skin infection. A rodent in Resident #3's room was definitely more difficult for him because Resident #3 could not move.Interview on 09/23/25 at 2:35 pm with the Administrator reflected that she could not remember when they brought up the possible rodent situation in Resident #2's room. She said both she and the MD went into Resident #2's room with a flashlight and looked around. She said they did not see anything but there was gap in the floorboard which the MD filled with a foam substance. She said on 09/19/25 the charge nurse called her and said the night agency nurse said she saw a rat running through Resident #2's room. The Administrator thought Resident #2 was delusional because he said it was a possum and Resident #2 had UTIs. The administrator said the MD said Resident #2 made stuff up. They now know there was a rodent in the facility because it was reported by a nurse.Interview on 09/23/25 at 2:35 pm with the Administrator reflected she had not seen live bugs in the facility. She said she did not know if having rodents and bugs in the facility was an infection control issue. She said the facility was supposed to have a homelike environment and people who do not live at nursing facilities have bugs and rodents even though they do not want to. She said the facility tried to keep bugs and rodents out of the facility just like people who do not live in nursing facilities.Record review of facility Policies and Procedures Pest Control dated June 2024 reflected the facility will implement measures to prevent, monitor, and address pest activity in a manner that does not compromise resident safety, infection control, or environmental standards.

Based on record review and interviews, 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 for one (Resident #3) of six residents reviewed for pharmacy services.The facility failed to administer Resident #3's Lidocaine Pain Relief External 21 times between 08/08/25 and 09/06/25. This failure could place residents at risk of worsening of their condition, increased risk of falls, pain, and injury.Findings included:Review of Resident #3's face sheet, dated 09/11/25, reflected a 36-year-male who was admitted to the facility on [DATE] with diagnoses including paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), displaced fracture of acromial process, right shoulder, initial encounter for closed fracture (a broken bone (acromion) in the right shoulder where the bone fragments have moved from their normal position), displaced fracture of body of scapula, right shoulder, initial encounter for closed fracture (a broken shoulder blade (scapula) on the right side, where the broken pieces have shifted out of their normal alignment), and displaced fracture of acromial process, left shoulder, initial encounter for closed fracture (a broken bone at the acromion (the bony point of the shoulder blade) that is no longer in its normal alignment, on the left side, for which the patient is receiving initial medical care, and the skin is unbroken). Review of Resident #3's care plan focus, dated 08/14/25, reflected pain: [Resident #3] complained of increased pain/discomfort and was at risk for further episodes of increased pain/discomfort and injury.Review of Resident #3's Entry MDS, dated [DATE], reflected no functional status and no BIMS score. Record review of Resident #3's orders Lidocaine Pain Relief External start date 08/07/2025 D/C date 08/28/2025 Patch 4% (Lidocaine) apply to left shoulder topically every 24 hours for pain, remove both patches after 12 hours - remove daily at 7pm.Record review of Resident #3's MAR, dated 08/08/25 through 08/10/25, 08/12/25 through 08/15/25, and 08/19/25 through 08/26/25, reflected number 8 which indicated that further information about the medication administration was in the resident's progress notes.Record review of Resident #3's progress notes dated 08/08/25 through 08/10/25, 08/12/25 through 08/15/25, and 08/19/25 through 08/26/25 reflected no notes specific to the administration of Lidocaine Pain Relief External start date 08/07/2025 D/C date 08/28/2025 Patch 4 % (Lidocaine) apply to left shoulder topically every 24 hours for pain remove both patches after 12 hours - remove daily at 7pm.Record review of Resident #3's orders reflected Lidocaine Pain Relief External start date 08/28/25 (no d/c date) (Lidocaine Pain Relief External Patch 4% apply to left shoulder topically in the evening for pain remove both patches after 12 hours - remove daily at 7pm Record review of Resident #3's [DATE]/01/25 through 09/04/25 reflected number 8which indicated that further information about the medication administration was in the resident's progress notes.Review of Resident #3's MAR, dated 09/05/25, reflected a blank, no staff initials and no check mark.Review of Resident #3's MAR, dated 09/06/26, reflected number 8 which indicated that further information about the medication administration was in the resident's progress notes.Record review of Resident #3's progress notes, dated 09/01/25 through 09/04/25 and 09/06/26 reflected no notes specific to the administration of Lidocaine Pain Relief External start date 08/28/2025 Patch 4 % (Lidocaine) Apply to left shoulder topically every 24 hours for pain remove both patches after 12 hours - remove daily at 7pm.Interview on 09/19/25 at 4:56 pm with the ADON reflected a number 8 in a residents' MAR reflected that the resident did not receive the medication. The ADON reflected it usually means that the facility did not have the medication and there should be a progress note explaining why the resident did not get the medication. She said the process was if the resident did not receive the medication, the person who was to administer the medication informed the nurse, then made a progress note and then inform the NP. She said there should never be a blank space in the MAR because it indicated the medication was not given. She said if Resident #3 did not get his lidocaine pain patch he could have been in pain. She said there was trouble getting the lidocaine patches from the pharmacy and he missed some lidocaine patch administration. She said the nursing staff notified the ADON and the DON if the facility did not have resident medication so it could be obtained. She said it was the responsibility of the medication aide and charge nurse to ensure residents' medication was in the building. She said the lidocaine patches could be purchased at [name of discount store] and they could have gone over there to pick them up. She said the possible negative effect of him not getting the lidocaine patch was pain, but he had several other pain medications he was received. She said Resident #3 was taking tramadol and hydrocodone. She said the NP should have been notified if Resident #3 did not receive his medication. She said residents should receive all the medications ordered for them unless the resident refused medications. She said the potential negative effect of a resident not receiving medications was that they could be in pain, suffer from blood pressure problems, and missing medication administration could cause more serious issues for the residents. Interview on 09/22/25 at 11:47 am with the DOR reflected Resident #3 told her he was not getting his lidocaine patch, and he said the patch helped with the pain. She said she knew staff were going to the pharmacy to get the patches over the counter. She said that he did display some pain medication seeking behavior and did not feel comfortable stating if she thought he was in pain. Interview on 09/22/25 at 1:23 pm with the NP reflected she was not aware that the resident was not receiving his lidocaine patches, and this was something that the facility should have told her. She said she could have ordered an alternate medication, maybe a gel, until the patches were available. She said when she saw him, he did not complain about any shoulder pain. She said the negative effect of her not being informed about Resident #3 not getting his lidocaine patches was that she was not informed so she could make decisions for an alternative solution.Interview on 09/22/25 at 5:40 pm with the MA reflected she gave lidocaine patches to Resident #3 when the facility had them. She said she told the agency nurses when she did not have Resident #3's medication but did not remember the names of the nurses. She said she had not seen the DON to tell him when she did not have the patches. She said she did not know how to enter a note in resident progress notes. She said when there was a number 8 in the resident's MAR, it meant the medication was not given to the resident. She said she told the nurse on duty when medication was not given and left it at that. She said it was the responsibility of the MAs and the nurses to make sure that resident medications were in the building. She did not know why he did not have his lidocaine patches. She said she entered a refill for them in the system. She said he was never upset when she was not able to give him the lidocaine patch. She said the negative effect of him not getting his lidocaine patch was that he was not getting the medication that was ordered for him. Interview on 09/22/25 at 5:56 pm with the RN reflected she did not give Resident #3 his Lorazepam on 8/24/25 and she charted in the progress notes medication was not available. The RN said Lorazepam was for anxiety and the negative effect of him not getting the Lorazepam would be that he was anxious. She said she could not give what she did not have, and she said the medication was on order, but the pharmacy was slow. She said she did not tell anyone that Resident #3did not get the Lorazepam, and she should have told the DON and the NP. She said the possible negative effect of not telling the NP was Resident #3 could have had a negative reaction to not having the medication and the NP would not have known what had gone on with him. Interview on 09/22/25 at 7:02 pm with the MA B reflected the number 8 in a residents' MAR meant pending delivery of a medication and the medication was not administered to the resident because the facility did not have it. When Resident #3 first arrived, the pharmacy was not sending his lidocaine patch. She did not know why. She said everyone knew about it, the ADON, DON, and the nurses. She said she informed the nurses, and they would get some into the facility, but they would run out quickly. She said she asked Resident #3 if he only wanted 1 patch to make them last longer and she would only give him one patch. She said sometimes they were purchased from [name of discount store]. She said the DON was responsible for making sure all medications for the residents were in the building. She said the possible negative effect of him not getting his lidocaine patches would be that he was in pain.Interview on 09/22/25 at 7:13 pm with Resident #3 reflected he did not get his lidocaine patch about 20% of the time and he did not receive other medications, he believed, intentionally. He said he felt neglected because he did not get his medication.Interview on 09/22/25 at 7:25 pm with LVN D reflected MAs notified the DON one or two times that Resident #3 did not receive his lidocaine patch. The pharmacy informed her that it was an over-the-counter medication unless there was a consent form signed and then it could be sent out to the facility. She thinks she told this to the people in the morning meeting. She said she did not remember who was at the meeting. She said it was the responsibility of everyone on the team to make sure that all of the medications for residents were in the building. She said the possible negative effects of Resident #3 not receiving his medication was that the resident could have been in pain. Interview on 09/22/25 at 7:54 pm with the DON reflected Resident #3 was not getting his lidocaine patches because there was a problem with availability. The DON said sometimes Resident #3 would get one patch administered instead of two patches administered and this was not good medication administration. He said he saw no information to indicate that the NP was told Resident #3 was not getting the lidocaine patches. He said if there were blanks in the MAR for a medication means the medication was not given or was skipped. The DON said residents should receive all the medications prescribed to them. The DON said that the negative effect of a residents not getting their medication was that the medication did not sustain its sufficiency to maintain the efficiency of the medication or the effects of the medications. He said the negative effect of Resident #3 not getting his lidocaine patch was that he would not get the desired pain management. He said it was the responsibility of the person giving the medications to make sure that residents' medications were in the facility. He said if the medication was not given the medical doctor or NP and the RP should be notified. He said the MAs or the nurse should call the pharmacy to figure out why the medication was not there and tell the DON. He said all steps and phone calls should be documented in the residents' progress notes.Interview on 09/23/25 at 2:35 pm with the Administrator reflected the DON was responsible for making sure that medications were in the building properly administered and the administration of the medications was properly documented. She said the possible negative effects of residents not receiving their medication was that they could experience pain. She said if the doctor ordered the medications, Resident #3 needed to be administered the medications.Record review of facility Nursing Policies and Procedures Medication Management dated June 2019 reflected the facility It is the policy of the facility that the facility will implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements. The facility's Medical Director will have an active role in the oversight of medication management.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed and five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #6) of ten residents reviewed.The facility failed to serve warm food to residents.These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included:Review of Resident #1's face sheet, dated 09/22/25, reflected a 62-year-male, admitted on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus [HIV] disease (a virus that attacks the body's immune system), type 2 diabetes mellitus with unspecified complications (a chronic condition in which the body does not use insulin effectively and has not developed any specific complications that can be identified), and bipolar disorder, current episode manic without psychotic features, moderate (periods of manic symptoms, including a prolonged elevated or irritable mood, increased energy, and goal-directed activity, lasting at least a week, without the presence of psychotic features such as delusions or hallucinations. The moderate severity suggests the symptoms are causing significant, but not severe, impairment in daily functioning).Review of Resident #1's care plan reflected focus, dated 09/19/25, Resident #1 was a diabetic and was at risk for fluctuations in blood glucose levels (the amount of sugar (glucose) in the bloodstream), hypo/hyperglycemia (abnormally low or high blood sugar levels) and other complications. Review of Resident #1's Nursing Home Comprehensive MDS, dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #3's face sheet, dated 09/11/25, reflected a 36-year-male, admitted on [DATE] with diagnoses including paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), displaced fracture of acromial process, right shoulder, initial encounter for closed fracture (a broken bone (acromion) in the right shoulder where the bone fragments have moved from their normal position), displaced fracture of body of scapula, right shoulder, initial encounter for closed fracture (a broken shoulder blade (scapula) on the right side, where the broken pieces have shifted out of their normal alignment), and displaced fracture of acromial process, left shoulder, initial encounter for closed fracture (a broken bone at the acromion (the bony point of the shoulder blade) that is no longer in its normal alignment, on the left side, for which the patient is receiving initial medical care, and the skin is unbroken). Review of Resident #3's care plan, dated 09/01/25, reflected Resident #3 refused meals.Review of Resident #3's Entry MDS, dated [DATE], reflected no functional status and no BIMS score.Review of Resident #4's face sheet, dated 09/11/25, reflected a 63-year-male, admitted on [DATE] and discharged on 08/07/25 with diagnoses including pressure ulcer of sacral region, unstageable (a full-thickness wound located on the bony prominence at the top of the buttocks (sacrum) that cannot be accurately staged due to the presence of thick, non-removable layers of necrotic tissue), paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), and unspecified protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their nutritional needs).Review of Resident #4's care plan reflected focus, dated 07/02/25, Resident #4 was a diabetic and was at risk for fluctuations in blood glucose levels, hypo/hyperglycemia, and other complications. Review of Resident #4's discharge MDS, dated [DATE], reflected no BIMS assessment. Review of Resident #4's BIMS assessment, dated 06/30/25, reflected a BIMS score of 13 indicating cognitively intact.Review of Resident #5'sface sheet, dated 09/17/25, reflected a 72-year-male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar levels that persist over time due to underlying condition with diabetic chronic kidney disease (occurs when a primary disease causes diabetes, which then leads to kidney damage), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood), and parkinsonism (a general term used to describe a group of neurological disorders that share similar symptoms to Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination)Review of Resident #5's care plan reflected focus, dated 04/22/25, Resident #5 was a diabetic and was at risk for fluctuations in blood glucose levels, hypo/hyperglycemia, and other complications. Review of Resident #5's Quarterly MDS, dated [DATE], reflected a BIMS score of 9 indicating moderate cognitive impairment.Review of Resident #6's face sheet, dated 09/17/25, reflected a 71-year-male, admitted on [DATE] with diagnoses including type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (nkhhc) (a serious complication of type 2 diabetes characterized by extremely high blood sugar levels (hyperglycemia) without the presence of ketones (molecules produced by the liver from fat, serving as an alternative energy source when glucose is unavailable, and they are a sign of fat breakdown in the body) in the blood) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). Review of Resident #6's care plan reflected focus, dated 04/22/25, Resident #6 was a diabetic and was at risk for fluctuations in blood glucose levels, hypo/hyperglycemia and other complications. Review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 10 indicating moderate cognitive impairment. Observation on 09/17/25 at 11:57 am reflected lunch meal consisting of diced cooked carrots, mashed sweet potatoes, and ham mixed with beans on uncovered trays passed to residents in the secured unit. Using facility thermometer measured the temperature of lunch meal:Carrots - 118 degrees Fahrenheit Mashed sweet potatoes - 115 degrees FahrenheitHam - 120 degrees FahrenheitBeans - 114 degrees FahrenheitReview of Concern Report from Resident #4, dated 06/03/25, reflected a concern reported to the IDT team that food was served cold on multiple occasions.Record review of resident council meeting, dated 07/02/25, reflected, Kitchen: Foods cold.Record review of resident council meeting, dated 09/02/25, reflected, food is still cold.Interview on 09/11/2025 at 12:25 pm with the RD revealed meals needed to be served at a temperature of 120 degrees Fahrenheit or above for hot food items and this temperature needed to be maintained to the last tray served to a resident. She said today, her dietary staff, told her the meals served to the residents were not hot when the residents received their meals. She said Resident #1 had previously told herthat the meals were not hot when they received them. She said it was the responsibility of the dietary staff and the nursing staff who passed the trays to the residents to make sure the food was both hot and passed in a manner that would keep the food hot. She said the negative effect of the food not being 120 degrees and hot when it was given to the residents was residents were not satisfied with their food and residents look forward to their meals. She said there could also be food safety concerns depending on how long the food was not in the acceptable temperature range. Interview on 09/17/2025 at 11:01 am with Resident #5 reflected he ate in the dining room. He said, hell no, the food was not hot when he gets it. He said it was always cold and he did not want to eat it because it was cold. He said he had told the people who work in the dining room that his food was cold. He said it made him mad and disappointed when his food was cold. Interview on 09/17/2025 at 11:04 am with Resident #6 reflected he ate in the dining room and said 50% of the time his food was not hot when it was served to him. He said residents were always griping about the food being cold when it is served. He said he made him feel not good' and disappointed when he was served food that was cold. He could not remember if he has told any of the staff about the food being cold. Interview on 09/17/2025 at 12:11 pm with Resident #1 reflected the food was sometimes warm when he got it and sometimes not. He said if the food was not warm the dining room staff would go get him another plate or a sandwich, but he would rather have a warm plate the first time around, so he did not have to wait for his food. He did not remember the names of the staff members he talked to about the cold food. Interview on 09/17/25 at 12:24 pm with Resident #3 reflected the food was cold in the mornings and there was a resident council meeting about food being cold. He said the cold food made him feel neglected and unimportant. Interview on 09/17/25 at 12:36 pm with CNA A reflected Resident #1 complained a lot about the food being cold when it was served. CNA A said Resident #1 would tell him, food cold man and would not eat the food when it was cold. Interview on 09/17/25 at 1:36 pm with LVN B reflected the residents' food was not warm when they received it. She said some of the dining staff would take the residents' food and warm it up for them but some of the dining staff would not. Interview on 09/17/25 at 2:25 pm with the Administrator reflected the cook was responsible for making sure the food was warm. She said if during resident council meetings and if there were grievances that said the food was cold and it should have been addressed by the dietary manager, and the administrator should have followed up to make sure it was resolved. She said if the food was cold, it did not make residents feel good and she could sympathize with them because she would not want cold food if it was supposed to be hot. She said residents could be upset and have a grievance if their food was not hot or they might not get the proper nutrition because they do not want to eat the food.Interview on 09/17/25 at 5:31 pm with the facility cook reflected she heard residents complain the food was cold when it got to them, but she did not know the names of the residents who complained. She said the food temperature should be 140 degrees Fahrenheit when residents received their food. She said the residents were a little upset about the cold food. She felt there was a lack of communication between the dietary service and the staff who passed out the resident trays. She said it would normally be the responsibility of the dietary manager to make sure residents received their food at the correct temperature, but they currently did not have a dietary manager. She said the residents complained about cold food for the past three months.Interview on 09/19/25 at 10:43 am with the DA reflected Residents #1 and #7 complained that residents did not receive food when it was hot. Residents #1 and #7 would tell the staff if the food was cold. She did not feel it was cold because it was not cold when it left the kitchen. She said it was the responsibility of the aides to make sure that the residents got their food before it got cold because it was the correct temperature when it left the kitchen. She had not told the Administrator, the DON or any nurses that residents complained that the food was cold when they got it. She was pretty sure that the residents told the Administrator and the nursing staff because there were some pretty vocal residents. She said they have not solved the problem, and residents were still getting cold food. She said they cut the kitchen staff down to two aides, and it got pretty hectic in the kitchen. She said it would make her feel very upset if she got cold food. She said she would feel like they did not put any care into the food service. Interview on 09/19/25 at 4:56 pm with the ADON reflected Resident #1 and a former resident, Resident #4, complained that the food was cold. She said it was a group effort between the kitchen and the aides and everyone to make sure that the trays got passed out so that residents' food was hot when they received it. She said residents might not feel happy if their food was cold and she would not be happy if she got served cold food.Review of facility Nutrition Services Policies and Procedures, undated, reflected it is the policy of this facility that food temperatures would be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. Review of facility food Palatability policy, dated 11/31/24, reflected food temperatures were monitored prior to service to ensure palatability and safe point-of-service temperatures.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #1 received adequate supervision to prevent him from exiting the facility undetected on 12/09/24 and 12/31/24. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/24 and ended on 01/01/25. The facility corrected the non-compliance before the investigation began on 01/08/25. The Past Non-Compliance form (a document used to report a past violation that has been rectified, at the time of the current investigation) sent to Administrator on 01/17/25 at 3:20pm. This failure could place the residents with exit seeking behaviors at risk for injury or death. The findings included: Record review of Resident #1's admission record dated 01/08/25 reflected a [AGE] year-old male initially admitted to the facility on [DATE] and re admitted on [DATE]. His diagnoses including Parkinson, Dementia, Abnormalities of gait and mobility, Lack of coordination, Muscle wasting and atrophy, Cognitive communication deficit, Pain, Tremor and Schizophrenia. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11, indicating Resident #1' s cognition was moderately impaired. The MDS stated he had hallucinations and delusions however there was no wandering behavior exhibited. Record review of Resident #1's care plan dated 01/01/25 reflected: Resident #1 was deemed at risk for wandering. On 12/09/24 and 12/31/24 he eloped from the facility. The relevant interventions were: 1. Reeducated staff on elopement. 2. Q 15 min monitoring, 3. Look for alternative placement. 4. Maintain resident safety during increased episodes of wandering. 5. Observe and document resident's location frequently throughout shift. Record review of Resident #1's quarterly Elopement risk evaluation dated 11/15/22 reflected Resident #1 had a score of 17 indicating he was at moderate risk for elopement. Record review of Resident #1's Elopement risk evaluation dated 01/01/25 reflected Resident #1 had a score of 33 indicating he was at high risk for elopement. Record review of FRI dated 12/09/24 and Inservice records reflected , on 12/09/24 at 2:30 pm, Resident #1 eloped through a malfunctioning gate and the facility completed the following interventions : In serviced the staff on elopement risks on 12/09/24. 1. Q 15 min monitoring commenced immediately after the elopement episode on 12/09/24 and continued till the resident discharged from the facility on 01/09/25. 2. Psychiatric Subsequent Assessment conducted on Resident #1 on 12/09/24. 3. Maintain resident safety during increased episodes of wandering. 4. Observed and documented resident's location frequently throughout shift 5. All the interventions were monitored and audited by DON on daily basis. Record review of FRI dated 01/01/25 and Inservice records reflected, on 12/31/24, Resident #1 was up during the night and entered into the kitchen through a door to the kitchen from memory care unit and then eloped down the street through the door at the back of the kitchen. The facility completed the following interventions : 1. Completed Inservice on 'kitchen Door Check on 01/01/25. 2. Looked for alternative placement. Resident #1 was discharged to another facility on 01/09/25. During an interview on 01/08/25 at 11:30 am , RN A stated she was the charge nurse on 01/08/25. She stated she was not on duty on 12/09/24 as well as on 12/31/24 when Resident #1 eloped. She stated she was informed by the DON that on 12/09/24 at about 2:00 pm, memory care residents were smoking in the yard. After the smoking session over, all the residents were returned to the memory care unit, however, the door to the yard from the memory care was not closed properly by the staff . She stated it was reported that one of the residents from the memory care reported to the staff that he saw Resident #1 getting out of the facility in his wheelchair by kicking the fence gate. RN A stated she also was informed, on 12/31/24 at night, Resident #1 entered the kitchen through the unlocked kitchen door that opened to the memory care, and from there, went to the street through the exit door at the back of the kitchen. She stated as the staff was not giving proper attention to ensure the doors were closed properly , Resident #1 had the opportunity to elope. RN A said the resident was on 15 minutes checks since the first incident that happened on 12/09/24 and that helped the staff who worked in the night on 12/31/24 to notice Resident #1's absence in the facility sooner than later at that time . During an interview on 01/08/24 at 2:00pm, CNA C stated she was working at the facility on 12/09/24. She stated on 12/09/24 at about 2:30 pm, one of the residents who resided in memory care reported to the staff that he saw Resident #1 leaving the facility in his wheelchair by opening the fence gate. CNA C stated she immediately went out with CNA D in search of Resident #1 and found him two blocks away on the street. She stated Resident #1 was not very happy to come back, however, he was compliant with nursing directions and returned to the facility with her and CNA D. She stated every staff who worked at the facility should ensure residents' safety by making sure all the exit doors remained locked properly. CNA C stated she received an in-service on elopement process on 12/09/24 and learnt the importance of securing the safety of the residents by ensuring the external doors and gates were closed and locked properly. CNA C stated she also learnt the process that to be followed step by step, after an incident of elopement occurred. During an interview on 01/08/25 at 2:30 pm, CNA D stated on 12/09/24, he worked at the memory care unit in the day shift. He said, on that day at about 2:00 pm, the residents were having q smoking session in the courtyard. He stated at about 2:30 pm, one resident from memory care reported to him that he noticed Resident #1 exiting the facility through the gate that opens from the yard to the street. CNA D said he and CNA C went out immediately in search of Resident #1 and found him in a church compound about 50 yards away from facility. CNA D stated Resident #1 was humorous and playful at that time and made numerous jokes about his elopement attempt. CNA C stated he received an in-service on elopement process on 12/09/24 and learnt the importance of securing the safety of the residents by ensuring the external doors and gates were closed and locked properly. CNA C stated she also learnt the process that to be followed step by step, after an incident of elopement occurred. During a telephone interview on 01/08/25 at 3:13 pm, LVN G stated she was the nurse who assessed Resident #1 after the incident of elopement on 12/09/24. She said the head-to-toe assessment revealed Resident #1 had no issues with skin integrity or any discoloration or inflammation. There were no deformities noticed. His vitals were within normal parameters. She said Resident #1 presented as jovial and funny, and did not show any signs of any injury, trauma, or pain. During an interview on 01/08/25 at 12.35 pm, MM B stated he started working at the facility as MM on 11/24/24 . He stated he was informed that on 12/09/24, in the afternoon, Resident #1 escaped from the memory care unit to the street through the door that opened to the yard, and from the yard through the gate on the fence. He said the incident of elopement occurred as the staff had not ensured that the door and gate were closed properly. He stated the staff should have pushed the door and gate after closing, to ensure they were locked properly. He stated the facility replaced the gate's digital lock with a more powerful magnet by a professional company. He said prior to 12/09/24, he used to check the gate twice a week. However, after the incident, it was increased to daily to make sure it was working properly. He said the second incident of elopement also occurred as the staff had not locked the kitchen door properly. During a telephone interview on 01/08/25 at 3:40 pm, RN H stated on 12/31/24, she worked in the night shift . RN H stated she was checking on Resident #1 every 15 minutes and noticed he was in his room until 11:00 pm . She said, at 11:00 pm, he approached her at the nursing station for snacks. She said he was at the nursing station area eating the snack until about 11:15pm. RN H stated, when she went to check on him at 11:30pm, he was not in his room, and she started searching other areas in the unit. She said since he was not seen anywhere, she requested the help from the staff who worked at the other side of the facility (non-secured area). She said , as the search was not fruitful, she called 911 and police arrived to help. In the meantime, one of the staff members noticed the kitchen door was to remain opened , made to assume he might have eloped through that door. RN H stated the police located Resident #1 four blocks away and brought him back to the facility. RN H stated she made a head-to-toe assessment and there were no injuries or issues noticed. RN H stated , when she asked Resident #1 how he managed to escape , Resident #1 replied that he went into the kitchen and from there to the street through the exit door at the back of the kitchen. She stated she asked him why he attempted to go away and in response he giggled and stated he was naughty to make that decision. She stated the facility amended the care plan to include the elopement risk and interventions. During an interview on 01/08/25 at 2:45 pm, DA E stated she worked at the facility as the DA for about 6 years. She said she started her shift every day at 11:00am and finished at 6:00pm, after the dinner being served. She stated after her shift finished, she made sure the exit door at the back of the kitchen and the passage door to the dining area of the memory care unit were locked properly . She added, she exited the facility through the secured door between the memory care unit and the non-secured area and left the facility through the main entrance. She said on 12/31/24, she worked the evening shift with DA F. She stated DA F was the last person who left the kitchen on 12/31/24 and she was sure that he secured all the kitchen doors before he left the facility. She stated she received an Inservice on Kitchen Door Check on 01/01/25 and learnt the importance of securing the safety of the residents by ensuring the kitchen doors were closed and locked properly. During an interview on 01/08/25 at 2:50 pm, DA F stated he started to work at the facility 4 days ago, on 12/27/24. He stated on 12/31/24, he worked with DA E and left the kitchen with her in the evening at approximately 6:30pm . DA F stated he was the one who exited the kitchen last, and clearly remembered that he closed the door. However, he was not sure if he made a point to check if it was locked . DA F stated he heard one resident escaped through the kitchen door on 12/31/24 , indicating he might not have locked the door properly . He said the incident was a lesson and thereafter made it sure that the kitchen doors were locked properly any time before leaving the kitchen . He said he received an Inservice on Kitchen Door Check on 01/01/25 and learnt the importance of securing the safety of the residents by ensuring the kitchen doors were closed and locked properly. During an observation on 01/08/25 at 11:30 am of the memory care unit, it was revealed the facility's kitchen was situated in the memory care unit. There were two doors that opened from the kitchen to the memory care, and they had keypad on it. There was an exit door at the back of the kitchen that opened to an open yard and a street. The street was not busy with traffic. The exit door at the back of the kitchen was locked from the inside with a latch. The entrance to the secured unit (memory care unit) from the general area of the facility was through a door ,controlled with keypad and required passcode. There was another door with a number lock and passcode and that opens to a fenced yard. The smoking area was in this yard. There was a gate on the fence that opened to a main street. It was a busy street with traffic. This gate also was protected with a digital pad and required passcode to open it. All the doors and gate were closed and locked during the observation. During an observation and interview on 01/08/25 at 1:45 pm, Resident #1 was in the hallway in his wheelchair interacting with staff and other residents. There was a carry-on bag beside his wheelchair and he stated he was ready to go to the new facility. He was pleasant, jovial, and humorous on interaction. When asked about the elopement attempts that he made on 12/09/24 and 12/31/24, he changed the subject and made some jokes on other issues. When re-directed to the subject of elopement, after some time, he stated he was being stupid . He again changed the subject and showed his disinterest in discussing it anymore. He stated he was moving out of the facility on that day and waiting for someone from the new facility to pick him up. He stated he had no issue or concern about going to another facility. During an interview on 01/08/25 at 4:10 pm, the DON stated he started working at the facility about 6 weeks ago; he transferred from a sister facility. He said when the resident was admitted initially about a year ago, he was at low risk of elopement . However after the elopement incident happened on 12/09/24, on further investigation, it was revealed that he had long history of elopement at the previous facility, and they had not communicated about it during his discharge from the old facility. He stated after the incident on 12/09/24, he was under 15-minute observations . He added, the facility did an in-service with all staff members regarding the importance of ensuring all the exit doors and the gate on the fence remained closed. He said the next day, the lock on the gate had been changed by a professional company. The DON stated the new kitchen staff, who started 4 days prior to the incident, did not follow through the practice of ensuring the doors were locked, and that led to another elopement. DON stated on further assessment, it was revealed the layout of the facility and the location of the memory care unit was not suitable for Resident #1. He stated , for that reason the facility was looking out for an appropriate placement and managed to find a safer facility for Resident #1. DON said Resident #1 would be discharged to that facility on 01/08/25. DON said Resident #1 did not have any family and his legal guardian agreed with this arrangement. During an interview on 01/17/25 at 12:20pm ADM stated she joined the facility about 6 weeks ago. She stated the elopement on 12/09/24 happened before she joined however was aware of the incident and the interventions that were in place for monitoring Resident #1 from elopement. She stated the second incident of elopement that happened on 12/31/24 was due to a lapse that was totally unexpected. She stated the new dietary staff had not ensured if the kitchen door was locked. ADM stated the kitchen staff were in serviced immediately about the importance of keeping the kitchen door locked all the time. She stated Resident #1 was transferred on 01/09/24 to a facility that was more appropriate to his needs and safety. Record review on 01/08/25 of the 15-minute checks on the MAR revealed the checks were completed starting from 12/09/24 and record review of the Inservice revealed all the staff worked in the memory care unit were in serviced on elopement process and all kitchen staff were in serviced on the expectation of before checking all the doors to ensure its closed before leaving the kitchen specially on last Shift for the day. Record review of the facility's policy Elopement revised in 08/2019 reflected: It is the policy of this facility to safely and timely redirect residents to a safe environment. A prompt investigation and search will be conducted if a resident is considered missing. It is the policy of this facility to safely and timely redirect residents to a safe environment. A prompt investigation and search will be conducted if a resident is considered missing. 3)The DON or designee organizes and institutes an immediate and thorough search of the facility and surrounding grounds. including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resides or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. 4)The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. .7) When the resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Service Designee assesses the resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing or designee. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and resident's legal representative. Record review and verification of the corrective action implemented by the facility beginning on 12/09/24. 1. In serviced the staff on elopement risks on 12/09/24. 2. Q 15 min monitoring commenced immediately after the elopement episode on 12/09/24 and continued till the resident discharged from the facility on 01/09/25. 3. Psychiatric Subsequent Assessment conducted on 12/09/24. 4. Maintained resident safety during increased episodes of wandering. 5. Observed and documented resident's location frequently throughout shift. 6. All the interventions were monitored and audited by DON on daily basis. 7. The gate lock was fixed on 12/11/24. 8. Completed Inservice on 'kitchen Door check on 01/01/25. 9. Looked for alternative placement. Resident #1 was discharged to new facility on 01/09/25. 10. Elopement risk assessment conducted on 12/10/24 on all the 26 residents in the secured unit revealed there were no residents with high risk of elopement except Resident #1. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/24 and ended on 01/01/25. The facility corrected the non-compliance before the investigation began on 01/08/25. Past Non-Compliance form sent to Administrator on 01/17/25 at 3:20pm.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for two (Resident #1 and Resident #2) of eight residents reviewed for administration. The facility Administrator failed to: - Investigate or report to HHSC an incident where Resident #2 was observed sexually assaulting Resident #1. - Allow LVN A to document the incident between Residents #1 and #2, notify law enforcement, or send Resident #1 to the hospital for evaluation. - Accurately document CNA B's witness statement without altering what she wrote regarding the incident between Residents #1 and #2. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. While the IJ was removed on 11/07/24 at 3:21 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for abuse, serious injury, serious harm, serious impairment, and death. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, depressive episodes, anxiety disorder, and muscle weakness and atrophy (wasting away). Review of Resident #1's quarterly care plan assessment, dated 09/03/24, reflected a BIMS score of 0, indicating she had a severe cognitive impairment. Review of Resident #1's quarterly care plan, revised 09/04/24, reflected she had impaired cognitive cognition and was at risk for further decline and injury with an intervention of explaining all procedures using terms and gestures the resident can understand. It further reflected she had a diagnosis of dementia and was at risk for increased confusion and decline in ADLs as the disease progresses with an intervention of re-assuring her when confusion has increased. Review of Resident #2's undated care plan reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including history of stroke and muscle wasting and atrophy. Review of Resident #2's quarterly MDS assessment, dated 09/12/24, reflected a BIMS score of 13, indicating he had no cognitive impairment. Review of Resident #2's quarterly care plan, revised 06/28/24, reflected he was a registered sex offender with an intervention of staff redirecting as needed. Review of a witness statement, dated 11/04/24 and typed by the ADM, reflected a statement made by CNA B: We laid [Resident #1] down after lunch, fully clothed. After I finished up on my hall I assisted another CNA with a hoyer lift. After we finished, I went back to my hall and [CR C] stated [Resident #1] had her clothes off. [Resident #1] was in [Resident #2]'s room. Clothes off, chair looked dirty and hands were shitty as if he had his hands in her private area. Her clothes were in a pile where she could reach. The nurse was notified. We removed [Resident #1] from the room and she stated she was afraid of him and we removed him from that hall. Review of a witness statement, dated 11/04/24 and hand-written by CNA B, reflected the following: We laid [Resident #1] down after lunch (fully clothed). After I finished up on my hall I assisted a coworker with a hoyer lift. After we finished, I went back to my hall. A resident stated, He had her clothes off. [Resident #1] was in [Resident #2]'s room. Clothes off. Chair locked, hands in her private area, her clothes in a pile where she couldn't reach. (The nurse was notified.) We removed [Resident #1] from his room. She stated, she was afraid for her life. She cried. We removed him from the hall. During a telephone interview on 11/05/24 at 10:14 AM, MA C stated she was working on 11/02/24. She stated sometime after lunch she observed Resident #1 in her wheelchair sitting in front of the door to her room. She saw Resident #2 cross the hall and got in front of Resident #1 and she told him to back up because he was too close to her face. She stated she then went and tended to another resident and when she went back into the hall, she didn't see either Resident #1 or #2 and she just thought they had gone to their rooms. She stated a few minutes passed when she saw CR D trying to flag her down, using his hand in a come here motion like something was wrong. She stated as she approached CR D, CNA B, CNA E and LVN A showed up due to the commotion. She stated she then noticed there was another resident in Resident #2's room where CR D was pointing. She stated as they approached the room, they saw Resident #2 with his hand between Resident #1's legs penetrating her private area. She stated she was completely naked including her brief which had BM in it. She stated Resident #2 had BM on one of his hands. She stated Resident #1 was shaking as if she was scared. She stated she and CNA E were in shock and removed Resident #1 from the area. She stated she had never known Resident #2 to do anything of that nature but did know he watched porn on his cell phone a lot which made her uncomfortable. She stated LVN A did contact the ADM right away and was told not to do or say anything about the incident. She stated when she worked the next day (11/03/24), Resident #1 was not herself - she was agitated, could not sit still, and kept trying to leave the building. She stated she still could not believe the ADM did not acknowledge something so serious. She stated she and other staff members were outraged. She stated in her opinion, every resident in the facility was at risk of being harmed by Resident #2. She began crying and stated she knew Resident #1 was psychologically harmed as that was a very traumatic event. During an interview on 11/05/24 at 10:32 AM, CR D stated he remembered calling for the CNAs when he saw Resident #1 in Resident #2's room (on 11/02/24). He stated he did not see much but he did see Resident #2 touching her inappropriately. During an interview on 11/05/24 at 10:38 AM, the SW stated she was notified of an incident between Residents #1 and #2 on Monday, 11/04/24. She stated she was told Resident #1 was in Resident #2's room and disrobed somehow and that Resident #2 had some of her BM on his hand somehow. She stated she had spoken to Resident #2 directly and he had told her he was helping her get dressed and must have gotten BM on his hand. She stated two staff members (MA C and CNA E) reported to her that they saw Resident #2's hands between Resident #1's legs. She stated when she spoke to the ADM the on 11/04/24, they decided to keep other residents safe, they would move him to the locked unit. She stated she knew Resident #1 had a history of disrobing and a history of wandering into other resident's rooms, but since they did not have all of the facts yet, that was probably why the ADM had not made a report to HHSC. She stated if it had been her, she would have wanted Resident #1 to have been sent to the hospital for evaluation as she could have suffered trauma. She stated that to her knowledge, the nurse (LVN A) was 'blocked' from sending her out to the hospital but was not sure by who. During a telephone interview on 11/05/24 at 11:11 AM, the ST stated she worked all day on 11/02/24. She stated LVN A sought her out after the incident between Residents #1 and #2. She was told Resident #1 was found in her wheelchair, wheelchair locked (which is was not able to do), she was shaking, all of her clothes were off and Resident #2's hands were between her legs. She stated when they took his hands, he had BM on his fingers. LVN A stated she contacted the ADM and told her not to do anything. She stated in the morning meeting on 11/04/24, the ADM stated it was Resident #1's fault because she should not have been in his room in the first place. She stated everyone was disgusted and it brought her to tears. She stated the police should have been called and Resident #1 should have been sent to the hospital. She stated the ADM was the Abuse and Neglect Coordinator and should have done something. She stated she had turned in her resignation due to this situation. During a telephone interview on 11/05/24 at 11:22 AM, LVN A stated she was the charge nurse on Saturday, 11/02/24. She stated she heard a loud commotion sometime after lunch. She stated she went down the hall towards the commotion and got to Resident #2's room at the same time as CNA B, MA C, and CNA E. She stated CR D was in the hall screaming that Resident #2 was messing with Resident #1 and was pointing in the room. When she got there, she saw Resident #1 in her wheelchair which was locked. She stated her wheelchair was never locked because she did not have the mental capacity to know to lock it. She stated she was completely nude, and her clothes and brief were beside her wheelchair and Resident #2's hands were between her legs. She stated when she raised her voice Resident #2 raised his hands and stated, I'm not doing anything! She stated Resident #1 rarely talked but when she went into the room, she put her arms around her chest, was shaking, and kept stating, I'm scared. She stated she did conduct an assessment on her but put it on paper because the ADM told her not to document anything in her chart. She stated while on the phone with her, she kept cutting her off and telling her to do nothing. She then told her to not call her anymore after threatening her license. She stated she wanted to send Resident #1 to the hospital, but the ADM told her not to. She stated one of Resident #2's hands had feces on it. She stated she worked the following day, 11/03/24, and Resident #1 was not the same person. She stated she was more withdrawn and anxious. She stated she contacted the ADON on 11/02/24 after she spoke with the ADM, and she told her to follow the ADM's instructions. She stated she also contacted the SW who did not do anything. She stated if it had been up to her, she would have called 911 and sent Resident #1 to the hospital. She stated in the morning meeting on 11/04/24, the ADM stated that they were not going to do anything because it was absolutely Resident #1's fault and everyone was outraged by the comment. During a telephone interview on 11/05/24 at 11:38 AM, Resident #1's NP stated she had no knowledge of an incident between Residents #1 and #2. She stated Resident #1 did not have the ability to consent to any kind of sexual interactions. She stated it would have been a wise thing to do when asked if her expectation would be for Resident #1 to have been sent to the hospital after the incident. During a telephone interview on 11/05/24 at 1:15 PM, Resident #1's RP stated he had not been notified by the facility of anything regarding an incident from 11/02/24. He stated as far as he was aware, she did not have a history of wandering into other resident rooms or disrobing herself. He stated she would not have the ability to consent to a sexual relationship and would have loved to have been notified. He stated she would have a hard time taking off her own clothes due to her dexterity and she would not even think to lock her wheelchair. During a telephone interview on 11/05/24 at 1:33 PM, CNA B was read the statement the ADM provided the Surveyor. She stated that was not the statement she wrote, and she would send her hand-written statement. She stated she saw Resident #2's hand penetrating Resident #1's private area. She stated she believed all of the woman residents were in danger of him. During a telephone interview on 11/05/24 at 1:55 PM, the ADON stated she did receive a call from LVN A on 11/02/24. She stated she was informed that Resident #1 was naked in Resident #2's room and his room was on her leg or something of that nature. She stated she never mentioned any kind of fondling. She stated the ADM told her she was going to do the investigation and get written statements. During an interview on 11/05/24 at 2:00 PM, the ADM stated she received a call sometime Saturday (11/02/24) night and was informed that Resident #1 was in Resident #2's room and she did not have any clothes on. She stated she asked LVN A where the CNAs were because if they had been around, she would not have been able to get in his room. She stated she contacted CNA B the following day (11/03/24) and she told her that Resident #1 had been found naked in Resident #2's room. She stated she asked her to write a statement. She stated nobody was in the room, nobody could have witnessed him touching her. She stated on 11/04/24, she interviewed Resident #2 who told her that Resident #1 had come into his room, and she had tried to hold his hand. She stated he told her he was looking at the TV and when he turned around, she had no clothes on. She stated he then told her he tried to help her put her clothes back on and did not have any sexual contact with her. She stated she did move Resident #2 into the locked unit to keep him safe from Resident #1 wandering in/out of his room because he is a sex offender and did not want him to be put in a situation like he was in today. She stated she only interviewed CNA B and no other staff because that was her hall she was working on, not MA C or CNA E. She stated she did not interview CR D because he was not competent enough to tell her what happened. She stated no staff members told her there had been any kind of penetration. She stated if they would have, she would have reported it at that time. When asked what the time frame was to report abuse, she stated it would have to be considered abuse. She stated there were no witnesses and Resident #2 told her he did not touch Resident #1, and he would not lie to her. She stated a possibility/suspicion of abuse did not mean it needed to be reported. When asked if she was always contacted when a resident was found naked and for no other purpose (such as abuse), she stated not always but sometimes. During a telephone interview on 11/05/24 at 2:28 PM, LVN A stated the ADM was not telling the truth. She stated she contacted her on 11/02/24 around 2:30 - 3:00 PM right after the incident between Residents #1 and #2 happened. She stated if she had just found Resident #1 naked without the witnessed abuse, she would not have had a reason to contact the ADM. She stated she did tell her about the explicit abuse, and she told her to do absolutely nothing and to not call her back. During an interview on 11/05/24 at 2:53 PM, Resident #2 stated the lady (Resident #1) went to his room, took off her clothes, and now they brought him down (to the locked unit). He stated she had a dirty diaper and when he was trying to help her, he may have stuck his hands in that. He stated he did not touch her, that he did [AGE] years (in prison) for that and I know better. During an interview on 11/06/24 at 10:23 AM, the MDSC stated Resident #1 having a history of disrobing had not been care planned was because that was the first time she had heard of her doing that - she did not have a history of it. She stated her care plan does mention her wandering, but she had never heard of her wandering into other residents' rooms. She stated she could not care plan what the nurses did not document. She stated, as a nurse, if she walked in and saw the incident between Residents #1 and #2, she would have definitely called the ADM who is the Abuse and Neglect Coordinator, and that was why LVN A called the ADM. She said Resident #1 was forgetful and never locked her wheelchair. She stated obviously Resident #2 was doing something inappropriate for her to make that phone call. The MDSC then stated to the Surveyors that she wanted to be honest about something. She stated that on 11/04/24, she, the ADM, the DON, and the SW interviewed Resident #2 and he admitted that he touched her. She stated he was then asked about the BM on his hand was told you had to have touched her butt and he replied with, well . her diaper was off . She stated he kept trying to back-track after that, but he definitely admitted to touching her. She stated the ADM was aware of what he had done. Review of the facility's undated Governing Body Policy reflected the following: The Governing Body is ultimately responsible for the operation of the Facility. The Governing Body must act in good faith in the exercise of its oversight responsibility for its organization, including making inquiries to ensure: (1) a data gathering, risk analysis and reporting systems exists and (2) the reporting system is adequate to assure the Governing Body that appropriate information relating to compliance with applicable laws will come to its attention timely and as a matter of course. Review of the facility's Abuse and Neglect Policy, revised 06/2019, reflected the following: . If abuse/neglect is suspected, the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the abuser and/or provision of medical care. 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. 3. The facility's Leadership will conduct a careful and deliberate investigation, centering on facts, observations and statements from the alleged victim and witnesses, of any allegation received of suspected abuse, neglect, or exploitation or mistreatment and will implement immediate action to safeguard resident. 4. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. 5. Report the investigation findings to the appropriate State Agencies, as required by law. The ADM was notified on 11/05/24 at 3:47 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/07/24 at 11:44 AM: F 835 According to the IJ template, the facility failed to ensure the Administrator acted in a professional manner. According to the IJ template, the administrator failed to allow a nurse to document an incident of sexual abuse between Residents #1 and #2. On 11/5/24 the Regional Director of Operations suspended the Administrator pending investigation of failure to report and investigate the incident from 11/2/24. The Regional Director of Operations reported the allegation of sexual abuse to HHSC on 11/5/24 and initiated an investigation. The Regional Director of Operations will act as the Abuse, Neglect, and Exploitation Prohibition Coordinator effective 11/5/24 until an Interim Administrator is identified. On 11/5/24 the Regional Director of Operations reviewed the Abuse, Neglect, and Exploitation Prohibition Policies and Procedures with no changes required. The Interim DON educated the Charge Nurse, and she completed an SBAR and Incident Report on Resident # 1 and Resident # 2 on 11/5/24 detailing the events of the incident from 11/2/24. The Charge Nurse notified the Physician and Responsible Party of Resident # 1 and # 2 on 11/5/24 of the event from 11/2/24. The Regional Nurse Consultant educated the Interim DON on 11/05/2024, and the Interim DON began training Charge Nurses on completing SBARs and Incident Reports for any resident-to-resident incidents, including those involving sexual allegations, and emphasized the importance of notifying the Administrator as of 11/5/24. QAPI meeting was conducted on 11/05/2024 with the Medical Director, Administrator and Interim DON over Abuse, Neglect, and Exploitation Prohibition Policies and Procedures. The Surveyor monitored the POR on 11/07/24 as followed: During an interview on 11/07/24 at 2:29 PM, the DO stated she was the direct Supervisor for the Administrator. She stated the ADM was suspended on 11/05/24 pending their investigation. She stated she would be the Abuse and Neglect Coordinator for the time being. She stated she if she had known about the incident between Residents #1 and #2, she would have told the ADM to report it and to send Resident #2, not allow him to stay in the facility. She stated he had since been sent out and would not be coming back. She stated she spoke to the RP of Resident #1, and he did not want to send her out to the hospital, stating it would be more traumatic. She stated all staff had been trained on abuse and neglect - went through the entire provider letter and policy, compliance training, reporting, incident reports, and SBAR. During interviews on 11/07/24 from 12:42 PM - 2:40 PM, staff (four CNAs, one LVN, one RN, and the SW) from multiple shifts stated they were in-serviced before working their shift. They stated they were in-serviced on abuse and neglect and to notify the IADM (the DO) immediately if there was every any abuse or neglect suspected. They all gave examples of abuse such as mental, physical, sexual, and emotional. They all stated if they did not like the way it was being handled, they were to call the compliance hotline which was posted in the hallways. The RN and LVN stated that an SBAR was to be completed whenever a resident had a change in condition. They stated this was to ensure all nursing staff were aware of any changes or issues that needed monitoring. Review of the facility's QAPI attendance sheet, dated 11/05/24, reflected the MD, the ADM, the DON, the ADON, the MAINTD, and the DOR were in attendance. Review of Resident #1's SBAR, dated 11/05/24, reflected a Change of Condition assessment had been completed. Review of Resident #2's SBAR, dated 11/05/24, reflected a Change of Condition assessment had been completed. Review of an Incident Intake, dated 11/05/24, reflected the incident between Residents #1 and #2 on 11/02/24 was reported to HHSC by the DO. Review of an in-service, dated 11/05/24 and conducted by the RLNFA, reflected the DON and LVN A were in-serviced on their abuse and neglect policies and procedures. Review of an in-service, dated from 11/05/24 -11/07/24 and conducted by the DON, reflected staff from all shifts were in-serviced on their abuse and neglect policies and procedures. Review of an in-service entitled Compliance Hotline, dated 11/05/24 and conducted by the DO, reflected the DON was in-serviced on utilizing the compliance hotline for any incidents that may require further investigation by the corporate team: including incidents where abuse, neglect, or exploitation may not be reported or investigated properly. Review of an in-service entitled Compliance and Ethics, dated from 11/05/24 - 11/07/24 and conducted by the DON, reflected staff from all shifts on the Compliance Hotline. Review of an in-service entitled SBAR/Notification of Abuse to Coordinator/Administrator, dated 11/05/24 and conducted by the RNC, reflected the DON was in-serviced on the following: Charge Nurses/Licensed Nurses are required to complete an SBAR and incident report for any type of resident-to-resident incident, including those including sexual allegations and are required to notify the Administrator. Review of an in-service entitled SBAR/Notification of Abuse to Coordinator/Administrator, dated 11/05/24 - 11/07/24 and conducted by the DON, reflected staff from all shifts were in-serviced on the following: Charge Nurses/Licensed Nurses are required to complete an SBAR and incident report for any type of resident-to-resident incident, including those including sexual allegations and are required to notify the Administrator. The DO was notified on 11/07/24 at 3:21 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to protect Resident #1's right to be free of sexual abuse by Resident #2. The facility failed to keep Resident #1 from being sexual assaulted by Resident #2 on 11/02/24. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. While the IJ was removed on 11/07/24 at 3:21 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Resident #1 Review of Resident #1's undated care plan reflected a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, depressive episodes, anxiety disorder, and muscle weakness and atrophy (wasting away). Review of Resident #1's quarterly care plan assessment, dated 09/03/24, reflected a BIMS score of 0, indicating she had a severe cognitive impairment. Section E (Behaviors) reflected she had not exhibited any physical or verbal behaviors. Review of Resident #1's quarterly care plan, revised 09/04/24, reflected she had impaired cognitive cognition and was at risk for further decline and injury with an intervention of explaining all procedures using terms and gestures the resident can understand. It further reflected she had a diagnosis of dementia and was at risk for increased confusion and decline in ADLs as the disease progresses with an intervention of re-assuring her when confusion has increased. Resident #2 Review of Resident #2's undated care plan reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including history of stroke and muscle wasting and atrophy. Review of Resident #2's quarterly MDS assessment, dated 09/12/24, reflected a BIMS score of 13, indicating he had no cognitive impairment. Section E (Behaviors) reflected he had not exhibited any physical or verbal behaviors. Review of Resident #2's quarterly care plan, revised 06/28/24, reflected he was a registered sex offender with an intervention of staff redirecting as needed. Review of a witness statement, dated 11/04/24 and hand-written by CNA B, reflected the following: We laid [Resident #1] down after lunch (fully clothed). After I finished up on my hall I assisted a coworker with a hoyer lift. After we finished, I went back to my hall. A resident stated, He had her clothes off. [Resident #1] was in [Resident #2]'s room. Clothes off. Chair locked, hands in her private area, her clothes in a pile where she couldn't reach. (The nurse was notified.) We removed [Resident #1] from his room. She stated, she was afraid for her life. She cried. We removed him from the hall. During a telephone interview on 11/05/24 at 1:33 PM, CNA B was read the statement the ADM provided the Surveyor. She stated that was not the statement she wrote, and she would send her hand-written statement. She stated she saw Resident #2's hand penetrating Resident #1's private area. She stated she believed all the woman residents were in danger of him. During a telephone interview on 11/05/24 at 10:14 AM, MA C stated she was working on 11/02/24. She stated sometime after lunch she observed Resident #1 in her wheelchair sitting in front of the door to her room. She saw Resident #2 cross the hall and got in front of Resident #1 and she told him to back up because he was too close to her face. She stated she then went and tended to another resident and when she went back into the hall, she didn't see either Resident #1 or #2 and she just thought they had gone to their rooms. She stated a few minutes passed when she saw CR D trying to flag her down, using his hand in a come here motion like something was wrong. She stated as she approached CR D, CNA B, CNA E and LVN A showed up due to the commotion. She stated she then noticed there was another resident in Resident #2's room where CR D was pointing. She stated as they approached the room, they saw Resident #2 with his hand between Resident #1's legs penetrating her private area. She stated she was completely naked including her brief which had BM in it. She stated Resident #2 had BM on one of his hands. She stated Resident #1 was shaking as if she was scared. She stated she and CNA E were in shock and removed Resident #1 from the area. She stated she had never known Resident #2 to do anything of that nature but did know he watched porn on his cell phone a lot which made her uncomfortable. She stated LVN A did contact the ADM right away and was told not to do or say anything about the incident. She stated when she worked the next day (11/03/24), Resident #1 was not herself - she was agitated, could not sit still, and kept trying to leave the building. She stated she still could not believe the ADM did not acknowledge something so serious. She stated she and other staff members were outraged. She stated in her opinion, every resident in the facility was at risk of being harmed by Resident #2. She began crying and stated she knew Resident #1 was psychologically harmed as that was a very traumatic event. During an interview on 11/05/24 at 10:32 AM, CR D stated he remembered calling for the CNAs when he saw Resident #1 in Resident #2's room (on 11/02/24). He stated he did not see much but he did see Resident #2 touching her inappropriately. During an interview on 11/05/24 at 10:38 AM, the SW stated she was notified of an incident between Residents #1 and #2 on Monday, 11/04/24. She stated she was told Resident #1 was in Resident #2's room and disrobed somehow and that Resident #2 had some of her BM on his hand somehow. She stated she had spoken to Resident #2 directly and he had told her he was helping her get dressed and must have gotten BM on his hand. She stated two staff members (MA C and CNA E) reported to her that they saw Resident #2's hands between Resident #1's legs. She stated when she spoke to the ADM the on 11/04/24, they decided to keep other residents safe, they would move him to the locked unit. She stated she knew Resident #1 had a history of disrobing and a history of wandering into other resident's rooms, but since they did not have all of the facts yet, that was probably why the ADM had not made a report to HHSC. She stated if it had been her, she would have wanted Resident #1 to have been sent to the hospital for evaluation as she could have suffered trauma. She stated that to her knowledge, the nurse (LVN A) was 'blocked' from sending her out to the hospital but was not sure by who. During a telephone interview on 11/05/24 at 11:11 AM, the ST stated she worked all day on 11/02/24. She stated LVN A sought her out after the incident between Residents #1 and #2. She was told Resident #1 was found in her wheelchair, wheelchair locked (which is was not able to do), she was shaking, all of her clothes were off and Resident #2's hands were between her legs. She stated when they took his hands, he had BM on his fingers. LVN A stated she contacted the ADM and told her not to do anything. She stated in the morning meeting on 11/04/24, the ADM stated it was Resident #1's fault because she should not have been in his room in the first place. She stated everyone was disgusted and it brought her to tears. She stated the police should have been called and Resident #1 should have been sent to the hospital. She stated the ADM was the Abuse and Neglect Coordinator and should have done something. She stated she had turned in her resignation due to this situation. During a telephone interview on 11/05/24 at 11:22 AM, LVN A stated she was the charge nurse on Saturday, 11/02/24. She stated she heard a loud commotion sometime after lunch. She stated she went down the hall towards the commotion and got to Resident #2's room at the same time as CNA B, MA C, and CNA E. She stated CR D was in the hall screaming that Resident #2 was messing with Resident #1 and was pointing in the room. When she got there, she saw Resident #1 in her wheelchair which was locked. She stated her wheelchair was never locked because she did not have the mental capacity to know to lock it. She stated she was completely nude, and her clothes and brief were beside her wheelchair and Resident #2's hands were between her legs. She stated when she raised her voice Resident #2 raised his hands and stated, I'm not doing anything! She stated Resident #1 rarely talked but when she went into the room, she put her arms around her chest, was shaking, and kept stating, I'm scared. She stated she did conduct an assessment on her but put it on paper because the ADM told her not to document anything in her chart. She stated while on the phone with her, she kept cutting her off and telling her to do nothing. She then told her to not call her anymore after threatening her license. She stated she wanted to send Resident #1 to the hospital, but the ADM told her not to. She stated one of Resident #2's hands had feces on it. She stated she worked the following day, 11/03/24, and Resident #1 was not the same person. She stated she was more withdrawn and anxious. She stated she contacted the ADON on 11/02/24 after she spoke with the ADM, and she told her to follow the ADM's instructions. She stated she also contacted the SW who did not do anything. She stated if it had been up to her, she would have called 911 and sent Resident #1 to the hospital. She stated in the morning meeting on 11/04/24, the ADM stated that they were not going to do anything because it was absolutely Resident #1's fault and everyone was outraged by the comment. During a telephone interview on 11/05/24 at 11:38 AM, Resident #1's NP stated she had no knowledge of an incident between Residents #1 and #2. She stated Resident #1 did not have the ability to consent to any kind of sexual interactions. She stated it would have been a wise thing to do when asked if her expectation would be for Resident #1 to have been sent to the hospital after the incident. During a telephone interview on 11/05/24 at 1:15 PM, Resident #1's RP stated he had not been notified by the facility of anything regarding an incident from 11/02/24. He stated as far as he was aware, she did not have a history of wandering into other resident rooms or disrobing herself. He stated she would not have the ability to consent to a sexual relationship and would have loved to have been notified. He stated she would have a hard time taking off her own clothes due to her dexterity and she would not even think to lock her wheelchair. During a telephone interview on 11/05/24 at 1:55 PM, the ADON stated she did receive a call from LVN A on 11/02/24. She stated she was informed that Resident #1 was naked in Resident #2's room and his room was on her leg or something of that nature. She stated she never mentioned any kind of fondling. She stated the ADM told her she was going to do the investigation and get written statements. During an interview on 11/05/24 at 2:00 PM, the ADM stated she received a call sometime Saturday (11/02/24) night and was informed that Resident #1 was in Resident #2's room and she did not have any clothes on. She stated she asked LVN A where the CNAs were because if they had been around, she would not have been able to get in his room. She stated she contacted CNA B the following day (11/03/24) and she told her that Resident #1 had been found naked in Resident #2's room. She stated she asked her to write a statement. She stated nobody was in the room, nobody could have witnessed him touching her. She stated on 11/04/24, she interviewed Resident #2 who told her that Resident #1 had come into his room, and she had tried to hold his hand. She stated he told her he was looking at the TV and when he turned around, she had no clothes on. She stated he then told her he tried to help her put her clothes back on and did not have any sexual contact with her. She stated she did move Resident #2 into the locked unit to keep him safe from Resident #1 wandering in/out of his room because he was a sex offender and did not want him to be put in a situation like he was in today. She stated she only interviewed CNA B and no other staff because that was her hall she was working on, not MA C or CNA E. She stated she did not interview CR D because he was not competent enough to tell her what happened. She stated no staff members told her there had been any kind of penetration. She stated if they would have, she would have reported it at that time. When asked what the time frame was to report abuse, she stated it would have to be considered abuse. She stated there were no witnesses and Resident #2 told her he did not touch Resident #1, and he would not lie to her. She stated a possibility/suspicion of abuse did not mean it needed to be reported. When asked if she was always contacted when a resident was found naked and for no other purpose (such as abuse), she stated not always but sometimes. During a telephone interview on 11/05/24 at 2:28 PM, LVN A stated the ADM was not telling the truth. She stated she contacted her on 11/02/24 around 2:30 - 3:00 PM right after the incident between Residents #1 and #2 happened. She stated if she had just found Resident #1 naked without the witnessed abuse, she would not have had a reason to contact the ADM. She stated she did tell her about the explicit abuse, and she told her to do absolutely nothing and to not call her back. During an interview on 11/05/24 at 2:53 PM, Resident #2 stated the lady (Resident #1) went to his room, took off her clothes, and now they brought him down (to the locked unit). He stated she had a dirty diaper and when he was trying to help her, he may have stuck his hands in that. He stated he did not touch her, that he did [AGE] years (in prison) for that and I know better. During an interview on 11/06/24 at 10:23 AM, the MDSC stated Resident #1 having a history of disrobing had not been care planned was because that was the first time she had heard of her doing that - she did not have a history of it. She stated her care plan does mention her wandering, but she had never heard of her wandering into other residents' rooms. She stated she could not care plan what the nurses did not document. She stated, as a nurse, if she walked in and saw the incident between Residents #1 and #2, she would have definitely called the ADM who was was the Abuse and Neglect Coordinator, and that was why LVN A called the ADM. She said Resident #1 was forgetful and never locked her wheelchair. She stated obviously Resident #2 was doing something inappropriate for her to make that phone call. The MDSC then stated to the Surveyors that she wanted to be honest about something. She stated that on 11/04/24, she, the ADM, the DON, and the SW interviewed Resident #2 and he admitted that he touched her. She stated he was then asked about the BM on his hand was told you had to have touched her butt and he replied with, well . her diaper was off . She stated he kept trying to back-track after that, but he definitely admitted to touching her. She stated the ADM was aware of what he had done. Review of in-services, dated 08/16/24 and 10/28/24, reflected staff were in-serviced on Abuse and Neglect. Review of the facility's Abuse and Neglect Policy, revised 06/2019, reflected the following: . Types of Abuse and Examples: Sexual: Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault. If an allegation of sexual abuse towards a resident is reported by any of the following persons, a family member, employee, volunteer and/or visitor, the facility will send the resident to the emergency room to be evaluated . A report will be made to the local police department the same day the allegation is made. Review of an in-service, dated 09/07/24, reflected staff were in-serviced on Sexual Allegations. Review of the facility's Abuse - Sexual Allegations Policy, revised 03/2019, reflected the following: Resident (victim) will remain with a same gender staff person until transferred to the hospital. The person accused will remain 1:1 with a staff person until police arrive for questioning. . Notify the appropriate State Agencies within two (2) hours. . If the person accused of the sexual abuse is a resident, they will be sent to the hospital for a further psych evaluation. The ADM was notified on 11/05/24 at 3:47 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/07/24 at 11:44 AM and indicated: F 600 According to the IJ template, the facility failed to keep the residents free from abuse. According to the IJ template, the facility failed to ensure Resident #1 was not sexually assaulted by Resident #2. According to the IJ template, the facility failed to appropriately assess Resident #1 after the incident, nor did they send her to the hospital or call Law Enforcement. Resident # 1 was assessed by the Interim DON on 11/5/24 with no adverse findings. The Interim DON was hired on 11/18/2022 before the incident occurred and promoted effective 11/01/2024. The Interim DON received training on 10/28/2024 and 11/05/2024, prior to and after the IJ, by the administrator. Resident # 1's POA was notified by the Administrator and Regional Director of Operations on 11/5/24 and refused transfer to the emergency room for Evaluation. Resident # 2 was placed on 1:1 observation by the social worker until the resident was transferred out. The social worker was instructed by the administrator on 11/05/2024 to not leave the resident unattended. On 11/5/24, the sheriff's Department was notified by the administrator and regional director of operations, and they came to the facility to investigate the incident and left without police intervention. Resident # 2 was admitted to inpatient psych on 11/5/24. Resident #2 Parole Officer was contacted by the social worker on 11/05/2024 & 11/06/2024 to issue a warrant for his arrest, awaiting a return call. The Regional Director of Operations contacted the admission department on 11/06/2024 to inform them that the resident would not return to this facility. On 11/5/24 the Regional Director of Operations suspended the Administrator pending investigation of failure to report and investigate the incident from 11/2/24. The Regional Director of Operations reported the allegation of sexual abuse to HHSC and initiated an investigation on 11/5/24. On 11/06/2024, safe surveys were conducted by the social worker with no adverse findings of sexual abuse. The Regional Director of Operations reviewed the Abuse, Neglect, and Exploitation Prohibition Policies and Procedures on 11/05/2024 with no changes required. The Regional Administrator educated the Interim DON on 11/05/2024, and the Interim DON initiated education on Abuse, Neglect, and Exploitation Prohibition with current, new and PRN staff on 11/5/24. The Regional Nurse Consultant educated the Interim DON on 11/05/2024 and the Interim DON began training Charge Nurses on completing SBARs and Incident Reports for any resident-to-resident incidents, including those involving sexual allegations, and emphasized the importance of notifying the Administrator as of 11/5/2024. The Regional Director of Operations initiated education with current, new and PRN staff on the Compliance Hotline and how to utilize the Compliance Hotline for any incidents that may require further investigation by the Corporate Team: including incidents where Abuse, Neglect, or Exploitation may not be reported or investigated properly on 11/05/24. Education will be completed by 11/6/24. The Regional Administrator/Designee will ensure staff members receive the education before starting their next shift. QAPI meeting was conducted on 11/05/2024 with the Medical Director, Administrator and Interim DON over Abuse, Neglect, and Exploitation Prohibition Policies and Procedures. The Surveyor monitored the POR on 11/07/24 as followed: During an interview on 11/07/24 at 2:29 PM, the DO stated she was the direct Supervisor for the Administrator. She stated the ADM was suspended on 11/05/24 pending their investigation. She stated she would be the Abuse and Neglect Coordinator for the time being. She stated she if she had known about the incident between Residents #1 and #2, she would have told the ADM to report it and to send Resident #2, not allow him to stay in the facility. She stated he had since been sent out and would not be coming back. She stated she spoke to the RP of Resident #1, and he did not want to send her out to the hospital, stating it would be more traumatic. She stated all staff had been trained on abuse and neglect - went through the entire provider letter and policy, compliance training, reporting, incident reports, and SBAR. During interviews on 11/07/24 from 12:42 PM - 2:40 PM, staff (four CNAs, one LVN, one RN, and the SW) from multiple shifts stated they were in-serviced before working their shift. They stated they were in-serviced on abuse and neglect and to notify the IADM (the DO) immediately if there was every any abuse or neglect suspected. They all gave examples of abuse such as mental, physical, sexual, and emotional. They all stated if they did not like the way it was being handled, they were to call the compliance hotline which was posted in the hallways. The RN and LVN stated that an SBAR was to be completed whenever a resident had a change in condition. They stated this was to ensure all nursing staff were aware of any changes or issues that needed monitoring. Review of the facility's QAPI attendance sheet, dated 11/05/24, reflected the MD, the ADM , the DON, the ADON, the MAINTD, and the DOR were in attendance. Review of Resident #2's progress note, dated 11/05/24 and documented by the SW, reflected the following: On Saturday, November 5 [sic], 2024, a naked female resident (Resident #1) was found in [Resident #2]'s room. [Resident #1] had an incontinent episide and [Resident #2] was observed with BM on his hand . it was determined that [Resident #2] should be admitted to (psychatric hospital). Review of Resident #1's SBAR, dated 11/05/24, reflected a Change of Condition assessment had been completed. Review of Resident #2's SBAR, dated 11/05/24, reflected a Change of Condition assessment had been completed. Review of an Incident Intake, dated 11/05/24, reflected the incident between Residents #1 and #2 on 11/02/24 was reported to HHSC by the DO. Review of an in-service, dated 11/05/24 and conducted by the RLNFA, reflected the DON and LVN A were in-serviced on their abuse and neglect policies and procedures. Review of an in-service, dated from 11/05/24 -11/07/24 and conducted by the DON, reflected staff from all shifts were in-serviced on their abuse and neglect policies and procedures. Review of an in-service entitled Compliance Hotline, dated 11/05/24 and conducted by the DO, reflected the DON was in-serviced on utilizing the compliance hotline for any incidents that may require further investigation by the corporate team: including incidents where abuse, neglect, or exploitation may not be reported or investigated properly. Review of an in-service entitled Compliance and Ethics, dated from 11/05/24 - 11/07/24 and conducted by the DON, reflected staff from all shifts on the Compliance Hotline. Review of an in-service entitled SBAR/Notification of Abuse to Coordinator/Administrator, dated 11/05/24 and conducted by the RNC, reflected the DON was in-serviced on the following: Charge Nurses/Licensed Nurses are required to complete an SBAR and incident report for any type of resident-to-resident incident, including those including sexual allegations and are required to notify the Administrator. Review of an in-service entitled SBAR/Notification of Abuse to Coordinator/Administrator, dated 11/05/24 - 11/07/24 and conducted by the DON, reflected staff from all shifts were in-serviced on the following: Charge Nurses/Licensed Nurses are required to complete an SBAR and incident report for any type of resident-to-resident incident, including those including sexual allegations and are required to notify the Administrator. Review of resident safe surveys, dated 11/06/24 and conducted by the SW, reflected no concerns from the residents. The DO was notified on 11/07/24 at 3:21 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for two (Resident #1 and Resident #2) of eight residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement the facility abuse and neglect policy when they failed to protect Resident #1 from being sexually assaulted by Resident #2. The ADM was notified, and she failed to action to keep Resident #1 from further abuse or psychosocial harm. She did not thoroughly investigate the incident or report it to HHSC. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. While the IJ was removed on 11/07/24 at 3:21 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of continued abuse, injury, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, depressive episodes, anxiety disorder, and muscle weakness and atrophy (wasting away). Review of Resident #1's quarterly care plan assessment, dated 09/03/24, reflected a BIMS score of 0, indicating she had a severe cognitive impairment. Review of Resident #1's quarterly care plan, revised 09/04/24, reflected she had impaired cognitive cognition and was at risk for further decline and injury with an intervention of explaining all procedures using terms and gestures the resident can understand. It further reflected she had a diagnosis of dementia and was at risk for increased confusion and decline in ADLs as the disease progresses with an intervention of re-assuring her when confusion has increased. Review of Resident #2's undated care plan reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including history of stroke and muscle wasting and atrophy. Review of Resident #2's quarterly MDS assessment, dated 09/12/24, reflected a BIMS score of 13, indicating he had no cognitive impairment. Review of Resident #2's quarterly care plan, revised 06/28/24, reflected he was a registered sex offender with an intervention of staff redirecting as needed. Review of a witness statement, dated 11/04/24 and hand-written by CNA B, reflected the following: We laid [Resident #1] down after lunch (fully clothed). After I finished up on my hall I assisted a coworker with a hoyer lift. After we finished, I went back to my hall. A resident stated, He had her clothes off. [Resident #1] was in [Resident #2]'s room. Clothes off. Chair locked, hands in her private area, her clothes in a pile where she couldn't reach. (The nurse was notified.) We removed [Resident #1] from his room. She stated, she was afraid for her life. She cried. We removed him from the hall. During a telephone interview on 11/05/24 at 10:14 AM, MA C stated she was working on 11/02/24. She stated sometime after lunch she observed Resident #1 in her wheelchair sitting in front of the door to her room. She saw Resident #2 cross the hall and got in front of Resident #1 and she told him to back up because he was too close to her face. She stated she then went and tended to another resident and when she went back into the hall, she didn't see either Resident #1 or #2 and she just thought they had gone to their rooms. She stated a few minutes passed when she saw CR D trying to flag her down, using his hand in a come here motion like something was wrong. She stated as she approached CR D, CNA B, CNA E and LVN A showed up due to the commotion. She stated she then noticed there was another resident in Resident #2's room where CR D was pointing. She stated as they approached the room, they saw Resident #2 with his hand between Resident #1's legs penetrating her private area. She stated she was completely naked including her brief which had BM in it. She stated Resident #2 had BM on one of his hands. She stated Resident #1 was shaking as if she was scared. She stated she and CNA E were in shock and removed Resident #1 from the area. She stated she had never known Resident #2 to do anything of that nature but did know he watched porn on his cell phone a lot which made her uncomfortable. She stated LVN A did contact the ADM right away and was told not to do or say anything about the incident. She stated when she worked the next day (11/03/24), Resident #1 was not herself - she was agitated, could not sit still, and kept trying to leave the building. She stated she still could not believe the ADM did not acknowledge something so serious. She stated she and other staff members were outraged. She stated in her opinion, every resident in the facility was at risk of being harmed by Resident #2. She began crying and stated she knew Resident #1 was psychologically harmed as that was a very traumatic event. During an interview on 11/05/24 at 10:32 AM, CR D stated he remembered calling for the CNAs when he saw Resident #1 in Resident #2's room (on 11/02/24). He stated he did not see much but he did see Resident #2 touching her inappropriately. During an interview on 11/05/24 at 10:38 AM, the SW stated she was notified of an incident between Residents #1 and #2 on Monday, 11/04/24. She stated she was told Resident #1 was in Resident #2's room and disrobed somehow and that Resident #2 had some of her BM on his hand somehow. She stated she had spoken to Resident #2 directly and he had told her he was helping her get dressed and must have gotten BM on his hand. She stated two staff members (MA C and CNA E) reported to her that they saw Resident #2's hands between Resident #1's legs. She stated when she spoke to the ADM the on 11/04/24, they decided to keep other residents safe, they would move him to the locked unit. She stated she knew Resident #1 had a history of disrobing and a history of wandering into other resident's rooms, but since they did not have all of the facts yet, that was probably why the ADM had not made a report to HHSC. She stated if it had been her, she would have wanted Resident #1 to have been sent to the hospital for evaluation as she could have suffered trauma. She stated that to her knowledge, the nurse (LVN A) was 'blocked' from sending her out to the hospital but was not sure by who. During a telephone interview on 11/05/24 at 11:11 AM, the ST stated she worked all day on 11/02/24. She stated LVN A sought her out after the incident between Residents #1 and #2. She was told Resident #1 was found in her wheelchair, wheelchair locked (which is was not able to do), she was shaking, all of her clothes were off and Resident #2's hands were between her legs. She stated when they took his hands, he had BM on his fingers. LVN A stated she contacted the ADM and told her not to do anything. She stated in the morning meeting on 11/04/24, the ADM stated it was Resident #1's fault because she should not have been in his room in the first place. She stated everyone was disgusted and it brought her to tears. She stated the police should have been called and Resident #1 should have been sent to the hospital. She stated the ADM was the Abuse and Neglect Coordinator and should have done something. She stated she had turned in her resignation due to this situation. During a telephone interview on 11/05/24 at 11:22 AM, LVN A stated she was the charge nurse on Saturday, 11/02/24. She stated she heard a loud commotion sometime after lunch. She stated she went down the hall towards the commotion and got to Resident #2's room at the same time as CNA B, MA C, and CNA E. She stated CR D was in the hall screaming that Resident #2 was messing with Resident #1 and was pointing in the room. When she got there, she saw Resident #1 in her wheelchair which was locked. She stated her wheelchair was never locked because she did not have the mental capacity to know to lock it. She stated she was completely nude, and her clothes and brief were beside her wheelchair and Resident #2's hands were between her legs. She stated when she raised her voice Resident #2 raised his hands and stated, I'm not doing anything! She stated Resident #1 rarely talked but when she went into the room, she put her arms around her chest, was shaking, and kept stating, I'm scared. She stated she did conduct an assessment on her but put it on paper because the ADM told her not to document anything in her chart. She stated while on the phone with her, she kept cutting her off and telling her to do nothing. She then told her to not call her anymore after threatening her license. She stated she wanted to send Resident #1 to the hospital, but the ADM told her not to. She stated one of Resident #2's hands had feces on it. She stated she worked the following day, 11/03/24, and Resident #1 was not the same person. She stated she was more withdrawn and anxious. She stated she contacted the ADON on 11/02/24 after she spoke with the ADM, and she told her to follow the ADM's instructions. She stated she also contacted the SW who did not do anything. She stated if it had been up to her, she would have called 911 and sent Resident #1 to the hospital. She stated in the morning meeting on 11/04/24, the ADM stated that they were not going to do anything because it was absolutely Resident #1's fault and everyone was outraged by the comment. During a telephone interview on 11/05/24 at 11:38 AM, Resident #1's NP stated she had no knowledge of an incident between Residents #1 and #2. She stated Resident #1 did not have the ability to consent to any kind of sexual interactions. She stated it would have been a wise thing to do when asked if her expectation would be for Resident #1 to have been sent to the hospital after the incident. During a telephone interview on 11/05/24 at 1:15 PM, Resident #1's RP stated he had not been notified by the facility of anything regarding an incident from 11/02/24. He stated as far as he was aware, she did not have a history of wandering into other resident rooms or disrobing herself. He stated she would not have the ability to consent to a sexual relationship and would have loved to have been notified. He stated she would have a hard time taking off her own clothes due to her dexterity and she would not even think to lock her wheelchair. During a telephone interview on 11/05/24 at 1:33 PM, CNA B was read the statement the ADM provided the Surveyor. She stated that was not the statement she wrote, and she would send her hand-written statement. She stated she saw Resident #2's hand penetrating Resident #1's private area. She stated she believed all of the woman residents were in danger of him. During a telephone interview on 11/05/24 at 1:55 PM, the ADON stated she did receive a call from LVN A on 11/02/24. She stated she was informed that Resident #1 was naked in Resident #2's room and his room was on her leg or something of that nature. She stated she never mentioned any kind of fondling. She stated the ADM told her she was going to do the investigation and get written statements. During an interview on 11/05/24 at 2:00 PM, the ADM stated she received a call sometime Saturday (11/02/24) night and was informed that Resident #1 was in Resident #2's room and she did not have any clothes on. She stated she asked LVN A where the CNAs were because if they had been around, she would not have been able to get in his room. She stated she contacted CNA B the following day (11/03/24) and she told her that Resident #1 had been found naked in Resident #2's room. She stated she asked her to write a statement. She stated nobody was in the room, nobody could have witnessed him touching her. She stated on 11/04/24, she interviewed Resident #2 who told her that Resident #1 had come into his room, and she had tried to hold his hand. She stated he told her he was looking at the TV and when he turned around, she had no clothes on. She stated he then told her he tried to help her put her clothes back on and did not have any sexual contact with her. She stated she did move Resident #2 into the locked unit to keep him safe from Resident #1 wandering in/out of his room because he is a sex offender and did not want him to be put in a situation like he was in today. She stated she only interviewed CNA B and no other staff because that was her hall she was working on, not MA C or CNA E. She stated she did not interview CR D because he was not competent enough to tell her what happened. She stated no staff members told her there had been any kind of penetration. She stated if they would have, she would have reported it at that time. When asked what the time frame was to report abuse, she stated it would have to be considered abuse. She stated there were no witnesses and Resident #2 told her he did not touch Resident #1, and he would not lie to her. She stated a possibility/suspicion of abuse did not mean it needed to be reported. When asked if she was always contacted when a resident was found naked and for no other purpose (such as abuse), she stated not always but sometimes. During a telephone interview on 11/05/24 at 2:28 PM, LVN A stated the ADM was not telling the truth. She stated she contacted her on 11/02/24 around 2:30 - 3:00 PM right after the incident between Residents #1 and #2 happened. She stated if she had just found Resident #1 naked without the witnessed abuse, she would not have had a reason to contact the ADM. She stated she did tell her about the explicit abuse, and she told her to do absolutely nothing and to not call her back. During an interview on 11/05/24 at 2:53 PM, Resident #2 stated the lady (Resident #1) went to his room, took off her clothes, and now they brought him down (to the locked unit). He stated she had a dirty diaper and when he was trying to help her, he may have stuck his hands in that. He stated he did not touch her, that he did [AGE] years (in prison) for that and I know better. During an interview on 11/06/24 at 10:23 AM, the MDSC stated Resident #1 having a history of disrobing had not been care planned was because that was the first time she had heard of her doing that - she did not have a history of it. She stated her care plan does mention her wandering, but she had never heard of her wandering into other residents' rooms. She stated she could not care plan what the nurses did not document. She stated, as a nurse, if she walked in and saw the incident between Residents #1 and #2, she would have definitely called the ADM who is the Abuse and Neglect Coordinator, and that was why LVN A called the ADM. She said Resident #1 was forgetful and never locked her wheelchair. She stated obviously Resident #2 was doing something inappropriate for her to make that phone call. The MDSC then stated to the Surveyors that she wanted to be honest about something. She stated that on 11/04/24, she, the ADM, the DON, and the SW interviewed Resident #2 and he admitted that he touched her. She stated he was then asked about the BM on his hand was told you had to have touched her butt and he replied with, well . her diaper was off . She stated he kept trying to back-track after that, but he definitely admitted to touching her. She stated the ADM was aware of what he had done. Review of in-services, dated 08/16/24 and 10/28/24, reflected staff were in-serviced on Abuse and Neglect. Review of an in-service, dated 09/07/24, reflected staff were in-serviced on Sexual Allegations. Review of the facility's Abuse and Neglect Policy, revised 06/2019, reflected the following: . Types of Abuse and Examples: Sexual: Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault. If an allegation of sexual abuse towards a resident is reported by any of the following persons, a family member, employee, volunteer and/or visitor, the facility will send the resident to the emergency room to be evaluated . A report will be made to the local police department the same day the allegation is made . . If abuse/neglect is suspected, the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the abuser and/or provision of medical care. 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. 3. The facility's Leadership will conduct a careful and deliberate investigation, centering on facts, observations and statements from the alleged victim and witnesses, of any allegation received of suspected abuse, neglect, or exploitation or mistreatment and will implement immediate action to safeguard resident. 4. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. 5. Report the investigation findings to the appropriate State Agencies, as required by law. Review of the facility's Abuse - Sexual Allegations Policy, revised 03/2019, reflected the following: Resident (victim) will remain with a same gender staff person until transferred to the hospital. The person accused will remain 1:1 with a staff person until police arrive for questioning. . Notify the appropriate State Agencies within two (2) hours. . If the person accused of the sexual abuse is a resident, they will be sent to the hospital for a further psych evaluation. The ADM was notified on 11/05/24 at 3:47 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/07/24 at 11:44 AM indicated: F 607 According to the IJ template, the facility must develop and implement written policies and procedures that prohibit and prevent abuse and neglect. According to the IJ template, the facility failed to follow their abuse and neglect policy after Resident #1 was sexually assaulted by Resident #2. According to the IJ template, the facility failed to investigate or report the abuse allegation per the policy. On 11/5/24 the Regional Director of Operations suspended the Administrator pending investigation of failure to report and investigate the incident from 11/2/24. The Regional Director of Operations reported the allegation of sexual abuse to HHSC on 11/5/24 and initiated an investigation. On 11/5/24, the sheriff's Department was notified by administrator and regional director of operations, and they came to the facility to investigate the incident and left without police intervention. Resident # 2 was admitted to inpatient psych on 11/5/24. Resident #2 Parole Officer was contacted by the social worker on 11/05/2024 & 11/06/2024 to issue a warrant for his arrest, awaiting a return call. Resident # 1's POA was notified by the Administrator and Regional Director of Operations on 11/5/24 and refused transfer to the emergency room for Evaluation. The Regional Director of Operations will act as the Abuse, Neglect, and Exploitation Prohibition Coordinator effective 11/5/24 until an Interim Administrator is identified, this information is relayed with the ANE education related to this incident. The Regional Director of Operations reviewed the Abuse, Neglect, and Exploitation Prohibition Policies and Procedures on 11/05/2024 with no changes required. The Surveyor monitored the POR on 11/07/24 as followed: During interviews on 11/07/24 from 12:42 PM - 2:40 PM, staff (four CNAs, one LVN, one RN, and the SW) from multiple shifts stated they were in-serviced before working their shift. They stated they were in-serviced on abuse and neglect and to notify the IADM (the DO) immediately if there was every any abuse or neglect suspected. They all gave examples of abuse such as mental, physical, sexual, and emotional. They all stated if they did not like the way it was being handled, they were to call the compliance hotline which was posted in the hallways. Review of the facility's QAPI attendance sheet, dated 11/05/24, reflected the MD, the ADM , the DON, the ADON, the MAINTD, and the DOR were in attendance. Review of an Incident Intake, dated 11/05/24, reflected the incident between Residents #1 and #2 on 11/02/24 was reported to HHSC by the DO. Review of Resident #1's incident report, dated 11/05/24 and documented by the DON, reflected the following: [Resident #1] was assessed on 11/05/24 with no adverse findings. POA refused any type of hospital transfer, and no new order was received from the physician. Review of Resident #2's progress note, dated 11/05/24 and documented by the SW, reflected the following: On Saturday, November 5 [sic], 2024, a naked female resident (Resident #1) was found in [Resident #2]'s room. [Resident #1] had an incontinent episode and [Resident #2] was observed with BM on his hand . it was determined that [Resident #2] should be admitted to (psychatric hospital). During an interview on 11/07/24 at 2:29 PM, the DO stated she was the direct Supervisor for the Administrator. She stated the ADM was suspended on 11/05/24 pending their investigation. She stated she would be the Abuse and Neglect Coordinator for the time being. She stated she if she had known about the incident between Residents #1 and #2, she would have told the ADM to report it and to send Resident #2, not allow him to stay in the facility. She stated he had since been sent out and would not be coming back. She stated she spoke to the RP of Resident #1, and he did not want to send her out to the hospital, stating it would be more traumatic. She stated all staff had been trained on abuse and neglect - went through the entire provider letter and policy, compliance training, reporting, incident reports, and SBAR. The DO was notified on 11/07/24 at 3:21 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #3) of five residents reviewed for a homelike environment. The facility failed to fix a plumbing issue in Resident #3's closet for approximately six months which caused his closet to secrete a musty/moldy odor causing him to be embarrassed and humiliated to wear his clothes which embodied the odor. This failure could affect residents by placing them at risk for diminished quality of life and being in an unsafe environment. Findings included: Review of Resident #3's undated care plan reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a disabling disease of the brain and spinal cord), depression, and muscle wasting and atrophy (wasting away). Review of Resident #3's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 15, indicating he had no cognitive impairment. Review of Resident #3's quarterly care plan, revised [DATE], reflected he had a mood problem with an intervention of assisting the resident, family, caregivers to identify strengths, positive coping skills, and reinforcing these. Review of a Maintenance Request form, dated [DATE] and requested by the nursing department, reflected the following: Work Location - Closet in (room) Description of work/repair - Closet is flooded with water. Requested Priority - Low - When you get a chance. Date Work Completed: [DATE] and [DATE] During an observation and interview on [DATE] at 9:54 AM revealed Resident #3 requesting to speak and show something to the Surveyor. He asked the Surveyor to look at his closet. His room had a musty/moldy odor that intensified at the location of his closet. His closet floor was warped from moisture and there were dirty soaked towels lining the floor of the closet. He stated he felt like it had been that way since he moved in, but it had only progressively gotten worse. He stated the odor made his clothes smell bad and it made him feel humiliated to wear them. He stated, I am not a dirty person, but I bet that is what people think of me. He stated he had been asking for it to be fixed forever as it embarrassed him to live like that. During an observation and interview on [DATE] at 10:01 AM revealed the MAINTD walking into Resident #3's room with a mop bucket and dry towels. He stated Resident #3's closet had been like that since he started working at the facility six months ago. He stated he had been told it had to do with an AC unit located above/behind the closet that was leaking condensation. He stated he had been told it was going to be fixed by an outside party. He stated he only worked at the facility three days a week but on those days, he removed the wet dirty towels, mopped up the excess water, and put new towels down. During an interview on [DATE] at 10:23 AM, the MDSC stated Resident #3's closet had been that way for awhile, but at least six months. She stated she had not really noticed an odor due to her persistent allergies. She stated from a nursing perspective, being in that environment could cause Resident #3 to be exposed to mold or fungus which could lead to breathing issues. During an interview on [DATE] at 2:29 PM, the DO stated she was covering as the IADM. She observed Resident #3's closet and stated there had been a dry wall problem and thought it had been fixed. She acknowledged the floor was all wet and stated they would have to get a plumber. She stated it should not be leaking like that and once any of the staff found out, they should have moved the resident to another room until it had been repaired. She stated the state of his closet was not good and would contact a company that day. She stated it was important for the residents to have a safe, clean, and homelike environment because this was their home, and it promoted their overall well-being. She stated the residents could get an infection or have an accident with the floor being wet. Review of the facility's Resident Rights/Dignity Policy, revised ,d+[DATE], reflected the following: . 7.) Create a home-like environment for the resident that includes: . c. Clean, orderly, comfortable, safe environment .

Based on interviews, and record reviews the facility failed to protect residents' rights to be free from physical abuse for 1 (Resident #1) of 6 residents reviewed for abuse. The facility failed to identify aggressive patters to ensure Resident #1 was free from physical abuse. Resident #2 had a history of aggressive behaviors and actions towards other residents. Resident #1 has a history of wandering in the unit and has known wandering behavior. Resident #1 wandered into Resident #2's room and staff failed to intervene. Resident #1 was abused by Resident #2 and sustained fractures. Resident #2 did not have the proper interventions in place. An IJ (Immediate Jeopardy) was identified on 05/11/2023 and removed on 05/13/2023.While the IJ was removed on 05/13/2023 the facility remained out of compliance at actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings Included: Resident #1 Review of Resident #1's face sheet, dated 05/11/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), failure to thrive, abnormalities in gait and mobility, and depression. Review of Resident #1's quarterly MDS, dated , 03/07/2023, reflected a BIMS of 03, indicating a severe cognitive impairment. Further review of Resident #1's quarterly MDS revealed wandering behavior of this type occurred 4 to 6 days, but less than daily, walk in room as supervision with set-up only, walk in corridor as supervision with set-up only, locomotion on unit as supervision with set-up only, and locomotion off unit as supervision with set-up only. Review of Resident #1's care plan, undated, revealed a focus of being at risk for wandering with a goal of to wander in a safe environment without the occurrence of injury and dignity will be maintained and will not wander outside the facility, with interventions of resident safety during increased episodes of wandering observe and documents Resident #1's location frequently throughout shift, and offer fluids and snacks during increased episodes of wandering-encourage frequent breaks. Observation on 05/11/2023, Resident #1 appeared in room, laying in bed, covered in blanket, and did not appear to be in physical or emotional distress. further observations revealed no bruising in area of injuries, and no scratches. Resident #1 did not respond to interview questions. Review of the facility's provider investigation report, dated 04/24/2023, revealed the date of incident was 04/24/2023 at 4:00 a.m., The description of the incident indicated Resident #2 was hitting Resident #1 in the head with his fists. The description of injury revealed a closed fracture to facial bone, concussion for Resident #1. Resident #2 was sent out to a psychiatric hospital for assessment. Review of Resident #1's hospital record, date 04/25/2023, revealed a note of abrasions to forehead with CT (Computed Tomography) of head revealed mild right temporal scalp swelling, and a CT of face revealed left nasal bone and lateral orbital wall and zygomatic arch (cheek bone) fractures. Resident #2 Review of Resident #2's face sheet, dated 05/11/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury (head injury causing damage to the brain by external force or mechanism), dementia (impaired ability to remember, think, or make decisions), delusional disorders, anxiety, and schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder). Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS of 4, indicating a severe cognitive impairment. Further review of Resident #2's quarterly MDS revealed Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as not exhibited, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) as occurring 1 to 3 days, other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) as occurring 1 to 3 days, locomotion on unit as supervision with set-up only, locomotion off unit as supervision with set-up only, and mobility devices-wheelchair. Review of the facility's incident/accident cumulative tracking and trending log, undated, revealed Resident #2 has physical altercations on 03/04/2023 and 04/24/2023. Review of Resident #2's care plan, undated, revealed the following care area: -Resident #2 had a focus physical altercation with another resident, initiated 02/25/2023. A goal was for Resident #2 to not have any more physical altercations through the review year. The interventions were for staff to redirect resident when he was becoming aggressive. -Resident #2 had a focus physical altercation with another resident 02/19/2023. A goal was for Resident #2 not to have further altercations. The intervention was for staff to remove resident from other residents. -Resident #2 slapped a fell ow resident without provocation, initiated 03/06/2023. A goal was for Resident #2 to attend/participate in activities of choice by next review date. The interventions were for the staff to assist with arraigning community activities, arrange transportation, introduce Resident #2 to resident with similar background, interests, and encourage/facilitate interactions, invite Resident #2 to scheduled activities, and provide a program of activities that was of interest and empowered Resident #2 by encouraging/allowing choices self-expression and responsibility. Review of the Resident #2's change of condition forms indicated the following: -dated 02/25/2023 revealed Resident #2 had an identified change of condition-altercation with another resident, -dated 03/07/2023 revealed Resident #2 had an identified change of condition-initiated physical altercation with another resident, and -dated 04/24/2023 Resident #2 had an identified change of condition-altercation with another resident. Review of Resident #2's progress notes revealed the following: -dated 02/19/2023, revealed Resident #2 had an altercation with another resident. Further review of Resident #2's progress note, -dated 03/04/2023, revealed initiated physical altercation with another resident. Additional review of Resident #2's progress note, -dated 04/23/2024, reported a physical altercation, Resident #1 was laying in floor in fetal position unconscious with Resident #2 hitting him in the head with his fists. Interview on 05/11/2023 at 2:37 p.m., LVN A revealed Resident #2 displayed both physical and verbal aggressive behavior, LVN A gave an example if people come into Resident #2's space or if you are close to him, Resident #2 can become aggressive. LVN A revealed Resident #2 had altercations with other residents on 02/19/2023, 03/04/2023 in that he slapped another resident, and the incident on 04/23/2023. LVN A further stated Resident #1 is known to wander in the unit and in residents' room, staff would attempt to redirect him when needed. Interview on 05/11/2023 at 2:47 p.m., CNA A revealed Resident #2 liked a certain distance around him, if staff went go into his space he may react aggressively stated Resident #2 is nice to her, and is all smiles with her, staff keep an eye out for him staff notice that Resident#2 t likes a certain distance around him, in that if you go into Resident #2's space he may react. CNA A stated, Resident #1 wanders, and staff are supposed to keep an eye on him. Interview on 05/11/2023 at 2:54 p.m., CNA B revealed Resident #2 had his moments of aggression. She stated the resident gets angry, but staff talk to him calmly, staff avoid triggers, try not to get him angry. CNA B added that staff separate other residents from Resident #2, to create space. Interview on 05/11/2023 at 3:43 p.m., DON stated that the facility has attempted in the past to transfer the resident, although other facilities did not accept him. DON further stated in the two incidents on 02/19/2023 and 3/4/2023 Resident #2 was not sent to a psychiatric behavioral hospital. Interventions were in pace for his behaviors, changes would be made if needed, medication adjustments if needed, and we have in house psychiatric services if needed. Interview on 05/11/2023 at 3:54 p.m., SW stated that Resident #2 has alcohol induced dementia, and cognition wise he is severely impaired with a BIMS score around 3 or 4, Resident #2 is a poor historian with poor short and long-term memory. Resident #2 has triggers such as brushing up against him. Resident #2 does need constant redirecting. SW further added due to his payor, they are limited in services such as psychotherapy and talk therapy, and in-house psychiatric services is available. Interview on 05/11/2023 at 3:54 p.m., ADM stated Resident #2 came back from the behavioral hospital after the incident on 04/23/2023. ADM stated the facility cannot medically restrain Resident #2, the facility must provide Resident #2 with rights and dignity, the facility must respect Resident #2. ADM stated staff redirect Resident #2 as often as they can. Review of the facility's nursing policies and procedures, subject Abuse/neglect, Revised 06/2019, revealed policy to provide professional care and services in an environment that is free from any type of abuse. examples of physical abuse: hitting, slapping, kicking, squeezing, punching, Procedure for if ANE is suspected take immediate steps, this may involve separation from the alleged abuser, report immediately, but no later than 2 hours after allegation. Further review revealed details for prevention such as identifying, correcting, and intervening in situation in which abuse is more than likely to occur. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 05/11/2023 at 08:16 p.m. An IJ (Immediate Jeopardy) was identified on 05/11/2023. The ADM was notified on 05/11/2023 at 08:22 p.m. an IJ situation was identified to the above failures, and an IJ Template was provided to the facility on [DATE] at 08:37 p.m. to ADM and a Plan of Removal was requested. The plan of Removal was accepted on 05/13/2023 at 1:45 p.m., and included: Plan of Removal On 05/11/2023 an abbreviated survey was initiated at [facility] on 5/11/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follow (state the issue you will find the info on the template you were provided): The facility failed to that a Resident #1 was free from physical abuse, as Resident #2 has a history of aggressive behavior. A facility self-report revealed resident to resident abuse, as Resident #2 was the alleged perpetrator. Resident #1 wandered into Resident #2 room, an observing resident notified staff, and staff intervened. Staff observed Resident #1 unconscious, and Resident #2 punching him in the face. Staff intervened, separated the residents. Resident #1 was assessed, found unable to arouse, unlabored breathing. All parties were called, DON notified, and EMS called. Resident #1 was sent to the hospital for further tests, Resident #1 was found to have a closed fracture to facial bones, and a concussion. Resident #2 was admitted to an in-patient psych hospital for further tests and treatments. Record review revealed that Resident #2 had other aggressive incidents with residents. The Resident #1 cursed at another resident and swung at a staff member inadvertently scratched another resident's face. The resident was treated with no serious injury. Another progress note revealed no details, but a resident had a physical altercation with a different resident. Action: ADON initiated the one on one at the request of the DON with Resident #2. However, due to staffing challenges another employee took over one on one with Resident #2 and completed the one on one on 5/11/2023 at which time Resident #2 was transferred to a geriatric behavioral facility. Start Date: 05/11/2023 Completion Date: 5/11/2023 Responsible: ADON/ CNA Action: Resident #2 was transferred to a geriatric behavioral facility. A discharge was made after transferring due to the return would endanger the health or safety of the resident(s) or other individuals in the facility. The Nurse Practitioner ordered, and the DON completed. The facility DON conducted an audit to ensure all other residents were free from injury or harm. There were no negative findings, and no further interventions were needed. Documentation and a letter of discharge and all other requirements was made and added in Resident #2 file as Resident #2 is own responsible party. Also the discharge letter was sent to the Ombudsman. All parties were notified. Additionally, if an appeal is filed by Resident #2 and should Resident #2 return, prior to returning, the facility will conduct a comprehensive assessment to establish appropriate interventions. This will consist of mood or behavior needs, how to manage the behaviors, and identify any new needs or behaviors. The facility will eliminate any physiological concerns and considerations, pain, infections, medication side effects, sleep deprivation by speaking with the psychiatric mental health nurse practitioner. This information will be documented, and the Director of Nursing (DON) and the MDS Coordinator will be responsible to track mood and behaviors and document non-pharmacological attempts to intervene with mood or behavior issues. All medications will be monitored by nursing each shift. If necessary, the DON will then refer Resident #2 to geriatric behavior clinic for support to have a review of medications. Behavior documentation and interventions will be reviewed monthly for any patterns. Time of day, week or monthly behaviors occurs, and what task will be performed. This information will be reviewed and discussed with the IDT team weekly and the MDS Coordinator, will document in Resident #2's care plans. The DON will also review Resident #2's diagnosis with similar diagnosis to determine the possible root causes of mood and behavior issues. The MDS Coordinator is responsible to determine if Resident #2 qualifies for specialized services under PASARR, to ensure the services are present to meet Resident #2's needs in relationship to diagnosis and a PASARR care plan is developed. Resident has already had a PASARR evaluation. The proceeding process will be added to the already IDT team weekly meeting task and followed for new and current residents with similar behaviors, moods, and conditions indefinitely. Start Date: 5/11/2023 Completion Date: 5/12/2023 Responsible: Administrator Action: Have 100% audit no residents have any injuries Start Date: 5/11/2023 Completion Date: 5/11/2023 Responsible: DON Resident #2 was sent to inpatient psych and returned with new orders to be given trazadone 50 MG, 3 tablets at bedtime, Seroquel 100 MG 1 tablet 3x day. Clonazepam/Klonopin 0.5 MG 1 tablet by mouth daily. Resident # 1 was sent to ER and returned with no new orders., . Resident # 2 will be transferred to a geriatric behavioral facility to evaluate and treat on 5/11/23. However, Resident #2 was discharged after transfer due to the return would endanger the health or safety of the resident or other individuals in the facility. Other residents were given and survey is completed and they felt safe Medical Director was notified of the IJ 5/11/23. AD-HOC QAPI was held 5/11/23 to review IJ template and Plan of Removal with the Medical Director, Administrator, and DON. Regional Director of Operations in-serviced Administrator and DON 5/11/23 on Abuse / Neglect policies, timely reporting, and ensuring appropriateness of resident placement. 100% of resident vs resident incidents were reviewed from beginning of the year up to the current date 5/11/23 by DON. Incidents were reviewed for the result of significant injury and action taken. There were No negative findings and no further interventions needed. Administrator initiated education/in-servicing with facility staff on 5/11/23 on abuse/neglect, resident vs resident incidents to include interventions such as behavioral interventions; redirection, supervised smoke breaks, increased supervision, removing resident from triggering events, as well as activities, reporting incidents to Administrator and DON, and resident appropriateness for facility. Education will be completed on 5/12/23. Staff will receive training prior to the initiation of their shift. Any staff and future staff who do not receive the training by 5/12/23 will either be trained prior to their shift or removed from the schedule until training is completed. The facility does not use agency staff. Incidents/Accidents will be reviewed by the DON, the Administrator and All Administrative Staff in the morning meeting. This will be a process that will be added and performed daily in the morning meetings indefinitely. This will ensure appropriate interventions are in place and residents remain appropriate for the facility. DON, Administrator, and all other administrative staff will review and discuss incidents / accidents in the morning meeting beginning on 5/12/23 which, as stated above, will be a part of the daily morning process indefinitely. This process will include ensuring interventions are in place for resident vs resident incidents, and that residents remain appropriate for the facility. On 05/13/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation on 05/12/2023 at 09:10 a.m., revealed Resident #2 was not in the facility. Observation on 05/12/2023 09:28 a.m., staff receiving in-services. Record review on 05/12/2023, revealed letter to Resident #2, dated 05/12/2023, stating the facility, loves to care for all the patients, unfortunately, the facility is no longer able to meet the needs of Resident #2. Please consider this a 30-day notice to get Resident #2 moved expeditiously, to get him proper care he requires. If you should have ay questions or concerns, please feel free to reach out to ADM or DON. They can be reached at the facility. Record review on 05/12/2023, undated, revealed wellness and safety check on residents. Record review on 05/12/2023, dated 05/11/2023, monitoring sheet Quarterly 15 min from 06:00 p.m. to 10:30 p.m. Record review on 05/12/2023, revealed in-service meetings: Dated 05/11/23 to 05/12/2023, time 09:00 p.m., specific details: how to manage a residents' behavior. Dated 05/11/23 to 05/12/2023, time 09:00 p.m., specific details: reporting abuse, neglect, and misappropriation to the state. Dated 05/11/23 to 05/12/2023, time 09:00 p.m., specific details: facility policies regarding abuse, neglect. Record review on 05/12/2023 revealed Resident #2 orders: send to psychiatric behavioral hospital to evaluate and treat for aggression and medication review, ordered 05/11/2023, created by DON. Observations on 05/13/2023 at 12:40 p.m., revealed a clean, home-like appearance in the facility. Resident were up, and out of rooms, appeared dressed and groomed appropriately for the weather. No foul odors present or soiled resident. observation of staff assisting residents in common area, answering call lights in a timely manner, and staff to resident interaction appropriate. Further observations revealed adequate staff members to meet residents' needs. No residents appeared distress, anxious, or agitated. Interview on 05/13/2023 at 12:51 p.m., CNA C stated she was in-serviced on interaction between residents, if there is an altercation or incident staff must report it to the charge nurse immediately after separating the residents. Interview on 05/13/2023 at 01:02 p.m., LVN B stated she was in-serviced on interaction between residents, resident to resident altercations, and recognizing signs and symptoms of agitation. Incidents are reported immediately to DON, and residents are separated. Interview on 05/13/2023 at 01:08 p.m., CNA B stated for signs and symptoms of agitation, behaviors become significantly different, pacing, resident do not respond to questions asked, staff re-direct the resident. CNA B added if there is witness aggression between residents, separate the residents, get an inform charge nurse immediate, and inform the ADM. Interview on 05/13/2023 at 01:13 p.m., LVN A stated Resident #2 is out of the physical and is an inpatient at psychiatric behavioral hospital. LVN A stated signs and symptoms are demeanors such as how a resident is talking if they are pacing. LVN A added, interventions for resident-to-resident abuse, or aggression id to immediate separate them, take resident to their rooms to remain calm, offer a snack and try and work the resident's behavior, LVN A stated to report findings immediately to ADM. Record review on 05/13/2023, revealed in-services being conducted. An IJ (Immediate Jeopardy) was removed on 05/13/2023.While the IJ was removed on 05/13/2023 the facility remained out of compliance at actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to meet professional standards of quality for 4 of 8 residents (Residents # 1, #2, #10, and #12). A. Resident # 2 was readmitted to the facility on [DATE] without pressure sores. A Stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss) was identified to Resident # 2's sacral by the survey team on 01/30/2013. The facility did not consistently and accurately document assessments and did not promptly notify physician for treatment orders for a facility acquired Stage III pressure sore to his sacral. The facility identified and notified the physician Resident # 2 had an abrasion between his buttocks. B. The facility failed to accurately assess Resident # 1's Stage II pressure sore (01/18/2013) (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) to his left heel. The facility identified the pressure sore as an unstageable Deep Tissue Injury (DTI - A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) The pressure sore advanced to a Stage III (01/30/2013). The facility did not accurately assess, identify, and notify the physician of Resident # 1's Stage II pressure sore that advanced to a Stage III. C. The facility failed to accurately assess, document and notify the physician of Resident # 12's six (6) Stage II pressure sores identified to her left hip on 01/31/2013 (identified by the survey team). The facility identified Resident # 12's 6 pressure sores as one (1) abrasion. D. The facility failed to provide continuous and preventative treatment to ensure Resident #10 did not have pressure sores worsen from healed to suspected deep tissue injury (SDTI) to right heel. Also Resident #10 had no plan of care addressing skin breakdown to right heel. This resulted in an Immediate Jeopardy (IJ) on 01/30/2013. While the IJ was removed on 02/18/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 17 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: Upon Administrative and Enforcement review, the original Plan of Removal submitted by the facility on 01/31/2013 was determined to not have removed the immediacy. The plan did not include a qualified nurse to perform skin assessments for all residents, identify, stage and treat pressure sores. The Health Survey was reopened on 02/15/2013 to collect additional information and interview facility staff. Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to all Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board 's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse 's current area of nursing practice; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth; (T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. A) Review of Resident # 2's Face Sheet reflected a [AGE] year old male who entered the facility on 12/06/2011 and as readmitted to the facility on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of the admittance skin assessment dated [DATE] reflected no pressures sores to any part of his body. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is moderately cognitively impaired. The assessment reflected Resident # 2 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present prior assessment. The assessment reflected there were skin/ulcer treatments as 1) application of nonsurgical dressings other than to feet; 2) applications of ointments/medications other than to feet; and 3) application of dressings to feet (with or without topical medications). Review of Resident # 2's Comprehensive Care Plan dated 12/14/2012 reflected no plan of care preventative measures or interventions for current pressure sores to ensure pressure sores were healed or prevented. Review of Resident # 2's Weekly Skin Assessments reflected: 01/17/2013 - Skin warm and dry. Mucus membranes pink/moist. Turgor poor. Fluids encouraged. Has scattered bruising due to insulin administration. Incision remains, all staples intact. Small amount of bloody drainage, blister remains. No other skin issues. The blister remained on Right Above the Knee Amputation incision site. Record review of Resident # 2's Treatment Administration Record (TAR) dated 1/20/2013 reflected RN P wrote in treatment "sacral area-cleaned and covered with dressing" and initialed in date box. There was no identification of the wound RN P treated and no notification was made to the Physician by RN P. There was no entry was made in the Nurses Notes regarding Resident # 2's sacral wound. There was no notification made to Physician regarding sacral wound till 1/22/2013 two days later. Review of Resident # 2's Physician Notification dated 01/22/2013, by the Treatment Nurse, LVN A, reflected "Resident # 2 is breaking down between buttocks. Barrier cream applied. Please advise." Physician response was "Keep clean and dry. Report every week." Review of the Nurses Notes dated 01/22/2013 reflected there was no documentation regarding wounds other than the Right Above the Knee Amputation incision cite for Resident # 2. Review of Physician Telephone Orders dated 1/22/2013 reflected an order to apply barrier cream to buttocks every shift and prn (as needed). There was no order to reflect the physician's response to the notification sent to "keep clean and dry and report every week." The physician did not order barrier cream to buttocks at this time. The fax notification dated 1/22/2013 reflected an order to "keep clean and dry and report every week." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"cleaned and covered with dressing." There was no physician order for [REDACTED]." This entry had no date. The facility began that order on 01/22/2013. Review of Weekly Skin assessment dated [DATE] reflected- Abrasion between buttocks; barrier cream applied. No pressure sore was documented. Observation on 01/30/2013 at 11:00 AM revealed a Stage III pressure sore to Resident # 2's sacral by surveyor was, approximately 3.0 by 2.0 centimeters (cm). The Stage III pressure sore did not have a dressing. There was a thick layer of barrier cream over entire coccyx and peri area. The pressure sore had granulation tissue and had slight redness to edges. There was no bleeding. During this observation, Certified Nurse Aide (CNA) I completed incontinent care for Resident # 2 after the resident had a bowel movement. In preparation for incontinent care, CNA I did not wash hands prior to donning gloves. CNA I inappropriately cleaned Resident # 2 from back to front, but did not thoroughly cleanse the barrier cream. CNA I did not change gloves or wash her hands prior to placing additional barrier cream to Resident # 2's coccyx/sacral. No dry dressing was applied to Resident 2's sacral pressure sore. Resident # 2 was lying in bed on his back on a regular mattress with no foam like qualities. After completion of incontinent care, Resident # 2 was lifted by a Hoyer lift onto a wheel chair with a plastic wedge cushion. There was no pressure relieving device in Resident # 2's wheel chair. In an interview on 01/30/2013 at 11:20 AM, CNA I stated she could not remember having any training regarding incontinent care or infection control provided by the facility. In an interview on 01/30/2013 at 11:45 AM the Wound Care Nurse, Licensed Vocational Nurse (LVN) A stated she had seen Resident # 2's wound that morning and it was an area opened in a line formation that appeared to be a "crack" but she did not assessed and had not contacted the physician. LVN A stated she had not measured the wound. LVN A was notified of the Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 11:50 AM the Director of Nurses (DON) Q was made aware of Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 5:10 PM the DON Q stated it was possible Resident # 2's wedge cushion placed in his wheel chair could have caused the resident's pressure sore but if he didn't have it he might fall out of his chair. Review of LVN A's notification to the physician on 01/30/2013 reflected the LVN spoke with the physician's office at 12:25 PM but notified the physician Resident # 2 had an "abrasion between buttocks. Remains open. Please advise a tx (treatment)". LVN A did not notify the physician of Resident # 2's Stage III pressure sore to his sacral. The new orders were to cover with dry dressing each shift. In an interview on 1/30/2013 at 3:40 PM also the Facility Medical Director also Resident #2 physician, stated she was not notified of the Stage III pressure sore to Resident # 2's sacral. Observation made on 01/30/2013 at 6:15 PM revealed a Stage III pressure sore to Resident # 2's sacrum, just above the tailbone with granulation tissue, red edge to wound bed and surrounding skin slightly pink in color. There was no maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture). The depth of the wound was observed to be greater than 0.1 cm. Resident #2 was observed to be in bed on a regular mattress without any pressure relieving qualities. LVN A refused to measure Resident #2 sacral Stage III pressure sore during the observation. Review of notification to Resident # 2's physician on 01/30/2013 at 7:17 PM reflected a the physician was faxed the wound assessment that documented a "new" wound status of an area between buttocks that measured .8 x 1.5 cm. The Stage area on the wound assessment sheet was left blank. LVN A notified the physician the surrounding tissue was pale and the wound bed was covered with slough. Current treatment was dry dressing every shift. The physician agreed with treatment in response to the incomplete wound assessment information provided by facility. Review of the Patient Wound Care Order Sheet completed by the Certified Wound Specialist (CWS) who was called in by the facility on 01/31/2013 reflected Resident # 2's sacral wound was Unstageable, full thickness, 2.00 x 0.80 centimeters (cm) with utd (undetermined depth), no tunneling or undermining. There was Serosanguinous drainage. The wound bed was 80% yellow slough with 20% granulation tissue. Periwound was described as "edge [MEDICATION NAME] flush with wound base." Clinical Rationale/Wound Comments reflected "daily dressing change due to daily enzymatic debrider, foam to maintain thermal wound healing." Treatment Intervention reflected "clean wound with normal saline or wound cleanser; apply santyl (nickel thickness) to entire wound bed for enzymatic debridement; apply bordered foam; change qd (every day)." In an interview on 01/31/2013 at 10:30 AM the CWS stated, after looking at pictures of Resident # 2's wound from 01/30/2013, the resident's sacral wound was unstageable today and agreed the wound had declined from 01/30/2013. There was no noted treatment preformed to Resident #2's sacral wound from 1/30/2013 to 1/31/2013. In an interview on 01/31/2013 at 10:35 AM the DON Q and MDS Coordinator both stated Resident # 2's wound had declined since it was originally observed on 01/30/2013. B) Review of Resident #1's Face Sheet reflected an [AGE] year old male who was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 07/12/2012 and last updated on 10/12/2012, reflected the resident was at high risk of impaired skin integrity R/T incontinence, with Resident will not develop any new skin breakdown for 90 days. Interventions the facility listed to meet this goal include: 1) Nurse will assess residents skin condition q week and PRN; 2) Nurse aide will visualize residents skin during bathing, changing of clothes, incontinent care, etc. for possible breakdown; 3) Nurse aide will notify nurse of any skin breakdown as soon as it is noticed; 4) Dietary will review residents ordered diet PRN; 5) Dietary will serve balanced diet TID; 6) Serve diet as ordered by MD; 7) Turn and reposition resident every 2 hours and PRN; 8) Ensure adequate fluid hydration daily; 9) Incontinent care every 2 hours and PRN; 10) Notify MD when breakdown is noticed; 11) Perform treatments as ordered by MD. The care plan did not include any devices to protect Resident # 1's heels from breaking down. Review of Resident # 1's Nursing Notes reflected the resident went to the hospital on [DATE] and returned 01/16/2013. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. The assessment reflected Resident # 1 was at risk for pressure sores but had no current pressure sores. In an interview on 1/29/2013 at 10:35 AM, on initial tour, Medication Aide (MA) L stated she was unsure if Resident #1 had any pressure sores, but "he used to". Review of Resident #1's Wound Assessment sheet dated 1/16/2013, and completed by LVN A, reflected the Resident had an unstageable DTI to the left heel. Also reflected on this Wound Assessment sheet was, "Resident returned from the hospital. Unstageable. Wound bed pink surrounding tissue has noted DTI ", with the current treatment being "Hydrogel silver apply small amt (amount) cover with dressing QD (every day), off load heels". This assessment identified entire wound as a unstageable DTI and failed to identify, and assess, the "wound bed pink" open area as a stageable pressure ulcer as separate to that of the unstageable "dark purple" suspected DTI with intact skin. In addition, the initial treatment of [REDACTED]. Review of Resident #1's Physician Telephone Orders dated on or around 1/16/2013 reflected no physician orders for left heel pressure sore treatment were received from the physician prior to intervention of the Hospice nurse on 1/18/13, two days after the Resident's admission to the facility. Review of a facsimile notification to Resident #1's physician, who is also the Facility's Medical Director, from LVN A dated 1/16/2013, reflected the Resident's return from the hospital with "3 wounds" to bilateral "feet/heels", "surrounding all open wounds are DTI's". This notification to the Resident's physician did not completely and accurately reflect a description of the wound to the left heel to enable the physician to determine if the initial treatment provided by LVN A was an appropriate treatment to promote wound healing for this pressure ulcer. Review of Resident # 1's Dietician Progress Notes dated 01/23/2013 reflected the resident had "unstageable areas to left inner foot and left and right heels." Intake inadequate to meet EST (estimated needs) Weight loss is expected." There was no supplement ordered to promote wound healing. Per nurse's notes, Resident # 1 was eating magic cups and thickened juices. Review of Facility photograph of Resident #1's left heel dated 1/16/2013, and provided by DON Q, reflected a round open ulcer to a medial heel, pink in color, with darkened area from approximately the 3 o'clock position clockwise to the 1 o'clock position surrounding open ulcer. Review of Resident # 1's Nursing Notes reflected the Resident went to the Emergency Department on 01/17/2013 and returned on 01/18/2013. Review of Resident #1's Hospice Admission assessment dated [DATE] reflected the resident was admitted to Hospice services on 1/18/2013. This Admission Assessment reflected the Hospice RN had assessed Resident #1 to have a Stage II pressure ulcer to the left heel. In an interview on 1/29/2013 at 11:40 AM, Licensed Vocational Nurse (LVN) A, also appointed as the wound care nurse, stated Resident #1 came back from the hospital on [DATE] with a DTI to left heel that was unstageable. LVN A stated the Resident ' s Hospice nurse had mistakenly staged the left heel as a Stage II pressure sore on 1/18/2013. When questioned by the surveyor about the discrepancy in staging of the wound, LVN A stated that the Resident "has an open wound to left heel, but it is surrounded by dark purple area and that makes it an unstageable DTI". LVN A stated that if a pressure ulcer had any dark purple "mushy" areas, even if there were any open areas within the purple, "the pressure ulcer cannot be staged". LVN A stated the treatment was scheduled for every three days but usually she had to change the dressing daily as Resident # 1's movement in bed made the dressing roll up. Review of Resident #1's Physician Telephone Orders dated 1/18/2013 reflected a Physician Telephone Order form to change the left heel wound treatment to an appropriate treatment for [REDACTED]. This order was signed by the Hospice Nurse,. Review of Resident # 1's weekly Wound assessment dated [DATE] incorrectly reflected a wound to the resident's left heel that measured 2.5 x 2.5 x 0.0 cm in that any "open" area of skin has a depth to the wound. Observation made on 01/29/2013 revealed Resident # 1's [MEDICATION NAME] dressing was rolled up on his heel leaving the wound open to air. LVN A cleansed Resident # 1's left heel wound with wound cleanser then patted dry. LVN A then placed Silvagel cream on the open wound and placed a [MEDICATION NAME] dressing over the wound. LVN A did not follow the physician order dated 01/18/2013. Observation made on 1/30/2013 at 10:30 AM of Resident #1' s wound revealed a Stage III pressure sore approximately 3.0 cm round to Resident # 1's left heel with a peeling callous surrounding the wound, and a purple area to top left of the wound bed. The Stage III pressure sore was confirmed by the Hospice Registered Nurse (RN)'s and the RN surveyor during the observation. In an interview on 1/30/2013 at 10:45 AM the Minimum Data Set (MDS) Coordinator incorrectly stated that a Deep Tissue Injury (DTI) was a deep multi-layer open area. The National Pressure Ulcer Advisory Panel defines a DTI as, " A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. " (NPAUP, 2002). In an interview on 1/30/2013 at 10:55 AM the DON Q stated that to his knowledge a DTI was an unopened area dark purple, and mushy. The DON Q stated that his expectation was that staff that performed wound care were trained and know how to stage pressure sores; accurately assess and describe the wound when notifying the physician; and to obtain accurate physician's orders for the correct treatment. The DON Q also stated that he was not a wound care nurse, but with his limited understanding of staging of pressure sores, "if it's a DTI the wound is unstageable. " In an interview on 1/30/2013 at 3:40 PM Resident #1's Physician, stated that the most current left heel wound treatment order was in response to the notification she had received from the facility dated 1/16/2013, when the facility requested an order for [REDACTED]. Observation made on 1/31/2013 at 2:30 PM of Resident #1's wound assessment performed by the CWS confirmed a Stage III pressure sore to Resident's left heel. Review of Resident #1's Wound Care, Skin Integrity, and Evaluation form completed by the PT on 1/31/2013 reflected a left heel wound, a Stage III, measurements were "3.0 cm long x 3.5 cm wide x 0.2 cm deep" with a wound bed of "95% pink granulation tissue with 5% slough". In an interview on 2/16/2013 at 12:41 PM RN P stated that she did not do treatments on the weekends. Review of Resident #1's January, 2013 Treatment Administration Record (TAR) reflected RN P provided the pressure ulcer treatment to the Resident's pressure ulcer on January 19, and 20, indicated by RN P initialing the TAR. Observation on 2/18/2013 at 2:5 revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. There was no dressing in place to the resident ' s left heel. LVN A measured Resident #1 ' s stage III pressure sore to his left heel as 2 cm x 2 cm cm and stated she " can ' t tell " a depth. LVN A measured a callous looking area on the left heel. CWS was also in room and instructed LVN A how to measure the Stage III. DON R took a picture of Resident #1 ' s left heel. This surveyor noted a small open area in the middle of the callous looking area with a red wound bed. Interview on 2/18/2013 at 2:3 CWS stated she instructed LVN A to measure the outside edge of the callous skin looking area because there is " still a sore underneath and did not see an open area. CWS was shown the picture of the left heel on Resident #1 taken by the facility and stated " will have LVN A re-measure for depth " because the area has an opening. Interview on 2/18/2013 at 3:5 DON R stated if the area was open her plan was to re-measure and to assess for a depth. Observation on 2/18/2013 at 3:1 revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. The dressing was still in place from previous treatment at 2:5. LVN A performed the treatment again with the DON R and Administrator present in room. DON R used a cotton swab to determine a depth of 0.1 cm, the length and width equaled 0.4 cm x 0.3 cm. Interview on 2/18/2013 at 3:3 DON R stated LVN A will have supervised guidance on all wounds by DON R. C) Review of Resident #12's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is severely cognitively impaired. The assessment reflected Resident #12 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present on prior assessment. Review of Resident #12's care plan reflected no skin related care plans written. Review of Weekly Skin Assessments for Resident # 12 reflected: 01/21/2013 reflected "no issues" found. 01/31/2013 reflected "abrasion to the left hip - awaiting treatment" Review of the early morning skin assessments on 1/31/2013 by the DON Q, Assistant Director of Nurses (ADON), MDS Coordinator and Wound Care Nurse, LVN A revealed Resident #12 had an abrasion to her left hip. Observation made on 1/31/2013 at 11:35 am revealed Resident #12 with six (6) Stage II pressure sores on her left hip. There are four open and 2 closed, blister areas in a circular pattern located in the incontinent brief area of her left hip. The wound beds are red and approximately less than 0.1 centimeter (cm) in depth. In an interview on 1/31/2013 at 11:40 am CWS stated Resident #12 had one (1) Stage II pressure sore to left hip. The CSW stated the open areas were all in a circular shape but considered one (1) Stage II pressure sore instead of identifying each open area separately in staging and measuring, and then notifying the Physician.. Review of the wound assessment dated [DATE] revealed LVN A measured the entire area as 1.0 cm x 2.0 cm instead of measuring each open area separately. In an interview on 1/31/2013 at 11:45 am the DON Q stated he agreed with whatever CWS staged the open areas. D) Review of Resident #10 ' s Face sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #10 ' s Quarterly MDS assessment dated [DATE] reflected BIMS of 8 indicating moderate cognitive impairment. The assessment reflected Resident #10 was at risk for pressure sores. Also noted two unstageable, suspected deep tissue injury pressure sores. Resident #10 had treatments checked for pressure sore care and application of dressings to feet. Review of Resident #10 ' s care plan for skin integrity reflected no plan of care for the Resident ' s right heel. The care plan reflected the Resident was at risk for impaired skin integrity related to incontinence of urine. Review of Resident #10 ' s Wound Assessments reflected: 12/3/2012-New facility acquired right heel stage II measured 0.8 x 0.8 cm, no depth noted, wound bed and surrounding tissue pink. The treatment was hydrogel every day. 12/12/2012-Resident #10 continues with stage II to right heel measured 0.5x 0.8x 0.0 cm, meaning no depth and wound should be noted as healed. The description notes reflected the " surrounding tissue and wound bed pink, no dressing at this time " , but current treatment reflected hydrogel and dry dressing every day. Also the assessment reflected no change to the wound even though the assessment reflected improvement. 12/19/2012-Resident #10 returned from hospital with heel hardened and to use preventative treatment of [REDACTED]. Also the assessment reflected a negative change to the wound even though the assessment reflected improvement. 12/28/2012-Resident #10 ' s right heel was unstageable and measured 0.8 x0.8 x 0.0 cm. The description notes reflected " eschar to heel hard, no drainage or odor, denies pain, surrounding tissue within normal limits " . The treatment was to float heels and wear booties. Also the assessment reflected no change to the wound even though the assessment reflected a decline. There were no assessments completed from 12/29/2012 through 1/13/2013. 1/14/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " eschar noted on heel intact, hard, no drainage, surrounding tissue dry, color good " . The treatment was to apply skin prep every day. 1/23/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " heel remains eschar and hard, no change, remains closed, no drainage or pain, surrounding tissue dry/scaly " . The treatment was to apply skin prep every day. Record review of the TAR for December 2012 reflected Resident #10 ' s treatment of [REDACTED]. Record Review of Resident #10 reflected the Resident was hospitalized on [DATE]th and returned to the facility on the 19th, there were no written orders on the TAR for the right heel treatment, yet the Wound Assessment for 12/19/2012 reflected a current treatment of [REDACTED]. Record Review of Resident #10 ' s Physician Telephone orders dated 1/8/2013 reflected a new order " skin prep to bilateral heels every day and to float heels". On the TAR for January 2013 there was no order written to float the heels. Record review of the TAR for January 2013 reflected Resident #10 ' s treatment of [REDACTED].

Based on observation, interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to implement the facility policy and procedure and failed to supervise, monitor and consult with the Director of Nursing (DON) Q to ensure residents residing in the facility received the care and services to meet their individual needs and ensure the nursing staff was provided pertinent information relating to the care and needs of each resident. The Administrator failed to ensure that facility ' s policies and procedures were implemented and followed to ensure residents received care to attain and maintain their highest practicable physical, mental, and psychosocial well-being. The DON Q failed to supervise and monitor nursing staff to ensure the staff were correctly identifying, accurately assessing and documenting pressure sores, initializing and updating care plans, promptly, implementing policy and procedures, and accurately notifying the physician and initializing treatments for residents at risk for and who currently had pressure sores. A. Resident # 2 was readmitted to the facility on [DATE] without pressure sores. A Stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss) was identified to Resident # 2's sacral by the survey team on 01/30/2013. The facility did not consistently and accurately document assessments and did not promptly notify physician for treatment orders for a facility acquired Stage III pressure sore to his sacral. The facility identified and notified the physician Resident # 2 had an abrasion between his buttocks. B. The facility failed to accurately assess Resident # 1's Stage II pressure sore (01/18/2013) (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) to his left heel. The facility identified the pressure sore as an unstageable Deep Tissue Injury (DTI - A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) The pressure sore advanced to a Stage III (01/30/2013). The facility did not accurately assess, identify, and notify the physician of Resident # 1's Stage II pressure sore that advanced to a Stage III. C. The facility failed to accurately assess, document and notify the physician of Resident # 3's facility acquired Stage II pressure sore (identified by survey team on 01/30/2012). The facility identified the pressure sore as scratches (01/31/2013). D. The facility failed to accurately assess, document and notify the physician of Resident # 12's six (6) Stage II pressure sores identified to her left hip on 01/31/2013 (identified by the survey team). The facility identified Resident # 12's 6 pressure sores as one (1) abrasion. E. The facility failed to provide continuous and preventative treatment to ensure Resident #10 did not have pressure sores worsen from healed to suspected deep tissue injury (SDTI) to right heel. Also Resident #10 had no plan of care addressing skin breakdown to right heel. This resulted in an Immediate Jeopardy (IJ) on 01/30/2013. While the IJ was removed on 02/18/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 17 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: Upon Administrative and Enforcement review the original Plan of Removal submitted by the facility on 01/31/2013 was determined to not have removed the immediacy. The plan did not include a qualified nurse to perform skin assessments for all residents, identify, stage and treat pressure sores. The Health Survey was reopened on 02/15/2013 to collect additional information and interview facility staff. A) Review of Resident # 2's Face Sheet reflected a [AGE] year old male who entered the facility on 12/06/2011 and as readmitted to the facility on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of the admittance skin assessment dated [DATE] reflected no pressures sores to any part of his body. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is moderately cognitively impaired. The assessment reflected Resident # 2 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present prior assessment. The assessment reflected there were skin/ulcer treatments as 1) application of nonsurgical dressings other than to feet; 2) applications of ointments/medications other than to feet; and 3) application of dressings to feet (with or without topical medications). Review of Resident # 2's Comprehensive Care Plan dated 12/14/2012 reflected no plan of care preventative measures or interventions for current pressure sores to ensure pressure sores were healed or prevented. Review of Resident # 2's Weekly Skin Assessments reflected: 01/17/2013 - Skin warm and dry. Mucus membranes pink/moist. Turgor poor. Fluids encouraged. Has scattered bruising due to insulin administration. Incision remains, all staples intact. Small amount of bloody drainage, blister remains. No other skin issues. The blister remained on Right Above the Knee Amputation incision site. Record review of Resident # 2's Treatment Administration Record (TAR) dated 1/20/2013 reflected RN P wrote in treatment "sacral area-cleaned and covered with dressing" and initialed in date box. There was no identification of the wound RN P treated and no notification was made to the Physician by RN P. There was no entry was made in the Nurses Notes regarding Resident # 2's sacral wound. There was no notification made to Physician regarding sacral wound till 1/22/2013 two days later. Review of Resident # 2's Physician Notification dated 01/22/2013, by the Treatment Nurse, LVN A, reflected "Resident # 2 is breaking down between buttocks. Barrier cream applied. Please advise." Physician response was "Keep clean and dry. Report every week." Review of the Nurses Notes dated 01/22/2013 reflected there was no documentation regarding wounds other than the Right Above the Knee Amputation incision cite for Resident # 2. Review of Physician Telephone Orders dated 1/22/2013 reflected an order to apply barrier cream to buttocks every shift and prn (as needed). There was no order to reflect the physician's response to the notification sent to "keep clean and dry and report every week." The physician did not order barrier cream to buttocks at this time. The fax notification dated 1/22/2013 reflected an order to "keep clean and dry and report every week." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"cleaned and covered with dressing." There was no physician order for [REDACTED]." This entry had no date. The facility began that order on 01/22/2013. Review of Weekly Skin assessment dated [DATE] reflected- Abrasion between buttocks; barrier cream applied. No pressure sore was documented. Observation on 01/30/2013 at 11:00 AM revealed a Stage III pressure sore to Resident # 2's sacral by surveyor was, approximately 3.0 by 2.0 centimeters (cm). The Stage III pressure sore did not have a dressing. There was a thick layer of barrier cream over entire coccyx and peri area. The pressure sore had granulation tissue and had slight redness to edges. There was no bleeding. During this observation, Certified Nurse Aide (CNA) I completed incontinent care for Resident # 2 after the resident had a bowel movement. In preparation for incontinent care, CNA I did not wash hands prior to donning gloves. CNA I inappropriately cleaned Resident # 2 from back to front, but did not thoroughly cleanse the barrier cream. CNA I did not change gloves or wash her hands prior to placing additional barrier cream to Resident # 2's coccyx/sacral. No dry dressing was applied to Resident 2's sacral pressure sore. Resident # 2 was lying in bed on his back on a regular mattress with no foam like qualities. After completion of incontinent care, Resident # 2 was lifted by a Hoyer lift onto a wheel chair with a plastic wedge cushion. There was no pressure relieving device in Resident # 2's wheel chair. In an interview on 01/30/2013 at 11:20 AM, CNA I stated she could not remember having any training regarding incontinent care or infection control provided by the facility. In an interview on 01/30/2013 at 11:45 AM the Wound Care Nurse, Licensed Vocational Nurse (LVN) A stated she had seen Resident # 2's wound that morning and it was an area opened in a line formation that appeared to be a "crack" but she did not assessed and had not contacted the physician. LVN A stated she had not measured the wound. LVN A was notified of the Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 11:50 AM the Director of Nurses (DON) Q was made aware of Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 5:10 PM the DON Q stated it was possible Resident # 2's wedge cushion placed in his wheel chair could have caused the resident's pressure sore but if he didn't have it he might fall out of his chair. Review of LVN A's notification to the physician on 01/30/2013 reflected the LVN spoke with the physician's office at 12:25 PM but notified the physician Resident # 2 had an "abrasion between buttocks. Remains open. Please advise a tx (treatment)". LVN A did not notify the physician of Resident # 2's Stage III pressure sore to his sacral. The new orders were to cover with dry dressing each shift. In an interview on 1/30/2013 at 3:40 PM also the Facility Medical Director also Resident #2 physician, stated she was not notified of the Stage III pressure sore to Resident # 2's sacral. Observation made on 01/30/2013 at 6:15 PM revealed a Stage III pressure sore to Resident # 2's sacrum, just above the tailbone with granulation tissue, red edge to wound bed and surrounding skin slightly pink in color. There was no maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture). The depth of the wound was observed to be greater than 0.1 cm. Resident #2 was observed to be in bed on a regular mattress without any pressure relieving qualities. LVN A refused to measure Resident #2 sacral Stage III pressure sore during the observation. Review of notification to Resident # 2's physician on 01/30/2013 at 7:17 PM reflected a the physician was faxed the wound assessment that documented a "new" wound status of an area between buttocks that measured .8 x 1.5 cm. The Stage area on the wound assessment sheet was left blank. LVN A notified the physician the surrounding tissue was pale and the wound bed was covered with slough. Current treatment was dry dressing every shift. The physician agreed with treatment in response to the incomplete wound assessement information provided by facility. Review of the Patient Wound Care Order Sheet completed by the Certified Wound Specialist (CWS) who was called in by the facility on 01/31/2013 reflected Resident # 2's sacral wound was Unstageable, full thickness, 2.00 x 0.80 centimeters (cm) with utd (undetermined depth), no tunneling or undermining. There was Serosanguinous drainage. The wound bed was 80% yellow slough with 20% granulation tissue. Periwound was described as "edge [MEDICATION NAME] flush with wound base." Clinical Rationale/Wound Comments reflected "daily dressing change due to daily enzymatic debrider, foam to maintain thermal wound healing." Treatment Intervention reflected "clean wound with normal saline or wound cleanser; apply santyl (nickel thickness) to entire wound bed for enzymatic debridement; apply bordered foam; change qd (every day)." In an interview on 01/31/2013 at 10:30 AM the CWS stated, after looking at pictures of Resident # 2's wound from 01/30/2013, the resident's sacral wound was unstageable today and agreed the wound had declined from 01/30/2013. There was no noted treatment preformed to Resident #2's scaral wound from 1/30/2013 to 1/31/2013. In an interview on 01/31/2013 at 10:35 AM the DON Q and MDS Coordinator both stated Resident # 2's wound had declined since it was originally observed on 01/30/2013. B) Review of Resident #1's Face Sheet reflected an [AGE] year old male who was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 07/12/2012 and last updated on 10/12/2012, reflected the resident was at high risk of impaired skin integrity R/T incontinence, with Resident will not develop any new skin breakdown for 90 days. Interventions the facility listed to meet this goal include: 1) Nurse will assess residents skin condition q week and PRN; 2) Nurse aide will visualize residents skin during bathing, changing of clothes, incontinent care, etc. for possible breakdown; 3) Nurse aide will notify nurse of any skin breakdown as soon as it is noticed; 4) Dietary will review residents ordered diet PRN; 5) Dietary will serve balanced diet TID; 6) Serve diet as ordered by MD; 7) Turn and reposition resident every 2 hours and PRN; 8) Ensure adequate fluid hydration daily; 9) Incontinent care every 2 hours and PRN; 10) Notify MD when breakdown is noticed; 11) Perform treatments as ordered by MD. The care plan did not include any devices to protect Resident # 1's heels from breaking down. Review of Resident # 1's Nursing Notes reflected the resident went to the hospital on [DATE] and returned 01/16/2013. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. The assessment reflected Resident # 1 was at risk for pressure sores but had no current pressure sores. In an interview on 1/29/2013 at 10:35 AM, on initial tour, Medication Aide (MA) L stated she was unsure if Resident #1 had any pressure sores, but "he used to". Review of Resident #1's Wound Assessment sheet dated 1/16/2013, and completed by LVN A, reflected the Resident had an unstageable DTI to the left heel. Also reflected on this Wound Assessment sheet was, "Resident returned from the hospital. Unstageable. Wound bed pink surrounding tissue has noted DTI ", with the current treatment being "Hydrogel silver apply small amt (amount) cover with dressing QD (every day), off load heels". This assessment identified entire wound as a unstageable DTI and failed to identify, and assess, the "wound bed pink" open area as a stageable pressure ulcer as separate to that of the unstageable "dark purple" suspected DTI with intact skin. In addition, the initial treatment of [REDACTED]. Review of Resident #1's Physician Telephone Orders dated on or around 1/16/2013 reflected no physician orders for left heel pressure sore treatment were received from the physician prior to intervention of the Hospice nurse on 1/18/13, two days after the Resident's admission to the facility. Review of a facsimile notification to Resident #1's physician, who is also the Facility's Medical Director, from LVN A dated 1/16/2013, reflected the Resident's return from the hospital with "3 wounds" to bilateral "feet/heels", "surrounding all open wounds are DTI's". This notification to the Resident's physician did not completely and accurately reflect a description of the wound to the left heel to enable the physician to determine if the initial treatment provided by LVN A was an appropriate treatment to promote wound healing for this pressure ulcer. Review of Resident # 1's Dietician Progress Notes dated 01/23/2013 reflected the resident had "unstageable areas to left inner foot and left and right heels." Intake inadequate to meet EST (estimated needs) Weight loss is expected." There was no supplement ordered to promote wound healing. Per nurse's notes, Resident # 1 was eating magic cups and thickened juices. Review of Facility photograph of Resident #1's left heel dated 1/16/2013, and provided by DON Q, reflected a round open ulcer to a medial heel, pink in color, with darkened area from approximately the 3 o'clock position clockwise to the 1 o'clock position surrounding open ulcer. Review of Resident # 1's Nursing Notes reflected the Resident went to the Emergency Department on 01/17/2013 and returned on 01/18/2013. Review of Resident #1's Hospice Admission assessment dated [DATE] reflected the resident was admitted to Hospice services on 1/18/2013. This Admission Assessment reflected the Hospice RN had assessed Resident #1 to have a Stage II pressure ulcer to the left heel. In an interview on 1/29/2013 at 11:40 AM, Licensed Vocational Nurse (LVN) A, also appointed as the wound care nurse, stated Resident #1 came back from the hospital on [DATE] with a DTI to left heel that was unstageable. LVN A stated the Resident ' s Hospice nurse had mistakenly staged the left heel as a Stage II pressure sore on 1/18/2013. When questioned by the surveyor about the discrepancy in staging of the wound, LVN A stated that the Resident "has an open wound to left heel, but it is surrounded by dark purple area and that makes it an unstageable DTI". LVN A stated that if a pressure ulcer had any dark purple "mushy" areas, even if there were any open areas within the purple, "the pressure ulcer cannot be staged". LVN A stated the treatment was scheduled for every three days but usually she had to change the dressing daily as Resident # 1's movement in bed made the dressing roll up. Review of Resident #1's Physician Telephone Orders dated 1/18/2013 reflected a Physician Telephone Order form to change the left heel wound treatment to an appropriate treatment for [REDACTED]. This order was signed by the Hospice Nurse,. Review of Resident # 1's weekly Wound assessment dated [DATE] incorrectly reflected a wound to the resident's left heel that measured 2.5 x 2.5 x 0.0 cm in that any "open" area of skin has a depth to the wound. Observation made on 01/29/2013 revealed Resident # 1's [MEDICATION NAME] dressing was rolled up on his heel leaving the wound open to air. LVN A cleansed Resident # 1's left heel wound with wound cleanser then patted dry. LVN A then placed Silvagel cream on the open wound and placed a [MEDICATION NAME] dressing over the wound. LVN A did not follow the physician order dated 01/18/2013. Observation made on 1/30/2013 at 10:30 AM of Resident #1' s wound revealed a Stage III pressure sore approximately 3.0 cm round to Resident # 1's left heel with a peeling callous surrounding the wound, and a purple area to top left of the wound bed. The Stage III pressure sore was confirmed by the Hospice Registered Nurse (RN)'s and the RN surveyor during the observation. In an interview on 1/30/2013 at 10:45 AM the Minimum Data Set (MDS) Coordinator incorrectly stated that a Deep Tissue Injury (DTI) was a deep multi-layer open area. The National Pressure Ulcer Advisory Panel defines a DTI as, " A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. " (NPAUP, 2002). In an interview on 1/30/2013 at 10:55 AM the DON Q stated that to his knowledge a DTI was an unopened area dark purple, and mushy. The DON Q stated that his expectation was that staff that performed wound care were trained and know how to stage pressure sores; accurately assess and describe the wound when notifying the physician; and to obtain accurate physician's orders for the correct treatment. The DON Q also stated that he was not a wound care nurse, but with his limited understanding of staging of pressure sores, "if it's a DTI the wound is unstageable. " In an interview on 1/30/2013 at 3:40 PM Resident #1's Physician, stated that the most current left heel wound treatment order was in response to the notification she had received from the facility dated 1/16/2013, when the facility requested an order for [REDACTED]. Observation made on 1/31/2013 at 2:30 PM of Resident #1's wound assessment performed by the CWS confirmed a Stage III pressure sore to Resident's left heel. Review of Resident #1's Wound Care, Skin Integrity, and Evaluation form completed by the PT on 1/31/2013 reflected a left heel wound, a Stage III, measurements were "3.0 cm long x 3.5 cm wide x 0.2 cm deep" with a wound bed of "95% pink granulation tissue with 5% slough". In an interview on 2/16/2013 at 12:41 PM RN P stated that she did not do treatments on the weekends. Review of Resident #1's January, 2013 Treatment Administration Record (TAR) reflected RN P provided the pressure ulcer treatment to the Resident's pressure ulcer on January 19, and 20, indicated by RN P initialing the TAR. Observation on 2/18/2013 at 2:05pm revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. There was no dressing in place to the resident ' s left heel. LVN A measured Resident #1 ' s stage III pressure sore to his left heel as 2x2 cm and stated she " can ' t tell " a depth. LVN A measured a callous looking area on the left heel. CWS was also in room and instructed LVN A how to measure the Stage III. DON R took a picture of Resident #1 ' s left heel. This surveyor noted a small open area in the middle of the callous looking area with a red wound bed. Interview on 2/18/2013 at 2:35pm CWS stated she instructed LVN A to measure the outside edge of the callous skin looking area because there is " still a sore underneath and did not see an open area. CWS was shown the picture of the left heel on Resident #1 taken by the facility and stated " will have LVN A re-measure for depth " because the area has an opening. Interview on 2/18/2013 at 3:05pm DON R stated if the area was open her plan was to re-measure and to assess for a depth. Observation on 2/18/2013 at 3:15pm revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. The dressing was still in place from previous treatment at 2:05pm. LVN A performed the treatment again with the DON R and Administrator present in room. DON R used a cotton swab to determine a depth of 0.1 cm, the length and width equaled 0.4x 0.3 cm. Interview on 2/18/2013 at 3:37pm DON R stated LVN A will have supervised guidance on all wounds by DON R. C) Review of Resident #12's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is severely cognitively impaired. The assessment reflected Resident #12 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present on prior assessment. Review of Resident #12's care plan reflected no skin related care plans written. Review of Weekly Skin Assessments for Resident # 12 reflected: 01/21/2013 reflected "no issues" found. 01/31/2013 reflected "abrasion to the left hip - awaiting treatment" Review of the early morning skin assessments on 1/31/2013 by the DON Q, Assistant Director of Nurses (ADON), MDS Coordinator and Wound Care Nurse, LVN A revealed Resident #12 had an abrasion to her left hip. Observation made on 1/31/2013 at 11:35am revealed Resident #12 with six (6) Stage II pressure sores on her left hip. There are four open and 2 closed, blister areas in a circular pattern located in the incontinent brief area of her left hip. The wound beds are red and approximately less than 0.1 centimeter (cm) in depth. In an interview on 1/31/2013 at 11:40am CWS stated Resident #12 had one (1) Stage II pressure sore to left hip. The CSW stated the open areas were all in a circular shape but considered one (1) Stage II pressure sore instead of identifying each open area separately in staging and measuring, and then notifying the Physician.. Review of the wound assessment dated [DATE] revealed LVN A measured the entire area as 1.0 cm x 2.0 cm instead of measuring each open area separately. In an interview on 1/31/2013 at 11:45am the DON Q stated he agreed with whatever CWS staged the open areas. D) Review of Resident #10 ' s Face sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #10 ' s Quarterly MDS assessment dated [DATE] reflected BIMS of 8 indicating moderate cognitive impairment. The assessment reflected Resident #10 was at risk for pressure sores. Also noted two unstageable, suspected deep tissue injury pressure sores. Resident #10 had treatments checked for pressure sore care and application of dressings to feet. Review of Resident #10 ' s care plan for skin integrity reflected no plan of care for the Resident ' s right heel. The care plan reflected the Resident was at risk for impaired skin integrity related to incontinence of urine. Review of Resident #10 ' s Wound Assessments reflected: 12/3/2012-New facility acquired right heel stage II measured 0.8 x 0.8 cm, no depth noted, wound bed and surrounding tissue pink. The treatment was hydrogel every day. 12/12/2012-Resident #10 continues with stage II to right heel measured 0.5x 0.8x 0.0 cm, meaning no depth and wound should be noted as healed. The description notes reflected the " surrounding tissue and wound bed pink, no dressing at this time " , but current treatment reflected hydrogel and dry dressing every day. Also the assessment reflected no change to the wound even though the assessment reflected improvement. 12/19/2012-Resident #10 returned from hospital with heel hardened and to use preventative treatment of [REDACTED]. Also the assessment reflected a negative change to the wound even though the assessment reflected improvement. 12/28/2012-Resident #10 ' s right heel was unstageable and measured 0.8 x0.8 x 0.0 cm. The description notes reflected " eschar to heel hard, no drainage or odor, denies pain, surrounding tissue within normal limits " . The treatment was to float heels and wear booties. Also the assessment reflected no change to the wound even though the assessment reflected a decline. There were no assessments completed from 12/29/2012 through 1/13/2013. 1/14/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " eschar noted on heel intact, hard, no drainage, surrounding tissue dry, color good " . The treatment was to apply skin prep every day. 1/23/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " heel remains eschar and hard, no change, remains closed, no drainage or pain, surrounding tissue dry/scaly " . The treatment was to apply skin prep every day. Record review of the TAR for December 2012 reflected Resident #10 ' s treatment of [REDACTED]. Record Review of Resident #10 reflected the Resident was hospitalized on [DATE]th and returned to the facility on the 19th, there were no written orders on the TAR for the right heel treatment, yet the Wound Assessment for 12/19/2012 reflected a current treatment of [REDACTED]. Record Review of Resident #10 ' s Physician Telephone orders dated 1/8/2013 reflected a new order " skin prep to bilateral heels every day and to float heels". On the TAR for January 2013 there was no order written to float the heels. Record review of the TAR for January 2013 reflected Resident #10 ' s treatment of [REDACTED]. Record review of the TAR for January 2013 reflected Resident #10 ' s treatment of [REDACTED]. Also the TAR had no time frames to indicate when to apply the boots. In an interview dated 1/31/2013 at 3:00pm with LVN A stated the bunny boots should be documented and checked that the boots are on while Resident #10 was in bed. LVN A also stated when asked if she checked the placement of the boots while the Resident was in bed and stated " No, I don ' t always know when she is in bed. " In an interview dated 1/31/2013 at 3:05pm with DON Q stated the TAR ' s for December 2012 and January 2013 have missed initials and he has had a couple of complaints related to weekend RN ' s in regards to charting and performing treatments. He also stated he was at the facility several times to get it straight in the last few months. Observation on 1/31/2013 at 10:55am revealed the right heel was closed. Observation on 1/31/2013 at 6:55pm revealed Resident #10 was in bed, alert, pleasant. She was able to place her feet out from under the covers and noted no booties on them. One blue booty was on the floor next to the bed and egg crate booty was on the floor next to the trash can. Observation on 2/1/2013 at 10:00am revealed Resident #10 was in bed, alert, with no booties on her feet. The booties were in the exact same location on the floor. The egg crate booty was on the floor by the trash can and a cabinet. Observation on 2/18/2013 at 1:35pm revealed Resident #10 lying in bed on her back, head of bed slightly raised, her right heel with dark eschar and yellow calloused edge, measured per LVN A to equal 0

Based on observation, interview and record review the facility failed to ensure residents who enter the facility without pressure sores do not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable, and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 4 of 8 residents (Residents # 1, #2, #10, and #12) reviewed for pressure sores. A. Resident # 2 was readmitted to the facility on [DATE] without pressure sores. A Stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss) was identified to Resident # 2's sacral by the survey team on 01/30/2013. The facility did not consistently and accurately document assessments and did not promptly notify physician for treatment orders for a facility acquired Stage III pressure sore to his sacral. The facility identified and notified the physician Resident # 2 had an abrasion between his buttocks. B. The facility failed to accurately assess Resident # 1's Stage II pressure sore (01/18/2013) (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) to his left heel. The facility identified the pressure sore as an unstageable Deep Tissue Injury (DTI - A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) The pressure sore advanced to a Stage III (01/30/2013). The facility did not accurately assess, identify, and notify the physician of Resident # 1's Stage II pressure sore that advanced to a Stage III. C. The facility failed to accurately assess, document and notify the physician of Resident # 12's six (6) Stage II pressure sores identified to her left hip on 01/31/2013 (identified by the survey team). The facility identified Resident # 12's 6 pressure sores as one (1) abrasion. D. The facility failed to provide continuous and preventative treatment to ensure Resident #10 did not have pressure sores worsen from healed to suspected deep tissue injury (SDTI) to right heel. Also Resident #10 had no plan of care addressing skin breakdown to right heel. This resulted in an Immediate Jeopardy (IJ) on 01/30/2013. While the IJ was removed on 02/18/2013, the facility remained out of compliance at a Severity Level of Harm with a Scope of pattern that is not IJ. This deficient practice placed 17 residents at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection), severe pain and death. Findings Include: Upon Administrative and Enforcement review the original Plan of Removal submitted by the facility on 01/31/2013 was determined to not have removed the immediacy. The plan did not include a qualified nurse to perform skin assessments for all residents, identify, stage and treat pressure sores. The Health Survey was reopened on 02/15/2013 to collect additional information and interview facility staff. A) Review of Resident # 2's Face Sheet reflected a [AGE] year old male who entered the facility on 12/06/2011 and as readmitted to the facility on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of the admittance skin assessment dated [DATE] reflected no pressures sores to any part of his body. Review of Resident # 2's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is moderately cognitively impaired. The assessment reflected Resident # 2 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present prior assessment. The assessment reflected there were skin/ulcer treatments as 1) application of nonsurgical dressings other than to feet; 2) applications of ointments/medications other than to feet; and 3) application of dressings to feet (with or without topical medications). Review of Resident # 2's Comprehensive Care Plan dated 12/14/2012 reflected no plan of care for preventative measures or interventions for current pressure sores to ensure pressure sores were healed or prevented. Review of Resident # 2's Weekly Skin Assessments reflected: 01/17/2013 - Skin warm and dry. Mucus membranes pink/moist. Turgor poor. Fluids encouraged. Has scattered bruising due to insulin administration. Incision remains, all staples intact. Small amount of bloody drainage, blister remains. No other skin issues. The blister remained on Right Above the Knee Amputation incision site. Record review of Resident # 2's Treatment Administration Record (TAR) dated 1/20/2013 reflected RN P wrote in treatment "sacral area-cleaned and covered with dressing" and initialed in date box. There was no identification of the wound RN P treated and no notification was made to the Physician by RN P. There was no entry was made in the Nurses Notes regarding Resident # 2's sacral wound. There was no notification made to Physician regarding sacral wound till 1/22/2013 two days later. Review of Resident # 2's Physician Notification dated 01/22/2013, by the Treatment Nurse, LVN A, reflected "Resident # 2 is breaking down between buttocks. Barrier cream applied. Please advise." Physician response was "Keep clean and dry. Report every week." Review of the Nurses Notes dated 01/22/2013 reflected there was no documentation regarding wounds other than the Right Above the Knee Amputation incision cite for Resident # 2. Review of Physician Telephone Orders dated 1/22/2013 reflected an order to apply barrier cream to buttocks every shift and prn (as needed). There was no order to reflect the physician's response to the notification sent to "keep clean and dry and report every week." The physician did not order barrier cream to buttocks at this time. The fax notification dated 1/22/2013 reflected an order to "keep clean and dry and report every week." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"cleaned and covered with dressing." There was no physician order for [REDACTED]." This entry had no date. The facility began that order on 01/22/2013. Review of Weekly Skin assessment dated [DATE] reflected- Abrasion between buttocks; barrier cream applied. No pressure sore was documented. Observation on 01/30/2013 at 11:00 AM revealed a Stage III pressure sore to Resident # 2's sacral by surveyor was, approximately 3.0 by 2.0 centimeters (cm). The Stage III pressure sore did not have a dressing. There was a thick layer of barrier cream over entire coccyx and peri area. The pressure sore had granulation tissue and had slight redness to edges. There was no bleeding. During this observation, Certified Nurse Aide (CNA) I completed incontinent care for Resident # 2 after the resident had a bowel movement. In preparation for incontinent care, CNA I did not wash hands prior to donning gloves. CNA I inappropriately cleaned Resident # 2 from back to front, but did not thoroughly cleanse the barrier cream. CNA I did not change gloves or wash her hands prior to placing additional barrier cream to Resident # 2's coccyx/sacral. No dry dressing was applied to Resident 2's sacral pressure sore. Resident # 2 was lying in bed on his back on a regular mattress with no foam like qualities. After completion of incontinent care, Resident # 2 was lifted by a Hoyer lift onto a wheel chair with a plastic wedge cushion. There was no pressure relieving device in Resident # 2's wheel chair. In an interview on 01/30/2013 at 11:20 AM, CNA I stated she could not remember having any training regarding incontinent care or infection control provided by the facility. In an interview on 01/30/2013 at 11:45 AM the Wound Care Nurse, Licensed Vocational Nurse (LVN) A stated she had seen Resident # 2's wound that morning and it was an area opened in a line formation that appeared to be a "crack" but she did not assess and had not contacted the physician. LVN A stated she had not measured the wound. LVN A was notified of the Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 11:50 AM the Director of Nurses (DON) Q was made aware of Resident # 2's pressure sore to his sacral by the survey team. In an interview on 01/30/2013 at 5:10 PM the DON Q stated it was possible Resident # 2's wedge cushion placed in his wheel chair could have caused the resident's pressure sore but if he didn't have it he might fall out of his chair. Review of LVN A's notification to the physician on 01/30/2013 reflected the LVN spoke with the physician's office at 12:25 PM but notified the physician Resident # 2 had an "abrasion between buttocks. Remains open. Please advise a tx (treatment)". LVN A did not notify the physician of Resident # 2's Stage III pressure sore to his sacral. The new orders were to cover with dry dressing each shift. In an interview on 1/30/2013 at 3:40 PM also the Facility Medical Director also Resident #2 physician, stated she was not notified of the Stage III pressure sore to Resident # 2's sacral. Observation made on 01/30/2013 at 6:15 PM revealed a Stage III pressure sore to Resident # 2's sacrum, just above the tailbone with granulation tissue, red edge to wound bed and surrounding skin slightly pink in color. There was no maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture). The depth of the wound was observed by the surveyor to be approximetly larger than 0.1 cm. Resident #2 was observed to be in bed on a regular mattress without any pressure relieving devices. LVN A refused to measure Resident #2 sacral Stage III pressure sore during the observation. Review of notification to Resident # 2's physician on 01/30/2013 at 7:17 PM reflected a the physician was faxed the wound assessment that documented a "new" wound status of an area between buttocks that measured .8 x 1.5 cm. The Stage area on the wound assessment sheet was left blank. LVN A notified the physician the surrounding tissue was pale and the wound bed was covered with slough. However the surveyor observed granualtion tissue not slough. This was also not a "new" wound and there was no depth measurment documented on the skin assessment. Surveyors also observed the wound to be larger than documented by LVN A. Current treatment was dry dressing every shift. The physician agreed with this treatment in response to the incomplete and incorrect wound assessement information provided by the LVN A. Review of the Patient Wound Care Order Sheet completed by the Certified Wound Specialist (CWS) who was called in by the facility on 01/31/2013 reflected Resident # 2's sacral wound was Unstageable, full thickness, 2.00 x 0.80 centimeters (cm) with utd (undetermined depth), no tunneling or undermining. There was Serosanguinous drainage. The wound bed was 80% yellow slough with 20% granulation tissue. Periwound was described as "edge [MEDICATION NAME] flush with wound base." Clinical Rationale/Wound Comments reflected "daily dressing change due to daily enzymatic debrider, foam to maintain thermal wound healing." Treatment Intervention reflected "clean wound with normal saline or wound cleanser; apply santyl (nickel thickness) to entire wound bed for enzymatic debridement; apply bordered foam; change qd (every day)." In an interview on 01/31/2013 at 10:30 AM the CWS stated, after looking at pictures of Resident # 2's wound from 01/30/2013, the resident's sacral wound was unstageable today and agreed the wound had declined from 01/30/2013. There was no noted treatment preformed to Resident #2's scaral wound from 1/30/2013 to 1/31/2013. In an interview on 01/31/2013 at 10:35 AM the DON Q and MDS Coordinator both stated Resident # 2's wound had declined since it was originally observed on 01/30/2013. B) Review of Resident #1's Face Sheet reflected an [AGE] year old male who was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 07/12/2012 and last updated on 10/12/2012, reflected the resident was at high risk of impaired skin integrity R/T incontinence, with Resident will not develop any new skin breakdown for 90 days. Interventions the facility listed to meet this goal include: 1) Nurse will assess residents skin condition q week and PRN; 2) Nurse aide will visualize residents skin during bathing, changing of clothes, incontinent care, etc. for possible breakdown; 3) Nurse aide will notify nurse of any skin breakdown as soon as it is noticed; 4) Dietary will review residents ordered diet PRN; 5) Dietary will serve balanced diet TID; 6) Serve diet as ordered by MD; 7) Turn and reposition resident every 2 hours and PRN; 8) Ensure adequate fluid hydration daily; 9) Incontinent care every 2 hours and PRN; 10) Notify MD when breakdown is noticed; 11) Perform treatments as ordered by MD. The care plan did not include any devices to protect Resident # 1's heels from breaking down. Review of Resident # 1's Nursing Notes reflected the resident went to the hospital on [DATE] and returned 01/16/2013. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. The assessment reflected Resident # 1 was at risk for pressure sores but had no current pressure sores. In an interview on 1/29/2013 at 10:35 AM, on initial tour, Medication Aide (MA) L stated she was unsure if Resident #1 had any pressure sores, but "he used to". Review of Resident #1's Wound Assessment sheet dated 1/16/2013, and completed by LVN A, reflected the Resident had an unstageable DTI to the left heel. Also reflected on this Wound Assessment sheet was, "Resident returned from the hospital. Unstageable. Wound bed pink surrounding tissue has noted DTI ", with the current treatment being "Hydrogel silver apply small amt (amount) cover with dressing QD (every day), off load heels". This assessment identified entire wound as a unstageable DTI and failed to identify, and assess, the "wound bed pink" open area as a stageable pressure ulcer as separate to that of the unstageable "dark purple" suspected DTI with intact skin. In addition, the initial treatment of [REDACTED]. Review of Resident #1's Physician Telephone Orders dated on or around 1/16/2013 reflected no physician orders for left heel pressure sore treatment were received from the physician prior to intervention of the Hospice nurse on 1/18/13, two days after the Resident's admission to the facility. Review of a facsimile notification to Resident #1's physician, who is also the Facility's Medical Director, from LVN A dated 1/16/2013, reflected the Resident's return from the hospital with "3 wounds" to bilateral "feet/heels", "surrounding all open wounds are DTI's". This notification to the Resident's physician did not completely and accurately reflect a description of the wound to the left heel to enable the physician to determine if the initial treatment provided by LVN A was an appropriate treatment to promote wound healing for this pressure ulcer. Review of Resident # 1's Dietician Progress Notes dated 01/23/2013 reflected the resident had "unstageable areas to left inner foot and left and right heels." Intake inadequate to meet EST (estimated needs) Weight loss is expected." There was no supplement ordered to promote wound healing. Per nurse's notes, Resident # 1 was eating magic cups and thickened juices. Review of Facility photograph of Resident #1's left heel dated 1/16/2013, and provided by DON Q, reflected a round open ulcer to a medial heel, pink in color, with darkened area from approximately the 3 o'clock position clockwise to the 1 o'clock position surrounding open ulcer. Review of Resident # 1's Nursing Notes reflected the Resident went to the Emergency Department on 01/17/2013 and returned on 01/18/2013. Review of Resident #1's Hospice Admission assessment dated [DATE] reflected the resident was admitted to Hospice services on 1/18/2013. This Admission Assessment reflected the Hospice RN had assessed Resident #1 to have a Stage II pressure ulcer to the left heel. In an interview on 1/29/2013 at 11:40 AM, Licensed Vocational Nurse (LVN) A, also appointed as the wound care nurse, stated Resident #1 came back from the hospital on [DATE] with a DTI to left heel that was unstageable. LVN A stated the Resident ' s Hospice nurse had mistakenly staged the left heel as a Stage II pressure sore on 1/18/2013. When questioned by the surveyor about the discrepancy in staging of the wound, LVN A stated that the Resident "has an open wound to left heel, but it is surrounded by dark purple area and that makes it an unstageable DTI". LVN A stated that if a pressure ulcer had any dark purple "mushy" areas, even if there were any open areas within the purple, "the pressure ulcer cannot be staged". LVN A stated the treatment was scheduled for every three days but usually she had to change the dressing daily as Resident # 1's movement in bed made the dressing roll up. Review of Resident #1's Physician Telephone Orders dated 1/18/2013 reflected a Physician Telephone Order form to change the left heel wound treatment to an appropriate treatment for [REDACTED]. This order was signed by the Hospice Nurse,. Review of Resident # 1's weekly Wound assessment dated [DATE] incorrectly reflected a wound to the resident's left heel that measured 2.5 x 2.5 x 0.0 cm in that any "open" area of skin has a depth to the wound. Observation made on 01/29/2013 revealed Resident # 1's [MEDICATION NAME] dressing was rolled up on his heel leaving the wound open to air. LVN A cleansed Resident # 1's left heel wound with wound cleanser then patted dry. LVN A then placed Silvagel cream on the open wound and placed a [MEDICATION NAME] dressing over the wound. LVN A did not follow the physician order dated 01/18/2013. Observation made on 1/30/2013 at 10:30 AM of Resident #1' s wound revealed a Stage III pressure sore approximately 3.0 cm round to Resident # 1's left heel with a peeling callous surrounding the wound, and a purple area to top left of the wound bed. The Stage III pressure sore was confirmed by the Hospice Registered Nurse (RN)'s and the RN surveyor during the observation. In an interview on 1/30/2013 at 10:45 AM the Minimum Data Set (MDS) Coordinator incorrectly stated that a Deep Tissue Injury (DTI) was a deep multi-layer open area. The National Pressure Ulcer Advisory Panel defines a DTI as, " A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. " (NPAUP, 2002). In an interview on 1/30/2013 at 10:55 AM the DON Q stated that to his knowledge a DTI was an unopened area dark purple, and mushy. The DON Q stated that his expectation was that staff that performed wound care were trained and know how to stage pressure sores; accurately assess and describe the wound when notifying the physician; and to obtain accurate physician's orders for the correct treatment. The DON Q also stated that he was not a wound care nurse, but with his limited understanding of staging of pressure sores, "if it's a DTI the wound is unstageable. " In an interview on 1/30/2013 at 3:40 PM Resident #1's Physician, stated that the most current left heel wound treatment order was in response to the notification she had received from the facility dated 1/16/2013, when the facility requested an order for [REDACTED]. Observation made on 1/31/2013 at 2:30 PM of Resident #1's wound assessment performed by the CWS confirmed a Stage III pressure sore to Resident's left heel. Review of Resident #1's Wound Care, Skin Integrity, and Evaluation form completed by the PT on 1/31/2013 reflected a left heel wound, a Stage III, measurements were "3.0 cm long x 3.5 cm wide x 0.2 cm deep" with a wound bed of "95% pink granulation tissue with 5% slough". In an interview on 2/16/2013 at 12:41 PM RN P stated that she did not do treatments on the weekends. Review of Resident #1's January, 2013 Treatment Administration Record (TAR) reflected RN P provided the pressure ulcer treatment to the Resident's pressure ulcer on January 19, and 20, indicated by RN P initialing the TAR. Observation on 2/18/2013 at 2:05pm revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. There was no dressing in place to the resident ' s left heel. LVN A measured Resident #1 ' s stage III pressure sore to his left heel as 2x2 cm and stated she " can ' t tell " a depth. LVN A measured a callous looking area on the left heel. CWS was also in room and instructed LVN A how to measure the Stage III. DON R took a picture of Resident #1 ' s left heel. This surveyor noted a small open area in the middle of the callous looking area with a red wound bed. Interview on 2/18/2013 at 2:35pm CWS stated she instructed LVN A to measure the outside edge of the callous skin looking area because there is " still a sore underneath and did not see an open area. CWS was shown the picture of the left heel on Resident #1 taken by the facility and stated " will have LVN A re-measure for depth " because the area has an opening. Interview on 2/18/2013 at 3:05pm DON R stated if the area was open her plan was to re-measure and to assess for a depth. Observation on 2/18/2013 at 3:15pm revealed Resident #1 lying in bed on his back. His knees were bent like in a fetal position and his heels were against the bed. His booties were not on his feet and located at the foot of his bed. The dressing was still in place from previous treatment at 2:05pm. LVN A performed the treatment again with the DON R and Administrator present in room. DON R used a cotton swab to determine a depth of 0.1 cm, the length and width equaled 0.4x 0.3 cm. Interview on 2/18/2013 at 3:37pm DON R stated LVN A will have supervised guidance on all wounds by DON R. C) Review of Resident #12's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident is severely cognitively impaired. The assessment reflected Resident #12 was at risk for pressure sores but had no unhealed pressure sores and no pressure sores present on prior assessment. Review of Resident #12's care plan reflected no skin related care plans written. Review of Weekly Skin Assessments for Resident # 12 reflected: 01/21/2013 reflected "no issues" found. 01/31/2013 reflected "abrasion to the left hip - awaiting treatment" Review of the early morning skin assessments on 1/31/2013 by the DON Q, Assistant Director of Nurses (ADON), MDS Coordinator and Wound Care Nurse, LVN A revealed Resident #12 had an abrasion to her left hip. Observation made on 1/31/2013 at 11:35am revealed Resident #12 with six (6) Stage II pressure sores on her left hip. There are four open and 2 closed, blister areas in a circular pattern located in the incontinent brief area of her left hip. The wound beds are red and approximately less than 0.1 centimeter (cm) in depth. In an interview on 1/31/2013 at 11:40am CWS stated Resident #12 had one (1) Stage II pressure sore to left hip. The CSW stated the open areas were all in a circular shape but considered one (1) Stage II pressure sore instead of identifying each open area separately in staging and measuring, and then notifying the Physician.. Review of the wound assessment dated [DATE] revealed LVN A measured the entire area as 1.0 cm x 2.0 cm instead of measuring each open area separately. In an interview on 1/31/2013 at 11:45am the DON Q stated he agreed with whatever CWS staged the open areas. D) Review of Resident #10 ' s Face sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #10 ' s Quarterly MDS assessment dated [DATE] reflected BIMS of 8 indicating moderate cognitive impairment. The assessment reflected Resident #10 was at risk for pressure sores. Also noted two unstageable, suspected deep tissue injury pressure sores. Resident #10 had treatments checked for pressure sore care and application of dressings to feet. Review of Resident #10 ' s care plan for skin integrity reflected no plan of care for the Resident ' s right heel. The care plan reflected the Resident was at risk for impaired skin integrity related to incontinence of urine. Review of Resident #10 ' s Wound Assessments reflected: 12/3/2012-New facility acquired right heel stage II measured 0.8 x 0.8 cm, no depth noted, wound bed and surrounding tissue pink. The treatment was hydrogel every day. 12/12/2012-Resident #10 continues with stage II to right heel measured 0.5x 0.8x 0.0 cm, meaning no depth and wound should be noted as healed. The description notes reflected the " surrounding tissue and wound bed pink, no dressing at this time " , but current treatment reflected hydrogel and dry dressing every day. Also the assessment reflected no change to the wound even though the assessment reflected improvement. 12/19/2012-Resident #10 returned from hospital with heel hardened and to use preventative treatment of [REDACTED]. Also the assessment reflected a negative change to the wound even though the assessment reflected improvement. 12/28/2012-Resident #10 ' s right heel was unstageable and measured 0.8 x0.8 x 0.0 cm. The description notes reflected " eschar to heel hard, no drainage or odor, denies pain, surrounding tissue within normal limits " . The treatment was to float heels and wear booties. Also the assessment reflected no change to the wound even though the assessment reflected a decline. There were no assessments completed from 12/29/2012 through 1/13/2013. 1/14/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " eschar noted on heel intact, hard, no drainage, surrounding tissue dry, color good " . The treatment was to apply skin prep every day. 1/23/2013-Resident #10 ' s right heel continues unstageable and measured 1 x 1 x 0 cm. The description notes reflected " heel remains eschar and hard, no change, remains closed, no drainage or pain, surrounding tissue dry/scaly " . The treatment was to apply skin prep every day. Record review of the TAR for December 2012 reflected Resident #10 ' s treatment of [REDACTED]. Record Review of Resident #10 reflected the Resident was hospitalized on [DATE]th and returned to the facility on the 19th, there were no written orders on the TAR for the right heel treatment, yet the Wound Assessment for 12/19/2012 reflected a current treatment of [REDACTED]. Record Review of Resident #10 ' s Physician Telephone orders dated 1/8/2013 reflected a new order " skin prep to bilateral heels every day and to float heels". On the TAR for January 2013 there was no order written to float the heels. Record review of the TAR for January 2013 reflected Resident #10 ' s treatment of [REDACTED]. Record review of the TAR for January 2013 reflected Resident #10 ' s treatment of [REDACTED]. Also the TAR had no time frames to indicate when to apply the boots. In an interview dated 1/31/2013 at 3:00pm with LVN A stated the bunny boots should be documented and checked that the boots are on while Resident #10 was in bed. LVN A also stated when asked if she checked the placement of the boots while the Resident was in bed and stated " No, I don ' t always know when she is in bed. " In an interview dated 1/31/2013 at 3:05pm with DON Q stated the TAR ' s for December 2012 and January 2013 have missed initials and he has had a couple of complaints related to weekend RN ' s in regards to charting and performing treatments. He also stated he was at the facility several times to get it straight in the last few months. Observation on 1/31/2013 at 10:55am revealed the right heel was closed. Observation on 1/31/2013 at 6:55pm revealed Resident #10 was in bed, alert, pleasant. She was able to place her feet out from under the covers and noted no booties on them. One blue booty was on the floor next to the bed and egg crate booty was on the floor next to the trash can. Observation on 2/1/2013 at 10:00am revealed Resident #10 was in bed, alert, with no booties on her feet. The booties were in the exact same location on the floor. The egg crate booty was on the floor by the trash can and a cabinet. Observation on 2/18/2013 at 1:35pm revealed Resident #10 lying in bed on her back, head of bed slightly raised, her right heel with dark eschar and yellow calloused edge, measured per LVN A to equal 0.5 x 0.5 cm, no depth. Also the surrounding tissue of the wound towards the head (proximal) was " macerated " . Review of Weekly Skin Condition Reports for Resident # 10's right heel reflected: 01/31/2013 - "Vasta" (huge, vast) Eschar, measured 1.0 x 1.0 cm, treatment as skin prep each day. 02/08/2013 - Unstageable, measured 1.0 x 1.0 cm, treatment skin prep each day. 02/15/2013 "Vasta" Eschar, measured 1.1 x 1 cm, treatment was skin prep each day. In an interview on 2/16/13 at 12:15 PM LVN D stated "I do not do treatments on the weekends, the RN on duty does them". In an interview on 02/18/2013 at 4:50 PM LVN F stated she works on the weekends as the charge nurse and does not complete wound treatments. LVN

Based on observation, interview and record review the facility failed to establish infection control measures when: A. The facility failed to establish an infection control program to prevent the transmission of infections and disease by blood borne pathogens for 3 of 12 diabetic residents who receive blood glucose testing (Residents #17, 18, and 20). During the evening blood glucose testing the facility staff failed to clean the glucometer (blood glucose testing machine) between residents while performing glucose checks. The glucometer has the potential to touch the skin and come in close proximity to resident ' s blood with every use. Blood borne pathogens such as Hepatitis C could potentially be transmitted from one resident to another. An Immediate jeopardy (IJ) was identified on 11/15/2011 at 6:15 PM. While the IJ was removed prior to exit on 11/16/2011, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the lack of time to monitor the Plan of Removal for effectiveness. This deficient practice placed 3 residents (Residents #17, #18, and #20) and the additional 9 residents identified as requiring blood glucose testing, at risk for contracting a blood borne infection. B. Non- Immediate Jeopardy: The facility failed to ensure proper infection control procedures were used for 1 of 3 residents reviewed for wound care (Resident #1). During wound care on Resident #1, Licensed Vocational Nurse (LVN) B did not change her gloves or cleanse her hands after removing the dirty dressing on Resident #1 ' s coccyx. LVN B also did not wash or cleanse her hands after completing wound care to Resident #1 ' s coccyx and starting wound care to Resident #1 ' s foot. This deficient practice placed 1 resident (Resident #10) and the additional 3 residents identified with wounds and receiving wound care, at risk for infections, and delayed wound healing. Findings Include: A. Review of Resident #10 ' s clinical record face sheet reflected he is a [AGE] year old male admitted on [DATE] with diagnosis of Hypertension, Cirrhosis, Type 2 Diabetes and Hepatitis C. According to the Treatment Administration Record (TAR) Resident #10 was to have blood glucose monitoring 4 times a day. Observations on 11/14/2011 at 4:15 PM revealed LVN A performing blood glucose monitoring. LVN A used proper technique while performing the blood glucose monitoring for Resident # 17. After the monitoring was completed, LVN A did not clean the glucometer. She moved to Resident # 18 ' s room and did not clean the glucometer before testing Resident #18' s blood glucose. After completing the blood glucose test, and leaving Resident # 18 ' s room, LVN A once again did not clean the glucometer. LVN A moved to Resident # 20 ' s room, LVN A failed to clean the glucometer before testing Resident # 20 ' s blood glucose. After completing the blood glucose testing and exiting Resident # 20 ' s room, LVN A failed to clean the glucometer. In addition, although LVN A changed gloves between residents, she did not wash/cleanse her hands between residents. After blood glucose testing completed, glucometer was stored in the nurse ' s treatment cart at the nurse ' s station between the east and west wing. Interview on 11/15/2011 at 3:15 PM, LVN A stated the wipes on cart are used to clean the cart. She also stated " I don ' t clean the meters (glucometer) because I don ' t work the 10:00 to 6:00 shift. The 10:00 to 6:00 shift is the only time the blood glucose meters are cleaned. " Interview on 11/15/2011 at 3:45 PM, LVN A stated that Resident #10 gets his blood sugars tested with the same machine as everyone else. LVN A stated " We do not have a separate machine for him. " Interview on 11/15/2011 at 3:40 PM, Resident #10 stated that he does not have his own blood glucose machine, his blood sugars are tested with the facility ' s glucometer. Interview on 11/15/2011 at 5:10 PM, the facility Director of Nursing (DON) stated his expectations are that the facility nurses clean the glucometer between each resident and follow the manufacturer ' s recommendations for cleaning the glucometers. Review of the Manufacturer's Recommendations for the Arkay Assure 4 Blood Glucose monitoring system reflected " Healthcare professionals should wear gloves when cleaning the Assure 4 meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risks. We suggest cleaning the meter between patients." Interview on 11/16/2011 at 10:10 AM, Assistant Director of Nursing (ADON) stated that LVN A has been in training and 11/14/2011 was the first evening that LVN A was going to be the treatment nurse. LVN A was supposed to have a trainer with her on the evening of 11/14/2011 but the trainer called in sick. LVN A was not taken off treatments because LVN A told the ADON that she felt confident that she could do the treatments properly. Review of LVN A ' s employee file on 11/16/2011 reflected no documentation of training on the proper procedures for blood glucose testing found. Review of the facility ' s New Employee Checklist reflected that no blood glucose testing was included with the new employee training. Review of facility ' s blood sugar monitoring policy (Long Term Care Clinical Procedures, Briggs Corporation 2006) reflected under Procedures #3: Follow manufacturer ' s directions for use and care of equipment used in your facility. Review of Information posted by the Centers of Disease Control, "Infection Prevention during Blood Glucose Monitoring and Insulin Administration " at website <http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html> contained the following: These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed and/or insulin is administered, including assisted living or residential care facilities, clinics, health fairs, shelters, detention facilities, schools, and camps. Protection from blood borne viruses and other infections is a basic requirement and expectation anywhere healthcare is provided. Blood glucose meters are devices that measure blood glucose levels. ? Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. ? If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. On 11/16/2011 at 8:50 AM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Immediate inservice of licensed staff in the building at the time of the IJ. All licensed staff to receive inservice material for future reference and competency evaluation. All inservices will be given by DON (Director of Nursing) or designee. Inservices to be completed between 11/15/2011 to 11/16/2011 at 5:00PM for all licensed nurses. 2. Inservicing to include cleaning of glucometer and potential harm from spread of blood and bloodborne pathogens through glucometers (blood glucose testing meters). 3. All remaining nursing staff to be inserviced before start of schedules shift by nursing management and to receive all inservicing material for future reference. 4. Continuing inservices provided to all nursing staff, throughout the year by DON or designee, concerning the potential harm to other residents possibly being exposed to bloodborne pathogens. 5. All inservicing material and competency evaluation to be included within all nursing new-hire packets. 6. All current and future nurses employed by Colonial Care Center will have a competency check list completed for blood glucose monitoring and cleaning to be given by DON or Designee and annually the month of November and/or as needed. 7. Medical Doctor (MD) of diabetic residents potentially put at harm, to be notified by 5:00 PM on 11/16/2011. 8. Cleaning of the glucometers will be monitored by the DON or designee routinely and documented for future reference. 9. Upon placement of the IJ, all glucometers were immediately cleaned per the manufacturer ' s standard to eliminate any potential harm to diabetic residents. The survey team confirmed the facility had started to implement the plan of removal on 11/16/2011 at 11:15 AM. 1. Inservices were conducted on 11/15/2011 and 11/16/2011 with the facility nurses regarding the proper cleaning of the facility blood glucose meters and to ensure that all licensed staff clean the blood glucose meter between residents. The inservice also included the potential harm that could be caused from bloodborne pathogens if the glucometers are not cleaned between residents. 2. Inservice records for the inservices conducted on 11/15/2011 and 11/16/2011 were provided to the surveyors. Competency check-off sheets for glucometer cleaning also were provided on 11/16/2011. 3. Interviews were conducted on 11/16/2011 with facility nurses to confirm inservices were conducted and nurses understood the importance of cleaning the blood glucose meter between every resident to prevent the spread of bloodborne pathogens. 4. Observations on 11/16/2011 of evening blood glucose testing revealed that LVN #3 cleaned the facility glucometer between all residents whose blood glucoses were tested . While the IJ was removed on 11/16/2011 at 3:15 PM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. There were 12 diabetics in the facility that required blood glucose monitoring in the facility according to a list provided by the DON on 11/15/2011 at 5:30 PM. B. Non-Immediate Jeopardy: Review of Resident #1 ' s face sheet reflected the Resident was readmitted to the facility on [DATE]. The Resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Observation on 10/14/2011 at 3:00 PM revealed Resident #1 with 2 (two) non-facility acquired wounds. A 0.1 centimeters (cm) X 1.0 cm wound was observed to Resident #1 ' s coccyx and a 3cm X 2cm wound was observed to Resident #1 ' s right heel. Observation on 11/14/2011 at 3:00 PM revealed LVN B doing wound care to Resident #1 ' s two wounds. LVN B left the resident ' s room to wash her hands pre-procedure. After washing her hands, she gathered her supplies, placed them on a clean field and took them into Resident #1 ' s room. LVN B placed her supplies on the bedside table. LVN B did not wash or cleanse hands after gathering her supplies or bringing them into Resident #1 ' s room. LVN B donned her gloves, turned resident and removed his coccyx dressing. LVN B threw the dirty dressing away into a trash bag, and immediately started cleaning the coccyx wound without changing gloves or cleansing her hands. After completing wound care on Resident #1 ' s coccyx, LVN B removed her gloves, threw them away into a trash bag and donned new gloves without washing or cleansing her hands. LVN B proceeded to remove the dressing from Resident #1 ' s right foot wound and threw the dressing away into her trash bag beside the bed. LVN B did not change gloves or cleanse her hands after removing the dirty dressing. LVN B cleansed and applied a clean dressing to Resident #1 ' s foot wound. Interview on 11/16/2011 at 9:30 AM with LVN C, she stated nurses should be washing hands before and after wound care, as well as when the nurse changes gloves. She also stated the nurses should be changing gloves after removing dirty bandages and before cleaning and redressing wounds. Interview on 11/16/2011 at 2:00 PM with DON stated his expectation during wound care was that the nurses maintain a clean field. He also expects the nurses to change gloves between removing dressings and before cleaning and applying a new dressing. The DON also stated the nurses should also be washing/cleansing hands often during wound care. Record Review of the facility ' s Clean Dressing Change policy (Long Term Care Clinical Procedures, Briggs Corporation, 2006) revealed procedures for changing a clean dressing included: 1. Place plastic bag near foot of bed to receive soiled dressing. 2. Create clean field with paper towels or towelette drape. 3. Remove old adhesive with adhesive remover, if necessary, taking care not to get solution into wound. 4. Open dressing pack. 5. Put on first pair of disposable gloves. 6. Remove old soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Put on second pair of disposable gloves. 9. Pour prescribed solution onto gauze to be used for cleaning, if required. 10. Cleanse wound with prescribed solution. 11. Apply prescribed medication if ordered. 12. Apply dressing and secure with tape. 13. Remove gloves and discard with all unused supplies in plastic bag. 14. Assist resident to comfortable position with call light in reach. Interview on 11/14/2011 at 10:00 AM, MDS Coordinator stated that MDS/care plan not available because he does not have a MDS/Care plan book yet. She stated "He has not been here long enough." MDS Coordinator was also unable to print them out for me bacause her "laptop was down and being fixed" and that is where has the MDS/Care plan information is kept. She would be able to get the information to the survey team if her computer was fixed before the survey was completed. MDS Coordinator confirmed on 11/16/2011 that her computer would not be repaired before the survey team left. There were 5 residents in the facility with wounds that required wound care according to a facility supplied list.

Based on observation, interview and record review the facility failed to establish infection control measures when: A. The facility failed to establish an infection control program to prevent the transmission of infections and disease by blood borne pathogens for 3 of 12 diabetic residents who receive blood glucose testing (Residents #17, 18, and 20). During the evening blood glucose testing the facility staff failed to clean the glucometer (blood glucose testing machine) between residents while performing glucose checks. The glucometer has the potential to touch the skin and come in close proximity to resident ' s blood with every use. Blood borne pathogens such as Hepatitis C could potentially be transmitted from one resident to another. An Immediate jeopardy (IJ) was identified on 11/15/2011 at 6:15 PM. While the IJ was removed prior to exit on 11/16/2011, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of a pattern due to the lack of time to monitor the Plan of Removal for effectiveness. This deficient practice placed 3 residents (Residents #17, #18, and #20) and the additional 9 residents identified as requiring blood glucose testing, at risk for contracting a blood borne infection. B. Non- Immediate Jeopardy: The facility failed to ensure proper infection control procedures were used for 1 of 3 residents reviewed for wound care (Resident #1). During wound care on Resident #1, Licensed Vocational Nurse (LVN) B did not change her gloves or cleanse her hands after removing the dirty dressing on Resident #1 ' s coccyx. LVN B also did not wash or cleanse her hands after completing wound care to Resident #1 ' s coccyx and starting wound care to Resident #1 ' s foot. This deficient practice placed 1 resident (Resident #10) and the additional 3 residents identified with wounds and receiving wound care, at risk for infections, and delayed wound healing. Findings Include: A. Review of Resident #10 ' s clinical record face sheet reflected he is a [AGE] year old male admitted on [DATE] with diagnosis of Hypertension, Cirrhosis, Type 2 Diabetes and Hepatitis C. According to the Treatment Administration Record (TAR) Resident #10 was to have blood glucose monitoring 4 times a day. Observations on 11/14/2011 at 4:15 PM revealed LVN A performing blood glucose monitoring. LVN A used proper technique while performing the blood glucose monitoring for Resident # 17. After the monitoring was completed, LVN A did not clean the glucometer. She moved to Resident # 18 ' s room and did not clean the glucometer before testing Resident #18' s blood glucose. After completing the blood glucose test, and leaving Resident # 18 ' s room, LVN A once again did not clean the glucometer. LVN A moved to Resident # 20 ' s room, LVN A failed to clean the glucometer before testing Resident # 20 ' s blood glucose. After completing the blood glucose testing and exiting Resident # 20 ' s room, LVN A failed to clean the glucometer. In addition, although LVN A changed gloves between residents, she did not wash/cleanse her hands between residents. After blood glucose testing completed, glucometer was stored in the nurse ' s treatment cart at the nurse ' s station between the east and west wing. Interview on 11/15/2011 at 3:15 PM, LVN A stated the wipes on cart are used to clean the cart. She also stated " I don ' t clean the meters (glucometer) because I don ' t work the 10:00 to 6:00 shift. The 10:00 to 6:00 shift is the only time the blood glucose meters are cleaned. " Interview on 11/15/2011 at 3:45 PM, LVN A stated that Resident #10 gets his blood sugars tested with the same machine as everyone else. LVN A stated " We do not have a separate machine for him. " Interview on 11/15/2011 at 3:40 PM, Resident #10 stated that he does not have his own blood glucose machine, his blood sugars are tested with the facility ' s glucometer. Interview on 11/15/2011 at 5:10 PM, the facility Director of Nursing (DON) stated his expectations are that the facility nurses clean the glucometer between each resident and follow the manufacturer ' s recommendations for cleaning the glucometers. Review of the Manufacturer's Recommendations for the Arkay Assure 4 Blood Glucose monitoring system reflected " Healthcare professionals should wear gloves when cleaning the Assure 4 meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risks. We suggest cleaning the meter between patients." Interview on 11/16/2011 at 10:10 AM, Assistant Director of Nursing (ADON) stated that LVN A has been in training and 11/14/2011 was the first evening that LVN A was going to be the treatment nurse. LVN A was supposed to have a trainer with her on the evening of 11/14/2011 but the trainer called in sick. LVN A was not taken off treatments because LVN A told the ADON that she felt confident that she could do the treatments properly. Review of LVN A ' s employee file on 11/16/2011 reflected no documentation of training on the proper procedures for blood glucose testing found. Review of the facility ' s New Employee Checklist reflected that no blood glucose testing was included with the new employee training. Review of facility ' s blood sugar monitoring policy (Long Term Care Clinical Procedures, Briggs Corporation 2006) reflected under Procedures #3: Follow manufacturer ' s directions for use and care of equipment used in your facility. Review of Information posted by the Centers of Disease Control, "Infection Prevention during Blood Glucose Monitoring and Insulin Administration " at website <http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html> contained the following: These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed and/or insulin is administered, including assisted living or residential care facilities, clinics, health fairs, shelters, detention facilities, schools, and camps. Protection from blood borne viruses and other infections is a basic requirement and expectation anywhere healthcare is provided. Blood glucose meters are devices that measure blood glucose levels. ? Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. ? If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. On 11/16/2011 at 8:50 AM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Immediate inservice of licensed staff in the building at the time of the IJ. All licensed staff to receive inservice material for future reference and competency evaluation. All inservices will be given by DON (Director of Nursing) or designee. Inservices to be completed between 11/15/2011 to 11/16/2011 at 5:00PM for all licensed nurses. 2. Inservicing to include cleaning of glucometer and potential harm from spread of blood and bloodborne pathogens through glucometers (blood glucose testing meters). 3. All remaining nursing staff to be inserviced before start of schedules shift by nursing management and to receive all inservicing material for future reference. 4. Continuing inservices provided to all nursing staff, throughout the year by DON or designee, concerning the potential harm to other residents possibly being exposed to bloodborne pathogens. 5. All inservicing material and competency evaluation to be included within all nursing new-hire packets. 6. All current and future nurses employed by Colonial Care Center will have a competency check list completed for blood glucose monitoring and cleaning to be given by DON or Designee and annually the month of November and/or as needed. 7. Medical Doctor (MD) of diabetic residents potentially put at harm, to be notified by 5:00 PM on 11/16/2011. 8. Cleaning of the glucometers will be monitored by the DON or designee routinely and documented for future reference. 9. Upon placement of the IJ, all glucometers were immediately cleaned per the manufacturer ' s standard to eliminate any potential harm to diabetic residents. The survey team confirmed the facility had started to implement the plan of removal on 11/16/2011 at 11:15 AM. 1. Inservices were conducted on 11/15/2011 and 11/16/2011 with the facility nurses regarding the proper cleaning of the facility blood glucose meters and to ensure that all licensed staff clean the blood glucose meter between residents. The inservice also included the potential harm that could be caused from bloodborne pathogens if the glucometers are not cleaned between residents. 2. Inservice records for the inservices conducted on 11/15/2011 and 11/16/2011 were provided to the surveyors. Competency check-off sheets for glucometer cleaning also were provided on 11/16/2011. 3. Interviews were conducted on 11/16/2011 with facility nurses to confirm inservices were conducted and nurses understood the importance of cleaning the blood glucose meter between every resident to prevent the spread of bloodborne pathogens. 4. Observations on 11/16/2011 of evening blood glucose testing revealed that LVN #3 cleaned the facility glucometer between all residents whose blood glucoses were tested . While the IJ was removed on 11/16/2011 at 3:15 PM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. There were 12 diabetics in the facility that required blood glucose monitoring in the facility according to a list provided by the DON on 11/15/2011 at 5:30 PM. B. Non-Immediate Jeopardy: Review of Resident #1 ' s face sheet reflected the Resident was readmitted to the facility on [DATE]. The Resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Observation on 10/14/2011 at 3:00 PM revealed Resident #1 with 2 (two) non-facility acquired wounds. A 0.1 centimeters (cm) X 1.0 cm wound was observed to Resident #1 ' s coccyx and a 3cm X 2cm wound was observed to Resident #1 ' s right heel. Observation on 11/14/2011 at 3:00 PM revealed LVN B doing wound care to Resident #1 ' s two wounds. LVN B left the resident ' s room to wash her hands pre-procedure. After washing her hands, she gathered her supplies, placed them on a clean field and took them into Resident #1 ' s room. LVN B placed her supplies on the bedside table. LVN B did not wash or cleanse hands after gathering her supplies or bringing them into Resident #1 ' s room. LVN B donned her gloves, turned resident and removed his coccyx dressing. LVN B threw the dirty dressing away into a trash bag, and immediately started cleaning the coccyx wound without changing gloves or cleansing her hands. After completing wound care on Resident #1 ' s coccyx, LVN B removed her gloves, threw them away into a trash bag and donned new gloves without washing or cleansing her hands. LVN B proceeded to remove the dressing from Resident #1 ' s right foot wound and threw the dressing away into her trash bag beside the bed. LVN B did not change gloves or cleanse her hands after removing the dirty dressing. LVN B cleansed and applied a clean dressing to Resident #1 ' s foot wound. Interview on 11/16/2011 at 9:30 AM with LVN C, she stated nurses should be washing hands before and after wound care, as well as when the nurse changes gloves. She also stated the nurses should be changing gloves after removing dirty bandages and before cleaning and redressing wounds. Interview on 11/16/2011 at 2:00 PM with DON stated his expectation during wound care was that the nurses maintain a clean field. He also expects the nurses to change gloves between removing dressings and before cleaning and applying a new dressing. The DON also stated the nurses should also be washing/cleansing hands often during wound care. Record Review of the facility ' s Clean Dressing Change policy (Long Term Care Clinical Procedures, Briggs Corporation, 2006) revealed procedures for changing a clean dressing included: 1. Place plastic bag near foot of bed to receive soiled dressing. 2. Create clean field with paper towels or towelette drape. 3. Remove old adhesive with adhesive remover, if necessary, taking care not to get solution into wound. 4. Open dressing pack. 5. Put on first pair of disposable gloves. 6. Remove old soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Put on second pair of disposable gloves. 9. Pour prescribed solution onto gauze to be used for cleaning, if required. 10. Cleanse wound with prescribed solution. 11. Apply prescribed medication if ordered. 12. Apply dressing and secure with tape. 13. Remove gloves and discard with all unused supplies in plastic bag. 14. Assist resident to comfortable position with call light in reach. Interview on 11/14/2011 at 10:00 AM, MDS Coordinator stated that MDS/care plan not available because he does not have a MDS/Care plan book yet. She stated "He has not been here long enough." MDS Coordinator was also unable to print them out for me bacause her "laptop was down and being fixed" and that is where has the MDS/Care plan information is kept. She would be able to get the information to the survey team if her computer was fixed before the survey was completed. MDS Coordinator confirmed on 11/16/2011 that her computer would not be repaired before the survey team left. There were 5 residents in the facility with wounds that required wound care according to a facility supplied list. During the onsite follow-up conducted on 01/11/2012 the following evidence was identified indicating the deficient practice continued. Based on interview and record review the facility failed to complete the plan of correction by failure to ensure an in-service on wound care and evaluation had been provided by a third party entity. Findings Include: In an interview on 01/10/2012 at 11:00 AM the Director of Nurses (DON) stated there had been no in-services nor evaluations regarding wound care completed by a third party entity. Review of in-service records reflected no third party entity had completed in-services or evaluations regarding wound care. Non-Immediate Jeopardy evidence gathered on the follow-up visit dated 01/11/2012 is as follows: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (b) Preventing Spread of Infection (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Based on observation, interview, and record review the facility failed to establish and maintain an Infection Control Program designed to provide a safe, and sanitary environment and to help prevent the development and transmission of disease and infection when (Licensed Vocational Nurse, (LVN A) was observed performing 2 of 2 Resident's wound care, failed to change gloves and maintain a sterile procedure during wound care. (Resident #'s 1 and 2). LVN A failed to wash hands or use a hand sanitizing solution after touching nonsterile items with her bare hands and failed to change gloves after touching unsanitary and nonsterile items with her gloved hands before and during wound care for Resident #'s 1 and 2. This deficient practice of failure to implement hand hygiene practices consistent with accepted standards of practice could cause the spread of infections and cross-contamination for Resident #'s 1 and 2 and has the potential to create outbreaks and cross-contamination to the other 4 residents identified by the facility as receiving wound care. Findings Include: A. Review of the Face Sheet for Resident # 1 reflected the Resident was a [AGE] year old male that entered the facility on 09/20/2011. Resident # 9 had [DIAGNOSES REDACTED]. Observation made on 01/10/2012 at 9:30 AM revealed Resident # 1 to be cognitively impaired and non-interviewable. Observation on 01/10/2012 at 9:50 AM in the hall revealed LVN A preparing to complete wound care for Resident # 1. LVN A placed her hands in her pocket to obtain the key to open the treatment cart, touched the treatment cart including supplies in the locked drawers and on top of the cart, placed her hands in her pocket to return the key. LVN A then proceeded to place gloves on her hands without washing nor did she use hand sanitizer prior to placing the gloves on her hands. After applying the gloves, LVN A took the supplies into Resident # 1's room and placed the supplies on a bedside table. She then touched the curtain in Resident # 1's room to ensure privacy and proceeded to continue with the treatment. Resident # 1 was lying in his bed and the wounds on his left leg were open, without covering. In an interview on 01/10/2012 at 12:45 PM, LVN A stated she had been trained. She stated she should have used hand sanitizer prior to placing the gloves on her hands in preparation for wound care after she touched all of the supplies in and on her cart, and hand placed her hands in her pocket. LVN A stated she should not have touched the curtain with her gloved hands. In an interview on 01/10/2012 at 2:45 PM the Director of Nurses (DON) stated he had trained and performed a competency check for LVN A. The DON did not comment on the hand washing procedure. B. Review of Resident # 2's Face Sheet reflected the resident was a [AGE] year old male who entered the facility on 06/06/2007. Resident # 2's [DIAGNOSES REDACTED]. Observation on 01/10/2012 at 12:30 PM revealed LVN A preparing for a wound treatment for [REDACTED]. In the hallway, LVN A placed her bare hands in her pockets to obtain the key to open the treatment cart, touched supplies with her bare hands in and on top of the treatment cart. LVN A then placed gloves on her hand without washing her hands and did not apply hand sanitizer. With her gloves on, LVN A entered Resident # 2's room, touched a back pack lying on the floor and moved it. The back pack had dust balls and particles of dust on the outside. LVN A, wearing the same gloves, proceeded to apply wound cleanser to the wound, then she changed her gloves. In an interview on 01/10/2012 at 12:45 PM, LVN A stated she had been trained in proper hand sanitization and should have used hand sanitizer prior to placing the gloves on her hands in preparation for wound care after she touched all of the supplies in and on her cart and hand placed her hands in her pocket. LVN A stated she should not have touched the back pack with her gloved hands. In an interview on 01/10/2012 at 2:45 PM the Director of Nurses (DON) stated he had trained and performed a competency check for LVN A. The DON did not comment on the hand washing procedure. The DON stated the policy provided "Hand Cleaner, Antiseptic" was the only policy the facility had regarding hand hygiene during wound care. Review of the undated facility policy regarding Hand Cleaner, Antiseptic did not reflect Universal Precaution procedures regarding hand hygiene. After requesting the facility Handwashing Procedure Policy on 01/10/2012 at 2:45 PM and again on 01/11/2012 at 3:00 PM, in an interview on 01/11/2012 at 3:30 PM the DON stated the Hand Cleaner, Antiseptic policy is the only policy the facility had regarding hand washing procedures, even for hand washing techniques during wound care. Review of the MayoClinic Hand Washing Procedures reflected: When to wash your hands As you touch people, surfaces and objects throughout the day, you accumulate germs on your hands. In turn, you can infect yourself with these germs by touching your eyes, nose or mouth. Although it's impossible to keep your hands germ-free, washing your hands frequently can help limit the transfer of bacteria, viruses and other microbes. Always wash your hands before: ? Preparing food or eating ? Treating wounds, giving medicine, or caring for a sick or injured person ? Inserting or removing contact lenses Always wash your hands after: ? Preparing food, especially raw meat or poultry ? Using the toilet or changing a diaper ? Touching an animal or animal toys, leashes, or waste ? Blowing your nose, coughing or sneezing into your hands ? Treating wounds or caring for a sick or injured person ? Handling garbage, household or garden chemicals, or anything that could be contaminated - such as a cleaning cloth or soiled shoes The facility provided a of list of 6 residents who received wound care. The current Resident census was 59, per the Administrator

Based on observation, interview and record review the facility failed to consult the resident's physician regarding a significant change in physical condition for 1 of 4 residents reviewed for pressure ulcer management (Resident #2). The facility failed to notify the physician of Resident #2's developing pressure ulcers on her left heel and great toe from 10/24/11-11/14/11. This deficient practice could contributed to Resident #2's delay in medical evaluation and treatment and with the potential to affect the additional 3 residents with pressure ulcers. Findings include: Review of Resident #2's Admission Face Sheet reflected a [AGE] year old woman with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Care Plan, dated 10/06/11 reflected; 1. Provide measures to decrease pressure/irritation to skin: fleece pad, egg crate mattress, heel protectors. 2. Keep skin clean and dry. 3. Apply protective or barrier lotion after incontinence. 4. Avoid hot water and irritating soaps. 5. Keep bed linen clean, dry and wrinkle free. 6. Assist resident to turn and reposition every two hours. 7. Position with pads and cushions to prevent pressure. 8. Use a draw sheet or lifting device to move resident in bed. 9. Increase out of bed activity as tolerated. 10. Maintain adequate nutrition and hydration. 11. Keep nails short. 12. Inspect and chart skin integrity weekly. An observation on 11/14/11 at 10:30 AM revealed Resident #2 in bed, on her right side with her heels pulled up towards her torso with a right elevator boot on (Cushioned bootie that elevates foot off bed to relieve pressure). Resident #2 was not wearing a left elevator boot and it was not seen in Resident #2's bedroom. Her left foot was resting on top of her right foot. Licensed Vocational Nurse (LVN) D lifted Resident #2's left foot off the top of her right foot, and revealed a reddened area (approximately 7 x 7 centimeters (cm) where her foot was resting. Resident #2's right foot was soaked and macerated (softening of skin from being exposed to water or urine). Resident #2's left foot was wrapped with a gauze bandage, which was soaked and smelled strongly of urine. Upon removal of Resident #2's left foot dressing, a 6 cm wide by 10 cm long skin flap on her right heel was observed which appeared macerated. Resident #2 did not have any pressure reducing devices for her feet. She also did not have cushions or pads between her knees to reduce pressure. Resident #2's left great toe was swollen and had black tissue visible along the side of the toe. Resident #2's right 5th toe was partially blackened and red. Her 4th toe was red with a scab forming on the inside. A circular reddened area was also observed on Resident #2's right buttock that was approximately 10 x 10 cm. In an interview on 11/14/11 at 10:30 AM, LVN D stated that she thought Resident #2's left heel sore was a skin tear from a transfer. In an interview on 11/14/11 at 10:30 AM, Minimum Data Set (MDS) Coordinator stated Resident #2's feet looked like they had been wet. Review of Nurse's Treatment Sheet for Resident #2, dated 10/31/11 reflected "left outer heel bruised with apparent skin tear." Further review of Nurse's Treatment Sheets reflected Resident #2's pressure ulcer on left big toe was not included. Review of Incident and Accident Reports for September through November 2011 reflected no skin tear reports for Resident #2's left heel. Review of Weekly Skin Assessment for Resident #2 reflected "10/31/11 noted bruised heel with apparent closed skin tear with macerated area." Review of undated Weekly Skin Assessment for Resident #2 reflected "MD faxed by wound care nurse regarding an abrasion on right inner ankle." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "three blisters intact to left foot back, covered with hydrogel and [MEDICATION NAME], wrap with kerlix continues until healed." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "Noted macerated tissue to lateral aspect of both feet. During treatment posterior sheet of tissue to left back foot peeled off." Review of Resident #2's Clinical Record reflected there were no Physician notifications or Physician order [REDACTED]. Further review of the Clinical Record reflected there were no Weekly Skin Assessment, Physician notification, or Physician order [REDACTED]. In an interview on 11/14/2011 at 1:00 PM the Podiatrist stated the sores on Resident #2's feet are all pressure related. In an interview on 11/15/11 at 1:30 PM with Medical Director (also Resident #2's physician) stated she would expect the nurses to either call or fax her office with any significant changes and a pressure ulcer is a significant change. The Medical Director looked through the chart and stated she could not find any notification for Resident #2's pressure ulcers to left heel, great big toe or right 5th toe. The Medical Director also looked on the computer notification page but could not find notification in reference to Resident #2 ' s pressure ulcers. Review of Physician order [REDACTED]. Review of the facility's "Pressure Ulcer, Prevention of" procedures, dated 2006, reflected to notify the physician when change in skin condition is observed. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. A facility generated skin report revealed four residents with pressure ulcers.

Based on observation, interview and record review the facility failed to consult the resident's physician regarding a significant change in physical condition for 1 of 4 residents reviewed for pressure ulcer management (Resident #2). The facility failed to notify the physician of Resident #2's developing pressure ulcers on her left heel and great toe from 10/24/11-11/14/11. This deficient practice could contributed to Resident #2's delay in medical evaluation and treatment and with the potential to affect the additional 3 residents with pressure ulcers. Findings include: Review of Resident #2's Admission Face Sheet reflected a [AGE] year old woman with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Care Plan, dated 10/06/11 reflected; 1. Provide measures to decrease pressure/irritation to skin: fleece pad, egg crate mattress, heel protectors. 2. Keep skin clean and dry. 3. Apply protective or barrier lotion after incontinence. 4. Avoid hot water and irritating soaps. 5. Keep bed linen clean, dry and wrinkle free. 6. Assist resident to turn and reposition every two hours. 7. Position with pads and cushions to prevent pressure. 8. Use a draw sheet or lifting device to move resident in bed. 9. Increase out of bed activity as tolerated. 10. Maintain adequate nutrition and hydration. 11. Keep nails short. 12. Inspect and chart skin integrity weekly. An observation on 11/14/11 at 10:30 AM revealed Resident #2 in bed, on her right side with her heels pulled up towards her torso with a right elevator boot on (Cushioned bootie that elevates foot off bed to relieve pressure). Resident #2 was not wearing a left elevator boot and it was not seen in Resident #2's bedroom. Her left foot was resting on top of her right foot. Licensed Vocational Nurse (LVN) D lifted Resident #2's left foot off the top of her right foot, and revealed a reddened area (approximately 7 x 7 centimeters (cm) where her foot was resting. Resident #2's right foot was soaked and macerated (softening of skin from being exposed to water or urine). Resident #2's left foot was wrapped with a gauze bandage, which was soaked and smelled strongly of urine. Upon removal of Resident #2's left foot dressing, a 6 cm wide by 10 cm long skin flap on her right heel was observed which appeared macerated. Resident #2 did not have any pressure reducing devices for her feet. She also did not have cushions or pads between her knees to reduce pressure. Resident #2's left great toe was swollen and had black tissue visible along the side of the toe. Resident #2's right 5th toe was partially blackened and red. Her 4th toe was red with a scab forming on the inside. A circular reddened area was also observed on Resident #2's right buttock that was approximately 10 x 10 cm. In an interview on 11/14/11 at 10:30 AM, LVN D stated that she thought Resident #2's left heel sore was a skin tear from a transfer. In an interview on 11/14/11 at 10:30 AM, Minimum Data Set (MDS) Coordinator stated Resident #2's feet looked like they had been wet. Review of Nurse's Treatment Sheet for Resident #2, dated 10/31/11 reflected "left outer heel bruised with apparent skin tear." Further review of Nurse's Treatment Sheets reflected Resident #2's pressure ulcer on left big toe was not included. Review of Incident and Accident Reports for September through November 2011 reflected no skin tear reports for Resident #2's left heel. Review of Weekly Skin Assessment for Resident #2 reflected "10/31/11 noted bruised heel with apparent closed skin tear with macerated area." Review of undated Weekly Skin Assessment for Resident #2 reflected "MD faxed by wound care nurse regarding an abrasion on right inner ankle." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "three blisters intact to left foot back, covered with hydrogel and [MEDICATION NAME], wrap with kerlix continues until healed." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "Noted macerated tissue to lateral aspect of both feet. During treatment posterior sheet of tissue to left back foot peeled off." Review of Resident #2's Clinical Record reflected there were no Physician notifications or Physician order [REDACTED]. Further review of the Clinical Record reflected there were no Weekly Skin Assessment, Physician notification, or Physician order [REDACTED]. In an interview on 11/14/2011 at 1:00 PM the Podiatrist stated the sores on Resident #2's feet are all pressure related. In an interview on 11/15/11 at 1:30 PM with Medical Director (also Resident #2's physician) stated she would expect the nurses to either call or fax her office with any significant changes and a pressure ulcer is a significant change. The Medical Director looked through the chart and stated she could not find any notification for Resident #2's pressure ulcers to left heel, great big toe or right 5th toe. The Medical Director also looked on the computer notification page but could not find notification in reference to Resident #2 ' s pressure ulcers. Review of Physician order [REDACTED]. Review of the facility's "Pressure Ulcer, Prevention of" procedures, dated 2006, reflected to notify the physician when change in skin condition is observed. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. A facility generated skin report revealed four residents with pressure ulcers. During the onsite follow-up conducted on 01/11/2012 the following evidence was identified indicating the deficient practice continued. Based on interview and record review the facility failed to complete the plan of correction by failure to ensure an in-service on wound care and evaluation had been provided by a third party entity. Findings Include: In an interview on 01/10/2012 at 11:00 AM the Director of Nurses (DON) stated there had been no in-services nor evaluations regarding wound care completed by a third party entity. Review of in-service records reflected no third party entity had completed in-services or evaluations regarding wound care. The current Resident census was 59, per the Administrator.

Based on observation, interview and record review the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores, received the necessary treatment and services to promote healing and prevent new sores from developing for 1 of 4 sampled residents reviewed for pressure ulcer management. (Resident #2) Resident # 2 developed pressure ulcers on left heel and left great toe and developed pre-ulcerative [MEDICAL CONDITION] (Stage I pressure ulcer) at the middle of the lateral right foot and right posterior lateral heel. The facility failed to notify the doctor, implement care plan interventions, and accurately assess three pressure ulcers. Resident # 2 was affected and three other residents with pressure ulcers could be affected by this deficient practice. Failure to notify the doctor, implement care plan, interventions, and accurately assess three pressure ulcers could result in the development of new pressure ulcers or the deterioration of existing pressure ulcers. Four residents with pressure ulcers could be affected by this deficient practice. Failure to notify the doctor, implement care plan, interventions, and accurately assess three pressure ulcers could result in the development of new pressure ulcers or the deterioration of existing pressure ulcers. Findings Include: Review of Resident #2's face sheet reflected a [AGE] year old woman with [DIAGNOSES REDACTED]. An observation on 11/14/11 at 10:30 AM revealed Resident #2 in bed, on her right side with her heels pulled up towards her torso with a right elevator boot on (Cushioned bootie that elevates foot off bed to relieve pressure). Resident #2 was not wearing a left elevator boot and it was not seen in Resident #2's bedroom. Her left foot was resting on top of her right foot. Licensed Vocational Nurse (LVN) D lifted Resident #2's left foot off the top of her right foot, and revealed a reddened area (approximately 7 x 7 centimeters (cm) where her foot was resting. Resident #2's right foot was soaked and macerated (softening of skin from being exposed to water or urine). Resident #2's left foot was wrapped with a gauze bandage, which was soaked and smelled strongly of urine. Upon removal of Resident #2's left foot dressing, a 6 cm wide by 10 cm long skin flap on her right heel was observed which appeared macerated. Resident #2 did not have any pressure reducing devices for her feet. She also did not have cushions or pads between her knees to reduce pressure. Resident #2's left great toe was swollen and had black tissue visible along the side of the toe. Resident #2's right 5th toe was partially blackened and red. Her 4th toe was red with a scab forming on the inside. A circular reddened area was also observed on Resident #2's right buttock that was approximately 10 x 10 cm. Review of Resident #2's Care Plan dated 10/06/11 reflected; 1. Provide measures to decrease pressure/irritation to skin: fleece pad, egg crate mattress, heel protectors.. 2. Keep skin clean and dry. 3. Apply protective or barrier lotion after incontinence. 4. Avoid hot water and irritating soaps. 5. Keep bed linen clean, dry and wrinkle free. 6. Assist resident to turn and reposition every two hours. 7. Position with pads and cushions to prevent pressure. 8. Use a draw sheet or lifting device to move resident in bed. 9. Increase out of bed activity as tolerated. 10. Maintain adequate nutrition and hydration. 11. Keep nails short. 12. Inspect and chart skin integrity weekly. In an interview on 11/14/11 at 1030 AM, LVN D stated that she thought Resident #2's left heel sore was a skin tear from a transfer. In an interview on 11/14/11 at 1030 AM, MDS Coordinator stated Resident #2's feet looked like they had been wet. Review of Weekly Skin Assessment for Resident #2 reflected "10/31/11 noted bruised heel with apparent closed skin tear with macerated area." Review of undated Weekly Skin Assessment for Resident #2 reflected "MD faxed by wound care nurse regarding an abrasion on right inner ankle " . Review of incident and accident reports reflected no skin tear reports for Resident #2's heel. Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "three blisters intact to left foot back, covered with hydrogel and [MEDICATION NAME], wrap with kerlix continues until healed." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "Noted macerated tissue to lateral aspect of both feet. During treatment posterior sheet of tissue to left back foot peeled off." Review of Nurse's Treatment Sheet for Resident #2, dated 10/31/11 reflected "left outer heel bruised with apparent skin tear." Review of Incident and Accident Reports for September through November 2011 reflected no skin tear reports for Resident #2's left heel. Review of Resident #2's Clinical Record reflected there were no Physician notifications or Physician order [REDACTED]. Further review of the Clinical Record reflected there was no Weekly Skin Assessment, Physician notification, or Physician order [REDACTED]. Review of Mobile Podiatric Medicine, PLLC dated 11/14/11, reflected Resident #2, [AGE] year old female, non-communicative. Nursing states there are multiple wounds on both feet and toes present for several weeks apparently due to pressure, secondary to her contracted lower extremities: Objective: Ruptured bullous lesion with underlying superficial ulceration at the left posterior heel approximately 5cm x 5cm x 0.1cm depth with a granular base with surrounding skin slough noted. Left hallux medialungual labia hypertrophied (abnormal growth of tissue on left big toe) with incurvated nail border and surrounding escar (dead tissue that falls off (sheds) from healthy skin) and ecchymosis (bruising). Assessment: Left Heel Boullous Lesion (ruptured). Left Hallux Onychocry[DIAGNOSES REDACTED], (refers to ingrown toenail) (no infection). Multiple Pre-ulcerative [MEDICAL CONDITION] (increased). Onychomycosis, (unchanged) (refers to a fungal infection that affects the toenails) [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Plan: Sharp partial thickness debridement (the process of removing nonliving tissue from pressure ulcers) of surrounding skin slough; Partial nail avulsion at left great toe with debridement of surrounding non-viable tissue. Cleansed both areas and applied antibiotic cream with 4x4 gauze. Continue daily dressing changes until healed. Continue off weighting with heel protectors. In an interview on 11/14/2011 at 1:00 PM the Podiatrist stated the sores on Resident #2's feet are all pressure related. In an interview on 11/15/11 at 1:30 PM with Medical Director (also Resident #2's physician) stated she would expect the nurses to either call or fax her office with any significant changes and a pressure ulcer is a significant change. The Medical Director looked through the chart and stated she could not find any notification for Resident #2's pressure ulcers to left heel, great big toe or right 5th toe. The Medical Director also looked on the computer notification page but could not find notification in reference to Resident #2 ' s pressure ulcers. Review of Physician order [REDACTED]. Review of the facility's "Pressure Ulcer, Preventions of" procedures, dated 2006, reflected the following: 2. Assess and identify complicating condition that may contribute to pressure ulcer development. 3. Develop care plan to eliminate or minimize risk factors. D. Pressure relief 7. Use appropriate support surface in the resident's bed or chair. 11. Position with appropriate surfaces to protect bony prominences. Under documentation Guidelines: Documentation may include: Date, time, approaches to prevent pressure ulcers development. Condition of the resident's skin. Physician notification when change in skin condition is observed. If a pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. Under Care Plan Documentation Guidelines: Identify and treat the underlying cause of the pressure ulcer. Consider listing complicating conditions, as well as possible risks and complications. A facility generated skin report revealed four residents with pressure ulcers Review of the facility's "Pressure Ulcer, Prevention of" procedures, dated 2006, reflected to notify the physician when change in skin condition is observed. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. A facility generated skin report revealed four residents with pressure ulcers.

Based on observation, interview and record review the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores, received the necessary treatment and services to promote healing and prevent new sores from developing for 1 of 4 sampled residents reviewed for pressure ulcer management. (Resident #2) Resident # 2 developed pressure ulcers on left heel and left great toe and developed pre-ulcerative [MEDICAL CONDITION] (Stage I pressure ulcer) at the middle of the lateral right foot and right posterior lateral heel. The facility failed to notify the doctor, implement care plan interventions, and accurately assess three pressure ulcers. Resident # 2 was affected and three other residents with pressure ulcers could be affected by this deficient practice. Failure to notify the doctor, implement care plan, interventions, and accurately assess three pressure ulcers could result in the development of new pressure ulcers or the deterioration of existing pressure ulcers. Four residents with pressure ulcers could be affected by this deficient practice. Failure to notify the doctor, implement care plan, interventions, and accurately assess three pressure ulcers could result in the development of new pressure ulcers or the deterioration of existing pressure ulcers. Findings Include: Review of Resident #2's face sheet reflected a [AGE] year old woman with [DIAGNOSES REDACTED]. An observation on 11/14/11 at 10:30 AM revealed Resident #2 in bed, on her right side with her heels pulled up towards her torso with a right elevator boot on (Cushioned bootie that elevates foot off bed to relieve pressure). Resident #2 was not wearing a left elevator boot and it was not seen in Resident #2's bedroom. Her left foot was resting on top of her right foot. Licensed Vocational Nurse (LVN) D lifted Resident #2's left foot off the top of her right foot, and revealed a reddened area (approximately 7 x 7 centimeters (cm) where her foot was resting. Resident #2's right foot was soaked and macerated (softening of skin from being exposed to water or urine). Resident #2's left foot was wrapped with a gauze bandage, which was soaked and smelled strongly of urine. Upon removal of Resident #2's left foot dressing, a 6 cm wide by 10 cm long skin flap on her right heel was observed which appeared macerated. Resident #2 did not have any pressure reducing devices for her feet. She also did not have cushions or pads between her knees to reduce pressure. Resident #2's left great toe was swollen and had black tissue visible along the side of the toe. Resident #2's right 5th toe was partially blackened and red. Her 4th toe was red with a scab forming on the inside. A circular reddened area was also observed on Resident #2's right buttock that was approximately 10 x 10 cm. Review of Resident #2's Care Plan dated 10/06/11 reflected; 1. Provide measures to decrease pressure/irritation to skin: fleece pad, egg crate mattress, heel protectors.. 2. Keep skin clean and dry. 3. Apply protective or barrier lotion after incontinence. 4. Avoid hot water and irritating soaps. 5. Keep bed linen clean, dry and wrinkle free. 6. Assist resident to turn and reposition every two hours. 7. Position with pads and cushions to prevent pressure. 8. Use a draw sheet or lifting device to move resident in bed. 9. Increase out of bed activity as tolerated. 10. Maintain adequate nutrition and hydration. 11. Keep nails short. 12. Inspect and chart skin integrity weekly. In an interview on 11/14/11 at 1030 AM, LVN D stated that she thought Resident #2's left heel sore was a skin tear from a transfer. In an interview on 11/14/11 at 1030 AM, MDS Coordinator stated Resident #2's feet looked like they had been wet. Review of Weekly Skin Assessment for Resident #2 reflected "10/31/11 noted bruised heel with apparent closed skin tear with macerated area." Review of undated Weekly Skin Assessment for Resident #2 reflected "MD faxed by wound care nurse regarding an abrasion on right inner ankle " . Review of incident and accident reports reflected no skin tear reports for Resident #2's heel. Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "three blisters intact to left foot back, covered with hydrogel and [MEDICATION NAME], wrap with kerlix continues until healed." Review of Weekly Skin assessment dated [DATE] for Resident #2 reflected "Noted macerated tissue to lateral aspect of both feet. During treatment posterior sheet of tissue to left back foot peeled off." Review of Nurse's Treatment Sheet for Resident #2, dated 10/31/11 reflected "left outer heel bruised with apparent skin tear." Review of Incident and Accident Reports for September through November 2011 reflected no skin tear reports for Resident #2's left heel. Review of Resident #2's Clinical Record reflected there were no Physician notifications or Physician order [REDACTED]. Further review of the Clinical Record reflected there was no Weekly Skin Assessment, Physician notification, or Physician order [REDACTED]. Review of Mobile Podiatric Medicine, PLLC dated 11/14/11, reflected Resident #2, [AGE] year old female, non-communicative. Nursing states there are multiple wounds on both feet and toes present for several weeks apparently due to pressure, secondary to her contracted lower extremities: Objective: Ruptured bullous lesion with underlying superficial ulceration at the left posterior heel approximately 5cm x 5cm x 0.1cm depth with a granular base with surrounding skin slough noted. Left hallux medialungual labia hypertrophied (abnormal growth of tissue on left big toe) with incurvated nail border and surrounding escar (dead tissue that falls off (sheds) from healthy skin) and ecchymosis (bruising). Assessment: Left Heel Boullous Lesion (ruptured). Left Hallux Onychocry[DIAGNOSES REDACTED], (refers to ingrown toenail) (no infection). Multiple Pre-ulcerative [MEDICAL CONDITION] (increased). Onychomycosis, (unchanged) (refers to a fungal infection that affects the toenails) [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Plan: Sharp partial thickness debridement (the process of removing nonliving tissue from pressure ulcers) of surrounding skin slough; Partial nail avulsion at left great toe with debridement of surrounding non-viable tissue. Cleansed both areas and applied antibiotic cream with 4x4 gauze. Continue daily dressing changes until healed. Continue off weighting with heel protectors. In an interview on 11/14/2011 at 1:00 PM the Podiatrist stated the sores on Resident #2's feet are all pressure related. In an interview on 11/15/11 at 1:30 PM with Medical Director (also Resident #2's physician) stated she would expect the nurses to either call or fax her office with any significant changes and a pressure ulcer is a significant change. The Medical Director looked through the chart and stated she could not find any notification for Resident #2's pressure ulcers to left heel, great big toe or right 5th toe. The Medical Director also looked on the computer notification page but could not find notification in reference to Resident #2 ' s pressure ulcers. Review of Physician order [REDACTED]. Review of the facility's "Pressure Ulcer, Preventions of" procedures, dated 2006, reflected the following: 2. Assess and identify complicating condition that may contribute to pressure ulcer development. 3. Develop care plan to eliminate or minimize risk factors. D. Pressure relief 7. Use appropriate support surface in the resident's bed or chair. 11. Position with appropriate surfaces to protect bony prominences. Under documentation Guidelines: Documentation may include: Date, time, approaches to prevent pressure ulcers development. Condition of the resident's skin. Physician notification when change in skin condition is observed. If a pressure ulcer is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. Under Care Plan Documentation Guidelines: Identify and treat the underlying cause of the pressure ulcer. Consider listing complicating conditions, as well as possible risks and complications. A facility generated skin report revealed four residents with pressure ulcers Review of the facility's "Pressure Ulcer, Prevention of" procedures, dated 2006, reflected to notify the physician when change in skin condition is observed. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective. A facility generated skin report revealed four residents with pressure ulcers. During the onsite follow-up conducted on 01/11/2012 the following evidence was identified indicating the deficient practice continued. Based on interview and record review the facility failed to complete the plan of correction by failure to ensure an in-service on wound care and evaluation had been provided by a third party entity. Findings Include: In an interview on 01/10/2012 at 11:00 AM the Director of Nurses (DON) stated there had been no in-services nor evaluations regarding wound care completed by a third party entity. Review of in-service records reflected no third party entity had completed in-services or evaluations regarding wound care. The current Resident census was 59, per the Administrator