Every finding on record at Pleasant Springs Healthcare Center

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient nursing staff on 07/01/2026, 07/02/2026, 07/03/2026, 07/04/2026, 07/05/2026, 07/06/2026, 07/07/2026, 07/08/2026, 07/09/2026, 07/11/2026, 07/12/2026, 07/13/2026, 07/15/2026, 07/18/2026, 07/19/2026, 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/24/2026, 07/25/2026, 07/26/2026, 07/27/2026, 07/28/2026, 07/29/2026, 07/30/2026, 07/31/2026, 08/01/2026, 08/02/2026, 08/03/2026, 08/05/2026, 08/06/2026. This failure places residents at risk of inadequate supervision, an unsafe environment, and not receiving timely care. Findings included: During an interview on 08/06/2026 at 10:34 AM, a resident representative said their family member was having to wait a long time to be assisted to the bathroom due to the facility not having enough staff. During a confidential interview at an undisclosed date and time, Anonymous Staff #1 said the facility had been short staffed for a long time, and the residents had reported to them having to wait too long for care and lack of care due to not having enough staff. Anonymous Staff #1 said they had reported this to management and they told them it was going to get better and they were hiring. Anonymous Staff #1 said not having enough staff resulted in the residents not receiving the care they needed in a timely manner. During a confidential interview at an undisclosed date and time, Anonymous Staff #2 said the facility was frequently short staffed, and there were not enough CNAs to provide the required care to the residents. Anonymous Staff #2 said the 6 AM- 2 PM was the shift with the least CNAs available to work. They said they often noticed the residents who were not able to ask for assistance had not been changed or were not clean. Anonymous Staff #2 said the residents complained to them about having to wait long periods of time to be assisted with their ADLs. Anonymous Staff #2 said they had reported this to the DON and been told they were working on hiring more staff. Anonymous Staff #2 said the lack of staff placed the residents at risk for not receiving the care they needed. During an interview on 08/07/2026 at 9:25 AM, LVN B said she was the treatment nurse for about 4-6 weeks, but she had been working PRN since 08/05/2026. LVN B said she believed wound care treatments were missed due to lack of staffing. LVN B said they did not have enough staff on the 6 AM-2 PM shift. LVN B said the DON, the current Treatment Nurse, and herself had to work as charge nurses and CNAs, and it had been rough. She said it was hard to be the charge nurse and have to complete wound care treatments too. LVN B said not having enough staff could result in the residents not getting the care they needed and it could cause skin breakdown. During an interview on 08/07/2026 at 12:02 PM, the ADON said she was responsible for staffing, and the requirements for the facility included having 2 nurses on day shift and 2 nurses for the night shift (the nurses worked 12 hour shifts), at the least 4-5 CNAs on each shift for 6 AM- 2PM and 2 PM- 10 PM, and 4 CNAs for 10 PM- 6 AM. The ADON said the Treatment Nurse, DON and herself were having to fill in as nurses and CNAs due to the lack of staff available. The ADON said currently they had 2 job openings on the day shift and 1 on the night shift for nurses, and they needed 2-3 CNAs for 6 AM- 2 PM and 1-2 CNAs for 2 PM- 10 PM. The ADON said they posted the jobs on online advertising, and they were also reaching out to people they knew to offer them jobs. The ADON said not having enough staff would result in the residents not receiving the proper care they needed. During an interview on 08/07/2026 at 12:32 PM, the Treatment Nurse said the facility was lacking staff on the 6 AM- 2 PM shift and they had a lot of call ins on the 2 PM- 10 PM shift. He said this resulted in him having to work the floor and not being able to accomplish his tasks as the treatment nurse. He said if he had to work on the floor the charge nurses were responsible for completing the wound care treatments. The Treatment Nurse said not having enough staff could result in lack of care for the residents and the residents would not receive the care they required. During an interview on 08/07/2026 at 1:27 PM, the DON said the nurses worked 12-hour shifts and they had 2 nurses on the day shift and 2 nurses on the night shift. The DON said per shift they should have 5 CNAs on the 6 AM- 2PM and 2 PM- 10 PM shift and 3-4 CNAs for the 10 PM- 6 AM shift, and 1 shower CNA and 1 transport CNA. The DON said they currently had 7 CNA and 1 full time nurse job openings. The DON said they were trying to hire more staff, but it had been challenging because they did not have a human resources coordinator. The DON said they had job postings on websites. The DON said she had asked about using a staffing agency but had been told by the area director of operations that they were not allowed to use a staffing agency. The DON said she received multiple complaints from the residents about the lack of care due to the staffing shortage. The DON said not having enough staff placed the residents at risk for getting bed sores, urinary tract infections, and falls. During an interview on 08/07/2026 at 2:07 PM, the Administrator said she was aware there was a staffing shortage in the facility, and she was working diligently to get it corrected. The Administrator said the facility was staffed based on a PPD and the PPD requirement for nursing staff was 3.0 (PPD a calculation used by the facility to determine the nursing staff hours per day and the calculation for the facility should be equivalent to 3.0). The Administrator said she was not meeting the required PPD for nursing staff. The Administrator said they had job postings and had offered extra shift bonuses and sign on bonuses. The Administrator said she had not asked if they could use a staffing agency because they have had applicants applying for the job openings. The Administrator said not having enough staff affected the residents' health and well-being. During an observation and interview on 08/07/2026 at 4:18 PM, the Administrator said she was unable to print a report to show the daily nursing staff PPD for 07/01/2026 to 8/6/2026. The Administrator pulled up the system the facility used to calculate the daily staffing needs of the facility on her computer and the surveyor was able to see the daily nursing staff PPD for the months of July 2026 and August 2026. The facility's PPD was less than 3.0 on 07/01/2026, 07/02/2026, 07/03/2026, 07/04/2026, 07/05/2026, 07/06/2026, 07/07/2026, 07/08/2026, 07/09/2026, 07/11/2026, 07/12/2026, 07/13/2026, 07/15/2026, 07/18/2026, 07/19/2026, 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/24/2026, 07/25/2026, 07/26/2026, 07/27/2026, 07/28/2026, 07/29/2026, 07/30/2026, 07/31/2026, 08/01/2026, 08/02/2026, 08/03/2026, 08/05/2026, 08/06/2026. The policy for staffing was requested and not received upon exit of the facility.

Based on interview and record review, the facility failed to refrain from utilizing the DON as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents for 1 of 1 facility reviewed for nursing services. The facility failed to ensure the DON did not work as a charge nurse or CNA when the census was more than 60 for the months of July 2026 and August 2026. This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone. Findings included: During an interview on 08/07/2026 at 9:25 AM, LVN B said the DON had to work as a charge nurse or CNA when they did not have enough nursing staff to cover all the shifts. During an interview on 08/07/2026 at 12:02 PM, the ADON said due to the lack of nursing staff the DON was having to fill in as a charge nurse or CNA. During an interview on 08/07/2026 at 12:32 PM, the Treatment Nurse said the facility was having an issue with staffing. He said they were short staffed the DON was also having to work as a charge nurse or CNA when they did not have enough coverage. During an interview on 08/07/2026 at 1:27 PM, the DON said she was allowed to work on the floor as long as the facility's census was under 70. The DON said she had to work as a CNA and charge nurse due to not having enough staff to cover all shifts. The DON was unable to provide exact dates for when she had been working on the floor. The DON said her working as a CNA and charge nurse resulted in her not being able to do her monitoring and fulfill her job duties as the DON. During an interview on 08/07/2026 at 2:07 PM, the Administrator said she was aware the facility had a staffing issue. The Administrator said the DON should not be working as a charge nurse or CNA if the census was above 60. The Administrator said she was aware the DON had been working as a CNA and charge nurse due to the facility's staffing issues. The Administrator said just this past weekend the DON had to work as a charge nurse. The Administrator said the DON working the floor affected the residents' overall well-being. The policy for the DON working the floor was requested and not received upon exit of the facility. Record review of the Daily Census Summary for the Months of July 2026 and August 2026 indicated the facility's census was between 66-75.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA E, the Treatment Nurse, and the DON followed enhanced barrier precautions when providing care to Resident #1 on 08/06/2026. This failure could place residents at risk for cross contamination and the spread of infection.Findings included: Record review of Resident #1's face sheet dated 08/07/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included mild dementia with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with agitation), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and recurrent depressive disorders ( recurrent mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was usually understood and usually understood others. Resident #1's BIMS score was a 6, which indicated her cognition was severely impaired. Resident #1 was dependent on staff for toileting and required supervision or touching assistance with eating. The MDS assessment indicated Resident #1 had a stage 2 pressure ulcer (shallow open wound that may also present as an intact or open/ruptured blister). Record review of Resident #1's Order Summary Report dated 07/01/2026-08/31/2026 did not indicate she required enhanced barrier precautions. Record review of Resident #1's care plan with a date initiated of 08/06/2026 indicated she required enhanced barrier precautions and gloves and a gown should be put on if any of the following activities were to occur linen change, resident hygiene, transfer, dressing, and wound care. During an observation on 08/06/2026 starting at 9:15 AM, CNA E assisted Resident #1 from her wheelchair to the bed. CNA E did not put on gloves or a gown. During an observation on 08/06/2026 at 5:04 PM, the DON and the Treatment Nurse assisted Resident #1 with dressing herself. The DON and the Treatment Nurse put on gloves but did not put on a gown. During an interview on 08/07/2026 at 11:53 AM, CNA E said residents with a wound required enhanced barrier precautions. CNA E said she did not wear a gown or gloves when transferring Resident #1 because she did not know Resident #1 required enhanced barrier precautions. CNA E said when a resident required enhanced barrier precautions, they had a sign on their door and the PPE was hung on the resident's door, and since Resident #1 did not have these, she did not know Resident #1 required enhanced barrier precautions. CNA E said not following enhanced barrier precautions could result in carrying bacteria to someone else's room. During an interview on 08/07/2026 at 12:32 PM, the Treatment Nurse said enhanced barrier precautions were required when a resident had a wound and gloves, and a gown should be worn when providing direct care. The Treatment Nurse said he should have worn a gown when assisting Resident #1 with changing her shirt, but he forgot. The Treatment Nurse said not following enhanced barrier precautions could result in cross contamination. During an interview on 08/07/2026 at 1:36 PM, the DON said enhanced barrier precautions should be followed when providing wound care and any type of personal hygiene including transferring and dressing. The DON said they did not place signs on the outside door anymore. The DON said she monitored the staff by conducting random checks when she walked the hall, and she also conducted in-services with the staff. The DON said when she assisted Resident #1 with changing her shirt she should have worn a gown. She said she did not realize she did not have one on. The DON said it was important to follow enhanced barrier precautions to prevent the spread of infection. During an interview on 08/07/2026 at 2:02 PM, the Administrator said she expected the staff to follow enhanced barrier precautions and put on a gown and gloves when providing care to the residents. The Administrator said the nursing staff was responsible for ensuring enhanced barrier precautions were followed. The Administrator said not following enhanced barrier precautions could result in carrying infection to someone else. Record review of the facility's undated policy Enhanced Barrier Precautions, indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following.Examples of chronic wounds include, but are not limited to, pressure ulcers. Donning PPE for Residents on EBP Based on Activity Provided/Assistance while in Resident Room [NAME] Gloves and Gown Transfer a Resident Yes, Dressing a resident Yes.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 residents (Resident #1) and 1 of 2 medication carts (A/B Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure Resident #1's medication label for duloxetine (medication used to treat anxiety and depression) matched the physician order. The facility failed to ensure LVN C secured the A/B Nurse Medication Cart, when it was not in use on 08/06/2026. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #1's face sheet dated 08/07/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included mild dementia with agitation, anxiety disorder, and recurrent depressive disorders. Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was usually understood and usually understood others. Resident #1's BIMS score was a 6, which indicated her cognition was severely impaired. Resident #1 was dependent on staff for toileting and required supervision or touching assistance with eating. The MDS assessment indicated Resident #1 received an antidepressant. Record review of Resident #1's Order Summary Report dated 08/06/2026 indicated:Duloxetine hydrochloride 30 mg delayed release capsules give 2 capsules by mouth one time a day with an order date of 07/30/2026. Record review of Resident #1's care plan reviewed 07/14/2026 indicated she required antidepressant medication to administer it as ordered by the physician. During an observation and interview on 08/06/2026 at 4:37 PM with MA F, Resident #1's duloxetine medication label instructed duloxetine 30 mg DR give 1 capsule by mouth two times a day. MA F said he only worked PRN, so he was not aware there had been a change in Resident #1's medication. MA F said he was not aware of what the process would be if there was a change in directions on a resident's medication. MA F said the medication label not matching the physician order could result in a medication error. During an interview on 08/07/2026 at 8:58 AM, RN A said she received the order to change Resident #1's duloxetine 30 mg to 2 capsules by mouth one time a day. RN A said she did not know what the proper process was as far as labeling medications when there was a medication order change. RN A said Resident #1's duloxetine medication label not having the current doctor's order on it could result in a medication error. 2. During an observation and interview on 08/06/2026 starting at 3:44 PM, there was an unlocked and unattended medication cart on the A Hall staff, and a resident passed by the unlocked medication cart. At 3:56 PM, LVN C came down the hall and said it was the A/B Nurse Medication cart, and she was responsible for it. LVN C said she was called away from the medication cart, and she had not noticed she walked away from the medication cart without locking it. She said medication carts should be locked at all times when not standing in front of them. LVN C said if the medication cart was unlocked anybody could get into it and get medications that were not theirs. During an interview on 08/07/2026 at 12:02 PM, the ADON said when there was a change in a medication order the nurse who received the medication order should notify the medication aide and the medication aide should place a change in direction label on the medication card to alert staff the medication order had been changed. The ADON said she monitored the medication orders for changes, and in her absence the DON was responsible for monitoring. The ADON said she was not sure what happened with Resident #1's duloxetine. The ADON said it was important for the medication labels to match the physician's order to prevent medication errors. The ADON said medication carts should be locked when they walked away from them, when their backs were turned to them, or when not physically in front of the medication cart. The ADON said she monitored to ensure the medication carts were locked when she was walking around the facility, and if she noticed there was a medication cart unlocked, she locked it. The ADON said unlocked, unattended medication carts did not happen often. The ADON said it was important for unattended medication carts to be locked to ensure the residents, family members, or anybody not trained for the medication to not get into the medication carts and take the medications. During an interview on 08/07/2026 at 1:21 PM, the DON said medication carts should always be locked unless you were in front of them. The DON said when she walked around the facility, she checked the medication carts to ensure they were locked, and if she saw an unlocked medication cart she locked it. The DON said an unlocked medication cart could result in the residents getting into the medications and the medications could be stolen. The DON said when a new order was received for a medication the charge nurse who received the order was responsible for letting the medication aide know and placing a change of order sticker on the medication card. The DON said the medication label should match the physician's order. The DON said the charge nurses were responsible for ensuring this process was followed. The DON said the medication label not matching the order could result in a medication error. During an interview on 08/07/2026 at 1:55 PM, the Administrator said when there was a change in the order for a medication, she expected the nurses to place a sticker on the medication label to indicate there was a change and for them to contact the pharmacy for a new label. The Administrator said she did not know how it could affect the resident if this was not done. The Administrator said medication carts should be locked anytime the staff was not at the medication cart. The Administrator said the nurse responsible for the medication cart should ensure this was done. The Administrator said if a medication cart was unlocked and unattended anybody could get inside and get anything that was in it. Record review of the facility's undated Medication Storage in the Facility, indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure residents were free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents' medical symptoms for 1 of 3 residents (Resident #1) reviewed for unnecessary medications administered at a higher dosage than prescribed. The facility failed to ensure Resident #1 did not receive quetiapine fumarate 50 mg (an antipsychotic medication used to treat mental disorders) in the morning from 07/31/2026-08/06/2026 (7 days), when the physician's order was for quetiapine fumarate 25 mg every morning. This failure could place residents at risk of receiving unnecessary psychotropic medications, oversedation, adverse consequences, and a decreased quality of life.Findings included: Record review of Resident #1's face sheet dated 08/07/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included mild dementia with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with agitation), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and recurrent depressive disorders ( recurrent mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was usually understood and usually understood others. Resident #1's BIMS score was a 6, which indicated her cognition was severely impaired. Resident #1 was dependent on staff for toileting and required supervision or touching assistance with eating. The MDS assessment indicated Resident #1 received hospice care and received an antipsychotic medication. Record review of a hospice Physician's Telephone/Verbal Order signed by Resident #1's Hospice RN dated 07/29/2026 indicated start quetiapine 25 mg by mouth every morning. Record review of Resident #1's Order Summary Report dated 08/06/2026 indicated:Quetiapine fumarate 50 mg give 1 tablet by mouth one time a day with an order date of 07/30/2026 and a start date of 07/31/2026. Record review of Resident #1's care plan reviewed 07/14/2025 indicated she required the use of anti-psychotic medications related to behavior management to administer medications as ordered. Record review of Resident #1's Progress Note dated 07/30/2026 at 7:26 PM indicated new order from hospice to start quetiapine 25 mg by mouth every morning signed by RN A. Record review of Resident #1's July 2026 MAR indicated:Quetiapine fumarate 50 mg give 1 tablet by mouth one time a day for depression was administered for the morning shift on 07/31/2026. Record review of Resident #1's August 2026 MAR indicated:Quetiapine fumarate 50 mg give 1 tablet by mouth one time a day for depression discontinued 08/06/2026 (after surveyor intervention) was administered for the morning shift from 08/01/2026-08/06/2026. During an observation and interview on 08/06/2026 at 9:15 AM, Resident #1 was in her wheelchair falling asleep. She said she was sleepy and felt like she had been sleeping more. Resident #1 did not know what medications she took. During an observation on 08/06/2026 at 12:09 PM, Resident #1 was in her wheelchair in the dining room. She appeared awake and alert and was talking with a visitor. During an interview on 08/06/2026 at 3:38 PM, the Hospice RN said Resident #1 had been having increased hallucinations and agitation, and she had notified the hospice doctor and received an order to begin quetiapine 25 mg one time a day in the morning. The Hospice RN said that day one of Resident #1's family members was in the room, and the new order was reported to them. The Hospice RN said she discussed the new order with RN A and provided a written order. The Hospice RN said she was unable to provide specific dates because she did not have access to Resident #1's records at the time. During an interview on 08/07/2026 at 8:42 AM, RN A said the Hospice RN had given her the order for Resident #1 to begin quetiapine 25 mg in the morning. RN A said she did not remember when the order was given, and she did not know how she entered the order into Resident #1's electronic medical record incorrectly. RN A said there was a possibility she did not enter the order for the quetiapine until the following day after she received it because her days ran late, and sometimes she did not have enough time to accomplish all of her tasks within her shift. RN A said Resident #1 receiving the wrong dose of quetiapine could result in her being overdosed. RN A said she had not noticed Resident #1 had any increased drowsiness or oversedation. During an interview on 08/07/2026 at 12:02 PM, the ADON said she was responsible for reviewing new orders. She said she printed off the 24-hour summary and reviewed it for any new orders and verified they were completed. The ADON said for the written hospice orders the nurse put the order in the electronic medical record, and the paper copy was placed in the medical records box for it to be uploaded into the medical records. The ADON said she did not remember if she verified the order for Resident #1's quetiapine 25 mg one time a day. She said she could have missed it. The ADON said if Resident #1 did not receive the correct dose it would be considered a medication error. The ADON said she did not know how receiving more quetiapine than what was ordered could affect Resident #1. During an interview on 08/07/2026 at 1:14 PM, the DON said there had been a medication error with Resident #1's quetiapine, and she did not know how verifying the order was missed. The DON said the ADON followed up with new orders to verify they were completed correctly. The DON said the ADON checked new orders daily, and the written order should not be taken directly to medical records. The DON said written orders should be placed in a folder for nurse management to review, and she did not know why this was not done. The DON said Resident #1 had not suffered any adverse effects from receiving the incorrect dose of quetiapine. The DON said administering the wrong dose of quetiapine could result in the resident being overmedicated and lethargic. During an interview on 08/07/2026 at 1:53 AM, the Administrator said she expected the nurses to input orders into the resident's electronic medical record as they were given to them. The Administrator said nurse administration was responsible for ensuring physician's orders were entered correctly into the resident's electronic medical record. The Administrator said Resident #1's quetiapine being placed in the medical record as 50 mg instead of 25 mg could cause her to be drowsy. Record review of the facility's policy Psychotropic Drugs, revised 10/15/2017, indicated, The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing.Any prescribed antipsychotic medication must be administered at the lowest possible dosage for the shortest period of time.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure Resident #1 received wound care as ordered to her right heel on 07/17/2026, 07/18/2026, and 07/19/2026. The facility failed to ensure Resident #1's wound care order for her right heel was changed to betadine and a gauze island dressing three times a week and as needed after the order was changed by the wound care provider on 08/04/2026. These failures could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of Resident #1's face sheet dated 08/07/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included mild dementia with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with agitation), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and recurrent depressive disorders ( recurrent mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was usually understood and usually understood others. Resident #1's BIMS score was a 6, which indicated her cognition was severely impaired. Resident #1 was dependent on staff for toileting and required supervision or touching assistance with eating. The MDS assessment indicated Resident #1 had a stage 2 pressure ulcer (shallow open wound that may also present as an intact or open/ruptured blister). Record review of Resident #1's Order Summary Report dated 07/01/2026-08/31/2026 indicated:Cleanse wound with wound cleaner, apply betadine and allow to dry, place foam and wrap with gauze one time a day with an order date of 07/16/2026.Cleanse stage 2 pressure ulcer on right heel with wound cleanser, pat dry with gauze, apply alginate calcium and cover with foam silicone bordered gauze three times a week with a start date of 07/31/2026. Cleanse stage 2 pressure ulcer on right heel with wound cleanser, pat dry with gauze, paint with betadine and apply gauze island three times a week every day shift on Monday, Wednesday, and Friday for wound care with a start date of 08/06/2026. Record review of Resident #1's care plan reviewed 07/14/2025 did not address her stage 2 pressure ulcer. Record review of Resident #1's July 2026 WAR indicated:cleanse wound with wound cleaner, apply betadine and allow to dry, place foam and wrap with gauze one time a day for wound care there were no initials to indicate the wound care was completed on 07/17/2026, 07/18/2026, and 07/19/2026. Record review of Resident #1's Wound Evaluation and Management Summary dated 07/30/2026 indicated for her Stage 2 pressure wound of the right heel to continue with alginate calcium and foam silicone border three times a week and as needed. Record review of Resident #1's Wound Evaluation and Management Summary dated 08/04/2026 indicated for her Stage 2 pressure wound of the right heel to discontinue alginate calcium and foam silicone border and start betadine and a gauze island dressing three times a week and as needed. During an interview on 08/06/2026 at 9:15 AM, Resident #1 said she did not know if she had any wounds. During an interview on 08/06/2026 at 10:34 AM, Resident #1's representative said Resident #1 had a blister to her right heel, and the facility was not providing the wound care every day. They said one day when they visited, they noticed the bandage on her heel had a date that was 2-3 days prior to the date of their visit. Resident #1's representative was unable to provide the specific dates. They said they notified RN A who called LVN B and the wound care was completed. During an observation of wound care with the DON and the Treatment Nurse on 08/06/2026 at 5:04 PM, Resident #1's wound to her heel appeared to be healing. During an interview on 08/07/2026 at 8:51 AM, RN A said Resident #1's family reported to her that Resident #1's dressing had not been changed, and she reported it to the DON. RN A said she had also noticed the dates not matching, and she would complete the wound care treatment. RN A said she did not remember the dates. RN A said she believed some of the treatments could have been missed because there was lack of communication when the nurses were supposed to complete the wound care treatments as opposed to when the treatment nurse was completing wound care treatments. She said many times the treatment nurse had to work the floor, and the nurses were notified late in the shift they needed to do the wound care treatments. RN A said sometimes on the weekend they had a nurse come in to do all the wound care treatments, and sometimes they did not. RN A said Resident #1's wound had not worsened and was not infected. During an interview on 08/07/2026 at 9:25 AM, LVN B said she was the treatment nurse for about 4-6 weeks, but she had been working PRN since 08/05/2026. LVN B said when she worked as the treatment nurse, she noticed the dates being a few days old or that treatments were not checked off on the WAR. LVN B said she notified the DON, and the DON said she would handle it, but she did not know what the DON did. LVN B said the DON was trying to get a nurse to complete the wound care treatments on the weekends, but she was not always able to. LVN B said she believed the treatments were missed due to lack of staffing. LVN B said if she did not have time to complete a wound care treatment she would let the charge nurses on the following shift they were responsible for completing the wound care treatments. LVN B said on Resident #1 she had noticed one day, on a Monday (did not remember the specific date) that the wound care treatments were not completed over the weekend. She said she completed the wound care treatment and notified the DON. LVN B said not completing wound care treatments as ordered could cause an infection and the wound to worsen. LVN B said not having enough staff could result in the residents not getting the care they needed and it could cause skin breakdown. During an attempted phone interview on 08/07/2026 at 11:15 AM, LVN D did not answer the phone. During an interview on 08/07/2026 at 12:32 PM, the Treatment Nurse said he had been the treatment nurse at the facility for about a week. The Treatment Nurse said when providing wound care, he noticed the treatments were not done as ordered, but he did not remember the specifics of who the residents were or the dates. He said he addressed the issue verbally with the nurse who was supposed to complete the treatment. The Treatment Nurse said prior to being the treatment nurse he was a charge nurse and he had not noticed any worsening of wounds or wound infections. The Treatment Nurse said there was a delay in putting in Resident #1's order after her wound care visit on 08/04/2026 because he had to work on the floor as a CNA. The Treatment Nurse said it was difficult to complete his tasks when he was having to work the floor due to lack of staff. The Treatment Nurse said not providing wound care as ordered and not entering wound care orders promptly could result in a wound infection or worsening of the wound. During an interview on 08/07/2026 at 1:24 PM, the DON said if the Treatment Nurse had to work the floor she completed the wound care treatments or she delegated it to another nurse. The DON said she was aware the nurses were not completing wound care treatments whenever the Treatment Nurse had to work the floor as a CNA or charge nurse. She said there could have been a time when wound care treatments were missed, but she was not aware of Resident #1's wound care treatments being missed. The DON said she was not aware Resident #1's wound care treatment was not implemented after her wound care visit on 08/04/2026. She said the wound care orders should be updated as soon as the new order was received. The DON said there had been a change in treatment nurses and she believed this could have caused things to not be put in place promptly. The DON said none of the wounds had worsened and there had been no wound infections. The DON said not providing wound care treatments as ordered and not implementing new wound care orders when they were given could result in worsening of the wounds and wound infections. The DON said the MDS Coordinator was responsible for putting the residents wounds in the care plan, and she did not know why Resident #1's pressure ulcer to her heel was not in her care plan. During an interview on 08/07/2026 at 1:58 PM, the Administrator said she expected the nurses to provide wound care as ordered. The Administrator said she expected new wound care orders to be implemented when the order was received. The Administrator said nursing administration was responsible for ensuring wound care was provided as ordered and wound care orders were implemented. The Administrator said not providing wound care as ordered and not implementing orders when given could result in the wounds worsening. The Administrator said she expected for the residents' pressure ulcers to be included in their care plans. She said nurse management was responsible for ensuring it was included in the care plans. The Administrator said it was important for pressure ulcers to be included in the residents' care plans to ensure everyone knew how to take care of the resident. During an interview on 08/07/2026 at 2:24 PM, the MDS Coordinator said putting the pressure ulcers in the residents' care plans could be a team effort. She said she did not know why Resident #1 did not have a care plan for the pressure ulcer to her heel. The MDS Coordinator said it was important for pressure ulcers to be included in the care plan to ensure the correct plan of care was followed for the resident. Record review of the facility's undated policy Wound Treatment Management, indicated, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the Treatment Administration Record.

Based on observation, interviews, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 2 of 3 (Residents #13 and #19) reviewed for physical abuse. 1. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator when the ADON and RN A reported to her on 5/26/2026 that Resident #13 stated CNA B pinched her and was rough with her. 2. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator during the week of 5/25/2026- 5/28/2026 when Resident #19 told RN A and LVN C that CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else. 3. RN A identified a bruise on Resident 13's right forearm and failed to report it to the Administrator. 4. The Administrator failed to investigate allegations of abuse made by Resident #13 and Resident #19, and report allegations of abuse to HHSC during the week of 5/25/2026- 5/28/2026. 5. The facility to follow their abuse policy when they continued to allow CNA B to work with assigned residents including Resident #13 and Resident #19 until the surveyor's intervention on 5/31/2026. An IJ was identified on 06/01/26. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 06/02/26, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of unreported and continued abuse and neglect, fear, harm, and a decreased quality of life. Findings included: Record review of the facility's policy, Abuse and Neglect, from the Nursing Policy and Procedure Manual revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Abuse is 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 psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of 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.Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident.Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. 6. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Mistreatment: means inappropriate treatment or exploitation of a resident.The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. 1. Record review of Resident #13's face sheet, dated 06/04/26, reflected Resident #13 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in mental abilities due to physical brain deterioration in older age). Record review of Resident #13's quarterly MDS assessment, dated 03/12/26, reflected Resident #13 made herself understood and understood others. Resident #13's BIMS score was a 7, which reflected her cognition was severely impaired. Resident #13 required partial/moderate assistance with sit to stand and bed to chair transfer mobility. Record review of Resident #13's undated comprehensive care plan, reflected Resident #13 had an ADL self-care performance deficit related to activity tolerance, fatigue (tiredness), limited mobility and low back pain. The care plan interventions included: independent with bed mobility. Record review of Resident #13's electronic medical records did not reflect a skin assessment completed on 05/26/26 until state surveyor intervention on 05/31/26. During an observation and interview on 05/31/26 at 1:28 p.m., with Resident #13 a bruise was observed on Resident #13's right forearm. When Resident #13 was asked about the bruise, she stated the CNA caused it when she made her go to bed. Resident #13 stated the CNA grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. Resident #13 stated she tried to pull away when the CNA pushed her down and the CNA stated to her don't fight. Resident #13 stated the CNA had long fingernails and when she grabbed her, the mark came up. Resident #13 described the CNA as a black lady, heavy set, and her hair was curled to the side, but was unable to state a name. Resident #13 stated she could not remember the date this incident happened or who she reported it to, but she did report it. Resident #13 stated, this is not the first time this has happened, ever since she has been here, she reaches out and grabs me. Resident #13 stated when she reported this, before, she was told the CNA was just that way. Resident #13 stated, I was really scared. During an interview on 05/31/2026 at 1:05 PM, RN A stated when she was assessing Resident #13 for shingles (a viral infection that caused a painful rash), Resident #13 stated to her I must tell you something that needs to stay between me and you. RN A stated Resident #13 reported to her that the CNA who put her to bed the night before was ruff and pinched her. RN A stated Resident #13 told her she was being forced to go to bed and she was not ready, the CNA insisted it was her bedtime and she put her to bed. RN A stated Resident #13 stated the CNA told her it was her fault because she was fighting her about going to bed. RN A stated Resident #13 did not provide her any names, but said it was a black woman. RN A stated she reported it immediately to the ADON and Administrator the day Resident #13 reported it to her, and the Administrator told her it would be a self-report to state, and she would talk to Resident #13. RN A stated she did not mention the bruise to anyone, but she did not notice the bruise when Resident #13 reported the incident, but she was focused on the shingles. During an interview on 06/01/26 at 9:50 a.m., the ADON stated, on 05/25/26 as she was making rounds prior to supper, she noticed Resident #13 lying in bed. The ADON stated she asked her why she was in bed so early and Resident #13 stated she told me I had to go to bed because everyone else was in bed. The ADON stated she told her she did not have to go to bed early if she did not want to. The ADON stated she offered to get her back up. The ADON stated she did not report the incident to anyone because she did not feel like it was abuse or neglect. The ADON stated the next day (26th) RN A came to her and reported Resident #13 told her a CNA was ruff and pinched her. The ADON stated her and RN A immediately went to the Abuse Coordinator which was the Administrator, and RN A told her what Resident #13 reported, which was the CNA was ruff and pinched her. The ADON stated the Administrator stated, Ok, I will investigate. During an interview on 06/01/26 at 10:22 a.m., the Administrator stated around 5/18/26 forward, the ADON notified her about a complaint that Resident #13 stated she was made to go to bed. The Administrator stated her and the ADON went down to Resident #13 room and informed her it was her right when she wanted to go to bed. The Administrator stated as Resident #13 was mentioning about the CNA making her go to bed, Resident #13 showed her the rash that was identified as shingles (a viral infection that caused a painful rash) under her right side. The Administrator stated she asked Resident #13 if she could identify the CNA and she stated a regular-sized black lady that normally worked that hall. The Administrator stated she looked at the ADON and asked her who the CNA was that worked yesterday, and the ADON stated she would look at the schedule. The Administrator stated after she left Resident #13's room, her and the ADON went to look at the schedule and saw CNA B worked the hall that night before. The Administrator stated she thought she had conducted an in-service on resident rights but could not find the documentation. The Administrator stated CNA B never was suspended or spoken to about the incident and was able to continue to work with Resident #13. The Administrator stated she was not aware of the second incident that involved the CNA been ruff or pinching Resident #13. The Administrator stated the ADON nor RN A reported to her about Resident #13 being pinched or ruff during transfer on 05/25/26. The Administrator stated she was not aware of the bruise to Resident #13's right forearm until after the state surveyor's intervention. The Administrator stated she went down to Resident #13's room on 05/31/26 to start an investigation and when she spoke to Resident #13 about the bruise, Resident #13 stated it happened, when she put me to bed. During an interview on 06/01/26 at 10:46 a.m., the ADON stated she did not notify the Administrator about a complaint herself. The ADON stated when RN A reported Resident #13's allegation to her, they both went to the Administrator's office, and RN A reported the allegation to the Administrator. The ADON stated she did not recall speaking with Resident #13 with the Administrator. 2. Record review of Resident #19's face sheet dated 06/01/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (deterioration of the brain which leads to cognitive decline, memory impairment, and changes in behavior and personality), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and essential primary hypertension (high blood pressure). Record review of Resident #19's MDS assessment dated [DATE] indicated she was understood by others and understood others. Resident #19 had a BIMS score of 15, which indicated her cognition was intact. Resident #19 was dependent on staff for toileting hygiene. Resident #19 was frequently incontinent of urine and bowel. Record review of Resident #19's care plan reviewed 04/21/2026 indicated she had impaired though processes to engage in simple, structured activities that avoided overly demanding tasks and to provide her with a homelike environment. Resident #19's care plan indicated she had bowl and bladder incontinence to provide perineal care after each incontinent episode. Resident #19 had an ADL self-care performance deficit related to fatigue and limited mobility and required assistance of one staff member for toilet use, bathing, bed mobility, and dressing. During an interview on 05/31/2026 at 10:02 AM, Resident #19 said there was an African American CNA who wore brown glasses and worked the 2 PM- 10 PM shift that was rough when she provided care to her. Resident #19 said the CNA did not identify herself and did not wear a name badge, so she did not know her name. Resident #19 said the CNA grabbed her arm roughly and was rough when turning her to provide care. Resident #19 said she told the CNA she needed to stop grabbing her arm so roughly and the CNA told her that's the way she was. Resident #19 said she was scared of the CNA and had reported her to everybody. Resident #19 said the CNA did not work this past weekend, but she provided care to her every day. Resident #19 said one of the girls upfront told her they were trying to figure out who it was, but she was unable to provide a name. Resident #19 said one day last week me and her had it out. Resident #19 said she told the CNA to stop treating her roughly and the CNA told her she did not care if they fired her, she could always work elsewhere. One of the nurses she reported it to was LVN C. During an interview on 05/31/2026 at 1:05 PM, RN A said Resident #19 reported to her yesterday (05/30/2026) morning that an African American woman who wore glasses on the 2 PM-10 PM shift was really rough with her, and she never wanted her to be her CNA again. RN A said she notified the Administrator immediately via text message and she said it would be a self-report to state and to send the DON a text message. RN A said the way Resident #19 was treated was abuse and abuse should be reported to the Administrator immediately to protect the residents from further abuse. During an interview on 05/31/2026 at 1:47 PM, the ADON said CNA B was the CNA that usually provided care to Resident #19 on the 2 PM-10 PM shift and she matched the description provided by Resident #19. The ADON said she did not think CNA B was mean, but she was very demanding and wanted things done her way. The ADON said the Administrator called her yesterday, 05/30/2026, and told her she was filing a grievance because Resident #19 felt her ADLs were rushed by CNA B, but she was not involved in any of the process. The ADON said if a resident reported a CNA was rough it should be reported to the Abuse Coordinator, the Administrator, immediately because it could be considered abuse, and then the CNA should be removed and spoken with. The ADON said it was important for abuse to be reported and investigated because the residents needed to be safe, and if they did not feel safe with a CNA the CNA did not need to be providing their care. The ADON said none of the CNAs were suspended and this places the residents at risk for further abuse. During an interview on 05/31/2026 at 2:06 PM, the DON said she had not received any reports from the residents or staff about any staff being rough with the residents or mistreating them. The DON said yesterday evening, 05/30/2026, she was notified by the Administrator that Resident #19 had reported a CNA was rough with her, but she did not talk to Resident #19. The DON said if a resident reported a staff member was rough with them it should be reported to the Abuse Coordinator, the Administrator, immediately. The DON said the Administrator would then see what the resident was saying and get a statement from the staff member involved, and if deemed reportable follow the abuse policy process. The DON said the staff member would be suspended to protect the residents from further abuse. The DON said an allegation of staff being rough could be considered abuse. The DON said she was not aware of Resident #13 having a bruise or being mistreated. The DON said nothing regarding Resident #13 had been reported to her. The DON said if the staff noticed a new bruise, they should complete a skin assessment, open an incident, monitor the bruise, notify the family and the doctor, and the Administrator usually was notified during the daily clinical morning meetings. The DON said she reviewed the staffing schedule and identified the CNA involved in Resident #19 and Resident #13's incidents as CNA B. The DON said the CNA was working today, 05/31/2026, for her 2 PM-10 PM shift, but would be moved to a different hall. The DON said it was important for abuse to be reported per the facility's abuse policy and for the proper measures to be taken to not place other residents at risk for abuse. During an interview on 05/31/2026 at 2:19 PM, the Administrator said last night (05/30/2026) at 7 PM, LVN C called her and reported to her that Resident #19 reported to her that the CNA from Thursday, 05/28/2026, was rough with her and rushed her when she provided care. The Administrator said she went to the facility approximately 15-20 minutes after she was notified by LVN C to talk to Resident #19. The Administrator said when she spoke to Resident #19, she felt like it was more that CNA B had rushed her. She said Resident #19 told her CNA B rushed her and pushed her over when she was turning her on her side. The Administrator said Resident #19 told her she did not want CNA B back in her room. The Administrator said she filed a grievance and moved CNA B to a different hall. She said CNA B would start her shift today, 05/31/2026, at 2 PM, but would be on a different hall. The Administrator said Resident #19 had no injuries from CNA B being rough with her. The Administrator said RN A reported to her yesterday (05/30/2026) that Resident #19 told her CNA B had been rough with her. The Administrator said she told RN A to report it to the DON. The Administrator said she was not sure if Resident #19 told her CNA B was rough or rushed her. The Administrator said the allegation Resident #19 made should have been reported for abuse and neglect within 2 hours. The Administrator said not reporting allegations of abuse placed the residents at risk for continued abuse. The Administrator said it had not been reported to her that CNA B pinched Resident #13 or any allegations made by Resident #13. The Administrator said if Resident #13 alleged she had been pinched by the CNA it should have been reported to her and she would have reported it to HHSC within 2 hours. The Administrator said if there was an unidentified bruise it should be reported to her and she would report to HHSC within the required timeframe of 2 hours. The Administrator said it was not reported to her that Resident #13 had a bruise on her arm. The Administrator said the staff should not force the residents to go to bed early because it went against resident rights. The Administrator said not reporting allegations of abuse and neglect, unidentified bruises, and not following their abuse policy placed the residents at risk for continued abuse. During an interview on 05/31/2026 at 2:49 PM, CNA B said she had been working at the facility for close to a month. CNA B said if a resident was not ready to go to bed, she would notify the nurse and let the nurse handle it because it was the residents right not to go to bed. CNA B said she had not forced any residents to go to bed. CNA B said she did not rush the residents when she provided care, and she had not received any complaints that she was rough. CNA B said there were no residents' rooms she was not allowed to go in. CNA B said she usually worked on the hall where Resident #13 and Resident #19 resided. CNA B said Resident #19 did not require a lot of assistance with her care that she allowed her to roll herself just gave her a little boost. CNA B said Resident #13 required assistance from one person for rolling and for standing up. She said usually she held her when she was getting up from under her arms to help her push up on her walker to get her to stand up. CNA B said she had never told any residents if she got fired, she could go work somewhere else. She said she was not aware of Resident #13 having any bruises. During an observation and interview on 05/31/2026 at 3:11 PM, RN A showed the surveyor the text message she sent to the Administrator and DON. The message to the Administrator dated 05/30/2026 at 10:08 AM indicated Resident #19 says she never wants the 2-10 aide back in her room, because her aide is being too rough with her. It happens every time she's been on the hall. The Administrator responded, send to DON and let her know. RN A said she took a screenshot of what she sent to the Administrator and the response and sent it to the DON. RN A showed the surveyor the message sent to the DON on 05/20/2026 at 11:02 AM, and it was the screenshot of what she sent the Administrator. RN A said she did not hear from the DON or the Administrator after this. During an interview on 06/01/2026 at 9:58 AM, LVN C said Resident #19 complained to her about one of the CNA's Thursday, 05/28/2026, being rough with her. She said Resident #19 did not report it to her until Saturday, 05/30/2026, at 7:00 PM. She said Resident #19 reported to her the CNA had been rough with her, rolled her over so hard, she hit her head against the bed rail. LVN C said Resident #19 told her it was a CNA with glasses that worked the 2 PM-10 PM shift, and the description fit CNA B. LVN C said she immediately reported what Resident #19 told her to the Administrator, and the Administrator went to the facility. LVN C said she conducted a skin assessment on Resident #19, and she had no injuries. LVN C said she had not received any complaints from the residents or staff about CNA B or any other staff mistreating the residents. LVN C said allegations of abuse should be reported to the Administrator immediately to protect the residents from further abuse. During an interview on 06/01/2026 at 10:40 AM, the Administrator said she was notified by RN A the morning of 05/30/2026 that Resident #19 alleged CNA B was rough with her. The Administrator said she identified it as abuse and told RN A to notify the DON because she was in an area where she did not have good signal and was not receiving messages and calls in a timely manner. The Administrator said she expected the DON to follow up, but the DON said RN A had not notified her of the allegation Resident #19 made. The Administrator said when LVN C reported the allegation Resident #19 made to her the evening of 05/30/2026, she was back in town and decided to go to the facility to speak with Resident #19. The Administrator said since she told RN A to report it to the DON, she assumed the DON had taken care of the situation. She said as the Abuse Coordinator she should have called the DON to follow up and ensure she had taken care of the situation. The Administrator said Resident #19 made an allegation of abuse, and it should have been reported within two hours to HHSC. During an interview on 06/04/2026 at 6:08 PM, the DON said when the Administrator called her the evening of 05/30/2026, she went back to review her messages and realized RN A sent her a screenshot of the message the morning of 05/30/2026 that she sent to the Administrator to report the allegation Resident #19 made. The DON said if she had noticed it when it was sent, she would have called the Administrator, removed the staff member, ensured the resident was safe, conducted a skin assessment, called the family and done all the things per the abuse policy, and reported the abuse to HHSC. The DON said not following the abuse policy placed the residents at risk for abuse and neglect. This was determined to be an Immediate Jeopardy (IJ) on 06/01/2026 at 5:56 PM the Area Director of Operations was notified. The Area Director of Operations was provided with the IJ template on 06/01/2026 at 6:00 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 06/01/2026 at 7:34 PM and included the following: Date: 6/1/26 Plan of Removal Problem: F607 Implement Abuse Policy Interventions: CNA B was suspended on 5/31/26 by the administrator. Resident #13 and #19 was interviewed by the Administrator and Regional Compliance Nurse. No further allegations of abuse were disclosed. Completed 5/31/26. Resident #13 and #19 had a head-to-toe assessment completed by the charge nurse. No injuries or signs of abuse were noted. Completed 5/31/26. A Trauma informed care assessment was completed by Regional Compliance Nurse on resident #13 and #19 documented in the chart. No new findings were assessed. Completed 5/31/26. On 5/31/26, safe surveys were completed for all residents who can be interviewed by the Administrator and Regional Compliance Nurse. No additional allegations of abuse from staff or residents were disclosed. Completed 5/31/26. On 5/31/26 staff interviews were conducted by the Administrator and Regional Compliance Nurse. No additional allegations of abuse towards residents were disclosed. Completed 5/31/26 The medical director was notified of the immediate jeopardy by the Administrator on 6/1/26. An ADHOC QAPI meeting was completed with the Administrator, Regional Compliance Nurse, IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 6/1/26. The policy for Abuse/Neglect was reviewed by the [NAME] President of Clinical Services, ADO, and Compliance Nurse. No changes were made to the Abuse/Neglect policy. Completed 6/1/26 The Administrator, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following policy. Completed 6/1/26. o Abuse and Neglect Policy reporting all allegations of abuse to the Administrator immediately. All alleged perpetrators will be suspended pending investigation. Allegations of abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse. The alleged perpetrator will remain suspended until the investigation has been completed. o Reporting Allegations of Abuse and Neglect- all allegations of abuse and neglect must be reported to HHSC immediately or within 2 hours. In-services: The following in-services were initiated by Regional Compliance Nurse, Administrator, DON, and ADON for all staff. Any staff member not present or in-serviced as of 6/1/26 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment Abuse and Neglect Policy- Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Any suspicious injury of unknown sources. o Reporting Allegations of Abuse and Neglect- all allegations of abuse and neglect must be reported to the Administrator immediately. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of the facility employee disciplinary report dated 05/31/2026 indicated CNA was suspended on 05/31/2026. Record review of the facility EMR for Resident #13 and Resident #19 indicated both residents were interviewed by the facility administrator and no further allegations of abuse were noted. Record review of Resident #13 and Resident #19's head to toe skin assessments dated 05/31/2026 completed by the DON indicated neither resident had any skin issues that suggested abuse. Record review of Resident #13 and Resident #19's Trauma Informed PRN Assessments completed on 05/31/2026 by the Regional Compliance Nurse indicated no trauma associated with incidents. Record review of the resident safe surveys completed on 05/31/2026 by the DON and the Regional Compliance Nurse indicated no allegations of abuse or neglect were reported by residents. Record review of the staff interviews completed by the Administrator and the Regional Compliance Nurse on 05/31/2026 indicated no allegations of abuse or neglect were reported by staff members. Record review of the ADHOC QAPI meeting completed on 06/01/2026 by the Administrator, Regional Compliance Nurse, IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Record review of the one-on-one in-services completed by the Regional Compliance Nurse on 06/01/2026 with the Administrator, DON and ADON included the abuse and neglect policy and reporting allegations. Record review of the in-service completed by the Administrator, Regional Compliance Nurse, the DON, and the ADON completed on 06/01/2026 indicated they had been in-serviced on the abuse and neglect policy and when to report abuse and neglect allegations. During an interview on 06/02/2026 at 9:53 AM the Medical Director said he was notified of the immediate jeopardy by the Administrator on 6/1/2026. During interviews conducted on 06/02/2026 between 9:55 AM-12:37 PM of staff across different shifts, the Area Coordinator of Medical Records and Supply, MDS Coordinator, Social Worker, Dietary Manager, Business Office Manager, Maintenance Director, Housekeeping Su

Based on interviews, observations, and record reviews, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents #13 and #19) reviewed for resident abuse. 1. The facility failed to protect Resident #13 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. 2. The facility failed to protect Resident #19 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else during the week of 5/25/2026- 5/28/2026. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #13's face sheet, dated 06/04/26, reflected Resident #13 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in mental abilities due to physical brain deterioration in older age). Record review of Resident #13's quarterly MDS assessment, dated 03/12/26, reflected Resident #13 made herself understood and understood others. Resident #13's BIMS score was a 7, which reflected her cognition was severely impaired. Resident #13 required partial/moderate assistance with sit to stand and bed to chair transfer mobility. Record review of Resident #13's undated comprehensive care plan, reflected Resident #13 had an ADL self-care performance deficit related to activity tolerance, fatigue (tiredness), limited mobility and low back pain. The care plan interventions included: independent with bed mobility. Record review of Resident #13's electronic medical records did not reflect a skin assessment completed on 05/26/26 until state surveyor intervention on 05/31/26. During an observation and interview on 05/31/26 at 1:28 p.m., with Resident #13 a bruise was observed on Resident #13's right forearm. When Resident #13 was asked about the bruise, she stated the CNA caused it when she made her go to bed. Resident #13 stated the CNA grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. Resident #13 stated she tried to pull away when the CNA pushed her down and the CNA stated to her don't fight. Resident #13 stated the CNA had long fingernails and when she grabbed her, the mark came up. Resident #13 described the CNA as a black lady, heavy set, and her hair was curled to the side, but was unable to state a name. Resident #13 stated she could not remember the date this incident happened or who she reported it to, but she did report it. Resident #13 stated, this is not the first time this has happened, ever since she has been here, she reaches out and grabs me. Resident #13 stated when she reported this, before, she was told the CNA was just that way. Resident #13 stated, I was really scared. During an interview on 05/31/2026 at 1:05 PM, RN A stated when she was assessing Resident #13 for shingles (a viral infection that caused a painful rash), Resident #13 stated to her I must tell you something that needs to stay between me and you. RN A stated Resident #13 reported to her that the CNA who put her to bed the night before was ruff and pinched her. RN A stated Resident #13 told her she was being forced to go to bed and she was not ready, the CNA insisted it was her bedtime and she put her to bed. RN A stated Resident #13 stated the CNA told her it was her fault because she was fighting her about going to bed. RN A stated Resident #13 did not provide her any names, but said it was a black woman. RN A stated she reported it immediately to the ADON and Administrator the day Resident #13 reported it to her, and the Administrator told her it would be a self-report to state, and she would talk to Resident #13. RN A stated she did not mention the bruise to anyone, but she did not notice the bruise when Resident #13 reported the incident, but she was focused on the shingles. During an interview on 06/01/26 at 9:50 a.m., the ADON stated, on 05/25/26 as she was making rounds prior to supper, she noticed Resident #13 lying in bed. The ADON stated she asked her why she was in bed so early and Resident #13 stated she told me I had to go to bed because everyone else was in bed. The ADON stated she told her she did not have to go to bed early if she did not want to. The ADON stated she offered to get her back up. The ADON stated she did not report the incident to anyone because she did not feel like it was abuse or neglect. The ADON stated the next day (26th) RN A came to her and reported Resident #13 told her a CNA was ruff and pinched her. The ADON stated her and RN A immediately went to the Abuse Coordinator which was the Administrator, and RN A told her what Resident #13 reported, which was the CNA was ruff and pinched her. The ADON stated the Administrator stated, Ok, I will investigate. During an interview on 06/01/26 at 10:22 a.m., the Administrator stated around 5/18/26 forward, the ADON notified her about a complaint that Resident #13 stated she was made to go to bed. The Administrator stated her and the ADON went down to Resident #13 room and informed her it was her right when she wanted to go to bed. The Administrator stated as Resident #13 was mentioning about the CNA making her go to bed, Resident #13 showed her the rash that was identified as shingles (a viral infection that caused a painful rash) under her right side. The Administrator stated she asked Resident #13 if she could identify the CNA and she stated a regular-sized black lady that normally worked that hall. The Administrator stated she looked at the ADON and asked her who the CNA was that worked yesterday, and the ADON stated she would look at the schedule. The Administrator stated after she left Resident #13's room, her and the ADON went to look at the schedule and saw CNA B worked the hall that night before. The Administrator stated she thought she had conducted an in-service on resident rights but could not find the documentation. The Administrator stated CNA B never was suspended or spoken to about the incident and was able to continue to work with Resident #13. The Administrator stated she was not aware of the second incident that involved the CNA been ruff or pinching Resident #13. The Administrator stated the ADON nor RN A reported to her about Resident #13 being pinched or ruff during transfer on 05/25/26. The Administrator stated she was not aware of the bruise to Resident #13's right forearm until after the state surveyor's intervention. The Administrator stated she went down to Resident #13's room on 05/31/26 to start an investigation and when she spoke to Resident #13 about the bruise, Resident #13 stated it happened, when she put me to bed. During an interview on 06/01/26 at 10:46 a.m., the ADON stated she did not notify the Administrator about a complaint herself. The ADON stated when RN A reported Resident #13's allegation to her, they both went to the Administrator's office, and RN A reported the allegation to the Administrator. The ADON stated she did not recall speaking with Resident #13 with the Administrator. 2. Record review of Resident #19's face sheet dated 06/01/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (deterioration of the brain which leads to cognitive decline, memory impairment, and changes in behavior and personality), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and essential primary hypertension (high blood pressure). Record review of Resident #19's MDS assessment dated [DATE] indicated she was understood by others and understood others. Resident #19 had a BIMS score of 15, which indicated her cognition was intact. Resident #19 was dependent on staff for toileting hygiene. Resident #19 was frequently incontinent of bladder and bowel. Record review of Resident #19's care plan reviewed 04/21/2026 indicated she had impaired though processes to engage in simple, structured activities that avoided overly demanding tasks and to provide her with a homelike environment. Resident #19's care plan indicated she had bowel and bladder incontinence to provide perineal care after each incontinent episode. Resident #19 had an ADL self-care performance deficit related to fatigue and limited mobility and required assistance of one staff member for toilet use, bathing, bed mobility, and dressing. During an interview on 05/31/2026 at 10:02 AM, Resident #19 said there was an African American CNA who wore brown glasses and worked the 2 PM- 10 PM shift that was rough when she provided care to her. Resident #19 said the CNA did not identify herself and did not wear a name badge, so she did not know her name. Resident #19 said the CNA grabbed her arm roughly and was rough when turning her to provide care. Resident #19 said she told the CNA she needed to stop grabbing her arm so roughly and the CNA told her that's the way she was. Resident #19 said she was scared of the CNA and had reported her to everybody (staff). Resident #19 said the CNA did not work over the past weekend, but she provided care to her every day. Resident #19 said one of the girls upfront told her they were trying to figure out who it was, but she was unable to provide a name. Resident #19 said one day last week me and her had it out. Resident #19 said she told the CNA to stop treating her roughly and the CNA told her she did not care if they fired her, she could always work elsewhere. One of the nurses she reported it to was LVN C. During an interview on 05/31/2026 at 1:05 PM, RN A said Resident #19 reported to her yesterday (05/30/2026) morning that an African American woman who wore glasses on the 2 PM-10 PM shift was really rough with her, and she never wanted her to be her CNA again. RN A said she did not have a way of figuring out who the CNA was. RN A said Resident #19 told her the CNA never wore a name tag. RN A said she notified the Administrator immediately via text message and she said it would be a self-report to state and to send the DON a text message. RN A said the way Resident #19 was treated was abuse and the facility was the residents' home. RN A stated the residents were someone's loved one, they should be treated with respect and dignity, trust the staff, feel safe in their home, and not be afraid to ask to be changed. During an interview on 05/31/2026 at 1:47 PM, the ADON said CNA B was the CNA that usually provided care to Resident #19 on the 2 PM-10 PM shift and she matched the description provided by Resident #19. The ADON said she did not think CNA B was mean, but she was very demanding and wanted things done her way. The ADON said the Administrator called her yesterday, 05/30/2026, and told her she was filing a grievance because Resident #19 felt her ADLs were rushed by CNA B, but she was not involved in any of the process. The ADON said if a resident reported a CNA was rough it should be reported to the Abuse Coordinator, the Administrator, immediately because it could be considered abuse. During an interview on 05/31/2026 at 2:06 PM, the DON said she had not received any reports from the residents or staff about any staff being rough with the residents or mistreating them. The DON said yesterday evening, 05/30/2026, she was notified by the Administrator that Resident #19 had reported a CNA was rough with her, but she did not talk to Resident #19. The DON said if a resident reported a staff member was rough with them it should be reported to the Abuse Coordinator, the Administrator, immediately. The DON said the Administrator would then see what the resident was saying and get a statement from the staff member involved, and if deemed reportable follow the abuse policy process. The DON said an allegation of staff being rough could be considered abuse. The DON said she was not aware of Resident #13 having a bruise or being mistreated. The DON said nothing regarding Resident #13 had been reported to her. The DON said if the staff noticed a new bruise, they should complete a skin assessment, open an incident, monitor the bruise, notify the family and the doctor, and the Administrator usually was notified during the daily clinical morning meetings. The DON said she reviewed the staffing schedule and identified the CNA involved in Resident #19 and Resident #13's incidents as CNA B. The DON said the CNA was working today, 05/31/2026, for her 2 PM-10 PM shift, but would be moved to a different hall. During an interview on 05/31/2026 at 2:19 PM, the Administrator said last night (05/30/2026) at 7 PM, LVN C called her and reported to her that Resident #19 reported to her that the CNA from Thursday, 05/28/2026, was rough with her and rushed her when she provided care. The Administrator said she went to the facility approximately 15-20 minutes after she was notified by LVN C to talk to Resident #19. The Administrator said when she spoke to Resident #19, she felt like it was more that CNA B had rushed her. She said Resident #19 told her CNA B rushed her and pushed her over when she was turning her on her side. The Administrator said Resident #19 told her she did not want CNA B back in her room. The Administrator said she filed a grievance and moved CNA B to a different hall. She said CNA B would start her shift today, 05/31/2026, at 2 PM, but would be on a different hall. The Administrator said Resident #19 had no injuries from CNA B being rough with her. The Administrator said RN A reported to her yesterday (05/30/2026) that Resident #19 told her CNA B had been rough with her. The Administrator said she told RN A to report it to the DON. The Administrator said she was not sure if Resident #19 told her CNA B was rough or rushed her. The Administrator said it had not been reported to her that CNA B pinched Resident #13 or any allegations made by Resident #13. The Administrator said if there was an unidentified bruise it should be reported to her. The Administrator said it was not reported to her that Resident #13 had a bruise on her arm. The Administrator said the staff should not force the residents to go to bed early because it went against resident rights. During an interview on 05/31/2026 at 2:49 PM, CNA B said she had been working at the facility for close to a month. CNA B said if a resident was not ready to go to bed, she would notify the nurse and let the nurse handle it because it was the residents right not to go to bed. CNA B said she had not forced any residents to go to bed. CNA B said she did not rush the residents when she provided care, and she had not received any complaints that she was rough. CNA B said there were no residents' rooms she was not allowed to go in. CNA B said she usually worked on the hall where Resident #13 and Resident #19 resided. CNA B said Resident #19 did not require a lot of assistance with her care that she allowed her to roll herself just gave her a little boost. CNA B said Resident #13 required assistance from one person for rolling and for standing up. She said usually she held her when she was getting up from under her arms to help her push up on her walker to get her to stand up. CNA B said she had never told any residents if she got fired, she could go work somewhere else. She said she was not aware of Resident #13 having any bruises. During an observation and interview on 05/31/2026 at 3:11 PM, RN A showed the surveyor the text message she sent to the Administrator and DON. The message to the Administrator dated 05/30/2026 at 10:08 AM indicated Resident #19 says she never wants the 2-10 aide back in her room, because her aide is being too rough with her. It happens every time she's been on the hall. The Administrator responded, send to DON and let her know. RN A said she took a screenshot of what she sent to the Administrator and the response and sent it to the DON. RN A showed the surveyor the message sent to the DON on 05/30/2026 at 11:02 AM, and it was the screenshot of what she sent the Administrator. RN A said she did not hear from the DON or the Administrator after this. During an interview on 06/01/2026 at 9:58 AM, LVN C said Resident #19 complained to her about one of the CNA's Thursday, 05/28/2026, being rough with her. She said Resident #19 did not report it to her until Saturday, 05/30/2026, at 7:00 PM. She said Resident #19 reported to her the CNA had been rough with her, rolled her over so hard, she hit her head against the bed rail. LVN C said Resident #19 told her it was a CNA with glasses that worked the 2 PM-10 PM shift, and the description fit CNA B. LVN C said she immediately reported what Resident #19 told her to the Administrator, and the Administrator went to the facility. LVN C said she conducted a skin assessment on Resident #19, and she had no injuries. LVN C said she had not received any complaints from the residents or staff about CNA B or any other staff mistreating the residents. During an interview on 06/01/2026 at 10:40 AM, the Administrator said she was notified by RN A the morning of 05/30/2026 that Resident #19 alleged CNA B was rough with her. The Administrator said she identified it as abuse and told RN A to notify the DON because she was in an area where she did not have good signal and was not receiving messages and calls in a timely manner. The Administrator said she expected the DON to follow up, but the DON said RN A had not notified her of the allegation Resident #19 made. The Administrator said when LVN C reported the allegation Resident #19 made to her the evening of 05/30/2026, she was back in town and decided to go to the facility to speak with Resident #19. The Administrator said since she told RN A to report it to the DON, she assumed the DON had taken care of the situation. During an interview on 06/04/2026 at 6:08 PM, the DON said when the Administrator called her the evening of 05/30/2026, she went back to review her messages and realized RN A sent her a screenshot of the message the morning of 05/30/2026 that she sent to the Administrator to report the allegation Resident #19 made. The DON said if she had noticed it when it was sent, she would have called the Administrator, removed the staff member, ensured the resident was safe, conducted a skin assessment, called the family and done all the things per the abuse policy, and reported the abuse to HHSC. Record review of the facility's policy, Abuse and Neglect, from the Nursing Policy and Procedure Manual revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Abuse is 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 psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.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.Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident.Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. 6. Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Mistreatment: means inappropriate treatment or exploitation of a resident.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 residents (Resident #2, Resident #45, and Resident #57) reviewed for urinary catheters. 1. The facility failed to ensure Resident #57 was provided with proper foley catheter and incontinent care on 06/03/2026.The facility failed to ensure the split in Resident #57's penis was routinely assessed.The facility failed to ensure Resident #57's physician and family were notified of the split in his penis. 2.The facility failed to ensure Resident #2 had on a catheter strap (urinary drainage bag straps) and CNA N wiped correctly and performed hand hygiene while providing incontinent care on 06/02/26. 3. The facility failed to ensure Resident #45's catheter bag was off the ground. These failures could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: 1. Record review of Resident #57's face sheet dated 06/04/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness and paralysis of the right side of the body after a stroke), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Record review of Resident #57's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. Resident #57 had a BIMS score of 15, which indicated his cognition was intact. Resident #57 had an indwelling catheter. Resident #57 was dependent on staff for toileting. Record review of Resident #57's care plan reviewed 05/12/2026 indicated, he had an foley catheter to change the catheter as ordered, check the tubing for kinks and maintain the drainage bag off the floor, monitor for signs and symptoms of discomfort on urination and frequency. The care plan indicated he required assistance of one staff member for toilet use and bed mobility. Resident #57's care plan did not address providing catheter care, securing the catheter, or care for the split in his penis. Record review of Resident #57's Order Summary Report dated 06/03/2026, indicated the following orders: *Change Foley Catheter using 18 Fr foley catheter every night shift starting on the 7th and ending on the 7th of every month for urinary retention with an order start date of 09/07/2025. *Ensure catheter strap in place and holding every shift for catheter use with an order start date of 06/25/2025. *Ensure foley bag is in privacy bag while in bed or wheelchair every shift for catheter use with an order start date of 06/25/2025. *Monitor foley catheter every shift for leakage, blockage, sediment buildup, or low output for catheter use with an order start date of 06/25/2025. *Provide catheter care every shift for catheter use with an order start date of 03/19/2026. *Urinary Catheter 18 Fr to gravity drainage with an order date of 06/23/2025. Record review of Resident #57's admission Nurse Note, completed by LVN P, dated 02/07/2025 indicated Resident #57 was continent of urine and did not have any genital abnormalities. Resident #57 did not have a foley catheter. Record review of Resident #57's initial skin assessment with an effective date of 02/07/2025 and completed by LVN P, indicated Resident #57 had multiple scattered bruising to bilateral upper extremities, skin tear to left antecubital (inner bend of arm), and an abrasion to right above the knee stump. The assessment did not indicate Resident #57 had penile erosion or penile abnormalities when he admitted to the facility. Record review of Resident #57's Weekly Skin Assessments dated from 02/2025- 06/2026 did not indicate Resident #57 had any penile abnormalities. Record review Resident #57's event note dated 02/28/2025 at 2:16 PM and signed by RN OO, indicated Shower aide reported observing res (resident) with minimal amt (amount) of bleeding from his penis when she removed his brief when she was getting ready to give him a shower. Affected area assessed for any trauma and no scratches, skin tears or lacerations noted. Record review of Resident #57's progress notes dated 03/10/2025- 06/04/2026 did not indicate Resident #57 had any penile abnormalities. Record review of Resident #57's TARs dated 02/2025-05/2026 did not indicate Resident #57's received treatment for penis injuries or penile erosion. Record review of Resident #57's TARs dated 08/2025 and 05/2026 indicated Resident #56 received catheter care every shift and the catheter strap was ensured it was in place. During an observation and interview on 06/03/2026 starting at 2:42 PM, CNA F put on gloves and a gown, unfastened Resident #57's brief pulled it down in front of him and provided catheter care. Resident #57 had brownish residue/spots from discharge coming from his penis. Resident #57's penis had a tear (split) from the top of his penis down to the base (bottom) of his penis. There was redness noted at the base (bottom) of the penis. CNA F used one wipe and circled around Resident #57's penis multiple times using the same wipe. CNA F grabbed another wipe and circled around his penis multiple times and then down the foley catheter tube. CNA F fastened the same brief back onto Resident #57, touched his covers, and repositioned him in the bed using the same gloves. CNA F failed to change her gloves and perform hand hygiene after completing the foley catheter care. CNA F exited the room. CNA F said she was finished. CNA F said she noticed the spots on Resident #57's brief but did not change it because it was just discharge from his penis. After surveyor intervened, CNA F said she would provide incontinent care to Resident #57. CNA F entered Resident #57's room applied gown and gloves, and unfastened Resident #57's brief. CNA F grabbed a wipe and cleaned Resident #57's penis in a circle motion multiple times with one wipe. Resident #57 complained of his penis hurting when CNA F was cleaning it. CNA F said she would notify the nurse. CNA F repeated this with another wipe and then wiped down the catheter tube. CNA F grabbed a clean brief with her dirty gloves and laid it on the bed. CNA F turned Resident #57 on his side but did not ensure the foley catheter was not pulling on his penis. Surveyor intervened, and CNA F placed Resident #57's foley catheter bag on his bed and readjusted the catheter tubing to prevent it from pulling. Resident #57 had flattened, dried stool on his buttocks. CNA F grabbed a wipe and wiped multiple times with the same wipe. CNA F grabbed another wipe and wiped Resident #57's buttocks multiple times to get the stool off. CNA F repeated this with another wipe. CNA F removed her gloves and applied new ones. CNA F failed to perform hand hygiene after removing her dirty gloves. CNA F applied the clean brief, removed her gloves, covered and repositioned Resident #57 with her bare hands. During an interview on 06/03/2026 at 2:57 PM, CNA M said she did not provide catheter care to Resident #57 during her shift because she had to leave at 1:00 PM. CNA M said she was not aware the CNAs could provide catheter care. She said she thought the nurses were responsible for providing catheter care. CNA M said she was not aware Resident #57 had a split in his penis. CNA M said it was important for catheter care to be provided to prevent skin breakdown and infection. During an interview on 06/03/2026 at 3:05 PM, CNA F said hand hygiene should be performed before providing care and when exiting the resident's room. CNA F said gloves should be changed if they were visibly soiled. CNA F said hand hygiene should be performed after removing her gloves. CNA F said when she was providing catheter care and incontinent care, she should only wipe in one swiping motion. She said the same wipe should not be used to wipe multiple times. CNA F said the clean brief and the residents' clean items should not be touched with dirty gloves. CNA F said she should not have touched Resident #57's covers and repositioned him with bare hands because he required enhanced barrier precautions. CNA F said it was important to change gloves for infection control. CNA F said not applying gloves when necessary and not performing adequate hand hygiene could result in the spread of infection. CNA F said not providing proper catheter care and incontinent care could result in an infection. CNA F said she had been working at the facility for nine years but usually did not provide care to Resident #57. CNA F said she had not noticed Resident #57 had a tear in his penis. CNA F said she should have ensured Resident #57's foley catheter was not pulling when she turned him over. She said the foley catheter pulling could cause an injury to his penis. During an interview on 06/03/2026 at 3:17 PM, the ADON said she was aware CNA M left at 1 PM, but CNA M did not inform her Resident #57 had not been checked on since before lunch and she did not perform catheter care. The ADON said the CNAs were supposed to provide foley catheter care at least once a shift and as needed. The ADON said the charge nurses were responsible for ensuring foley catheter care was performed. She said she was the charge nurse for Resident #57, and CNA M told her she had already completed the foley catheter care and she took her word for it. The ADON said when providing foley catheter care and incontinent care the CNAs should wash their hands prior to providing care and after. She said hand hygiene should be performed after glove removal. The ADON said the CNAs should not wipe more than once with the same wipe. They should wipe once, discard the wipe, and then get a clean wipe. The ADON said gloves should be changed prior to touching any clean items. The ADON said if a resident's brief was soiled it should be changed. The ADON said Resident #57 required enhanced barrier precautions and CNA F should not have touched his covers and repositioned him without gloves. The ADON said not performing hand hygiene and glove changes as required could result in cross contamination. The ADON said not providing proper foley catheter and incontinent care could result in UTIs. The ADON said not following enhanced barrier precautions could result in the spread of infection. The ADON said she thought Resident #57 had a foley catheter since he was admitted to the facility. The ADON said she noticed his penis was torn the end of last year (2025) but was unable to provide a date. The ADON said she did not document it because he already had it. She said it should have been documented so they could monitor to see if it had worsened. The ADON said CNA F should have placed Resident #57's catheter bag on the bed with him to prevent it from pulling when she turned him on his side. The ADON said the foley catheter pulling on Resident #57's penis could lead to an injury to his penis. During an observation on 06/03/2026 at 3:41 PM, the ADON measured the tear to Resident #57's penis from the top to the bottom and it was approximately 4 cm long. During a telephone interview on 06/03/26 at 4:14 PM, Resident #57's Representative #1 stated Resident #57 had a foley catheter on and off for about a year. They stated when he was first admitted he did not have a catheter and was able to urinate on his own. They stated they were not aware Resident #57 had a split in his penis. During an interview on 06/03/2026 at 4:15 PM, LVN P said she admitted Resident #57, and she did not remember him having a split penis. LVN P said she was the unit manager until the end of March 2026, and she did not recall it ever mentioned that he had a split penis. During a telephone interview on 06/03/26 at 4:20 PM, Resident #57's Representative #2 stated Resident #57 was not admitted to the facility with a catheter, and they were not aware of Resident #57 having a split on his penis. During an interview on 06/03/2026 at 4:52 PM, LVN FF said since she started providing care to Resident #57 in August 2025, she noticed he had a split on his penis. LVN FF said Resident #57 had no complaints about it. During an interview on 06/03/2026 at 4:38 PM, CNA D said she had been working at the facility for a couple of months. CNA D said Resident #57 complained of pain when she was changing him and she reported it to the nurses, but she was not sure if the nurses were following up. CNA D said she reported it again yesterday, 06/02/2026, to LVN E, and she said she would check on him. CNA D said she was not aware of Resident #57 having any abnormalities to his penis. During an interview on 06/03/2026 at 5:32 PM, the facility's NP said Resident #57's foley catheter was placed 02/18/2025 and then he had it off and on until it was left permanently due to urinary retention. The NP said it had not been reported to him that Resident #57 had a tear in his penis. The NP said if he had been notified, he would have had them remove the foley catheter or do in and out catheterization to allow it to heal up or he would have referred him to the urologist to see if he would qualify for a suprapubic catheter. The NP said he was under the assumption Resident #57 had been to the urologist but could not remember. The NP said pulling the foley catheter could make the tear larger. During an interview on 06/03/2026 at 5:55 PM, LVN C said she did not admit Resident #57 to the facility, but she had been providing care to him since his admission. LVN C said she was aware Resident #57 had a split in his penis. LVN C said it had been there for a long time, but she was not sure how long he had it. LVN C said she did not remember if she had documented the split in Resident #57's penis. LVN C said if a resident had a split in their penis it should be documented in a nurses note with a description and measurement and the doctor and family should be notified. During an interview on 06/04/2026 at 8:49 AM, the facility's Medical Director said he had not been notified of Resident #57 having a split in his penis. The Medical Director said it depended on the circumstance if he would have recommended intermittent catheterization or referral to the urologist for a suprapubic catheter. The Medical Director said he was under the impression Resident #57 had seen a urologist, but he was not sure. During an interview on 06/04/2026 at 9:16 AM, Resident #57 said he did not have a catheter prior to entering the facility. Resident #57 said the foley catheter was placed after he was admitted to the facility, and it had been about a year since he had it placed. Resident #57 was not aware of having any injuries to his penis. He said it was sore when they cleaned his penis, but he was not having ongoing pain. During an interview on 06/04/2026 at 3:35 PM, LVN E said the CNA reported to her on 06/02/2026 that Resident #57 reported pain to his penis when she provided incontinent care. LVN E said she went to check on him and he was sleeping, and she planned to go back later in her shift, but she did not make it back to him. LVN E said she should have followed up with Resident #57 and assessed him and notified the doctor to see if there were any new orders. LVN E said she usually did not work with Resident #57, so she had not noticed he had a split on his penis. LVN E said if a resident had split on their penis, it should be documented in the nurses' notes, and the doctor and resident representative should be notified. During an interview on 06/04/2026 at 4:34 PM, the Administrator said she was not aware of Resident #57 having a split in his penis. The Administrator said if a resident had a split in their penis she expected for the CNA to notify the nurse, and the nurse notify the doctor and family and document it. The Administrator said she expected the residents to be changed if they were dirty, and she expected the CNAs to follow the rules for proper perineal care and catheter care. The Administrator said the DON was responsible for ensuring the staff provided proper perineal/catheter care. The Administrator said proper perineal care and catheter care were necessary to prevent skin breakdown and infections. The Administrator said the CNAs should ensure the catheter was not pulled when they provided incontinent care. The Administrator said the catheter pulling placed the residents at risk for injury. During an interview on 06/04/2026 at 5:39 PM, the DON said she was not aware Resident #57 had a split in his penis. The DON said if a resident had a split in their penis, it should be documented and monitoring of it should be documented. The DON said the doctor and the resident representative should be notified. The DON said when providing catheter and incontinent care a wipe should be used in one motion and then a new wipe should be used. The DON said if the CNA noticed the brief was dirty it should have been changed. The DON said hand hygiene should be performed upon entering the resident's room and when exiting the room. The DON said gloves should be changed before touching a clean brief. The DON said when providing care to a resident with a catheter the catheter should be unhooked from the bed frame before rolling the resident, so it would not pull and cause trauma to the penile area or dislodgement of the catheter. The DON said if a resident reported pain during care the CNA should stop, notify the nurse, and the nurse should notify the doctor for any new orders. The DON said she and the charge nurses were responsible for ensuring the CNAs provided proper incontinent/catheter care. She said she monitored by completing competency checks and conducting random checks. 2.Record review of Resident #2's face sheet, dated 06/04/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include senile dementia (mental deterioration or loss of intellectual ability that is associated with or the characteristics of old age), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), parkinsonism (description for body movements that have become slow, small, stiff, shaky, and unsteady), and muscle weakness. Record review of Resident #2's significant change MDS assessment, dated 03/11/26, indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 12, which indicated his cognition was moderately impaired. The MDS indicated Resident #2 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and set up for eating. The MDS indicated he had an indwelling catheter and was frequently incontinent with bowels. Record review of Resident #2's physician orders, dated 06/15/25, indicated: Ensure catheter strap in place and holding every shift and change as needed. Record review of Resident #2's physician orders, dated on 01/10/26, indicated: Urinary Catheter 16french (refers to the diameter of the tube)/10 milliliters (refers to the capacity of the sterile water balloon that holds the catheter) coude (a specialized urinary catheter featuring a curved or bent tip) to gravity drainage every shift. Record review of Resident #2's hospital record dated 02/10/26 through 02/13/26 revealed Ertapenem (Invanz) intravenous daily for 8 days for Urinary Tract Infection also known as UTI (an infection anywhere in your urinary system (kidneys, bladder, or urethra) caused by bacteria). Record review of Resident #2's comprehensive care plan, revised on 03/17/26, indicated Resident #2 had an indwelling catheter related to obstructive uropathy. The interventions were for staff to monitor/record/report to MD for signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and position catheter bag tubing below the level of the bladder and in a privacy bag. Record review of Resident #2's comprehensive care plan, revised on 03/17/26, indicated Resident #2 had an ADL Self Care Performance Deficit. The care plan interventions were for staff to provide assistance x 1 with toileting. During an observation and interview on 05/31/26 at 10:30 a.m., Resident #2 was lying in his bed with an indwelling catheter. Resident #2 showed the surveyors his indwelling catheter without a catheter strap noted. He said he usually had a catheter strap. During an observation on 06/02/26 at 9:29 a.m., CNA N provided incontinent care for Resident #2 who had an indwelling catheter without a catheter strap and was incontinent with bowel. CNA N wiped his front area and then wiped his indwelling catheter tubing only in the middle; she did clean the head of his penis to the middle of the catheter tubing. CNA N changed her gloves but did not perform hand hygiene. CNA N and CNA D assisted Resident #2 to his left side while keeping the indwelling catheter hooked to the bed frame which caused the indwelling catheter to be pulled. The state surveyor intervened and CNA N disconnected the indwelling catheter bag from the bed frame and laid it on his bed. CNA N wiped his buttock which contained feces, using front to back and back to front motion. CNA N changed her gloves but did not perform hand hygiene before grabbing and applying a clean brief, reconnecting his indwelling catheter to the bed frame, pulling up his pants, and straightening his linen. CNA N then removed her gloves, gathered her equipment, left the room, and then performed hand hygiene. During an interview on 06/02/26 at 9:41 a.m., CNA N said she did not realize she did not perform hand hygiene after wiping Resident #2's front side, his backside, or before touching the clean brief, linen, and pulling up his pants. She said she realized after she had completed cleaning Resident #2 that she wiped front to back and back to front, did not clean his penis, or wipe down the whole catheter tubing. She said the proper way to wipe his indwelling catheter was to start at the tip of his penis and wipe in a circular motion and then wiping down the catheter tubing. CNA N said she should have disconnected his indwelling catheter bag from the bed frame before turning him to prevent it from pulling. She said the risk could have been pulling out the indwelling catheter. She said she should have wiped from front to back only to prevent urinary tract infections. She said she was supposed to wash her hands when she changed her gloves. She said she knew that without proper incontinent care, or hand hygiene, she could cause cross-contamination and infection. During an interview on 06/02/26 at 10:00 a.m., RN H said she was Resident #2's nurse. She said he should have a catheter strap to prevent pulling or dislodgement. She said she was not aware Resident #2 did not have a catheter strap. She said she had not checked the placement of his catheter strap since she started her 6am shift. She said it was nursing's responsibility for ensuring he had on a catheter strap. She said she would apply a catheter strap. During an interview on 06/04/26 at 3:01 p.m., the DON said she expected the staff to perform incontinent care correctly. She said she expected staff to wipe front to back and not back to front. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. She said staff should ensure residents who had an indwelling catheter had on a catheter strap to prevent pulling or dislodgement. She said staff should clean a male resident who had an indwelling catheter from the tip of the penis, cleaning in a circular motion, using a different wipe each time and then wiping the catheter tubing. The DON said they went over incontinence care, indwelling catheter care, and hand washing on hire, and as needed. She said she was the overseer of infection control. She said staff should wipe front to back, clean the indwelling catheter the correct way, change gloves and practice hand hygiene from dirty to clean to prevent urinary tract infections, and cross-contamination. During an interview on 06/04/26 at 5:20 p.m., the Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care, indwelling catheter care, and infection control. She said improper incontinent care, indwelling catheter care, and hand hygiene could place residents at risk for cross-contamination. Record review of CNA N's proficiency skills check off on perineal care with and without an indwelling catheter was successfully completed on 12/08/25. 3. Record review of face sheet dated 06/04/2026 revealed Resident #45 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of other pericardial effusion (heart does not pump blood effectively), benign prostatic hyperplasia with lower urinary tract symptoms (inflammation of the prostate) and obstructive and reflux uropathy (blockage of urine flow). Record review of Quarterly MDS dated [DATE] revealed Resident #45 was able to make himself understood to others and he understood others. MDS assessment indicated Resident #45 had a BIMS score of 15 indicating no cognitive impairment. MDS assessment indicated Resident #45 was occasionally incontinent of bladder. Record review of care plan dated 06/04/2026 revealed Resident #45 was care planned for a catheter for urinary retention with the intervention of check tubing for kinks and maintaining the drainage bag off the floor. Record review of order summary report dated 06/04/2026 revealed Resident #45 had an order for catheter care every shift started on 05/22/2026. During an observation on 05/31/2026 at 10:50 a.m., Resident #45 catheter bag was lying on the ground. During an observation on 05/31/2026 at 1:15 p.m., it was revealed Resident #45 catheter bag was lying on the ground and had not been emptied. During an interview on 05/31/2026 at 2:45 p.m., the CNA Q stated that she was responsible for emptying the catheter bag every shift. CNA Q stated that he performed rounds every two hours to check on the resident to ensure the catheter bag was up off the ground. CNA Q stated that the catheter bag must have fallen off of the bed rail and she was unaware of the bag on the ground at that time. The CNA Q stated she went in to help assist Resident #45 get dressed for the day when she found the catheter bag on the ground. The CNA Q stated Resident #45 was at risk of contamination. During an interview on 06/04/2026 at 3:30 p.m., the LVN K stated that he and all nursing staff were responsible for ensuring Resident #45's catheter bag was off of the ground. LVN K stated that he was not aware that Resident #45's catheter bag was on the ground. LVN K stated that Resident #45 was at risk of urinary tract infection and injury. During an interview on 06/04/2026 4:03 p.m., the DON stated Resident #45's catheter bag should not be on the ground. The DON stated Resident #45 was at risk of infection and contamination. The DON stated that it was all nursing staff's responsibility for checking Resident #45's catheter and ensuring it was not on the ground. The DON stated CNAs were responsible for checking the bag when emptying the catheter bag. During an interview on 06/04/2026 at 4:58 p.m., the Administrator stated that it was nursing's responsibility to ensure that Resident #45's catheter bag was off the ground. The Administrator stated that she expected nursing staff to follow policy and procedures on catheter care. The Administrator stated that Resident #45 was at risk of urinary tract infection and urinary injury. Record review of the facility's policy titled, Perineal care, dated 05/2022, indicated, Policy: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure Content:17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area – CLEAN to DIRTY! Male resident: If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about three inches. Pull back the foreskin on uncircumcised males. Hold penis by the shaft. Wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh. Reposition foreskin of uncircumcised males. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. Record review of the facility's undated policy, Catheter Care, indicated, Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site.Provide perineal care to the incontinent resident to prevent skin rashes and breakdown.Be sure the catheter tubing and drainage bag are kept off the floor.Report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urethral area. 11. Wash your hands thoroughly with soap and water or alcohol 12. Apply gloves 13. Providing as much privacy as possible, expose the residents genitalia 14. Hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum. 15. Keep drainage bag below level of bladder when cleaning the urethral area: 16. Gently wash, rinse and dry around the juncture of the catheter and meatus. If using Pre-moistened no-rinse disposable wash cloths, rinsing is not required) 17. Then wash the catheter from the meatus down the tube about 3 inches. 18. Dispose of wash cloths 19. Remove gloves 20. Straiten [sic] clothing or bedding 21. Wash Hands 22. Observe for and report to charge nurse: a. Problems or complaints related to procedure b. Skin changes such as rash, redness, irritation, bruising, swelling, discoloration, skin breakdown, drainage, foul odors c. Skin complaints such as burning, itching, tingling, numbness, pain. d. Problems at catheter-meatal junction such as redness, irritation, swelling, crusting, drainage, bleeding or pain e. Urinary complaints such as dysuria, burning, urgency, frequency, or flank pain f. Other significant observations.

Based on observation, interviews, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 8 of 8 confidential residents who were reviewed for resident rights. The facility failed to ensure staff or visitors did not disturb the resident council meetings.This failure could place residents at risk of not being able to voice concerns, fear of retaliation, and discomfort due to a lack of privacy. Findings included: During a resident council meeting held by the state surveyor on 06/02/26 at 10:40 a.m., 1 staff member and the facility's medical doctor came into the activity room and stated they needed to see two residents that were attending the meeting in a loud tone. During an observation on 06/02/26 at 10:45 a.m., a sign posted on the activity door stating a meeting was in progress.During an interview on 06/02/26 at 10:50 a.m., with 8 alert and orientated residents who attended resident council meeting, they stated the resident council met in the activity room. They stated staff came in and out with no privacy at times, and they filtered what they said due to staff's presence. They could not recall how often they were interrupted but knew it occurred. Residents stated the Activity Director placed a large sign at the entrance to the activity room asking staff not to enter the dining room due to resident council being held. However, staff did not respect the sign.During an interview on 06/03/26 at 10:30 a.m., the Activities Director said she had only been employed for a month but was told the resident council meetings were held in the activity room. She said she posted a sign on the door stating a meeting was in progress for the one meeting they had since her employment. She said she was not aware of staff coming in and out during the resident council meetings. She said she knew staff or visitors could only come to the resident council meeting if they were invited.During an interview on 06/04/26 at 5:00 p.m., LVN E said that the resident council meetings were a closed meeting. She said staff should not come to the meeting unless invited. She said she and the doctor came into the meeting because he needed to see 2 residents. She said one resident had an allergic reaction, and she thought it would be best to interrupt the meeting to meet the residents' needs. During an interview on 06/04/26 at 5:20 p.m., the Administrator said she had only been at the facility for over two months. She said she was not aware of staff coming into the resident council meetings. She said staff had to be invited to come to the resident council meetings and if they were not invited it was against resident rights. Record review of the facility's undated policy titled, Resident Rights, indicated, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records.1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. [NAME] restraints were worn. 3. The dome covers were not stacked with water pooled between them. 4. The microwave was clean and free of food debris.5. The deep fryer was clean. 6. The ice scoop holder was clean. 7. Food was discarded after 7 days per facility policy or by best by date. These failures could place residents at risk for foodborne illness.Findings included: During an initial tour observation and interview with [NAME] T on 05/31/26 beginning at 9:16 a.m. until 9:45 a.m. the following was revealed: 1.Cook T was not wearing a beard restraint. The state surveyor observed facial beard hair. He stated he forgot to put one on. 2. A bag of turkey breast dated 05/20/26. 3. A bag of crumble feta cheese with a best by date 11/18/25 with green substance noted. 4. A box of cream cheese undated. 5. A clear bag with onion that was identified by [NAME] T unlabeled and undated. 6. 2 chocolate pies unlabeled and undated. 7. (4) 16 oz of cool whip undated. 8. A bag of mixed berries that was identified by [NAME] T unlabeled and undated. 9. 3 loaves of Texas toast bread undated. 10. 1 loave of cinnamon bread undated. 11. Inside the microwave was a brown buildup. 12. The deep fryer had golden food crumbs of various sizes observed on the inside surfaces. 13. The dome covers were stacked and remained wet with water pooled in between. 14. The ice machine scoop holder had several black pieces floating in the bottom. 15. The water, juice and tea that was located at the beverage station was labeled 05/30/26. During an interview on 06/04/26 at 1:23 p.m., Dietary Aide V stated all staff were responsible for labeling and dating. Dietary Aide V stated all staff were responsible for cleaning the microwave. Dietary Aide V stated the beverage at the beverage station should be discarded every 24 hours by the dietary aide. Dietary Aide V stated the failures put residents at risk for food borne illness and cross contamination. During an interview on 06/04/26 at 1:32 p.m., Dietary Aide U stated all staff were responsible for labeling and dating. Dietary Aide U stated she was the person that washed the dishes, which was her responsibility for ensuring the dome covers were air dried before stacking. Dietary Aide U stated the failures could potentially put residents at risk for foodborne illness and cross contamination. During a telephone interview at 06/04/26 at 1:45 p.m., the Dietician stated the turkey breast should have been discarded between 3-7 days. The Dietician stated the crumble cheese should have been discarded by the best by date once it was taken out of the freezer. The Dietician stated the deep fryer should be cleaned once a week and as needed. The Dietician stated the microwave should be cleaned daily and as needed. The Dietitian stated all staff were responsible for labeling and dating. The Dietitian stated the dome covers should be air dried before stacking. The Dietitian stated she was not sure what the policy was on the ice scoop holder, but she believed it should be cleaned weekly at the minimum. The Dietitian stated bear guard should be worn while in the kitchen. The Dietitian stated the beverage station should be discarded every 24 hours. The Dietician stated she monitored by monthly observations. The Dietician stated the failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 06/09/26 at 1:55 p.m., [NAME] T stated all staff were responsible for labeling and dating. [NAME] T stated the cook was responsible for ensuring food was discarded after 7 days of the best by date. [NAME] T stated the microwave should be cleaned daily and as needed. [NAME] T stated the deep fryer should be cleaned at least twice a week. [NAME] T stated Maintenance was responsible for cleaning the ice scoop holder. [NAME] T stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 06/04/26 at 2:04 p.m., the Maintenance Supervisor stated he was responsible for cleaning the ice scoop holder. The Maintenance Supervisor stated it should be cleaned monthly. The Maintenance Supervisor stated a dirty ice scoop holder could contaminate the ice. During an interview on 06/04/26 at 2:51 p.m., the Dietary Manager stated all food should be labeled and dated by the date received and the date it was opened. The Administrator stated kitchen equipment should be cleaned daily for sanitization purposes. The Dietary Manager stated the turkey breast should have been discarded within 7 days and the crumble cheese by the best by date after removing it from the freezer. The Dietary Manager stated dome covers should be air dried before stacking. The Dietary Manager stated the juice station should be discarded every night. The Dietary Manager stated beard restraints should be worn while in the kitchen. The Dietary Manager stated she was responsible for monitoring and overseeing daily walk throughs and when there was an issue staff were verbally in service. The Dietary Manager stated the failures could potentially put residents at risk for cross contamination and foodborne illness. During a telephone interview on 06/04/26 at 4:06 p.m., the Administrator stated she expected food to be labeled/dated properly, discarded by the end of the 7th date and best by date. The Administrator stated kitchen equipment should be cleaned after use and as needed for sanitization purposes. The Administrator stated the drome covers should be air dried prior to stacking. The Administrator stated the beverage bar should be discarded after 24 hours. The Administrator stated the beard restraint should be worn while in the kitchen. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator stated she did do daily rounds in the kitchen and has not noticed any issues. The Administrator stated the failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE_SERVICE and SINGLE-USE ARTICLES. Record review of the facility's policy titled, Dietary Food Service Personnel Policy and Procedures dated 2012 reflected. Sanitation and Food Handling: 2. [NAME] guards are required for facial hair.11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container unless instructed to do otherwise. Record review of the facility's policy titled, Food Storage and Supplies dated 2012 reflected. All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies.6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Record review of the facility's policy titled, Food Safety dated 2012 reflected. 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. 5. Place scoop in a separate container with the handle up. It is to be washed daily.

Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 4 of 6 residents (Resident's #2, #53, #39, and #52) reviewed for accidents.1.The facility failed to ensure Resident #2 had his fall mat down on 06/01/26, 06/03/26 and 06/04/26.2. The facility failed to ensure CNA Q and CNA O locked the mechanical lift during a transfer for Resident #53 on 05/31/26.3.The facility did not ensure Alcohol Wipes and sanitizing spray were not stored on Resident #39's dresser. 4.The facility failed to ensure Resident #52 room was free from a knife. These failures could place residents at risk of injury or harm. Findings included: 1.Record review of Resident #2's face sheet, dated 06/04/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include senile dementia (mental deterioration or loss of intellectual ability that is associated with or the characteristics of old age), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), parkinsonism (description for body movements that have become slow, small, stiff, shaky, and unsteady), and muscle weakness. Record review of Resident #2's significant change MDS assessment, dated 03/11/26, indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 12, which indicated his cognition was moderately impaired. The MDS indicated Resident #2 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and set up for eating. The MDS indicated he had a history of falling. Record review of Resident #2's comprehensive care plan, last reviewed on 03/17/26, indicated Resident #2 was at risk for falls related to impaired cognition, and impaired mobility. The intervention was for staff to place a Call don't fall sign, ensure floor mat was beside the bed, bed in low position, anticipate and meet the resident's needs, and be sure the resident's call light was within reach and encourage the resident to use it. Record review of Resident #2's comprehensive care plan, last reviewed on 03/17/26, indicated Resident #2 had an ADL Self Care Performance Deficit. The care plan intervention was for staff to transfer the resident using a mechanical lift and required one staff member to assist with bed mobility. Record review of Resident 2's incident report revealed Resident #2 had a fall from his bed on 3/16/25, 06/01/25, and 06/04/26. The incident report from 06/04/26 indicated he received two skin tears to his 3rd and 4th toes. No other injuries were noted. During an observation and interview on 06/01/26 at 8:59 a.m., Resident #2 was in bed with fall mat noted on the wall in front of his bed. Resident #2 said he was not aware if he needed the fall mat beside his bed. During an observation on 06/03/26 at 11:23 a.m., Resident #2 was in bed with fall mat noted on the wall in front of his bed. During an interview on 06/04/26 at 2:02 p.m., CNA Q said she was Resident #2's aide on 06/01/26 and she did not place his fall mat down. She said she did not know he was a fall risk. She said she was new to the facility. She said if she did not know how to care for a resident she would ask and look in their Kardex (provided a snapshot of a resident's current status and care requirements). She looked in his Kardex and did not see where Resident #2 had a floor mat care plan. She said she was Resident #2's aide today (06/04/26) and he had a floor mat because he had a fall either late last night (06/03/26) or early this morning (06/04/26). During an interview on 06/04/26 at 2:12 p.m., the Regional Nurse Consultant said the aides were supposed to look at the Kardex to see about the care of a resident. She looked at the Kardex for Resident #2 and did not see the floor mat on his Kardex. She said it should be there because he had a fall this morning (06/04/26). She said she was not aware prior to the fall that he should have had the floor mat in place. She said she would get his floor mat placed on his Kardex. During an interview on 06/04/26 at 2:23 p.m., LVN K said he was the charge nurse for Resident #2. He said he expected floor mats to be in place for the residents who were at risk for falls. He said as far as he knew Resident #2 was not a fall risk. He said Resident #2 did not have a floor mat down prior to fall today (06/04/26). He said he was unaware Resident #2 had a floor mat on his care plan. He said he had access to Resident #2's care plan but had not seen the floor mat until mentioned by the state surveyor. He said he does have a floor mat down today (06/04/26). Record review of Resident #2's Kardex on 06/04/26 at 3:37 p.m., did not reveal the Kardex had been updated to reflect his fall mat at bedside. 2. Record review of Resident #53's face sheet, dated 06/04/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), Chronic Obstructive Pulmonary Disease also known as COPD (is a progressive, incurable lung disease that restricts airflow and makes breathing difficult depression(sadness), and high blood pressure. Record review of Resident #53's quarterly MDS dated [DATE] indicated she rarely understood and was rarely understood by others. The MDS indicated she had a BIMS score of 00 which meant she was severely cognitively impaired. The MDS indicated Resident #53 required total assistance with her ADLs including transfer. Record review of Resident #53's comprehensive care plan last reviewed date of 04/28/26, indicated Resident #53 was at risk for falls related to deconditioning and cognitive impairment. Resident #53 used a wheelchair for mobility and required 2-person mechanical lift for all transfers. The interventions were to use a mechanical lift, anticipate and meet the resident's needs, apply a bolster mattress, and keep furniture in locked position. Record review of Resident #53's physician order dated 06/04/26 did not reveal an order for a mechanical lift. During an observation on 05/31/26 at 11:31 a.m., Resident #53 was in her bed. CNA Q and CNA O explained to Resident #53 that they were going to assist her to her chair using the mechanical lift. CNA Q and CNA O started connecting the slings to the mechanical lift without locking the wheels of the mechanical lift. CNA Q and CNA O then transported Resident #53 from her bed to her chair and started disconnecting the sling from the mechanical lift without locking the wheels. During an interview on 06/01/26 at 3:11 p.m., CNA O said she thought they locked the mechanical lift prior to getting Resident #53 out of bed and when they placed her in her chair and before they removed the sling from the mechanical lift. She said they should have locked the wheels on the mechanical lift when they connected and disconnected the mechanical lift sling for the safety of Resident #53. During an interview on 06/01/26 at 4:19 p.m., CNA Q said they did not lock the wheels of the mechanical lift when they connected and disconnected the mechanical lift sling for Resident #53. She said they should have locked the wheels on the mechanical lift when connecting and disconnecting for the safety of Resident #53. During an interview on 06/04/26 at 2:55 p.m., LVN K said he was Resident #53's day shift nurse and was responsible for random checks of the CNAs to ensure they were locking the mechanical lift during the transfer process. He said it was important to lock the wheels of the mechanical lift because the residents' weight could shift and cause the residents to fall out of the slings. During an interview on 06/04/26 at 3:01 p.m., the DON said she expected the staff to lock the mechanical lift during the transfer's process. She said they trained on how to use the mechanical lift on hire, annually and as needed. She said she was the overseer of nursing. She said it was important to lock the mechanical lift wheels during the connection and disconnection of the sling to prevent it from moving. She said if the sling moved it could cause the resident to get hurt by falling out or hitting a resident in the head. She said if a resident has an order or if the floor mat was on the care plan she expected the floor mat to be beside the resident's bed. She said nursing staff were responsible for ensuring the floor mat was in place. She said the floor mat was placed beside the bed to prevent further injury. She said the CNAs had access to Kardex. She said Kardex was a communication tool used for staff to see what needs the residents needed for their care. She said she was unaware Resident #2's floor mat was not listed on his Kardex. During an interview on 06/04/26 at 5:20 p.m., the Administrator said she expected the staff to use the mechanical lift as they had been trained. She said when staff used the mechanical lift it should be two staff members and they should lock the wheels to prevent the lift from rolling or causing an injury. She said if a resident had an order or care plan for a floor mat then she expected it to be beside the bed when the resident was in bed to prevent injury. She said the DON was the overseer of nursing. 3. Record review of Resident #39's face sheet, dated 06/04/26, reflected Resident #39 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of Resident #39's significant change in status MDS assessment, dated 04/15/26, reflected Resident #39 made herself understood and usually understood others. Resident #39's BIMS score was 7, which reflected his cognition was severely impaired. Record review of Resident #39's comprehensive care plan, revised on 07/08/25, reflected Resident #39 had impaired cognitive function/dementia and impaired thought processes due to Alzheimer's. The care plan interventions included: keep the resident's routine consistent and try to provide consistent care as much as possible to decrease confusion. During an observation and interview on 05/31/26 at 10:13 a.m., there was a plastic container labeled alcohol wipes, and a bottle labeled sanitizing on Resident #39's dresser. An attempted interview with Resident #39, reflected she was non-interview able due to resident was Spanish speaking only. During an interview on 06/03/26 at 9:03 a.m., CNA M stated all staff were responsible for ensuring items were stored properly and securely. CNA M stated she normally did not work this hall and had not noticed the alcohol wipes nor the sanitizing spray on Resident #39's dresser. CNA M stated the wipes should be stored in the storage room and she did not know if the sanitizing spray was allowed in the facility. CNA M stated it was important to ensure items were not left on the resident's dresser for residents' safety. During a telephone interview on 06/03/26 at 1:59 p.m., RN A stated all staff were responsible for ensuring items were stored properly and securely. RN A stated she never noticed the items on Resident #39's dresser. RN A stated if she had noticed the items, she would have removed the items and gave them to the ADON or DON. RN A stated she was new and did not know where the items should be stored. RN A stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 06/04/26 at 3:14 p.m., the MDS Coordinator stated she was responsible for daily champion rounds for Resident #39. The MDS Coordinator stated during champion rounds she looked for items that should not be in the resident's room. The MDS Coordinator stated she did not notice the wipes and spray during her rounds this morning. The MDS Coordinator stated the wipes, and spray should be stored in the supply cart or on the nurse's/housekeeping cart. The MDS Coordinator stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 06/04/26 at 3:30 p.m., the DON stated she expected the sanitizing spray to be stored on the housekeeping cart, and wipes to be stored either on the nurses' cart or storage room. The DON stated all staff were responsible for ensuring items were stored properly and securely. The DON stated she monitored compliance by ensuring champion rounds were completed by the assigned department head and random spot checks. The DON stated it was important to ensure items were not left on the resident's dresser for residents' safety. During a telephone interview on 06/04/26 at 4:06 p.m., the Administrator stated she expected wipes and sanitizing spray to be behind a locked door or not in the facility. The Administrator stated she did random spot checks, but she expected champions rounds to be done daily by the assigned department head. The Administrator stated it was important to ensure items were not left on the resident's dresser for residents' safety. 4. Record review of face sheet dated 06/04/2026 revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with the primary diagnosis of heart failure. Record review of Quarterly MDS dated [DATE] revealed Resident #52 was able to make herself understood and understood others. MDS assessment revealed Resident #52 had a BIMs score of 15 indicating no cognitive impairment. Record review of care plan dated 04/14/2026 revealed Resident #52 was care planned for resident has family bring food and knife. An intervention was listed as staff will remove knife from room when brought and ensure to assist with cutting food if needed. During an observation and interview on 05/31/2026 at 11:20 a.m. Resident #52 had a kitchen knife on her bedside table. Resident #52 stated that her daughter brought her fruits and vegetables that she uses the knife to cut with. During an interview on 05/31/2026 at 12:00 p.m., LVN K stated that he did not know there was a knife in Resident #52's room. LVN K stated that it was his responsibility to monitor Resident #52's room for hazard items. LVN K stated that Resident #52 was at risk of harming herself with the knife. LVN K stated that he removed the knife from the room and reported it to the DON and Administrator. During an interview on 06/04/2026 at 3:36 p.m., the Social Worker stated that facility staff conduct daily Champion Rounds to ensure residents possess only authorized items and that potentially hazardous items are identified and removed. The SW stated champion rounds were not completed on Sunday, 05/31/2026. The SW stated family members bring items into the facility that are not allowed and stated unauthorized items have previously been found in the resident's room. The SW stated Resident #52 was not supposed to have a knife in her room because she was at risk for harm. During an interview on 06/04/2026 at 3:41 p.m., the Housekeeping Supervisor stated she entered Resident #52's room daily and was expected to observe the environment for safety concerns including sharp objects and other hazards. The housekeeping supervisor stated room inspections occur while cleaning rooms and emptying trash and are intended to identify environmental hazards that Resident #52 was at risk for injury. During an interview on 06/04/2026 at 3:43 p.m., the CNA Q stated he performs rounds every two hours to check on Resident #52 to monitor and identify hazardous materials. The CNA Q stated the resident was not permitted to possess a knife in her room. CNA Q stated she was at risk of harming herself or another resident. The CNA Q stated all staff were responsible for monitoring residents' rooms for safety concerns. During an interview on 06/04/2026 at 3:47 p.m., the ADON stated she was not aware of the knife in the room. The ADON stated she found out Resident #52 had a knife in her room after surveyor intervention. The ADON stated that no residents were allowed to have a knife in their room. The ADON stated that Resident #52 was at risk of harming herself. ADON expected all nursing staff and the Champion rounds to ensure Resident #52's room was free of hazards. During an interview on 06/04/2026 at 4:01 p.m., the DON stated that Resident #52 should not have had a knife in her room. The DON stated that Resident #52 was at risk of harming herself and others. The DON stated that it was the responsibility of nursing staff to check Resident #52's room for the knife. During an interview on 06/04/2026 at 4:56 p.m., the Administrator stated that she was not aware that Resident #52 had a knife in her room until staff brought it to her attention. The Administrator stated that Resident #52 was not allowed to have a knife in her room and she could injure herself or others. The Administrator stated it was ultimately her responsibility to ensure Resident #52's room was safe and clear of hazards. During an interview on 06/04/2026 at 6:33 p.m., the Regional Nurse Consultant stated they do not have a policy for accidents and hazards. The Regional Nurse Consultant stated that they use an admission packet with a list of prohibited items. Record review of the Safety Data Sheet .revised on 06/03/2020 reflected. 2. Hazard(s) identification. Classification: serious eye damage/eye irritation, specific target organ toxicity, flammable liquids. 15. Regulatory Information. keep out of reach of children. Record review of the Safety Data Sheet .revised on 10/15/19 reflected. Hazard Identification.keep out of reach of children. Record review of the facility's policy titled, Hydraulic Lift, undated, indicated, The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer's recommendations. Goals: #1.The resident will achieve safe transfer to bed or chair via a mechanical lift device. 2.The caregiver will demonstrate safe and correct transfer of the residents to the bed or chair via the hydraulic lift. Procedure: #6. Place the chair next to the head of the bed with the front facing the foot . Lock the wheelchair or Geri chair. #7. Raise the bed to accommodate the lift under the bed. #8. Prepare the lift by setting the adjustable base to the widest possible position. Lock the base wheels according to the lift manufacturer's recommendations. Record review of the facility's policy titled, Fall, undated, indicated, Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. Procedure:.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. Interventions will be resident centered.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #67), 2 of 3 medication carts (A/B MA Medication Cart and C/D Nurse Medication Cart) and 1 of 1 Medication Storage Room reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #67's medication labels for his gabapentin (medication used for nerve pain and seizures) and metoclopramide (medication used to treat nausea, vomiting, and improves stomach emptying) matched his physician orders. 2. The facility failed to ensure a bottle of Active Liquid Protein on the A/B MA Medication Cart was dated when opened. 3. The facility failed to ensure one insulin lispro pen, one Breztri (inhaler used to manage breathing problems), and 2 saline nasal sprays on the C/D Nurse Medication Cart were dated when opened. 4. The facility failed to ensure a multi-dose vial of Aplisol (test administered to diagnose TB) 1 ml in the Medication Storage Room refrigerator was dated when opened. 5. The facility failed to ensure a bottle of liquid Ativan (controlled medication used for the treatment of anxiety) was stored in a permanently affixed lock box in the refrigerator in the Medication Storage Room. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #67's face sheet dated 06/02/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis and weakness of the right side of the body after a stroke) and dysphagia (difficulty swallowing). Record review of Resident #67's Quarterly MDS assessment dated [DATE] indicated he was rarely/never understood and rarely/never understood others. Resident #67 had a short-term and long-term memory problem. Resident #67 was dependent on staff for eating. Resident #67's MDS assessment did not indicate a feeding tube. Record review of Resident #67's Order Summary Report dated 06/02/2026 indicatedGabapentin 100 mg give 100 mg via g-tube three times a day with a start date of 05/28/2026Metoclopramide 10 mg give 10 mg via g-tube four times a day with a start date of 05/29/2026. Record review of Resident #67's care plan initiated 05/28/2026 indicated he had a g-tube related to dysphagia and was NPO. During an observation of medication administration with RN H on 06/01/2026 starting at 4:10 PM, the pharmacy label on the medication card for Resident #67's metoclopramide 10 mg instructed give 10 mg by mouth four times a day, and the pharmacy label on the medication card for Resident #67's gabapentin 100 mg instructed to give 1 tablet by mouth three times a day. RN H administered Resident #67's medications via g-tube. RN H said Resident #67 had gone to the hospital about a week ago and had a g-tube placed. RN H said Resident #67 was NPO and received all his medications and nutrition via g-tube. RN H said when the order was changed to g-tube a change of direction sticker should have been placed on Resident #67's medication cards to indicate the route of administration had changed. RN H said the route was one of the rights of medications so it was important it was correct and somebody that did not know Resident #67 was NPO could try to give his medications by mouth. 2. During an observation and interview with MA L on 06/02/2026 at 10:06 AM, the A/B MA Medication Cart had a bottle of Active Liquid Protein that was opened and there was no date indicating when it was opened. The label of the Active Liquid Protein indicated it had a 3-month shelf life from date opened. MA L said she had been instructed that the liquid protein did not have to be dated when opened. MA L said she could not remember who told her she did not have to date it when it was opened. 3. During an observation and interview with RN H on 06/02/2026 at 10:14 AM, the C/D Nurse Medication Cart had one insulin lispro pen, one Breztri inhaler, and 2 saline nasal sprays with no date opened. RN H said the nurse who opened the medication was responsible for dating it. She said she randomly went through the medications on the medication cart and threw away the ones with no open date. RN H said it was important to date these medications when they opened them because they could become ineffective or lose their potency. 4. During an observation and interview with LVN K on 06/03/2026 at 8:42 AM, in the facility's only medication storage room, the refrigerator with medications in it had an open vial of Aplisol 1 ml with no open date on it. LVN K said whoever opened the medication should place an open date on it. LVN K said it was important for medications like Aplisol to be dated when opened because once it was opened it only lasted certain days, and administering past the designated number of days could result in it being ineffective. 5. During an observation and interview with the ADON on 06/03/2026 at 9:07 AM, in the facility's only medication storage room, the locked refrigerator had a lock box with a bottle of liquid Ativan inside of it. The lock box had a chain to it but was not bolted to the refrigerator. The lock box was easily removed from the inside of the refrigerator. The ADON said the lock box had always been detachable. The ADON said the DON was responsible for ensuring controlled medications were stored properly. The ADON said the lock box not being permanently affixed to the refrigerator could result in somebody stealing the lock box and leaving with the controlled medications inside it. During an interview on 06/04/2026 at 4:43 PM, the Administrator said she expected medications to be labeled and dated properly. The Administrator said the DON was responsible for monitoring this. The Administrator said the residents could get expired medications if they were not dated properly. The Administrator said she expected controlled medications to be stored properly. The Administrator said someone could walk away with the lock box if it was not permanently affixed to the refrigerator. The Administrator siad the DON was responsible for ensuring controlled medications were stored properly. During an interview on 06/04/2026 at 5:25 PM, the ADON said insulin pens, the liquid protein, nasal sprays, and inhalers should be dated immediately when opened. The ADON said she and the DON monitored for this, but she was not sure on how frequently they monitored. The ADON said when there was a medication change a change of direction label should be placed on the medication card. The ADON said the label not matching the medication order could result in the wrong medication being administered or the wrong route. During an interview on 06/04/2026 at 5:53 PM, the DON said insulin pens, the liquid protein, nasal sprays, and inhalers should all be dated when opened, so the staff knew when they would expire after being opened and they could be discarded. The DON said she had only been at the facility a couple of weeks, but she tried to spot check the medication carts. The DON said she currently did not have a system in place for monitoring for labeling and dating of medications. The DON said a sticker indicating the route had changed should have been placed on Resident #67's medications. The DON said the charge nurse was responsible for doing this. The DON said the medication could have been administered via the wrong route. The DON said the lock box containing the Ativan should have been permanently affixed to the refrigerator because if it was not somebody could just pick it up and take it out. She said she was not aware it was not permanently affixed, and she, the ADON, and nurses were responsible for ensuring the lock box was affixed to the refrigerator. During an interview on 06/04/2026 at 6:30 PM, the Regional Compliance Nurse said there was no policy for dating medications when opened. Record review of the facility's policy, Ordering Schedule II Controlled Medications, form the Pharmacy Policy & Procedure Manual 2003, indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations. The policy did not further address the storage of controlled medications in a lock box. Record review of the facility's policy, Physician Orders, from the Medical Records Manual 2015, indicated, To monitor and ensure the accuracy and completeness of the medication orders.The receiving nurse will contact any other department or external facilities as required, i.e. dietary department, pharmacy. The policy did not further address labeling medication cards after an order change.

Based on observations, interviews, 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 7 of 22 residents (Resident #67, #2, #13, #57, #21, #19, and # 45) reviewed for infection control.1.The facility did not ensure LVN E performed hand hygiene when providing wound care for Resident #67's who had methicillin-resistant staphylococcus aureus also known as MRSA (is a type of staph that can be resistant to several antibiotics) and who put dirty wipes on his bed linen on 06/02/26.2. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #2 on 06/02/26.3. The facility failed to ensure the Housekeeping Supervisor followed contact precautions while cleaning Resident #13's room. 4. The facility failed to ensure the Social Worker followed contact precautions while placing Resident #13's lunch tray on her bedside table5.The facility failed to ensure CNA O followed enhanced barrier precautions when she provided direct care to Resident #57, who had a catheter, on 06/04/2026 and did not wear a gown. 6.The facility failed to ensure MA G performed hand hygiene and cleaned the blood pressure cuff during medication administration on 06/01/2026. 7.The facility failed to ensure EBP was worn while providing care to Resident #45. These failures could place any resident at the facility at risk for cross-contamination and the spread of infection. Finding included: 1. Record review of Resident #67's face sheet, dated 06/04/26, reflected Resident #67 was an [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis which included stroke, malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it actually consumes), dysphagia (difficulty or discomfort in swallowing), diabetes (high blood sugars), and high blood pressure. Record review of Resident #67's quarterly MDS assessment, dated 05/11/26, reflected Resident #67 rarely made himself understood, and was rarely understood by others. Resident #67's had severe cognitive skills for daily decision making. The MDS indicated he required total assistance with his ADL's including toileting. The MDS indicated he was frequently incontinent of bladder and always incontinent with bowls. The MDS indicated he had venous and/or arterial ulcers and skin tears. Record review of Resident #67's comprehensive care plan, revised on 06/02/22, indicated Resident #67 had an ADL Self Care Performance Deficit related to his stroke. The care plan interventions were for staff to provide assistance x 1 with toileting. Record review of Resident #67's comprehensive care plan revised date of 05/12/26 reflected Resident #67 had arterial/ischemic ulcers (a sore caused by poor blood flow, usually on the legs or feet) related to arteriosclerosis (a broad term for the thickening, hardening, and loss of elasticity in the walls of your arteries). He had arterial wounds on his bilateral heels. The intervention was for staff to monitor/document wound size, depth, margins: peri wound skin, and signs or symptoms of infection. Provide wound care as ordered, obtain lab as ordered, and see wound physician. Record review of Resident #67's physician;s orders dated 05/12/26 indicated: Right heel arterial ulcer: Clean w/wound cleaner; pat dry, apply calcium alginate with silver to the wound bed, and cover with optifoam heel (non-adhesive foam) dressing and secure with Coban self-adherent wrap until resolved. every day shift for wound care. Record review of Resident #67's physician's orders dated 05/14/26 indicated: Cleanse wound to the right buttocks with wound cleanser, pat dry with gauze, and prepare wound with skin prep, place collagen sheet to the wound bed, place calcium alginate with silver on top of collagen, and cover with a border gauze dressing daily and as needed every day for wound care. Record review of Resident #67's physician's order dated 05/19/26 indicated: contact isolation related to MRSA in the right heel wound. Record review of Resident #67's comprehensive care plan revised date of 05/31/26 reflected Resident #67 had contact precautions related to MRSA in his right heel wound. The intervention was for staff to put gown and gloves prior to entering the resident's room, after resident care, remove gown and gloves in the resident's room and place in the container for soiled PPE, and perform hand hygiene after removing gown and gloves. During an observation on 06/02/26 at 1:00 p.m., revealed LVN E performed wound care for Resident #67. LVN E removed the old wound dressing from his right heel, then cleaned area with wound cleanser and applied new dressing without performing hand hygiene after removing the dirty dressing. She then pulled down his linen with the same dirty gloves. LVN E then assisted Resident #67 to turn on his side while touching his skin and clothing with the same dirty gloves. Resident #67 had a bowel movement and LVN E cleaned him while placing the dirty wipes on the bed. LVN E then grabbed a clean brief and applied it while still having on the same dirty gloves. She then removed the old dressing from his right buttock, cleaned the area, and applied clean a dressing while still having on the same dirty gloves from the right heel treatment and incontinent episode of bowel. LVN E then gathered her equipment, removed her gloves, and performed hand hygiene. During an interview on 06/02/26 at 1:54 p.m., LVN E said she did not realize she did not perform hand hygiene or change her gloves after removing Resident #67's old dressing or providing incontinent care. She said she was nervous. She said she should have removed his old dressing, removed her gloves, performed hand hygiene, and applied new gloves before cleaning and applying his new dressing. She said she should have removed her gloves and performed hand hygiene and applied new gloves after she provided incontinent care and before she applied his clean brief. She said she should have placed the dirty wipes in the trash and not on his bed. She said anytime she went from dirty to clean she should have changed her gloves and performed hand hygiene to prevent cross-contamination, infection, and/or further spread of infection. 2.Record review of Resident #2's face sheet, dated 06/04/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include senile dementia (mental deterioration or loss of intellectual ability that is associated with or the characteristics of old age), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), parkinsonism (description for body movements that have become slow, small, stiff, shaky, and unsteady), and muscle weakness. Record review of Resident #2's significant change MDS assessment, dated 03/11/26, indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 12, which indicated his cognition was moderately impaired. The MDS indicated Resident #2 required assistance with toileting. The MDS indicated he had an indwelling catheter and was frequently incontinent with bowels. Record review of Resident #2's physician's orders, dated on 01/10/26, indicated: Urinary Catheter 16french (refers to the diameter of the tube)/10 milliliters (refers to the capacity of the sterile water balloon that holds the catheter) coude (a specialized urinary catheter featuring a curved or bent tip) to gravity drainage every shift. Record review of Resident #2's comprehensive care plan, revised on 03/17/26, indicated Resident #2 had an indwelling catheter related to obstructive uropathy. The interventions were for staff to position catheter bag and tubing below the level of the bladder and in a privacy bag. Record review of Resident #2's comprehensive care plan, revised on 03/17/26, indicated Resident #2 had an ADL Self Care Performance Deficit. The care plan interventions were for staff to provide assistance x 1 with toileting. During an observation on 06/02/26 at 9:29 a.m., revealed CNA N provided incontinent care for Resident #2 who had an indwelling catheter. and was incontinent with bowel. CNA N wiped his front area and then wiped his indwelling catheter tubing only in the middle; she did clean the head of his penis to the middle of the catheter tubing. CNA N changed her gloves but did not perform hand hygiene. CNA N and CNA D assisted Resident #2 to his left side. while keeping the indwelling catheter hooked to the bed frame. CNA N disconnected the indwelling catheter bag from the bed frame and laid it on his bed. CNA N wiped Resident #2's buttock which contained bowel using front to back and back to front motion. CNA N changed her gloves but did not perform hand hygiene before grabbing and applying a clean brief, reconnecting his indwelling catheter to the bed frame, pulling up his pants, and straightening his linen. CNA N then removed her gloves, gathered her equipment, left the room, and then performed hand hygiene. During an interview on 06/02/26 at 9:41 a.m., CNA N said she did not realize she did not perform hand hygiene after wiping Resident #2, front side, his backside, or before touching the clean brief, linen, and pulling up his pants. She said she was supposed to wash her hands when she changed her gloves. She said she knew that without proper incontinent care, or hand hygiene, she could cause cross-contamination and infection. During an interview on 06/04/26 at 2:23 p.m., LVN K said he was the charge nurse for Resident #2. He said he expected staff to use proper techniques when providing incontinent or indwelling catheter care. He said for incontinent care they should change gloves and hand hygiene when going from front to back, and they should only wipe front to back. He said he expected them to do those things to prevent infections. He said if he saw staff doing something wrong, he would correct and educate them. During an interview on 06/04/26 at 3:01 p.m., the DON said she expected the staff to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. The DON said she expected the treatment nurse to perform wound care the correct way without contamination. She said when performing wound care, staff should remove the old dressing (if present), remove the dirty gloves, perform hand hygiene, and apply new gloves. The DON said they went over incontinence care, hand washing, and wound care on hire, and as needed. She said she was the overseer of infection control. She said staff should not put dirty wipes on residents beds, change gloves and practice hand hygiene from dirty to clean to prevent infection, and cross-contamination. During an interview on 06/04/26 at 5:20 p.m., the Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the DON was responsible for ensuring staff were trained on incontinent care, wound care, and infection control. She said improper incontinent care, wound care, and hand hygiene could place residents at risk for cross-contamination. 3.Record review of Resident #13's face sheet, dated 06/04/26, reflected Resident #13 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in mental abilities due to physical brain deterioration in older age). Record review of Resident #13's quarterly MDS assessment, dated 03/12/26, reflected Resident #13 made herself understood and understood others. Resident #13's BIMS score was a 7, which reflected his cognition was severely impaired. Record review of Resident #13's undated comprehensive care plan, reflected Resident #13 was on contact precautions related to shingles (a viral infection that causes a painful rash). The care plan interventions included: put on a gown and gloves prior to entering the resident's room. Record review of Resident #13's order summary dated 06/04/26 reflected an active contact isolation order related to shingles diagnosis every shift for infection control with a start date 05/28/26. During an observation and interview on 05/31/26 at 1:15 p.m., revealed the Housekeeping Supervisor was observed coming out of Resident #13's bathroom without wearing a gown. The Housekeeping Supervisor removed her gloves, performed hand hygiene and reapplied gloves, and went to open Resident #13's window blinds. The Housekeeping Supervisor stated while in the bathroom she cleaned Resident #13's toilet, bathroom sink, swept, mop and took out the trash can. The Housekeeping Supervisor stated she only had to wear a gown and mask if she was touching the resident. During an observation and interview on 05/31/26 at 1:18 p.m., the DON approached where the Housekeeping Supervisor was being interviewed. The DON was asked what PPE the Housekeeping Supervisor should wear while in Resident #13's room and she stated gloves because she was not providing care to Resident #13. During an observation on 05/31/26 at 1:20 p.m., the Social Worker took Resident #13's lunch tray and placed it on her bedside table without wearing a gown and gloves. During an interview on 06/03/26 at 3:34 p.m., the Social Worker stated she was not aware Resident #13's was on contact precautions. The Social Worker stated she thought if she was not touching Resident #13 a gown and gloves did not have to be worn. The Social Worker stated it was important to ensure infection control practices were done to prevent the spread of infection. During an interview on 06/4/26 at 3:30 p.m., the DON stated she was the Infection Control Preventionist for the facility. The DON stated she was caught off guard on 05/31/26 when she asked what PPE should be worn with contact precautions. The DON stated after she thought about it, she immediately went and did a verbal in-service with the Housekeeping Supervisor. The DON stated a gown and gloves should be worn prior to entering the room. The DON stated she monitored infection control practices by random spot checks, skill checks and in-services. The DON stated it was important to ensure infection control practices were followed to prevent the spread of infection. During a telephone interview on 06/04/26 at 4:06 p.m., the Administrator stated she expected a gown and gloves to be worn prior to entering Resident #13's room. The Administrator stated the DON and ADON were responsible for monitoring infection control practices. The Administrator stated it was important to ensure infection control practices were followed to prevent the spread of infection. 4. During an observation and interview of medication administration on 06/01/2026 beginning at 7:50 AM, MA G checked Resident #21's blood pressure and returned the blood pressure cuff to the top of her medication cart. MA G did not clean the blood pressure cuff. MA G administered medications to Resident #21. MA G did not perform hand hygiene. MA G checked Resident #19's blood pressure with the same blood pressure cuff she used on Resident #21 returned the blood pressure cuff to the top of her medication cart. MA G did not clean the blood pressure cuff. MA G prepared and administered medications to Resident #19. MA G said hand hygiene should be performed before and after providing care to the residents. MA G said she should have performed hand hygiene when she finished administering medications to Resident #21 and before administering medications to Resident #19. MA G said the blood pressure cuff should be sanitized between residents. MA G said not performing adequate hygiene could result in the residents catching what the other resident had. MA G said the blood pressure cuff needed to be sanitized because it could get germs on it. Record review of Resident #57's face sheet dated 06/04/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness and paralysis of the right side of the body after a stroke), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Record review of Resident #57's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. Resident #57 had a BIMS score of 15, which indicated his cognition was intact. Resident #57 had an indwelling catheter. Resident #57 was dependent on staff for toileting. Record review of Resident #57's Order Summary Report dated 06/03/2026 indicated urinary catheter 18 fr to gravity with a start date of 06/23/2025. Resident #57's Order Summary Report did not indicate the use of enhanced barrier precautions. Record review of Resident #57's care plan reviewed 05/12/2026 indicated, he required enhanced barrier precautions related to a foley catheter. Resident #57's care plan indicated gloves and gown should be donned if any of the following activities were to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, catheter care, bathing or other high-contact activity. During an observation on 06/04/2026 at 9:13 AM, CNA O entered Resident #57's room, put on gloves, unbuckled his brief, and was touching his brief, penis, and foley catheter for the surveyor to make an observation of Resident #57's penis and foley catheter insertion site. CNA O failed to put on a gown. During an interview on 06/04/2026 at 1:18 PM, CNA O said enhanced barrier precautions should be followed if the resident had a foley catheter. CNA O said she should have put on a gown when she went into Resident #57's room. CNA O said she was in a hurry and forgot to put the gown on. CNA O said it was important for enhanced barrier precautions to be followed to avoid transmitting infections to others. During an interview on 06/04/2026 at 4:49 PM, the Administrator said she expected the staff to follow enhanced barrier precautions and wear the appropriate PPE when providing care to the residents. The Administrator said the facility's infection control preventionist was responsible for ensuring this happened. The Administrator said not wearing the proper PPE could cause an infection. The Administrator said she expected the staff to perform hand hygiene as required, and if they did not it could cause an infection to travel. The Administrator said the DON and nurse management were responsible for monitoring to ensure hand hygiene was performed. The Administrator said the blood pressure cuff should be wiped down between residents. The Administrator said the DON and nurse management were responsible for monitoring to ensure this happened. The Administrator said no cleaning the blood pressure cuff between residents could lead to an infection. During an interview on 06/04/2026 at 5:19 PM, the ADON said a gown and gloves should be applied when entering the room of a resident requiring enhanced barrier precautions. The ADON said a resident with a foley catheter required the use of enhanced barrier precautions. The ADON said the charge nurses and nurse administration were responsible for ensuring enhanced barrier precautions were followed. The ADON said she monitored by making observations when she was walking through the halls. The ADON said not following enhanced barrier precautions could result in infection being spread. The ADON said hand hygiene should be performed before starting medication administration, after preparing the medications, before giving the resident their medications, and when finished administering medications. The ADON said nursing administration was responsible for ensuring proper hand hygiene was taking place during medication administration and she monitored by making observations when she was walking around the facility. The ADON said not performing hand hygiene as required could result in infection being passed from one resident to another. The ADON said the blood pressure cuff should be cleaned between residents. The ADON said the nurses were responsible for ensuring this happened and it was monitored when she walked through the halls. The ADON said not cleaning the blood pressure cuff between residents was an infection control issue. During an interview on 06/04/2026 at 5:46 PM, the DON said a resident with a foley catheter required enhanced barrier precautions when providing direct care. The DON said gown and gloves should be worn when touching the patient in any kind of way. The DON said she was responsible for monitoring, and she randomly checked when she was walking through the facility to see if the staff were following the enhanced barrier precautions. The DON said if a gown and gloves were not worn, they could transfer infections or bugs to other residents. The DON said wearing the gown and gloves protected the residents from infection. The DON said hand hygiene should be performed before starting medication administration and then after, before they moved on to the next resident. The DON said she was responsible for ensuring the staff was performing hand hygiene adequately, and she monitored by checking randomly when she was walking through the facility. The DON said hand hygiene was necessary for infection control because if hand hygiene was not performed when needed they could give germs from resident to resident. The DON said the blood pressure cuff should be sanitized after use, and she was responsible for monitoring to ensure this happened. The DON said she made random observations to ensure the staff were properly sanitizing the blood pressure cuffs. The DON said not sanitizing the blood pressure cuff between residents was an infection control issue. 5. Record review of face sheet dated 06/04/2026 revealed Resident #45 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of other pericardial effusion (heart does not pump blood effectively), benign prostatic hyperplasia with lower urinary tract symptoms (inflammation of the prostate) and obstructive and reflux uropathy (blockage of urine flow). Record review of Quarterly MDS dated [DATE] revealed Resident #45 was able to make himself understood to others and he understood others. MDS assessment indicated Resident #45 had a BIMS of 15 indicating no cognitive impairment. MDS assessment indicated Resident #45 was occasionally incontinent of bladder. Record review of care plan dated 06/04/2026 revealed Resident #45 was care planned for a catheter for urinary retention with the invention of check tubing for kinks and maintaining the drainage bag off the floor. Record review of order summary report dated 06/04/2026 revealed Resident #45 had an order for catheter care every shift started on 05/22/2026. Observation on 06/03/2026 at 9:43 a.m., it was revealed Shower Aide R did not wear EBP when showering Resident #45. Interview on 06/03/2026 at 10:40 a.m., Resident #45 stated that staff did not wear a gown and gloves for EBP when proving him with a shower. Interview on 06/03/2026 at 10:45 a.m., Shower Aide R revealed that she was unaware she needed to wear a gown and gloves when showering Resident #45 with a catheter. Shower Aide R stated it was her job to shower Resident #45. Interview on 06/04/2026 at 11:11 a.m., the LVN K stated Resident #45 was on EBP and he expected all nursing staff to wear a gown and gloves when providing direct contact care to Resident #45. The LVN K stated EBP was to prevent the spread of infection and contamination. Interview on 06/04/2026 at 3:49 p.m., the ADON revealed she expected Shower Aide R to wear PPE when showering Resident #45. The ADON stated Resident #45 was at risk of infection with his catheter. The ADON stated that she was not aware staff were not wearing PPE when providing showers to residents with catheters. Interview on 06/04/2026 at 4:00 p.m., the DON stated she expected all staff to wear a gown and gloves when providing direct contact care to Resident #45 who is on EBP. The DON stated that she expected Shower Aide R to wear a gown and gloves when showing Resident #45. The DON stated that she had spoken to nursing staff about wearing gowns and gloves in the shower but had not had a formal in-service since taking on her role. The DON stated that the gown and gloves were to prevent the spread of infection. Interview on 06/04/2026 4:59 p.m., the Administrator stated that she expected Shower Aide R to wear gown and gloves when showering Resident #45 with a catheter to prevent the spread of infection. The Administrator stated that it was the DON responsibility to ensure nursing staff were aware of the policy and procedures regarding infection prevention. The administrator stated that all direct care staff were supposed to wear a gown and gloves when they provided care to Resident #45. Record review of the facility's policy titled Wound Treatment Management, undated, indicated, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. -Policy Explanation and Compliance Guidelines: #1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions, undated, indicated, Policy: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. #1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty; When hands are visibly soiled (hand washing with soap and water);Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after performing any invasive procedure (e.g., fingerstick blood sampling); Before and after entering isolation precaution settings; Before and after assisting a resident with personal care (e.g., oral care, bathing); Before and after inserting indwelling catheters; Before and after changing a dressing; Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident);.Before and after assisting a resident with toileting (hand washing with soap and water);After contact with a resident's mucous membranes and body fluids or excretions; After handling soiled or used linens, dressings, bedpans, catheters and urinals; After handling soiled equipment or utensils; After removing gloves or aprons; and After completing duty. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infection. Record review of the facility's undated policy, Enhanced Barrier Precautions, indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. Indwelling medical device examples include urinary catheters. Changing briefs or assisting with toileting, Dressing a resident, Any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device don gloves and gown.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 5 residents (Resident #39) reviewed for quality of life. The facility failed to provide communication or translation assistance to effectively communicate with Resident #39. This failure could place residents at risk for declining and diminishing quality of life, and neglect. Findings included:Record review of Resident #39's face sheet, dated 06/04/26, reflected Resident #39 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements).Record review of Resident #39's significant change in status MDS assessment, dated 04/15/26, reflected preferred language was Spanish and she needed/wanted an interpreter to communicate with a doctor or health care staff. Resident #39 made herself understood and usually understood others. Resident #39's BIMS score was 7, which reflected her cognition was severely impaired. Resident #48 could repeat 3 words after the first attempt. Record review of Resident #39's comprehensive care plan, revised on 04/30/24, reflected Resident #39 had a communication problem related to the language barrier. Resident #39's primary language was Spanish. The care plan interventions included: anticipate/meet needs and provide translator as necessary to communicate with the resident. Record review of the facility's undated/untitled form reflected Resident #39 spoke in a non-dominant language. During an interview and observation on 05/31/26 at 10:13 a.m., Resident #39 was sitting on the side of the bed with her family member at bedside. The surveyor began talking to Resident #39 in English and asked if her needs were being met. Resident #39 never replied. Resident #39's family member stated she did not speak English. There was no communication board observed in her room. During a telephone interview on 06/02/26 at 10:20 a.m., Resident #39's family member stated Resident #39 preferred language was Spanish and her communication should be Spanish. Resident #39'ss family member stated at one point approximately six months ago staff (unable to recall names) would call her 2-3 times throughout the night to translate for Resident #38. Resident #38's family member stated it had come to the point where she told them they could not call her in the middle of night because it was hard for her to go back to sleep. Resident #38's family member stated she printed out a list in Spanish with things Resident #38 could want or need to help with providing care and had given it to a CNA (unable to recall name), but she never saw the list in the room. During an interview on 06/03/26 at 9:03 a.m., CNA M stated Resident #38 primary language was Spanish and Resident #38 understood very little English. CNA M stated she knew little Spanish words such as medicine, bathroom, and pain. CNA M stated she mentioned to the Administrator and charge nurse (unable to recall name) about a translator, or Spanish communication board because it was hard to understand what Resident #38 said at times. CNA M stated she was told to utilize staff that could speak Spanish. CNA M stated it was important to ensure effective communication to provide the best care. During a telephone interview on 06/03/26 at 1:59 p.m., RN A stated Resident #38's primary language was Spanish. RN A stated Resident #38 understood simple words in English. RN A stated if Resident #38's family member was not at bedside or there was no staff in the facility that spoke Spanish, she would notify her hospice nurse that spoke Spanish. RN A stated a communication board or translator would be effective for staff that only spoke English to meet Resident #38's needs. RN A stated it was important to effectively communicate with Resident #38 to ensure her wants/needs were met and if there was a problem she could communicate with staff. During an interview on 06/04/26 at 3:30 p.m., the DON stated she had never had a full conversation with Resident #38. The DON stated she spoke broken Spanish. The DON stated she expected Resident #38 to have a proper way of communication for her daily tasks/needs. The DON stated she had mentioned to the Administrator about a device to help translate for Resident #38, but she stated there were several staff members that could speak Spanish. The DON stated it was important to effectively communicate with Resident #38 to ensure her needs were being met.During a telephone interview on 06/04/26 at 4:06 p.m., the Administrator stated she never had a full conversation with Resident #38. The Administaor stated there was an incident she could recall about CNA M asking about how she should communicate with Resident #38 due to her primary language was Spanish. The Administrator stated she told her to utilize the staff in the building. The Administrator stated staff had the ability to use a translator but did not know if staff were aware, it was available. The Administrator stated it was important to ensure Resident #38 was able to communicate effectively to make sure her needs were met. Record review of facility's undated policy titled Resident Rights , reflected. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Information and communication. 1. The facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information may be made available to the patient at their request and expense in accordance with applicable law.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 21 residents (Resident #19) reviewed for resident rights. The facility failed to ensure CNA B treated Resident #19 with dignity and respect, when she failed to identify herself and ensured she wore a name badge while providing care to Resident #19. This failure could place residents at risk of decreased self-worth, loss of dignity and trust, and a diminished quality of life.Findings included: Record review of Resident #19's face sheet dated 06/01/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (deterioration of the brain which leads to cognitive decline, memory impairment, and changes in behavior and personality), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and essential primary hypertension (high blood pressure). Record review of Resident #19's MDS assessment dated [DATE] indicated she was understood by others and understood others. Resident #19 had a BIMS score of 15, which indicated her cognition was intact. Resident #19 was dependent on staff for toileting hygiene. Record review of Resident #19's care plan reviewed 04/21/2026 indicated she had impaired thought processes to engage in simple, structured activities that avoided overly demanding tasks and to provide the residents with a homelike environment. Resident #19's care plan indicated she had an ADL self-care performance deficit and required assistance of one staff member for bathing, bed mobility, dressing, toilet use and transfers. During an interview on 05/31/2026 at 10:02 AM, Resident #19 said there was an African American CNA with brown glasses that did not identify herself and did not wear a name badge. Resident #19 said she did not like that the CNA did not identify herself and did not wear a name badge because she did not know who she was. During an observation and interview on 05/21/2026 at 2:49 PM, CNA B was not wearing a name badge. CNA B said when she provided care, she identified herself and explained to the residents what she was going to do. CNA B said she had worked at the facility for about a month and she had not been provided with a name badge, so she had not been wearing one. She said when she was hired the human resources person told her they were going to provide a name badge for her, but it had not been provided, and she had not asked about it again. CNA B said it was important to identify herself when she provided care and wore a name badge because it was the resident's right to know who she was. During an interview on 06/04/2026 at 4:29 PM, the Administrator said she expected the staff to always introduce themselves and always wear a name tag in a visible area. The Administrator said it was her responsibility to ensure the staff were doing that. The Administrator said usually the name tag was obtained from the human resources coordinator, but they currently did not have one. She said she thought CNA B received a name tag upon hire, but it could have been an oversight. The Administrator said the staff identifying themselves and wearing a name tag was important for the staff to be identified by the residents and this could make the residents feel unsafe. During an interview on 06/04/2026 at 5:03 PM, the Regional Human Resources Specialist said the staff were provided with a name tag in orientation, and if they lost it they could go to them to have it replaced. The Regional Human Resources Specialist said she was not at the facility for CNA B's orientation, and she did not know who was supposed to give CNA B her name tag. The Regional Human Resources Specialist said she was in the facility because the facility currently did not have a human resources coordinator, and the staff could go to her office anytime for a name tag. The Regional Human Resources Specialist said it was important for staff to wear a name tag for everybody to identify what their job title was and what they did and residents would not know who they were or what the care they should be providing was. During an interview on 06/04/2026 at 5:14 PM, the ADON said staff should always identify themselves and wear name tags. The ADON said she, the DON, and the Administrator verified staff were identifying themselves and wearing name tags when they walked around the facility daily. The ADON verified Resident #19's description matched that of CNA B, and she was aware CNA B did not wear name tags as a means of identifying herself to the residents. The ADON said she did not know if CNA B was identifying herself during care, but she was aware she was not wearing a name tag, and she had instructed her to get one from human resources, but she never got it. The ADON said the staff identifying themselves and wearing a name tag was important because the residents would not be able to identify them if they did something to them or they could think it was anybody off the street. During an interview on 06/04/2026 at 5:35 PM, the DON said she expected the staff to introduce themselves and have a name badge on when they walked into the room, so the residents could see who they were and know what they were there for. The DON said she was responsible for ensuring the staff identified themselves and wore a name badge, and she checked this when she was rounding the halls. The DON said she was aware CNA B did not have a name badge and they were not able to get her one because they did not have human resources in the building. The DON said the residents had a right to know who was going into their room and providing care to them, and seeing the staff's name on the name tag may help them to remember who provided care to them. Record review of the facility's undated policy, Resident Rights, indicated, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care .

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 21 residents (Resident #41) reviewed for resident rights. The facility failed to ensure Resident #41's call light was reasonably accommodated to her needs, and her call light was within reach. This failure could place residents at risk for a delay in assistance and a decreased quality of life. Findings include: Record review of Resident #41's face sheet dated 06/04/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified symptoms and signs involving cognitive functions following cerebral infarction (cognitive impairment after a stroke), repeated falls, and essential primary hypertension (high blood pressure). Record review of Resident #41's MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #41 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #41 required partial/moderate assistance with toileting hygiene, dressing, transfers, and supervision or touching assistance with personal hygiene. Record review of Resident #41's care plan reviewed 04/07/2026 indicated she was at risk for falls to be sure her call light was within reach and encourage her to use it for assistance as needed. During an interview on 05/31/2026 at 10:20 AM, Resident #41 said she did not like the current red button (call light) because it was too hard for her to find and she had difficulty activating it. Resident #41 said she reported to 2-3 different staff that she had difficulty activating the current call light but was unable to provide specific names. Resident #41 said she was told by one of the staff (but could not remember their name) they would change her call light out, but it still had not been done. During an observation and interview on 06/03/2026 at 9:39 AM, Resident #41 was sitting in her room in her wheelchair, and her call light was observed on the floor under her bed by the head of the bed behind her. Resident #41 said she did not know where her call light was and she needed water. Resident #41 said since she could not locate her call light she would yelled for help until someone came. During an interview on 06/04/2026 at 2:06 PM, CNA M said she was responsible for ensuring Resident #41 had her call light within reach. CNA M said she was not sure why it was not within Resident #41's reach on 06/03/2026. CNA M said Resident #41 mentioned to her she was having difficulty with the call light with a red button. CNA M said she thought it had been changed to a call light you tap on to activate it, so she was not sure why she had the one with the red button. CNA M said it was important for the residents to have a call light they could use and have it within reach so they could call for help when they needed it. During an interview on 06/04/2026 at 4:32 PM, the Administrator said residents' call lights should be within reach at all times, and the CNAs should be making sure they placed them within reach anytime they were in the residents' rooms. The Administrator said she was not aware Resident #41 was having difficulty activating the call light with a red button. She said they had flat ones, and the call light should have been switched out to accommodate her needs. The Administrator said not having the call light within reach and not having a call light they could easily activate could affect the resident's safety. During an interview on 06/04/2026 at 5:16 PM, the ADON said the residents' call lights should always be within reach, and whoever puts them in their room should ensure the call light was within reach. The ADON said she was not aware Resident #41 was having difficulty pressing her call light. She said they had call light buttons the residents could tap on, and when Resident #41 reported it to the staff they should have switched the call light. The ADON said Resident #41 not having her call light in her room and not having a call light she could easily use could result in her falling or being in any kind of emergency and them not being able to help her. During an interview on 06/04/2026 at 5:37 PM, the DON said she was not aware Resident #41 was having difficulty with her current call light. The DON said she expected the call light to be in reach at all times. The DON said the staff should have provided resident #41 with a touch light she could tap on. The DON said all staff were responsible for ensuring the call light was within reach. The DON said Resident #41 would not be able to call for help if she needed it and it would delay her care or intervention she was needing. During an interview on 06/04/2026 at 6:30 PM, the Regional Compliance Nurse said the facility did not have a policy regarding call lights and ensuring the call lights met the residents' needs.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints (the use of medication to restrict a person's movement or behavior) that were not required to treat the residents' medical symptoms for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. The facility failed to ensure Resident #39 had an appropriate diagnosis on entered orders for her Seroquel, also known as Quetiapine (an antipsychotic medication that treats several kinds of mental health conditions, including schizophrenia and bipolar disorder.) This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.Findings included:Record review of Resident #39's face sheet, dated 06/04/26, reflected Resident #39 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions), and depression (sadness that interferes with daily life). Record review of Resident #39's consent for the use of antipsychotic medication, Seroquel was documented in the chart signed 04/20/24 as the following psychiatric condition and/or maladaptive behavior Alzheimer's. Record review of Resident #39's significant change in status MDS assessment, dated 04/15/26, reflected Resident #39 made herself understood and usually understood others. Resident #39's BIMS score was 7, which reflected her cognition was severely impaired. The assessment reflected Resident #39 received an antipsychotic and antidepressant medication.Record review of Resident #39's comprehensive care plan, revised on 08/13/24, reflected Resident #39 required an antipsychotic medication related to night terrors. The care plan interventions included to discuss with the MD, and family regarding ongoing need for use of medication and monitor/record/report to the MD as needed regarding side effects and adverse reactions of psychoactive medications. Record review of Resident #39's order summary report, dated 06/04/26, reflected an active physician's order for Seroquel 50 mg: 1 tablet by mouth one time a day for sleep with a start date 08/28/25. Record review of Resident #39's medication administration record dated from 05/01/26 through 05/31/26 revealed, Resident#39 received Seroquel oral tablet 50 MG (Quetiapine) Give 1 tablet by mouth one time a day for sleep. Record review of Resident #39's consent for the use of antipsychotic medication, Seroquel was documented in the chart signed 04/20/24 as the following psychiatric condition and/or maladaptive behavior Alzheimer's. During a telephone interview on 06/02/26 at 10:20 a.m., Resident #39's family member stated she was aware of the Seroquel being taken for night terrors. Resident #39's family member stated Resident #39 Parkinson's physician had prescribed her the medication.During a telephone interview on 06/04/26 at 1:59 p.m., RN A stated she was not aware Resident #39 had an Alzheimer's diagnoses for her Seroquel. RN A stated she did not know what diagnosis could be used. RN A stated the nurse that obtained the order should verify with the physician what diagnosis was indicated for the medication. RN A stated it was important to ensure the correct diagnosis was used for the resident safety. During an interview on 06/04/26 at 3:30 p.m., the DON stated Alzheimer's was not an appropriate diagnosis for Seroquel. The DON stated the previous DON was responsible for ensuring the consent had the appropriate diagnosis. The DON stated Resident #39's diagnosis should have been reviewed to see if there was an appropriate diagnosis to meet the criteria and if there was not the MD should have been notified for a GDR (tapering of a medication's dosage over time). The DON stated she had only been in her position for three weeks and time had not allowed her to complete an audit. The DON stated it was important to ensure the correct diagnosis was used to prevent unnecessary medication which could cause heavily sedated. During a telephone interview on 06/04/26 at 4:06 p.m., the Administrator stated she expected the appropriate diagnosis to be used for psychotropic medication use. The Administrator stated she had no clue if Alzheimer's could be used for Seroquel. The Administrator stated the DON was responsible for overseeing and monitoring consents. The Administrator stated it was important to ensure the correct diagnosis was used to prevent unnecessary medication. During a telephone interview on 06/04/26 at 5:26 p.m., the Nurse Practitioner stated Seroquel could be used for sundowners (increased confusion, anxiety, and agitation that peaks in the late afternoon and continues into the night) related to Alzheimer's, but other diagnosis would be reviewed to see what would be most appropriate. The Nurse Practitioner stated the diagnosis should reflect as to why the residents was on the medication and he expected them to have the proper diagnosis. The Nurse Practitioner stated it was important to follow stimulations related to Seroquel but could be a great medication if used correctly. Record review of the facility policy for Psychotropic Medication, revised 02/12/25 reflected. Based on a comprehensive assessment of a resident, the facility will ensure that: a. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.

Based on observation, interviews, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 3 (Residents #13 and #19) residents reviewed for reporting physical abuse. 1. The facility failed to ensure the Administrator reported to HHSC, within 2 hours during the week of 5/25/2026- 5/28/2026 when CNA B grabbed Resident #13 by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her right forearm. 2. The facility failed to ensure the Administrator reported to HHSC, within 2 hours on 05/30/2026, when RN A and LVN C reported to her that Resident #19 alleged CNA B was rough with her while providing care. These failures could place the residents at risk for continued physical abuse. Findings included: 1. Record review of Resident #13's face sheet, dated 06/04/26, reflected Resident #13 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included senile degeneration of brain (progressive decline in mental abilities due to physical brain deterioration in older age). Record review of Resident #13's quarterly MDS assessment, dated 03/12/26, reflected Resident #13 made herself understood and understood others. Resident #13's BIMS score was a 7, which reflected her cognition was severely impaired. Resident #13 required partial/moderate assistance with sit to stand and bed to chair transfer mobility. Record review of Resident #13's undated comprehensive care plan, reflected Resident #13 had an ADL self-care performance deficit related to activity tolerance, fatigue (tiredness), limited mobility and low back pain. The care plan interventions included: independent with bed mobility. Record review of Resident #13's electronic medical records did not reflect a skin assessment completed on 05/26/26 until state surveyor intervention on 05/31/26. During an observation and interview on 05/31/26 at 1:28 p.m., with Resident #13 a bruise was observed on Resident #13's right forearm. When Resident #13 was asked about the bruise, she stated the CNA caused it when she made her go to bed. Resident #13 stated the CNA grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. Resident #13 stated she tried to pull away when the CNA pushed her down and the CNA stated to her don't fight. Resident #13 stated the CNA had long fingernails and when she grabbed her, the mark came up. Resident #13 described the CNA as a black lady, heavy set, and her hair was curled to the side, but was unable to state a name. Resident #13 stated she could not remember the date this incident happened or who she reported it to, but she did report it. Resident #13 stated, this is not the first time this has happened, ever since she has been here, she reaches out and grabs me. Resident #13 stated when she reported this, before, she was told the CNA was just that way. Resident #13 stated, I was really scared. During an interview on 05/31/2026 at 1:05 PM, RN A stated when she was assessing Resident #13 for shingles (a viral infection that caused a painful rash), Resident #13 stated to her I must tell you something that needs to stay between me and you. RN A stated Resident #13 reported to her that the CNA who put her to bed the night before was ruff and pinched her. RN A stated Resident #13 told her she was being forced to go to bed and she was not ready, the CNA insisted it was her bedtime and she put her to bed. RN A stated Resident #13 stated the CNA told her it was her fault because she was fighting her about going to bed. RN A stated Resident #13 did not provide her any names, but said it was a black woman. RN A stated she reported it immediately to the ADON and Administrator the day Resident #13 reported it to her, and the Administrator told her it would be a self-report to state, and she would talk to Resident #13. RN A stated she did not mention the bruise to anyone, but she did not notice the bruise when Resident #13 reported the incident, but she was focused on the shingles. During an interview on 06/01/26 at 9:50 a.m., the ADON stated, on 05/25/26 as she was making rounds prior to supper, she noticed Resident #13 lying in bed. The ADON stated she asked her why she was in bed so early and Resident #13 stated she told me I had to go to bed because everyone else was in bed. The ADON stated she told her she did not have to go to bed early if she did not want to. The ADON stated she offered to get her back up. The ADON stated she did not report the incident to anyone because she did not feel like it was abuse or neglect. The ADON stated the next day (26th) RN A came to her and reported Resident #13 told her a CNA was ruff and pinched her. The ADON stated her and RN A immediately went to the Abuse Coordinator which was the Administrator, and RN A told her what Resident #13 reported, which was the CNA was ruff and pinched her. The ADON stated the Administrator stated, Ok, I will investigate. During an interview on 06/01/26 at 10:22 a.m., the Administrator stated around 5/18/26 forward, the ADON notified her about a complaint that Resident #13 stated she was made to go to bed. The Administrator stated her and the ADON went down to Resident #13 room and informed her it was her right when she wanted to go to bed. The Administrator stated as Resident #13 was mentioning about the CNA making her go to bed, Resident #13 showed her the rash that was identified as shingles (a viral infection that caused a painful rash) under her right side. The Administrator stated she asked Resident #13 if she could identify the CNA and she stated a regular-sized black lady that normally worked that hall. The Administrator stated she looked at the ADON and asked her who the CNA was that worked yesterday, and the ADON stated she would look at the schedule. The Administrator stated after she left Resident #13's room, her and the ADON went to look at the schedule and saw CNA B worked the hall that night before. The Administrator stated she thought she had conducted an in-service on resident rights but could not find the documentation. The Administrator stated CNA B never was suspended or spoken to about the incident and was able to continue to work with Resident #13. The Administrator stated she was not aware of the second incident that involved the CNA been ruff or pinching Resident #13. The Administrator stated the ADON nor RN A reported to her about Resident #13 being pinched or ruff during transfer on 05/25/26. The Administrator stated she was not aware of the bruise to Resident #13's right forearm until after the state surveyor's intervention. The Administrator stated she went down to Resident #13's room on 05/31/26 to start an investigation and when she spoke to Resident #13 about the bruise, Resident #13 stated it happened, when she put me to bed. During an interview on 06/01/26 at 10:46 a.m., the ADON stated she did not notify the Administrator about a complaint herself. The ADON stated when RN A reported Resident #13's allegation to her, they both went to the Administrator's office, and RN A reported the allegation to the Administrator. The ADON stated she did not recall speaking with Resident #13 with the Administrator. 2. Record review of Resident #19's face sheet dated 06/01/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (deterioration of the brain which leads to cognitive decline, memory impairment, and changes in behavior and personality), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and essential primary hypertension (high blood pressure). Record review of Resident #19's MDS assessment dated [DATE] indicated she was understood by others and understood others. Resident #19 had a BIMS score of 15, which indicated her cognition was intact. Resident #19 was dependent on staff for toileting hygiene. Resident #19 was frequently incontinent of urine and bowel. Record review of Resident #19's care plan reviewed 04/21/2026 indicated she had impaired though processes to engage in simple, structured activities that avoided overly demanding tasks and to provide her with a homelike environment. Resident #19's care plan indicated she had bowl and bladder incontinence to provide perineal care after each incontinent episode. Resident #19 had an ADL self-care performance deficit related to fatigue and limited mobility and required assistance of one staff member for toilet use, bathing, bed mobility, and dressing. During an interview on 05/31/2026 at 10:02 AM, Resident #19 said there was an African American CNA who wore brown glasses and worked the 2 PM- 10 PM shift that was rough when she provided care to her. Resident #19 said the CNA did not identify herself and did not wear a name badge, so she did not know her name. Resident #19 said the CNA grabbed her arm roughly and was rough when turning her to provide care. Resident #19 said she told the CNA she needed to stop grabbing her arm so roughly and the CNA told her that's the way she was. Resident #19 said she was scared of the CNA and had reported her to everybody. Resident #19 said the CNA did not work this past weekend, but she provided care to her every day. Resident #19 said one of the girls upfront told her they were trying to figure out who it was, but she was unable to provide a name. Resident #19 said one day last week me and her had it out. Resident #19 said she told the CNA to stop treating her roughly and the CNA told her she did not care if they fired her, she could always work elsewhere. One of the nurses she reported it to was LVN C. During an interview on 05/31/2026 at 1:05 PM, RN A said Resident #19 reported to her yesterday (05/30/2026) morning that an African American woman who wore glasses on the 2 PM-10 PM shift was really rough with her, and she never wanted her to be her CNA again. RN A said she notified the Administrator immediately via text message and she said it would be a self-report to state and to send the DON a text message. RN A said the way Resident #19 was treated was abuse and abuse should be reported to the Administrator immediately to protect the residents from further abuse. During an interview on 05/31/2026 at 1:47 PM, the ADON said CNA B was the CNA that usually provided care to Resident #19 on the 2 PM-10 PM shift and she matched the description provided by Resident #19. The ADON said she did not think CNA B was mean, but she was very demanding and wanted things done her way. The ADON said the Administrator called her yesterday, 05/30/2026, and told her she was filing a grievance because Resident #19 felt her ADLs were rushed by CNA B, but she was not involved in any of the process. The ADON said if a resident reported a CNA was rough it should be reported to the Abuse Coordinator, the Administrator, immediately because it could be considered abuse, and then the CNA should be removed and spoken with. The ADON said it was important for abuse to be reported and investigated because the residents needed to be safe, and if they did not feel safe with a CNA the CNA did not need to be providing their care. The ADON said none of the CNAs were suspended and this places the residents at risk for further abuse. During an interview on 05/31/2026 at 2:06 PM, the DON said she had not received any reports from the residents or staff about any staff being rough with the residents or mistreating them. The DON said yesterday evening, 05/30/2026, she was notified by the Administrator that Resident #19 had reported a CNA was rough with her, but she did not talk to Resident #19. The DON said if a resident reported a staff member was rough with them it should be reported to the Abuse Coordinator, the Administrator, immediately. The DON said the Administrator would then see what the resident was saying and get a statement from the staff member involved, and if deemed reportable follow the abuse policy process. The DON said the staff member would be suspended to protect the residents from further abuse. The DON said an allegation of staff being rough could be considered abuse. The DON said she was not aware of Resident #13 having a bruise or being mistreated. The DON said nothing regarding Resident #13 had been reported to her. The DON said if the staff noticed a new bruise, they should complete a skin assessment, open an incident, monitor the bruise, notify the family and the doctor, and the Administrator usually was notified during the daily clinical morning meetings. The DON said she reviewed the staffing schedule and identified the CNA involved in Resident #19 and Resident #13's incidents as CNA B. The DON said the CNA was working today, 05/31/2026, for her 2 PM-10 PM shift, but would be moved to a different hall. The DON said it was important for abuse to be reported per the facility's abuse policy and for the proper measures to be taken to not place other residents at risk for abuse. During an interview on 05/31/2026 at 2:19 PM, the Administrator said last night (05/30/2026) at 7 PM, LVN C called her and reported to her that Resident #19 reported to her that the CNA from Thursday, 05/28/2026, was rough with her and rushed her when she provided care. The Administrator said she went to the facility approximately 15-20 minutes after she was notified by LVN C to talk to Resident #19. The Administrator said when she spoke to Resident #19, she felt like it was more that CNA B had rushed her. She said Resident #19 told her CNA B rushed her and pushed her over when she was turning her on her side. The Administrator said Resident #19 told her she did not want CNA B back in her room. The Administrator said she filed a grievance and moved CNA B to a different hall. She said CNA B would start her shift today, 05/31/2026, at 2 PM, but would be on a different hall. The Administrator said Resident #19 had no injuries from CNA B being rough with her. The Administrator said RN A reported to her yesterday (05/30/2026) that Resident #19 told her CNA B had been rough with her. The Administrator said she told RN A to report it to the DON. The Administrator said she was not sure if Resident #19 told her CNA B was rough or rushed her. The Administrator said the allegation Resident #19 made should have been reported for abuse and neglect within 2 hours. The Administrator said not reporting allegations of abuse placed the residents at risk for continued abuse. The Administrator said it had not been reported to her that CNA B pinched Resident #13 or any allegations made by Resident #13. The Administrator said if Resident #13 alleged she had been pinched by the CNA it should have been reported to her and she would have reported it to HHSC within 2 hours. The Administrator said if there was an unidentified bruise it should be reported to her and she would report to HHSC within the required timeframe of 2 hours. The Administrator said it was not reported to her that Resident #13 had a bruise on her arm. The Administrator said the staff should not force the residents to go to bed early because it went against resident rights. The Administrator said not reporting allegations of abuse and neglect, unidentified bruises, and not following their abuse policy placed the residents at risk for continued abuse. During an interview on 05/31/2026 at 2:49 PM, CNA B said she had been working at the facility for close to a month. CNA B said if a resident was not ready to go to bed, she would notify the nurse and let the nurse handle it because it was the residents right not to go to bed. CNA B said she had not forced any residents to go to bed. CNA B said she did not rush the residents when she provided care, and she had not received any complaints that she was rough. CNA B said there were no residents' rooms she was not allowed to go in. CNA B said she usually worked on the hall where Resident #13 and Resident #19 resided. CNA B said Resident #19 did not require a lot of assistance with her care that she allowed her to roll herself just gave her a little boost. CNA B said Resident #13 required assistance from one person for rolling and for standing up. She said usually she held her when she was getting up from under her arms to help her push up on her walker to get her to stand up. CNA B said she had never told any residents if she got fired, she could go work somewhere else. She said she was not aware of Resident #13 having any bruises. During an observation and interview on 05/31/2026 at 3:11 PM, RN A showed the surveyor the text message she sent to the Administrator and DON. The message to the Administrator dated 05/30/2026 at 10:08 AM indicated Resident #19 says she never wants the 2-10 aide back in her room, because her aide is being too rough with her. It happens every time she's been on the hall. The Administrator responded, send to DON and let her know. RN A said she took a screenshot of what she sent to the Administrator and the response and sent it to the DON. RN A showed the surveyor the message sent to the DON on 05/20/2026 at 11:02 AM, and it was the screenshot of what she sent the Administrator. RN A said she did not hear from the DON or the Administrator after this. During an interview on 06/01/2026 at 9:58 AM, LVN C said Resident #19 complained to her about one of the CNA's Thursday, 05/28/2026, being rough with her. She said Resident #19 did not report it to her until Saturday, 05/30/2026, at 7:00 PM. She said Resident #19 reported to her the CNA had been rough with her, rolled her over so hard, she hit her head against the bed rail. LVN C said Resident #19 told her it was a CNA with glasses that worked the 2 PM-10 PM shift, and the description fit CNA B. LVN C said she immediately reported what Resident #19 told her to the Administrator, and the Administrator went to the facility. LVN C said she conducted a skin assessment on Resident #19, and she had no injuries. LVN C said she had not received any complaints from the residents or staff about CNA B or any other staff mistreating the residents. LVN C said allegations of abuse should be reported to the Administrator immediately to protect the residents from further abuse. During an interview on 06/01/2026 at 10:40 AM, the Administrator said she was notified by RN A the morning of 05/30/2026 that Resident #19 alleged CNA B was rough with her. The Administrator said she identified it as abuse and told RN A to notify the DON because she was in an area where she did not have good signal and was not receiving messages and calls in a timely manner. The Administrator said she expected the DON to follow up, but the DON said RN A had not notified her of the allegation Resident #19 made. The Administrator said when LVN C reported the allegation Resident #19 made to her the evening of 05/30/2026, she was back in town and decided to go to the facility to speak with Resident #19. The Administrator said since she told RN A to report it to the DON, she assumed the DON had taken care of the situation. She said as the Abuse Coordinator she should have called the DON to follow up and ensure she had taken care of the situation. The Administrator said Resident #19 made an allegation of abuse, and it should have been reported within two hours to HHSC. During an interview on 06/04/2026 at 6:08 PM, the DON said when the Administrator called her the evening of 05/30/2026, she went back to review her messages and realized RN A sent her a screenshot of the message the morning of 05/30/2026 that she sent to the Administrator to report the allegation Resident #19 made. The DON said if she had noticed it when it was sent, she would have called the Administrator, removed the staff member, ensured the resident was safe, conducted a skin assessment, called the family and done all the things per the abuse policy, and reported the abuse to HHSC. The DON said not reporting abuse placed the residents at risk for further abuse and neglect. Record review of the facility's policy, Abuse and Neglect, from the Nursing Policy and Procedure Manual revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #57) reviewed for quality of life. The facility failed to ensure Resident #57 was assisted with incontinent care in a timely manner after his brief had brownish residue/spots on it and he had a bowel movement on 06/03/2026. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.Findings included: Record review of Resident #57's face sheet dated 06/04/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness and paralysis of the right side of the body after a stroke), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Record review of Resident #57's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. Resident #57 had a BIMS score of 15, which indicated his cognition was intact. Resident #57 had an indwelling catheter. Resident #57 was dependent on staff for toileting. Resident #57 was always incontinent of bowel. Record review of Resident #57's Order Summary Report dated 06/03/2026 indicated provide catheter care every shift 03/19/2026. Record review of Resident #57's care plan reviewed 05/12/2026 indicated he had an ADL self-care performance deficit related to stroke and right above the knee amputation. Resident #57 required assistance from one staff for toilet use, bed mobility, and dressing. During an observation and interview on 06/03/2026 starting at 2:42 PM, CNA F unfastened Resident #57's brief pulled it down in front of him and provided catheter care. Resident #57's brief had brownish residue/spots on it from discharge he was having from his penis. After cleaning Resident #57's penis and catheter area, CNA F fastened the same brief back onto Resident #57 and exited the room. CNA F said she was finished. CNA F said she noticed the spots on Resident #57's brief but did not change it because it was just discharge from his penis. After surveyor intervened, CNA F said she would provide incontinent care to Resident #57. CNA F turned Resident #57 onto his side and he had flattened, dried stool on his buttocks. CNA F had to wipe multiple times to get the stool off due to it being dried on Resident #57's buttocks. CNA F said her shift started at 2:00 PM, and this was the first time she had provided incontinent care to Resident #57 since her arrival. CNA F said it was important to provide prompt incontinent care to the residents to prevent skin breakdown and so they could be clean. Resident #57 said CNA M did not change him during her shift. He said she had gone into his room and told him he did not need to be changed. Resident #57 was not aware he had a bowel movement. Resident #57 said he did not recall around what time CNA M had told him he did not need to be changed. During an interview on 06/03/2026 at 2:57 PM, CNA M said her shift was from 6 AM-2 PM, but today (06/03/2026) she had to leave at 1 PM. CNA M said she went in Resident #57's room twice on her shift and the last time she checked on him was before lunch, around 11 AM, and he was not soiled. CNA M said the residents should be checked on every two hours. CNA M said she notified the ADON, who was also the charge nurse for Resident #57's hall that she was leaving, and she assumed the ADON knew she was supposed to check on him because she did not have time to go back to check on Resident #57 before she left. CNA M said it was important to provide the residents with incontinent care to prevent skin breakdown and infections. During an interview on 06/03/2026 at 3:17 PM, the ADON said she was aware CNA M left at 1 PM, but CNA M did not inform her Resident #57 had not been checked on since before lunch. The ADON said the residents should be checked on every 2 hours. She said the CNAs should turn the residents to ensure they were not soiled when they were checking the residents every 2 hours. The ADON said not providing prompt incontinent care could result in skin breakdown, UTIs, and could be considered neglect. During a confidential interview, Anonymous Staff Member #1, said some of the residents have reported to them that CNA M was not providing incontinent care. They said they noticed when starting their shift some of the residents were not changed or heavily soaked. Anonymous Staff Member #1 said they noticed CNA M did not turn the residents to check to see if they were soiled. They said Resident #57 was one of the residents that required being turned and checked because he was unable to tell them if he was soiled. Anonymous Staff Member #1 said they reported it to the ADON and DON multiple times, but nothing changed. They said it was important for the residents to be provided with incontinent care for their cleanliness and to prevent skin breakdown. During a confidential interview, Anonymous Staff Member #2, said they noticed CNA M was not providing incontinent care to the residents like she should. They said they probably should have reported it to the DON or ADON, but they did not report it because they just changed the residents when they noticed it. Anonymous Staff Member #2 said it was important for the residents to receive incontinent care so they did not have any skin issues and so they were clean. During an interview on 06/04/2026 at 4:34 PM, the Administrator said she expected the CNAs to provide proper and prompt incontinent care, and if a resident was dirty, they needed to change them for infection control. The Administrator said the DON was responsible for ensuring incontinent care was provided. The Administrator said not providing incontinent care could result in skin breakdown and infection. During an interview on 06/04/2026 at 5:31 PM, the ADON said within the past 6 weeks it was reported to her that CNA M worked the night shift and left the residents soiled, wet. She did not remember who reported it to her. The ADON said she had provided verbal education to CNA M about changing the residents but had not reported it to the DON or Administrator. The ADON said she was not sure if she was supposed to report it to the Administrator or DON. The ADON said the charge nurses should be ensuring the residents were provided with incontinent care. She said she was the charge nurse for Resident #57 on 06/03/2026, and she did not notice he was not changed. The ADON said if the residents were not provided with incontinent care, it could cause UTIs, skin breakdown, and dignity issues. During an interview on 06/04/2026 at 5:59 PM, the DON said she had not received any reports about residents not being changed from the staff or residents. The DON said she expected the staff to provide incontinent care promptly and to make sure the residents were very clean. The DON said the charge nurses should be monitoring to ensure the residents were provided with the care they required. The DON said if the residents were not provided with incontinent care, it was a dignity issue and could lead to skin breakdown. Record review of the facility's undated policy, Catheter Care, indicated, Provide perineal care to the incontinent resident to prevent skin rashes and breakdown. Record review of the facility's policy, Perineal Care, effective 05/11/2022, indicated, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 3 residents (Resident #1) and 1 of 1 shower rooms (Hall C communal shower) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised after she had been wandering and exit seeking, which resulted in Resident #1 exiting the facility and being found outside the facility in the facility's driveway headed toward a busy public street on 05/17/2025. An IJ was identified on 02/19/2026. The IJ began on 05/17/2025 and removed on 06/13/2025. While the IJ was removed on 06/13/2025, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from spilling coffee on herself on 05/02/2025. The facility failed to ensure a safe environment when the door to the communal shower on Hall C was left open and there were puddles of water on the floor, and an open cabinet inside the shower room had cleaning chemicals in it on 02/18/2026. These failures could place residents at risk of potential accidents, injuries, harm or death. Findings included: 1. Record review of a face sheet dated 02/19/2026 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and was discharged on 05/19/2025 with diagnoses which included dementia severe with other behavioral disturbances (deterioration of memory, language, and other thinking abilities with behaviors), longstanding persistent atrial fibrillation (irregular heartbeat lasting more than 12 months which can lead to health complications), and chronic kidney disease stage 3A (mild to moderate loss of kidney function). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated she was usually understood by others and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 was dependent on staff for toileting, personal hygiene, and showering/bathing self, and required setup or clean-up assistance with eating. The MDS assessment indicated Resident #1 was dependent on staff for transfers. The MDS assessment indicated Resident #1 required supervision or touching assistance with wheeling in her manual wheelchair. The MDS assessment indicated Resident #1 wandered 1 to 3 days in the 7-day look-back period. Record review of Resident #1's care plan indicated the following: Focus with date initiated 01/12/2025 and revised 05/17/2025, indicated she was at risk for wandering, was an elopement risk, and attempted to elope. Interventions with date initiated 01/12/2025 included if the resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member or via call system. Interventions with date initiated 05/17/2025 indicated placed on 1 on 1 supervision, assess/record/report to doctor risk factors for potential elopement such as wandering, repeated requests to leave facility, statements such as I am leaving, I am going home, attempts to leave the facility, elopement attempts from previous facility, home, or hospital, supervise closely and make regular compliance rounds whenever resident is in room, determine the resident is attempting to elope, is the resident looking for something or someone, does it indicate the need for more exercise, intervene as appropriate, provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, and books. Record review of Resident #1's electronic medical record indicated she was an elopement risk on Elopement Risk Assessments with assessment dates of 01/06/2025, 04/06/2025, 05/02/2025, and 05/17/2025. Record review of Resident #1's progress notes indicated: Resident was seen pushing on the door going out to the courtyard. Resident was unable to get out because the door is locked. Signed by LVN A 05/02/2025 4:02 PM. Event-Elopement/Attempted, Door exited B Hall, how long missing 5 minutes, the resident was outside the courtyard by C Hall exit. Cognition / Behavior at Time of Event: Restless, Cognitive Impairment, refuses to call for assistance, Wanders, Exit seeking, The resident was wandering around the facility and was last seen on B hall. The med aid [sic] for C/D was looking for the resident to administrate medication. Staff then begin looking for the resident. LVN C was taking her trash to the dumpster when she said, I saw her out of the corner of my eye, she was by gated area of C hall courtyard on the outside of the gate. Initial Treatment/New Orders: one on one monitoring, Resident Statement: I'm looking for my dog. You can have one too. Signed by LVN A, 05/17/2025 5:58 PM. During an observation and interview on 02/17/2026 at 2:45 PM, LVN C said on 05/17/2026, she was the one who saw Resident #1 outside of the facility in the driveway outside of the gate by the C Hall exit. LVN C said it was towards the end of her shift, and she was taking out her trash to the bins outside of the B Hall exit door. LVN C said she happened to look to her right and saw Resident #1 in her wheelchair in the driveway outside of the gate by the C Hall exit. LVN C said Resident #1 was headed towards the road in her wheelchair. LVN C said she was not Resident #1's nurse that LVN A was her nurse that day, and CNA CC was providing care to Resident #1. LVN C said she called LVN A, and they took Resident #1 back inside the facility for LVN A to assess her, and Resident #1 did not have any injuries. LVN C demonstrated where she found Resident #1. Observation of where Resident #1 was found revealed a narrow driveway approximately 75 feet from the B Hall exit door and approximately 20 feet from the busy public street. During an interview on 02/18/2026 at 4:04 PM, LVN A said on 05/17/2025 when Resident #1 was found outside of the facility in the driveway, the alarm on the door for the exit to the laundry on B hall did not go off. LVN A said before Resident #1 was found outside she had been exit seeking and trying to get out the doors. LVN A said Resident #1 had been exit seeking since she returned to the facility, and she had reported it to the DON. LVN A said she told the DON Resident #1 needed a memory care unit. LVN A said Resident #1 has been roaming around the facility, caught the door behind somebody else leaving, and went outside. LVN A said they were trying to watch Resident #1, when she was roaming the facility. LVN A said she did not remember when the last time she saw Resident #1 was prior to her being found outside. LVN A said Resident #1 could have gotten injured. LVN A said after Resident #1 was brought back inside the facility, she was assessed and had no injuries. LVN A said Resident #1 was placed on one-on-one monitoring until she was discharged to a memory unit. During an interview on 02/19/2026 at 10:51 AM, CNA CC said she was no longer working at the facility. CNA CC said she was the CNA when Resident #1 was found outside in the driveway on 05/17/2025. CNA CC said Resident #1 had been trying to escape the day she was found outside, and it was not the first time she tried to leave the facility. CNA CC said when Resident #1 was found outside she was doing her rounds or passing ice. CNA CC said a nurse was taking out her trash and saw her outside by the gate near the road. CNA CC said Resident #1 was being monitored by rounds every 2 hours, and they were trying to keep her in the day area. CNA CC said the last time she saw Resident #1 before she was found outside, she was rolling around the nurses' station. CNA CC said she did not remember how long it was from the last time she saw Resident #1 to when she was found outside. CNA CC said somebody left the door going to the laundry open. CNA CC said she thought it was a housekeeper who left the door open, but she did not remember who it was. CNA CC said Resident #1 could have gotten hurt, hit by a car, or fallen out of her wheelchair. During an interview on 02/23/2026 at 5:45 PM, the DON said when Resident #1 was found outside on 05/17/2025, she received a phone call from the nurse reporting Resident #1 was found outside, taken back inside the facility, and was not hurt. The DON said Resident #1 was placed on one-on-one monitoring until she was transferred to a secured unit at another facility. The DON said after Resident #1 eloped they completed elopement risk assessments on all the other residents to see who was at risk. The DON said she could not remember everything that was completed after Resident #1 eloped, but they had followed their policy. The DON said when she interviewed the staff working the day Resident #1 eloped, the staff told her Resident #1 had been wandering on the wrong hall asking for her room and had to be redirected. The DON said to her knowledge Resident #1 had not been exit seeking. The DON said Resident #1's baseline was confusion, and she could have rolled out into traffic or fallen. During an interview on 02/23/2026 at 7:11 PM, the Administrator said she started working at the facility on 01/19/2026. The Administrator said her expectations were if a resident was wandering, they should have an elopement assessment completed, and if they were exit-seeking, they should be placed on one-on-one supervision. The Administrator said if a resident was exit-seeking and got out of the facility without the staff's supervision/knowledge, it placed them at risk for injuries. Record review of the facility's undated policy titled, Elopement Prevention, indicated, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record.Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort. Allow the resident to wander in a safe and secure setting, use door locks that are out of reach/sight to prevent wanderers from opening doors, use door alarms or monitoring devices to notify staff when residents try to leave the facility. Physical Plant All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices: Wanderguard system (locking or alarming), Keypad exit magnetic locks, Keyed Alarms, Secured Unit or a combination. The facility had corrected the noncompliance on 05/17/2025 by the following: One on one monitoring of Resident #1 until discharged from the facility on 05/19/2025 Resident #1's care plan was updated Trauma Assessment for Resident #1 Physician notification Elopement risk assessments completed for all other residents Care plans updated for those determined to be at risk for elopement In-service 05/17/2025 on Elopement and Abuse and Neglect Notified families to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Signage placed at visitor exits to be mindful of residents attempting to exit the facility Doors were checked for alarms functioning properly for four weeks Elopement drills were conducted three times per week once every shift Record review completed of the one-on-one monitoring tool for Resident #1 dated from 05/17/2025-05/19/2025. Record review completed of Resident #1's Trauma Informed assessment dated [DATE], did not indicate any negative findings. Record review completed of the Elopement Risk Assessments dated 05/17/2025. The Elopement Risk Assessments indicated Resident #1, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident#16, Resident #17, Resident #18, Resident #19, Resident #20, and Resident #21 were at risk for elopement. Record review completed of Resident #1, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident#16, Resident #17, Resident #18, Resident #19, Resident #20, and Resident #21, care plans and they were all updated on 05/17/2025. Record review of the Resident Transfer Form dated 05/19/2025 indicated Resident #1 was transferred to a facility with a lockdown unit. Record review completed of the elopement drills conducted indicated they were completed as follows: Week 1 05/19/2025 6-2 shift Week 1 05/19/2025 2-10 shift Week 1 05/20/2025 10-6 shift Week 2 05/30/2025 6-2 shift Week 2 05/30/2025 2-10 shift Week 2 05/31/2025 10-6 shift Week 3 06/06/2025 6-2 shift Week 3 06/06/2025 2-10 shift Week 4 06/07/2025 6-2 shift Week 4 06/07/2025 2-10 shift Week 4 06/07/2025 10-6 shift. Record review of the elopement monitoring indicated the doors were checked for proper functioning daily from 05/17/2025-05/21/2025, 05/26/2025-05/30/2025, 06/02/2025-06/06/2025, and 06/09/2025-06/13/2025. Record review of the elopement monitoring indicated visitors were observed through daily rounds for allowing residents to exit the facility unsupervised from 05/17/2025-05/21/2025, 05/26/2025-05/30/2025, 06/02/2025-06/06/2025, and 06/09/2025-06/13/2025. Record review of the Ad Hoc QAPI tool indicated the Medical Director was notified on 05/17/2025. On 02/18/2026 starting at 10:14 AM, observations were made of the signs posted at visitor exits to be mindful of residents attempting to exit the facility. During interviews between 02/17/2026 2:45 PM-02/20/2026 1:54 PM, LVN A, LVN B, LVN C, [NAME] D, NA E, Housekeeper F, PTA G, SLT H, CNA K, LVN L, CNA M, CNA N, CNA O, CNA P, CNA Q, OT R, CNA S, CNA T, LVN U, RN V, OTA W, Housekeeper X, CNA Y, and NA Z were able to verbalize proper procedures for handling a wandering resident, an elopement, and they verbalized understanding of the facility's abuse and neglect policy. All staff interviewed indicated they had been in-serviced on elopement procedures, interventions to implement with a wandering resident, making sure the door locked behind them when they exited and there were no residents behind them. 2. Record review of Resident #1's Order Summary Report dated 02/17/2026 indicated monitor redness to abdomen and left upper thigh for worsening notify the doctor if blistering occurs for 3 days with a start date of 05/02/2025 and end date of 05/05/2025. Record review of Resident #1's care plan indicated the following: Focus with date initiated 01/07/2025, Resident #1 had an ADL self-care performance deficit and was able to feed herself. Focus with date initiated 05/02/2025, indicated she was at risk of burns due to hot liquids and required physical assistance when she had hot liquids, a cup with a lid, clothing/lap protector when drinking hot liquids, and should be seated in an upright position with table or overbed table when hot liquids were being consumed. Record review of Resident #1's Event Nurses' Note-Burn dated 05/02/2025 indicated Burn/Blister, the location was the dining room. The burn was caused by coffee, tea, or other hot liquid. The part of body burned was indicated as, scattered, left side of abdomen small area, and left upper thigh (no measurements indicated). The type of injury, dimensions, appearance indicated blanchable redness to affected areas (no measurements indicated). The cognition/behavior at time of event was cognitive impairment, refused to call for assistance, wandered, required cueing, resists redirection. The nurse description of the event indicated resident spilled coffee on self while in the dining room, resident statement related to event I spilled it all over me, responsible party and physician notified. Other information indicated resident has blanchable redness without complaint of pain. The interventions initiated by nurse indicated lid on cup/mug/glass, supervision when drinking or eating hot fluids, signed by the MDS Coordinator on 05/02/2025. Record review of Resident #1's Weekly Skin assessment dated [DATE] indicated other skin findings spilled hot liquid on 5/5/25 left thigh with redness 5 cm x 1.5 cm and 8 cm x 1.5 cm completed by the ADON. During an interview on 02/18/2026 at 3:38 PM, the MDS Coordinator said she could not exactly remember what happened when Resident #1 spilled coffee on herself on 05/02/2025. The MDS Coordinator said she thought maybe she was the one that found Resident #1 when she spilled coffee on herself. The MDS Coordinator said she was not able to remember if there were any new orders or what the burn looked like. The MDS Coordinator said she documented the burn did not have any blisters and there was blanchable redness. The MDS Coordinator said she believed after the burn they talked about putting lids on Resident #1's drinks. During an observation and interview on 02/18/2026 at 3:45 PM, [NAME] D said he had worked at the facility for four months, and to his knowledge there had been no coffee burns. [NAME] D said when he made the coffee he checked the temperature, wrote it down, and put it on top of the Dietary Manager's desk. [NAME] D said the Dietary Manager was gone for the day. [NAME] D said the coffee was supposed to be 155 F and was not supposed to be higher than 165 F. [NAME] D said if the coffee was higher than 165 F, he could put ice in it or let it sit for a few minutes and re-check the temperature. [NAME] D said if a resident required a lid on their coffee the meal ticket would indicate it. [NAME] D said he was making the coffee for dinner. An observation of the coffee temp was made with [NAME] D. The coffee temperature was 162 F. [NAME] D took the coffee into the dining room and set it out for the residents. During an interview on 02/18/2026 at 4:04 PM, LVN A said she was the nurse when Resident #1 spilled coffee on herself. LVN A said she did not document the incident because she did not witness it. LVN A said she was just told about it by somebody else, but was unable to remember who it was. LVN A said Resident #1 was monitored after the incident, and she did not think it ever blistered. She just had redness. LVN A said after Resident #1 spilled coffee on herself they started putting lids on her coffee. LVN A said she did not do the hot liquid assessments. LVN A said if a resident was observed to be shaky, she would put a lid on their coffee to prevent injuries. During an interview on 02/20/2026 at 1:30 PM, NA Z said she had been working at the facility for about 2 months. NA Z said she had not been instructed that there were certain residents who required a lid on their coffee. NA Z said she noticed sometime lids were placed on coffee cups and sometimes they were not. NA Z said that she was aware there had not been any burns. NA Z said there were some residents who were shaky and could possibly spill coffee on themselves and get burned. During an interview on 02/20/2026 at 1:40 PM, NA E said she had been working at the facility for about 2 months. NA E said lids were placed on the coffee cups here and there. NA E said in the dining room she had just been handing the coffee to the residents without a lid. NA E said she had not been instructed that there were residents who required a lid on their coffee. NA E said she was not aware of any residents getting burned. NA E said if the resident needed assistance, she would put a lid on the coffee because it could burn their tongue. During an interview on 02/23/2026 at 8:12 AM, the Dietary Manager said the coffee temperature should be taken prior to putting the coffee out for the residents, and the temperature should not be more than 140 F. The Dietary Manager said it was important for the coffee temperature not to be too high because it could burn the residents. The Dietary Manager said the residents meal ticket would indicate if they needed a lid on their coffee. During an interview on 02/23/2026 at 4:39 PM, the MDS Coordinator said she did not remember why she did not document any measurements for Resident #1's burn. The MDS Coordinator said measurements should be documented so they could monitor for any changes accurately, and not documenting properly could lead to missing something or worsening of the skin condition. During an interview on 02/23/2026 at 5:45 PM, the DON said she remembered Resident #1 spilled coffee on herself, and they monitored the red spot she has after the coffee spill, but it did not blister. The DON said the doctor was notified and they were instructed to monitor the area for a few days. The DON said they implemented the measure to place a lid on Resident #1's cup. The DON said Resident #1 was not able to get coffee for herself, therefore, the staff had to have given Resident #1 the coffee when she spilled it on herself. The DON said it would have been helpful to have measurements to Resident #1's reddened area after the coffee spill, and a better description of the injury should have been documented. The DON said it was important for an accurate description of the injury and measurements to be documented to be able to see if the injury had improved or worsened. The DON said the staff should be monitoring who is safe to have hot liquids by observations and conducting the hot liquid assessments quarterly. The DON said residents having hot liquids placed them at risk for getting burned and they needed to lessen the risk as much as possible. During an interview on 02/23/2026 at 7:11 PM, the Administrator said the kitchen staff were responsible for ensuring coffee was served between 135-140 F. The Administrator said she did not know how the facility was monitoring to see which residents were safe to get hot liquids. The Administrator said residents with hot liquids were at risk for burns. The Administrator said if a resident received a burn the doctor should be called, and their instructions followed. The Administrator said she expected for a thorough assessment to be completed and for measurements to be taken and properly documented. The Administrator said proper documentation of the injury and measurements was necessary because burns could get worse and it allowed for proper monitoring. Record review of the coffee temperature logs for February 2026 indicated from 02/01/2026-02/17/2026 the coffee temperatures were between 134 F-149 F. The coffee logs for the month of May 2025 were requested from the Administrator and not provided upon exit of the facility. Record review of the breakfast menu for 2/18/2026 indicated the coffee for breakfast was 162 F. Record review of the facility's undated policy, Guidelines on Serving Coffee in the Nursing Facility, 2. the standard for coffee service will be 135 degrees, unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented, or the safety of residents warrants a lower temperature. If coffee is served at 135 degrees, it will cool to 133 degrees when dispensed into a room­temperature coffeecup or mug, and per Time and Temperature Relationship to Serious Burns from the American Burn Association website, this temperature will allow approximately 15 seconds before a serious burn will occur, based on the physical condition of the individual person. 3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability.Process for cooling coffee in the kitchen 1. Brew coffee in kitchen until brewing process is complete. 2. Add xxx (change the xxx to the amount of ice needed to cool the coffee at your facility)- 8 oz cups of ice stir well until ice is dissolved. 3. Take temperature of coffee in TF server, if it is 135-140, then screw on lid tightly and take to dining room to be served. 4. If it is still over 140 degrees, stir until it reaches 140 degrees or less, or add ice, a few cubes at a time, until it reaches 140 degrees or less. Then screw on lid and take to dining room to be served. 3. During an observation on 02/18/2026 at 10:32 PM, the communal shower room located on Hall C door was open and unoccupied. The floor was wet with scattered puddles of water. There was an open cabinet door adjacent to the shower stall with an opened K-Quat spray cleaner bottle and a Tub and Tile Cleaner spray bottle sitting on the second shelf. There was a resident sitting in the hall across from the shower room unsupervised. During an interview on 02/18/2026 at 10:40 PM, LVN U said she was not aware of any resident that had received a bath/shower since she arrived for her shift at 6:00 PM. LVN U said the baths/showers were not scheduled on the 6PM-6AM shift. LVN U said the cleaning supplies should have been behind a closed cabinet and the shower room door should remain closed and locked to prevent accidents such as falls or accidental ingestion of the cleaning supplies by a resident. LVN U said all staff are responsible for the safety of the residents but normally the aide that completed the resident's shower would ensure the shower room door is shut and locked. During an interview on 02/18/2026 at 10:45 PM, CNA T said she worked Hall C. CNA T said she had not assisted any residents with any baths/showers on her shift. CNA T said she had no knowledge of the shower room being used. CNA T said a resident could wander in the shower room and slip or spray the cleaner on their skin or eyes. CNA T said she was busy at the opposite end of the hall and had not noticed the shower room door opened. CNA T said anyone could close the shower room door and lock it at any time. CNA T said it was the responsibility of the last staff member who provided a shower to clean the area, close and lock the shower room door to prevent an accident. During an interview on 02/23/2026 at 6:04 PM, the DON said she noticed upon her arrival that evening that the shower door was open. The DON said she closed the door immediately. The DON expected the nursing staff to pick up, close and lock the shower room door after each use. The DON said that all staff were responsible for ensuring the facility was safe and accident free to protect the residents. The DON said a resident could have entered the open shower room and slipped. The DON said a resident could have entered the open shower room and drank the cleaning supplies. The DON said both instances could have resulted in harm to a resident. During an interview on 02/23/2026 at 07:11 PM, the Administrator said all staff were responsible for preventing and ensuring the safety of each resident. The Administrator said all cleaning supplies should be kept in a cabinet out of access to the residents. The Administrator said the shower door should be closed and locked if there was water on the floor. During an interview on 02/23/2026 at 11:18 AM, the Administrator said they did not have a policy regarding accidents/supervision or to address the shower room and storage of cleaning supplies.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's freestanding closet was secured to the wall resulting in him pulling it down on top of his self when he fell on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), heart failure (a chronic condition in which the heart does not pump blood as well as it should), muscle weakness, abnormalities of gait and mobility (an deviation from a normal walking pattern), and history of falling. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #1 was independent with dressing, personal hygiene, and transfers. Record review of the care plan dated revised on [DATE] indicated Resident #1 was at risk for falls related to impaired vision, history of falling, and weakness with intervention in place including educating Resident #1 on using his call light, call don't fall signs in Resident #1's room, keeping Resident #1's call light within reach, medication reviews, ensuring Resident #1 wore appropriate footwear, and keeping Resident #1's room free of clutter. Record review of an Incident report dated [DATE] indicated Resident #1 had inwitnessed fall and was found in the floor by a CNA. The iIncident report indicated Resident #1 said I was trying to see if my speaker was on and I fell backwards. I landed on my head, I think I broke it. The incident report indicated Resident #1 was transferred to the hospital due to hitting his head, Record review of an incident report dated [DATE] indicated Resident #1 had an unwitnessed fall. The incident report indicated, Responded to resident call light, resident was discovered on the floor in their room. upon assessment resident stated I tried to get to the bathroom from my bed and my legs gave out on me. Resident stated I hit my head on the recliner arm. Upon EMS arrival resident was noncompliant with going. Resident stated I will not go, you have me damned if I do. This nurse educated resident on risks from injury's, resident stated It's just a scrape, I'll be fine. Record review of the Nurse's Progress note dated [DATE] indicated, [the] nurse observed [Resident #1 lying] flat on the floor with the closet toppled over and door was laying on [Resident #1's] left side with head on bottom of bedside table with blood observed on bedside table. [The] nurse and a CNA picked up the closet off of the resident to assess and help resident. Resident was bleeding from a laceration to the back of the head .Resident stated, I was trying to get clothes out of the closet and lost my balance and tried to catch the closet to keep from falling. Resident alert to person and place and time. Resident sent to the ER for further evaluation from the fall due to severity of bleeding and of the closet being toppled over . Record review of the Nurse's Fall Note dated [DATE] indicated Resident #1 had an unwitnessed fall and was discovered in his room with the closet on top of him. The note indicated Resident #1 hit his head when he fell . The Nurse's Fall Note indicated the closet was picked up off Resident #1, pressure was applied to the back of head his head, and he was sent to ER for further evaluation. The Nurse's Fall Note indicated [Resident #1] stated I just lost my balance looking in the closet for pants and I fell holding onto the closet. The Nurse's Fall Note indicated Resident #1 refused to call for help. Record review of the hospital records dated [DATE] indicated Resident #1 had a diagnosis of subdural hematoma (a pool of blood between the brain and its outermost covering). The hospital records indicated Resident #1 had multiple falls. The hospital records indicated Resident #1 started having an altered level of consciousness and was found to have a right subdural hematoma. The hospital record indicated Resident #1's neuro exam deteriorated at the other hospital and became unresponsive a was transferred to this hospital. The hospital records indicated a cat scan at this hospital showed worsening of the right subdural hematoma. The hospital records indicated Resident #1 was in critical condition with the extremely poo prognosis, however his only chance of survival was an immediate craniotomy (a surgical procedure that involves removing a piece of the skull to access the brain). The hospital records indicated Resident #1's was sent to the OR for emergent craniotomy. The hospital record indicated Resident #1 expired on [DATE]. During an interview on [DATE] at 2:10 p.m. the Administrator said on [DATE] at approximately 1:00 a.m. the charge nurse heard a loud noise from Resident #1's room. The Administrator said when the nurse entered the room the resident was lying in the floor with the closet on top of him and door to the closet open. The Administrator said Resident #1 told the nurse he was trying to get some pants, lost his balance, and pulled the closet down with him. The Administrator said the nurse assessed the resident and made the decision to send him to the ER. The Administrator said the charge nurse received a call from the local ER reporting Resident #1 had a subdural hematoma and was being transported to a [NAME] hospital. The Administrator said the family had informed the facility Resident #1 expired at approximately 6:00 pm on [DATE] shortly following surgery. The Administrator said the facility had been informed Resident #1's prognosis was poor. The Administrator said they have requested medical records from both hospitals but had not yet received them. She said she did not believe Resident #1 was taking any blood thinning medication. She said he had a history of falls, was independent, and refused all fall interventions the facility tried to put in place. During an observation and interview on [DATE] at 2:20 p.m. the closets observed in the room were free-standing heavy-duty cabinet/wardrobes. The Administrator said the closets were not secured to the wall at the time of the incident. The Administrator said she had never had a resident pull one of the closets down. The Area Manager said since the incident they have secured all the closets in the building to the walls with L-brackets attached to the wall and the top of the closets. Record review of the facility's Falls/Ambulation policy dated 2003 indicated, .Risk factors should be assessed upon admission and thereafter as necessary .Risk factors include: 1. level of consciousness/mental status 2. history of falls 3. ambulation/elimination status 4. vision status 5. gait/balance 6. systolic blood pressure (the pressure in the arteries when the heart contracts and pumps blood) 7. Medications 8. predisposing diseases .Reducing Environmental Hazards . Record review of the facility's Preventive Strategies to Reduce Fall Risk policy revised [DATE] indicated, The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the residents' mobility. The facility will complete a fall assessment on each resident at the time of admission to the facility. The Fall Assessment Tool will be used to assess the resident's risk of falls until completion of the MDS assessment. The comprehensive MDS assessment will assist in identifying those residents at risk for falls. Residents at risk will be care planned for fall prevention .Incident reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s) .Environment: Keep bed in low position. Keep the bed wheels locked. Use mobility handles or ,d+[DATE] rails in bed, low bed, scoop mattress bolsters, or any combination of the previous. Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed. Maintain adequate illumination in bedrooms and bathrooms. Maintain nonslip floor surface. Keep hallway clear. Provide grab bars and toilet risers in the bathroom . The Administrator was notified on [DATE] at 11:57 a.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 12:00 p.m. The facility had corrected the noncompliance by the following: Securing all free-standing closets to the wall. In-servicing staff regarding fall prevention and monitoring closets for being secured to the wall Monitoring risk management for hazards during daily stand-up meeting 5 days a week for 6 weeks Monitoring all free-standing closets for being secured to the wall 5 days a week for 6 weeks. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: [DATE] Observed free-standing closets in Resident #1's room, the closets were secured to the wall by an L-bracket. The Administrator said all free-standing closets in the facility had been secured to the walls. * [DATE] Observed free-standing closets in 8 randomly selected resident rooms to ensure they were secured to the wall. Staff interviewed (LVNA A, RN B, ADON, CNA C, CNA D, CNA E, MA F) on [DATE] between 10:08 a.m. and 11:00 a.m. were able to answer all question regarding in-services including fall precautions including beds in low position, call light in reach, fall mats at bedside, call don't fall signs, and appropriate footwear to be put in place, fall assessments to be performed quarterly and following each fall incident, monitoring free-standing closets to ensure they are secured to the wall, reporting to maintenance or the Administrator if a free-standing closet becomes unsecured to the wall or broken. Record review of risk management monitoring check-off Record review of free-standing closet monitoring check-off.

Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. The facility failed to ensure Resident #1 did not develop two avoidable facility acquired pressure injuries. The facility failed to initiate new orders for Resident #1. The facility failed to remove the immoblizer boot (a medical device worn during treatment and recovery of a variety of foot injuries - it is a form of immoblizing and weight bearing for injuries to foot areas) and accurately assess Resident #1's right lower leg during weekly skin assessments from 10/02/2023 - 10/18/2023. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for developing new pressure wounds, inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization . Findings included: Record review of Resident #1's face sheet dated January 2, 2024, indicated she was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of Displaced Tri malleolar Fracture of Right Lower Leg (fracture at the ankle joint), Subsequent Encounter For Closed Fracture with Routine Healing, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block air flow and makes it difficult to breathe), Muscle weakness, Senile Degeneration of Brain (a loss of intellectual ability). Record review of Resident #1's physician's order summary dated 10/18/2023 indicated Resident #1 had no wound care orders for her right lower extremity. Record review of the MDS Resident Assessment and care screening Nursing Home Comprehensive Item Set dated September 1, 2023, indicated Resident #1 was cognitively impaired with BIMS score of 07. She was at risk for pressure injuries, and none were noted on this assessment. Resident #1 had no issues with her skin. Record review of the care plan updated on 10/25/2023, indicated Resident #1 had the potential for impairment to skin integrity related to hard case from fracture with a focus of 10/19/2023 pressure ulcer to right lateral calf, 10/19/2023 trauma wound to right medial calf and 10/19/2023 trauma wound to right medial ankle - resolved 10/25/2023. Interventions included 10/19/2023 resident to receive weekly wound care by wound care physician. Monitor and document location, size and treatment of skin injury, Report abnormalities, failure to heal, signs and symptoms infection, maceration etc. to MD. Record review of Resident #1's weekly body skin assessments dated 10/05/2023, LVN B indicated Resident #1 did not have issues with her skin. Record review of Resident #1's weekly body skin assessments dated 10/12/2023, LVN C indicated Resident #1 did not have issues with her skin. Record review of Resident #1's weekly body skin assessments dated 10/19/2023, LVN C indicated Resident #1 did not have issues with her skin. Record review of Resident #1's progress notes dated 10/02/2023, LVN A indicated Resident #1 had returned from a follow-up physician's appointments after removal of the hard cast from right lower extremity with new orders for range of motion to right ankle out of boot, continue with non- weight bearing to right lower extremity, clean ankle once daily with saline and follow-up in four weeks. Record review of Resident #1's progress note dated 10/18/2023, indicated Resident #1 had developed two avoidable pressure injuries on her right lower leg resulting in surgical debridement and infection. On 10/18/2023, the wound care MD was notified of the areas and new treatments were initiated. The resident had a full thickness (the damage extends below the epidermis and dermis - all layers of the skin) wound to her right medial (middle) calf and an unstageable (the depth of the ulcer is obscured by slough - yellow, gray, green or brown substance in the wound bed) full thickness wound to her right lateral - (side) calf. During an interview on 12/27/2023 at 11:15 AM, Resident #1's Responsible Party said Resident #1 was brought home on or about 11/22/2023. Resident #1 Responsible Party said the wounds are almost healed. During an interview on 12/27/2023 at 01:05 PM, RN D said on 10/18/2023, Resident #1 complained of pain to her right lower leg. RN D removed the immobilizer boot and found the three ulcerated areas. RN D said she contacted the wound care physician, DON, and resident's family. RN D said she was the treatment nurse but had not received any notifications to treat Resident #1. RN D said it was the duty of the night charge nurse assigned to Resident' #1's room to do a weekly skin assessment. Attempted telephone call at 12/27/2023 at 11:15 AM, unable to reach LVN B and left a request for return call. Attempted telephone call at 12/27/2023 at 11:18 AM, unable to reach or leave a message for LVN C. During an interview on 12/28/2023 at 1:18 PM, LVN A said Resident #1 returned from her physician's appointment on 10/02/2023 with the boot immobilizer on her right foot. LVN A said the transportation aide handed her the physician's orders for Resident #1. LVN A said she put a progress note into the Resident #1 electronic medical record but failed to enter the new orders she had received. LVN A said it had been a very busy day and she forgot. LVN A said she was Resident #1's nurse and she should have assessed Resident #1 upon her return from the appointment. LVN A said she was educated on the facility's policy regarding entering orders. LVN A said she was in serviced on the appropriate way to perform a head-to-toe assessment and received checkoffs weekly on performing skin assessments. LVN A stated she received disciplinary actions regarding her job duties. LVN A said a new system was in place due to the identified failure. LVN A said the new process was as follows: when a resident left the facility for any appointment and no new orders were received, then the DON contacted the physician's office to ensure there were no new orders. LVN A said the importance of orders entered timely and appropriately was to prevent the resident from neglect and a decline in the resident's health by not receiving services and care. During an interview on 12/28/2023 at 1:30 PM, the DON said the charge nurse was responsible for assessing and updating/inputting any new orders upon a resident's return to the facility after any physician appointments. The DON said the weekly skin assessments were assigned by hall and divided out to the day or night nurse per a schedule. The DON said the night nurse was assigned to Resident #1's room. The DON said LVN B and LVN C had failed to perform proper head to toe assessments from 10/02/2023 through 10/19/2023 on Resident #1 by not removing the immobilizer. The DON said there was a failure in the system which had been identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The DON said she followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders were inadvertently not sent to the facility. The DON said all appointments were now discussed in the staff morning meeting. The DON said LVN A failed to enter the orders upon Resident #1 returning from the physician appointment on 10/02/2023. The DON said she expected head to toe assessments to be completed by removing immobilizers per orders and examining for skin integrity issues to prevent a decline in the health and healing of residents. The DON expected all orders to be entered into the system timely and appropriately to ensure the residents getting all the necessary services and care to promote healthy lifestyles. The DON said all licensed staff were educated with one-to-one weekly skills check-off on head-to-toe assessments, in-services were completed on job duties and responsibilities for charge nurses, staff in-services for abuse and neglect, and disciplinary actions were provided on staff involved in Resident #1's care. During an interview on 12/28/2023 at 1:30 PM, the Administrator said there was a failure in the system which was identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The Administrator said the DON followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator said all appointments were discussed in the staff morning meeting. The Administrator said all staff was educated and in-serviced on abuse and neglect, and immobilizers. All licensed staff was educated and completed weekly skills check offs on head-to-toe assessments. The Administrator said LVN A, LVN B, LVN C had received disciplinary actions. The Administrator said LVN C was no longer employed at the facility. The Administrator said she expected all orders entered timely. The Administrator said she expected head to toe assessments done appropriately according to policy. The Administrator said entering orders timely and appropriate head to toe assessments were vital to providing and promoting healthy resident care. During an interview on 12/28/2023 at 2:08 PM, LVN B said she was the night charge nurse for Resident #1. LVN B said her job duties included weekly skin assessments for Resident #1. LVN B said she should have removed the immobilizer boot and examined Resident's #1 skin. LVN B said she was not sure why she had not fully removed the immobilizer during 10/02/2023 - 10/18/2023. LVN B said the importance of removing the immobilizer and performing full head to toe assessments was to prevent any skin breakdowns that can lead to infections. LVN B said she was in-serviced on her job duties and responsibilities, abuse and neglect, one to one head to toe check offs with performance weekly. LVN B stated she received disciplinary actions from the facility. Attempted telephone call at 12/27/2023 at 2:18 PM, unable to reach or leave a message for LVN C. Record review of the facility's policy revised on 08/12/16 and titled, . Pressure Injury Prevention Program indicated All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. 5. If a pressure injury/ skin breakdown is identified, the following will be done- If a pressure injury/ skin breakdown is identified, the following will be done- If new area found-if pressure injury- complete new wound evaluation / assessment if non-pressure area-complete new wound evaluation / assessment must include: Size, Stage (staged by RN or PT), Location, Drainage amount If odor if present Signs and symptoms of infection if present Wound bed description, Wound edge and surrounding tissue description, How the resident tolerated the wound care If pain with dressing change identified, treatment paused to allow for appropriate pain management before resumption. If pain with dressing change previously identified, confirm order for pain management in place and pre-medication completed per order. Any noted changes in condition requiring new or updated interventions Wound status Notify MD-obtain treatment orders Notify RP/ or family if they are RP or Resident has directed family to be updated Update care plan Note on 24-hour report Referrals to therapy, dietician or other consultant as deemed necessary Monitor weekly via weekly wound reporting and skin integrity quality assurance processes . Record review of the facility's policy dated 2015 titled, .Physician's Orders indicated Written Orders by the Physician or Nurse Practitioner . 3. The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the order was received Record review of in service dated 10/26/2023 of sixteen licensed staff with one-to-one education on skin integrity, pressure ulcer (injury) prevention and treatment, and abuse and neglect, and inputting MD orders included LVN A, LVN B, and LVN C. Record Review of inservice dated 10/26/2023 of sixteen licensed staff completed competencies checks for performing skin assessments and inserviced on what to do when a resident was admitted with immobilizer/boot in place without orders to remove, when to remove to assess skin and pulses including LVN A, LVN B, and LVN C. Record Review of the documented facility completed skin sweep dated 10/18/2023 of all residents resulted in no new concerns. Record Review of Disciplinary Actions completed on 10/26/2023 with LVN B and LVN C over incomplete skin assessments and with LVN A who failed to put in the orders. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 8 CNAs (4 from each shift (CNA E, CNA F, CNA G, CNA H, CNA K, CNA L, CNA M, CNA N) were able to identify and define abuse and neglect, state the procedure of skin assessments and who to report to with questions and concerns. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 6 LVNs (3 from each shift (LVN A, LVN B, LVN O, LVN P, LVN Q, LVN R) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON and the Administrator immediately per procedures. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 4 RNs (RN T, DON, RN D, and the Regional Compliance Nurse) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON, physicians and/or the Administrator and family immediately per procedures. During interviews on 01/02/2024 from 08:00 AM to 5:00 PM., the Administrator, DON, Regional Compliance Nurse and LVN A said the DON was responsible for following up on new orders by ensuring all orders were entered into the electronic health system after the residents' physician appointments, and by contacting the physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator, DON, Regional Compliance Nurse and LVN A said all appointments were discussed in the staff morning meeting. Record review of a QAPI Committee Report dated 10/26/2023 indicated that there was a meeting held consisting of the Administrator, the assistant Administrator, the DON, the ADON, the MDS nurse, the social worker, and the Medical Director. The following interventions were put in place: In-service: re-education to staff on how to maintain skin integrity On 12/28/2023 at 03:46 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before survey began.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidnts for 1 of 7 residents sampled for accidents. (Resident #7) The facility failed to ensure CNA D used the proper two persons transfer according to his care plan instead of a sit to stand lift to transfer. Resident #7 had had open heart surgery and the use of the lift pressed up against his chest which caused him pain. The facility failed to ensure the residents comprehensive assessment was followed and the resident was not transferred in a manner that caused him pain and discomfort. This failure could place residents at risk of anxiety, injury, and pain. Findings included: A hospital face sheet dated 4/22/22 indicated Resident #7 received a cardiothoracic surgery (heart and blood vessel surgery). A hospital radiology report dated 4/22/22 indicated Resident #7's status was post sternotomy (incision made through the breast bone). A Record Review of an admission record indicated Resident #7 was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of acute congestive heart failure, chronic [CONDITION(S)], [CONDITION(S)] heart disease, limitation due to disability, acute respiratory failure with [CONDITION(S)], and a non-ST elevation (NSTEMI) [CONDITION(S)] infraction. (partial blockage of one of t coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle.) Review of MDS dated [DATE] indicated Resident #7's BIMS score was 15 (cognitively intact.) He required extensive assistance with transfers of two people. Record review of Resident #7's Baseline Care plan Summary dated 4/26/22 indicated he required set up help only with eating. All other ADLs he required one person assistance, with hygiene, transfers, toilet use, bed mobility, walking in the room, and locomotion on the unit. Record review of Resident #7' Occupational Therapy Plan of Care dated 4/27/22 indicated the patient presented with sternal precautions. (do not reach both overhead, out to the side or behind the back. Do not lift over 8 pounds, do not push with your arms, do not pull with your arms.) Record review of a facility Physical Exam for Resident #7 dated 4/27/22 indicated assessment and diagnoses indicated sternal precautions completed by the NP. Record review of Resident #7's Xray report dated 4/29/22 indicated a single chest view. The clinical indication was dyspnea/respiratory concern. The lungs were clean, and the impression was of no acute cardiopulmonary process. Record review of Resident #7's nursing notes dated 5/4/22 at 5:27 p.m., indicated the nurse removed 34 staples and 2 sutures, the resident tolerated the procedure well. Record review of Resident #7's nursing notes dated 5/9/22 indicated he was discharged home. During an interview on 7/12/22 at 10:01 a.m., the Therapy Director said she could not find any physician orders that said Resident #7 was on any special precautions. However, per the notes the resident was on sternal precautions. The precautions were no lifting over 10 pound, no lifting arms over head more than 90 degrees. During an interview on 7/12/22 at 1:50 p.m. Resident #7 said he asked CNA D not to use the sit to stand lift to transfer him. He said she would not listen. During the transfer she knew she caused him pain and did not care. She argued with him and was rude. He said CNA D placed him on the toilet and did not come back. Resident #7 said he told the DON and the Administrator about the treatment he received from CNA D. He was informed she was terminated two days later due to patient care. The Administrative staff placed a sign in his room over his bed that stated how he was supposed to be transferred. During an observation and interview of a sit to stand transfer on 7/12/22 at 3:12 p.m. showed CNA A and CNA J transferring Resident #2. They put Resident # 2's feet on the bottom of the lift. They placed a pad around his back that was attached to a belt. The belt was tightened in the front. During the transfer the belt was tighten again to make sure it was secure. There was a therapist in the room at the resident's request to ensure the transfer went smoothly. The Therapist said he would not use a sit to stand lift with someone who had just had open heart surgery. The belt could aggravate the surgical wound and or cause them pain. During an interview the DON on 7/12/22 at 3:19 p.m. She remembered Resident #7 had problems with a transfer. She said Resident #7 did not think the aide should have used a sit to stand lift to transfer him. CNA D had told her Resident #7 could not stand. The DON said she was shocked to see him leave a few days later waking. The DON said basically, his concern was the aide transferred him with a sit to stand lift and he did not want to be transferred that way. She said she did not remember him making a complaint that she hurt him. The DON said she did not know why he received the X ray the next day. He just did not like CNA D at all. The DON said CNA D was terminated, but it had nothing to do with Resident #7. During an interview on 7/12/22 at 4:02 p.m., the Administrator said Resident #7 complained about an aide transferring him the wrong way. The Administrator said she and the DON sat down and talked to Resident #7 one on one. She said the resident told CNA D he did not like to be transferred with the sit to stand lift, and the aide told him he needed to be transferred that way because he could not bear 50 percent of his weight. The Administrator said CNA I was the other aide in the room. The administrator said the resident did not complain of pain. The next day we did an Xray because he said his chest did not feel right. The Administrator said she had completed a grievance form but could not find it, she also said she had obtained statements. During an interview on 7/13/22 at 12:01 p.m. LVN E said Resident #7 was her resident for a little while. She said Resident #7 said he was transferred unsafely by CNA D. She said he asked her repeatedly to stop and she would not. He complained of severe pain during and after the transfer. She said there did not appear to be anything wrong with his cognitive status, he was very with it and very knowledgeable. LVN E said he had the x ray because he started to have the pain underneath his chest cavity. He received an in house Xray the next day because he was hurting. During an interview on 7/13/22 at 1:39 a.m. CNA I said she tried to tell CNA D not to use the sit to stand lift on Resident #7. Resident #7 told her over and over he did not want to be transferred with the sit to stand lift. The resident said he did not like it; he was scared of the lift because he had open heart surgery. He told her not to do it, the whole time and she kept right on strapping him to the lift. CNA I said CNA D did not listen to Resident #7 or to her. CNA I said, I told her one last time, she turned to me and put her finger in my face and told me I am doing this. CNA I said CNA D told Resident #7 we cannot lift you we have to do it this way, we are a lift free facility. CNA I said she did not know the resident; it was her first time seeing him. She said when she and CNA C got him off the commode, we stood him up with a walker and he did good. He did not need the lift. During an interview on 7:13/22 at 1:53 p.m. with CNA C said Resident # 7 was upset by the whole incident with CNA D. He was holding his chest and said he was in pain. She said CNA D worked mostly as a medication aide had lifted Resident #7 with a sit to stand lift. She said he had just had open heart surgery, you could see the stables in his chest, he started having chest pains. CNA C said she knew not transfer a patient with a sit to stand lift that just had open heart surgery. She said the aide left him on the toilet still hooked up to a sit to stand lift and she was not supposed to do that. CNA C said when she and CNA I went in to get him off the toilet. They asked Resident #7 what he could do? He said he could stand. She said he just needed his walker. She said Resident #7 was able to do for himself if you helped him stand. CNA C said CNA D was a medication aide and was working as a CNA. She said after the incident They put instructions on Resident #7's wall on how to transfer him. The aide said she was educated on who to transfer with a lift, and they were not supposed to transfer an open heart surgery resident with a sit to stand lift. Record review of a job description for Resident Care Specialist (certified nursing assistant) completing assignments including but not limited to following safety rules and requirements including lift and transfer procedures, most safely operate mechanical lift sit to stand, and gait belts. The job description was signed by CNA D on 6/29/21. Record review of CNA D's Competency Use for Mechanical Lifts indicated performance criteria was to identify and define correct lift and sling type, sizes, and uses for residents. Determine the dependency categories, resident size, cognition, comfort, and special needs. Remove sling from Residents unless clinically contraindicated, see care plan. CNA D signed the form on 3/23/22. CNA D had a checklist performed on the sit to stand transfer. A checked off was completed on 3/23/22. The form was signed as met by the DON

Based on observation, interview, and record review the facility failed to provide necessary behavioral health care services to maintain the highest psychosocial wellbeing for 1 of 3 residents reviewed for behavioral services. (Resident #1) The facility failed to ensure Resident #1 received counseling services when requested and prescribed by the NP for almost a month. This failure resulted in Resident #1 being hospitalized due to making suicidal statements. This failure caused the resident to suffer emotional trauma and anxiety. Findings include: Record Review of Resident #1's admission record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan dated 6/21/22 indicated a Focus area of Resident was a category 4 for transfer, transfers were to be completed with a mechanical lift with 2 staff. A Focus area of a history of exclaiming suicidal ideations and wishing he was not alive. He has a history of anxiety, depression, and behavior issues. The interventions are to redirect the resident when he is upset or feeling down, refer to the emergency room as needed, and he is seen by Counseling Agency. (An initial date of 5/24/22) A Focused area with a history of verbal aggression to staff. The resident will get frustrated when not put to bed when he wanted, he will yell at staff and call them names as a result, he followed staff and recorded them with his phone. (an initial date of 5/3/22) Record review of Resident #1's Progress Note/History completed by the nurse practitioner dated 4/29/22 Indicated resident number one was seen for routine visit to evaluate condition. The resident is a [AGE] year old Caucasian male with a past history of significant for [CONDITION(S)], [CONDITION(S)], diabetes mellitus type 2, uncontrolled hypertension, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] bladder, [CONDITION(S)] bowel, [CONDITION(S)], and spinal cord injury with [CONDITION(S)] . He is seen for routine evaluation of condition. One of the Plans was to consult with counseling agency to manage [CONDITION(S)] disorder, anxiety, an [CONDITION(S)]. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 5/17/22 for [MEDICATION(S)] 150 mg and [MEDICATION(S)] 75 mg. On 5/23/22 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/22/222 at 9:11 p.m. Resident #1 was Screaming, crying, shaking and bedrails. He stated he wanted to die and end it all. Resident # 1 stated he did not want to live like this anymore. The resident was upset due to paralysis status, and nursing home placement. The nurse attempted to calm the resident. Resident #1 complained of pain in his back, head, and bladder. He stated it was a 10 out of 10 pain level. Tylenol number three was given as ordered. A Telehealth physician was notified of the resident's behavior complaints. An increase in [MEDICATION(S)], a new order was [MEDICATION(S)] 2 milligrams one time dose was ordered and scheduled psychiatric evaluation. A Telehealth evaluation (audio and video conference) with a medical doctor dated 5/22/22 at 9:11 p.m. indicated Resident #1's chief complaint was agitation. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He is currently frustrated about having to live in a nursing home. He stated he did not want to live anymore and wanted to die. He did not have a plan. Medications was offered and he calmed down. Offered to transfer him to the hospital but he refused. He said he does not want to kill himself but is frustrated with his current living situation. He needs psychiatry and psychology to see him. Record review of Resident #1's (notes) dated on 5/23/22 at 4:14 p.m. dressed Resident #1's toe with kerlix. The resident stated, Let's just put that around my neck. The Resident had those behaviors last night hitting his own chest and stating, I wish my heart would just stop. Record review of Resident #1's (notes) dated on 5/23/22 at 6:22 p.m. the Resident will be sent to the hospital emergency room due to making suicidal statements. Record review of Resident #1's notes dated 5/23/22 at 7:04 p.m. the Administrator and DON spoke to Resident #1 about his suicidal statements. He laughed and said it was just a joke. He said he did have anxiety and depression due to his current physical state and would go to the emergency room . He said he was referred to a counselor as requested. Record review of Resident #1's (notes) dated on 5/23/22 at 11: 30 Resident #1 returned to the facility. Record Review of facility Provider Investigation Report dated 5/23/22 indicated Resident #1 a [AGE] year-old male BIMS score 15, required excessive assistance with ADLs, he ambulated around the facility with a motorized wheelchair. On May 23, 2022 Resident #1 made suicidal statement to the unit manager who reported to the administrator and the DON. Upon communication with Resident #1 reported he requested to be seen by a counselor due to increased anxiety. He said he told the nurse practitioner weeks ago but had not seen one yet. He felt as though he was being neglected. The administrator assured the resident he would we looked into it with it is a local emergency room . The investigation verified the NP had written an order on 4/29/22 for Resident #1 to receive counseling. The Social worker was out for a few days and LVN E said she had placed the order in the Social Workers office. In serviced management staff and nursing staff of neglect and counseling referral process in the event the Social worker is absent. The report included a statement from the NP who said she had seen Resident #1 and he did request to see counselor due to increased anxiety. She wrote and order and gave it to LVN E. Record Review of and in service conducted 5/23/22. The in service indicated in the event that the Social Worker is out of the office and a referral to a counselor, eye doctor, podiatrist, ear, nose, and throat by physician. Those need to go to the Administrator to ensure they have been completed in a timely manner. Failure to do this could result in neglect of care both physical and mental to the resident. Record review of Resident #1's hospital records dated 5/23/22 indicated the patient presented with concerns from the nursing home of statements that he made about self-harm. The patient stated he was talking to his wife last night and made some comments about his just wanted it all to be over. He was Speaking of the nursing home issues. He also made a comment tonight about wrapping a cord around his neck. They sent him to the hospital for an evaluation. He denied wanting to harm himself at this time and knew the comments were taken out of context. He said he had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He did think his anxiety was worse. He reported his anxiety medication had been decreased recently and that was his main concern. Record review of Resident #1's Counseling assessment dated [DATE] indicated the resident had moderate depressive symptoms and severe anxiety. He dismissed comments that suggested suicidal ideations. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident had the ability to adapt to situations and respond in the way he believed is expected. He tended to be tangential/circumstantial in responding to questions and not easily redirected. He placed emphasis when responding on comments that would elicit empathy or sympathy or achieve personal gain. The plan was to treat anxiety and depression. During an interview on 7/7/22 at 4: 49 p.m., the DON said Resident #1 said he wanted to commit suicide, but when they tried to send him to the hospital. He said he was just playing. He said he did not want to go. But after they threaten to call the police he did go to the hospital. She and the MDS nurse said Resident #1 was manipulative. They said the Ombudsman was at the facility on yesterday 7/6/22, and they had a care plan meeting. The care plan meeting was to address Resident #1's issues he that he needed to give the staff at least 30 minutes to get him to bed. During an interview 7/11/22 at 11:44 a.m. Resident #1 said he did not feel like he would hurt himself. He said he took medications for depression. Resident #1 said he was on medications but felt they did not fully address his symptoms at that time. He said had an anxiety attack while on the phone with wife. Resident #1 said there were quite a few things going on at that time like, he had not seen his dogs in months. He was experiencing a lot of pain in his back. He was asking his wife to make it stop. Resident #1 said he told the nurse to make an appointment with his back doctor. He said he had back surgery and had been in a wheelchair for months. Resident #1 said it was depressing to be depend on others for care and they acted like they did not want to do anything for him. Resident #1 said he had asked to see a psychologist about a month prior to going to the hospital. Resident #1 said he saw a psychologist after coming back from the hospital. During an interview on 7/11/22 at 12:23 p.m. the Administrator said on 5/22/22 Resident #1 was crying and upset and he had a telehealth visit. The next day the NP saw him and wrote the order to increase his [MEDICATION(S)]. The Administrator said she along with the Social Worker went to talk to him about his statements, he wanted to put something around his neck. He said he had some anxiety and depression. During an interview on 7/13/22 at 10:51 a.m. the Social Worker said Resident #1 told the NP he was depressed and felt he needed to see a counselor on 4/29/22. The Social worker said she was out for a few days during that time. Apparently, the normal process was not followed, and the order was not followed. The Social Worker said she was not aware of the order until Resident #1 said he requested to see a counselor. The Social Worker said the normal process was the NP or doctor wrote an order. The Social Worker said she had to have an actual order to make the referral and consent form. Once these things were obtained, they were faxed to the counselor office. The counseling office did their checks and then sent out a counselor. After Resident #1 went to the hospital there was an in-service for when Social Worker was unavailable. The staff should give the referral to the administrator to handle. During an interview on 7/13/22 at 11:30 a.m. Resident #1 said he talked to the NP around the last of April about seeing a counselor, no one said anything else to him until after her went to the hospital. Resident #1 said it was after his hospitalization that he saw a counselor. During an interview on 7/13/22 at 12:01 p.m. LVN E said on 4/29/22 she asked the NP to check on Resident #1 because he said he was depressed. The NP gave her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices was provided for 1 of 6 resident reviewed for accidents. (Resident #1) The facility did not place Resident #1's call light within reach. The resident fell from her chair while attempting to reach for the call light and sustained a fractured left ankle. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk for injury, pain and decreased quality of life. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The order indicated Resident #1 was to receive the following pain medications: [REDACTED] *[MEDICATION NAME] HCL 50 mg 2 times daily for pain with a start date of 11/16/18; *Tylenol 500 mg 2 tabs every 6 hours as needed for pain. with a start date of 11/29/18; *[MEDICATION NAME] 1 mg every 12 hours as needed for pain with a start date of 7/20/19 and a discontinuation date of 10/28/19; *Tylenol #4 ((300 mg Tylenol and 60 mg [MEDICATION NAME]) every 6 hours as needed for pain with a start date of 10/20/19. An MDS assessment dated [DATE] indicated Resident #1 was understood and understood others and her cognition was moderately impaired. The MDS indicated she required extensive assistance of two persons with bed mobility, transfers, dressing, toileting and personal care. The assessment indicated she required a wheelchair for ambulation and extensive assistance with locomotion on and off the unit and she had decreased ROM in left lower extremity. The assessment indicated Resident #1 was frequently incontinent of bladder and always incontinent of bowel. A care plan initiated 11/18/18 indicated Resident #1 had a history of [REDACTED]. The care plan indicated she was incontinent of bowel and bladder and required 2 staff for toileting, dressing and personal hygiene. A care plan dated 6/22/19 indicated Resident #1 had a risk for falls related to history of left knee replacement and history of falls. Interventions included Resident #1 required extensive assistance of 2 staff to turn and reposition in bed, dress, toileting and transfers with gait belt. The interventions included for staff to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed and provide prompt response to all requests for assistance. An incident report dated 10/14/19 at 8:00 p.m., indicated Resident #1 was found sitting on the floor with her back against her recliner. The report indicated she said she was reaching for her call light and slid out of her chair. The report indicated Resident #1 denied injury. The report indicated Resident #1's call light was out of her reach. An x-ray report dated 10/15/19 at 4:22 p.m., indicated Resident #1 had an acute fracture to her left ankle. The report for Resident #1's x-ray indicated possible osteopenia (weak bones) or [MEDICAL CONDITION] (bone density is reduced) likely chronic [MEDICAL CONDITION] remodeling of the fibular (calf bone) tip and grossly displaced medial malleolar fracture (break in the back of the large bone in the lower front portion of the leg) with diffuse (over a large area) soft tissue swelling. During an interview on 1/3/19 at 12:43 p.m., the DON said on 10/15/19 Resident #1 complained of pain to her left foot and an x-ray was completed on 10/15/19. She said the ADON checked the results of the mobile x-ray via the computer within 4 hours of the x-ray and the results indicated there was no evidence of an acute fracture for Resident #1. The DON said the resident continued to request pain medication after the fall and the medication was reported to be effective by the resident. The DON said on 10/19/19 after continued pain, swelling and bruising the resident was sent to the ER and an x-ray confirmed a fracture to her left ankle. She said on 10/19/19 after receiving the results of the x-ray completed at the hospital, she requested Resident #1's x-ray results from the mobile x-ray completed on 10/15/19. She said the faxed results from the mobile x-ray indicated Resident #1 had a left ankle fracture. The DON said the mobile x-ray failed to call the critical results or fax a copy of the results to the facility. The DON said the charge nurses were responsible for following up on x-ray results. She said residents awaiting x-ray results were placed on the 24-hour report for follow-up. The DON said the ADON checked the mobile x-ray online and verbally reported to the charge nurse the finding indicated Resident #1 did not have a fracture. The DON said there should have been documentation of the results and a call to mobile imaging for the report. A MAR indicated [REDACTED] *[MEDICATION NAME] (scheduled) for pain 2 times daily *10/2/19 - [MEDICATION NAME] 1 mg at 5:39 a.m.- pain level 8 *10/4/19 - Tylenol 500 mg at 9:42 p.m.- pain level 8 *10/12/19 - Tylenol 500 mg at 11:30 a.m. - pain level 5 *10/14/19 - Tylenol 500 mg at 9:52 p.m.- pain level 7 *10/15/19- Tylenol 500 mg at 8:08 p.m.- pain level 8 *10/16/19 - [MEDICATION NAME] 1 mg at 11:34 a.m.-pain level 8 *10/17/19 - [MEDICATION NAME] 1 mg at 10:44 a.m.-pain level 9 *10/19/19 - Tylenol 500 mg at 2:45 a.m.- pain level 7 *10/21/19 - Tylenol #4 at 3:31 p.m.- pain level 6 *10/21/19 - Tylenol #4 at 9:33 p.m.-pain level *10/22/19 - Tylenol #4 at 11:19 a.m.- pain level 6 *10/23/19 - Tylenol #4 at 6:57 a.m.-pain level 6 *10/23/19 - Tylenol #4 at 2:46 p.m.- pain level 6 *10/23/19 - Tylenol #4 at 11:58 p.m.- pain level 8 *10/24/19 - Tylenol #4 at 6:52 a.m.- pain level 6 *10/24/19 - Tylenol #4 at 3:31 p.m.- pain level 6 *10/25/19 - Tylenol #4 at 11:27 a.m.- pain level 9 *10/29/19 - Tylenol #4 at 4:30 p.m.- pain level 7 *10/30/10 - Tylenol #4 at 5:55 a.m.- pain level 6 *10/30/19 - Tylenol #4 at 3:11 p.m.- pain level 7 *10/31/19 - Tylenol #4 at 10:45 a.m. pain level 8 A MAR indicated [REDACTED] *[MEDICATION NAME] (scheduled) for pain 2 times daily *11/2/19 - Tylenol #4 at 4:00 p.m.- pain level 7 *11/4/19 - Tylenol #4 at 9:31 a.m.- pain level 7 *11/6/19 - Tylenol #4 at 12:99 p.m.- pain level 7 *11/7/19 - Tylenol #4 at 6:46 a.m. - pain level 8 *11/10/19 - Tylenol #4 at 11:53 p.m.-pain level 6 *11/15/19 - Tylenol 500 mg at 2:45 a.m.- pain level 5 *11/15/19 - Tylenol #4 at 10:54 a.m.- pain level 6 *11/17/19 - Tylenol #4 at 6:51 a.m.- pain level 8 *11/21/19 - Tylenol #4 at 7:31 a.m.- pain level 7 *11/23/19 - Tylenol #4 at 9:55 a.m.- pain level 7 A nursing progress noted dated 10/19/19 at 4:21 p.m., indicated Resident #1 reported continued pain and swelling in her left ankle. The note indicated the left ankle was elevated, swollen, bruised and tender to touch. The note indicated Resident #1 requested to go to the emergency room for a second opinion. An after-visit summary report dated 10/19/19 indicated Resident #1 received x-rays at a local hospital and was diagnosed with [REDACTED].#4 every 6 hours as needed. The summary report indicated Resident #1 was to follow up with an orthopedic specialist in 1 week. A physician visit report dated 10/24/19 indicated Resident #1 saw an orthopedic specialist and was directed to continue the orthopedic boot and current pain medications. An after-visit summary dated 11/14/19 indicated Resident #1 was seen by the orthopedic specialist and received an order to discontinue the orthopedic boot. During an interview on 1/3/19 at 10:14 a.m., CNA K said Resident #1 was compliant with the use of her call light for assistance with transfers and mobility before and after her fall in (MONTH) 2019. CNA K said the resident did not complain of pain after she fell on [DATE] but she complained her left foot was tender to touch. She said Resident #1 was able to bear weight on her right leg and pivot during transfers before and after fall on 10/14/19. She said Resident #1 did not bear weight on her left leg before or after fall because of knee pain. The CNA said she was in-serviced on fall prevention, lock wheel chair during transfer, keep frequently used items within reach, keep call light beside the resident and encourage use. During an interview on 1/3/19 at 10:43 a.m., CNA [NAME] said Resident #1 was able to transfer with the assistance of 2 staff prior to her fall. She said the resident was aware of her own safety and always used the call light for assistance before and after her fall on 10/14/19. CNA [NAME] said after the resident fell on [DATE] she continued to transfer the same as before the fall. She said she was in-serviced on fall prevention, abuse and neglect and proper placement of call lights after Resident #1 fell . The CNA said the in-service included effects of a fall in the elderly, how to recognize residents at risk of falls and to assure wheel chairs are locked during transfers, walkers are easily accessible for those that transfer independently and to remind residents of safety measures when in the room. During an interview on 1/3/19 at 11:02 a.m., LVN B said Resident #1 was compliant with use of the call light before and after her fall. She said the resident would not attempt to get up without assistance before and after she fell on [DATE]. LVN B said the resident complained of pain after she fell , and it was relieved with PRN medication for pain. LVN B said she was in-serviced on tracking x-ray results, using a tool to document the date, resident name, x-ray ordered, time completed, time results received and add to the 24-hour report if results not available before end of shift. She said she was in-serviced on assuring call lights were in place, wheel chairs were locked during transfer and items the resident frequently used in reach, nonskid socks or shoes were in use, floors were dry and pathways clear. LVN B said the staff were in-serviced on abuse and neglect every month during the staff meeting. During an interview on 1/3/19 at 11:14 a.m., CNA H said Resident #1 stayed in her recliner most of the time. She said the resident used her call light when she needed anything, and she had not witnessed her get up without assistance. CNA H said Resident #1 required assistance of 2 staff and a gait belt when transferring before and after her fall on 10/14/19 and her mobility had not changed. CNA H said she was in-serviced after Resident #1's fall on how to recognize residents at risk of falls and to assure wheel chairs were locked during transfers, walkers were easily accessible for those that transfer independently, call lights were within reach, the floor was clean, dry and no objects were in the way and to remind residents of safety measures when in the room. During an interview on 1/3/19 at 2:23 p.m., CNA F said Resident #1 used her call light when she needed assist before and after her fall because she knew she could not safely transfer without assistance. She said after the resident fell on [DATE] staff were in-serviced on call light placement, fall precautions and abuse and neglect. CNA F said she was instructed to make sure the floor was clean, dry and no objects were in the way and to remind residents of safety measures when in the room and call light was within reach. During an interview on 1/3/19 at 2:30 p.m., LVN A said after Resident #1 fell on [DATE] she was in-serviced on call light placement, fall precautions and tracking the results of x-rays. She said when an x-ray was ordered the charge nurse would document the resident, date, x-ray or lab ordered, time completed, when the results were received and put all information on the 24 hour report. During an interview on 1/3/19 at 2:43 p.m., LVN D said Resident #1 was aware of her own safety and used the call light for assist with transfers before and after her fall. She said after Resident #1 fell on [DATE] she was in-serviced on fall precautions, call light placement and following up on x-ray results. LVN D said when an x-ray or laboratory test was ordered the charge nurse documented the date, resident name, x-ray / laboratory test ordered, time completed, time results were received and add to the 24-hour report if results were not received during the shift worked. She said she was in-service on assuring call lights were in place, wheel chairs were locked during transfer and items the resident frequently used were in reach, nonskid socks or shoes are in use, floors were dry and pathways clear. During an interview on 1/3/19 at 3:01 p.m., the DON said on 10/14/19 at approximately 8:00 p.m., Resident #1 fell from her recliner in her room. She said staff reported the resident did not initially complain of pain or injury and was assisted back to her chair. She said the resident reported she was reaching for the call light when she fell . The DON said she confirmed with staff the call light was out of reach of the resident when she was found on the floor. She said she began an in-service on 10/15/19 regarding call light placement being within the reach of the resident. She said she and the ADON conducted the in-service with all staff members and created a monitoring tool to ensure call light placement. The DON said on 10/21/19 she in-serviced all staff on fall prevention, assuring the resident's floor were clean, dry, clutter free, wheel chair was locked during and after transfer, walker was within reach, call light within reach and reminders to the resident to use the call light for assistance. She said she put a process in place to assure x-ray results were received and reviewed by the nurse. The DON said she instructed the ADON and charge nurses to use a spread sheet to document the resident, date, time and x-ray or lab ordered. The DON said the charge nurses were instructed to document the time laboratory test/x-ray was completed, the time of results and what the results were and to document on the 24-hour report if waiting for the report/results and pass on to the oncoming nurse for follow up if not received prior to end of shift. During an interview on 1/3/19 at 3:48 p.m., the administrator said she expected the staff to follow up on resident x-rays for the results. She said the staff were expected to ensure all call lights were within reach of the resident. The administrator said the staff had been in-serviced and a monitoring plan was put in place to prevent further failures. A fall prevention and management policy indicated . implementation to prevent falls . keep the call light positioned so it is within the residents reach at all times. The surveyor determined the facility was in non-compliance from 10/14/19 - 10/22/19. The facility took the following actions to correct the non-compliance: *During an interview on 1/3/19 at 3:48 p.m., the administrator said the QAPI committee met on 10/21/19 and implemented a monitoring plan of action to prevent recurrence of the incident. She said staff were to follow up on resident x-rays for the results using the monitoring tool. She said the staff were to ensure all call lights were within reach of the resident and use the monitoring tool for compliance of call light placement. *10/15/19 - The DON and ADON in-serviced staff on fall prevention and ensuring call lights were within the residents reach. *A monitoring log dated 10/21/19 indicated staff began daily monitoring for call light placement . The document indicated call lights were within reach or placed within reach during the monitoring. The monitoring tool was dated through 1/3/19. *An in-service dated 10/19/19 indicated the DON in-serviced staff on abuse and neglect. *An in-service dated 10/21/19 indicated the DON in-serviced the staff on fall prevention. The in-service documentation included to be aware of the residents fall risk status, keep the call light positioned within reach and assure placement each time staff was in the room and before leaving the room; place the residents personal belongings (tissues, purse/wallet. books or remote), walker, wheelchair, urinal or bed side commode all within reach of the resident. The in-service included to lock the wheels on the resident bed and wheelchair and keep the bed in the lowest position, keep the resident room uncluttered and the floor surfaces clean and dry with clear pathways and assure proper footwear is in use. *An in-service dated 10/21/19 indicated the DON in-serviced licensed staff on following up after x-rays were completed. The in-service indicated the DON instructed the ADON and charge nurses to use a spread sheet (made available and kept at the nursing station) to document the resident, date, time and x-ray or laboratory test ordered. Charge nurses were to document the time laboratory test/x-ray was completed, the time of results and what the results were and to document on the 24-hour report if waiting for the report/results and pass on to the oncoming nurse for follow up if not received prior to end of shift. *A monitoring log dated 10/22/19 indicated staff began monitoring the date an x-ray was ordered, completed and results obtained. On 1/3/19, the surveyor determined interventions were completed by: *6 LVNs were interviewed and indicated they received training prior to the surveyor's entrance regarding, monitoring residents call light placement, fall precautions, abuse and neglect and following up on x-ray results. *9 CNAs were interviewed and indicated they received training prior to the surveyor's entrance regarding resident safety, call light placement, fall precautions and abuse and neglect.

Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of 19 residents reviewed for behavioral health services. (Resident #49) The facility did not identify the need for and obtain behavioral health services when Resident #49 indicated on multiple occasions she wanted to die and demonstrated repeated episodes of anxiety and tearfulness. This failure could place residents with behavioral health needs at risk of not receiving needed services and treatments and a decreased quality of life. Findings included: The consolidated physician orders [REDACTED].#49 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #49 could be seen and treated by a mental health worker. The orders indicated busiprone for anxiety was started on 1/3/19 and [MEDICATION NAME] for depression was started on 1/25/19. The MDS dated [DATE] indicated Resident #49 had moderate cognitive impairment and was able to understand and could make herself understood. The MDS indicated she was depressed or hopeless for several days and had trouble sleeping or sleeping too much nearly every day. The MDS indicated Resident #49 had behavioral symptoms including physical symptoms or verbal vocal symptoms such as screaming, or disruptive sounds. Resident #49 required extensive assistance with most ADLs including transfers, dressing, toileting and personal hygiene, was incontinent of bowel and had a urinary catheter. The MDS indicated Resident #49 received an antidepressant for the duration of the lookback period. The care plan dated 1/7/19 indicated Resident #49 made constant noises while in bed; interventions included administer medications as ordered, observe for side effects and effectiveness; anticipate and meet resident's needs. The care plan indicated Resident #49 was resistive to care at times and would yell at staff, become agitated and cry; interventions included educate resident/family, praise resident when behavior was appropriate and provide consistency in care. The care plan indicated Resident #49 received an antidepressant; interventions included staff would sit and talk with resident when she was feeling depressed. The care plan indicated Resident #49 had a [DIAGNOSES REDACTED]. A progress note dated 12/22/18 indicated Resident #49 was yelling, help me. Resident #49 stated she did not want to be alone. A progress note dated 1/2/19 indicated Resident #49 was yelling, I don't care if I fall in the floor, I want to die. A progress note dated 1/3/19 indicated Resident #49 refused for the treatment nurse to conduct wound care and said she did not want to be bothered and she just wanted to die. During an interview on 1/30/19 at 4:08 p.m., the treatment nurse said she should have notified the DON, MD and SW when Resident #49 told her that she wanted to die. She said that she did not follow up on this statement. During an observation and interview on 1/28/19 at 9:50 a.m., Resident #49 was lying in bed crying, please help me, please get me out of here. Resident #49 was hallucinating that people were standing over her against the wall. Resident #49 was inconsolable, she continued to say, please help me, help me get out of here. During an observation on 1/28/19 at 2:00 p.m., Resident #49 was crying in her room, asking to go home. During an observation on 1/28/19 at 2:41 p.m., Resident #49 was lying in bed, pleading to go home. During an interview on 1/28/19 at 3:19 p.m., LVN E said Resident #49 had behaviors of yelling out wanting to go home since she was admitted . She said the behaviors had changed in that she would now hallucinate. A progress note dated 1/28/19 indicated Resident #49 was seeing a little boy and a monkey in her room, insisting staff to get them out of here. Staff notified Resident #49's son and the physician. During an interview on 1/30/19 at 8:47 a.m., CNA M said Resident #49 would cry and yell out at times, she said she figured she was in pain and would let the nurse know. During an interview on 1/30/19 at 2:56 p.m., RN D said that if a resident continually stated they wanted to die she would report it to the DON and MD. During an interview on 1/30/19 at 3:03 p.m., the social worker said no one had advised her of Resident #49 saying she wanted to die. She said they normally would get a psychological consult and or a psychological evaluation. During an interview on 1/30/19 at 3:16 p.m., RN F said if a resident told her that they wanted to die she would tell DON, MD, family and ensure there was follow up with psychological counseling or treatment. During an interview on 1/30/19 at 4:15 p.m., the DON said if a resident verbalized they wanted to die that staff should notify the SW, administrator and if they had a plan to harm themselves, they would need to possibly be sent for a psychological evaluation or treatment. She said no one had reported to her that Resident #49 wanted to die. During an interview on 1/30/19 at 4:21 p.m., the administrator said if a resident said they wanted to die that the SW should be notified to follow up and assess resident. She said they would talk to family, get counseling or send out for treatment. The undated social services policy indicated the facility would conduct social service assessment and history for each resident in the facility to identify the specific factors that impact the resident's psychosocial well-being, functioning and to provide appropriate services as indicated.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent development of pressure injuries for 1 of 5 residents reviewed for pressure injury. (Resident #71) The facility did not provide treatment and interventions for Resident #71's deep tissue injury on her right 4th toe and did not provide repositioning and offloading for a stage 3 pressure injury on her right buttock. This failure could place residents at risk for development of new pressure injuries and worsening of existing pressure injuries. Findings included: The physician orders [REDACTED].#71 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. An order started on 1/23/19 indicated to cleanse area with normal saline, pat dry and apply santyl ointment to wound bed follwed by wet to dry gauze and cover with dry protective dressing. The admission MDS assessment dated [DATE] indicated Resident #71 did not have a pressure injury. The most recent MDS dated [DATE] indicated Resident #71 was understood by others and understood others. The MDS assessment indicated Resident #71 required extensive assistance of two staff for bed mobility and transfers, was frequently incontinent of bladder, always incontinent of bowels and had 1 stage 2 pressure injury. A care plan updated on 1/24/19 indicated Resident #71 had a stage 3 pressure injury on her coccyx and required repositioning and turning at frequent intervals to provide pressure relief. A weekly pressure ulcer report dated 1/18/19 indicated Resident #71 had a stage 2 pressure injury on her right buttock and it measured 1.5 cm x 1 cm x 0.1 cm. The report indicated the date of onset was 12/12/18 and the wound had deteriorated. A weekly pressure ulcer report dated 1/24/19 indicated Resident #71 had a stage 3 pressure injury to her right buttock (coccyx) and it measured 1.5 cm x 1.2 cm x 0.1 cm. The report indicated the resident had a blood blister on her right fourth toe with no measurement, description or treatment. During an observation and interview on 1/28/19 at 3:25 p.m., Resident #71 was lying on her back on a low air-loss mattress with the sheet and blanket on her feet. She was alert and oriented and answered questions appropriately. She said she was unable to use her right arm due to a previous stroke. Resident #71 said she was unable to turn or move herself in the bed and she had a sore on her bottom that required treatment. During an observation on 1/29/19 at 8:33 a.m., Resident #71 was asleep, lying on her back with the bed sheet and blanket on top of her toes. During an observation and interview on 1/29/18 at 9:15 a.m., the treatment nurse provided wound care for Resident #71. The resident was lying in bed on her back with the bed sheet and blanket on top of her toes. The resident had a pressure injury on her coccyx, the treatment nurse said it was a stage 2 prior to admission to the hospital on [DATE]. She said when the resident was discharged back to the facility on [DATE] it was a stage 3. During wound care the stage 3 pressure injury measured 1.5 cm x 1 cm x 0.3 cm. The wound bed was moist, pink with pink edges. A non-blanchable area was observed on Resident #71's left buttock that measured 1.3 cm x 1 cm. The treatment nurse said she did not remember if the area was present during the dressing change on 1/28/19. Resident #71 was noted to have a deep tissue injury on the front of her right fourth toe. The treatment nurse measured the area as 1 cm x 1 cm and said it was a blister. The wound was dark purple, and the edges were black. The front of the resident's right great toe, second and third toe had non- blanchable redness. The treatment nurse said the resident did not ambulate or wear shoes and the blister on her 4th right toe was caused from the blanket applying pressure on her toes. She said since the injury was over a bony prominence it would be considered a deep tissue injury. During an observation on 1/29/19 at 11:30 a.m., Resident # 71 was asleep, lying on her back with the bed sheet and blanket on top of her toes. During an observation on 1/29/19 at 1:31 p.m., Resident # 71 was lying on her back with the bed sheet and blanket on top of her toes. During an observation on 1/29/19 at 2:32 p.m., Resident # 71 was asleep, lying on her back with the bed sheet and blanket on top of her toes. During an interview on 1/29/19 at 2:40 p.m., the treatment nurse said Resident #71 did not have a stage 1 pressure injury on her left buttock during the dressing change on 1/28/19. The treatment nurse said she did not know what to do to prevent further breakdown on Resident #71's toes. She said she would try heel protectors to raise the blanket off her feet. During an observation on 1/29/19 at 3:22 p.m., Resident # 71 was lying on her back with the bed sheet and blanket on top of her toes. She did not have on heel protectors. During an interview on 1/29/19 at 3:23 p.m., CNA G said Resident #71 should be turned and repositioned every two hours. CNA G said Resident #71 did not resist care and did not complain or refuse to be turned or repositioned. During an observation on 1/29/19 at 4:04 p.m., Resident # 71 was lying on her back with the bed sheet and blanket on top of her toes. She did not have on heel protectors. During an interview on 1/29/19 at 4:12 p.m., CNA K said Resident #71 required the assistance of two CNA's to turn and reposition and should be turned every two hours. She said the resident did not resist or refuse repositioning. During an observation on 1/30/19 at 8:15 a.m., Resident # 71 was in bed with her head elevated. A CNA was feeding her breakfast and the bed sheet, blanket and a pillow were on top of the resident's feet. Resident #71 did not have on heel protectors. During an observation and interview on 1/30/19 at 8:54 a.m., Resident # 71 said she laid on her back most of the time. She said she was unable to move in the bed and staff had to assist her. Resident #71 said she did not want to bother the staff to move her off her back. She said staff did not turn her during the day. She continued to have the bed sheet and blanket on her toes and she did not have on heel protectors. During an interview on 1/30/19 at 9:01 a.m., LVN D said Resident #71 should be turned every two hours to prevent new or worsening pressure areas. She said the resident should have a foot cradle to prevent further injury to her toes. During an interview on 1/30/19 at 10:01 a.m., the treatment nurse said Resident #71 should be repositioned every two hours and she should have a tent over her feet. The treatment nurse said she should have implemented an intervention when the deep tissue injury was discovered on 1/23/19. During an interview on 1/30/19 at 9:37 a.m., the DON said the treatment nurse should have implemented an intervention for Resident #71 at the onset of skin breakdown. She said she expected the treatment nurse to provide care in a manner to promote healing and prevent further skin breakdown. The DON said she expected staff to turn and reposition dependent residents. A policy titled Skin Management dated (YEAR) indicated .resident receive care to aid in the prevention worsening of wound pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing and prevent new ulcers from developing . staging classification . stage lll .full thickness loss of skin, in which fat tissue is visible. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 2/5/19 indicated the following: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance was provided to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident #1) The facility failed to monitor Resident #1 while she sat out in the sun in the courtyard, in temperatures exceeding 93 degrees Fahrenheit, for an undetermined amount of time. Resident #1 suffered a heat stroke [MEDICAL CONDITION] the soles of her feet, requiring a hospital stay. An Immediate Jeopardy was identified that existed from 5/26/18 at approximately 4:00 p.m. and was corrected on 5/26/18 at 10:45 p.m. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place 16 residents with dementia who were independently mobile at risk for injuries or death. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 understood others and was understood. The MDS indicated Resident #1 required extensive assistance with dressing and limited assistance with locomotion. The MDS indicated Resident #1 used an elopement alarm daily. The care plan revised on 4/3/18 indicated Resident #1 had impaired cognition related to dementia. The care plan indicated she was an elopement risk and wandered aimlessly. The care plan indicated she had impaired safety awareness and had a history of [REDACTED]. The care plan indicated staff would observe Resident #1's location at regular and frequent intervals. During an observation on 5/26/18 at 8:30 a.m. Resident #1 was observed in the hospital. Resident #1 was sitting upright in the bed. Her left foot was wrapped with gauze and the first three toes on her right foot were covered with scabs. Resident #1 was not interviewable due to her cognitive status. Based on a weather report accessed on 6/1/18 at 12:29 p.m., at www.wunderground.com, the local temperature on 5/26/18 at 4:15 p.m. was 93.9 degrees, with a reported heat index of 97.5. During an interview on 6/1/18 at 8:45 a.m., Resident #1's daughter said she received a call on 5/26/18 from RN A. She said RN A told her Resident #1 was found unresponsive in the courtyard. RN A told her she did not know how long Resident #1 had been sitting in the courtyard, but she was last seen in the building around 2:00 p.m. Resident #1's daughter said RN A told her the paramedics were working on her now. Resident #1's daughter said she rushed to the facility and the ambulance was leaving with the resident, so she followed them to the emergency room . Resident #1's daughter said the emergency room physician told her Resident #1's core temperature was 107 degrees Fahrenheit and the bottom of her feet had 2nd and 3rd degree burns. Resident #1's daughter said the top of Resident #1's feet and toes were scraped and bloody from being dragged on the concrete. Resident #1's daughter said Resident #1 spent 3 days in the intensive care unit. Resident #1's daughter said Resident #1 had dementia but could answer simple direct questions. She said Resident #1 propelled herself in her wheelchair. Resident #1's daughter said her mother had been in the facility for 7 years and the staff should have monitored her more closely because they knew she wandered all over the facility. During an interview on 6/1/18 at 9:51 a.m., CNA B said she had last seen Resident #1 at approximately 2:00 p.m. (on 5/26/18) when she provided incontinent care. CNA B said Resident #1 was assisted back into her wheelchair and she rolled out of her room. CNA B said Resident #2 approached her and said someone needed to check on Resident #1 in the courtyard because she had been out there for a while. CNA B said she went to the courtyard and called Resident #1's name but she did not respond. CNA B said Resident #1 was sitting in the sun on the sidewalk. She said Resident #1's head was down and her shoulders were slumped. CNA B said she kneeled down and so she could see Resident #1's face and she saw blood coming from Resident #1's mouth. CNA B said she was scared and quickly pushed Resident #1 forward in her wheelchair to get the resident back into the building. CNA B said she did not think about Resident #1's feet dragging on the concrete. CNA B said she did not realize she was hurting the top of Resident #1's feet and toes, because she did not react or respond to her feet being dragged on the concrete. CNA B said she rolled Resident #1 to the nurse's station and called for RN A. She said they took Resident #1 to her room and cleaned the blood from Resident #1's mouth and feet. CNA B said Resident #1 was jerking her shoulders upward repeatedly. CNA B said Resident #1's skin was hot to touch and her face was reddened. CNA B said the residents could come and go freely in the courtyard. She said staff did not usually monitor the residents in the courtyard. During an interview on 6/1/18 at 10:09 a.m., RN A said she worked the day Resident #1 was found unresponsive (5/26/18). RN A said when CNA B called her, she saw Resident #1 in the wheelchair with her head down and she was slumped over. Resident #1 was shaking uncontrollably. RN A said Resident #1 was wearing a heavy navy colored sweater with a cotton housecoat and her feet were bare. RN A said Resident #1's legs were under the wheelchair and there was a pool of blood at her feet. RN A said she had to lean the wheelchair back to get her legs out from under the chair. RN A said Resident #1 had frothy bloody sputum coming from her mouth and pooled on her chest. RN A said Resident #1 was not responsive to verbal, tactile, or noxious stimuli. RN A said she called 911 at 4:49 p.m. RN A said she removed Resident #1's sweater and placed a fan in front of her. RN A said Resident #1's skin was reddened all over and she was hot to touch. RN A said Resident #1's temporal (forehead) temperature was 104.9 and her oxygen saturation was low at 88%. RN A said she was unable to obtain a blood pressure because Resident #1 was shaking uncontrollably. RN A said emergency personnel arrived and took over. RN A said the ambulance left with Resident #1 at 5:20 p.m. RN A said she notified the physician and administration. RN A said she took witness statements and went to the courtyard to investigate the surroundings. She said Resident #1's shoes were outside and there was a trail of blood where her feet had dragged on the concrete from where she was found to inside the facility. RN A said she did not know how Resident #1 got in the courtyard. She said Resident #1 was not strong enough to open the door. During an interview on 6/1/18 at 12:14 p.m., Resident #2 said she watched Resident #1 in the courtyard from her window on 5/26/18. She said she first noticed the resident sitting outside by the brick wall at approximately 3:50 p.m. Resident #2 said Resident #1 had kicked off her shoes and was leaning over playing with the grass. Resident #2 said Resident #1 was outside for a while, but she assumed staff would come and get her shortly because it was almost time for supper. Resident #2 said she saw Resident #1 tapping her feet on the concrete. Resident #2 said she thought Resident #1 was just playing. Resident #2 said she noticed Resident #1 had leaned over the wheelchair with her arm dangling down beside the wheel. She said Resident #1 was not moving. Resident #2 said it was 4:50 p.m. and staff had not came to get Resident #1 for supper. Resident #2 said she could see no other residents or staff in the courtyard. Resident #2 said she told CNA B to go to the courtyard and check on Resident #1. Resident #2 said CNA B went right away and checked on Resident #1. During an interview on 6/1/18 at 1:11 p.m., LVN C said she worked the evening Resident #1 was found unresponsive. LVN C said she remembered seeing Resident #1 at the nurse's station before dinner. She said it was approximately 4:00 p.m. She said she finished her blood sugar checks on hall C and was going to Hall D. She said the residents were bunched up around the nurse's station waiting for dinner. LVN C said she had to move Resident #1's wheelchair over so she could fit her medication cart through. She said she did not remember Resident #1's name at the time but she remembered her face. During an interview on 6/1/18 at 1:30 p.m., the DON said she was made aware of the situation at 5:10 p.m. on the day of the incident. The DON said she had never known Resident #1 to open the courtyard door on her own and go outside. The DON said the courtyard was enclosed and was a safe area, so the door did not have an alarm. The DON said initially she did not know Resident #1's feet were injured in the process of bringing her inside. She said she was unsure of the extent of her injuries because they were unable to get an update from the hospital per the family's request. During an interview on 6/1/18 at 2:30 p.m., the administrator said he learned of the incident with Resident #1 after she was sent to the hospital. He said RN A was instructed to begin the investigation and gather witness statements. The administrator said he learned that CNA B may have caused some injuries to Resident #1's feet when transporting her in the wheelchair. He said they were unaware of the extent of the injuries. The administrator said the incident happened on a day that was not that hot, and he guessed they had trusted that everything would be okay. He said they realize now that heatstroke can happen very quickly. The administrator said as a result of this incident, staff are now responsible for conducting 20 minute monitoring in the courtyard. He said there was a sign in sheet at the nurse's station and there was a person designated every 20 minutes to walk the perimeter of the courtyard and check on the residents. He said this staff member is to monitor the residents and ensure they are dressed appropriately to be outside. The administrator said 2 hydration stations were set up and staff were to offer the residents drinks while they were outside. He said the courtyard would be shut down when the temperature exceeds 85 degrees. A communication form and progress note dated 5/26/18 indicated Resident #1's primary [DIAGNOSES REDACTED]. The form indicated Resident #1's vital signs at 5:05 p.m. were pulse 103, respirations 24, and temperature 104.9. The communication form indicated Resident #1 had bloody, frothy secretions from her mouth and pooled on her chest. She had labored irregular breathing and her oxygen saturation was 88%. Resident #1 was transferred by EMS to the emergency room for higher level of care. An emergency room triage report dated 5/26/18 indicated Resident #1 was found outside of the nursing home for an undetermined amount of time. The report indicated she had blisters to the bottoms of her feet, she was hot to touch, and had a flushed face. The EMS reported a temporal temperature of 107 degrees on their arrival with decreased level of consciousness and possible [MEDICAL CONDITION] activity. An ICU history and physical note dated 5/26/18 indicated Resident #1 had altered mental status and hyperthermia/heat stroke with a rectal temperature of 106 degrees. An Elopement Management policy dated 7/2017 indicated .Each resident is assisted in attaining/maintaining his/her highest practicable level of functioning by providing the resident with adequate supervision and safety interventions to minimize elopement risk .unsafe wandering may be associated with falls and related injuries . It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from approximately 4:00 p.m. on 5/26/18 through 10:45 p.m. on 5/26/18. The facility took the following actions to correct the non-compliance on 5/26/18 by 10:45 p.m. The DON in-serviced staff on transporting residents in wheelchairs, hydration in the courtyard, and monitoring the courtyard. In-service sign in sheets for transporting residents and hydration were dated 5/26/18. These in-services did not include a time. An in-service for Monitoring the Patio was dated 5/26/18 at 10:45 p.m. Three LVN's were interviewed on 6/1/18 from 2:30 pm to 3:22 p.m. and said they received training prior to the surveyor's entrance regarding transporting residents in wheelchairs, hydration in the courtyard, and monitoring the courtyard. Four CNAs were interviewed on 6/1/18 from 2:30 pm to 3:22 p.m. and said they received training prior to the surveyor's entrance regarding transporting residents in wheelchairs, hydration in the courtyard, and monitoring the courtyard. Red signs were posted on the entrance door and the courtyard door stating Heat Alert- Patio time will be restricted in the event temperatures exceed 85 degrees. There will be no patio access when temperature is considered excessive or extreme. Patio Monitoring logs indicated staff began the 20-minute monitoring in the courtyard on 5/26/18 at 6:00 p.m. A list provided by the DON on 6/1/18 indicated there were 16 residents with dementia who were mobile.

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose, for an excessive duration, with inadequate monitoring, and failed to reduce a medication when adverse consequences (falls) occurred for 1 of 7 residents reviewed for unnecessary medications (Resident #75) The facility did not monitor or attempt to reduce Resident #75's [MEDICATION NAME]. Resident #75 fell multiple times at night after receiving [MEDICATION NAME] 30 mg, with one fall resulting in a [MEDICAL CONDITION] on 1/2/18. This failure could place 46 residents on psychoactive medications at risk for falls, injury, pain or death. Findings included: Physician orders [REDACTED].#75 was [AGE] years old, readmitted on [DATE], original admitted was 12/16/14, with [DIAGNOSES REDACTED]. January (YEAR) physician orders [REDACTED]. A significant change MDS dated [DATE] noted Resident #75 understood others and made herself understood, required extensive assistance for her ADLs and was always incontinent of bowel and bladder. A previous MDS dated [DATE] indicated Resident #75 had clear comprehension, and made herself understood, required limited assistance with bed mobility and toilet use, supervision with eating and was frequently incontinent of bowel and bladder. The care plan updated 1/19/18 indicated Resident #75 was a safety/ fall risk due to decreased safety awareness. Her care plan noted she had fallen due to self-transfers on 7/28/17, 8/21/17 to BSC (bed side commode), 10/5/17, 11/22/17, 12/9/17, 12/21/17, 12/22/17 to BSC. On1/2/18 Resident #75 fell , resulting in a fractured right hip. The care plan interventions included to keep the resident's call light in reach with reminders and encouragment to use the call light, initiate safety checks, offer frequent toileting in early morning and every round. The care plan indicated the resident wanted to remain independent. Another care plan entry for the 1/19/18 indicated Resident #75 received hypnotic therapy related to sleep disturbances. The interventions included: observe and report for adverse side effects to the medication including day time drowsiness, and confusion, loss of appetite in morning, increased falls, fractures and dizziness. The most recent accident reports for Resident #75 included the following: * 1/2/18 at 4:45 a.m. - Resident #75 was transferring herself from her bedside commode to her bed, and her lost her balance and fell , resulting in a [MEDICAL CONDITION]; * 12/21/17 at 6 a.m. - self transferred to BSC and fell with skin tears to left arm; * 12/9/17 at 3 a.m. - resident called out for help, and was found sitting on the floor; * 11/22/17 at 3:30 a.m. - resident was found sitting on the floor, stating her legs got weak; * 10/5/17 at 5:30 a.m. - resident was heard calling for help, when she slid off of her bed on to the floor while attempting to use her bed side commode. During an observation and interview on 2/12/18 at 9:15 a.m., Resident #75 was lying in bed, stating she did not feel well, did not sleep well, and did not want to continue receiving therapy. During an observation and interview on 02/12/18 at 2:09 p.m., Resident #75 said she did not always know when she needed to go to the bathroom since she broke her hip. During an interview on 2/13/18 at 9:00 a.m., Resident #75 said she said she was hurting some and just could not sleep. During an observation on 2/14/18 at 2:00 p.m., Resident #75 was seen sitting in a wheelchair up in the therapy room. During an interview on 02/13/18 at 3:00 p.m., the ADON said Resident #75 was continent of bowel and bladder, and did not need to be on a bladder training program. The ADON said there was a BSC near the resident's bed, and the resident was asked to use the call light. The ADON said Resident #75 attempted to toilet herself, and would fall. During an interview on 2/15/18 at 3:30 p.m., the ADON said she made a mistake regarding Resident #75's bowel and bladder assessment, because she had episodes of incontinence. During an interview on 02/14/18 at 3:30 p.m., the DON reviewed Resident #75's falls. She said Resident #75 falls while transferring to the BSC all occurred early in the morning. The DON said the resident's reaction to the high dose of [MEDICATION NAME] could have contributed to the falls. She said I did not think of reducing the med as a possible contributing factor to the falls. The DON looked at the pharmacy recommendations and noted Resident #75's [MEDICATION NAME] 30 mg had not been reduced since 4/13/16. During an interview on 02/14/18 at 04:02 p.m., the Consultant Pharmacist said she normally did not recommend a gradual dose reduction for hospice patients, unless the medication was an antipsychotic. She said the last reduction of Resident #75's for her [MEDICATION NAME] was on 4/13/16. The pharmacist said the facility had not notified her of Resident #75's frequent falls. The pharmacist said [MEDICATION NAME] 30 mg was a high dose for the elderly. She said falls were a side effect of the medication and could have contributed to her falls. The pharmacist said if she knew Resident #75 experienced frequent falls, she would have recommended slowly reduced the [MEDICATION NAME] the pharmacist said she looked at all residents' [MEDICAL CONDITION] medications, even if the resident was on hospice, and checked their laboratory test results. During an interview on 02/15/18 at 10:15 a.m., the clinical director of the hospice agency said she addressed Resident #75's falls, and requested more frequent checks to prevent falls for Resident #75, but did not recall if medications were a concern related to causing the falls. A nursing progress note dated 2/5/18 indicated the [MEDICATION NAME] was decreased from 30 mg to 15 mg per family request. A website (www.drugs.com) accessed on 2/16/18 at 4:36 p.m., indicated dose selection for an elderly patient should be cautious, usually starting at the low end of dosing range, . [MEDICATION NAME] 7.5 mg is recommended as the initial dosage for patient aged 65 and over since the risk of the development of over sedation, dizziness, confusion, ataxia and/or falls increases substantially with larger doses of benzodiazepines in elderly and debilitated patients .Sleep Driving and other Complex Behaviors . There have been reports of people getting out of bed after taking a sedative hypnotic and driving their cars while not fully awake, often with no memory of the event .(Resident #75 always got out of bed, after taking [MEDICATION NAME] and fell .) A website (www.accessdata.fda.gov) accessed on 2/19/18 at 8:26 a.m. indicated - it is important to use the lowest possible effective dose. Elderly patients are especially at risk. Some of these changes may be characterized complex behaviors such as sleep driving (ie. driving while not fully awake after ingestion of a sedative hypnotic, with amnesia for the event) .these events can occur in sedative naïve as well as in sedative-hypnotic-experienced persons . In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy commonly observed in this population. [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg is recommended as the initial dosage for patients age 65 and over since the risk of development of over sedation, dizziness, confusion, ataxia, and/or falls increases substantially with larger doses of benzodiapzepines in elderly and debilitated patients. A [MEDICAL CONDITION] Management policy revised on (MONTH) (YEAR) said the facility would only use [MEDICAL CONDITION] medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and wellbeing of the resident . gradual dose reductions of [MEDICAL CONDITION] medications and behavioral or non-pharmacological interventions are attempted unless clinically contraindicate, in an effort to discontinue the medications Hypnotics ([MEDICATION NAME] The CMS 672 dated 2/12/18 indicated 46 residents received psychoactive medications. The CMS 672 dated 2/12/18 indicated 46 residents received psychoactive medications.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent injury for 1 of 3 residents reviewed for accidents. (Resident #75) The facility did not review Resident #75's hypnotic medication to assess if it contributed to her falls. Resident #75 had multiple falls, one of which resulted in a [MEDICAL CONDITION] on 1/2/18. This failure could place 54 residents with high fall risk at risk for injury, hospitalization , pain and decreased quality of life. Findings included: Physician orders [REDACTED].#75 was [AGE] years old, readmitted on [DATE], original admitted was 12/16/14, with [DIAGNOSES REDACTED]. January (YEAR) physician orders [REDACTED]. A significant change MDS dated [DATE] noted Resident #75 understood others and made herself understood, required extensive assistance for her ADLs and was always incontinent of bowel and bladder. A previous MDS dated [DATE] indicated Resident #75 had clear comprehension, and made herself understood, required limited assistance with bed mobility and toilet use, supervision with eating and was frequently incontinent of bowel and bladder. The care plan updated 1/19/18 indicated Resident #75 was a safety/ fall risk due to decreased safety awareness. Her care plan noted she had fallen due to self-transfers on 7/28/17, 8/21/17 during a transfer to the bed side commode, 10/5/17, 11/22/17, 12/09/17, 12/21/17, 12/22/17 during a transfer to the bed side commode. On 1/2/18, Resident #75 fell , resulting in a fractured right hip. The care plan interventions included to keep the resident's call light in reach with reminders and encouragment to use the call light, initiate safety checks, offer frequent toileting in early morning and every round. The care plan indicated the resident wanted to remain independent. Another care plan entry for the 1/19/18 plan indicated Resident #75 received hypnotic therapy related to sleep disturbances. The interventions included: observe and report for adverse side effects to the medication including day time drowsiness, and confusion, loss of appetite in morning, increased falls, fractures and dizziness. The most recent accident reports for Resident #75 included the following: * 1/2/18 at 4:45 a.m. - Resident #75 was transferring herself from her bedside commode to her bed, and her lost her balance and fell , resulting in a [MEDICAL CONDITION]; * 12/21/17 at 6 a.m. - self transferred to the bed side commode and fell with skin tears to left arm; * 12/9/17 at 3 a.m. - resident called out for help, and was found sitting on the floor; * 11/22/17 at 3:30 a.m. - resident was found sitting on the floor, stating her legs got weak; * 10/5/17 at 5:30 a.m. - resident was heard calling for help, when she slid off of her bed on to the floor while attempting to use her bed side commode. During an observation and interview on 2/12/18 at 9:15 a.m., Resident #75 was lying in bed, stating she did not feel well, did not sleep well, and did not want to continue receiving therapy. During an observation and interview on 02/12/18 at 2:09 p.m., Resident #75 said she did not always know when she needed to go to the bathroom since she broke her hip. During an interview on 2/13/18 at 9:00 a.m., Resident #75 said she said she was hurting some and just could not sleep. During an observation on 2/14/18 at 2:00 p.m., Resident #75 was seen sitting in a wheelchair up in the therapy room. During an interview on 02/13/18 at 3:00 p.m., the ADON said Resident #75 was continent of bowel and bladder, and did not need to be on a bladder training program. The ADON said there was a bed side commode near the resident's bed, and the resident was asked to use the call light. The ADON said Resident #75 attempted to toilet herself, and would fall. During an interview on 2/15/18 at 3:30 p.m., the ADON said she made a mistake regarding Resident #75's bowel and bladder assessment, because she had episodes of incontinence. During an interview on 02/14/18 at 3:30 p.m., the DON reviewed Resident #75's falls. She said Resident #75 falls while transferring to the bed side commode all occurred early in the morning. The DON said the resident's reaction to the high dose of [MEDICATION NAME] could have contributed to the falls. She said I did not think of reducing the med as a possible contributing factor to the falls. The DON looked at the pharmacy recommendations and noted Resident #75's [MEDICATION NAME] 30 mg had not been reduced since 4/13/16. During an interview on 02/14/18 at 04:02 p.m., the Consultant Pharmacist said she normally did not recommend a gradual dose reduction for hospice patients, unless the medication was an antipsychotic. She said the last reduction of Resident #75's for her [MEDICATION NAME] was on 4/13/16. The pharmacist said the facility had not notified her of Resident #75's frequent falls. The pharmacist said [MEDICATION NAME] 30 mg was a high dose for the elderly. She said falls were a side effect of the medication and could have contributed to her falls. The pharmacist said if she knew Resident #75 experienced frequent falls, she would have recommended slowly reduced the [MEDICATION NAME] the pharmacist said she looked at all residents' [MEDICAL CONDITION] medications, even if the resident was on hospice, and checked their laboratory test results. During an interview on 02/15/18 at 10:15 a.m., the clinical director of the hospice agency said she addressed Resident #75's falls, and requested more frequent checks to prevent falls for Resident #75, but did not recall if medications were a concern related to causing the falls. A nursing progress note dated 2/5/18 indicated the [MEDICATION NAME] was decreased from 30 mg to 15 mg per family request. A website (www.drugs.com) accessed on 2/16/18 at 4:36 p.m., indicated dose selection for an elderly patient should be cautious, usually starting at the low end of dosing range, . [MEDICATION NAME] 7.5 mg is recommended as the initial dosage for patient aged 65 and over since the risk of the development of over sedation, dizziness, confusion, ataxia and/or falls increases substantially with larger doses of benzodiazepines in elderly and debilitated patients .Sleep Driving and other Complex Behaviors . There have been reports of people getting out of bed after taking a sedative hypnotic and driving their cars while not fully awake, often with no memory of the event .(Resident #75 always got out of bed, after taking [MEDICATION NAME] and fell .) A website (www.accessdata.fda.gov) accessed on 2/19/18 at 8:26 a.m. indicated - it is important to use the lowest possible effective dose. Elderly patients are especially at risk. Some of these changes may be characterized complex behaviors such as sleep driving (ie. driving while not fully awake after ingestion of a sedative hypnotic, with amnesia for the event) .these events can occur in sedative naïve as well as in sedative-hypnotic-experienced persons . In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy commonly observed in this population. [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg is recommended as the initial dosage for patients age 65 and over since the risk of development of over sedation, dizziness, confusion, ataxia, and/or falls increases substantially with larger doses of benzodiapzepines in elderly and debilitated patients. The Fall Management policy revised on 11/2017 said on a fall event, the nurse would enter a risk console, an incident/accident report, complete an SBAR communication form, add fall event to the 24 hours report and initiate an IDT (interdisciplinary) post fall review. The policy stated the nurse would discuss recommended interventions to reduce the potential for additional falls with the resident and the resident's representative and document in the care plan and progress notes. The DON provided a list on 2/15/18 at 2:33 p.m., indicating 54 residents were at high risk of falling.

Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 2 residents reviewed for accidents. (Resident #1) The facility did not provide required assistance during a transfer for Resident #1 who had a fractured right ankle, to the toilet from her wheelchair. The resident fell and sustained a left leg (ankle) fracture. This failure could place 48 residents who required assistance of 1-2 staff for transfers at risk for injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 required extensive assistance of one staff member for transfers. A care plan initiated 5/10/17 indicated Resident #1 required extensive assistance with one staff for transfers and toilet use. Assistance was required for completion of ADL tasks. An incident report dated 5/04/17 indicated Resident #1 was being transferred from her wheelchair to the toilet. The resident was able to stand on her left leg and bounce towards the toilet. Resident #1 lost her balance while bouncing, causing her to fall; she complained of pain in her left lower leg. She was sent to the hospital crying in pain and diagnosed with [REDACTED]. A nursing note dated 5/04/17 indicated CNA A reported to the charge nurse while transferring Resident #1 from her wheelchair to the toilet she lost her balance and fell . During an interview on 5/17/17 at 8:00 a.m. the administrator said Resident #1 was admitted with a fractured ankle and when she fell on [DATE], she now had two fractured ankles. She said she should have been transferred with a gait belt. She said all nursing staff had been in-serviced on the policy and procedures regarding transfers. She said Resident #1 returned to the facility on Monday 5/15/17 and was sent back to the hospital Tuesday 5/16/17 due to unrelated issues. During an interview on 5/17/17 at 12:30 p.m., CNA A said she was the CNA involved with the transfer for Resident #1 in the bathroom on 5/04/17. She said Resident #1 requested an assist to the bathroom. CNA A said when she got to the room, Resident #1 got out of bed and into her wheelchair and CNA A pushed the resident to the bathroom. She said the resident was holding on to the grab bar in the bathroom, and let go and fell to the floor. CNA A said she never touched Resident #1 and did not use a gait belt, because therapy had told her Resident #1 only required stand-by assistance. She said Resident #1 was crying and screaming in pain and she went to get the charge nurse. During an interview on 5/17/17 at 9:40 a.m., the director of therapy said Resident #1 was deemed unsafe to transfer without assistance. She said the resident required extensive assistance with one staff for transfers and a gait belt was required. During an interview on 5/17/17 at 8:10 a.m., the DON said Resident #1 was able to bear some weight on her left foot prior to her fall. She said Resident #1 was admitted for short term therapy with a fractured right ankle. The DON said CNA A did not use a gait belt and Resident #1 lost her balance and fell and sustained a left ankle fracture. The DON said Resident #9 should have been transferred with a gait belt. A no lift policy dated 1/24/17 indicated staff must use gait belts with residents that were able to bear weight but needed hands on guidance. The policy included there were no exceptions to the rule. The CMS 672 dated 5/17/17 indicated there were 48 residents who required assistance of 1-2 staff for transfers.

Based on observation, interview, and record review the facility failed to implement interventions based on a comprehensive assessment to prevent development and worsening of pressure ulcers for 3 of 18 residents reviewed for pressure ulcers. (Resident #'s: 11, 12 and 18). Resident #11 was removed from a low air loss mattress on 11/4/13 and developed three facility-acquired pressure ulcers (deep tissue injury and two stage 2) within a month. Resident #12 admitted to the facility on [DATE], without pressure ulcers, but was at high risk for the development of pressure ulcers. She developed one facility-acquired unstageable pressure ulcers on each heel. (Total 2) Resident #18 had pressure ulcers inside his nose and on his ear caused by oxygen tubing that were not assessed or treated until surveyor intervention. These failures contributed to the development of new and the worsening of existing pressure ulcers for Resident #'s:11,12 and 18. These failures could place 4 residents with pressure ulcers at risk for developing new pressure ulcers and decline the worsening of existing pressure ulcers. Findings included: 1. Physician orders [REDACTED]. Resident #11 was discontinued from hospice services on 11/4/13. A medical equipment delivery slip dated 3/21/11 indicated Resident #11 was supplied with a low air loss mattress upon admission to hospice service.ospice services The Braden scale assessment dated [DATE] indicated Resident #11 was at moderate risk for pressure ulcer development. The MDS dated [DATE] indicated Resident #11 had no pressure ulcers at the time of this assessment. The most recent MDS dated [DATE] indicated Resident #11 required extensive assistance for ADLs, had functional limitations to both upper and lower extremities. She was at risk for developing pressure ulcers. Resident #11 had an unstageable pressure ulcer at the time of this assessment. A comprehensive plan of care dated 12/14/13 indicated the treatment for [REDACTED]. Telephone orders for Resident #11's wound care included: *12/14/13- Pad blister to back of left calf with abdominal pad, wrap lightly with Kerlix for protection , daily until healed. Have treatment nurse evaluate area on Monday 12/16/13. *1/1/14- Clean open area back left calf apply triple antibiotic ointment and dressing daily until healed. *1/13/14 -Clean area back left calf with normal saline, apply Santyl, hydrogel, and cover with dressing change daily. A telephone order dated 1/13/14 indicated Resident #11 received the following supplements for wound healing: " [MEDICATION NAME] one package twice daily in 8 ounces of water, and protein powder 2 scoops daily with 8 ounces of juice or water was initiated 29 days after the wound developed ... " physician progress notes [REDACTED].#11's left calf. During an interview on 1/28/14 at 10:15 a.m., the treatment nurse said hospice services for Resident #11 were discontinued on 11/4/13. She said the air loss mattress supplied by the hospice service was picked up on 11/4/13. The treatment nurse said they did not replace the mattress because they were trying to see how well Resident #11 would do without the low air loss mattress. A wound culture report dated 1/26/14 indicated Resident #11's left leg pressure sore had bacteria present. A nursing note dated 1/28/14 indicated the following " ...left calf showed no improvement. The area was larger. Admit Resident #11 to hospice and implement pain control protocol... " Wound treatment progress records for Resident #11's left leg pressure sore indicated: 1/2/14- wound measured 5 centimeter (cm) x 2 cm 0.2 cm, deep open with eschar. 1/9/14- wound measured 5cm x 2 cm 0.2 cm deep open with eschar 1/16/14- wound measured 5 cm x2 cm 0.3 cm deep open with grey slough. 1/20/14- wound measured 6 cm x 3 cm x 0.3 cm deep grey slough, redness surrounding wound, foul odor During an observation and interview on 1/28/14 at 9:35 a.m., the treatment nurse said the pressure ulcer on Resident # 11's left lower, outer leg was a Stage 3. The pressure ulcer measured 16 cm x 3 cm with an area of black necrotic tissue that measured 4 cm x 4 cm, from 12 o ' clock down to 10 and 2 o'clock (top of the pressure ulcer). The bottom of the pressure sore from 6 o'clock extending to the 7 and 5 o'clock position measured 4 cm x 3 cm. and had black necrotic tissue. The center of the wound bed was beefy red, with yellow-grey stringy slough that measured approximately 6 cm in length. Tendon was exposed. The treatment nurse said the area began as a blister on 12/14/13. The treatment nurse said the current wound care orders included, [MEDICATION NAME] gel (prior to wound care), clean with normal saline, hydrogel and Santyl and cover with dressing. During an observation and interview on 1/29/14 at 8:50 a.m., the treatment nurse said the pressure ulcer on Resident #11's left lower leg was a Stage 4 and measured 20 cm x 3.5 cm with 16 cm x 3.5 cm open area and 3 cm x 3 cm eschar at 11 o'clock and eschar measuring 3 cm x 3 cm at 4 o'clock. The wound bed was red and had exposed tendon. The treatment nurse said tendon was exposed and the wound had increased in size. The treatment nurse said Resident #11 now required the use of [MEDICATION NAME] sulfate 30 minutes prior to wound care with [MEDICATION NAME] gel and [MEDICATION NAME] 1 mg to tolerate the treatment procedure. A laboratory result dated 1/20/14 for a pre-[MEDICATION NAME] level was 10 which is an indicator of [MEDICAL CONDITION]. During an interview on 1/28/14 at 11:20 a.m., the dietician was aware Resident #11's last dietary annual assessment was 2/7/13. She said the assessment did not address any nutritional needs related to pressure ulcers. During an interview on 1/28/14 at 12:20 p.m., the treatment nurse said the Braden assessment on 11/8/13 was not an accurate reflection of Resident #11's activity and mobility sections. She said the score should reflect 2 points lower resulting in Resident #11's score reflecting a high risk for pressure sore development. The treatment nurse said Resident #11 rarely got out of bed and could not make significant changes in her body position to help with pressure relief. During an observation and interview on 1/28/14 at 12:50 p.m., CNA B said Resident #11's appetite had decreased. During the noon meal Resident #11 required multiple attempts of verbal cueing throughout the meal and consumed only three bites of food. During an interview on 1/28/14 at 2:27 p.m., the DON said she was aware hospice services were discontinued and Resident #11 lost the use of their low air loss mattress. The DON said she was not aware Resident #11 was without a low air loss mattress for 28 days. The DON said she delegated duties to the treatment nurse and did not monitor or follow up. She said the treatment nurse knew what to do and would come to her if she needed anything. She said she would expect a dietary evaluation to implement supplements for wound healing. The DON could not provide any training or in-services provided to the treatment nurse regarding wound care and prevention. 2.) Physician orders [REDACTED]. Her orders said bed rest, wound and skin care daily, hip precautions and abductor pillow (triangular shaped pillow between legs). An MDS assessment dated [DATE] indicated Resident #12 made herself understood and understood others. She required extensive assistance with most of her ADLs, including bed mobility. She was frequently incontinent of bowel and had a catheter at the time of the assessment. No weight loss or pressure ulcers; only a surgical wound. Her initial care plan dated 1/2/14 indicated Resident #12 was at risk for pressure ulcer, due to recent right hip (fracture) with decrease in mobility. Interventions included: " ...turn and reposition every two hours, nurse will inspect skin weekly and CNAs will inspect skin daily, observe especially bony prominences. (head, elbows, scapula, ears, bottom and heels) ... " Braden Scale assessments dated 1/1/14 (admission), 1/8/14, 1/15/14 and 1/22/14 indicated Resident #12 to be at moderate risk for skin breakdown. Resident #12's CNA daily skin inspection record dated January 1-26-2014 checked redness but rash, bruise or open areas were left blank. The body figure on the inspection record used to identify the area of redness or any skin issues was blank. An admission nursing note dated 12/31/13 at 11:45 p.m., indicated Resident #12 had an incision to her right hip with 28 staples, no pressure sores or ulcers assessed. During an observation and interview on 1/27/14 at 7:15 a.m., CNA M said Resident #12 had recent [MEDICAL CONDITION] repair. She said Resident #13 answered questions and was incontinent at times. CNA M said Resident #12 had occasional pain but no falls or no skin break down. During an observation and interview with the treatment nurse on 1/27/14 at 2:17 p.m., of Resident #12's had the following pressure ulcers: *Right heel- unstageable- closed pressure ulcer, upper wound bed partial red/pink, lower wound bed; measured 7 cm x 6 cm in size (total sore). Black eschar measured 5 cm x 3 cm. The treatment nurse said the pressure ulcer occurred after Resident #12 was admitted . She said the eschar area was firm to touch. The treatment for [REDACTED]. *Left heel- unstageable pressure ulcer, red to pale pink in color, measured 5 cm x 3 cm (total sore). The 12 o'clock to 9 and 3 o'clock (upper sore area) appeared to have opened (dried blister appearance) and the (lower area) from 9 and 3 o'clock to 6 o'clock area of sore had intact blister that was red beneath. The treatment nurse said Resident #12's wound care treatment was a foam dressing to her left heel. During an interview on 1/27/14 at 2:30 p.m., the treatment nurse said upon admission Resident #12 had been on a pressure reducing mattress and had an abduction pillow between her legs. She said about two weeks after admission the areas on her heels began as blisters and she was placed on a low air loss mattress, sent to the wound care center and staff were off loading her heels with foam booties. Resident #12's wound treatment and progress record indicated the following: Right heel: * 1/12/14- 7 cm x 4 cm; open blister with skin flap with red wound. * 1/19/14- 7 cm x 4 cm; open blister with black necrotic tissue in center. (unstageable) * 1/27/14- 7 cm x 6 cm; black necrotic 5 cm x 3 cm, red around edges. (unstageable) Left heel: * 1/12/14- 6 cm x 4 cm; intact blister. * 1/19/14- 6 cm x 4 cm; intact blister. * 1/27/14- 5 cm x 3 cm; open blister with skin flap with red wound bed. During an observation and interview on 1/29/14 at 8:40 a.m., Resident #12 was lying in bed, on a low air loss mattress, covers on her feet (foot cradle on bed, covers not over foot cradle). CNA M uncovered her feet and her feet were positioned on a flat pillow that did not off-load her heels (heels on mattress). CNA M said upon admission Resident #12's heels were pink, not red. She was on a regular bed mattress and had a pillow between her legs. CNA M said she tried to put a pillow under her heels and turn her every two hours. CNA M said Resident #12 did not always have a pillow under her heels when she would come on duty. Resident #12 said her heels were not always positioned on pillows for the first couple of weeks after her admission. Resident #12 said she did not have pain in her heels. She said she was a diabetic, and received home health care for wounds on her feet and legs in the past. During an observation on 1/29/14 at 11:45 a.m., the treatment nurse indicated Resident #12's pressure ulcer on her left heel had approximately 50% black eschar to the wound bed and deteriorated since 1/27/14. Her right heel had black eschar approximately 5 cm x 4 cm. During an interview on 1/28/14 at 9:15 a.m., the PT said during therapy Resident #12 had not complained of her feet hurting. She denied assessing her feet during her initial evaluation. She said Resident #12 had a regular mattress and did not recall her having any type of heel lifts when she was evaluated, but did have an abduction pillow. During an interview on 1/28/14 at 9:40 a.m., Resident #12's home health nurse said she had provided wound care on her heels and legs. She said Resident #12 had been weak and did not move or change positions often. Her wounds had healed on 8/5/13. During an interview on 1/29/14 at 5:15 p.m., the DON said they in-serviced staff on pressure ulcers and skin assessments. She said they completed annual competency checks for nurses. She was unsure the last time her treatment nurse had attended any wound care trainings or seminars. During an interview on 1/29/14 at 12:41 p.m., the treatment nurse indicated her Braden scale assessment of Resident #12 being a moderate risk for pressure sores was incorrect. She said she had not changed the moisture rating from a 3 to a 2 (after her Foley was discontinued) and had given her a "4" on sensory perception because she was interviewable. The treatment nurse said she had not considered she might have decreased sensations or [MEDICAL CONDITION] due to her diabetes, and was unaware of her history of pressure areas to her feet and legs until she had talked to her family after her heel wounds were found. A list provided by the DON on 1/27/14 at 9:00 a.m., indicated 3 residents with pressure sores. Resident #12 was listed. 3.) Physician orders [REDACTED]. His orders said oxygen per nasal canula 2-4 liters per minute every shift PRN (as needed). An MDS assessment dated [DATE] indicated Resident #18 made himself understood and understood others. He required extensive assistance with his ADLs. He was frequently incontinent of bowel and bladder, and had one, Stage 2 pressure ulcer on admission. A care plan dated 1/7/14 indicated Resident #18 had a Stage 2 pressure ulcer on his sacral area. Interventions included " ...to perform treatment per order, assist with turning and positioning, use padding between pressure areas and positioning devices ... " Braden Scale assessment dated [DATE], 1/14/14, and 1/21/14 indicated Resident #18 was at moderate risk for skin breakdown. Resident #18's wound treatment and progress record included the following: * 1/7/14 - Stage 2 sacral area- measured 5 cm x 2.75 cm, red wound bed. * 1/14/14- stage 2 sacral area- measured 5 cm x 2 cm, red wound bed. * 1/21/14- stage 2 sacral area- measured 4.5 cm x 3 cm, red wound bed. There were no other skin concerns documented. During an observation and interview on 1/27/14 at 11:00 a.m., Resident #18 was lying in bed, with dried blood on the end of his nose and under his nose. His left nostril looked red and puffy. The treatment nurse wiped his nose with a damp cloth and Resident #18, hollered, "oh oh!" The treatment nurse put his oxygen on per nasal cannula and Resident #18 said it hurt. During an observation on 1/27/19 at 12:30 p.m., Resident #18 was lying in bed, and his nasal cannula was partially removed hanging on his right ear. During an observation on 1/28/14 at 10:00 a.m., Resident #18's nose was clean, but his left nostril and below his nose looked red and puffy. CNA L said, Resident #18 had "nose rot," he said his nose had a sore inside caused from his (nasal cannula) oxygen tubing. Resident #18 had dried blood to the top of his right ear and dried blood matted in his hair. Resident #18 said his nose and ear had hurt for a while, and he had told staff, but it did not change anything. During an interview on 1/28/14 at 10:07 a.m., the treatment nurse said Resident #18 had a Stage 2 pressure sore in his nose. She said she had talked to his family and they told her he had an area come up in his nose in the past. She said his oxygen was just PRN (as needed) and so they were going to leave it off. She received a physician's orders [REDACTED]. The treatment nurse was not aware of the area on his ear. During an interview on 1/28/14 at 11:00 a.m., the treatment nurse said she cleaned his ear and he had a small stage 2 open area measured about 0.1 cm x 0.2 cm. The undated policy and procedure for risk assessment, skin assessment and prevention strategies was provided by the DON on 1/29/14 at 4:00 p.m., indicated " ...the goal for preventing the development of pressure ulcers was early identification of an at-risk patient and implementation of prevention strategies... " The NPUAP web site at <http://www.npuap.org/pr2.htm> notes that in February 2007 the NPUAP redefined the definition of a pressure ulcer and the stages of pressure ulcers: Stage II pressure ulcer as " ...partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough ..." A Stage III is defined as, " ...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. May include undermining and tunneling...". A Stage IV pressure ulcer is defined as, " ...Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling ...". The NPUAP notes that a pressure sore is defined as Unstageable if there is, " ...Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined..." During an interview on 1/29/14 at 2:25 p.m., the treatment nurse provided a list of 4 residents assessed at high risk for pressure ulcers. The CMS 672 dated 1/27/14 indicated 4 residents had pressure ulcers.