Every finding on record at Pleasant Valley Healthcare and Rehabilitation Cent

Based on observation, interview and record review the facility failed to ensure that residents 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 6 residents (Resident #1) reviewed for pressure ulcers. -The facility failed to complete weekly head-to-toe skin assessments from 05/20/26 to 06/17/26. During this time, the resident developed a sacral wound first identified on 06/15/26 with an area of 28.71 cm2 and 5% necrotic tissue. The notes on 07/06/26 revealed the sacral wound area had increased 49.50 cm2, while the necrotic tissue escalated to 75%. On 07/09/26, the resident was sent to the hospital after becoming unresponsive. The hospital documented she had a foul smelling necrotic sacral wound with bone exposure, bacteremia, and sepsis. This failure could place residents at risk of infection, worsening wounds, and overall deterioration of health.Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 06/12/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1 had a BIMS score of 2, which indicated severe cognitive impairment. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 was dependent on staff for all ADLs. The MDS Assessment under Section H-Bladder and Bowel reflected Resident #1 had frequent urinary and bowel incontinence. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: heart failure, Alzheimer's Disease (brain disorder that causes loss of memory and thinking), chronic embolism and thrombosis of unspecified vein (blood clot in vein that blocks blood flow), pressure ulcers (localized skin and tissue damage caused by prolonged pressure or friction), and protein-calorie malnutrition (inadequate intake or absorption of protein and calories). The MDS Assessment under Section M-Skin Conditions reflected Resident #1 was at risk of developing pressure ulcers and required pressure reducing devices for chair and bed, nutrition and hydration intervention, applications of medications. Record review of Resident #1's Care Plan, revised 03/18/26, reflected Resident #1 had potential for pressure ulcer development r/t decline immobility. Interventions included: use of a low air loss mattress, monitoring nutritional status, monitoring, documenting and reporting changes in skin status to MD, treating pain per orders prior to treatment and turning to ensure comfort, turning and repositioning as needed and off-loading heels, and weekly head to toe skin at risk assessments. Record review of Resident #1's Braden Scale for predicting pressure ulcer risk evaluation, dated 03/10/26, reflected a score of 17 which indicated mild risk. Record review of Resident #1's EHR reflected the resident received the following weekly skin check assessments (head-to toe assessments):-05/06/26 by LVN B-05/13/26 by LVN B-05/19/26 by RN E-05/20/26 by LVN B-06/17/26 by LVN B Record review of Resident #1's EHR reflected the resident received the following weekly skin issue assessments (existing wound/skin issue assessment):-05/04/26 by LVN A-05/11/26 by LVN A-05/18/26 by LVN A-05/25/26 by LVN A-06/01/26 by LVN A-06/08/26 by LVN A-06/15/26 by LVN A Record review of Resident #1's skin check assessment, dated 05/20/26 by LVN B, reflected the resident had no new skin issues on evaluation, with existing wounds that included a skin tear on the right dorsum (top surface) foot, Stage 3 pressure ulcer on left gluteus (buttock), Stage 3 pressure ulcer on right iliac crest (top of hip bone), and Stage 4 pressure ulcer on left heel. Record review of Resident #1's skin check assessment, dated 06/17/26 by LVN B, reflected the resident had no new skin issues on evaluation, with existing wounds that included an unstageable pressure ulcer on sacrum. Record review of Resident #1's progress notes, dated 05/18/26 at 2:12 p.m. by LVN A, reflected the following: Skin Issues: 0Skin Issue: #001: Skin issue has been evaluated. Location: Right Iliac Crest. Additional location information: R distal lateral hipIssue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressureulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.9 Width (cm): 0.8 Depth (cm): 0.2 Area (cm2): 0.72 Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: leptospermum honey (skin sub application q 7 days) Secondary dressing: Composite dressing. frequency of treatment: 3x week and PRN0Skin Issue: #002: Skin issue has been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving: overall woundcharacteristics improved. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin andtissue loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 1.6 Width (cm): 1.5 Depth (cm): 0.8 Area (cm2): 2.4Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: methylene blue foam (skin sub application q 7days) Secondary dressing: Composite dressing. frequency of treatment: 3x week and PRN0Skin Issue: #003: New skin Issue. Location: Left gluteus. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcerstaging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Signs and symptoms of infection: None. Staged by: Wound care clinic. Length (cm): 1 Width (cm): 1 Depth(cm): 0.1 Area (cm2): 1 Cleansing solution: Normal saline. Other primary dressing: collagen, anasept (wound cleanser) Secondary dressing: Composite dressing (multi-layered wound cover). frequency of treatment: daily and PRN Record review of Resident #1's progress notes, dated 05/18/26 at 2:20 p.m. by LVN A, reflected the following: [Resident #1] seen by [wound care physician] for weekly assessment and evaluation for Stage 4 pressure L heel, 1.6x1.5x0.8,moderate exudate, improved, no infection, no pain, methylene blue (antiseptic foam/liquid) and gauze island dressing, daily and PRN, and skin sub application q 7 days, Stage 3 pressure R distal lateral hip (outer side of hip, towards upper thigh), 0.9x0.8x0.2, improved, moderate sero-sang exudate (wound drainage), no infection, no pain, order for leptospermum honey (honey made with properties from leptospermum plant) gauze island dressing 3x week and PRN and skin sub application q 7 days, stage 3 pressure L buttock, initial, 1x1x0.1, no pain no infection, anasept, collagen, gauze island dressing daily and PRN,Intervention:-daily wound care-offload-turn and reposition-oral supplementsAppetite poor, wheelchair bond, [mechanical lift] for transfers. MD, RD aware of wounds, status and orders, [Resident #1's RP] notified of wounds, status, orders, plan of care Record review of Resident #1's progress notes, dated 05/25/26 at 6:00 p.m. by LVN A, reflected the following: Skin Issues: 0Skin Issue: #001: Skin issue has been evaluated. Location: Right Dorsum foot. Laterality / Orientation: Right. Issue type: Skintear. Progress: Improving: overall wound characteristics improved. Type 2: Partial flap loss. Wound acquired in-house. Signs and symptoms ofinfection: None. Measurements not documented as part of this assessment. Reason measurements not documented as part of thisassessment: wound care /doctor to assess cleansing solution: Normal saline. Primary dressing: Film/Membrane. Secondary dressing:Composite dressing. frequency of treatment: daily and PRN0Skin Issue: #002: Skin issue has been evaluated. Location: Left gluteus. Issue type: Pressure ulcer / injury. Progress: Improving: overallwound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skinloss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.5 Width (cm): 0.5 Depth (cm): 0.1 Area (cm2): 0.25 Cleansingsolution: Normal saline. Primary dressing: Hydrocolloid. Secondary dressing: No secondary dressing applied. frequency of treatment: 3x dayand PRN0Skin Issue: #003: Skin issue has been evaluated. Location: Right Iliac Crest. Additional location information: R distal lateral hip Issue type:Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury -full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.8 Width (cm): 0.9 Depth (cm): 0.1 Area (cm2): 0.72 Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: leptospermum honey (skin sub application q 7days) Secondary dressing: Composite dressing. frequency of treatment: daily and PRN0Skin Issue: #004: Skin issue has been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving: overall woundcharacteristics improved. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin andtissue loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 1.3 Width (cm): 1.4 Depth (cm): 0.8 Area (cm2): 1.82Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: methylene blue foam Secondary dressing:Composite dressing. frequency of treatment: daily and PRN0Skin Issue: #005: New skin Issue. Location: Right gluteus. Issue type: Pressure ulcer / injury. Progress: Improving: overall woundcharacteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skinloss. Wound acquired in-house. Signs and symptoms of infection: None. Painful: No. Staged by: Wound care clinic. Length (cm): 1.6 Width(cm): 1.4 Depth (cm): 0.1 Area (cm2): 2.24 Cleansing solution: Normal saline. Primary dressing: Hydrocolloid (moisture-retentive wound dressing). Secondary dressing: Nosecondary dressing applied. frequency of treatment: 3x day and PRN Record review of Resident #1's progress notes, dated 05/25/26 at 6:07 p.m. by LVN A, reflected the following: [Resident #1] seen by [wound care physician] for weekly assessment and evaluation for Stage 4 pressure L heel, 1.3x1.4x0.8,moderate exudate, improved, no infection, no pain, methylene blue and gauze island dressing, daily and PRN, and skin sub application q 7days, Stage 3 pressure R distal lateral hip, 0.8x0.9x0.1, improved, moderate sero-sang, exudate, no infection, no pain, order forleptospermum honey gauze island dressing 3x week and PRN and skin sub application q 7 days, stage 3 pressure L buttock, 0.5x0.5x0.1, nopain no infection, hydrocolloid paste 3x day and PRN, tolerates well, NARN, stage 3 R buttock, 1.6x1.4x0.1, improved, no pain no infection,hydrocolloid paste 3x day and PRNIntervention:-daily wound care-offload-turn and reposition-oral supplementsAppetite poor, wheelchair bond, [mechanical lift] for transfers. MD, RD aware of wounds, status and orders, [Resident #1's RP] notified of wounds, status,orders, plan of care Record review of Resident #1's progress notes, dated 06/01/26 at 1:56 p.m. by LVN A, reflected the following: Skin Issues: 0Skin Issue: #001: Skin issue has been evaluated. Location: Left gluteus. Issue type: Pressure ulcer / injury. Progress:Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skinloss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.4 Width (cm): 0.5 Depth (cm): 0.1 Area (cm2): 0.2 Cleansingsolution: Normal saline. Other primary dressing: triad paste frequency of treatment: 3x day and PRN0Skin Issue: #002: Skin issue has been evaluated. Location: Right gluteus. Issue type: Pressure ulcer / injury. Progress: Improving: overallwound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.6 Width (cm): 0.6 Depth (cm): 0.1 Area (cm2): 0.36 Cleansing solution: Normal saline. Other primary dressing: triad paste0Skin Issue: #003: Skin issue is resolved. Location: Coccyx (tailbone). Issue type: Open lesion. Progress: Resolved: Wound healed and / or closed.Wound was present on admission. Undermining: No. Tunneling: No.0Skin Issue: #004: Skin issue has been evaluated. Location: Right Iliac Crest. Additional location information: R distal lateral hip Issue type:Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury -full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.7 Width (cm): 0.9 Depth (cm): 0.1 Area (cm2): 0.63Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: leptospermum honey (skin sub application q 7days) Secondary dressing: Composite dressing. frequency of treatment: daily and PRN0Skin Issue: #005: Skin issue is resolved. Location: Right Dorsum foot. Laterality / Orientation: Right. Issue type: Skin tear. Progress:Resolved: Wound healed and / or closed. Type 2: Partial flap loss. Wound acquired in-house.0Skin Issue: #006: Skin issue has been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving: overall woundcharacteristics improved. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin andtissue loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 1.1 Width (cm): 1.1 Depth (cm): 0.7 Area (cm2): 1.21Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: methylene blue foam (skin sub application q 7days) Secondary dressing: Composite dressing. frequency of treatment: daily and PRN Record review of Resident #1's progress notes, dated 06/01/26 at 2:03 p.m. by LVN A, reflected the following: [Resident #1] seen by [wound care physician] for weekly assessment and evaluation for Stage 4 pressure L heel, 1.1x1.1x0.7,moderate exudate, improved, no infection, no pain, methylene blue and gauze island dressing, daily and PRN, and skin sub application q 7days, improved, Stage 3 pressure R distal lateral hip, 0.7x0.9x0.1, improved, moderate sero-sang, exudate, no infection, no pain, order forleptospermum honey gauze island dressing 3x week and PRN and skin sub application q 7 days, stage 3 pressure L buttock, 0.4x0.5x0.1, nopain no infection, hydrocolloid paste 3x day and PRN, tolerates well, NARN [sic], improved, stage 3 R buttock, 0.6x0.6x0.1, improved, no pain noinfection, hydrocolloid paste 3x day and PRN.Intervention:-daily wound care-offload-turn and reposition-oral supplementsAppetite poor, wheelchair bond, [mechanical lift] for transfers. MD, RD aware of wounds, status and orders, [Resident #1's RP] notified of wounds, status,orders, plan of care Record review of Resident #1's progress notes, dated 06/08/26 at 1:11 p.m. by LVN A, reflected the following: Skin Issues: 0Skin Issue: #001: Skin issue has been evaluated. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Improving:Overall, wound characteristics improved. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin andtissue loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 0.9 Width (cm): 1 Depth (cm): 0.3 Area (cm2): 0.9Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Primary dressing: Hydrocolloid. Other primary dressing: skin subapplication Secondary dressing: No secondary dressing applied. frequency of treatment: weekly and PRN0Skin Issue: #002: Skin issue has been evaluated. Location: Right Iliac Crest. Additional location information: R distal lateral hip Issue type:Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury -full thickness skin loss. Wound acquired in-house. Signs and symptoms of infection: None. Staged by: Wound care clinic. Length (cm): 0.5 Width (cm): 0.5Depth (cm): 0 Area (cm2): 0.25 Undermining: No. Tunneling: No. Cleansing solution: Normal saline. Other primary dressing: skin prepSecondary dressing: No secondary dressing applied. frequency of treatment: 3x week and PRN0Skin Issue: #003: Skin issue is resolved. Location: Right gluteus. Issue type: Pressure ulcer / injury. Progress: Resolved: Wound healed and/or closed. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic.0Skin Issue: #004: Skin issue is resolved. Location: Left gluteus. Issue type: Pressure ulcer / injury. Progress: Resolved: Wound healed and /or closed. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Record review of Resident #1's progress notes, dated 06/08/26 at 1:16 p.m. by LVN A, reflected the following: [Resident #1] seen by [wound care physician] for weekly assessment and evaluation for Stage 4 pressure L heel, 0.9x1x0.3,moderate exudate, improved, no infection, no pain, skin sub application q 7 days, hydrocolloid sheet q 7days, improved, Stage 3 pressure Rdistal lateral hip, 0.5x0.5x0, improved, moderate sero-sang, exudate, no infection, no pain, order skin prep 3x week and PRN, stage 3pressure L buttock, resolved, stage 3 R buttock, resolvedIntervention:-daily wound care-offload-turn and reposition-oral supplementsAppetite poor, wheelchair bond, Hoyer for transfers. MD, RD aware of wounds, status and orders, [Resident #1's RP] notified of wounds, status,orders, plan of care Record review of Resident #1's progress notes, dated 06/15/26 at 3:07 p.m. by LVN A, reflected the following: Skin Issues: 0Skin Issue: #001: Skin issue is resolved. Location: Right Iliac Crest. Additional location information: R distal lateral hip Issuetype: Pressure ulcer / injury. Progress: Resolved: Wound healed and / or closed. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - fullthickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Undermining: No. Tunneling: No.0Skin Issue: #002: Skin issue is resolved. Location: Left heel. Issue type: Pressure ulcer / injury. Progress: Resolved: Wound healed and / orclosed. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin andtissue loss. Wound acquired in-house. Staged by: Wound care clinic. Undermining: No. Tunneling: No.0Skin Issue: #003: New skin Issue. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging:Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house. Painful: No. Staged by:Wound care clinic. Length (cm): 3.3 Width (cm): 8.7 Depth (cm): 0 Area (cm2): 28.71 Cleansing solution: Normal saline. Other primarydressing: collagen, anasept Secondary dressing: Composite dressing. Record review of Resident #1's progress notes, dated 06/15/26 at 3:09 p.m. by LVN A, reflected the following: [Resident #1] seen by [wound care physician] for weekly assessment and evaluation for Stage 4 pressure L heel, resolved.Stage 3 pressure R distal lateral hip, resolved. Unstageable sacrum, 3.8x8.7x0, no pain, no infection, anasept, collagen sheet daily and PRN,tolerates well, NARN [sic]Intervention:-daily wound care-offload-turn and reposition-oral supplementsAppetite poor, wheelchair bond, [mechanical lift] for transfers. MD, RD aware of wounds, status and orders, [Resident #1's RP] notified of wounds, status,orders, plan of care Record review of Resident #1's progress notes, dated 06/16/26 at 4:34 a.m. by LVN A, reflected the following: 1/3 change in condition for wound sacrum. continues on air mattress, supplements and offloading. No signs of pain or infection noted Record review of Resident #1's progress notes, dated 06/17/26 at 2:03 a.m. by RN F, reflected the following: Change of condition day 2/3 for sacral wound. No pain or discomfort noted. Continuing to monitor. Record review of Resident #1's progress notes, dated 06/18/26 at 2:03 a.m. by LVN G, reflected the following: COC day 3/3 for sacral wound. No complaints of pain or discomfort noted. Resident sleeping well. Continue to monitor Record review of Resident #1's progress notes, dated 07/09/26 at 1:11 p.m. by LVN A, reflected the following: [Resident #1's RP] notified [LVN A] that [Resident #1] would be sent out to [hospital] for further evaluation for decreased responsiveness, on call nurse notified. Record review of Resident #1's progress notes, dated 07/10/26 at 1:43 p.m. by the MD, reflected the following: [Resident #1's] recent condition was reviewed and discussed with the facility's [DON] and [Administrator]. [Resident #1] wasapparently sent to an outpatient visit for an infusion ordered related to a previous hospital admission. [Resident #1] was reportedly referred forZoledronic Acid infusion for the treatment of osteoporosis, though why this is being done in a patient with severe Alzheimer's disease and anon-ambulatory status is unclear. While at that outpatient encounter, [Resident #1] was described as being lethargic, though unclear how that evaluation differed from her recent orprevious baseline behavior. [Resident #1] was not described as lethargic prior to transfer to the outpatient appointment, and received a meal without difficulty, medication administration as ordered, and VS check (which was not abnormal). [Resident #1] was sent to the hospital ED at [hospital]. Per information available at this time, [Resident #1] was to be admitted to hospital for the treatment of altered mentalstatus.Review of recent laboratory studies indicate a gradual increase in [Resident #1's] serum Na+ level, from 145 in February 2026 to 148 then 149 and now 150 last week. Reportedly, the Na+ level determined at Parkland ED was 148. Patient had recently been diagnosed with a UTI and treated with oral antibiotics, after urine culture. [Resident #1's] dietary intake decreased over the past week, per report.Review of recent wound care notes would suggest that these wounds represent in part skin failure in an elderly patient who remains non-ambulatory with advanced Alzheimer's disease. It is at this time unclear if [Resident #1's] wound can be healed, given her underlying medicalcomorbidities, including advanced age, non-ambulatory status, peripheral arterial disease, and chronic diastolic congestive heart failure.(Draft) Record review of Resident #1's wound evaluation summary, dated 06/15/26, reflected the following: Chief Complaint:[Resident #1] has wounds on her sacrum; left heel; right distal lateral hip.Focused wound exam (Site 10)Unstageable (due to necrosis) sacrum full thicknessEtiology (quality): pressureMDS 3.0 Stage: unstageable necrosisDuration: >4 daysObjective: healing/maintain healingEstimated time to heal: 2-4 monthsCare goals: Decrease Ulcer Area, Decrease NecrosisApproach: Off-Loading, Close Monitoring, Optimizing Moist WoundHealing, Debridement as Needed, Microbe ManagementWound size: 3.3 x 8.7 x not measurable; Depth is unmeasurable due to presence of nonviable tissue andnecrosis.Surface Area: 28.71 cm^2Cluster Wound: open ulceration area of 5.74 cm^2Periwound radius: Surrounding DTI (Purple/Maroon)Exudate: light serous (clear fluid)Thick adherent devitalized necrotic tissue: 5%Slough: 5%Granulation tissue: 10%Skin: Intact normal color 80 %Pain Assessment: noneInfection Assessment: no sign(s) of infection Dressing Treatment PlanPrimary Dressing(s)Collagen sheet apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Sodium hypochlorite gel (anasept) apply once dailyand as needed: if saturated, soiled, or dislodged. For 30 days Secondary Dressing(s)Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days Reason for no sharp debridementChronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now Record review of Resident #1's wound evaluation summary, dated 07/06/26, reflected the following: Chief Complaint:[Resident #1] has wounds on her sacrum; right medial buttock.Focused wound exam (Site 10)Unstageable (due to necrosis) sacrum full thicknessEtiology (quality): pressureMDS 3.0 Stage: unstageable necrosisDuration: >25 daysObjective: healing/maintain healingHealing Potential: FairCare goals: Decrease Ulcer Area, Decrease NecrosisApproach: Off-Loading, Close Monitoring, Optimizing Moist WoundHealing, Debridement as Needed, Microbe ManagementWound size: 7.5 x 6.6 x not measurable; Depth is unmeasurable due to presence of nonviable tissue andnecrosis. This visit's measurements are noted by the clinician to be exactly thesame as the previous visit.Surface Area: 49.50 cm^2Exudate: moderate serous (clear fluid)Thick adherent devitalized necrotic tissue: 75%Slough: 10%Granulation tissue: 15%Wound Progress: Not at goal due to need more timePain Assessment: noneInfection Assessment: no sign(s) of infection Dressing Treatment PlanPrimary Dressing(s)Gauze sponge sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 22 days; Sodium hypochlorite solution (dakins) applyonce daily and as needed: if saturated, soiled, or dislodged. For 22 days: 1/4 str Secondary Dressing(s)Superabsorbent gelling fiber w/ silicone bdr & faced apply once daily and as needed: if saturated, soiled, or dislodged. For 22 days Site 10: Surgical excisional debridement procedure Indication for procedureRemove Necrotic Tissue and Establish the Margins of Viable Tissue Consent for procedureThe indicated debridement was discussed with the primary physician on06/22/2026 and it's necessity was mutually agreed upon MDS 3.0 Post-stage: Unstageable Necrosis PROCEDURE NOTEThe wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 bladewas used to surgically excise 4.95cm^2 of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 85percent to 75 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan ofcare are documented in the Assessment and Plan section below. Record review of Resident #1's consolidated physician orders, dated 07/17/26, reflected in part the following:- Unstageable due to necrosis sacrum: cleanse NS or wound cleanser, pat dry, apply anasept, collagen daily and PRN as needed change ifsaturated soiled or dislodged. Order Date: 06/15/26; Start Date: 06/15/26. Discontinued.- Unstageable due to necrosis sacrum: cleanse NS or wound cleanser, pat dry, apply anasept, collagen daily and PRN every day shift. Order Date: 06/15/26; Start Date: 06/16/26. Discontinued.- Unstageable Sacrum: cleanse with NS or wound cleanser, pat dry, apply santyl, apply calcium alginate, cover with bordered gauze island dressing daily and PRN every day shift for unstageable wound Assess for pain prior to and during wound care. Order Date: 06/22/26. Start Date: 06/22/26. Discontinued. Record review of an in-service titled Following Physician orders and Care Plans; Prevention practices of pressures ulcers, dated 06/04/26, reflected that nursing staff were educated on the facility's policy and procedures for skin and wound monitoring and management. Record review of an in-service titled Incontinent Care/Hygiene, dated 07/08/26, reflected that nursing staff were educated on the facility's policy and procedures for incontinent care to prevent infection and pressure sores. Record review of an in-service titled Change in condition, Assessment, Documentation and Communication, dated 07/09/26, reflected that nursing staff were educated on the facility's policy and procedures on assessing, reporting, and documenting changes in condition. Record review of Resident #1's hospital records, dated 07/09/26, reflected in part the following: Chief complaint: 78 yo female sent from the clinic. When EMS arrived, [Resident #1] unresponsive for about 20 minutes, was at clinic for infusion, no medications given. The [sic] did EKG and concern for possible STEMI (severe type of heart attack). [Resident #1] does report that having chest pain.As per [Resident #1's RP], [Resident #1] with history of blood clot in left leg, on thinners. History of dementia and multiple falls in the past that required surgical intervention. History of staring seizures in the hospital, also was recently diagnosed with UTI, on antibiotics. When [Resident #1's RP] saw her at the clinic [Resident #1] unresponsive, difficulty awaking her. At this time, [Resident #1] more awake, closer to baseline.Assessment & Plan:78 yo w/PMHx of HTN, HLD, GERD, Alzheimer's dementia, falls, osteoporosis w/hx fragility fx, and tonic clonic seizures who was admitted for unresponsiveness episode. [Resident #1] was found to have significant sacral wound w/concern for fat stranding infection. EGS following. [Resident #1] is now noted to be bacteremic (bacteria in bloodstream)-final cultures pending.Sacral decubitus, unstageableBedbound status[Resident #1] with significant wound in her sacrum, high concern for infection and LRINEC is 9 (high risk for necrotizing fasciitis (inflammation of tissue), severe sepsis, and mortality (death rate)), CRP 25 (moderate to high elevation, which indicates inflammation or tissue injury). [Resident #1] reports significant pain when she does become more responsive. High concern for necrotizing fasciitis.CT: Large sacral decubitus ulcer with bone exposure. Skin thickening and mild surrounding fat stranding. No walled off fluid collection. Diffuse osteopenia (reduction in bone density) limits evaluation of lytic bone lesions (bone damage that appears as a dark spot or hole). Cannot exclude underlying bone erosions.Plan for OR 7/12.[Resident #1] presented from infusion clinic with unresponsiveness for 20 minutes, and sacral ulcer noted on arrival for which EGC was consulted to rule out possible source of sepsis. On exam, [Resident #1] is not overly septic but has AMS in setting of dementia (unclear baseline), WBC and CRP elevated with likely infectious source. The sacral ulcer is necrotic with foul smell but not definitively the source. [Resident #1's] UA was clean, and there were no signs of HDS. Last Eliquis (blood thinner) dose unknown but presumed to be this AM at SNF. [Resident #1's RP] is the decision maker and has been getting intermittent updates from SNF. Overall presentation consistent with Stage IV ulcer with necrotic overlying tissue and no gross purulence (thick, pus-like fluid). Bed bound status since the fractures the likely etiology (cause of condition). -Agree with medicine admission-Plan for debridement 7/12, no acute surgical interventions needed-Agree with broad spectrum antibiotics-Further investigation of sepsis per primary-Hold Eliquis-Recommend GOC discussion given [Resident #1's] advanced age, medical co-morbidities and bed bound status. In an interview on 07/17/26 at 7:45 a.m., the RN from the local hospital stated Resident #1 was admitted to the hospital due to AMS and a significant sacral wound. She stated the wound care team decided that emergent surgical intervention was not needed but they were going to perform a debridement procedure. She stated Resident #1 was in a stable status and the hospital was working on finding the resident placement at a different SNF per family's request. However, the RN stated Resident #1 became unstable again after her potassium levels dropped and they were trying to resolve that issue. In an observation on 07/17/26 at 7:58 a.m., Resident #1 was observed at the hospital resting in bed, and she did not wake or respond to verbal stimuli. Resident #1's wound was unable to be observed due to location. Resident #1 appeared to be physically fragile. In an interview on 07/17/26 at 10:28 a.m., Resident #1's RP stated the hospital notified him that Resident #1 was likely at the end of her life due to infection and the wound taking a toll on her body. He stated the family needed to decide

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility kitchen reviewed for environment .The facility failed to maintain an effective pest control system to prevent the presence of flies in the facility's only kitchen. This failure could place residents at risk for an unsafe environment. Findings were:During an observation on 06/03/26 at 9:30 AM, revealed the back door of the kitchen was propped open with a marble rock. During an observation on 06/03/2026 at 9:30 AM, flies were in the kitchen near the food preparation area. During an interview on 06/03/26 at 9:35 AM with the acting Dietary Manager, she stated the risk of the back door being propped open was the kitchen was not secured and flies or rodents could come into the kitchen. She stated the back door was the entrance for all grocery deliveries, which presented a pest problem when the door was open.During an interview on 06/03/26 at 9:40 AM, [NAME] I revealed the exit door to the kitchen should never be propped open. [NAME] I stated the risk of the door being left open was pests such as flies would come in. During an interview on 06/03/26 at 9:55 AM, [NAME] J revealed the exit door was not to be propped open or left unlocked due to the safety of the staff and residents. The risk of leaving the door opened was the flies and rodents could enter the facility through the open door .In an interview on 6/04/17 at 4:00 PM, the Administrator revealed the back door in the kitchen should not be propped opened. The Administrator stated groceries were delivered through the same door. Pest control went monthly and as needed . Record review of the facility's, undated Pest Control policy reflected: It is the policy of this facility to provide an environment free of pests. PROCEDURES: The facility will have a pest contract that provides frequent treatment of the environment for pests; It will allow for additional visits when a problem is detected; Monitoring of the environment will be done by the facility's staff; Pest Problems will be reported promptly.

Based on observation, interview and record review the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for 1 of 3 residents (Resident #10) reviewed for treatment of pressure ulcers. The facility failed to follow Resident #10's physician orders to ensure the resident had heel protectors on while in bed on 06/04/26. This failure could place residents at risk of developing new or worsening pressure ulcers. Findings include:Record review of Resident #10's quarterly MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), foot drop left foot (inability to lift the front part of the foot due to muscle weakness or nerve damage) and muscle contracture (a type of scarring in soft tissues causing them to tighten and stiffen). Resident #10 had a BIMS score of 2, which indicated severe cognitive impairment. Resident #10 was dependent on staff for all ADLs. Record review of Resident #10's care plan, dated 06/04/26, reflected the Resident wore bilateral heel boots while in bed with interventions which included apply bilateral heel boots while in bed and float heels.Record review of Resident #10's physician orders reflected the following orders:- Offload heels with pillows while in bed Q shift - start date 12/09/25- Apply bilateral heel boots while in bed every shift for protect heel - start date 12/10/25 During an observation and interview on 06/04/26 at 9:46 AM, revealed Resident #10 was lying in bed with no heel protectors on. Resident #10's lower legs were propped up on a pillow . Resident #10 was not interviewable. During an observation on 06/04/26 at 10:42 AM, revealed Resident #10 was lying in bed and no heel protectors were observed on the resident or in the room. During an interview on 06/04/26 at 12:40 PM, CNA B stated she had not seen any heel protectors for Resident #10 and had not used them for her. She said she always put a pillow underneath for Resident #10's heels to relieve pressure. She stated if not done it could make the wound worse . During an interview on 06/04/26 at 1:44 PM, LVN C stated she was working on the hall for another nurse who had to leave and was aware Resident #10 had a wound on the left heel. She stated she was not aware Resident #10 had orders for heel protectors , and nobody had told her the resident did. She stated the heel protectors were to help the wound heal and prevent other issues from developing. During an interview on 06/04/26 at 2:19 PM, ADON A stated CNAs, Nurses and she were responsible for ensuring the heel protectors were placed on Resident #10 while she was in bed and to verify they were on. She stated she did not know why Resident #10 did not have them today (06/04/26). ADON A stated they were used to protect the heels from the pressure of the mattress. She said the risk to Resident #10 was the left heel could get worse . During an interview on 06/04/26 at 3:09 PM CNA D stated Resident #10 was supposed to have boots on while in bed and CNA's were responsible to ensure she was wearing them. He said they were worn to help the tissue and if not done could make the wound worse.During an interview on 06/04/26 at 3:43 PM, RN E stated Resident #10 was supposed to have boots all the time while in bed. She stated the CNAs, nurses and the wound care nurse were responsible to make sure they were on. She said the risk to residents if not worn was it could lead to pressure sores and could make a pressure sore worse. During an interview on 06/04/26 at 4:48 PM, the DON stated Resident #10 did have heel boots and if they were not present they were probably being washed. She stated the heel protectors were to offload the heels and reduce pressure. She said her expectation was for staff to implement appropriate measures to reduce pressure. Record review of the facility's policy titled, Skin and Wound Monitoring and Management, revised 12/2023, reflected in part: Procedure.3. Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: .d. Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc .).5. Treatment a. Continue preventive measures as appropriate, including but not limited to: Pressure reduction.6. Monitoring a. Daily via medication administration and treatment administration records. Confirm all orders have been implemented as ordered.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 medication carts (Hall 400 nurses' medication cart) reviewed for pharmacy services.The facility failed to ensure expired medications were removed from the Hall 400 nurses' medication cart.This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings include:During an observation on 06/03/26 at 1:21 PM of the Hall 400 nurses' medication cart with LVN G, two bubble packs of Dicyclomine capsules 2 mg one with 30 pills and the other with 18 pills (used to treat functional bowel/irritable bowel syndrome by relaxing the muscles in the stomach and intestines to reduce cramping and spasms) with an expiry date of 03/31/2026. During an interview on 06/03/26 at 1:48 PM, LVN G stated she was responsible for checking the cart for expired medications. She stated she checked her cart for expired medications that morning, and she missed the expired medication. LVN G stated she checked her cart daily for expired medication and expiry dates. LVN G said failing to remove the expired medication could result in the medications being administered which could cause the residents not to get the required therapy. She stated the risk of having expired medication if administered was, it would not be effective. During an interview on 06/03/26 at 2:20 PM, ADON B revealed his expectation was for nurses to check their cart for expired medications every week. He stated the ADON's were responsible for checking behind the nurses weekly. He said the last time he audited the cart was on 5/29/2026 and he also missed the expired medications. He stated the risk of having expired medications on the cart was it being administered, and they would not be effective.During an interview on 06/04/26 at 3:47 PM, the DON stated her expectation was all nurses were responsible for checking the carts every shift, to ensure expired medications were removed from the carts. She stated it was the responsibility of ADON to go behind the nurses weekly and ensure expired medications were being removed from the carts. She stated she was not sure when the ADON last checked the carts. She said the cart was last checked on 06/02/2026 by the pharmacist and she also missed the expired medications. She stated if expired medications were administered, it could place residents at risk of having side effects.Record review of the facility's Medication Access and Storage / Drug Destruction policy, dated January 2026, reflected: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists

Based on observation, interview and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 (Resident #85) residents reviewed for food and nutrition services.The facility failed to ensure that Resident #85 received his breakfast meal tray. This failure could place residents at risk of not meeting the nutritional needs of the residents.Findings include:Record review of Resident #85's admission record, dated 06/04/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnosis which included cerebral infarction (an ischemic stroke caused by the blockage of a blood vessel in the brain, where the specific artery or cause does not fit into standard diagnostic categories like the carotid or cerebral arteries), seizures (abnormal electrical activity in the brain that affects consciousness, muscle control and behavior), and asthma (a condition that causes airways to swell, narrow and fill with mucus).Record review of Resident #85's admission MDS, dated [DATE], revealed Resident #85's BIMS score was 05 , which indicated severe cognitive impairment. Resident #85 usually was understood stating ability to express ideas and wants. He had difficulty communicating some words or finishing thoughts but was able if prompted or given time. Resident #85 usually understood verbal content but missed some part/intent of messages but comprehended most of the conversation.During an interview on 06/03/26 at 9:54 AM, LVN F revealed he received report of a new admission. He said when residents admitted , they gave the diet form to the kitchen. He said when he administered medication he went and checked on them. The reason he did not get him was he thought the kitchen made a mistake. He said the CNA was supposed to let him know Resident #85 did not get a tray. The CNA was supposed to notify him if a resident missed a tray. If a meal was missed the risk was malnutrition fatigue and adverse reaction when getting medications.During an interview on 06/03/26 at 10:30 AM, CNA G revealed she helped with cleaning and passing trays. CNA G said she was the one who passed trays on Hall 100 and she only passed what was on the cart and she did not know there was a new resident in the room because she did not read the names on the doors. During an interview on 06/03/26 at 10:32 AM, CNA H revealed she was assigned 100 and 200 halls. CNA H stated she did her rounds in the morning, and she knew she had a new resident. She said they checked meal tickets. She said she did not check the morning she passed trays because she was on 100 hall trying to feed a resident who's family requested to be fed before she took her pills. CNA H said she started on 100 hall and then came back to 200. She said she had not noticed the resident did not eat until later at 09:30 when the DON came and asked her whether she passed the tray. CNA H went to the kitchen, and they were preparing a tray, and she left and she did not know who passed the tray. The risk of not getting a tray would be the resident would feel hungry.During an interview on 06/04/26 at 12:36 PM, Resident #85 revealed he received his dinner tray on Tuesday evening, 06/02/26, when he was admitted to the facility. He stated he did not receive his breakfast tray Wednesday morning, on 06/03/26. He stated he did receive breakfast today, 06/04/26, and he was waiting on lunch now . During an interview on 06/04/26 at 3:30 PM, the RD revealed the staff were in-serviced on the importance of following up on new admissions to make sure the residents diet cards were implemented to avoid a missed meal. The RD stated the [NAME] and the Dietary Aide were to both supposed to check that new admission information was provided from the nursing department and diet slips were implemented.During an interview on 06/04/26 at 4:00 PM, the Administrator revealed when a new admission arrived at the facility, nursing implemented the diet ticket for the new admission and took it to the kitchen for the kitchen staff to add to the meal tickets for meals. The Administrator stated a resident would not get a tray if the meal ticket was not implemented from the diet ticket.The facility did not have a policy regarding residents receiving daily meals.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services.The facility failed to ensure the seal on the walk-in freezer door was replaced properly.This failure could place residents at risk of not having essential equipment maintained and in working order. Findings include:During an observation on 06/02/2026 at 10:00 AM, revealed ice buildup was accumulated along the door frame, threshold, and on the boxes of food items on the shelves in the walk in-freezer . During an interview on 06/02/2026 at 10:00 AM, the acting Dietary Manager stated Maintenance was responsible for ensuring the freezer was clean. She stated she noticed the ice buildup today and would request maintenance to replace the seal around the door or the freezer. The facility did not have a Maintenance Director. A Maintenance Director from another facility would have to come in and repair the seal on the door. The acting Dietary Manager stated the risk was the freezer could maintain the correct temperature if the door was not able to shut correctly due to the ice build-up . During an interview and observation on 06/03/2026 at 9:45 AM, revealed ice buildup was still accumulated along the door frame and the door would not close easily. The acting Dietary Manager revealed the Maintenance Director cleared all the ice the day before, but there was ice accumulated again. The acting Dietary Manager did not know if the seal had been replaced. During an interview on 06/04/2026 at 4:00 PM, the Administrator stated he expected kitchen staff to report to the Maintenance Director and himself if major repairs were needed, including the freezer, stove, or dishwasher. The Administrator stated if the freezer was not working it could affect the quality of the food if the temperature was not kept within range. Record review of the U.S. FDA Food Code 2022 revealed, .4-501.11 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.(B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 medications carts (Nurses cart for hall 400) reviewed for infection control practices.1. LVN G failed to disinfect the glucometer machine after checking blood sugars for unknown residents. 2. LVN G failed to discard the used glucometer strip in biohazard container and had left the used glucometer attached with a used strip with dried blood on the drawer of 400 nurse's cart. These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection. Findings include :During an observation on 06/03/26 at 1:21 PM with LVN G, revealed there was a glucometer with a used test strip inserted in her medication cart drawer. During an interview and observation with LVN G on 06/03/26 at 1:51 PM, she revealed the glucometer connected to the strip was in the drawer. The strip was observed with dry blood on it. She stated she was supposed to use the disinfectant wipes to clean the glucometer after using it. She said she was supposed to discard the used strip into a biohazard container afterwards to prevent the spread of infection and cross contamination, but she could not tell how it happened. She stated she received training on the care and disinfection of reusable equipment, but she could not recall when .No observation made of her moving between residents. She was asked why she had not disinfected the glucometer, but she could not explain.During an interview and observation with the ADON on 06/03/26 at 2:23 PM, he revealed the strip had blood. He said his expectation was for staff to disinfect the reusable equipment after using it on a resident. He stated he also expected staff to discard non-reusable contaminated items after use in the biohazard container. He stated failure to disinfect reusable equipment after use could also lead to cross contamination. He stated failure to discard contaminated items could lead to infection and cross contamination. He stated the facility management and him were responsible for auditing to ensure staff were practicing infection control procedures. During an interview with the DON on 06/04/26 at 3:44 PM, she revealed her expectation was for staff to maintain clean equipment. She said she expected staff to disinfect the reusable equipment after use and dispose of used strips in the biohazard container attached to the nurses' carts. She said they should not put contaminated strips and glucometer in the cart. She stated failure to disinfect reusable equipment after use could also lead to cross contamination and spread of blood pathogens. She said management was responsible for checking on staff to ensure they were observing measures to prevent the spread of infection. She stated she did training on infection control and care of re-usable items and discarding sharps and strips in the biohazard containers.Record review of the facility's current Infection Control policy, dated October 2022, reflected the following: .C Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

Based on observations, interviews and record reviews the facility failed to ensure all treatment and care was provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 7 residents reviewed for quality of care. LVN B, LVN C and LVN E failed to ensure Resident #1's change of condition of a rash on his extremities was followed up on 12/16/25, 12/17/25 and 12/18/25; subsequently no plan of care orders was obtained until Treatment Nurse F called NP G on 12/18/25 at 1:23 pm, for nystatin and Benadryl orders for moisture related dermatitis. This failure could cause all residents with skin conditions to be at risk of not getting properly assessed and treated in a timely manner, which could result in worsening skin conditions, decreased health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS dated [DATE] revealed, a [AGE] year old male who admitted [DATE] with a BIMS Score of 09 (moderate cognitive impairment). He had no behaviors or rejection of care, used a wheelchair and required helper assist for most ADLs . He was frequently incontinent with urinary continence and always incontinent with bowel incontinence. His primary medical condition was stroke. He had diagnoses of hypertension (high blood pressure), renal insufficiency (Kidney insufficiency), septicemia (blood stream infection), diabetic mellitus (high blood sugar level), Cerebrovascular Accident (stroke), non-Alzheimer's dementia (cognitive deficit), hemiplegia (one sided weakness), malnutrition (imbalance or deficit in nutrients), anxiety (persistent worry or fear) and depression (persistent sadness). He was at risk of developing pressure ulcers and he did not have any pressure injuries or other skin problems. He also needed to have skin applications of ointments/medications applied to areas other than to his feet. (He had no diagnosis of psoriasis - chronic non-contagious autoimmune skin condition causing thick red and itchy patches). Record review of Resident #1's December 2025 Order Summary Report by his Physician dated 12/18/25 revealed, Order Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth at bedtime for itchiness for 3 Days at bedtime (12/18/2025 - 12/21/2025). Nystatin-Triamcinolone Cream 100000-0.1 UNIT/GM- % Apply to per additional directions topically two times a day for moisture related dermatitis (skin inflammation from bodily fluids) x 10 days for 10 Days apply to BUE and BLE (There were not any treatment orders for his rash prior to 12/18/25). Record review of Resident #1's December 2025 MAR revealed he was given 25 mg Benadryl at bedtime on Thursday 12/18/25 at night. And 100000-0.1 Unit/GM-% Nystatin-Triamcinolone cream was given one time at bedtime Thursday 12/18/25 at night and the morning of Friday 12/19/25. Record review of Resident #1's Care Plans printed 12/18/25 revealed, at risk for impaired cognition/dementia or impaired thought processes related to CVA (stroke), due to psychiatric impairment. Had a potential for mood problem related to new diagnosis major depressive, anxiety, insomnia. He had a primary dementia diagnosis from 2024 and potential impairment of skin integrity related to itching (date initiated 10/17/24). He had potential for pressure ulcer development related to limited mobility and had seizures related to stroke and bowel/bladder incontinence related to neurological impairment. He had ADL self-care performance deficit related to weakness and took anti-anxiety and depressive medications. Record review of Resident #1's Change of condition dated 12/16/25 at 1:57 pm by LVN C revealed, No new medications changes, status of evaluation was for a rash: New skin issues #001) front axilla (under shoulder joint) wound acquired in-house, #002) below right elbow wound acquired in-house, #003) front left thigh wound acquired inhouse, #004) Right Achilles (heel). (all areas were unmeasurable). Skin issues note: Resident has rash like areas over various areas of skin. Resident statesareas [sic] itch. The primary care provider feedback: was blank for recommendations, new testing orders and new intervention orders . (There were no orders to monitor). Record review of Resident #1's Nurse Progress note dated 12/16/25 at 2:22 pm by LVN C revealed, Resident's skin assessment performed. Resident noted with itchy rash like areas over extremities. Resident states this has occurred before but unsure of past treatment. [NP G ]notified via telephone message. No orders received at this time. [FM ] notified. (There were no orders to monitor). Record review of Resident #1's Nurse Progress note dated 12/17/25 at 2:25 am by LVN B revealed, Rash all over extremities Day 2. (The Doctor/NP was not called). Record review of Resident #1's Nurse Progress note dated 12/18/25 at 1:01 am, by LVN E revealed, Change of condition day 3/3 for rash on extremities. NARN . Continuing current treatment orders. (The Doctor/NP was not called and there were no treatment orders given yet). Record review of Resident #1's Skin Wound note dated 12/18/25 at 12:47 pm by Treatment Nurse F revealed, Skin/Wound Note: Skin assessment complete. Skin warm and dry, color appropriate to ethnicity: no pallor (pale skin), cyanosis (bluish skin, lips or nails), or jaundice (yellowish skin) observed. Resident noted with calm rash to BUE and BLE and low back. Resident states it is very itchy. Rash noted to L armpit with an odor. Body wiped with cleanser with effective results. NP G notified by phone of findings. Pending review. Record review of Resident #1's Skin Wound note dated 12/18/25 at 1:23 pm by Treatment Nurse F revealed, No bruising, abrasions, irritations to perineal area. NP G ordered nystatin/ triamcinolone 100000units BID for moisture related dermatitis x 10 days and Benadryl 25 mg daily at bedtime x 3 days. EMR updated. FM contacted by phone. FM informed this nurse that resident has a hx of psoriasis. FM notified of findings, orders and plan of care with no concerns voiced. Interview and observation on 12/18/25 at 10:47 am, Resident #1 was lying in bed at a 45 degree angle and did not appear to be in any distress or pain. He stated he was not able to use left arm because of a stroke he had but his right arm worked well. Resident #1's right upper arm close to his shoulder had three small reddish spots on it that appeared dry and he used his right hand to scratch that same area and said he had occasional itchiness that did not interfere with his daily tasks during the day or at night. He stated he told the nurses about the arm rash about a week ago and the Doctor/NP was supposed to be getting him something for it. He stated in the past he had psoriasis and was not sure if it was that or something else. He stated the rash was on his back and right arm. He stated he hoped he would get some cream on the areas because he was tired of itching. Interview on 12/19/25 at 2:50 pm, LVN A stated he was a PRN nurse and was currently working the 400 hall. He stated he assessed Resident #1 today 12/19/25 and he had rashes under his right armpit and upper right arm. Interview on 12/19/25 at 1:09 pm, LVN B stated Resident #1 had a rash all over his body and he notified the [FM]. He stated Resident #1 started having a rash a week ago, that was on his right leg and thigh and pinkish in color. He stated he did not call the Doctor/NP because the previous nurse on shift said she had already called about it. He stated the last time he worked last Tuesday 12/16/25 and Resident #1 had a rash on his thigh that was pinkish in color. Interview on 12/19/25 at 1:26 pm, LVN C stated she worked the 400 hall last Tuesday 12/16/25, and noticed Resident #1 had a rash on different areas of his skin. She stated Resident #1's left and right arms and left foot were reddish in color. She stated Resident #1's rashes were different sizes and he complained of itchiness and she tried to get him something for it but it was 1:45 pm and her shift was almost over. She stated she called the NP and left a message and left after her shift ended. She stated she notified the [FM] last Tuesday 12/16/25. She stated the NP did not call back during her shift and she was not able to get treatment orders for his rashes that day. She stated the Doctor and NP phone number was the same and neither had called back before her shift ended. She stated she told the oncoming nurse LVN D to follow-up with the NP because of his rash. She stated she was not sure if Resident #1 still had the rash. Interview on 12/19/25 at 1:46 pm, LVN D stated she usually worked the 2:00 pm - 10:00 pm shift on the 400 hall. She stated she worked last Tuesday 12/16/25 and had not received any reports that Resident #1 had a rash or treatment order for a rash. She stated for rashes, the nurse would have to call the Doctor or NP for a treatment plan. She stated if Resident #1's medications for his rash were delivered she would have documented it and started doing the treatments to get rid of his rash. Interview on 12/19/25 at 2:14 pm, LVN E stated she usually worked 10:00 pm to 6:00 am on the 400 hall. She stated Resident #1 had a rash on his right arm and he had an order for nystatin cream to put on it as of yesterday 12/18/25. She stated she worked last Wednesday 12/17/25 and was aware of Resident #1's rash that was reported on a different shift Tuesday 12/16/25. She stated last night 12/18/25 she put the nystatin cream on Resident #1's right upper arm. She stated Resident #1's nystatin cream and Benadryl were ordered 12/18/25 by another nurse. Interview on 12/19/25 at 2:40 pm, LVN A stated Treatment Nurse F told him yesterday (12/18/25) after she assessed Resident #1 she noticed a rash underneath the back of his right arm. He stated when he went to check Resident #1 had a rash that was a small reddish colored area. He stated this was his first time seeing Resident #1 yesterday 12/18/25. He stated the last time he saw Resident #1 was last year. He stated today 12/19/25 he put the nystatin ointment on Resident #1's rash and stated his Benadryl was ordered to be given at bedtime. Interview on 12/19/25 at 3:08 pm, Treatment Nurse F stated when the residents had any skin issues the nurses were supposed to let her know about it. She stated she needed to assess the resident's skin issues as soon as the nurses noticed an issue for a treatment plan. She stated there were no reports of Resident #1 having any rashes earlier this week. She stated she went to Resident #1's room yesterday 12/18/25 just to check him out. She stated she was not asked by a nurse to check him out but noticed as she talked to him he was scratching and complained of itchiness. She stated she asked Resident #1 if he was having some itchiness and he said yes. She stated she assessed him and noticed some areas of redness then notified NP G about her findings and NP G ordered nystatin and Benadryl. She stated she called the [FM] and the [FM] said he had a history of having psoriasis. She stated she was not sure what was causing his rashes but the NP was called yesterday 12/18/25 at 12:47 pm. She stated the nurses needed to notify her if they saw something on the residents' skin, to let her know immediately so she could assess them and notify the Doctor/NP. She stated if she knew about Resident #1's rash last Tuesday 12/16/25 or Wednesday 12/17/25 she would have assessed him sooner and notified the Doctor/NP. She stated after she double checked her calendar she worked last Tuesday 12/16/25 and Wednesday 12/17/25 and none of the nurses notified her about Resident #1's rash issues. She stated for untreated rashes the rash could get way worse or infected. She stated a resident could pick or scratch the rash which could turn into an open wound that could get painful. Interview on 12/19/25 at 5:18 pm, the DON stated Resident #1 had a rash over various areas of his body that appeared on his skin and went away. She stated he had a treatment in place now with some cream and oral medication. She stated they found out about Resident #1's rash and complaints of itchiness yesterday 12/18/25. She stated yesterday Treatment Nurse F assessed Resident #1 and she called to get him a Doctor/NP's order for Nystatin-Triamcinolone cream and Benadryl. She stated Resident #1's rash flared up the evening of Tuesday 12/16/25 but he did not have a rash on 12/17/25. She stated she was not sure why LVN B documented on 12/17/25 saying Resident #1 had a rash all over his extremities. She stated LVN D said the Doctor/NP called her last Tuesday 12/16/25 and said the Doctor/NP gave no new orders and for the nurses to monitor the areas. She stated she was not sure why LVN D did not document what NP G said to just monitor the rashes. She stated she was not sure why LVN D told the HHSC investigator she was not aware of Resident #1 having a rash. She stated the process for reporting skin changes was for the nurse to get the initial report and pass it to the next shift nurse and document in the 24 hour report book. She stated the nurse managers were responsible for ensuring the change of condition processes were completed. She stated she was going to follow through on making sure she talked to the nurses about completing their nurse's documentation. She stated untreated rashes would not result in an infection but could cause symptoms of itching and the resident could scratch themselves. Interview on 12/19/25 at 5:57 pm, the Administrator stated the nurses were good about assessing and treating residents with rashes. He stated he was not aware of the delay in getting Resident #1 treatment of the rash. He stated the DON and ADON were responsible for ensuring the change of condition procedures were followed. He stated untreated rashes could spread and get worse. He stated the facility did not have a skin assessment policy. Interview on 12/19/25 at 5:59 pm, the DON interrupted the interview with the Administrator and said she spoke to LVN D. She stated LVN D said she was confused as to what was being asked by the HHSC Investigator. She stated LVN D said she received the report from NP G Tuesday night 12/16/25 to monitor Resident #1 with no new orders. She stated she was not sure why LVN D did not document NP G's report to monitor. She stated she was not sure why LVN D told the HHSC investigator she was not aware of Resident #1's rash condition last Tuesday 12/16/25 or Wednesday 12/17/25. Interview on 12/19/25 at 6:35 pm , NP G stated she was notified by LVN D last Tuesday 12/16/25 of Resident #1's arm rash, and the nurse said he had a rash. She stated Resident #1 did not complain of any itching and she told LVN D to notify her if Resident #1 continued to have a rash. She stated yesterday 12/18/25 she received a call from Treatment Nurse F about Resident #1 complaining of itching and a rash. She stated it was reported Resident #1 had had a rash around his arm pit and she gave Treatment Nurse F orders for nystatin cream and Benadryl and to keep Resident #1 dry (increase incontinent care). She stated Resident #1 had a previous history of having a rash and with him being bed bound the rash condition could have developed into contact dermatitis (skin inflammation from direct contact with soap, cleaners or allergen) . She stated she had no calls from Treatment Nurse F until yesterday 12/18/25. She stated she had not spoken to LVN B on 12/17/25 or LVN C on 12/16/25 about Resident #1's rash condition. She stated she only received a call from LVN D last Tuesday 12/16/25 and Treatment Nurse F yesterday 12/18/25 about Resident #1's rash. Record review of the Facility's Change of condition policy revised 07/2015 revealed, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. Procedures: .Routine Medical Changes - 1. Unusual signs and symptoms will be communicated to the physician promptly. Routine changes are minor changes in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. 2. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant changes in resident's condition is noted. 3. If unable to reach physician all calls to physicians or exchanges requesting callbacks will be documented on the nursing progress notes. 4. If the physician has not returned the call by the end of the shift, the on-coming nurse will be notified for follow-up. 5. If unable to contact attending physician or alternate timely, notify Medical Director for response and follow-up to change in residents status. 6. Document resident change of condition and response in nursing progress notes and update resident Care Plan, as indicated. 7. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. Follow-up: 1. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabilize.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #43) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #43 received treatment immediately after she complained of having symptoms of a urinary tract infection. The resident suffered pain that increased with each shift until treatment was administered. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment. Findings included: Review of Resident #43's Annual MDS Assessment, dated 03/28/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 15, indicating no cognitive impairment. The resident was occasionally incontinent of bowel and bladder. Her active diagnoses included end stage renal disease (kidney failure) requiring dialysis, heart failure, diabetes, and blindness. Review of Resident #43's Physician Order as of 04/22/25 reflected there were no orders for antibiotics or medications to treat a urinary tract infection. Review of the facility 24-report for 04/22/25 reflected there was no information documented about Resident #43. Review of Resident #43's Facility Medication Administration Record for April 2025 reflected the resident's pain level was 0 every shift and every day for 04/01/25 - 04/21/25. Review of Resident #43's progress notes reflected: Effective Date: 04/22/2025 11:00 AM Type: Nursing Note Text: resident returned from dialysis; assessment performed. Resident is alert and oriented to person, place, and time. Able to make needs known. Denies pain/discomfort. Dressing to left arm dry and intact. Thrill/bruit positive (fistula for dialysis assessment). No bleeding noted. Vitals sign obtained BP 137/78, Pulse 89, Resp 18, 97% oxygen level, Temperature 97.0 degrees farenheit. Call light within reached. no new order received. no concerns voiced. Written by LVN B There were no progress notes regarding Resident #43's complaint of a urinary tract infection. Review of Resident #43's care plans dated 04/22/25 at unknown time reflected: Resident states she feels like she has a urinary tract infection, and she has low output due to end stage renal disease. Facility interventions included: Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. An interview was attempted with Resident #43 on 04/22/25 at 11:26 AM. The resident said she could not talk because she was in the bathroom. An interview was attempted with Resident #43 on 04/22/25 at approximately 12:30 PM. The resident said she could not talk because she was in the bathroom. An interview with Resident #43 on 04/22/25 at 1:51 PM revealed the resident was feeling ill and having pain. The resident said she had a urinary tract infection and kept having to go to the bathroom due to urinary urgency. She said she notified LVN A the evening of 04/21/25 that she had a urinary tract infection. The resident said LVN A told her she was waiting to receive an order from the physician. Resident #43 said she had not received any treatment or medications to treat the urinary tract infection. An interview on 04/22/25 2:04 PM with ADON H revealed there were no orders, progress notes, or documentation on the facility 24-Hour Report to indicate Resident #43 had reported she had a urinary tract infection on 04/21/25 or 04/22/25. ADON H said he would call LVN A to see what happened. ADON H left the front desk. A follow-up interview on 04/22/25 at 2:16 PM revealed ADON H said an order for Macrobid (medication to treat urinary tract infection) was put in at 2:14 PM on 04/22/25. ADON H said it was expected that if a resident reported signs and symptoms of an infection the facility staff would immediately assess and treat. ADON H said the resident was not expected to have to wait. ADON H said the resident's complaint should have been documented on the 24-Hour Report. ADON H said that if a resident was not promptly treated for a UTI, then the resident would be at risk for increased infection and even death. An interview on 04/22/25 at 2:20 PM with LVN A revealed she was assigned to care for Resident #43 on the 2:00 PM - 10:00 PM shift on 04/21/25. LVN A said Resident #43 told her on the evening shift at unknown time on 04/21/25 that she had a UTI. LVN A said she told the physician who told LVN A that he would look at the resident. LVN A said the physician did not give any new orders. LVN A said she did not document a progress note or on the 24-hour report but thought she did. LVN A said the risk to Resident #43 for not receiving treatment was frequent urination, painful urination, and confusion. An interview on 04/22/25 at 3:01 PM with LVN B revealed she saw the Surveyors leave Resident #43's room on 04/22/25 at around 2:00 PM. LVN B said she went in to the resident's room to see what was going on. She said Resident #43 told her she felt funny and had burning pain when urinating. LVN B said she called the Family Nurse Practitioner and received an order for Macrobid and to not wait to get a urine sample. LVN B said the resident had not reported the issue to her on the 6:00 AM - 2:00 PM shift and she was not aware that the resident had complained on 04/21/25. LVN B said the resident had dialysis in the morning of the 6:00 AM - 2:00 PM shift and the next two times, she saw the resident, she was in the bathroom. LVN B said she thought the resident was having diarrhea but had not followed up with the resident. LVN B said she was not notified about the complaint of the resident having a urinary tract infection from the previous shift. LVN B said the resident was at risk for suffering for having to wait to get treatment. An interview on 04/22/25 at 2:25 PM revealed he was the physician for Resident #43 on 04/21/25. The physician said he was notified by LVN A on 04/21/25 that Resident #43 said she had a urinary tract infection. The physician said it was towards the end of the day and he did not go assess or see the resident. The physician said he told LVN A to monitor the resident an obtain a urine analysis. The Physician said Resident #43 would have been at risk for not being seen if the Surveyor had not intervened. The physician said on 04/22/25 he ordered Resident #43 an antibiotic. An interview on 04/23/25 at 10:19 AM with the DON revealed she was told Resident #43 thought she had a urinary tract infection on 04/21/25 and the physician saw her that evening but did not give any orders. The DON said the physician did say to monitor the resident. The DON said early on 04/22/25 LVN B called the physician and discussed whether to do a urine analysis prior to starting Macrobid. The DON said the decision was to go ahead and administer the Macrobid with no urine analysis because the resident was on dialysis and might not be able to give an adequate urine sample. The DON said LVN A did not document a progress note because the doctor did not give her any orders. The DON said the resident was awake, alert, and oriented and able to make her needs known. The DON said she would speak to Resident #43 to make sure she was being cared for and her needs were met. Follow-up interviews on 04/23/25 at 11:37 AM and 12:46 PM with the physician revealed the facility communicated with him by using his call line. He said he was notified by LVN B on 04/22/25 at 2:00 PM regarding Resident #43's complaint of urinary tract infection. The Physician said the issue was a miscommunication and error on his part. He said he gave an order to LVN A on 04/21/25 on the 2:00 PM - 10:00 PM shift to obtain a urine analysis and to monitor the resident, but maybe LVN A did not hear him. The physician said Resident #43 was a minimal risk due to the delay in treatment because there had been no issues with her dialysis or labs prior to 04/21/25. The Physician said the FNP was told about the resident's symptoms on 04/21/25 by him and the FNP was going to see the resident on 04/23/25. A follow-up interview on 04/23/25 at 1:03 PM with Resident #43 revealed she was feeling better and able to eat. She said she was not able to eat very much on 04/22/25 because she did not feel well. Resident #43 said her symptoms started on 04/20/25, but she did not report them until 04/21/25. Resident #43 said her pain levels on a scale of 1 (no pain) to 10 (extreme pain) were a 4 on the 2:00 PM - 10:00 PM shift of 04/21/25. The resident said her pain level increased to a 5 on the 10:00 PM - 6:00 AM shift and reached a 6 the morning of 04/22/25. She said the nurse did not ask if she was having pain on any of the shifts. Resident #43 said she did not tell anyone other than LVN A on 04/21/25 during the 2:00 PM - 10:00 PM shift about her pain or urinary tract infection. Resident #43 said she did not tell anyone else about it because she thought LVN A was going to take care of it. Resident #43 said she did not receive any pain medication 04/21/25 - 04/23/25. Review of the facility policy, Quality of Care: Significant Change in Condition, Response, revised December 2023, reflected: Policy It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care . Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency. 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3. The resident will then be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior/ acceptance of increased need of assistance will be monitored . 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/ her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The resident/ resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR).

Based on observations, interviews, and record review, the facility failed to ensure the facility provided, food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for dietary services. Facility failed to provide palatable, attractive, and appetizing food and drink to residents. These failures could place 77 residents who reside at the facility and eat meals prepared and served by the facility's kitchen at risk of contracting a foodborne illness, discourage residents to eat and drink, impaired nutrition and hydration status and or the recovery from, illness or injury. Findings Included: Observations during follow up visits to the kitchen on 4/24/25 beginning at 11:30am included the following: Cook Q did not use measuring cup to measure out the precise amount of milk to put in the blender while preparing the pureed food. Cook Q put chicken in blender without measuring the amount. Cook Q used scoop #10 Recipe calls for scoop #8. Observed and tasted on 4/23/25at 1:15pm test tray for regular and pureed meal that included cornbread. Surveyors tasted the pureed cornbread reflected bland taste and difficult to use utensil to spoon a bite in the overly thick consistency. Interview on 4/25/25 at 1:30pm with [NAME] Q revealed it is important to follow the recipe because it is the correct way to make the meal and if not followed food may not taste good. [NAME] Q said mistakes can be made if recipe was not followed. During follow up visits to the kitchen on 4/24/25 beginning at 11:30am included the following: Cook Q did not use measuring cup to measure out the precise amount of milk to put in the blender while preparing the pureed food. Cook Q put chicken in blender without measuring the amount. Interview on 4/23/25 at 11:30am with The Dietary Manager. The Dietary Manager revealed he has worked at the facility since 2022. The Dietary Manager revealed recipes are used when preparing the meals. The Dietary Manager revealed he attends the Resident Council meetings to hear from the residents about any food issues or suggestions. The Dietary Manager revealed the recipes are guidelines for how to prepare the meals, Interview on 4/23/25 at 11:30am The Dietitian revealed she was in the facility 3x per month with duties of oversee the Dietary Manager, monitor clinical issues, complete dietary assessments with all residents, monitor for weight loss, and oversee the therapeutic diets for each resident. Interview on 4/24/25 at 1:30pm with Dietary Aide R revealed he was new to the facility. Dietary Aide R revealed not following the recipe could not make enough or too much food or food may not have good taste. Review of facility's Policy/Procedure for Food and Nutritional Services dated 9/2024 reflected: POLICY: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. Menus shall provide a variety of foods and indicate standard portions at each meal. Menus shall be varied for the same day of consecutive weeks. When a cycle menu is used, the cycle shall be of no less than three (3) weeks duration and revised quarterly.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #51) of three residents reviewed for PASRR Screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #51. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Record review of Resident #51's quarterly MDS assessment, dated 03/24/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Section C - Cognitive Patterns was not completed. His diagnoses included stroke, anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Record review of Resident #51's Care Plan reflected: 03/15/24 At risk for re-traumatization related to history of trauma Veteran/PTSD. 03/15/23 At risk for depression. Record review of Resident #51's PASSR level 1 screening, dated 02/22/23, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #51's Electronic Health Record revealed no PASSR level 2 evaluation was completed. An interview with the MDS Nurse at 04/24/25 at 4:00 PM revealed Resident #51's PL-1 was incorrect. The MDS Nurse said it was entered into SIMPLE (PASRR electronic documentation system) incorrectly by a previous employee. The MDS Nurse usually checks the PL-1 for accuracy, but did not check Resident #51's. The MDS Nurse said that anyone who had been trained on MDS's was responsible for their accuracy. She said Resident #51 would have been at risk of not receiving appropriate services with an incorrect PL-1. An interview on 04/24/25 at 5:38 PM with the DON revealed she did not know if the resident's PL-1 was incorrect. The DON said she would reach out to the coordinator and have them complete an evaluation. An interview on 04/25/25 at 10:20 AM with the PASRR Evaluator for the facility regarding Resident #51 revealed his PL-1 was completed in 2023 and was negative. She said she did another PL-1 evaluation on 04/25/25 and the result was still negative. No PL-2 evaluation was completed. Review of the facility policy, Preadmission Screening and Resident Review, not dated, reflected: Policy: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have a documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #22) of 1 resident reviewed for incontinence care. 1. The facility failed to ensure CNA N did not double-brief Resident #22. 2. The facility failed to ensure CNA O thoroughly cleaned the vaginal area of Resident #22. This failure placed residents at risk for the development and/or worsening of urinary tract infections. Findings included: Record review of Resident #22's MDS quarterly assessment dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, kidney failure, diabetes, stroke, and Alzheimer's disease. She had a BIMS score of 6 which indicated moderate cognitive impairment. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #22's care plan, dated 08/14/24, reflected: The resident had bowel/bladder incontinence related to dementia, impaired mobility, and overactive disorder. Facility interventions included uses disposable briefs. Change as needed. Check as required for incontinence. Wash, rinse and dry perineum. An observation of incontinence care and a transfer for Resident #22 on 04/23/25 at 3:12 PM revealed CNA O and CNA P were preparing to do incontinence care and a transfer. Both CNAs washed their hands and donned (put on) gloves. The resident was transferred to bed. The resident was soaked with urine. It went through her clothes and onto the towel in the wheelchair. Both CNAs said they did not know when the resident was last changed for incontinence care. CNA O said the resident was usually soaked when he changed her after coming on the 2:00 PM shift. CNA P removed the resident pants. CNA O opened the brief, and it was revealed that the resident was wearing two briefs and both briefs were soaked. CNA O prepared to clean the resident. He cleaned the peri-area but did not open the resident's labia major and labia minor to cleanse the resident. CNA O and CNA P finished cleaning the resident and put on a clean brief. An interview on 04/24/25 at 6:18 PM with CNA O revealed he had been trained to perform incontinence care. He said he was checked off on 04/23/25 after changing Resident #22 and in January 2025 for incontinence care. He said he did not thoroughly cleanse the resident's vaginal area because he was nervous. He said if he did not thoroughly cleanse the resident then she could develop an infection, wounds, and itchiness. He said he did not know why the resident was double-briefed. He said he changed the resident every 2 hours on his shift. An interview on 04/25/25 at 10:06 AM with CNA N revealed she was assigned to care for Resident #22 on the 6:00 AM - 2:00 PM shift for 04/23/25. She said she was supposed to check and change the resident every 2 hours, but on 04/23/25 she only changed her twice. CNA N said she knew she was not supposed to double-brief the resident, but she was in a hurry. CNA N said she had never double briefed a resident before. She said double briefing a resident and not checking and changing her every 2 hours could cause breakdown, bed sores, and urinary tract infections. An interview with the DON on 04/24/25 at around 5:00 PM revealed CNAs were trained on how to perform incontinence care and received competency checks. The DON said annual training and as needed training was completed with CNAs. The DON said the resident should never be double-briefed and residents should be checked for timely incontinence care. The DON said the resident was at risk for skin breakdown and infection. Review of the facility's policy, Incontinent Care, revised May 2024, reflected: POLICY: It is the policy of this facility to: 1. Ensure residents are clean 2. Cleanse and lubricate skin as needed. PROCEDURES: Equipment: o Disposable incontinent brief, pad or resident's own undergarment (as a plan of care) o Linen, as needed o Washcloth or wipes as required. o Soap, peri wash or wipes. o Lotion or barrier cream as ordered. 1. Assemble equipment. Explain procedure. Provide privacy by closing door and securing privacy curtain. 2. Assist resident to lay in bed, explain procedure to resident. Clean from front to back, clean hands, change gloves, clean the back going upwards. 3. Clean hands and Donn gloves and apply brief. 4. Apply lotion or barrier cream as ordered. 5. Check for incontinence at least every two (2) hours.

Based on observations, interviews, 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 kitchen safety. Facility failed to utilize proper personal hygiene practices (e.g., proper hand washing and the appropriate use of gloves) to prevent contamination of food. These failures could place 77 residents who reside at the facility and eat meals prepared and served by the facility's kitchen at risk of contracting a foodborne illness. Findings Included: Observations during follow up visits to the kitchen on 4/24/25 beginning at 11:30am included the following: Cook Q left the prep area with gloves on and put trash in the recycle can then returned to prep and continued to prepare the food with the same gloves. Interview on 4/25/25 at 1:30pm with [NAME] Q revealed gloves are changed each time touch something different like touching trash can. [NAME] Q revealed important to change gloves when touching things other than the food because residents could become sick. Interview on 4/23/25 at 11:30am with The Dietary Manager. The Dietary Manager revealed he has worked at the facility since 2022. The Dietary manager revealed if sick not to come to work and if gets sick at work notify Administrator as his supervisor and if it is his staff they report to him/the The Dietary manager. Interview on 4/23/25 at 11:30am the The Dietitian revealed she was in the facility 3x per month with duties of oversee the Dietary Manager, monitor clinical issues, complete dietary assessments with all residents, monitor for weight loss, and oversee the therapeutic diets for each resident. Interview on 4/24/25 at 1:30pm with Dietary Aide R revealed he was new to the facility. Dietary Aide R revealed if he was sick at home at a time, he was scheduled to work Dietary Aide R would call his manager. Dietary Aide R revealed if he was at work and became sick, he would notify his manager and go home. Dietary Aide R revealed gloves are wore to not spread contamination. Dietary Aide R revealed one of the reasons to change gloves would be if the glove ripped, he would need to change his gloves. Review of the facility's Hand Hygiene Policy and Procedure dated: Original date: 5/2007 Revision/Review Date(s): 6.2021, 1.2022,10.2022 Reflected: Purpose Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Definitions Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. Hand washing is the vigorous, brief rubbing together of all surfaces of hands with soap and water, followed by rinsing under a stream of water. Alcohol-based hand rub (ABHR) is a 60-95 percent ethanol or isopropyl alcohol-containing preparation base designed for application to the hands to reduce the number of viable microorganisms. Procedure 1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled (e.g., blood, body fluids) b. After caring for a resident with known or suspected Clostridioides (C.) Difficile or Norovirus infection during an outbreak, or if infection rates of C. Difficile Infection (CDI) are high 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene. r. After removing and disposing of personal protective equipment.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of six residents (Resident #30 and #180) observed for infection control. MA K used her ungloved hand to pick medication from the medication cart and administered it to Resident #30. CNA L failed to perform hand hygiene while providing incontinence care to Resident #180 The failures could place the residents at risk for infection. Findings include: Record review of Resident #30's face sheet dated 04/24/25 reflected an [AGE] year-old female. She was admitted to the facility 10/11/24. Admitting diagnoses included, dementia, difficult walking, weakness, heart failure, type 2 diabetes, memory deficit. Review of Resident #30's MDS record dated 03/31/25 reflected the resident had a BIMS (Brief Interview of Mental Status) score of 11, indicative of moderate cognitive impairment. Review of Resident #30's care plan initiated 10/12/24 reflected Resident #30 required assistance with activities of daily living due to dementia. Observation on 04/22/25 at 09:52 AM with Resident #30 reflected MA K preparing medications for Resident #30. During prepping the following medications one-daily vitamin 1 tablet chewable aspirin 81 mg 1 tablet, escitalopram 5 mg 1 tablet, memantine 5 mg 1 tablet, atorvastatin 80 mg 1 tablet, a tablet fell on the medication cart and MA K picked the medication up with her bare hands and placed it in the medication cup and later administered the medication to the resident. In an interview on 04/22/25 at 10:10 AM with MA K, she stated she picked up the medication from the cart without gloves because her hands were clean, but then she stated she was not supposed to pick the medication from the cart, and she was not supposed to administer the medication to the resident because it could have been contaminated from the cart or her hands. MA K stated she was expected to maintain infection control during medication administration to prevent cross contamination. She stated she had been in-serviced on infection control. Record review of Resident #180's face sheet dated 04/24/25 reflected She was [AGE] years old female. She was admitted to the facility on [DATE]. She was admitted with the following diagnoses, vascular dementia, Dysphagia (difficult with swallowing), gastrostomy status (Placement of a feeding tube), muscle weakness and cognitive communication deficit. Review of Resident #180's care plan initiated 04/21/25 reflected Resident #180 had bladder incontinence related to Alzheimer's. The goal to remain free from skin breakdown due to incontinence and brief use through the review date and the intervention was to check as required for incontinence. Observation on 04/22/25 at 10:49 AM revealed CNA L providing incontinent care to Resident #180. CNA L was observed completing hand hygiene and gloved before care, then she informed the resident she was providing incontinent care. CNA L positioned the resident and unfastened the brief and proceeded to clean Resident #30's front area, then positioned the resident on her side and cleaned her bottom area. Resident #30 was minimally soiled with urine and feces. During the care CNA L was observed changing gloves but she did not complete any form of hand hygiene. In an interview on 04/22/25 at 10:54 AM with CNA L, she stated she was aware she was supposed to clean her hands after changing gloves, but she had forgotten her hand sanitizer. She stated that was the reason why she did not complete hand hygiene. When she was asked why she did not wash hands in the resident's bathroom, she then acknowledged, and stated she could have washed her hands instead. CNA L stated she was expected to complete hand hygiene to prevent the spread of infections. In an interview on 04/24/25 at 03:40 PM with the DON she stated she was the infection preventionist. The DON stated she expected the staff to maintain infection control during incontinent care and medication administration to prevent the spread of infection. The DON stated she expected MA K not to administer the medication that had fallen on top of the cart and picked up by her bare hands because it was considered contaminated. The DON also stated she expected CNA L to completed hand hygiene after taking off gloves to prevent the spread of infections. The DON stated the staff had been in-serviced on infection control. Review of the facility policy revised 10/2022 and titled Hand Hygiene reflected, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose. Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors.

Based on interviews and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for Dialysis Care. 1)The facility failed to follow Resident #1's Dialysis Communication: Special instructions/progress note dated Thursday [DATE] for Resident #1 to go to the hospital for a permacath placement because she was not able to be dialyzed that day. 2)LVN A failed to notify Resident #1's Doctor or NP about the Dialysis Center's special instructions for Resident #1 to go to the hospital on [DATE]. 3)LVN A failed to properly assess and document Resident #1's vital signs on [DATE], before leaving for dialysis and after she returned from dialysis. After administrative review, an IJ was identified on [DATE]. The Administrator was notified and an IJ Template was provided on [DATE] at 12:43 pm. While the Immediate Jeopardy was removed on [DATE] at 3:48 pm, The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could place all dialysis residents at risk of not being assessed and treated in a timely manner if they were not able to be dialyzed, which could cause abnormal vital signs and changes in condition, resulting in a decline in their health, psycho-social well-being, or death. Findings included: Record review of Resident #1's Admission MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted on [DATE] with a BIMS score of 08 (moderate cognitive impairment) and used a manual wheelchair and walker. She had no upper or lower impairments and dependent: helper does all assistance with all ADL care. Active diagnoses of other neurological conditions, anemia, hypertension, gastroesophageal reflux, renal insufficiency and diabetes mellitus, malnutrition, depression, asthma, and morbid obesity. Record review of Resident #1's Order Summary Report printed [DATE] revealed, she took Advair Diskus Aerosol Powder breath activated (for shortness of breath, COPD, mild persistent asthma), Albuterol Sulfate inhalation nebulization solution (for COPD, mild persistent asthma), carvedilol (for hypertension), renal-vite oral tablet (for kidneys), and Sevelamer Carbonate (for chronic kidney disease). And to monitor & record every shift AV (arteriovenous) shunt/fistula for bleeding. Redness, swelling, pain, s/s of infection. Document (-) absent or if (+) present notify MD and Dialysis center every shift. Record review of Resident #1's Order Summary Report printed on [DATE] did not reveal any Doctor/NP orders for a vascular consult. Record review of Resident #1's Care Plan dated [DATE] revealed, she needed dialysis (hemodialysis) r/t renal failure. Will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Will have no s/sx of complications from dialysis through the review date. Check and change dressing daily at access site. Document. Check arteriovenous fistula every day for bruit and thrill HEMODIALYSIS (filtering a patient's blood to remove waste and excess fluid) 3X/WEEK EVERY Tuesday/Thursday/Saturday AT 11AM DIALYSIS CENTER [The Dialysis Center] every day and evening shift every Tuesday, Thursday, Saturday Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Record review of Resident #1's last Blood Pressure check in the facility's EMR dated [DATE] at 7:43 am by MA P revealed, her blood pressure was ,d+[DATE] sitting left arm. Record review of Resident #1's Nurse Progress note dated [DATE] at 11:00 am by LVN A revealed, Resident up in a wheelchair ready for dialysis, denies pain when asked , and no s/s of distress noted, medications administered as ordered and well consumed, resident is on routine tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth four times a day for PAIN Pregabalin Oral Capsule 75 MG (Pregabalin) Give 2 capsule by mouth two times a day for NEUROPHATIC PAIN, resident has a behavior of yelling, when care is being provided, requires redirection at times . Will continue with her current plan of care. Record review of Resident #1's Social Services note dated [DATE] at 12:15 pm by SW G revealed, FM P called writer and advised resident needs to be picked up from dialysis. Writer notified nurse . Record review of Resident #1's Nursing Dialysis Communication Form by unknown nurse dated [DATE] at 11:24 am revealed, Fasting Blood sugar: 124, BP ,d+[DATE], Temp 98.2, Pulse 82, and respirations 17. Behavior: Yells. And at the bottom half of sheet by Dialysis Nurse special instructions/progress note, Patient was not dialyzed today, access site bruised, FM P will take patient to hospital for permacath placement. Record review of Resident #1's Dialysis Progress Note dated [DATE] revealed, Patient came in today brought in by nursing home transport patient was very lethargic, AVF site is still bruised and swollen, from previous infiltration on [DATE] as patient was always moving her access arm which is the reason why pt had permcath for a long time. So, I called FM P, I told her of the situation that we are not able to dialyze patient this day due to swollen access site, FM P said she will bring patient to Hospital today for permcath placement. I also consulted this with Nephrologist Doctor, and she is ok with permcath placement again as patient always move her arm during HD and causing infiltration. I called [The Nursing Facility] to make them aware of the plan. After about ,d+[DATE] minutes, Patient was picked up by nursing home transport via wheelchair, patient was stable at the time, patient was talking to staff when asked questions. Record review of Resident #1's Nurse Progress note dated [DATE] at 12:45 pm by the ADON in training I, revealed, Received request for patient to be picked up from dialysis at approximately 12:30 pm, placed call to [The Dialysis Center]and spoke with Dialysis Nurse stating that attempt to access patient fistula was unsuccessful due to swelling to the RUE and recommended patient be seen by vascular in hospital or at office, dialysis nurse did not have information for vascular, transport arranged to have patient picked up from dialysis center. Call placed to FM P at 12:40 and informed her that dialysis could not be completed and that transport was be arranging for pick up from dialysis and patient needed to have vascular appointment to establish access site, FM P provided vascular office information, at 12:47 pm call placed to [The Vascular Center] informed of need for appointment to establish dialysis access, [The Vascular Center] to return call with further instructions. FM P updated and aware of plan. Record review of Resident #1's Nurse Progress note dated [DATE] at 4:46 pm by ADON D revealed, This nurse passing by Resident's room approx. 2:35 pm noticed resident position in w/c with arms hanging at side. This nurse called out Resident's name while walking toward Resident no response, noticed chest not moving up and down called out for help while palpitating for pulse. No pulse palpitated initiated code blue. Staff transferred Resident to floor. CPR initiated. Resident review of Resident #1 Nurse Progress note dated [DATE] at 3:00 pm by ADON I revealed, At 2:47 pm this nurse and social services notified FM P, of change up call placed at 2:55 pm to update FM P that patient was being transported to hospital via 911 ambulance. Record review of Resident #1's Nurse Progress note by LVN A dated [DATE] at 3:21 pm revealed, At around 2:35 pm wound nurse called for help that Resident is unresponsive, Entered the room, on assessment Resident unresponsive, Code status verified. Resident is Full code, CPR initiated, 911 called. Foam like secretions from resident's mouth, suctioned EMS and Police arrived at 2.45 CPR taken over by EMS, 14:52 FM P notified, DON/ ED (Executive Director) notified. Resident transported to the hospital via stretcher. Record review of Resident #1's Nurse Progress note dated [DATE] at 3:46 by the DON and LVN A revealed, Change in Condition : Symptoms or signs noted of Condition change: Cardiac arrest Refer to e-INTERACT Change in Condition for Full Evaluation Vital Signs : BP ,d+[DATE] - [DATE] 07:43 Position: Sitting l/arm P 77 - [DATE] 07:43 Pulse Type: Regular R 0 - [DATE] 15:47 T 97.9 - [DATE] 19:52 Route: Forehead (non-contact) O2 93.0 % - [DATE] NP Date and time of clinician notification: [DATE] 2:45 PM. Record review of the Paramedic Prehospital Report dated [DATE] revealed, At [DATE] at 2:40 pm 911 called and at [DATE] at 2:43 pm paramedics arrived. Cardiac Arrest - Possible DOA: A female lying supine on the floor with staff performing CPR. Staff was using a bag valve mask with 100% O2 and performing chest compressions with an AED attached to the pt. Staff said pt was supposed to have dialysis today but it was not completed, and she was returned to the nursing/rehab facility. Staff said pt was last seen about 2pm and the arrest was not witnessed. Compressions continued while we prepared to move pt to the stretcher. We lifted pt and placed her on the stretcher without incident. We transported pt to the hospital while continuing CPR. Upon arrival to the ER, we were directed to a room and met by a team of nurses and a doctor. O2 at bedside was 90. We moved pt over to the ER bed with Paramedic still providing compressions. Pt care transferred to ER nurse. Transfer of care: [DATE] at 3:13 pm. Record review of Resident #1's Hospital Report dated [DATE] revealed, at 3:15 pm revealed, Pulse: 204, respiration:101, BP --, SPO2 --, Chief Complaint: Cardiac Arrest: 4:26 PM Resident #1 is a 67 y.o. female with past medical history of anemia, asthma, COPD, dementia, depression, diabetes, hypertension who presents to the ED (emergency department) c/o (complaints of) cardiac arrest. Patient was last seen at 2 PM. EMS was called at 2:35 pm when staff found her unresponsive. There was bystander CPR EMS responded and placed a [NAME] (airway device) and continued CPR. She received 3 rounds of epinephrine, sodium bicarbonate, calcium gluconate. Patient was still asystolic (no heartbeat) upon arrival. History limited secondary to patient's medical status. bicarbonate. Patient was defibrillated twice and regained a pulse. Patient in normal sinus rhythm currently. Blood pressure dropped transiently in the ER so Levophed (low blood pressure medications) was initiated. Plan is admission to the ICU. I spoke to the ICU app. The hospitalist will admit. Labs Reviewed - CBC WITH AUTO DIFFERENTIAL - Abnormal Result Value WBC 22.5 (*) RBC 2.75 (*) Hemoglobin 8.8 (*) Hematocrit 28.9 (*) MCV 105.1 (*) MCH 32.0 MCHC 30.4 (*) RDW-CV 15.9 (*) Platelet Count 284 MPV 10.0 COMPREHENSIVE METABOLIC PANEL W/EGFR - Abnormal Sodium 134 (*) Potassium 5.4 (*) Chloride 91 (*) CO2 26 Anion Gap 17 (*) BUN 64 (*) Creatinine 9.00 (*) Glucose 140 (*) Calcium 12.3 (*) AST 175 (*) ALT (SGPT) 45 (*) Alkaline Phosphatase 105 Total Protein 6.4 Albumin 3.1 (*) Total Bilirubin 0.5 eGFR 4.4 (*) Corrected Calcium 13.0 (*) BUN/Creatinine Ratio 7.11 (*) Osmolality Calc 280 [NAME] Score -2.02 (*) Icterus <2.0 Turbidity <20.0 Hemolysis 21.0 And on [DATE]: Hospital Course and Treatments Rendered: Status postcardiac arrest Etiology unclear, Family decided on withdrawal of care. Patient was terminally extubated on [DATE] and started on comfort measures. Patient expired and was pronounced deceased at 2:35 pm on [DATE]. Acute respiratory failure as above, Septic shock, S/p pressors and antibiotics, ESRD S/p hemodialysis. Initiated comfort measures as above. In an interview on [DATE] at 1:08 pm, ADON B stated Resident #1 was a new admit and on [DATE], FM P called this facility asking if they could send Resident #1 to the hospital for a problem with her catheter. He stated he was not sure what was going on, because the Dialysis Nurse said he called FM P to take Resident #1 to the hospital and not the facility. He stated the Dialysis Nurse said he called FM P about her shunt (dialysis access port) site not working right and she was not dialyzed. He stated he spoke to the dialysis nurse, but could not remember his name, he was told they were in the process of sending her to the hospital. He stated [The Nursing Facility] driver picked up and dropped off Resident #1 to this facility and FM P gave Resident #1's vascular Doctor information. He stated the last report was of Resident #1 watching TV and nothing was out of the ordinary going on with her then she became unresponsive. He stated they started CPR and called 911 and she was revived and transferred to the hospital. Resident #1 went to dialysis at 11:00 am and returned to this facility around 1:30 pm then she had a change in condition and the paramedics took her to the hospital at 2:45 pm. He stated Resident #1 had not returned yet and was unsure of her medical status. In an interview on [DATE] at 2:37 pm, CNA C stated a few weeks ago and a little after 2:00 pm, they announced the code blue to Resident #1's room and she was laid onto the floor to start CPR compressions. He stated a nurse was getting O2, ADON B and ADON D started doing CPR, then the paramedics arrived within 30 minutes. In an interview on [DATE] at 3:00 pm, ADON D stated on the morning of [DATE] Resident #1 was her normal self and her vitals were within normal limits. She stated she saw Resident #1 back from dialysis around 1:30 pm or 1:45 and she appeared fine. She stated around 2:30 pm she was walking down the hallway and noticed Resident #1 was in her room sitting in her wheelchair, with both of her hands down. She stated her chest was not rising and going down, then she called for help immediately, and LVN A and ADON B came in. She stated she was doing a sternal rub and CNA C and CNA E came and they lowered her to the floor to start doing chest compressions. She stated she continued doing chest compressions, the crash cart and AED was brought in and were used, and 911was called. She stated CPR compressions were being rotated between her, the DON in training, and LVN A until the paramedics arrived, and they took over chest compressions. She stated they were able to get Resident #1's heartbeat back and the paramedics took her on a stretcher to the hospital. She stated last she heard; she was on a ventilator in the ICU. She stated last week Resident #1's family came to pick up her personal belongings and FM P wanted to know what happened to their mother. In an interview on [DATE] at 3:54 pm, LVN F stated around the change of shift, LVN A was giving her report about Resident #1 and how she went to dialysis but was not dialyzed because a of problem with her access port. She stated being told vascular was pending to change Resident #1's access port when she received the code blue. She stated ADON D was the staff that initially saw the resident unresponsive, they started CPR and 911 was called, and the paramedics took over. She stated Resident #1 was then taken to the hospital and last she heard she was on a ventilator. In an interview on [DATE] at 4:18 pm, SW G stated on [DATE] around 11:00 am or 12:00 pm, FM P called saying the Dialysis Center wanted them to pick Resident #1 up. She stated there was never any mention for Resident #1 to go to the hospital, but she did notify the Facility's Van Driver H to pick her up from the Dialysis Center. In an interview on [DATE] at 4:06 pm, Facility Driver H stated he dropped Resident #1 off to dialysis at 11:00 am and she appeared to be fine. He stated he received a call to pick up Resident #1 because she was not dialyzed, and he picked her up around 12:00 pm or 12:30 pm. He stated she looked fine and dropped her to [This Nursing Facility] and he was not told to take her to the hospital. He stated he rolled her to her room, she said thank you, and he left to pick up another resident. He stated she was not in any distress. She had on her O2 and did not appear to be out of breath. In an interview on [DATE] at 4:52 pm, the DON in training I stated on [DATE] Resident #1 did not have a change in condition until after she returned to the facility. She stated SW G told her Resident #1 needed to be picked up from dialysis. She stated she called the Dialysis Nurse who said she was not dialyzed at all because they were not able to access her catheter port and needed to see her vascular Doctor. She stated she called FM P and asked if she had Resident #1's Vascular Doctor's number and said she was able to locate that, Doctor. She stated around 12:30 pm or 12:45 pm, she called FM P informing her the Vascular center said they could see her that day and would call back with a time. She stated she heard a code blue call shortly after the 2:00 pm shift change because the day shift staff were still in the building. She stated she went to Resident #1's room, CPR was being done, AED Pads were on her, and she was getting O2. She stated nurses were alternating doing chest compressions and rescue breaths then the paramedics arrived, and she was stable and breathing. She stated Resident #1 was transferred to the hospital and admitted to the ICU. She stated the nursing staff had a debriefing about Resident #1's incident to ensure they did not have any issues with what they did during her Code Status. In an interview on [DATE] at 10:02 am, the DON stated Resident #1 was admitted for rehabilitation and needed dialysis. She stated she was not at work this day but heard that on [DATE] Resident #1 went to dialysis and later that day around 12:30 pm, FM P called the DON in training to pick up Resident #1. She stated she needed to be picked up because of a problem with her dialysis port. She stated they called the dialysis center to confirm what FM P said and the Dialysis nurse said Resident #1 needed to see her Vascular Doctor because she was unable to dialyze. She stated Resident #1 returned to the facility around 1:30 pm by their Transport Driver H. She stated Resident #1 returned stable, had no change in condition, and they were in the process of setting an appointment for her with the Vascular Doctor. She stated around 2:30 pm ADON D found Resident #1 unresponsive, called for help, other nursing staff assisted with performing CPR, and 911 was called. She stated the paramedics arrived and took over CPR efforts and FM P and the NP were notified as to which hospital she was being transferred to. She stated anytime there was a code blue they reviewed what happened to the resident to ensure they practiced proper procedures with CPR, calling 911, and notifying the Doctor and the RP. She stated they were not able to determine any errors with how the code blue was done. She stated they had an AD HOC meeting with the Administrator, the SW, two ADON's, and the MDS Coordinator about Resident #1's incident and trainings with the staff were conducted. She stated FM P and other family members came to the facility on Labor Day ([DATE]) wanting her medical records and picked up her belongings. She stated they wanted to know what happened to Resident #1 because she had a lack of oxygen. She stated she educated them because they were not comprehending when the heart stops O2 was not getting to her. She stated she heard Resident #1 passed away on [DATE] at the hospital. She stated the dialysis residents had orders to check their access ports and vital signs before the resident goes to dialysis and after they return. She stated to her knowledge there were no issues with her dialysis port. In an interview on [DATE] at 10:55 am, LVN A stated on [DATE] she checked Resident #1's dialysis port around 11:00 am or 11:30 am. She stated she did not see anything abnormal with her dialysis access site and her vitals were checked and were within normal limits. She stated she was her normal baseline when she left the dialysis center and then FM P called the DON in training to have Resident #1 pick her up because she was not able to be dialyzed. She stated Resident #1 returned around 1:39 pm and her access site was checked, and the resident stated she felt ok and was not in any pain. She stated Resident #1 was sitting in her wheelchair, watching tv, then around 2:30 pm she heard the code blue. She stated Resident #1's chest was not rising, she had no pulse, and was full code so they transferred her from her wheelchair to the floor. She stated the paramedics came and CPR efforts continued and then she had a pulse. She stated her Doctor and FM P were notified and last she was told was that she was on a ventilator. She stated the reason why her vitals at 1:45 pm were not in Resident #1's EMR was because she misplaced the paper, she wrote the vitals on because she just got busy. In an interview on [DATE] at 11:29 am, the Dialysis Nurse stated Resident #1 had been a dialysis patient since 2018 and her last dialysis day was [DATE]. He stated on [DATE] she was not able to be dialyzed because her access port was swollen. He stated they thought possibly a needle got dislodged in the fistula access port and said he spoke to FM P and was told FM P was going to take Resident #1 to the hospital. He stated [The Nursing Facility] came to pick her up within 15 minutes and he thought she was being taken to the hospital. In an interview on [DATE] at 12:06 pm, the Dialysis Clinic Manager stated Resident #1 was a dialysis patient with them for a long time and on [DATE] she was not dialyzed because she needed a catheter replacement because the fistula port was not accessible. She stated FM P said she would take Resident #1 to the hospital to replace the permacath, then heard [The Nursing Facility] would pick her up. She stated the Dialysis Nurse spoke to [The Nursing Facility] staff to make them aware of the plan for her to go back to the hospital for the permacath replacement, per Resident #1's Nephrologist Doctor's order that was on the communication form. In an interview on [DATE] at 12:39 pm, the Vascular Center Representative stated Resident #1 was last seen in their office in 2023. He stated when a resident was at a nursing facility, they had to have a contract in place first before they could be seen by the Vascular Doctor. He stated they sent a contract to [The Nursing Facility] but they did not sign it and sent their own contract that was currently being reviewed by their legal department. He stated he called [The Dialysis] center on [DATE] to notify them they could not see Resident #1 and was informed she had already been sent to the hospital. He stated he was not sure who he spoke to [This Nursing Facility] but advised them they needed to either wait for the legal department to review their contract or take Resident #1 to the hospital. In an interview on [DATE] at 1:03 pm, DON in training I stated she was not sure what time Resident #1 got back to the facility on [DATE] and she did not do her vital signs. She stated the outcome of not checking the resident's vital signs varied and it depended on each resident's health condition and said she did not know what could happen to a resident if their vital signs were not checked and documented, it was just a wide variety of what if's. In an interview on [DATE] at 1:41 pm, FM P stated on [DATE] the Dialysis Nurse called her at 12:02 pm saying her fistula access port was swollen and she could not be dialyzed. She stated the Dialysis Nurse told her Resident #1 needed to be sent to the hospital and at 12:07 pm she called SW G to let her know she needed to be picked up and taken to the hospital. She stated SW G said she would let the ADON, and the DON know and get her picked up. She stated at 12:40 pm she spoke to the DON in training I about sending Resident #1 to the hospital. She stated DON in training I said she did not want to send Resident #1 to the hospital and wanted to send her to her vascular Doctor instead. She stated DON in training I said they were going to make an appointment and at 2:59 pm she received a call that Resident #1 was unresponsive. She stated the DON in training said she was going to get Resident #1 in to see Vascular Doctor then next thing she knew; Resident #1 had no pulse or heartbeat when they found her. She stated the last time she saw Resident #1 was [DATE] at 5:00 pm, she was her normal self, moving her feet more than she used to, and she was happy. In an interview on [DATE] at 1:52 pm, LVN A stated on [DATE] she received Resident #1's dialysis binder and her communication form said the patient did not get dialyzed today and her FM P was sending Resident #1 to the hospital, for a Permacath placement. She stated the reason Resident #1 did not go to the hospital was because one of the managers was working on getting Resident #1 a Vascular appointment. She stated based on her observation Resident #1 did not look like she needed or warranted going to the hospital. She stated they were waiting for the Vascular office to get back with them on an appointment. She stated the dialysis center did not send Resident #1 to the hospital because they were giving them an option to get a Vascular Doctor appointment or send the resident to the hospital. She stated she spoke to Resident #1's NP and she stated she was not dialyzed, and she said to monitor Resident #1 for change in condition and for fluid overload. She stated her fistula port did not look bad. She stated her usual timeframe for checking dialysis patient's vitals were as soon as the resident came back to this facility. She stated on [DATE], Resident #1's vitals were stable, and she wrote them down on her a sheet of paper. She stated she was not sure where she placed her vitals and stated if the vital signs were not checked and documented they would not know if there were any abnormalities. She stated for Resident #1's change in condition form, she did not have the vitals she took at 1:30 pm and used the early morning 7:43 am vitals. She stated Resident #1 returned to the facility at 1:30 pm, she saw Resident #1 at 1:45 pm, and at 2:30 pm she was nonresponsive. She stated she had a 1:1 training today ([DATE]) by the DON, HR, and the ADON on documenting timely when the residents return to the facility and to call the dialysis for clarification. She said when she looked at Resident #1's communication form and spoke to Van Driver I she was told she was not dialyzed. She stated the purpose of the dialysis treatment was to get the impurities out of their blood. She stated it was important for the nurses to check the resident's vitals due to any change in their body could cause the resident to decline causing them to have a change in condition from their normal baseline. In an interview on [DATE] at 2:18 pm, the DON stated vital sign checks of the dialysis residents were checked after dialysis and depended on the resident's circumstances. She stated there was not a scheduled time the nurses needed to check the resident's vitals, but she expected them to be checked within 1 hour of returning to this facility. She stated LVN A did Resident #1's vitals between 1:30 and 2:30 pm and would follow up once she reviewed the EMR. She stated FM P called them to pick up Resident #1 and they called dialysis and confirmed the Dialysis Nurse said to seek getting a Vascular Doctor's appointment or hospital transfer. She stated there was a process that they first called the Vascular office and talked to [The Vascular office representative]. She stated she was not sure about a contract needing to be signed before Resident #1 could be scheduled to the Vascular office. She stated FM P was aware of their plans for Resident #1 to get a doctor's appointment and told them the name of the vascular doctor. She stated ideally, they liked to document vitals into the EMR system after they were taken which was why they educated LVN A on documentation. She stated Resident #1's [DATE] Change in condition at 2:35 pm SBAR form had her vitals from [DATE] at 7:43 am because the SBAR prefilled what the last vitals on file were. She stated not documenting resident's vitals and nurses notes depended on the resident and the circumstances as to how it could affect the residents. She stated the nurse on duty was responsible for their own documentation and nurse managers. In an interview on [DATE]/ at 3:31 pm, the Administrator stated he heard Resident #1 went to dialysis and returned earlier than normal. He stated Resident #1 returned to this facility around 1:30 pm. He stated then she had a code blue and the nurse's provided CPR, and the paramedics picked her up and took her to the hospital. He stated he was not aware LVN A wrote Resident #1' vitals on a sheet of paper that she misplaced. He stated often the nurses were pulled in too many directions from staff and residents, and as far as he was aware she was stable. He stated not being aware of any contracts given to the Vascular Office and was not aware she needed to go to the hospital for a permacath placement. He stated it did not seem the Dialysis Center saw a need for her to go to the hospital and thought the Dialysis Center used hospital as a word of choice. He stated they had an AD HOC meeting the first week of September with the Medical Director, the DON, the ADON, and himself and was not sure what they went over. He stated he was not sure if LVN A not documenting in the EMR about Resident #1's change in condition was discussed but nurse management addressed that. He stated Nurse management was responsible for ensuring vital signs and documentation were completed. He stated he heard FM P came to the facility on Labor Day ([DATE]) and believed they asked questions about the resident not sure on the specifics. He stated he would check to see if they did a grievance about Resident #1. In an interview on [DATE] at 4:23 pm, the Medical Director stated he was also Resident #1's Facility Doctor. He stated Resident #1 was a dialysis patient who had a cardiac arrest late last month and she passed away. He stated he was not sure what her cause of death was and stated there were no issues with how the nursing staff responded when Resident #1 had a change in condition. He stated he had an on-call NP who was contacted on [DATE] about Resident #1's change in condition. He stated he was not sure of the day and time of what the nursing department did and the HHSC Surveyor needed to talk to the nursing department. He stated the last QA meeting was last month he attended but did not recall anything about Resident #1's incident and documentation of resident's vital signs. He stated generally the resident's vitals were done before the resident was transported to and from dialysis. He stated vital signs were of importance to understand the clinical condition of the patient. He stated he was not going to speak to what the Dialysis communication form said to take Resident #1 to the hospital for a permacath placement and would have to refer the HHSC Surveyor to nurse management. In an interview on [DATE] at 4:43 pm, LVN J stated she cared for Resident #1 on [DATE] and she was fine and had increased confusion. She stated she did not work [DATE] and when she returned, she heard Resident #1 passed away. She stated she heard Resident #1 was foaming from her mouth and they rushed to do CPR. In an interview on [DATE] at 5:25 pm, the DON stated she wanted to ensure the HHSC Surveyor had the timeline right. She stated Resident #1 went to dialysis on [DATE] around 11:00 am and at 12:00 pm they received a call from FM P that she needed to be picked up from dialysis. She stated Van Driver H picked Resident #1 up and brought her back to this facility around 1:30 pm. She stated LVN A assessed Resident #1

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of six residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's vital signs check in the EMR before she left and after she returned for dialysis on [DATE]. The facility failed to ensure LVN A completed documentation on [DATE] about the special instructions from Resident #1's Dialysis Center for her to go to the hospital for a permacath placement. The facility failed to ensure LVN A documented notifying Resident #1's Doctor/NP about the need to go to the hospital per the Dialysis Communication sheet on [DATE] and the outcome of what the Doctor/NP said. These failures could affect all residents and cause errors in care, treatments and communication which could result in a decline in their health and psycho-social well-being. Findings included: Record review of Resident #1's Admission MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted on [DATE] with a BIMS score of 08 (moderate cognitive impairment) and used a manual wheelchair and walker. She had no upper or lower impairments and dependent: helper does all assistance with all ADL care. Active diagnoses of other neurological conditions, anemia, hypertension, gastroesophageal reflux, renal insufficiency and diabetes mellitus, malnutrition, depression, asthma, and morbid obesity. Record review of Resident #1's Order Summary Report printed [DATE] revealed, she took Advair Diskus Aerosol Powder breath (activated (for asthma), Albuterol Sulfate inhalation nebulization solution (for asthma), carvedilol (for hypertension), renal-vite oral tablet (for kidneys), and Sevelamer Carbonate (for chronic kidney disease). Record review of Resident #1's Care Plan dated [DATE] revealed, she needed dialysis (hemodialysis) r/t renal failure. Will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Will have no s/sx of complications from dialysis through the review date. Check and change dressing daily at access site. Document. Check arteriovenous fistula every day for bruit and thrill HEMODIALYSIS 3X/WEEK EVERY Tuesday/Thursday/Saturday AT 11AM DIALYSIS CENTER [The Dialysis Center] every day and evening shift every Tuesday, Thursday, Saturday Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Record review of Resident #1's last Blood Pressure check in the facility's EMR dated [DATE] at 7:43 am by MA P revealed, her blood pressure was ,d+[DATE] sitting left arm. Record review of Resident #1's Nursing Dialysis Communication Form by unknown nurse dated [DATE] at 11:24 am revealed, Fasting Blood sugar: 124, BP ,d+[DATE], Temp 98.2, Pulse 82, and respirations 17. Behavior: Yells. And at the bottom half of sheet by Dialysis Nurse, Patient was not dialyzed today, access site bruised, FM P will take patient to hospital for permacath placement. In an interview on [DATE] at 10:55 am, LVN A stated on [DATE] she checked Resident #1's dialysis port around 11:00 am or 11:30 am. She stated she did not see anything abnormal with her dialysis access site and her vitals were checked and were within normal limits. She stated she was her normal baseline when she left the dialysis center and then FM P called the DON in training to have Resident #1 pick her up because she was not able to be dialyzed. She stated Resident #1 returned around 1:39 pm and her access site was checked, and the resident stated she felt ok and was not in any pain. She stated Resident #1 was sitting in her wheelchair, watching tv, then around 2:30 pm she heard the code blue. She stated Resident #1's chest was not rising, she had no pulse, and was full code so they transferred her from her wheelchair to the floor. She stated the paramedics came and CPR efforts continued and then she had a pulse. She stated her Doctor and FM P were notified and last she was told was that she was on a ventilator. She stated the reason why her vitals at 1:45 pm were not in Resident #1's EMR was because she misplaced the paper, she wrote the vitals on because she just got busy. In an interview on [DATE] at 1:03 pm, the DON in training I stated the outcome of not checking the resident's vital signs varied and it depended on each resident's health condition and said she did not know what could happen to a resident if their vital signs were not checked and documented, it was just a wide variety of what if's. In an interview on [DATE] at 1:52 pm, LVN A stated on [DATE] she received Resident #1's dialysis binder and her communication form said the patient did not get dialyzed today, FM P sending Resident #1 to the hospital for permacath placement. She stated she had a 1:1 training today [DATE] by the DON, HR, and the ADON on documenting timely when the residents return to the facility and getting clarification of the communication forms, if needed. She stated the purpose of dialysis treatment was to get the impurities out of their blood. She stated it was important for the nurses to check the resident's vital signs due to any change in their body could cause the resident to decline causing them to have a change in condition from their normal baseline. In an interview on [DATE] at 2:18 pm, the DON stated vital sign checks of the dialysis residents were checked after dialysis and depended on the resident's circumstances. She stated there was not a scheduled time the nurses needed to check the resident's vital signs, but she expected them to be checked within 1 hour of returning to this facility. She stated LVN A did Resident #1's vital signs between 1:30 and 2:30 pm and would follow up once she reviewed the EMR. She stated ideally, they liked to document vital signs into the EMR system after they were taken, which was why they educated LVN A on documentation. She stated Resident #1's [DATE] Change in condition at 2:35 pm SBAR form had her vitals from [DATE] at 7:43 am because the SBAR prefilled what the last vitals on file were. She stated not documenting resident's vitals and nurses notes depended on the resident and the circumstances as to how it could affect the residents. She stated the nurse on duty was responsible for their own documentation and nurse managers. Interview on [DATE]/ at 3:31 pm, the Administrator stated he heard Resident #1 went to dialysis and returned earlier than normal. He stated Resident #1 returned to this facility around 1:30 pm. He stated then she had a code blue and the nurses provided CPR and the paramedics picked her up and took her to the hospital. He stated he was not aware LVN A wrote Resident #1' vitals on a sheet of paper that she misplaced. He stated often the nurses were pull into many directions from staff and residents and as far as he was aware she was stable. He stated Nurse management was responsible for ensuring vitals and documentation were completed. He stated he heard FM P came to the facility on Labor Day [DATE] and believed they asked questions about the resident not sure on the specifics. He stated he would check to see if they did a grievance about Resident #1. In an interview on [DATE] at 10:51 am, the DON stated Resident #1's vital signs were checked before and after she was sent to dialysis and would follow up with HHSC Surveyor to provide the documentation. She stated dialysis said they did not do her vital signs because she was not treated on [DATE] and stated if they missed dialysis [This Facility] still needed their vital signs done because there was a change in their dialysis treatment plan. She stated LVN A had 1:1 counseling covering the documentation components in EMR system. She stated when they called the Dialysis Nurse to confirm what FM P said Resident #1 was not dialyzed and needed to go to the Vascular Doctor or hospital for permacath replacement. She stated she was not sure why Resident #1's vitals were not documented before and after dialysis in the EMR system and maybe LVN A misplaced the sheet of paper during the change of shift on [DATE]. In an interview on [DATE] at 10:32 am, Dialysis Nurse stated Resident #1 had been on dialysis services for a long time and at times she pulled out her catheter line. He stated in the past year FM P usually took Resident #1 to the hospital emergency room to get a catheter replacement. He stated No, no, no [The Nursing Facility] did not need to schedule her a vascular appointment and was not sure where that came from. He called Resident #1's Nephrologist, he wanted her to go to the hospital for the catheter placement which was what was also on the dialysis communication form on [DATE]. In an interview on [DATE] at 12:34 pm, LVN A stated she was trained this week on ensuring the resident's vital signs and access ports were checked and that head-to-toe assessments were completed prior to and post dialysis. She stated she was trained on checking their access site ask the resident how they felt and reviewing the communication form. She stated they needed to document their findings of any abnormalities and communicate that to the Doctor, family, and DON. She stated she was trained on making sure they were on the same page with the dialysis center and to know the plan of care to provide adequate care. She stated she was trained yesterday [DATE] on documentation of assessments, vitals, checking dialysis access sites and looking at how the resident was doing. And was trained on ensuring the resident's vitals were on the dialysis communication form and in the facility's EMR. She stated she was not sure why she did not put Resident #1's vitals into the EMR before and after dialysis and maybe she was in a rush. She stated on [DATE] she told Resident #1's Doctor she did not dialyze this day but did not mention what the dialysis communication form said about going to the hospital. She stated the importance doing the resident's vital signs was to get a baseline of the resident to see if they had a change in condition. She stated the importance of documenting was to ensure the resident was getting the proper plan of care and alert all nursing about the resident. In an interview on [DATE] at 2:17 pm, the Administrator stated the Dialysis Communication Form was not a doctor's order and his facility nurse did call the Dialysis Center to understand what was needed. He stated things happened when it came to LVN A misplacing the sheet with Resident #1's vital signs on [DATE] and was not sure what happened to the sheet. He stated in an ideal world she should have documented the vital signs in the EMR, but she could have got stopped to help pass out trays or answer the phone. He stated LVN A was not going to stop taking care of the resident's if she needed to document something. He stated it was concerning that Resident #1 vitals were not entered on [DATE] and seven days later Resident #1 passed away. He stated although LVN A failed to document Resident #1's vital signs in the EMR did not mean she did not check her vitals. He stated not putting documentation in the EMR and Resident #1 having a change in condition and coding was not a related. He stated he had to believe what his DON and nurses said that her vital signs were checked at 1:30 pm despite not having any documentation in the EMR. He stated his expectations for dialysis residents was whatever the standard of practices was and added the nurse leadership team ensured the nursing department did all they were supposed to do for each resident. He stated yesterday [DATE] and day before [DATE], they had staff trainings on dialysis care and were being tested for competency. In an interview on [DATE] at 2:47 pm, the DON stated she started trainings and knowledge checks on pre and post dialysis care and after auditing their three dialysis residents had no irregularities. She stated skills check offs on assessments and documentation, and dialysis access port care were done. She stated they trained on the expectations for their staff and Dialysis staff. Record review of LVN A's Counseling/Disciplinary Notice form dated [DATE] revealed, Counseling: per nurse, nurse misplaced assessment information completed on a patient and therefore was unable to document. Nurse was educated on importance of documenting assessments completed. Nurse is aware that if there are any documentation issues needs to notify DON or nurse manager. Signed by LVN A and DON. Record review of the facility's Nursing Care of Dialysis Resident Knowledge Check undated revealed, Learning Objective: Assist the resident in maintaining homeostasis pre and post renal dialysis: 1. Pre dialysis - nurse should obtain the resident's vital signs and document prior to being transported to dialysis center .5. Nurse should assess resident and obtain vital signs, document, and report .7. Nurse must complete and document on the pre and post dialysis communication .9. Nurse should document communication between the facility, dialysis staff, education, family, appointments, and transportation arrangements. Record review of the facility's Dialysis policy dated ,d+[DATE] revealed, It is the policy of this facility to: Assist resident in maintaining homeostasis (balance of all body systems to survive and function properly) pre- and post-renal dialysis, Documentation: Documentation related to pre- and post-dialysis care will be placed in the clinical record and include Resident assessments, interventions, and any provided education. Assessment of renal dialysis access site, to include presence or absence and quality of a bruit and thrill for residents with an arteriovenous fistula. Communication between facility and dialysis staff or medical provider. Record review of the facility's Medical record policy was requested on [DATE] at 3:48 pm, [DATE] at 1:01 pm, from the DON and Administrator and was told they did not have a policy.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #16) of 8 residents reviewed for Resident Rights. The facility failed to ensure Resident #16 was accommodated with a call light to meet her needs in order to call for assistance when she needed it. This failure could place residents at risk of not being able to call for staff assistance, which could cause delays with getting ADL care, pain management and other healthcare needs leading to health decline and decreased psycho-social well-being. Findings included: Record review of Resident #16's Admission MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a BIMS Score of 10 (Moderately impaired). She was impaired on both sides, upper and lower and used a wheelchair. She required substantial/maximal assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. And she required substantial/maximal assistance transferring sit to lying, chair to bed, toilet transfer and had a progressive neurological condition. She had active diagnoses of Deep vein thrombosis (blood clot), hypertension (high blood pressure), wound infection, diabetes mellitus, hyperlipidemia (high fat particles in blood), CVA (stroke), Non-Alzheimer's Dementia, anxiety and depression. Record review of Resident #16's Care Plan undated revealed, Date initiated: 01/10/24 - ADL Self-care Performance deficit related to weakness - interventions: Date initiated: 03/13/24 flat call light within reach. Date initiated 01/18/24 - Has limited physical mobility related to weakness - Interventions: Date initiated 01/18/24 Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date initiated: 01/10/24 - has bowel/bladder incontinence related to cognition, confusion, and weakness - Interventions: incontinent- Check as required for incontinence. Date initiated 01/10/24 - At risk for falls related to poor balance - Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Date initiated: 01/10/23 - Has potential acute/chronic pain related to debility, Neuropathy, muscle spasms - Interventions: Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal, or resistance to care. Interview and Observation on 03/12/24 at 11:45 am, Resident #16 was sitting up in her wheelchair and her call light was lying next to her, but she was unable to move her fingers to grab and press the button, she stated she could not use her call light button any longer. She stated when she first admitted she used to be able to do more for herself but now she needed more staff assistance. She stated it had been hard for her to press her call light button for about a month. Interview and observation on 03/13/24 at 3:24 pm, Resident #16 lying in bed, call light within reach, she said she was still not able to press the call light button because her fingers were too stiff. She stated she had to struggle to put the call light up to her mouth to turn it on but sometimes the call light did not appear to work right. She stated she would really like to get a soft touch call light. Interview on 03/13/24 at 2:44 pm, DOR stated Resident #16 had a stroke and was currently getting OT, ST, and PT to improve her ADL and ROM due to her stroke. He stated she had limited movement of her hands and range of motion on her weak side. Interview on 03/13/24 at 3:00 pm, OT B stated Resident #16 was evaluated yesterday 03/12/24 for a complaint of right-hand pain and her swollen left hand. He stated he spoke to Resident #16's nurse about pain management and the swelling her hand but not about the need for a soft touch call light. He stated not noticing she could not press her call light but agreed Resident #16 could benefit from a soft touch call light because of the stroke she had affecting her right hand and her swollen left hand. He stated with the soft touch call light Resident #16 could easily use her hand or elbow to get service. He stated if a resident was not able to effectively use their call light, they would not be able to call for help. Interview and observation on 03/13/24 at 3:34 pm, CNA C stated he cared for Resident #16 often and did not know she could not press her call light. He stated he was going to check with her nurse about getting a soft touch call light. He stated a lot of stuff could happen to a resident if they were not able to press their call lights, they could fall, and incidents could happen to them. Observation on 03/13/24 at 4:00 pm, LVN E was educating Resident #16 about how to use the soft touch call light and the resident demonstrated understand by pressing it with the back of her hand and the call light started ringing. Interview on 03/13/24 at 4:05 pm, RN D stated she was informed of Resident #16's need for a soft touch call light today (03/13/24) and added the soft touch call light was better for Resident #16 to use because she did not have enough strength to press the push button call light. Interview on 03/13/24 at 4:15 pm, the DON stated she was unaware Resident #16 was not able to press her call light button. She stated but now that they knew, they replaced it today (03/13/24) with a soft touch call light. She stated not being sure why Resident #16 had not already had a soft touch call light and planned to talk to the staff and the resident about the issue. She stated she was going to talk to the staff about the breakdown in communication and reporting it accordingly to the nurse. She stated there could be a delay and residents getting assistance if they were not able to press their call lights effectively. She stated she was responsible for ensuring the staff understood the processes when a resident was not able to use their call lights effectively. Interview on 03/14/24 at 1:14 pm, OM stated Resident #16's hands were starting to regress, and she was not able to use them. He stated not being aware of her need for a soft touch call light, until just recently. He stated Resident #16 had a soft touch call light now. He stated the DON was responsible for ensuring the nursing staff assessed the residents needs for more appropriate call light. He stated his expectations for call light assessment was for the staff to notify the DON, their doctor and family immediately to get them assessed for a more appropriate call light. Request of the facility's Resident Rights policy was requested on 03/14/24 but the OM did not provide it prior to exit. Record review of the Facility's Call light policy dated 05/2023 revealed, Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff .

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 13 of 13 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 03/13/24 beginning at 10:00 AM, during a confidential resident group meeting with 13 residents, revealed the meeting was held in the dining room. There were no doors or solid walls to separate the dining hall from the open activity/tv area. There were no signs posted to indicate that a confidential meeting was being held; however, multiple staff walked through the space to get to the kitchen and employee breakroom. During the confidential group meeting, 3 of the 13 residents revealed the meeting was held each month in the dining room or the library. 7-8 of the residents stated it was their first meeting. 2-3 others had fallen asleep. They all agreed that there was no privacy and staff could overhear them. The residents didn't know they had the right to private meeting. The former and current resident council presidents were both unaware of the right to have a private meeting without staff or other interruption. Interview on 03/13/24 at 2:35 PM with the Case Manager, revealed the activity director resigned last week due to family issues. She was responsible for the setup and planning of the meeting with the residents. She stated that she is helping until a new activity director can be put in place. She stated that she is helping, so she wasn't aware of the requirements other than it had to be monthly and for the residents. She stated that she understood the need for privacy and that it could make a resident feel awkward about being out in the open. She stated that she would also look for a place that offers privacy and is big enough for everyone to attend and offer more privacy and no interruptions. She offered the therapy gym as a possible location and then considered the activity area at the end of the hall. She expects them to hire a new activity director sometime soon and the responsibility will go to that person. Interview on 03/14/24 at 3:45 PM with the Operations Manager revealed the resident council meetings were always held in the dining room. He stated they have always met there. He stated that he understands the need for privacy but didn't think that was a problem. He stated that he would move the meeting to a different area. He first considered the therapy gym, but then thought the activity area was a better place to have the meeting as no one really goes to that area. He stated there have been no complaints to him about privacy, many of the residents in the council are outspoken and have no problem saying what they need to say. The Operations Manager stated his expectation was for the residents to have the privacy they deserve so they can voice their concerns openly. Record review of the resident council minutes for December, January and February, revealed no requests for a more private area. Record review of the facility's Resident Council policy, 07/2022 revision, revealed in part the following: Page 2 Section labeled Meeting, 1. Meetings shall be held monthly in the dining room or library to be accessible to all residents unless otherwise designated by the President of presiding officer. Lists the meeting area as the dining room or library, makes no mention of privacy or required postings.

Based on interview and record review the facility failed to have a governing body appointing the administrator who was licensed by the state, where licensing was required, responsible for the management of the facility and reported to and accountable to the governing body for one (facility) of one reviewed for Administrator. The facility failed to appoint an Administrator who was responsible for the management and operations of the facility. Some of the facility staff were not aware of who the facility Administrator was, and the identified Administrator was not actively involved in the day-to-day operations and management of the facility. Subsequently, the OM delayed reporting alleged Abuse/neglect to the identified Administrator and HHSC within the required timeframes. This failure could place residents at risk of inadequate response times when responding to abuse, neglect, and exploitation allegations, which could cause continued ANE, resulting in injury and decreased psycho-social well-being. Findings included: Interview on 03/12/24 at 9:30 am, ADON stated he was not sure who the facility's Administrator was but said he would have to go check. Interview by phone on 03/12/24 at 2:19 PM, Administrator A stated he Interworked (worked together) with this facility for the past six weeks and at the facility three times since then. He stated he mostly interacted with the OM about what was occurring at the facility until OM's Administrator's license transferred from another state because he currently did not have a Texas Administrator's license. He stated he did not attend the standup meetings in person or by phone but spoke to OM multiple times a week. He stated the OM managed the facility including the emergency preparedness plan and there were no other staff who contacted him about anything including Abuse, Neglect, Exploitation. He stated OM told him about Resident #5's Abuse allegation and was not sure when he was notified but knew it was reported to HHSC and investigated. Interview on 3/14/24 at 10:34 am, the OM stated he moved here from another state and was in the process of getting his Texas Administrator's license. He stated he needed a document notarized for his license to be transferred to the state of Texas. He stated he spoke to Administrator A daily about things going on at the facility. He stated today (03/14/24) he was clarifying with the staff who was the administrator because some of the staff had it mixed up and thought he was the Administrator. He stated he told the staff to continue to report ANE allegations and any other concerns to him. He stated Administrator A was physically at the facility three times since January 2024. He stated the role of the Administrator was to oversee the facility's day to day operation and all that entailed it, according to the state and federal government. He stated Administrator A did not work at the facility 40 hours every week and was just helping him until he received his license. He stated he would have to double check the policy on if they had to have a fulltime administrator at the facility. He stated he was the ANE coordinator designated by the administrator and the staff knew to contact him directly and Administrator A was secondary if he was not reachable. Interview on 03/14/24 at 12:50 pm, the DON stated she saw Administrator A maybe five times at this facility and was not sure how long he had been this facility's Administrator. She stated Administrator A was available by phone 24/7 and his phone number was posted for all staff to call him directly. She stated not being sure how long Administrator A was the administrator at this facility. She stated the timeframe for reporting ANE was within two hours of an incident allegation. She stated Resident #5's incident was not reported in two hours of that specific day (03/05/24) because they had problems accessing their computers and it was reported the next day (03/06/24). She stated they received further re-education from their Corporate Clinical resource Representative on the reporting requirements of reporting alleged ANE to HHSC within two hours of being notified. Interview on 03/14/24 at 1:14 pm, the OM stated Resident #5's ANE allegation was made on 03/05/24 about a black man had just come into her room and assaulted her and took her clothes off and put them back on her. He stated HHSC incidents should be submitted within two hours of being notified, but the incident of an Outside provider allegedly being abusive to Resident #5 was not reported to HHSC within two hours because there was a communication breakdown between him, and the other agency company involved as to what went down. He stated they started staff education, staff interviews, notifications with her doctor and family on 03/05/24. And he said he spoke to Administrator A on 03/06/24 about this incident and Administrator A told him to report it, then OM said he reported the incident to HHSC on 03/06/24. He stated Resident #5's alleged incident should have been reported to HHSC on 03/05/24 and the Corporate Clinical Resource Representative in-serviced himself and the DON on reporting Alleged ANE in two hours. He stated they were also instructed to notify corporate immediately on the same day to determine if something needed to be reported to HHSC. He stated he was responsible for reporting alleged ANE to HHSC and his expectations for ANE reporting was that he reported it within two hours. He stated not reporting Alleged ANE to HHSC within two hours could be a danger to a resident and they may not be safe. He stated the alleged perpetrator might still be running around unknowingly and it could be a multi factor of things that could occur. Record review of Resident #5's Provider Investigation Report revealed an allegation of sexual abuse was reported to the OM on 03/05/24 at 12:30 pm, but the OM did not report it to HHSC until 03/06/24 at 8:30 pm. Record review of the Staff Roster undated revealed OM was on the form, but the Job Title section was blank, and Administrator A was not listed on it. Record review of the Texas LTC Nursing Facility Administrator System on 03/13/24 revealed the status of OM was Prospective. Record review of the facility's Administrators Duties and Responsibilities dated 9.2017 and revised 1.2024 revealed, Policy: It is the policy of this facility that a licensed administrator shall be responsible for the day-to-day functions of the facility .Procedure: 1. Administrator A has been appointed as the facility's Administrator. 2. A. Managing the day-to-day functions of the facility .3. In absence of the Administrator, OM is authorized to act in the administrator's behalf

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (hall 400 nurses' cart) and 2 of 2 Residents (# 16 and #37) reviewed for pharmacy services. 1.The facility failed to ensure the hall 400 nurses medication cart contained accurate narcotic record for Residents #37 and #16. 2. The facility failed to ensure a bottle of Benadryl tablets that were expired were removed from the 400 Hall medication cart. This failure could place residents at risk for drug diversion, delay in medication administration and at risk of receiving medications that were ineffective. Findings included: 1. Review of Resident #16's face sheet, dated 03/14/24, reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #16's diagnoses included pressure ulcer of sacral region stage 3 (.skin injuries that occur in the sacral region of the body, near the lower back and spine that involves the full thickness of the skin and may extend into the subcutaneous tissue layer). Review of Resident #16 MDS revealed a BIMS score of 04 revealing she had severe cognitive impairment. Review of Resident#16 care plan dated 01/10/24 revealed potential acute/chronic pain rule out. Debility. The goals Will voice a level of comfort of through the review date. Interventions are: Observe and report changes in usual routine, sleep patterns, decrease in functional. Abilities, decrease ROM, withdrawal, or resistance to care. Pain assessment every shift. Review of Resident#16 physician's orders dated 12/21/23 revealed Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 06 hours as needed for pain. Review of the progress notes dated 3/13/24 at 01:59AM revealed, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG. Give 1 tablet by mouth every 06 hours as needed for pain. Resident medicated for complain of pain 7/10 on her right hand. Per as needed orders. 2.Review of Resident #37's face sheet, dated 03/14/24, reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #37's diagnoses included primary osteoarthritis (disease that worsens over time, often resulting in chronic pain. Joint pain and stiffness). Review of resident #37 MDS revealed a BIMS score of 00 revealing she had severe cognitive impairment. Review of Resident#37 care plan dated 08/27/23 revealed Has acute/chronic pain rule out Arthritis. Debility. The goals Will voice a level of comfort of through the review date. Interventions are: Anticipate need for pain relief and respond immediately to any complaint of pain. Follow pain scale to medicate as ordered. Pain assessment every shift. Review of Residnt#37 physician's orders dated 07/01/22 revealed Tramadol HCl Tablet 50mg.Give 1 tablet by mouth every 6 hours as needed. Observation on 03/13/24 at 10:26 AM, of the hall 400 nurse's cart and the narcotic administration record, with LVN E, revealed the following information: Resident #37's narcotic administration record sheet for Tramadol 50mgs was last signed off on 03/13/24 for one-tablet dose given at 01:59 AM, for a total of 7 pills remaining while the blister pack count was 8 pills signed by RN G. Resident #16's narcotic administration record sheet for Norco 5/325mgs was last signed off on 03/12/24 for one-tablet dose given at 16:00 PM, for a total of 55 pills remaining while the blister pack count was 54 pills. Did not have the name of the nurse that signed off. There was also a bottle of Benadryl with an expiry date of 02/24. Interview with LVN E on 03/13/24 at 10:48 AM, revealed it was her first time working on 400 hall. She stated she had not administered the Tramadol 50mgs and Norco 5/325mgs to resident's #37 and #16 during her shift . She stated she counted with outgoing nurse, and she had not realized the count were not correct. She stated when the narcotic log shows more or less medications it meant ether the resident received the medication and the nurse forgot to log off or the nurse were signing, they gave when they had not given . She stated the failure could lead to resident being overdosed because it is hard to tell when the medication was administered last, resident missing a dose, diversional and resident being in uncontrolled pians that would affect participating on her daily activities . She stated it was nurses' responsibility to check the carts for expired medications. She stated she checked the cart, in the morning and she did not see a Benadryl bottle. She stated failure to remove the expired medications on the cart, if administered it will not be effective. LVN E stated the procedure when taking over at the change of shift was to count physical medications on the blister pack and compare with narcotic administration record. Interview with Resident #16 on 03/13/24 at 11:32AM revealed she was administered a pain pill by the night nurse. Interview with Resident #37 on 03/13/24 at 11:38AM revealed she was not administered a pain pill and she could not remember the last time she was administered one. Interview with the ADON on 03/13/24 at 12:51PM revealed it was all nurse's responsibility to follow the five rights of administering medications that are not limited to ensuring the narcotic logs are balancing with the count. He stated he expected the nurse to ensure the counting during shift change were correct and report any discrepancies to the ADON and the DON. He stated it was also the nurse's responsibility to ensure they check their carts for expired medications. The ADON stated it was his responsibility to monitor the carts, but he is new to the facility, he had not gone through the carts. The ADON stated failure to ensure the correct count could lead to medication error and diversion. He stated expired medication if administered they would not be effective. Interview with RN G on 3/14/24 at 09:28AM revealed she was the night shift nurse on 3/12/24. She stated she was the one that administered Norco 5/325 mgs 1 tablet at 01:59 AM to Resident#16 and logged of on Resident #37 narcotic log. She stated she thought she signed-out on the narcotic count sheet for Residnet#16. She stated failure to log on the right resident narcotic log would cause the narcotic count to show less on the next count and it could lead to a narcotics diversion and uncontrolled pains . She stated she had done in-services on medication administration. Interview on 03/14/24 at 12:34 P M, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. The DON stated she expect the handing over to be done by 2 nurses and to report any discrepancy to her. She stated nurses are responsible of ensuring there no expired medications on their carts .The DON stated risk of not logging after administering the medication was that the resident can be administered an overdose or miss the dose. She also stated failure to remove the expired medications from the cart if administered they will not be effective. She stated the nursing management were responsible of checking the carts after the nurses. She stated she had done training on narcotic administration and logging off and no trainings were provided that were done prior to surveyor interventions. Review of the facility current Administration of Drugs policy, dated 2007, reflected the following: 10. The nurse administering the medications must initial the resident's MAR, on the appropriate line and date for that specific day. Review of the facility current Controlled Medications - Storage and Reconciliation policy, dated 2023, reflected the following: 6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: o Date and time of administration. o Amount administered. o Signature of the nurse administering the dose, completed after the medication is actually administered. 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. Alternatively, the shift change audit may.be recorded on the accountability record if there is a designated column for the audit.''

Based on observation, interview, and record review, the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress and to protect the resident's right to be free from neglect for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for neglect. The facility failed to ensure that one or more residents were free from neglect when LVN A and CNA C did not provide services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress to one or more residents. Cumulative effects from LVN A and CNA C individual failures to provide oversight of care delivery to Resident #1 for 8 hours on [DATE] 10:00 PM - 6:00 AM ([DATE]). During the 8-hour span, Resident #1 committed suicide. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:30 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. Resident #2 did not receive incontinence care [DATE] between 10:00 PM and 3:00 AM. An open area to Resident #2's right upper coccyx area was discovered on [DATE] during incontinence care observation. LVN A failed to perform adequate supervision or monitoring of residents throughout her scheduled shift on [DATE] 10:00 PM -6:00 AM ([DATE]) to oversee if resident care was provided by CNA C based on one or more resident's needs. Resident #4 and Resident #5 did not receive incontinence care [DATE] between 10:00 PM and 3:00 AM. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Abuse: Prevention of and Prohibition Against policy, Effective Date: [DATE], Revision/Review Date(s): [DATE]; [DATE]; [DATE]; [DATE], revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: 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. Prevention . The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Identification, Investigation, Protection, Reporting / Response Record review of the nursing schedule dated [DATE] revealed LVN A [Hall 100 even rooms and Hall 300] and CNA C [Rooms 309, 310, ,d+[DATE]] were scheduled and worked on [DATE] 10:00 PM - 6:00 AM. Record review of Police Department Incident Report dated [DATE] 7:28 AM, revealed Incident Related Property collected [by Officer #1] as evidence (found in [Resident #1's assigned room/bed near Resident #1's body]): Blue bucket/plastic container with apparent blood on it Camouflage pocketknife with apparent blood on it Kitchen knife with apparent blood from inside [Blue bucket/plastic container] Plastic bag and paper towel with apparent blood on it DNA swab of apparent blood from west side of bathroom door frame Scissors with orange handle/finger holes Record review of Police Department Narratives (OFFICER NARRATIVE) for Incident Report, Detective field notes, dated [DATE] 9:53 AM, reflected: On [DATE] at approximately 6:58 AM Officer #1 and Officer #2 were dispatched to the [SNF]. Officer #1 spoke with LVN B, who advised that at approximately 7:00 AM he discovered [Resident #1] in his bed, not breathing, with blood on his face and body. Officer #1 then spoke with LVN A, who advised that she last saw [Resident #1] alive at approximately 3:00 AM in his bed, moving his legs as if he were peddling a bicycle. Officer #1 entered [Resident #1's assigned room/bed] and observed [Resident #1] to be in his bed, laying on his right side, with his right hand toward his head and his left hand down near his left leg and crotch. A large laceration was visible on the left side of [Resident #1's] neck. [Resident #1's] neck and clothing (blue jeans and a green sweatshirt) were covered in blood. Between [Resident #1's] legs Officer #1 observed an orange handled scissors. RESIDENT #1 Record review of Resident #1's Admission Record, revealed an [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Uns; Unspecified Dementia, Uns Severity, with Agitation; Insomnia, Uns; Presence of Cardiac Pacemaker; MDD, Single Episode, Uns; Orthostatic Hypotension (lightheadedness or dizziness when standing after sitting or lying down); and Other Abnormalities of Gait and Mobility. Record review of Resident #1's modified Quarterly MDS review assessment, dated [DATE], revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's Mood Interview ([PHQ-9] objectifies and assesses degree of depression severity via questionnaire) reflected a total severity score of 10 which suggested moderate level of depression that required a treatment plan, counseling, follow-up and/or pharmacotherapy (treatment of conditions by using pharmaceutical products (drugs) as medication). The Mood Interview revealed Resident #1 presented symptoms several days (,d+[DATE] days) to nearly every day (,d+[DATE] days) over a 14-day look back. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 admitted to Hospice on [DATE] with active diagnoses of Malignant neoplasm, uns (cancerous tumor); uns CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs); COPD (a group of diseases that cause airflow blockage and breathing-related problems); CKD (kidneys have mild to moderate damage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) without lower urinary tract symptoms. Record review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: [DATE] at 10:08 PM [Entered: [DATE] at 8:30 AM], written by LVN A, reflected, During shift round resident observe lying in bed open eyes watching tv. s/v taken with normal limited. denied for pain or discomfort at this time. - Nurse's Note Effective Date: [DATE] at 12:30 AM [Entered: [DATE] at 8:33 AM], written by LVN A, reflected, During round resident in bed sleeping comfortable with eyes closed breathing even and unlabored with no distress - Nurse's Note Effective Date: [DATE] at 3:00 AM [Entered: [DATE] at 8:42 AM], written by LVN A, reflected, During round shift resident observed lying on the bed with eyes closed with no complaint of pain or discomfort. remain stable with no acute distress noted. - Nurse's Note Effective Date: [DATE] at 6:50 AM [Entered: [DATE] at 11:48 AM], written by LVN B, reflected, nurse making rounds, noted resident in bed, wound to left side of neck with blood on it, blood on hand, resident did not respond. touched forehead, resident warm, still did not respond. summoned night nurse and verified DNR. upon other nurse in room, noted scissors in left hand and blood on resident neck and left hand and on the floor between the bed and window.911 called. Responsible party and hospice notified. EMS at facility at approximately 0700 [7:00 AM]. Nurse gave report to EMS and Police also at facility. ADON was at the facility and notified of the situation. Resident #1's clinical physician orders reflected: o [DATE] Monitor level of pain every shift o [DATE] Refer to Senior Psych Care and/or Senior Psychological Care for Evaluation and Treatment o [DATE] Admit to hospice services with DX of malignant Neoplasm of unknown origin. o [DATE] Mirtazapine Tablet 7.5 MG (an atypical antidepressant used primarily for the treatment of MDD) Give 1 tablet by mouth at bedtime for Weight loss o [DATE] Norco Tablet ,d+[DATE] MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain o [DATE] Anti-depressant targeted behavior monitoring o [DATE] Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia o [DATE] Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for moderate pain/ dyspnea o [DATE] Lidocaine External Patch 4 % (Lidocaine) Apply to lower back topically one time a day for pain Record review of Resident #1's November MAR reflected MA M entered a chart/follow up code, '1' = Drug Refused, and his user initials in the time row (HS [7:00 PM]) under the date column for [DATE], [DATE], [DATE], and [DATE] (bedtime medications were not refused other nights in [DATE]) for Resident #1's scheduled medications at bedtime included: o Gabapentin 300 mg Capsule Give 1 capsule by mouth at bedtime for restless legs syndrome o Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia. o Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Weight loss Resident #1 MAR reflected Lidocaine patch last applied [DATE] at 6:00 AM. Morphine (Order date: [DATE] - never administered. Norco ,d+[DATE] mg tablet PRN last given [DATE] at 7:13 AM. MAR reflected: Monitor level of pain every shift. All responses reflected 0, even on days PRN pain medications were administered. Record review of Resident #1's Comprehensive Care Plan, dated [DATE], did not reveal Resident #1 had suicidal ideations, homicidal ideations, or a history of suicidal attempt(s). The care plan did not reflect that Resident #1's assistance was different between the day or night. Resident #1's Comprehensive Care Plan, dated [DATE], focused on Resident #1: Pacemaker status; Altered respiratory status; Bowel/bladder incontinence; Potential for mood problem r/t depression; and Fall Risk. Interventions reflected: Provide oxygen as ordered; Staff will provide the level of physical assist as needed with ADL's due to resident's self-performance may fluctuate; INCONTINENCE: Check as required for incontinence. The goal was to maintain safety, for Resident #1 to remain free of complications [pacemaker malfunction or failure], and provide quality care. Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 1:12 PM, reflected: [Det. #3] spoke with Officer #1 who told [Det. #3] the deceased , [Resident #1], appeared to have slit his throat sometime overnight. [Det. #3] entered [Resident #1's assigned room/bed] and observed Resident #1 to be laying on his right side with his right hand near his face. Resident #1's left hand was by his waist. [Det. #3] also observed a pair of orange handled scissors to be near Resident #1's left hand. [Det. #3] observed Resident #1 to have a deep wound in the left side of his neck. There was a large pool of blood on the floor between the bed and the wall, along with blood splatter on the air conditioning unit and wall, as well as on Resident #1's person. [Det. #3] observed the temperature of the room to be 73 degrees based on the thermostat on the air conditioning unit. [Det. #3] spoke with Resident #1's roommate [Resident #10] and he stated the following in summary. [Resident #10] last saw Resident #1 yesterday [[DATE]] around dinner time (between 5:00 PM - 6:00 PM). Resident #10 stated he never heard Resident #1 talk about suicide or wanting to harm himself. Resident #10 stated Resident #1 usually kept to himself, and as far as Resident #10 knew, Resident #1 didn't have problems with anyone at the facility. Resident #1's RP arrived at the location. RP stated Resident #1 had told the pastor how he was looking forward to RP coming on Friday ([DATE]), however within the last few days, Resident #1 had been complaining to the pastor about stomach pains. [Det. #3] spoke with PNFA. PNFA was able to pull up camera footage from a surveillance camera that is located close to Resident #1's and Resident #10's room. PNFA reviewed the video from approximately 3:00 AM to approximately 6:50 AM. PNFA stated no one entered the room in that time frame except Resident #10 and the nurse who found Resident #1 deceased . County ME MDI arrived on scene. MDI removed the scissors from near Resident #1's left hand and waist. MDI noted that the scissors appeared to be clear and had very little to no blood on them. Underneath the scissors, MDI located a metal file that can be used to sharpen a blade. MDI noted the file also had little to no blood on it. MDI rolled Resident #1 onto his back, exposing another large and deep laceration to the right side of Resident #1's neck as well as the large and deep laceration that was already visible on the left side of Resident #1's neck. The cut was not all the way across the neck as there was a small piece of flesh still intact in the front, center pat of Resident #1's neck. MDI then located a folding knife with blood on it in a blue tub which was located on a shelf next to Resident #1's bed. MDI also located several tissues inside the tub with blood on them. During an interview on [DATE] at 2:24 PM, the PNFA indicated that he was notified by the ADON about Resident #1. The PNFA said that the cluster DON from the sister facility assisted with reporting the incident to state agency. The PNFA said that he was not familiar with Resident #1, that he was still learning resident's names and living arrangements in the SNF. The PNFA said that he notified the medical director by phone around 10:00 AM. The PNFA said that he participated in an interview and cooperated with the police. The PNFA said that mental health service providers for contacted and arrived to the SNF to provide consultation with staff and residents, management conducted suicide and suicide prevention in-services (still on-going). The PNFA indicated he was a new hire as of a month ago and was still learning the specific policies and procedures of the SNF. The PNFA stated the ADON would be the staff to speak with because she was present around the time Resident #1 was discovered. Observation on [DATE] at 3:06 PM of [Resident #1's assigned room] revealed red tape across the door to block entry. Upon entry to room, there were two beds - Bed A was closest to the entry door, parallel to the common wall that is shared between the bathroom and room; [Resident #1's] bed was parallel to Bed A and a wall with a window and wall-mounted AC unit. The bed was made, and two personal fleece blankets were placed on the bed, folded back that formed a diagonal line. A brief overview of the area revealed two blood stains (the size of a saucer, an overall diameter of approx. 5 - 6 [inches]) on the right side of bed - one near the mid-upper edge of bed and one near the mid-lower edge of bed. On the right side of bed, blood drops and a thick blood puddle (approx. 11 - 12 [inches]) by visual estimation, was observed on the floor. Blood spatter was observed on the AC unit. Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 8:53 AM, reflected: On [DATE], . the pathologist who performed Resident #1's autopsy informed that Resident #1 had no defensive wounds on his person. Resident #1 had several hesitation type wounds on his neck, and the main deep cuts were parallel cuts which would be consistent with them being self-inflicted. The pathologist stated no major arteries were cut, but numerous veins were cut which would have caused a slower time to bleed out and allow time for Resident #1 to put the knife back in the blue bin by his bed. She also stated it was unlikely someone besides Resident #1 could have cut Resident #1's neck based on the wounds and the fact that the other individual would have gotten a large amount of blood on themselves due to the amount of blood loss from Resident #1. She also told that Resident #1 had a gastric rupture. She stated this would have been very painful for Resident #1 and may explain why he took the actions that he did. During an interview on [DATE] at 10:13 AM, the ADON indicated she worked at the SNF for less than one year as the ADON and the treatment nurse. The ADON said that her primary responsibility as the ADON and treatment nurse was to perform wound care, coordinate care with the wound doctor, and to oversee that care was provided by nursing staff (nurses and CNAs). The ADON said that she expected staff to perform standard practice withing their scope of work, to check on residents at least every two hours and as needed, for both on-coming and off-going nurse to conduct walking rounds together during shift change. The ADON said the purpose of resident rounds during shift change and at least every two hours was to know where the residents were and that they were safe. The ADON said in addition to verbal report, there was a written 24-hr report the nurses were expected to complete. The ADON said on [DATE], she arrived to work before 7:00 AM. The ADON said that LVN A and LVN B approached the nurses' station and informed her that Resident #1 was found dead. The ADON said while LVN B called 911, she called the PNFA and headed to Resident #1's room. The ADON said another day shift nurse accompanied her to the room. The ADON said that she observed Resident #1 in bed, lying on his right side and she left back out the room. The ADON said that she called the NP after she tried to contact the MD, called hospice and left a message with the on-call nurse. During an interview on [DATE] at 11:17 AM, the ULSW said that she worked at the SNF for less than one week and was not familiar with Resident #1. The ULSW said that she learned about Resident #1 on [DATE] when she arrived to work shortly after 7:00 AM. The ULSW said that she prioritized psych consultations were ordered and follow ups were conducted as needed. During an interview on [DATE] at 11:49 AM, the LCSW with psych consultation services stated during her last visit with Resident #1 (on [DATE]), he would not engage in conversation about his family or accomplishments. The LCSW said that Resident #1 was pre-occupied with the problems of the world at large, deeply religious, and looked forward to the day God comes down and destroys all the people not living a godly life . but he probably would not be alive to see it happen. The LCSW said that she would assist Resident #1 with processing feelings by providing supportive counseling and listening because it would decrease symptoms of depression and anxiety. The LCSW said that Resident #1 displayed symptoms such as agitation, adjustment difficulty, anxiety, and depression. The LCSW said the goal for therapy included symptoms of depression reduction. The LCSW said that Resident #1 had a diagnosis of MDD but scored less than 5 on the PHQ-9; therefore, Resident #1 did not require follow up. During an interview on [DATE] at 12:20 PM, the hospice CM indicated she admitted Resident #1 to hospice on [DATE] at the RP's home. The hospice CM stated she received clinical information from hospital records. The hospice CM said that at the time of admission, Resident #1 was seeing an Oncologist for stomach cancer but stopped treatments. The hospice CM said that she received a text on [DATE] at 7:22 AM from the DON that indicated the ADON needed to speak with [hospice CM] and provided a call back number. The hospice CM said that she received an email around the same time from the hospice on-call that notified to contact the SNF regarding Resident #1. The hospice CM said she placed a call to the ADON on [DATE] around 7:30 AM. The hospice CM said that she was shocked when she heard about Resident #1 and informed the ADON that she would be there as soon as possible. The hospice CM said that she arrived to the SNF around 9:45 AM and officers and the ME were on-site. The hospice CM said that she was not allowed to see Resident #1 but stayed with Resident #1's RP because she was alone. The hospice CM said that she communicated with the RP to inform on Resident #1's clinical status and of any changes. The hospice CM said that she conducted a hospice recertification visit on [DATE]. The hospice CM said that Resident #1 was more cooperative and in a good mood. The hospice CM said that she often received notifications from the hospice skilled nurse (LVN) and aide that Resident #1 was uncooperative, refused care, was grouchy, and/or refused visits. The hospice CM said that she received a picture via text from the RP of Resident #1 during a visit with the RP at her home. Resident #1 had been shaved and was making his own pizza. The hospice CM said that Resident #1 had chronic pain issues, N/V and diarrhea related to the stomach cancer. Resident #1 was last seen by the hospice skilled nurse (LVN) on [DATE]. Record review of hospice documentation revealed: [DATE] [Hospice Admission] - [Resident #1] is alert/oriented x 2 [to self and surroundings/time of day] with forgetfulness. [RP] states [Resident #1] is beginning to decline cognitively with intermittent confusion. [Resident #1] has chronic pain in left shoulder, back & abdomen. [Resident #1] ambulates with a walker, and gait is unsteady with muscle wasting to BLE (bilateral lower extremities). [Resident #1] was continent of bladder and bowel prior to illness & now has intermittent incontinence requiring pull ups. [DATE] - [Resident #1] has dyspnea (shortness of breath) with moderate exertion requiring oxygen PRN. [Resident #1] reports pain in back not always controlled with scheduled hydrocodone. [DATE] - [Resident #1] was lying in bed upon arrival. Chaplain got facility RN to help [Resident #1] put oxygen on which helped with confusion. [Resident #1] said back hurt but pain med had been given. [DATE] - [RP] present & reports [Resident #1] just had diarrhea . he was too weak to get to the bathroom. 02 sat is 75% on room air & pt feeling weak/fatigued. [hospice LVN] started [Resident #1] on continuous oxygen at 2 lpm . [Resident #1] now eating less than 30% of meals and continues to skip meals at times. is thin & frail in appearance with muscle wasting. ambulates with a walker, and gait is unsteady d/t generalized weakness. [Resident #1] requires assist with ADLS d/t pain . has intermittent incontinence of b&b. [DATE] - [Resident #1] reports chronic back pain & takes Hydrocodone (Norco ,d+[DATE] mg) as well as uses Fentanyl patch with fair relief. BP ,d+[DATE] . [DATE] - now takes hydrocodone, fentanyl patch as well as newly added morphine & lidocaine patches prn. [DATE] - [Resident #1] has chronic pain in left shoulder, back & abdomen. [Resident #1] was only taking hydrocodone at admission to hospice, but now also requires fentanyl patch & morphine prn to control pain. [Resident #1] continues having N/V ,d+[DATE]x week & requires scheduled promethazine to control. [Resident #1] continues to have diarrhea ,d+[DATE] x week & is now incontinent of B&B d/t increased weakness/fatigue. [DATE] - was lying in bed upon arrival. Patient complained that tummy hurt . facility staff aware. On [DATE] at 1:48 PM, observation of video surveillance on [DATE] 10:00 PM - [DATE] 7:00 AM was conducted with the PNFA. The following time stamps from the SNF video surveillance (right center downwards angle toward Resident #1's room) revealed: [DATE] at 10:44 PM: LVN A and off-going nurse entered Resident #1's room during change of shift walking rounds. The door was slightly ajar when the nurses exited the room. [DATE] at 12:16 AM: The door to Resident #1's room was pushed closed from the inside of the room. [DATE] at 6:18 AM: Resident #10 entered the room and exited at 6:22 AM. [DATE] at 6:24 AM: Resident #10 re-entered the room and exited at 6:25 AM. [DATE] at 6:39 AM: Resident #10 re-entered the room and exited at 6:41 AM. [DATE] at 6:50 AM: LVN B entered Resident #1's room. During an interview on [DATE] with the PNFA after video surveillance was observed, the PNFA indicated that he understood that staff only needed to check on residents based on their level of care. The PNFA said that he was informed that Resident #1 could use the call light when needed, did not need assistance to the restroom, was ambulatory; therefore, staff did not need to check on him every two hours. The PNFA said that he would need to review Resident #1's care plan to determine how often staff should check on him overnight. The PNFA stated that leadership informed him that staff were required to only check on residents who required incontinence care, turning and repositioning. The PNFA stated that best practice would be to following the facility protocol on resident rounds and he was not currently familiar with the actual written policy on resident rounds. An outbound call to CNA C on [DATE] at 3:20 PM was answered by an unidentified male. The unidentified male stated that CNA C had left her phone at home and did not know when she would return. The unidentified male said that he would have CNA C return the call to the number that showed up on the caller ID. Additional outbound calls were placed to CNA C on [DATE], [DATE], and [DATE] that were unanswered and unable to leave a message. No return call from CNA C before facility exit. During an interview on [DATE] at 4:36 PM, LVN A indicated she worked on [DATE] from 10:00 PM to 6:00 AM. LVN A said that she arrived to work on [DATE] around 9:50 PM. LVN A said that she was assigned to half of Hall 100 and all of Hall 300. LVN A said that she received report, counted narcotics, and conducted walking rounds with the off-going nurse. LVN A said that she conducted rounds on Resident #1's hall first. LVN A said after she conducted walking rounds, she administered medications and provided direct care to three G-tube residents, performed colostomy care and indwelling catheter care to residents on both halls. LVN A said that [CNA C] sat on the hall and would notify if something happened. LVN A said that she tried to do resident rounds every three hours. LVN A said that some residents did not like for staff to come back in their rooms after change of shift rounds were completed. LVN A said that she had a new admission that needed a PICC line, and she needed to assist the PICC line placement nurse because the resident was aggressive. LVN A said that she spent a long time on Hall 100. LVN A said that she had to assist a resident on Hall 300 for an IV line and had to collect a urine specimen. LVN A could not state what time she checked on Resident #1 again after change of shift rounds with off-going nurse. LVN A said that she usually checked on residents based on the resident preference. LVN A said that if the video surveillance was reviewed, she would be seen pushing a resident in a wheelchair down the hall around 1:00 AM. LVN A said that at the same time she peeked through the door to check on Resident #1. LVN A said that she could see Resident #1 lying on his bed, he was fine, no problem. LVN A said that there was enough light from the over the bed and TV light to see Resident #1. LVN A said that Resident #1 would use his call light if he needed assistance, he would always talk about the bible, and could go to the restroom without assistance. In a continued interview on [DATE] at 4:36 PM, LVN A said that on the morning of [DATE], she was waiting for LVN B to relieve her from her shift (at 6:00 AM). LVN A said that she needed to take her kids to school and was about to leave the medication cart keys with another nurse because LVN B was always late. LVN A said that she saw LVN B come in around 6:15 AM. LVN A said that she gave LVN B verbal report and performed narcotic count. LVN A said that LVN B told her that he would do walking rounds and would come back to the nurses' station to let her know if something happened. LVN A said LVN B returned to the nurses' station and told her that he thought that Resident #1 killed himself. LVN A said that she was shocked and did not know how that could happen, that she did not understand. LVN A said that she went to Resident #1's room with LVN B, donned gloves on the way to the room, and saw Resident #1 lying on his back with his left hand between his legs, his shirt raised enough to see his stomach. LVN A said she touched his stomach, to feel for movement (if Resident #1 was breathing). LVN A said Resident #1's stomach was warm, but it did not move (to indicate breathing). LVN A said that the blood looked fresh and since [Resident #1's] skin was still warm, he could not have been dead too long. LVN A said that she saw a pair of orange scissors under Resident #1's left hand between his legs. LVN A said that there was a cut on the left side of Resident #1's neck, there was no dripping blood. LVN A said that there was blood like a puddle of water on the floor on the right bedside. LVN A said that she checked for pulse on wrists but did not listen for a heartbeat because she did not have a stethoscope. LVN A said she returned to the nurses' station with LVN B to call the RP while LVN B called 911. LVN A said that she was not present when the hospice nurse arrived. LVN A said that she returned to work [DATE] to work the 10p - 6a shift. LVN A said that she was suspended on [DATE] after the on-coming nurse arrived, received verbal report, counted narcotics, and performed walking rounds. During a phone interview on [DATE] at 9:46 AM, LVN B indicated he worked at the SNF PRN and usually worked the 6A - 2P and 2P - 10P shifts. LVN B said that he worked [DATE] 6A - 2P shift. LVN B said that he arrived to work and clocked in between 6:20 AM - 6:25 AM; received verbal report from LVN A; performed narcotic count, accepted keys, and conducted walking rounds alone (LVN A remained at the nursing station). LVN B said that Resident #1's room was the last room on the left and arrived at the room around 6:50 AM. LVN B said that he entered the room, and the privacy curtain was pulled and could only see Resident #1's feet. LVN B said that he walked over to Bed B and discovered Resident #1 laying in a right lateral position, legs bent, facing window. LVN B said that there was a gash (a deep slash, cut, or wound) at left side of neck; clothes, bedsheets, and blanket were soaked with blood. LVN B said upon [TRUNCATED]

Based on observation, interviews, and records review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) of 28 residents reviewed for provision of care and services by staff. The facility failed to ensure staff implemented abuse and neglect policies and procedures during the provision of care and services to residents. The facility failed to implement abuse and neglect policies and procedures by immediately removing or suspending LVN A and CNA C from the care of any resident during the investigation of potential abuse or neglect to protect other residents from harm. LVN A and CNA C worked [DATE] 10:00 PM - 6:00 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:30 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Residents are at high risk of serious injury, harm, impairment, or death by not protecting from harm by staff identified in an abuse or neglect investigation. Findings included: Record review of the facility's Abuse: Prevention of and Prohibition Against policy, Effective Date: [DATE], Revision/Review Date(s): [DATE]; [DATE]; [DATE]; [DATE], revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: 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. Prevention . The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Protection . if the allegation of abuse, neglect . involves an employee, the Facility will: Immediately remove the employee from the care of any resident. Suspend the employee during the pendency of the investigation. Record review of the nursing schedule dated [DATE] revealed LVN A [Hall 100 even rooms and Hall 300] and CNA C [Rooms 309, 310, ,d+[DATE]] were scheduled and worked on [DATE] 10:00 PM - 6:00 AM. Record review of Police Department Incident Report dated [DATE] 7:28 AM, revealed Incident Related Property collected [by Officer #1] as evidence (found in [Resident #1's assigned room/bed near Resident #1's body]): Blue bucket/plastic container with apparent blood on it Camouflage pocketknife with apparent blood on it Kitchen knife with apparent blood from inside [Blue bucket/plastic container] Plastic bag and paper towel with apparent blood on it DNA swab of apparent blood from west side of bathroom door frame Scissors with orange handle/finger holes Record review of Police Department Narratives (OFFICER NARRATIVE) for Incident Report, Detective field notes, dated [DATE] 9:53 AM, reflected: On [DATE] at approximately 6:58 AM Officer #1 and Officer #2 were dispatched to the [SNF]. Officer #1 spoke with LVN B, who advised that at approximately 7:00 AM he discovered [Resident #1] in his bed, not breathing, with blood on his face and body. Officer #1 then spoke with LVN A, who advised that she last saw [Resident #1] alive at approximately 3:00 AM in his bed, moving his legs as if he were peddling a bicycle. Officer #1 entered [Resident #1's assigned room/bed] and observed [Resident #1] to be in his bed, laying on his right side, with his right hand toward his head and his left hand down near his left leg and crotch. A large laceration was visible on the left side of [Resident #1's] neck. [Resident #1's] neck and clothing (blue jeans and a green sweatshirt) were covered in blood. Between [Resident #1's] legs Officer #1 observed an orange handled scissors. RESIDENT #1 Record review of Resident #1's Admission Record, revealed an [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Uns; Unspecified Dementia, Uns Severity, with Agitation; Insomnia, Uns; Presence of Cardiac Pacemaker; MDD, Single Episode, Uns; Orthostatic Hypotension (lightheadedness or dizziness when standing after sitting or lying down); and Other Abnormalities of Gait and Mobility. Record review of Resident #1's modified Quarterly MDS review assessment, dated [DATE], revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. Resident #1's Mood Interview ([PHQ-9] objectifies and assesses degree of depression severity via questionnaire) reflected a total severity score of 10 which suggested moderate level of depression that required a treatment plan, counseling, follow-up and/or pharmacotherapy (treatment of conditions by using pharmaceutical products (drugs) as medication). The Mood Interview revealed Resident #1 presented symptoms several days (,d+[DATE] days) to nearly every day (,d+[DATE] days) over a 14-day look back. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 admitted to Hospice on [DATE] with active diagnoses of Malignant neoplasm, uns (cancerous tumor); uns CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs); COPD (a group of diseases that cause airflow blockage and breathing-related problems); CKD (kidneys have mild to moderate damage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) without lower urinary tract symptoms. Record review of Resident #1's progress notes indicated: Nurse's Note Effective Date: [DATE] at 10:08 PM [Entered: [DATE] at 8:30 AM], written by LVN A, reflected, During shift round resident observe lying in bed open eyes watching tv. s/v taken with normal limited. denied for pain or discomfort at this time. Nurse's Note Effective Date: [DATE] at 12:30 AM [Entered: [DATE] at 8:33 AM], written by LVN A, reflected, During round resident in bed sleeping comfortable with eyes closed breathing even and unlabored with no distress Nurse's Note Effective Date: [DATE] at 3:00 AM [Entered: [DATE] at 8:42 AM], written by LVN A, reflected, During round shift resident observed lying on the bed with eyes closed with no complaint of pain or discomfort. remain stable with no acute distress noted. Nurse's Note Effective Date: [DATE] at 6:50 AM [Entered: [DATE] at 11:48 AM], written by LVN B, reflected, nurse making rounds, noted resident in bed, wound to left side of neck with blood on it, blood on hand, resident did not respond. touched forehead, resident warm, still did not respond. summoned night nurse and verified DNR. upon other nurse in room, noted scissors in left hand and blood on resident neck and left hand and on the floor between the bed and window.911 called. Responsible party and hospice notified. EMS at facility at approximately 0700 [7:00 AM]. Nurse gave report to EMS and Police also at facility. ADON was at the facility and notified of the situation. Resident #1's clinical physician orders reflected: o [DATE] Monitor level of pain every shift [DATE] Refer to Senior Psych Care and/or Senior Psychological Care for Evaluation and Treatment [DATE] Admit to hospice services with DX of malignant Neoplasm of unknown origin. [DATE] Mirtazapine Tablet 7.5 MG (an atypical antidepressant used primarily for the treatment of MDD) Give 1 tablet by mouth at bedtime for Weight loss [DATE] Norco Tablet ,d+[DATE] MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain [DATE] Anti-depressant targeted behavior monitoring [DATE] Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia [DATE] Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for moderate pain/ dyspnea [DATE] Lidocaine External Patch 4 % (Lidocaine) Apply to lower back topically one time a day for pain Record review of Resident #1's November MAR reflected MA M entered a chart/follow up code, '1' = Drug Refused, and his user initials in the time row (HS [7:00 PM]) under the date column for [DATE], [DATE], [DATE], and [DATE] (bedtime medications were not refused other nights in [DATE]) for Resident #1's scheduled medications at bedtime included: o Gabapentin 300 mg Capsule Give 1 capsule by mouth at bedtime for restless legs syndrome o Melatonin Oral Capsule 3 MG Give 1 capsule by mouth at bedtime for insomnia. o Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Weight loss Resident #1 MAR reflected Lidocaine patch last applied [DATE] at 6:00 AM. Morphine (Order date: [DATE] - never administered. Norco ,d+[DATE] mg tablet PRN last given [DATE] at 7:13 AM. MAR reflected: Monitor level of pain every shift. All responses reflected 0, even on days PRN pain medications were administered. Record review of Resident #1's Comprehensive Care Plan, dated [DATE], did not reveal Resident #1 had suicidal ideations, homicidal ideations, or a history of suicidal attempt(s). The care plan did not reflect that Resident #1's assistance was different between the day or night. Resident #1's Comprehensive Care Plan, dated [DATE], focused on Resident #1: Pacemaker status; Altered respiratory status; Bowel/bladder incontinence; Potential for mood problem r/t depression; and Fall Risk. Interventions reflected: Provide oxygen as ordered; Staff will provide the level of physical assist as needed with ADL's due to resident's self-performance may fluctuate; INCONTINENCE: Check as required for incontinence. The goal was to maintain safety, for Resident #1 to remain free of complications [pacemaker malfunction or failure] and provide quality care. Record review of Police Department Narratives (CID Follow-up) for Incident Report, Det. #3 field notes, dated [DATE] 1:12 PM, reflected: [Det. #3] spoke with Officer #1 who told [Det. #3] the deceased , [Resident #1], appeared to have slit his throat sometime overnight. [Det. #3] entered [Resident #1's assigned room/bed] and observed Resident #1 to be laying on his right side with his right hand near his face. Resident #1's left hand was by his waist. [Det. #3] also observed a pair of orange handled scissors to be near Resident #1's left hand. [Det. #3] observed Resident #1 to have a deep wound in the left side of his neck. There was a large pool of blood on the floor between the bed and the wall, along with blood splatter on the air conditioning unit and wall, as well as on Resident #1's person. [Det. #3] observed the temperature of the room to be 73 degrees based on the thermostat on the air conditioning unit. [Det. #3] spoke with Resident #1's roommate [Resident #10] and he stated the following in summary. [Resident #10] last saw Resident #1 yesterday [[DATE]] around dinner time (between 5:00 PM - 6:00 PM). Resident #10 stated he never heard Resident #1 talk about suicide or wanting to harm himself. Resident #10 stated Resident #1 usually kept to himself, and as far as Resident #10 knew, Resident #1 didn't have problems with anyone at the facility. Resident #1's RP arrived at the location. RP stated Resident #1 had told the pastor how he was looking forward to RP coming on Friday ([DATE]), however within the last few days, Resident #1 had been complaining to the pastor about stomach pains. [Det. #3] spoke with PNFA. PNFA was able to pull up camera footage from a surveillance camera that is located close to Resident #1's and Resident #10's room. PNFA reviewed the video from approximately 3:00 AM to approximately 6:50 AM. PNFA stated no one entered the room in that time frame except Resident #10 and the nurse who found Resident #1 deceased . County ME MDI arrived on scene. MDI removed the scissors from near Resident #1's left hand and waist. MDI noted that the scissors appeared to be clear and had very little to no blood on them. Underneath the scissors, MDI located a metal file that can be used to sharpen a blade. MDI noted the file also had little to no blood on it. MDI rolled Resident #1 onto his back, exposing another large and deep laceration to the right side of Resident #1's neck as well as the large and deep laceration that was already visible on the left side of Resident #1's neck. The cut was not all the way across the neck as there was a small piece of flesh still intact in the front, center pat of Resident #1's neck. MDI then located a folding knife with blood on it in a blue tub which was located on a shelf next to Resident #1's bed. MDI also located several tissues inside the tub with blood on them. During an interview on [DATE] at 2:24 PM, the PNFA indicated that he was notified by the ADON that Resident #1 was deceased when found by LVN B during change of shift walking rounds. The PNFA said that the cluster DON from the sister facility assisted with reporting the incident to state agency. The PNFA said that he was not familiar with Resident #1, that he was still learning resident's names and living arrangements in the SNF. The PNFA said that he notified the medical director by phone around 10:00 AM. The PNFA said that he participated in an interview and cooperated with the police. The PNFA said that mental health service providers for contacted and arrived to the SNF to provide consultation with staff and residents, management conducted suicide and suicide prevention in-services (still on-going). The PNFA indicated he was a new hire as of a month ago and was still learning the specific policies and procedures of the SNF. The PNFA stated the ADON would be the staff to speak with because she was present around the time Resident #1 was discovered. During an interview on [DATE] at 10:13 AM, the ADON indicated she worked at the SNF for less than one year as the ADON and the treatment nurse. The ADON said that her primary responsibility as the ADON and treatment nurse was to perform wound care, coordinate care with the wound doctor, and to oversee that care was provided by nursing staff (nurses and CNAs). The ADON said that she expected staff to perform standard practice withing their scope of work, to check on residents at least every two hours and as needed, for both on-coming and off-going nurse to conduct walking rounds together during shift change. The ADON said the purpose of resident rounds during shift change and at least every two hours was to know where the residents were and that they were safe. The ADON said in addition to verbal report, there was a written 24-hr report the nurses were expected to complete. The ADON said on [DATE], she arrived to work before 7:00 AM. The ADON said that LVN A and LVN B approached the nurses' station and informed her that Resident #1 was found dead. The ADON said while LVN B called 911, she called the PNFA and headed to Resident #1's room. The ADON said another day shift nurse accompanied her to the room. The ADON said that she observed Resident #1 in bed, lying on his right side and she left back out the room. The ADON said that she called the NP after she tried to contact the MD, called hospice, and left a message with the on-call nurse. On [DATE] at 1:48 PM, observation of video surveillance on [DATE] 10:00 PM - [DATE] 7:00 AM was conducted with the PNFA. The following time stamps from the SNF video surveillance (right center downwards angle toward Resident #1's room) revealed: [DATE] at 10:44 PM: LVN A and off-going nurse entered Resident #1's room during change of shift walking rounds. The door was slightly ajar when the nurses exited the room. [DATE] at 12:16 AM: The door to Resident #1's room was pushed closed from the inside of the room. [DATE] at 6:18 AM: Resident #10 entered the room and exited at 6:22 AM. [DATE] at 6:24 AM: Resident #10 re-entered the room and exited at 6:25 AM. [DATE] at 6:39 AM: Resident #10 re-entered the room and exited at 6:41 AM. [DATE] at 6:50 AM: LVN B entered Resident #1's room. During observation of video surveillance on [DATE] at 1:48 PM revealed LVN A worked on [DATE] 10:00 PM - 6:00 AM. LVN A was assigned to the same residents as the night before ([DATE]). During an interview on [DATE] with the PNFA after video surveillance was observed, the PNFA indicated that LVN A was suspended during the pendency of the investigation. The PNFA said that staff are required to check on residents every shift for safety and as needed for repositioning or incontinence care. The PNFA said that he would have to review a resident's care plan to determine their care needs. The PNFA stated that best practice for resident safety would be to schedule staff based on acuity when individual staff assignments are coordinated for continuity of care. The PNFA said that he expected staff to follow the facility protocol on patient care and resident rounds. The PNFA was not able to speak to the policies and procedures for provision of care. The PNFA stated that written P&P should be reviewed with staff and ensured staff understood. The PNFA stated he has been in the role as Operations Manager pending his Administrator licensure for a month and is learning the process(es) to determine if new or updated policies were needed, and how they were develop or updated. Record review of LVN A's clock in/out history from [DATE] to [DATE] revealed LVA worked 10:12 AM - 7:51 AM. During an interview on [DATE] at 4:36 PM, LVN A indicated she worked on [DATE] from 10:00 PM to 6:00 AM. LVN A said that she arrived to work on [DATE] around 9:50 PM. LVN A said that she was assigned to half of Hall 100 and all of Hall 300. LVN A said that she received report, counted narcotics, and conducted walking rounds with the off-going nurse. LVN A said that she conducted rounds on Resident #1's hall first. LVN A could not state what time she checked on Resident #1 again after change of shift rounds ([DATE] at 10:45 PM) with off-going nurse. LVN A said that she tried to do resident rounds every three hours. LVN A said that some residents did not like for staff to come back in their rooms after change of shift rounds were completed. LVN A said that [CNA C] sat on the hall ([DATE]) and would notify if something happened. LVN A said that she usually checked on residents based on the resident preference. LVN A said that if the video surveillance was reviewed, she would be seen pushing a resident in a wheelchair down the hall around 1:00 AM. LVN A said that at the same time she peeked through the door to check on Resident #1. LVN A said that she could see Resident #1 lying on his bed, he was fine, no problem. LVN A said that there was enough light from the over the bed and TV light to see Resident #1. LVN A said that Resident #1 would use his call light if he needed assistance, he would always talk about the bible, and could go to the restroom without assistance. LVN A stated that Resident #1 was ambulatory with a rolling walker but was still considered a fall risk. LVN A stated that she worked [DATE] 10:00 PM - 6:00 AM shift. During an interview on [DATE] at 12:23 PM, the DON stated that ([DATE]) was her first day back to work after vacation. The DON said that she was contacted by the ADON on [DATE] (around 7:00 AM CST, could not state for sure because she was out of the country). The DON said that the ADON informed about Resident #1, needed to speak with the hospice CM, and did not know what to do. The DON said that she texted the hospice CM because she had her direct number and asked if she would contact the ADON as soon as possible to discuss Resident #1. The DON said that she was familiar with Resident #1 and his care needs. The DON said that Resident #1 was independent, private, was ambulatory with a rolling walker, could verbally make needs known, and voice concerns. The DON said that her expectations were for nursing staff to check on residents if they were not within the staff line of sight to be aware of their whereabouts and to meet the resident needs. The DON said that the capacity of needs was different based on the resident level of care - incontinence, feeding assistance, turning, and repositioning, etc. The DON said for staff to meet the basic needs of the resident, the staff would need to lay eyes on the resident to determine their clinical status. The DON said that some residents prefer that their doors remained closed, but staff should still check on the resident to ensure their safety. The DON said that the facility processes in place to prevent ANE was in-services, surveillance, random direct care observations, on-hire training. The DON said that LTC residents did not require daily skilled assessment notes; however, nurses should document any change in condition, new medications, any communication with the MD/NP or RP. The DON said that the SNF utilized PCC to electronically manage resident records and for care continuity. The DON said that nurses were not required to document every time they checked on a resident but should chart at least document once during their shift to reflect the resident status even if there were no concerns. Record Review of the facility's Rounds policy revised ,d+[DATE] reflected: It is the policy of this facility to account for the whereabouts of each resident; Facility staff will round on all residents every shift for whereabouts and safety; Staff will check trash from room at a minimum of once a shift; Staff will check for the whereabouts and safety of each resident at that time; If resident is not in his/her room, staff will round the facility and grounds to locate the resident; and Staff will document each shift in Point of Care. Record Review of the facility's Incontinent Care policy revised ,d+[DATE], reflected: It is the policy of this facility to remove urine or feces from skin; cleanse and lubricate skin; provide dry, odor free perineal care system. Record Review of the facility's Skin and Wound Monitoring and Management policy initiated ,d+[DATE], revised ,d+[DATE], reflected: It is the policy of this facility that: 1) A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2) A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The purpose of this policy is that the facility provides care and services to 1. Promote interventions that prevent pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury. Procedure: Resident Assessment; Skin and wound assessment on admission and readmission; Ongoing skin and wound assessments Prevention: Reposition the resident; If the resident is incontinent, make sure that his/her skin remains clean and dry with regular pericare and toileting when appropriate. Documentation: Pressure Ulcer, Non-pressure Ulcer, and PRN/Weekly skin assessment/evaluation forms; Weekly Skin Check Treatment: Continue preventive measures as appropriate, including but not limited to pressure reduction; continence care; mobility; nutrition and hydration management. Monitoring The NFA was notified of an Immediate Jeopardy (IJ) on [DATE] at 2:30 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on [DATE] at 2:45 PM and included: 1. The Medical Director was notified of IJs on [DATE] at 3:15 PM. 2. Education/in-servicing, (training with use of facility policy and procedures based on best practice), was initiated by DON, Clinical Resource, ADON, OPS Manager and cluster partners with all nursing staff on resident rounds on [DATE] and is ongoing with staff prior to the start of their next shift. Education/in-servicing, (training with use of facility policy and procedures based on best practice), was initiated with all staff on abuse and neglect on [DATE] and is ongoing with staff prior to the start of their next shift. 3. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Ops Manager, DON, and Clinical Resources. There were no concerns and facility will continue with current policy. The facility's policy on resident rounds was reviewed by the Ops Manager, DON and Clinical Resources and updated to include resident rounds completed every 2 hours or as needed, based on the resident's needs. 4. Education/in-servicing was initiated on [DATE] with all staff on abuse and neglect and education initiated on [DATE] with nursing staff for rounds. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report any and all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education on rounds included purposeful rounds, checking residents every 2 hours, or as needed, based on the resident's needs. Knowledge checks were completed with all nursing staff to ascertain their understanding of purposeful rounds. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect and resident rounds. This education/in-servicing was given using developed policy and procedures based on best practice, establishing clear guidelines on frequency and purpose of resident rounds every 2 hours and as needed to provide adequate supervision and monitoring as well as facility policy on abuse/neglect. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 5. All staff to receive education prior to working their next shift. All regular staff will receive the education by [DATE] or prior to their next shift at the facility. PRN staff received the mandatory training notice and will receive education prior to their next shift. 6. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. The facility does not use agency/registry staff. 7. An ad hoc QA meeting regarding items in the IJ template was completed on [DATE]. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Operations Manager, and will include the plan of removal items and interventions. 8. The DON, ADON, Cluster DONs or Clinical Resource will verify staff competency via knowledge checks / knowledge check forms with 10 nursing staff weekly on resident rounds. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. The facility does not use agency / registry staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 9. The PNFA and DON will investigate and report any and all allegations of neglect or abuse through staff reporting, observations, incident/accident reporting and review of the 24-hour report. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 10. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Resident #2 Record review of Resident #2's Admission Record revealed the resident was a 65 y.o. female, who admitted to the facility on [DATE] with the primary diagnosis: Non-Alzheimer's Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Other diagnoses on admission included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); Acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide in your blood); Morbid (severe) obesity due to excess calories; schizoaffective disorder, bipolar type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms such as mania and depression); COPD, unspecified; Pain; Anxiety; and Depression. Record review of Resident #2's Quarterly MDS review assessment, dated [DATE], revealed Resident #2's latest re-entry to SNF was [DATE]. Resident #2 had a BIMS of 10 which suggested moderately impaired cognition. Resident #2's functional status required two-person physical assist with ADLs. Resident #1 was always incontinent of bladder and bowel. Record review of Resident #2's weekly skin evaluations, revealed: On [DATE], completed by ADON, Skin clean dry and intact. Continue with barrier cream as preventative care. On [DATE], completed by LVN B, No skin issues found. On [DATE], completed by LVN B, No skin issues found. Record review of Resident #2's Comprehensive Care Plan, dated [DATE], revealed Resident #2 had: Potential impairment to skin integrity r/t limited mobility, malnutrition, and morbid obesity [Initiated [DATE]]; bowel/bladder incontinence . [Initiated [DATE]; Revision on [DATE]]; Potential for pressure ulcer development [Initiated [DATE]] The goal(s) reflected Resident #1 would will remain free from skin breakdown due to incontinence and brief use; [Target date [DATE]] Inter [TRUNCATED]