Every finding on record at Prairie Meadows Rehabilitation and Healthcare Cent

Based on interview, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 17 residents (Resident #3) reviewed for assessments: The facility failed to ensure Resident #3's Annual MDS dated [DATE] indicated she was PASRR positive. These failures could place residents at risk for inadequate care due to inaccurate assessments.Findings included: Record review of Resident #3's face sheet dated 06/23/2026 revealed an admission date of 03/28/2024, with diagnoses that included: Epilepsy (condition that causes recurring seizures) , Insomnia (sleep disorder), Impulse disorder (psychiatric conditions characterized by an inability to resist urges or impulses), Intellectual disabilities (condition characterized by significant limitations in intellectual functioning and adaptive behavior), Hyperlipidemia (condition of high cholesterol or fats in the blood) and, anxiety disorder (worry that are difficult to control and interfere with day-to-day activities). Record review of Resident #3's Annual MDS assessment dated [DATE] revealed a BIMS score of 9 indicating the resident was moderately cognitively impaired. Further review of the MDS under Section A - Identification Information revealed the assessment did not code Resident #3 as PASRR positive in the section A1500. Preadmission Screening and Resident Review (PASRR). Record review of Resident #3's care plan, dated 04/16/2024 revealed a focus area for the following: has been identified as having PASRR positive Level 2 (in depth assessment used to confirm whether has a serious mental illness, intellectual/developmental disability, or related condition) related to ID for Diagnostics of Pseudobulbar Affect (medical condition that causes crying and/or laughing that is sudden, frequent, uncontrollable and is exaggerated or doesn't match how one feels) and Unspecified Intellectual Disabilities Record review of Resident #3's medical record revealed a document titled Habilitation Service Plan (HSP) - Form 1057, dated 01/28/2025. The document revealed Resident #3 was receiving PASRR services. During an interview on 06/23/2026 at 2:45 p.m. with the DON, she revealed the new MDS coordinator was scheduled to start soon. The MDS coordinator was in charge of entering the corrected data in the MDS assessment. She stated Resident #3 was PASRR positive and was receiving services. She stated the Annual MDS dated [DATE] was wrong and should have coded for the resident being PASRR positive for ID/DD. An inaccurate MDS assessment could cause a resident to not receive the appropriate care. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, noted in section A: A1500: Preadmission Screening and Resident Review (PASRR) (cont.) Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 17 residents (Residents #17) reviewed for infection control, in that: The facility failed to ensure CNA A sanitized his hands and changed gloves between residents and while providing incontinent care for Resident #17. These deficient practices could place residents at-risk for infection due to improper care practices. Findings included: Record review of Resident #17's face sheet, dated 06/25/2026, revealed the resident was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses which included: Dysphagia (Difficulties swallowing), Dementia (Pattern of mental decline), Malignant neoplasm of brain (Brain cancer) and. Hypertension (High blood pressure), Record review of Resident #17's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. Resident #17 required extensive assistance to total care and was always incontinent of bowel and bladder. Record review of Resident #17's care plan, dated 04/09/2026, revealed a problem of The resident has episodes of bladderincontinence r/t Confusion, Impaired Mobility, Loss of peritoneal tone (cause loss of bladder control causing incontinence), Physical limitations and, an intervention of INCONTINENT: Staff to perform/assist with incontinent care during daily care and as needed. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes Observation on 06/25/26 at 5:20 AM revealed CNA A entered Resident #16's room with gloves to assess Resident #16's need for incontinent care. CNA A, then, entered Resident #17's room to assess his need for incontinent care. CNA A did not change gloves and washed his hands between the two residents. Further observation revealed CNA A did not change his gloves and sanitized his hands after cleaning Resident #17 and before putting new brief on Resident #17. During an interview with CNA A on 06/25/2026 at 5:28 AM, he stated he did not change his gloves before providing care for Resident #17 and also did not change gloves or wash his hands after cleaning the resident and before touching the clean brief for the resident. He stated he was nervous and forgot to change his gloves and wash his hands. He stated he had received infection control and incontinent care training. During an interview with the DON on 06/25/2026 at 5:45 AM, she stated the CNA should have changed his gloves and washed his hands before entering Resident #17's room and started providing care for the resident. The CNA should also have changed his gloves and sanitized his hands after cleaning the resident and before touching the clean brief to prevent cross contamination and infection. She stated infection control and incontinent care training were provided at least yearly. Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated 4/16/2026, revealed 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . 1. Hand hygiene is indicated: a. immediately before touching a resident; . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

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 for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to accurately perform a head-to-toe-readmission assessment of Resident #1 on 12/11/25 and did not identify and assess a peripheral IV catheter located on the resident's chest until 12/14/25. This failure placed the resident at risk for complications including infection, infiltration (leakage of IV fluid or medication into the surrounding tissue instead of the vein, which can cause swelling, pain, and tissue damage), and dislodgement (movement or accidental removal of the IV catheter from the vein, which can cause bleeding, injury, or infection).Findings included: Record review of Resident #1's admission record, dated 2/18/26, revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included atrial fibrillation (an irregular and often rapid heart rhythm that can increase the risk of stroke and decreased cardiac efficiency), type 2 diabetes mellitus (a chronic condition in which the body does not effectively use insulin, resulting in elevated blood glucose levels), Gastroesophageal Reflux Disease (GERD) (a digestive disorder in which stomach acid frequently flows back into the esophagus causing irritation), open wound of right lower leg (a break in the skin and underlying tissue on the right lower leg that may be at risk for infection and requires wound care), open wound of left buttocks (a break in the skin and underlying tissue on the left buttocks requiring monitoring and treatment to prevent complications), and muscle weakness. The resident was discharged on 12/17/25. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident's BIMS score was 12 (moderately impaired). Record review of Resident #1's baseline care plan, dated 12/11/25, revealed the resident did not receive any IV medications while a resident. Record review of Resident #1's hospital documents, dated 12/9/25, revealed an order for potassium chloride 20 mEq in sterile water, 100 mL premix, once, central line recommendation for this concentration and REQUIRED for IV administration for rates greater than 10 mEq/hr. Record review of Resident #1's skin assessment, dated 12/11/25, revealed Resident #1 had current skin or wound issues and they were not new. No other information was provided about an IV that was located on the resident's chest area. Record review of Resident #1's nursing progress notes, dated 2/18/26, revealed a note written on 12/14/25 resident [family member] found a peripheral IV located on left breast on resident and notified night nurse about the finding. removal of IV at 0910 [9:10 a.m.] this morning by day shift nurses. Catheter intact, no pain during or after removal. resident voiced no pain at this time.call light in reach. will be monitoring site. Written by LVN C. During an interview on 2/18/26 at 3:51 p.m. LVN B stated she was the charge nurse on 12/11/25 when Resident #1 was readmitted to the facility. LVN B stated she completed the head-to-toe assessment for Resident #1 which would have included any skin conditions or presence of any devices/IVs. LVN B stated she was not aware Resident #1 had an IV and never saw it and would have documented it if she had seen it. LVN B stated if an IV was not noted on a skin assessment it could get infected. During an interview on 2/20/26 at 11:42 a.m. LVN C stated when she arrived for her shift on 12/14/25 she received a report that an IV was found on Resident #1 the night of the 14th. LVN C stated her and another nurse went to remove it. LVN C stated it was a regular peripheral IV catheter and looked normal. LVN C stated normally during an head-to-toe assessment nurses would look over the entire body and notate things like an IV catheter. During an interview on 2/20/26 at 10:51 a.m. the DON stated if a resident had an IV it should have been noted on skin assessment during readmission and the assessment should have included the IV or any wound measurements. The DON stated normally if a resident had an IV they would call and notify the provider and receive orders for care of the IV to prevent any complications. Record review of the facility policy titled [company] Skin Integrity Prevention and Treatment Program, reviewed June 25, 2025, revealed, Braden Skin Risk Assessment and Documentation Standards include but not limited to: Completed within 24 hrs of admission as part of the nursing admission assessment, and further revealed, Weekly Skin Integrity Checks: Weekly assessment looking for new wounds-completed by a licensed nurse. Documented on Treatment Record, and, Weekly Wound Assessment: Each identified skin issue/area is assessed weekly in electronic medical record. A review of the facility policy titled Charting and Documentation, revised July 2017, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record, and further revealed, The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition, and, Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment.

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 2 of 4 residents (Resident #2, and Resident #4) reviewed for incontinent care: 1. The facility failed to ensure CNA A wiped between Resident #2's labia folds during incontinent care. 2. The facility failed to ensure Resident #2's catheter bag was not touching the floor during incontinent care. 3. The facility failed to ensure Resident #4's catheter bag was not touching the floor. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.1. Record Review of Resident #2's admission Record, dated 2/20/26, revealed a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain damage (brain injury caused by lack of oxygen resulting in impaired neurological function), contracture of muscle, right upper arm (permanent shortening and tightening of muscle limiting movement), contracture of muscle, left upper arm (permanent shortening and tightening of muscle limiting movement), tracheostomy status (presence of a surgically created opening in the neck into the trachea to assist with breathing), and neuromuscular dysfunction of bladder (impaired bladder control caused by nerve damage affecting bladder function). Record Review of Resident #2's annual MDS assessment, dated 1/19/26, reflected Resident #2 had severely impaired cognition for daily decision making and was always incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan, initiated 5/2/25, revealed a care area for Resident #2 had an indwelling catheter related to atonal bladder (loss of bladder muscle tone resulting in inability to effectively empty the bladder) and neurogenic bladder, with interventions to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #2's physician order summary, dated 2/20/26, revealed orders for foley catheter care every shift and as needed, with a start date of 2/16/26, and no end date. Foley catheter 16-18 fr 10-30 cc bulb change as needed for dislodgement or obstruction, with a start date of 2/16/26, and no end date. During an observation on 2/20/26 at 10:06 a.m. CNA A provided incontinent care to Resident #2, who was lying in bed and had a bowel movement. Before starting peri care the catheter bag was hanging on the side of the resident's bed and was touching the floor. During peri care CNA A used disposable wipes to cleanse the resident's perineal area and wiped the external front perineal area without separating the resident's legs or the labia. After CNA A completed the incontinent care and repositioned the resident, CNA A was asked to demonstrate how incontinent care had been provided. CNA A then repositioned the resident's legs and separated the labia, at which time brown fecal matter was observed present in the pubic hair and inner labial area. CNA A then obtained soap, water, and clean wipes and proceeded to cleanse the perineal area. During cleansing, the disposable wipes used by CNA A were observed to contain brown fecal matter. During an interview on 2/20/26 at 10:33 a.m. CNA A stated she should have opened the residents legs more so she could clean between the labia folds. CNA A stated not cleaning between then labia folds could place the resident at risk of infection. During an interview on 2/20/26 at 10:51 a.m. the DON stated staff should place a basin under the catheter bag to prevent it from touching the floor and prevent infections. The DON stated staff could also use foam peri cleanser during peri care. The DON stated staff should clean between the labia folds to prevent UTIs. A review of the facility document titled C.N.A. Orientation Check List for CNA A, dated April 1, 2025, revealed CNA A completed orientation training which included Activities of Daily Living (ADLs), including peri care. A review of the facility document titled Incontinent Care skills competency checklist for CNA A, dated April 1, 2025, revealed CNA A was evaluated and marked as MET competency for incontinent care. The checklist indicated CNA A demonstrated competency in positioning the resident with legs apart, using a wet washcloth and soap/peri wash, washing the perineal area from front to back, washing the buttocks and thighs thoroughly, rinsing thoroughly, drying with a towel, and applying a thin layer of skin barrier. A review of the facility policy titled Perineal Care, revised February 2023, revised April 16, 2024, and reviewed June 24, 2025, revealed under the section For a female resident, the policy instructed staff to wet a washcloth and apply soap or skin cleansing agent and wash the perineal area wiping from front to back. The policy further instructed staff to separate the labia and wash the area downward from front to back, continue to wash the perineum moving from inside outward to the thighs, wash the rectal area thoroughly wiping from the base of the labia toward and extending over the buttocks, and rinse and dry thoroughly. A review of the facility policy titled Foley Catheter Insertion, Female Resident, revised and reviewed June 2025, revealed the policy instructed staff to attach the catheter to the drainage tubing and secure the drainage tubing to the bed frame and allow tubing to rest on the bed surface. 2. Record review of Resident #4's admission Record dated 02/18/26 documented a [AGE] year-old male originally admitted to the facility 07/02/24 and the most recent admission on [DATE]. Resident #4's diagnoses included unspecified hydronephrosis (swelling of one or both kidneys caused by a backup of urine), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a progressive cognitive decline affecting memory, thinking, and daily functioning, where the specific type of dementia is not identified, and there are no significant behavioral issues like aggression, psychosis, or agitation). Record review of Resident #4's Annual MDS dated [DATE], documented a BIMS score of 9 that indicated moderate cognitive impairment. Record review of Resident #4's Care Plan with the last revision date of 08/26/25 documented a focus of: [Resident #4] has impaired bowel and bladder evacuation – incontinent of B & B – utilizes a foley catheter r/t dx neuromuscular dysfunction of bladder, BPH, AKI, impaired mobility –[ Resident #4] will at times remove his privacy bag and/or leg strap for his foley bag ** while sitting up in wheelchair at times he will pull on foley tubing to reach foley bag and will carry it in his lap or let it drop to floor **he will also place foley bag in bed with him – lying on mattress instead of hanging on side of bed frame ** he will also remove leg strap to hold catheter in place. On 02/19/26 at 11:14 am, an interview was attempted with Resident #4 who was laying on his bed located in the facility memory care unit. The catheter bag for Resident #4 was observed laying on the floor by his bed. Resident #4 stated they take good care of me and then he started asking what time do we eat? Resident #4 then dismissed this surveyor by saying OK, I'll see you later and waved. Another observation of the catheter bag on the floor was made on 02/19/26 at 11:30 am with nurse surveyor. During an interview with CNA D on 02/19/26 at 11:30 am, CNA D stated staff tried to hang the catheter bag on the side of the bed but since the bed was in a low position with a fall mat beside the bed, it was difficult to keep the catheter bag off the floor. CNA D also stated that the Resident #4 frequently moved it around himself. CNA D stated they encourage Resident #4 to use his call light so they can assist him to his wheelchair and properly position the catheter bag but he often forgets to do this and just gets up and walks while holding the bag. The catheter bag placement for Resident #4 was discussed during an interview with LVN E on 02/19/26 at 11:35 am. LVN E stated she knew the catheter bag touched the floor since the bed needed to be in the low position and that this position could cause an infection. LVN E also stated that when Resident #4 is in his wheelchair, he will often try to hook the bag on his belt and they have to tell him it needs to be lower. LVN E stated they had tried to take out the catheter but he retains urine so he must have it. LVN E further stated she was not sure what they could do to prevent infection from the catheter bag touching the floor.

Based on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 4 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication administration report did not contain blanks. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.Record review of Resident #1's admission record, dated 2/18/26, revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included atrial fibrillation (an irregular and often rapid heart rhythm that can increase the risk of stroke and decreased cardiac efficiency), type 2 diabetes mellitus (a chronic condition in which the body does not effectively use insulin, resulting in elevated blood glucose levels), Gastroesophageal Reflux Disease (GERD) (a digestive disorder in which stomach acid frequently flows back into the esophagus causing irritation), open wound of right lower leg (a break in the skin and underlying tissue on the right lower leg that may be at risk for infection and requires wound care), open wound of left buttocks (a break in the skin and underlying tissue on the left buttocks requiring monitoring and treatment to prevent complications), and muscle weakness. The resident was discharged on 12/17/25. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident's BIMS score was 12 (moderately impaired). Record review of Resident #1's baseline care plan, dated 12/11/25, revealed the resident required partial or moderate assistance with personal hygiene and did not self-administer medications. Record review of Resident #1's nursing progress notes, dated 2/18/26, revealed a note written on 12/10/25 Reached out to hospital. Resident is currently in [Hospital] . Written by LVN F Record review of Resident #1's nursing progress notes, dated 2/18/26, revealed a note written on 12/17/25 discharged home . Written by LVN G Record review of Resident #1's December 2025 MAR revealed blanks for 12/14/25 and 12/15/25 for esomeprazole magnesium capsule delayed release 40 mg give 1 capsule by mouth in the morning for GERD with an order date of 12/12/25 and DC date of 12/18/25. Further review of the MAR revealed scheduled orders were left blank with no coding, initials, or documentation to indicate whether the medications were administered, refused, held, or unavailable on 12/10/25, 12/17/25, and 12/18/25 for daily orders. During an interview on 2/20/26 at 10:51 a.m. the DON stated staff was expected to code something in the MAR and not leave it blank. The DON stated between 12/9/25 and 12/11/25 the resident was in the hospital. The DON stated they needed to enter the code that showed she was at the hospital. The DON stated this resident was known to refuses care and may have refused medications, but staff should have used the code to show she refused the medication. The DON stated leaving the MAR blank placed the resident at risk of not knowing if a medication was administered. Record review of facility policy titled Charting and Documentation, dated July 2001 and revised July 2017, revealed, The following information is to be documented in the resident medical record: . Medications administered. The policy further revealed, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observations, interview and record review, the facility failed to ensure that a resident received care, consistent with professional stands of practice, to prevent pressure ulcers for 1 of 3 residents (Resident #95) reviewed for Pressure Ulcers. The facility failed to implement the Wound Care NP recommendations for 8 days when Resident #1 was identified with a stage 3 pressure injury to the left buttock from 11/20/2025 to 11/28/2025. Resident #1 refused wound care 22 times from 11/28/2025 to 12/24/2025, and refused further assessment of the wound from the Wound Care NP. On 12/24/2025, Resident #1 had maggots in his wound and the wound had increased in size from 4 cm x 5 cm x 0.2 cm on 12/10/2025 to 6 cm x 3.5 cm x 2 cm on 12/24/2025. An IJ situation was identified on 01/02/2026. The IJ template was provided to the facility on [DATE] at 09:13 PM. While the IJ was removed on 01/04/2026, the facility remained out of compliance at a scope of isolation and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the need for monitoring of corrective measures and the effectiveness of its corrective plan. Findings Included: Record review of Resident #1's admission Record (Face sheet) dated 01/02/2026 revealed he was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (chronic elevated levels of sugar in the blood that can affect organs and delay healing), morbid obesity (excess body weight), and severe protein-calorie malnutrition (inadequate intake of protein resulting in breakdown of tissue and muscle loss). Resident #1 was listed as his own responsible party and his doctor was Physician A. Record review of Resident #1's MDS, a Quarterly Assessment, dated 09/30/2025 revealed his BIMS score was 12 out of 15, he was independent in his decision making; was occasionally incontinent of urine and always incontinent of bowel; was at risk for pressure ulcers and he did not have any unhealed pressure ulcers. Record review of Resident #'1s Care Plan for I have a Stage 3 pressure injury/ulcer Rt [right] buttock r/t [related to] immobility, refusal of care was created and revised on 12/31/2025 by the Corporate Clinical Specialist 41 days after the pressure ulcer was assessed and identified on his left buttock not his right, and had an initiation date of 11/20/2025; and it did not have any interventions for his refusals. Record review of Resident #1's Wound Assessment Report, dated 07/11/2025, completed by Wound Care NP revealed he had a stage 3 pressure ulcer on his left buttock that was present when he was readmitted to the facility on [DATE]. Record review of Resident #1's Wound Assessment Report, dated 09/30/2025, completed by Wound Care NP revealed the stage 3 pressure injury on his left buttock present when he was readmitted on [DATE] had resolved. Record review of Resident #1's Weekly Body Skin Check from 10/05/2025 to 10/19/2025 revealed Resident #1 allowed the DON to complete the skin check, and the resident did not have any skin or wound issues. Record review of Resident #1's Weekly Body Skin Check dated 10/26/2025 revealed the CNA reported Resident #1's healed wound on his bottom had reopened. Resident #1 refused to allow the DON to assess the wound and the Wound Care NP was notified. Record review of Resident #1's Weekly Body Skin Check dated 11/03/2025 at 11:48 (11:48 AM) revealed Resident #1 refused to allow the DON to assess the open area identified by the CNA on 10/26/2025, Resident #1 did not want the DON or the charge nurse to look at his skin. Resident #1 reported his skin was healed. The resident's Physician was notified, and the Wound Care NP would attempt to assess his skin. Record review of Resident #1's Weekly Body Skin Check dated 11/03/2025 at 14:50 (2:50 PM) revealed Resident #1 refused to allow the DON to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP tried twice last week to assess the wound and would try this week. Record review of Resident #1's Weekly Body Skin Check dated 11/04/2025 revealed Resident #1 refused to allow the nurse to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP attempted today, and Resident #1 declined her visit. Record review of Resident #1's Weekly Body Skin Check dated 11/16/2025 revealed Resident #1 refused to allow the nurse and the Wound Care NP to assess the open area identified by the CNA on 10/26/2025. Record review of Resident #1's Weekly Body Skin Check dated 11/18/2025 at 14:50 (2:50 PM) revealed Resident #1 refused to allow the nurse to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP attempted today, Resident #1 declined her visit. Record review of Resident #1's skin and wound progress note dated 10/28/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 10/30/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 11/04/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 11/11/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's Wound Assessment Report dated 11/20/2025 by Wound Care NP revealed the healed pressure ulcer on his left buttock reopened, was a stage 3 pressure ulcer that measured 4 cm length x 5 cm width x 0.2 cm depth and was to be cleansed with 0.25% Dakins solution, apply collagen with silver, and cover with a silicone bordered superabsorb dressing. Record review of Resident #1's skin and wound progress note dated 11/25/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/02/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/09/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/16/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/31/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's Weekly Wound Observation, dated 11/21/2025 completed by the DON, revealed he had stage 3 wound on his left buttock was acquired in the facility on 11/20/2025, and measured 4 cm length x 5 cm width x 0.2 cm depth. The resident's physician was notified on 11/20/2025, the resident was educated on the importance of incontinent care, importance of hygiene, importance of off-loading; and it was checked the resident's care plan was updated. Record review of Resident #1's Weekly Wound Observation, dated 12/03/2025 completed by the DON, revealed Resident #1 did not allow the DON to complete the weekly wound assessment and was noted No I [Resident #1] don't feel like turning. The DON offered additional pain medications and Resident #1 accepted but declined assessment. Record review of Resident #1's Weekly Wound Observation, dated 12/10/2025 completed by the DON, revealed he had stage 3 wound on his left buttock that was acquired in the facility on 11/20/2025, and measured 4 cm length x 5 cm width x 0.2 cm depth; the resident's physician was notified on 11/20/2025; education provided was on-going; and it was checked Resident #1 was mostly non-compliant with recommended interventions for wound healing and skin health. Resident receives re-education and encouragement from staff/family upon refusals but continues to elect to be non-compliant; and slowed wound healing or non-healing of the wound was an expected outcome. Record review of Resident #1's Weekly Wound Observation, dated 12/24/2025 completed by the DON, revealed he had stage 3 wound on his left buttock that was acquired in the facility on 11/20/2025, and measured 6 cm length x 3.5 cm width x 2 cm depth; the resident's physician was notified; educated provided was on-going; and it was checked Resident #1 was mostly non-compliant with recommended interventions for wound healing and skin health. Resident received re-education and encouragement from staff/family upon refusals but continues to elect to be non-compliant; and slowed wound healing or non-healing of the wound was an expected outcome; and the resident frequently declines bed baths and frequently refusing to be changed by staff. Record review of Resident #1's Physician Order Summary Report, dated 01/02/2026, revealed a wound care order, with a start date of 11/28/2025, for his left buttock, to be cleansed with Dakins 0.25% solution, pat dry, collagen with silver, and cover with silicone bordered superabsorbent dressing daily and as need when loose or soiled everyday shift. Record review of Resident #1's November 2025 TARs revealed he refused the daily wound care treatment to the stage 3 pressure ulcer on his left buttock on 11/29/2025 and 11/30/2025. Record review of Resident #1's December 2025 TAR revealed he refused the day shift wound care treatment to the stage 3 pressure ulcer on his left buttock on 12/01/2025, 12/02/2025, 12/03/2025, 12/05/2025, 12/06/2025, 12/07/2025, 12/09/2025, 12/10/2025, 12/11/2025, 12/12/2025, 12/14/2025, 12/15/2025, 12/16/2025, 12/17/2025, 12/19/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/23/2025. Record review of Resident #1's Nurses Note, dated 12/24/2025, the ADON noted Resident evaluated due to concerns related to hygiene and skin integrity and personal care needs.Nursing staff have made repeated attempts to provide care using redirection, choice of caregivers and modified approaches. Staff has provided resident with options for choices. Record review of Resident #1's Nurses Note dated 12/24/2025 at 10:34 AM, the DON noted This nurse and ADON went to talk with resident about refusing wound care.Asked resident about wound care and refusing. Resident reported that he didn't know why, just doesn't want to. Explained to resident that wound care was going to be changed to every shift to keep it clean and if resident wanted someone specific that day to do it. Resident explained that he would be okay with that. Reviewed with resident that his pain medication was as needed, and he could ask for a pain medication prior and once the medication took effect the staff could perform wound care and if the pain medication wasn't working that we could ask the doctor for a change in pain medication. Resident verbalized understanding and stated, 'yeah I know'. Record review of Resident #1's Nurses Note, dated 12/24/2025 at 3:04 PM, the DON noted she had informed LVN E the Wound Care NP had been notified about Resident #1's wound concerns but had not received a response back. LVN E reported she reached out to Resident #1's physician, left a message and would reach out to the physician's NP if he did not respond back. LVN E reported she reached out to the Psychiatric NP and was waiting for a response back. Record review of Resident #1's Nurses Note dated 12/24/2025 at 6:38 PM, the DON noted she followed up with LVN E if the nurse was able to reach Resident #1's physician and if any orders were obtained. LVN E reported she called Physician A twice with no response but reached out to Physician A's NP and explained the concern with no new orders received. Observation and interview on 12/31/2025 at 2:25 PM, Resident #1 was lying in bed on his back with the foot of his bed by the window and the bed linen was clean. A dead fly was observed on the window ledge. The surveyor asked Resident #1 if he was aware of any bugs in his bed or wounds, he responded oh yeah, that happened but it was my fault. When asked further probing questions, Resident #1 stated he didn't want to talk about it. In an interview on 12/31/2025 at 1:50 PM, CNA I stated he took care of Resident #1 on 12/24/2025. He asked Resident #1 at the start of the shift if the CNA could provide incontinent care and the resident said no, so the CNA told LVN E who said to try again later. The CNA said later Resident #1 turned on his call light and wanted the charge nurse; the CNA informed LVN E who said she would talk to Resident #1. CNA I stated sometime after breakfast but before lunch, LVN E told him Resident #1 needed to be cleaned up because the resident was very dirty. CNA I said other CNAs assisted with providing a bed bath to Resident #1. CNA I said he saw maggots in the bed and around the upper part of Resident #1's leg. In a further interview on 01/04/2026 at 10:17 AM, CNA I stated if Resident #1 refused care, he would tell the nurse; then 10 to 15 minutes later he would ask the resident again to see if the resident was receptive to care and if the resident continued to refuse, he would inform the nurse again. In a telephone interview on 01/01/2026 at 11:58 AM, CNA B reported on 12/24/2025 she was called to Resident #1's room to assist with providing the resident with a bed bath because he refused to be showered. CNA B stated when she had pulled back the bedding, she saw maggots in Resident #1's groin area. The CNA stated she and the other CNAs who were in the room had explained to Resident #1 that day that this was why he needed to let the CNAs change him. CNA B stated she would ask Resident #1 if he needed to be changed and he would tell the CNA to leave him alone or he would state he was fine. In a further interview on 01/02/2026 at 2:42 PM, CNA B stated when Resident #1 would refuse incontinent care or a shower, she would try to pursued the resident several times to let her provide care, and if he continued to refuse, she would inform the nurse. In an interview on 01/01/2026 at 1:55 PM, CNA C stated when she was assisting with providing Resident #1 a bed bath on 12/24/2025, she saw maggots on the resident and in his feces. In an interview on 01/02/2026 at 2:48 PM, LVN E stated on 12/24/2025 Resident #1 called her into his room around 9:30 AM to talk to her. The resident requested her to wash his hand which she did, then he pointed down to his incontinent brief and asked her to look at something. When she did, LVN E said she saw the resident had stool (feces) in his brief and there appeared to be maggots in the fecal material. LVN A came into the room, they explained to the resident the situation needed to be taken care of. Resident #1 wanted to be cleaned up later in the evening. LVN E said she gave Resident #1 options of taking a pain pill, waiting 30 minutes, then letting staff provide a bed bath but the resident agreed to have the bed bath done first, then the nurse could administer the pain medication. LVN E stated when the CNAs have informed her Resident #1 refused care, she would talk with the resident. Sometimes when she does this, he will become upset and ask to be left alone. Other times he would say maybe later, then when she goes back he would say the same thing and would keep putting off the In an interview on 01/01/2026 at 6:13 PM, LVN A stated on 12/24/2025 she had just walked into the facility when she was asked to speak to Resident #1 about trying to convince him to be showered or given a bed bath. Resident #1 had a very large bowel movement and had been refusing care days prior. LVN A asked him if they could provide care and Resident #1 said no, but then agreed to a bed bath after conversing with him. LVN A said when Resident #1 was turned to the side and was wiped, she saw bugs (maggots). In a telephone interview on 01/01/2026 at 1:00 PM, the Wound Care NP stated Resident #1 used to let her see his skin weekly and would only refuse once out of every 30 times, but now he refuses care every time. The Wound Care NP stated she was notified about the maggots found in the wound, she tried to see Resident #1's wound after the maggots were found on her next visit, but Resident #1 refused to let her see his wound. So, she continued with the order that was previously in place because she couldn't change the order without seeing the wound first to assess what treatment would be appropriate. The Wound Care NP stated the last time Resident #1 allowed her to see his wound was on 11/20/2025. In a further telephone interview on 01/02/2026 at 3:58 PM, the Wound Care NP stated when she assessed Resident #1's wound on 11/20/2025 she had recommended the wound order of cleaning the wound with Dakins solution, applying collagen silver, and covering with superabsorbent dressing. The Wound Care NP stated she does not put orders into the resident's electronic clinical record, they were provided to the DON, who contacts Resident #1's Physician A who reviews the order and the DON would let her know if the physician agreed or disagreed with her recommendations. The Wound Care NP stated the facility did not share with her the wound care order she recommended was not started until 11/28/2025, and stated the delay might have been waiting on Physician A's approval and she did not think it would have made a difference in the condition of Resident #1's wound due to his refusal history. The Wound Care NP said Resident #1's wound on his left buttock was completely unavoidable because he would refuse to receive incontinent care and would refuse to be repositioned. In a telephone interview on 01/02/2026 at 1:15 PM, Resident #1's Physician A stated he had been the resident's physician for several months and was notified of the resident's refusal of care. Physician A stated he had even tried to bribe Resident #1 to get staff to bathe/shower him but that didn't work. Physician A stated he was notified of the bugs in Resident #1's wound, he recommended wound care services and for the room to be fumigated. In an interview on 01/01/2026 at 6:31 PM, the DON stated it was brought to her attention Resident #1 had maggots in his wound when he was given a bed bath on 12/24/2025. In an interview on 01/01/2026 at 5:15 PM, the Administrator stated she came into the facility 12/24/2025, was informed Resident #1 had been refusing for days to let staff provide incontinent care or wound care and when they changed him that day, they found insects on him. The Administrator stated Resident #1's Physician A was notified along with Physician A's NP and informed the Wound Care NP. In a further interview on 01/02/2026 from 5:43 PM to 6:24 PM, the DON did not give a reason why the wound order recommendation from the Wound Care Practitioner provided to the DON on 11/20/2025 was not started until 11/28/2025, and stated she would have to look into it and did not provide an explanation for the delay before the surveyor exited the facility on 01/04/2026. Record review of the facility's policy Pressure Injury Prevention Program, revised 06/27/2025 revealed All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and up on significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the result of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new existing pressure injuries. An IJ was identified on 01/02/2026. The template was provided to the Administrator on 01/02/2026 at 9:13 PM. The following Plan of Removal submitted by the facility was accepted on 01/03/2026 at 2:45 PM and indicated the following: Plan of Removal 1/2/2026F686 Immediate Actions:-On 12/24/2025, Resident #1 received immediate wound assessment and cleansing following identification of maggots. Appropriate wound care interventions were performed.-The attending physician was notified immediately, and wound care orders were reviewed and confirmed.-Nursing leadership and the wound care provider reassessed the resident's condition and treatment needs.-The Corporate Clinical Nurse conducted an immediate in-service with the Director of Nursing (DON) on January 2, 2026, addressing:1. Expectations for timely submission and tracking of wound care recommendations requiring physician approval.2. Leadership accountability for ensuring physician orders are obtained and implemented without delay.3. Required escalation when wounds cannot be assessed or treated due to resident refusal, including physician notification, IDT involvement, and documentation of education regarding risks of refusal. Systemic Changes: On 01/02/1026 DON/Designee completed a facility-wide audit of all residents with active wounds to confirm: Timely wound identification, Timely physician notification, No delays between wound care recommendations and physician orders. On 01/02/2026 a standardized physician order tracking process was implemented requiring nursing leadership to monitor pending wound care recommendations and escalate unresolved orders. The DON or designee conducted in-service education on 01/02/2026 for licensed nurses and CNAs on: Proper management and documentation of refusal of skin assessments and wound treatment; Required escalation and notification when refusals place a resident at risk; Balancing resident rights with professional standards of care and safety. No staff will be able to work until education and competency is completed. All education will be incorporated into new hire on-boarding by Administrator on 01/02/2026.Physician NotificationThe licensed nurse {RN/LVN) caring for the resident is responsible for notifying the physician of any change in condition, inability to complete wound assessment or treatment due to refusal, or identified need for new or revised orders. The Director of Nursing (DON) or designee provides oversight to ensure notification occurs timely and is documented appropriately.Systemic Changes - Physician Order Tracking:Responsible Party for Monitoring: The Director of Nursing or designee is responsible for monitoring physician order tracking related to wound care recommendations and approvals.Frequency of Monitoring: Physician order tracking is reviewed daily for any pending wound care recommendations until orders are received and implemented.Duration of Practice: This process is an ongoing practice and has been incorporated into routine nursing leadership oversight. It was not limited to this incident and will continue as part of standard clinical operations. Monitoring and QA: The DON or designee will conduct weekly wound care and physician order audits for four (4) weeks, then monthly thereafter. Audits will include review of: Timeliness of wound assessments and treatment initiation; Documentation of refusals and escalation; Care plan updates related to wounds and refusals. Audit findings will be reviewed through the QAPI process, with corrective actions implemented as indicated. Verification of the facility's POR was as follows:Record review of Resident #1's Weekly Wound Observation form, dated 12/24/25, revealed the wound on his left buttock was acquired on 11/20/25, was a stage 3 Pressure Injury and measured 6.0 cm x 3.5 cm x 2.0 cm, there was no odor to the wound and did not show any signs of a wound infection. Record review of Resident #1's physician orders revealed his physician ordered on 12/24/2025 wound care to left buttock; cleanse with Dakins 0.25%, pat dry, collagen with silver, and cover with silicon bordered superabsorbent dressing every night shift and when loose or soiled. Record review of Resident #1's nurse's notes dated 12/24/25 revealed the resident's wound was assessed by the DON. Record review of the in-service education provided to the DON on 1/2/26 by the Corporate Clinical Specialist revealed the exception of the DON was for timely submission and tracking of wound care recommendations requiring physician approval, leadership accountability for ensuring physician orders are obtained and implemented without delay, required escalation when wounds cannot be assessed or treated due to resident refusal, including physician notification, IDT involvement, and documentation of education regarding risk of refusal. Record review of an undated employee list revealed there were 31 CNAs, 9 LVNs, and 6 RNs for a total of 46 nursing staff. Record review of the in-service signature page, dated 1/2/26, for the in-service on Management of Pressure Injuries, Care Refusals, and Escalation revealed 46 nursing staff (CNAs, LVNS, RNs) had received the training. The training covered how to respond when a resident refuses a personal care, skin assessment or wound care, when refusals required escalation to leadership and the physician, and documentation expectations. The training covered the resident had a right to refuse care but staff still had a duty to educate the resident on the risks of refusal, offer care again at appropriate intervals, escalate refusals that place a resident at risk, and document thoroughly. The training specified when refusals become high risk when they involve a wound assessment, wound treatment, signs of infection, deterioration or re-opening of a pressure injury, and repeated refusals over time. The required escalation process for CNA was to report immediately to the nurse, document refusal per facility process, and continue to offer care respectfully. The required escalation process for the nurse was to attempt assessment and/or treatment, educate resident on risk of refusal, notify the nurse manager or DON, the physician and ensure the care plan reflects refusals and risks. The training specified the documentation expectations which included what care was offered, exact nature of refusal, education provided to the resident, resident response, notifications made and follow-up actions planned. The nursing staff was given a quiz as part of the training. Record review of the quiz given to the CNAs on 1/3/26 on Management of Pressure Injuries, Care Refusals, and Escalation revealed 31 CNAs had taken the quiz in person or over the phone and all CNAs scored 100%. Review of the quiz given to the nurses on 1/3/26 on Management of Pressure Injuries, Care Refusals, and Escalation revealed 16 nurses had taken the quiz in person or over the phone and all nurses scored 100%. Record review of the Facility Wide Audit of residents with active wounds, dated 1/2/26, revealed 8 residents had wounds and all had been audited for notification of the physician, if there were delays between wound care recommendations and physician orders, when they were last seen by a specialist and if their orders had been updated by their primary care physician. Record review of the Monitoring Log revealed residents with wounds would be monitored for wound care recommendations that were not approved and implemented within 24-hours would be escalated and the log would be reviewed daily. Record review of the undated Monitoring Log for F686, had handwritten on 1/3/26 was no pend [pending] wound orders and was initialed by the DON. Interviews on 1/4/26 from 9:24 AM to 12:32 PM with 9 nursing staff (6 CNAs, 2 LVNs, 1 RN) which included 2 night shift nursing staff (1 CNA and 1 LVN) revealed they had been in-serviced on what to do when a resident refuses care which included approaching the resident several times, asking the resident if they would let another caregiver perform the care, notifying the nurse/physician immediately, documenting the refusal in the Point of Care system or the resident's clinical record, notification to the DON and Administrator of the resident's refusal and ensuring the care plan was updated. In an interview on 1/4/26 from 3:30 PM to 3:45 PM, the DON stated she assessed Resident #1's wound on 12/24/25, his physician was contacted who gave orders for wound care, the Wound NP was notified. The DON stated she was in-serviced by the Corporate Clinical Specialist on residents' refusal of wound care, timeliness of completing wound assessments and updating resident's care plans. The DON stated she would conduct weekly rounds on residents with wounds, would review their orders, review the timeliness of the wound assessment, review if the resident was allowing treatment to be provided and if not if it was documented and the care plan reflected the resident's refusal. The DON stated she would review physician orders daily for new wound care orders. The DON said the nurses and CNAs were in-serviced on what to do when a resident refused wound care, to make sure the care plan was updated to reflect the resident's refusal, to notify the physician the resident was refusing care, informing the DON/Administrator of the refusal of care, and documentation of residents refusal, education provided and the resident's response. The DON stated she would be monitoring the physician orders daily along with resident refusals documented on the MARS/TARS. In an interview on 1/4/26 from 4:00 PM to 4:25 PM, the Administrator stated Resident #'1 physician was notified of the issue on 12/24/25, the wound was assessed by the DON and the resident's orders were updated. The Administrator said when the Wound Care NP makes recommendations a copy of the recommendations would be given to the Administrator and DON to ensure the physician acted on the recommendation and if not why so the Wound NP could be notified of the physician's rationality. The Administrator stated if a physician continues to not implement the recommendations from the Wound Care NP, then she would have the Medical Director speak with the physician. The Administrator stated the DON would monitor the resident's wound treatments, if the resident was refusing the wound treatment, it the wound care orders were current, and if the refusal of treatment was documented along with the education provided to the resident. The audit would be done weekly for 4 weeks, then monthly until it was no longer needed. On 01/04/2026 at 7:05 PM, the Administrator was notified the IJ was removed on 01/04/2026 at 6:29 PM. However, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #1) reviewed for care plans.The facility failed to develop and implement a care plan that addressed Resident #1's wound on his left buttock identified as a stage 3 pressure ulcer (a bed sore which is an open wound that extends through the skin down into the fatty tissue, appearing as a deep crater but the bone, tendon or muscle are not exposed) by the Wound Care NP A on 11/20/2025 until 12/31/2025, 41 days later; did not address his refusals of skin assessments or wound care in the care plan and incorrectly listed the wound on his right buttock instead of his left. On 12/24/2025 maggots were observed in the stage 3 pressure ulcer, and the wound had increased from 4 cm x 5 cm x 0.2 cm on 12/10/2025 to 6 cm x 3.5 cm x 2 cm on 12/24/2025.An IJ was Identified on 01/02/2026. The template was provided to the facility on [DATE] at 09:13 PM. While the IJ was removed on 01/04/2026 the facility remained out of compliance at a scope of isolation and a severity level of no actual harm that was not immediate due to the to the need for monitoring of corrective measures and the effectiveness of its corrective plan.Findings included: Record review of Resident #1's admission Record (Face sheet) dated 01/02/2026 revealed he was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (chronic elevated levels of sugar in the blood that can affect organs and delay healing), morbid obesity (excess body weight), and severe protein-calorie malnutrition (inadequate intake of protein resulting in breakdown of tissue and muscle loss). Resident #1 was listed as his own responsible party and his doctor was Physician A. Record review of Resident #1's MDS, a Quarterly Assessment, dated 09/30/2025 revealed his BIMS score was 12 out of 15, he was independent in his decision making; was occasionally incontinent of urine and always incontinent of bowel; was at risk for pressure ulcers and he did not have any unhealed pressure ulcers. Record review of Resident #'1s Care Plan for I have a Stage 3 pressure injury/ulcer Rt [right] buttock r/t [related to] immobility, refusal of care was created and revised on 12/31/2025 by the Corporate Clinical Specialist 41 days after the pressure ulcer was assessed and identified on his left buttock not his right, and had an initiation date of 11/20/2025; and it did not have any interventions for his refusals. Record review of Resident #1's Wound Assessment Report, dated 07/11/2025, completed by Wound Care NP revealed he had a stage 3 pressure ulcer on his left buttock that was present when he was readmitted to the facility on [DATE]. Record review of Resident #1's Wound Assessment Report, dated 09/30/2025, completed by Wound Care NP revealed the stage 3 pressure injury on his left buttock that was present when he was readmitted on [DATE] had resolved. Record review of Resident #1's Weekly Body Skin Check from 10/05/2025 to 10/19/2025 revealed Resident #1 allowed the DON to complete the skin check, and the resident did not have any skin or wound issues. Record review of Resident #1's Weekly Body Skin Check dated 10/26/2025 revealed the CNA reported Resident #1's healed wound on his bottom had reopened. Resident #1 refused to allow the DON to assess the wound and the Wound Care NP was notified. Record review of Resident #1's Weekly Body Skin Check dated 11/03/2025 at 11:48 (11:48 AM) revealed Resident #1 refused to allow the DON to assess the open area identified by the CNA on 10/26/2025, Resident #1 did not want the DON or the charge nurse to look at his skin. Resident #1 reported his skin was healed. The resident's Physician was notified, and the Wound Care NP would attempt to assess his skin. Record review of Resident #1's Weekly Body Skin Check dated 11/03/2025 at 14:50 (2:50 PM) revealed Resident #1 refused to allow the DON to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP tried twice last week to assess the wound and would try this week. Record review of Resident #1's Weekly Body Skin Check dated 11/04/2025 revealed Resident #1 refused to allow the nurse to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP attempted today, and Resident #1 declined her visit. Record review of Resident #1's Weekly Body Skin Check dated 11/16/2025 revealed Resident #1 refused to allow the nurse and the Wound Care NP to assess the open area identified by the CNA on 10/26/2025. Record review of Resident #1's Weekly Body Skin Check dated 11/18/2025 at 14:50 (2:50 PM) revealed Resident #1 refused to allow the nurse to assess the open area identified by the CNA on 10/26/2025, Resident #1 reported his previous wound had healed, he was fine, the Wound Care NP attempted today, Resident #1 declined her visit. Record review of Resident #1's skin and wound progress note dated 10/28/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 10/30/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 11/04/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 11/11/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the open area identified by the CNA on 10/26/2025 because the resident refused care today. Record review of Resident #1's Wound Assessment Report dated 11/20/2025 by Wound Care NP revealed the healed pressure ulcer on his left buttock reopened, was a stage 3 pressure ulcer that measured 4 cm length x 5 cm width x 0.2 cm depth and was to be cleansed with 0.25% Dakins solution, apply collagen with silver, and cover with a silicone bordered superabsorb dressing. Record review of Resident #1's skin and wound progress note dated 11/25/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/02/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/09/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/16/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's skin and wound progress note dated 12/31/2025 by Wound Care NP revealed Resident #1 was unable to be evaluated by the Wound Care NP to assess the stage 3 pressure ulcer on his left buttock because the resident refused care today. Record review of Resident #1's Weekly Wound Observation, dated 11/21/2025 completed by the DON, revealed he had stage 3 wound on his left buttock was acquired in the facility on 11/20/2025, and measured 4 cm length x 5 cm width x 0.2 cm depth. The resident's physician was notified on 11/20/2025, the resident was educated on the importance of incontinent care, importance of hygiene, importance of off-loading; and it was checked the resident's care plan was updated. Record review of Resident #1's Weekly Wound Observation, dated 12/03/2025 completed by the DON, revealed Resident #1 did not allow the DON to complete the weekly wound assessment and was noted No I [Resident #1] don't feel like turning. The DON offered additional pain medications and Resident #1 accepted but declined assessment. Record review of Resident #1's Weekly Wound Observation, dated 12/10/2025 completed by the DON, revealed he had stage 3 wound on his left buttock that was acquired in the facility on 11/20/2025, and measured 4 cm length x 5 cm width x 0.2 cm depth; the resident's physician was notified on 11/20/2025; education provided was on-going; and it was checked Resident #1 was mostly non-compliant with recommended interventions for wound healing and skin health. Resident receives re-education and encouragement from staff/family upon refusals but continues to elect to be non-compliant; and slowed wound healing or non-healing of the wound was an expected outcome. Record review of Resident #1's Weekly Wound Observation, dated 12/24/2025 completed by the DON, revealed he had stage 3 wound on his left buttock that was acquired in the facility on 11/20/2025, and measured 6 cm length x 3.5 cm width x 2 cm depth; the resident's physician was notified; educated provided was on-going; and it was checked Resident #1 was mostly non-compliant with recommended interventions for wound healing and skin health. Resident received re-education and encouragement from staff/family upon refusals but continues to elect to be non-compliant; and slowed wound healing or non-healing of the wound was an expected outcome; and the resident frequently declines bed baths and frequently refusing to be changed by staff. Record review of Resident #1's Physician Order Summary Report, dated 01/02/2026, revealed a wound care order for his left buttock, to be cleansed with Dakins 0.25% solution, pat dry, collagen with silver, and cover with silicone bordered superabsorbent dressing daily and as need when loose or soiled everyday shift, with a start date of 11/28/2025. On 12/24/2025, a wound care order with a start date of 12/24/2025 for the left buttock to be cleansed with Dakins 0.25%, pat dry, collagen with silver, and cover with silicone bordered superabsorbent dressing every night shift and as needed was added to augment the treatment Resident #1 received during the day shift. Record review of Resident #1's November 2025 TARs revealed he refused the daily wound care treatment to the stage 3 pressure ulcer on his left buttock on 11/29/2025 and 11/30/2025. Record review of Resident #1's December 2025 TAR revealed he refused the day shift wound care treatment to the stage 3 pressure ulcer on his left buttock on 12/1/2025, 12/2/2025, 12/3/2025, 12/5/2025, 12/6/2025, 12/7/2025, 12/9/2025, 12/10/2025, 12/11/2025, 12/12/2025, 12/14/2025, 12/15/2025, 12/16/2025, 12/17/2025, 12/19/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/23/2025. Resident #1 refused the twice a day wound care treatment to the stage 3 pressure ulcer on his left buttock on day shift on 12/27/2025, 12/28/2025, and 12/29/2025; and on the evening shift on 12/26/2025, 12/29/2025, and 12/30/2025. Record review of Resident #1's Nurses Note, dated 12/24/2025, the ADON noted Resident evaluated due to concerns related to hygiene and skin integrity and personal care needs.Nursing staff have made repeated attempts to provide care using redirection, choice of caregivers and modified approaches. Staff has provided resident with options for choices. Record review of Resident #1's Nurses Note dated 12/24/2025 at 10:34 AM, the DON noted This nurse and ADON went to talk with resident about refusing wound care.Asked resident about wound care and refusing. Resident reported that he didn't know why, just doesn't want to. Explained to resident that wound care was going to be changed to every shift to keep it clean and if resident wanted someone specific that day to do it. Resident explained that he would be okay with that. Reviewed with resident that his pain medication was as needed, and he could ask for a pain medication prior and once the medication took effect the staff could perform wound care and if the pain medication wasn't working that we could ask the doctor for a change in pain medication. Resident verbalized understanding and stated , 'yeah I know'. Record review of Resident #1's Nurses Note, dated 12/24/2025 at 3:04 PM, the DON noted she had informed LVN E the Wound Care NP had been notified about Resident #1's wound concerns but had not received a response back. LVN E reported she reached out to Resident #1's physician, left a message and would reach out to the physician's NP if he did not respond back. LVN E reported she reached out to the Psychiatric NP and was waiting for a response back. Record review of Resident #1's Nurses Note dated 12/24/2025 at 6:38 PM, the DON noted she followed up with LVN E if the nurse was able to reach Resident #1's physician and if any orders were obtained. LVN E reported she called Physician A twice with no response but reached out to Physician A's NP and explained the concern with no new orders received. Record review of Resident #1's Nurses Note dated 12/27/2025 at 5:08 AM, LVN F noted resident refused to be checked and changed through out the whole shift 6pm-6am. Refused wound care and shower. Offered 4x. Record review of Resident #1's Nurses Note dated 12/28/2025 at 3:55 AM, LVN F noted Resident refused to get checked and changed, refuses wound care x3. Will not give a reason why. Record review of Resident #1's Nurses Note dated 12/28/2025 at 4:55 PM, LVN G noted Attempted to provide wound care to resident, refused x2. Resident unwilling to give reason for refusal, vocalized understanding of importance of wound care, peri care and risks associated with delayed care. Resident stopped responding verbally and faced wall. Record review of Resident #1's Nurses Note dated 12/29/2025 at 5:43 AM, LVN F noted Resident refused to be checked and changed throughout the night asked x4. Resident refused wound care, gets upset when we ask and does not answer why he is refusing and turns his face towards the wall. Record review of Resident #1's Nurses Note dated 12/29/2025 at 4:30 PM, the DON noted she followed with the resident refusing wound care during the weekend with the Social Worker present. The DON Explained to resident that eating is important for wound healing. Resident rolled his eyes and verbalized understanding, and he reported will eat when he is hungry. Noted resident does have three cases of soda at bedside and snacks in bedside drawers. Asked resident if there was anything the staff can assist with. Resident rolled his eyes and reported no. Explained to resident that tomorrow was Tuesday and the wound NP would be rounding and if resident wanted to do his bed bath prior to wound care and wanted this nurse present. Resident rolled his eyes and stated we will see. Explained to resident that it was important for the wound NP to see wound. Resident rolled his eyes and stated he knows. Record review of Resident #1's Nurses Note dated 12/29/2025 at 11:27 PM, LVN A noted Resident refused wound care treatment this evening. Resident also refused bed bath and refused to allow staff to provide him with personal care or personal hygiene care. Resident was educated on the risk associated with lack of proper peri care and wound care. Resident became extremely agitated and stated, 'I am fine, leave me alone'. Nurse attempted to ask again just for reassurance and clarity, and resident raised his voice and closed his eyes and would no longer communicate with nurse. Record review of Resident #1's Nurses Note dated 12/30/2025 at 3:13 PM, the DON noted she had notified Physician A's NP to inform them Resident #1 was refusing wound care, bed baths, and not wanting to eat. Explained that the dietitian was present in the facility and visiting with the resident. Explained that the Psychiatric NP visited with Resident #1 and would follow up later in the week. Record review of Resident #1's Nurses Note dated 12/31/2025 at 12:29 AM, LVN H noted the resident refused care and wound care, was educated on importance of clean and dry skin but continued to decline any care. Resident was offered choice of staff to provide care and he continued to decline care from all staff and wound care. Record review of Resident #1's Nurses Note dated 12/31/2025, the DON noted she and the ADON went to speak to the resident about wound care. The DON offered to perform wound care with assistance but Resident #1 refused. When the DON asked what barriers he had to wound care, Resident #1 stated that he did not want to talk about it. The DON offered pain medication to the resident so wound care could be performed and the resident declined to have wound care performed. The DON offered to obtain preferred staff and Resident #1 declined wound care. The DON offered to see if LVN E could come in today (12/31/2025) or tomorrow to provide wound care to the resident and he declined, and reported he would like to only receive wound care on Friday. Record review of Resident #1's Social Services Note dated 12/29/2025, the Social Worker noted she and the DON spoke to the resident about refusing meals and wound care. The DON educated resident on importance of nutrition to help wound healing and to get stronger. Resident rolled his eyes and said 'yeah' to the DON. Resident refused additional meals or substitutes offered by DON, resident stated he wasn't feeling very hungry. Observation and interview on 12/31/2025 at 2:25 PM, Resident #1 was lying in bed on his back with the foot of his bed by the window and the bed linen was clean. A dead fly was observed on the window ledge. The surveyor asked Resident #1 if he was aware of any bugs in his bed or wounds, he responded oh yeah, that happened but it was my fault. When asked further probing questions, Resident #1 stated he didn't want to talk about it. In an interview on 12/31/2025 at 1:50 PM, CNA I stated he took care of Resident #1 on 12/24/2025, he asked Resident #1 at the start of his shift if he could provide incontinent care and the resident said no so the CNA told LVN E who said to try again later. The CNA said later Resident #1 turned on his call light and wanted the charge nurse, the CNA informed LVNA E who said she would talk to Resident #1. CNA I stated sometime after breakfast but before lunch, LVN E told the CNA Resident #1 needed to be cleaned up because the resident was very dirty. CNA I said 2 other CNAs assisted with providing a bed bath to Resident #1. CNA I said he saw maggots in the bed and around upper part of Resident #1's leg. In a further interview on 01/04/2026 at 10:17 AM, CNA I stated if Resident #1 refused care, he would tell the nurse; then 10 to 15 minutes later he would ask the resident again to see if the resident was receptive to care and if the resident continued to refuse, he would inform the nurse again. In a telephone interview on 01/01/2026 at 11:58 AM, CNA B reported on 12/24/2025 she was called to Resident #1's room to assist with providing the resident with a bed bath because he refused to be showered. The CNA stated when she had pulled back the bedding and saw maggots in Resident #1's groin area. The CNA stated she and the other CNAs who were in the room had explained to Resident #1 that day that this was why he needed to let the CNAs change him. CNA B stated she would ask Resident #1 if he needed to be changed and he would tell the CNA to leave him alone or he would state he was fine. In a further interview on 01/02/2026 at 2:42 PM, CNA B stated when Resident #1 would refuse incontinent care or a shower, she would try to pursued the resident several times to let her provide care, and if he continued to refuse, she would inform the nurse. In an interview on 01/01/2026 at 1:55 PM, CNA C stated when she was assisting with providing Resident #1 a bed bath on 12/24/2025 because he was soiled, she saw maggots on the resident and in his feces. In an interview on 01/02/2026 at 2:48 PM, LVN E stated on 12/24/2025 Resident #1 called her into his room around 9:30 AM to talk to her. The resident requested her to wash his hand which she did, then he pointed down to his incontinent brief and asked her to look at something. When she did, LVN E said she saw the resident had stool (feces) in his brief and there appeared to be maggots in the fecal material. LVN A came into the room, they explained to the resident the situation needed to be taken care of. Resident #1 wanted to be cleaned up later in the evening. LVN E said she gave Resident #1 options of taking a pain pill, waiting 30 minutes, then letting staff provide a bed bath but the resident agreed to have the bed bath done first, then the nurse could administer the pain medication. LVN E stated when the CNAs have informed her Resident #1 refused care, she would talk with the resident. Sometimes when she does this, he will become upset and ask to be left alone. Other times he would say maybe later, then when she goes back he would say the same thing and would keep putting off the care. In an interview on 01/01/2026 at 6:13 PM, LVN A stated on 12/24/2025 she had just walked into the facility when she was asked to speak to Resident #1 about trying to convince him to be showered or given a bed bath. Resident #1 had a very large bowel movement and had been refusing care days prior. LVN A asked him if they could provide care and Resident #1 said no, but agreed to a bed bath after conversing with him. LVN A said when Resident #1 was turned to the side and was wiped, she saw bugs (maggots). In a telephone interview on 01/01/2026 at 1:00 PM, the Wound Care NP stated Resident #1 used to agree to let her see his skin weekly and would only refuse once out of every 30 times, but now he refuses care every time which the facility would notify her about. The Wound Care NP stated she was notified about the maggots found in the wound. The Wound Care NP stated she tried to see Resident #1's wound after the maggots were found on her next visit, but Resident #1 refused, so she continued with the order that was previously in place because she couldn't change the order without seeing the wound first to assess what treatment would be appropriate. The Wound Care NP stated the last time Resident #1 allowed her to see his wound was on 11/20/2025. In a telephone interview on 01/02/2026 at 1:15 PM, Resident #1's Physician A stated he had been the resident's physician for several months, he was notified of the resident's refusal of care. Physician A stated he had even tried to bribe Resident #1 to get staff to bathe/shower him but it didn't work Physician A stated he was notified of the bugs in Resident #1's wound, he recommended wound care services and for the room to be fumigated. In an interview on 01/01/2026 at 6:31 PM, the DON stated it was brought to her attention Resident #1 had maggots in his wound when he was given a bed bath on 12/24/2025. In an interview on 01/01/2026 at 5:15 PM, the Administrator stated she came into the facility 12/24/2025, was informed Resident #1 had been refusing for days to let staff provide incontinent care or wound care and when they changed him that day, they found insects on him. The Administrator stated Resident #1's Physician A was notified along with Physician A's NP and the Wound Care NP. In an interview on 01/02/2026 from 5:43 PM to 6:24 PM the DON said Resident #1's care plan for the stage 3 pressure ulcer was revised on 01/01/2026 and she did not know why it was not created after his wound reopened. The DON stated residents' care plans were revised when there were changes to a resident's care. In an interview on 01/03/2026 from 4:00 PM to 4:25 PM, the Administrator said the harm that could result in a resident's care plan not being revised in a timely manner was that the other staff would not know what to implement for the resident. In an interview on 01/03/2026 from 5:31 PM to 5:36 PM, the DON stated the harm that could happen from a resident's care plan not being revised or reviewed in a timely manner was the resident might not get the care that was in their plan. In an interview on 01/03/2026 from 5:46 PM to 5:57 PM, the MDS Nurse stated resident's care plans were reviewed quarterly unless there is a change in the resident. The MDS Nurse said Resident #1's care plan for the stage 3 pressure ulcer on his left buttock was revised on 12/31/2025 and the resident had a history of refusing showers, incontinent care and wound care. The MDS Nurse stated the care plan was where staff could see what should be done for a resident and if their care was not updated on the care plan, they might miss an action in providing care to the resident. In an interview on 01/04/2026 at 11:36 AM, the Corporate Clinical Specialist stated Resident #1's care plan for the stage 3 pressure ulcer was created and revised on 12/31/2025 and the initiation date of 11/20/2025 was chosen because that was when the wound was staged. Record review of the facility's policy Care Plans, Comprehensive Person-Centered, reviewed 06/02/2025 revealed A comprehensive, person-centered care plan that incudes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. An IJ was identified on 01/02/2026. The template was provided to the Administrator on 01/02/2026 at 9:13 PM. The following Plan of Removal submitted by the facility was accepted on 01/03/2026 at 2:45 PM and indicated the following: Plan of Removal 1/2/2026F656Immediate ActionsUpon identification of the deficient practice, Resident #l's care plan was immediately updated to address:Refusal of skin assessmentsRefusal of wound treatmentAssociated risks related to pressure injury deterioration and infectionThe updated care plan includes person-centered, measurable interventions addressing refusal management, education, monitoring, and escalation.Nursing leadership reviewed the updated care plan with staff to ensure awareness and implementation. Systemic ChangesThe DON or designee conducted in-service education for licensed nurses on 01/02/2026 on the following:l)Requirements for person-centered care planning under F656Incorporating care refusals into care plans when refusals impact medical or nursing needsEnsuring care plans include measurable objectives, timeframes, and specific interventionsThe DON or designee conducted in-service education on 01/02/2026 for licensed nurses and CNAs on:l)Proper management and documentation of refusal of skin assessments and wound treatmentRequired escalation and notification when refusals place a resident at riskBalancing resident rights with professional standards of care and safetyOn 01/02/2026 a care plan review process was reinforced requiring care plans to be updated when:Refusals of treatment or assessment are ongoingA resident's clinical condition changesIdentified risks increase due to refusal behavior No staff will be able to work until education and competency is completed.All education will be incorporated into new hire on-boarding by Administrator on01/02/2026.Process When a Refusal Occurs: When a resident refuses an assessment or treatment, the refusal is immediately communicated through the chain of care:CNAs notify the licensed nurse caring for the resident.The licensed nurse (RN/LVN) assesses the situation, provides education to the resident regarding risks of refusal, documents the refusal, and notifies the charge nurse and DON or designee when refusals involve assessment, wound care, or other high-risk treatments.The physician is notified when refusals impact the ability to assess or treat a condition requiring medical oversight. Responsibility for Updating the Care Plan: The licensed nurse, in collaboration with the interdisciplinary team, is responsible for initiating updates to the care plan when refusals are ongoing or impact medical, nursing, or psychosocial needs. The DON or designee provides oversight to ensure updates are completed timely and implemented. Continuity of the Process: Yes. This is a continuous process. Care plans are updated as long as refusals persist or risks remain, and are revised based on changes in the resident's condition, response, or acceptance of care. Monitoring of Updates: The DON or designee monitors care plan updates through routine audits and clinical oversight, including review of documentation related to refusals, care plan accuracy, and staff implementation. Staff Training on Refusals: Education on refusal of care has been provided to all direct care staff, including licensed nurses and CNAs. Training addresses identification of refusals, required reporting, documentation, escalation, and implementation of person*centered interventions.Monitoring and QA:The DON or designee will conduct weekly audits for four (4) weeks, then monthly thereafter, of:1} Residents with pressure injuries2} Residents with documented refusals of careAudits will verify:Refusals are reflected in the care planCare plans include measurable objectives and interventionsStaff are implementing care plan interventions as writtenAudit results will be reviewed through the QAPI process, and corrective actions will be implemented as indicated. The facility's Plan of Removal verification was as follows: Record review of Resident #1's care plans revealed a new care plan, created on 01/01/2026 for Noncompliance with plan of care r/t [related to] skin integrity due to refusal of splints or devices for contracture management, refusal to allow staff to turn and reposition frequently, refusal to all use of offloading devices such as cushions, pillows, mattress, boots, refusal to change clothing, refusal to elevate legs, refusal to receive incontinent care timely or at all, refusal to shower or bathe, resident refusing meals/alternates, resident refusing prescribed treatment regimen, resident refusing weekly wound assessments , staying in bed for extended periods of time/refusing position changes, weekly skin checks: resident refusing weekly skin checks, was initiated on 01/01/2026 by the DON. Interventions listed included: Actively listen to the resident's reasons for refusing care and address any anxiety or fears they might have about the process. Determine if pain is a factor of resident refusal and notify MD as appropriate. Discuss with resident what they would be willing to allow and notify physician. Encourage resident compliance. Ensure resident understands their specific plan of care. Educate on why certain supplies are used and why techniques are important to prevent infection. Explore pain management strategies to minimize discomfort during wound care/dressing changes to potentially improve the resident's willingness to cooperate. If resident refuses treatment, offer to come back at a later time in the day. Involve other healthcare professionals, family members, care givers to support the resident's understanding and compliance. Notify MD of any identified wound worsening or development of any new wounds. Refer to dietitian to ensure resident is receiving appropriate nutrition to help promote healthy skin as needed. Refer to Wound Care Physician as applicable/needed. See also actual wound care plans. Supplements as ordered to promote healthy skin and aid in wound healing. Record review of Resident #1's Social Service note, dated 01/01/2026, revealed the Social Worker, DON, Activity Director and Dietary Manager meet with the resident to discuss care in an IDT meeting. The resident's care plan was reviewed with the resident. Record review of an unda

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 1 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his left stage 3 buttock wound on 12/24/25. An IJ was identified on 1/1/26. The IJ template was provided to the facility on 1/1/26 at 8:25 p.m. While the IJ was removed on 1/3/26 at 7:24 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. The failure could place residents with wounds at risk for infection or infestations from pests. The findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses that included: seizures (abnormal release of electrical activity in the brain), type 2 diabetes mellitus with hyperglycemia (a condition resulting from insufficient production of insulin, causing high blood sugar), and hemiplegia and hemiparesis (complete paralysis to one side and weakness to one side of the body). Record review of Resident#1's MDS, dated [DATE], reflected a BIMS score of 12, indicative of moderate impairment in cognition. The ADLs for: B/B bowel was always incontinent. Transfer was not applicable; and bed mobility substantial assistance. Mobility devices were listed as non-used. Range of motion was documented as an impairment on one side to upper and lower extremities. Record review of Resident #1's clinical record revealed on 10/26/25 a CNA reported the wound on the resident's bottom reopened, but the resident declined to let the nurse see the wounds. Record review of Resident #1's wound progress note completed on 11/20/2025 written by the NP reflected a left buttock pressure ulcer/injury with measurements of 4 cm x 5 cm x 0.2 cm stage 3, 40% slough (puss) and moderate amount of serosanguinous (mix of blood and serum). Record review of Resident #1's wound assessment report dated 11/20/2025 and signed 11/21/2025 by the NP revealed a reopened wound of the left buttock reflected the following measurements: 4.0 Length by 5.0 Width by 0.20 Depth. Record review of Resident #1's care plan provided on 1/1/26 recorded a focus area for the following: I have a Stage 3 pressure injury/ulcer #18 Rt Buttock r/t Immobility, Refusal of Care initiated on 11/20/25, with interventions including Administer treatments as ordered and monitor for effectiveness initiated on 11/20/2025. Record review of Resident #1's NP's orders dated 11/28/25, read: Wound care to left buttock: cleanse with dakins 0.25%, pat dry, collagen with silver, and cover with silicone bordered superabsorbent dressing. Record review of pest control documents revealed a list of facilities receiving pest control services that included the facility with an effective date of 2/7/2021. Record review of the pest control service statement, dated 12/16/2025, revealed, Met with DON, she reported no issues. Kitchen manager said she's seen some roaches by the drains. During interview on 1/1/26 at 11:58 a.m. CNA B stated on 12/24/25 a nurse told her that Resident #1 needed to be changed, he smelled, and maggots were found in his groin area. CNA B stated when she got in Resident #1's room, after following EBP protocols, preparing to give Resident #1 a bed bath, she pulled down his covers and saw maggots in Resident #1's groin area. CNA B stated after witnessing the maggots she then was moved up to Resident #1's head to wash his hair. During interview on 1/1/26 at 1:55 p.m., CNA D stated on 12/24/25 while giving Resident #1 a bed bath they saw maggots on Resident #1 and in their feces. CNA D stated after seeing the maggots she still proceeded to give Resident #1 a bed bath. Observation on 1/1/26 at 2:40 p.m., revealed a dead fly on the window ledge in Resident #1's room. Observation on 1/1/26 at 3:00 p.m., of the area outside the exit door on hallway 300 revealed a box, with one side cut out, a blanket, and what appeared to be a bowl with some sort of food in it. Observation on 1/1/26 at 3:01 p.m., of the exit door on hallway 300 revealed the bottom of the door not reaching the floor allowing for a gap between the floor and bottom of the door. Observation on 01/01/2026 at 4:13 p.m., of Resident # 1's room revealed a small black electronic item on the resident's overhead light. The appliance had a hollow round circle with a UV colored light. Interview on 1/1/26 at 4:13 p.m. Resident #1 stated an insect fan was provided around the time insects were identified in his wound. Resident #1 stated prior to having the insect fan he had an issue with files in his room. He stated he notified several staff members of the files in his room including the DON and Administrator. Observation on 1/1/26 at 4:50 p.m. of the facility's windows revealed more than 3 screens missing or ill-fitting on each hall, 1 window in the lobby with no screen and opened approximately a quarter of an inch, and 1 window on the 400 hall with a torn screen and open approximately 3 inches. During interview on 1/1/26 at 5:15 p.m., the Administrator stated she had only one report of a pest in the past month which was in the therapy room. The administrator confirmed the torn screens, missing screens, and opened windows and stated that it could possibly allow for small pests to enter the facility. The administrator stated flies were treated by fly lights, insect fans and window screens and that pest control comes once a month or by special visit if requested by the facility. When asked about what appeared to be food in a bowl outside of the exit door on the 300 hall the administrator stated she had no idea what it was and when it got there. The administrator stated pest control was not notified of the maggots on 12/24/2025. When asked what harm could come to a resident who was exposed to pests the administrator stated she would have to ask the nursing staff. During an interview on 1/1/26 at 5:56 p.m., the Administrator confirmed the last time pest control came out to treat the facility was 12/16/2025. During an interview on 1/1/26 at 6:13 p.m., LVN B stated they had not heard any concerns regarding flies from residents since being hired. LVN B stated as she entered the facility on 12/24/25 the nursing staff approached her and asked her to speak to Resident #1 regarding bathing. LVN B stated the resident approved of a bed bath and while the CNAs were turning Resident #1 to the side she saw bugs. When asked what harm could come to a resident who was exposed to pests LVN B stated it could be an infection control problem and could make the residents sick. During an interview on 1/1/26 at 6:21 p.m., the DON stated she had not heard any concerns regarding flies in the past 90 days. The DON stated she was informed that Resident #1 had maggots in his wound by LVN B but did not witness any bugs herself. When asked what harm could come to a resident who was exposed to pests the DON stated they could get sick or an infection depending on what insect they were exposed to. Record review of facility's Pest Control policy dated revised May 2008 read, .Our facility shall maintain an effective pest control program 3. Windows are screened at all times. This was determined to be an Immediate Jeopardy (IJ) on 1/1/26 at 8:18 p.m. The Administrator was notified of the IJ and provided the IJ Template on 1/1/26 at 8:25 p.m. Observation on 1/2/26 at 9:50 a.m., of the kitchen and kitchen prep area revealed a dead roach in the cabinet that was under the 2-compartment sink by the microwave. During an interview on 1/2/26 at 9:51 a.m., the [NAME] stated the only insects he had seen was maybe just a fly last week, and the pest control guy did a round last week in the kitchen. Observation on 1/2/26 at 10:57 a.m. of the outside exit door at the end of the 300 hallway revealed it did not have a flying insect trap. During an interview on 1/2/26 at 11:25 a.m., the Maintenance Director stated the facility was treated monthly for pest control which included treating the building for insects such as ants, flies, roaches, scorpions. The Maintenance Director stated, the pest control company, sends him a text message the day they were going to be in the facility to service the building and if staff saw any insect activity between treatments, they were to put it in the pest control logbook that was located behind the nurse's station under the fire extinguisher. Observation on 1/2/26 at 11:29 a.m., of the dining room revealed it had 2 flying insect traps by the 2-exit doors that were in the dining room. Observation on 1/2/26 at 11:29 a.m., of the dining room exit door close to 300 hall where there was an outdoor courtyard between the dining room and 300 hall, the door was left propped open for an outdoor activity while various staff members brought residents out to the outdoor area and back inside. During an interview on 1/2/26 at 11:36 a.m., the activity director stated she was doing an outside activity with the residents so they could get some sunshine and that she was waiting for a CNA to come out and take a resident back in. Observation on 1/2/26 at 11:47 a.m., of the dining room exit door close to 300 hall activity revealed the activity director closing the door to the outside and setting the door alarm which beeped. During an interview on 1/2/26 at 11:49 a.m., the activity director stated she left the door open to the outdoor courtyard so residents could be brought outside and that she usually closes it and can open the door from the outside but sometimes it catches so she has to knock on the window for someone to let her into the building. Observation on 1/2/26 at 11:56 a.m., of the exit door at the end of 400 hall revealed not having a flying insect trap by the door. Observation on 1/2/26 at 12:00 p.m., of exit door at the end of 100 hall by the therapy department revealed it not having a flying insect trap by the door. During an interview on 1/2/26 at 2:28 p.m., CNA D stated they currently saw flies in the building because the facility has been doing construction on the halls, and the doors have been open. The plan of removal was accepted 1/2/26 at 3:31pm. During an interview on 1/3/26 at 12:36 p.m., the administrator stated the vendor who would be replacing the window screens would start installing them on 1/6/26 and would have all the window screens that needed to be replaced installed on 1/7/26. The administrator stated there were about 42 window screens that had to be replaced, and the vender removed any screen that was bent from the window because those screens had to be replaced and could not be repaired. During an interview 1/3/26 at 2:21 p.m., the maintenance director stated he had not seen any flies recently. The maintenance director stated he was to contact the pest control company anytime pests were seen and was to conduct walks around the facility every day to check for anything that needs to be repaired. During an interview on 1/3/26 at 3:35 p.m., Resident #1 stated he had the pest control device since Christmas and it was to kill pests that were in his room. It was documented as follows: Facility: Tag: F925 - Pest Control IJ Identified: 1/1/26 Resident: #1 Immediate Actions On 12/24/25, upon identification of maggots in Resident #1's left buttock stage 3 pressure injury, nursing staff immediately cleansed the wound, removed all visible insects, and applied a clean, secure dressing. The attending physician was notified and wound care orders were reviewed and implemented by DON on 12/24/2025. Resident #1 was assessed for signs of infection and discomfort and monitored per nursing protocol by DON/Designee on 12/24/25. An insect fan was placed in the resident's room to reduce fly exposure by DON/Designee on 12/26/2025. Emergency pest control services were contacted by Administrator on 1/1/2026 to provide additional services. Pest control services confirmed appointment 1/2/2026. On 1/1 /26, the Administrator and Maintenance Director conducted a facility-wide inspection. All missing, torn, or ill-fitting window screens were repaired, replaced, or secured by maintenance/ designee on 1/1/2026. DON/Nursing Admin conducted a visual assessment of all residents with wounds to ensure free of pests on 1/1/2026. On 1/1/2026, the Administrator notified Medical Director of Immediate Jeopardy. Systemic Action Regional Director of Operations in-serviced Administrator and DON on 1/1/2026 on the following: Prompt reporting of insects, or environmental concerns, updating pest controllog to reflect any issues noted, maintaining screened and closed windows, Monitoring wounds for contamination risks, Pest control policy and emphasizing that windows must remain screened, to include prompt follow up on addressing resident complaint. A quiz will be conducted post education to determine competency in the education material.Staff will not be able to work until quiz is passed with a grade of 100. All staff received immediate education 1 /1/26 by Administrator/Designee on: Prompt reporting of insects or environmental concerns, maintaining screened and closed windows, Monitoring wounds for contamination risks, Pest control policy and emphasizing that windows must remain screened. A quiz will be conducted post education to determine competency in the education material. Staff will not be able to work until quiz is passed with a grade of 100. No staff will be able to work until education and competency is completed. All education will be incorporated into new hire on-boarding by Administrator on 1/1/26. Monitoring Maintenance will complete weekly documented inspections of all windows and screens. Deficiencies will be corrected immediately, or the window taken out of service. Routine pest control services will continue as scheduled. Pest control logs will be reviewed weekly by the Administrator or designee. Any evidence of insect activity will trigger immediate treatment including prompt assessment, wound protection, removal of insects, physician notification as needed, and immediate environmental and pest control interventions at the time insect activity is identified. DON/designee will conduct weekly audits of residents with open wounds to ensure wounds are clean, covered, and free from environmental exposure. Findings will be documented and reviewed through QA/QAPI. The Administrator and DON will conduct weekly environmental rounds for 30 days to verify sustained compliance. The facility's POR verification was as follows: Record review of Resident #1's Weekly Wound Observation form, dated 12/24/25, revealed the wound on his left buttock was acquired on 11/20/25, was a stage 3 Pressure Injury and measured 6.0 cm x 3.5 cm x 2.0 cm, there was no odor to the wound and did not show any signs of a wound infection. Record review of Resident #1's physician orders revealed his physician ordered wound care to left buttock; cleanse with dakins 0.25%, pat dry, collagen with silver, and cover with silicon bordered superabsorbent dressing every night shift and when loose or soiled. Record review of Resident #1's nurse's notes dated 12/24/25 revealed the resident's wound was assessed by the DON. Record review of an undated employee list revealed the facility had 84 employees. Record review of an In-Service Attendance signature page for the topic of Pest Control presented 1/1/2026, Environmental Safely and Wound Protection revealed 84 employees had received in-service training in person or via telephone. Review of the attached training content revealed staff were responsible for observing and reporting environmental concerns immediately which included flies, maggots, roaches, ants or other insects in resident rooms or common areas, report any open windows or missing/torn/loose window screens. All windows were to remain closed and properly screened at all times. Residents with open wounds were at risk for increased contamination and staff were to report immediately if any insects were observed near or around a wound, and if the dressings were loose, soiled or compromised. A copy of the quiz given to employees was attached, which included 9 questions that covered the in-services they received. Record review of the quiz provided to employees revealed 84 employees had completed the quiz, the quiz was checked by the DON and ADON, and all employees scored 100%. Record review of the in-service training presented to the Administrator and DON on 1/1/2026 by the Regional Director of Operations revealed they were in-serviced on ensuring prompt reporting and follow-up of insect or environmental concerns, maintain oversite to ensure all windows remain closed and properly screened, ensure residents with wounds are protected from contamination risks, enforce pest control policy requirements, and ensure resident complaints are promptly addressed, investigated and resolved. The Administrator and DON were provided with a quiz on the in-service and both passed with 100% accuracy. Record review of the wound monitoring log revealed 6 residents with open wounds were monitored on 1/1/26 by the DON with no signs of insect activity. Record review of the Bid from Window Company A, dated 1/2/26, revealed 13 window screens would be replaced, and 37 screens would be repaired and rescreened. Record review of the Weekly Window & Screen Inspection form dated 1/1/26 listed every window in the facility; the screens were inspected with 7 window screens temporarily repaired. The Window Screen Inspection form dated 1/2/26 noted there were 37 screens that had been un-bended or would be rescreened. Record review of the undated QAPI Meeting log, revealed a QAPI meeting was held on 1/1/26, and future QAPI meetings would be held weekly for 3 months. Record review of the QAPI signature page, dated 1/1/26, revealed the Administrator, DON, Social Worker, Activity Director, BOM, Human Resources, ADON and Housekeeping Director attended the meeting that was held at 9 PM on 1/1/26. Record review of an email dated 1/1/26 from the Administrator to Pest Control Company A, was sent at 5:59 PM, requesting a technician to service the facility for an emergency visit as soon as possible. Record review of an invoice dated 1/2/26 from Pest Control Company A revealed Technician D came to the facility at 5 PM to service the building for flies. The report noted the technician met with the DON who reported a fly was found in room [ROOM NUMBER]. The technician was escorted to the room and performed a fly wipe down treatment throughout the room and bathroom. A fly wipe down was performed throughout the rest of the facility treating all hallways, doorways, nurses' station, kitchen, dining and all common areas. A liquid bait was applied in and around the dumpsters, and doorways. Record review of the undated Pest Control monitoring form, revealed the Administrator reviewed the pest control log for the week on 1/1/26, verified the Pest Control Company A Technician D had signed the log when he was in the facility to show he had reviewed the log. Record review of the undated Pest Log that was kept in the Pest Control binder, revealed Pest Control Company A Technician D had signed the log on 12/13/25 and 1/2/26. Record review of the Life Satisfaction Rounds, completed on 1/2/26, revealed all 58 residents of the facility were asked if they had any concerns or experienced any flies in their room and who would they tell if they noticed pest control issues. Residents who were non-verbal or could not answer the questions, staff had verified there were no pests in their room. In a telephone interview on 1/1/26 at 1:15 PM, the Medical Director stated he had been informed of the maggots that were in Resident #1's wound, recommended the wound care practitioner look at the resident's wound and to fumigate the resident's room. In an interview on 1/3/26 at 10:49 AM, the DON stated she and the ADON had reviewed the quiz the employees took, and all employees had passed the quiz the first time they took it. In an interview on 1/3/26 at 12:36 PM, the Administrator stated the vendor who was replacing the torn, bent, and missing window screens would install them on 1/6/26 and 1/7/26. The Administrator stated there were about 42 window screens that had to be replaced because they were bent, and the bent screens were removed from the window by the vendor on 1/2/26. In a telephone interview on 1/3/26 at 2:21 PM, the Maintenance Director stated the facility had been inspected for flies and all the window screens were checked to determine if they were missing or needed to be replaced. He said windows that had the screen removed because it was broken were covered with a screen mesh that was taped to the windows. The Maintenance Director stated he would check the Pest Control log book weekly to see if there were any new entries for signs of pest, and if so, he would contact the pest control company to come and service the facility. Interviews on 1/3/26 from 11:43 AM to 4:15 PM with 23 employees (2 housekeepers, 1 Laundry, Housekeeper Supervisor, Activity Director, Social Worker, Dietary Manager, Cook, 2 Dietary Aides, 2 LVN, 4 CNAs, 2 RNs, 1 MDS Nurse) which included 4 night shift employees (1 RN, 2 CNAs, 1 LVN) revealed they had been in-serviced on prompt reporting of insects or environmental concerns, maintaining screened and closed windows, Monitoring wounds for contamination risks, Pest control policy and emphasizing that windows must remain screened. All employees stated they were given a quiz on the topics they were in-serviced on. In a telephone interview on 1/3/26 at 5:10 PM, the RDO stated she had in-serviced the DON and Administrator on the regulations, the policy and procedures for pest control, reporting insects and environmental concerns was the responsibility of all the staff; she reviewed the in-service that would be presented to the employees, if the windows had screens that were torn would be replaced and to make sure the screens that were in place were secured. In an interview on 1/3/26 from 6:00 PM to 6:20 PM, the Administrator stated that Resident #1 was bathed, received wound care, his bed was cleaned and sanitized, his physician was notified, the wound care NP was notified, she bought a fly light that was placed in his room, they cleaned his room but the resident refused to let staff do a deep cleaning of his room. The nursing staff were monitoring Resident #1's wound for infection along with his vital signs. The Administrator said the pest control company was contacted on 1/1/26 with an email request and they were in the facility on 1/2/26 to treat the building and Resident #1's room. The Administrator said she reviewed all the window screens; screens that were out of place were put back in place. On 1/2/26 a window repair company representative looked at the screens on the windows and removed any screen that was bent so it could be repaired. The Administrator said window where the screens were removed were covered with a mesh material that was taped to the window that she is checking twice a day to make sure the tape is secured. The Administrator said the DON reviewed all the residents with open wound, and the wound NP would be reviewing the residents' wounds weekly in addition to the facility nurses. The Administrator stated she and the DON were trained by the Regional Director of Operations to take all resident complaints and escalate them as appropriate, look at the root cause, inform the resident what the solution would be. The Administrator said all the staff have been trained on reporting pest to the charge nurse or administrator, report any pest seen or reported by a resident so it could be recorded in the pest control log book so the pest control company can be contacted to treat the facility. The Administrator stated she and the Maintenance Director would do daily environmental rounds of the facility. Observation and interview on 1/3/26 at 3:35 PM in Resident #1's room revealed on top of the overbed light was a black pest control device that emitted a purple light. Resident #1 stated it was to kill pests that were in his room, and he had it since Christmas. Observation on 1/3/26 from 4:35 PM to 4:44 PM of the facility windows from the outside of the building revealed there were 46 windows covered with a window mesh screen that was taped to the window until the original window screen could be replaced or repaired. On 1/03/2026 at 7:33 PM, the Administrator was notified the IJ was removed on 1/3/26 at 7:24 PM. However, the facility remained out of compliance at a scope of isolated and severity of actual harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #8) reviewed for infection control in that: LVN J did not wear a gown when providing direct care to Resident #8 who had a tracheotomy and was on enhanced barrier precautions (EBP). This failure could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #8's undated face sheet revealed Resident #8 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (complete lack of oxygen to the brain leading to brain damage), dementia (a general term for impaired ability to remember, think, or make decisions) and tracheostomy status (surgical procedure that creates an opening through the neck into the windpipe that helps maintain an airway for a person who has difficulty breathing). Record review of Resident #8's quarterly MDS assessment, dated 09/23/2025, revealed Resident #8 had severely impaired cognitive skills for daily decision making. Section GG - Functional Abilities revealed Resident #8 had impaired upper and lower extremities and was dependent on staff for all ADL's and bed mobility. Section H - Bladder and Bowel revealed Resident #8 had an indwelling catheter. Section K - Swallowing/Nutritional Status revealed Resident #8 had a feeding tube for nutrition. Section O- Special Treatments, Procedures, and Programs, revealed Resident #8 received tracheostomy care and received oxygen therapy and suctioning. Record review of Resident #8's December 2025 treatment and medication administration orders revealed an order, enhanced barrier precautions (EBP) every shift, order date 06/18/2025. Resident #8 had an order, change trach ties every day and prn soiling every shift daily and prn, order date 06/17/2025. Record review of Resident #8's undated comprehensive care plan revealed a care plan, [Resident] has a tracheostomy, date initiated 03/03/2025 and revised 06/27/2025. Resident #8 had a care plan that revealed, Resident requires enhanced barrier precautions r/t feeding tube, tracheostomy, date initiated 03/03/2025. During an observation on 12/31/2025 at 9:37 a.m., Resident #8's room door had a sign beside the entry to the room that revealed Resident #8 was on enhanced barrier precautions and had a PPE supply cart outside of the room door. LVN J was observed entering Resident #8's room for tracheotomy care. LVN J donned gloves and proceeded to remove Resident #8's oxygen mask over Resident #8's tracheostomy and then attached a new oxygen mask to Resident #8's tracheostomy. LVN J was observed not wearing a gown during the tracheostomy care. During an interview with LVN J on, 12/31/2025 at 9:45 a.m., LVN J stated residents who had a foley catheter, and infections or trachs like her were on enhanced barrier precautions. LVN J stated residents on enhanced barrier precautions were identified by a sign outside of their doorway that revealed the resident was on enhanced barrier precautions. LVN J stated, when caring for a resident on enhanced barrier precautions, staff were supposed to wear gloves and maybe, it depends, sometimes gowns. LVN J stated Resident #8 was on enhanced barrier precautions for her tracheostomy and she did not think she needed to wear a gown for tracheostomy care. LVN J stated she had received training on enhanced barrier precautions and stated it was important to use enhanced barrier precautions, so we don't get extra bacteria into a resident who is immune compromised and stated, more infections could happen to the resident. During an interview with the DON on, 12/31/2025 at 2:40 p.m., the DON stated residents who had indwelling devices such as tracheostomies would have been on enhanced barrier precautions and stated staff would have worn a gown and gloves when staff provided direct care to residents on enhanced barrier precautions. The DON stated staff had received training on wearing the appropriate PPE for enhance barrier precautions and stated it was important for enhanced barrier precautions to be followed, to prevent MDROs and transferring of MDRO's to patients or staff. Record review of the enhanced barrier precaution sign posted outside of Resident #8's room revealed 2 large stop signs in the top corners and revealed, providers and staff must also: wear gloves and gown for the following High Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. Record review of a facility policy titled, Enhanced Barrier Precautions (Enhanced Barrier Precautions EBP Policy and Procedure 4/1/2024; Reviewed 3/19/2025, Reviewed 06/20/25), revealed, 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities and EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Based on observation, interview, and record review the facility failed to ensure personal privacy for 1 of 6 residents (Resident #8) reviewed for privacy, in that: LVN J provided tracheostomy care for Resident #8 with the resident room door open, curtain separating A and B bed open and window blinds open. This failure could affect residents receiving tracheotomy care by resulting in loss of dignity and low self-esteem. The findings were: Record review of Resident #8's undated face sheet revealed Resident #8 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (complete lack of oxygen to the brain leading to brain damage), dementia (a general term for impaired ability to remember, think, or make decisions) and tracheostomy status (surgical procedure that creates an opening through the neck into the windpipe that helps maintain an airway for a person who has difficulty breathing). Record review of Resident #8's quarterly MDS assessment, dated 09/23/2025, revealed Resident #8 had severely impaired cognitive skills for daily decision making. Section GG - Functional Abilities revealed Resident #8 had impaired upper and lower extremities and was dependent on staff for all ADL's and bed mobility. Section H - Bladder and Bowel revealed Resident #8 had an indwelling catheter. Section K - Swallowing/Nutritional Status revealed Resident #8 had a feeding tube for nutrition. Section O- Special Treatments, Procedures, and Programs, revealed Resident #8 received tracheostomy care and received oxygen therapy and suctioning. Record review of Resident #8's December 2025 treatment and medication administration orders revealed an order, change trach ties every day and prn soiling every shift daily and prn, order date 06/17/2025. During an observation on, 12/31/2025 at 9:37 a.m., LVN J was observed providing tracheostomy care to Resident #8 without closing Resident #8's room door, curtain or blinds to provide Resident #8 privacy and dignity during care. During an interview with LVN J, 12/31/2025 at 9:45 a.m., LVN J stated she had received training on resident privacy, and she should have closed Resident #8's room door and pulled the privacy curtain when LVN J provided tracheostomy care to Resident #8. LVN J stated it was important to provide a resident privacy when care was performed, for their dignity. During an interview with the DON on, 12/31/2025 at 2:40 p.m. the DON said staff members should pull the privacy curtains and close a resident's room door when any resident care was provided including tracheostomy care. The DON stated staff had received training on resident privacy and stated privacy was important, for the resident dignity. Record review of a facility policy titled, Resident Rights (Federal) (Edit 12.19.23; 1.11.24), revealed, Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. Facility must protect and promote the rights of each resident, including each of the following rights: 1. Exercise of rights. E. Resident has the right to be treated with dignity and respect for the personal integrity of the individual.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1. The facility failed to ensure a case of cinnamon rolls was properly sealed in the reach-in freezer. 2. The facility failed to ensure the interior of the ice machine in the kitchen was free of dirt and debris. 3. The facility failed to ensure opened bags of graham cracker crumbs, cookie pieces, cake mix and frosting mix were sealed in the dry storage room [ROOM NUMBER]. The facility failed to ensure opened bag of snacks and cookies were sealed in the kitchen. 5. The facility failed to record the chemical sanitizing solution concentrations of the dish machine on the log sheet in the dish room. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 08/26/2025 at 10:44 AM revealed one 28-lb. case of mini cinnamon rolls in a chest freezer in the middle of the kitchen. The case was open and the bag inside the case was open, exposing the contents to the ambient air in the freezer and potential exposure to cross contamination and deterioration in quality. During an interview on 08/26/2025 at 10:44 AM, the DM stated the case of cinnamon rolls should have been sealed. It was the responsibility of all dietary staff to ensure products stored in the freezer were properly sealed, labeled and dated. 2. Observation on 08/26/2025 at 10:45 AM of the ice machine in the kitchen revealed there were black spots on the surface of the interior white bin liner of the machine that might indicate the presence of mold, based on location and environmental conditions. During an interview 08/26/2025 at 10:47 AM, the DM stated there were black spots on the surface of the interior white bin liner and there should not have been. The DM further stated that the machine was cleaned monthly or as needed by dietary staff, and all staff was trained on how to clean the machine. 3. Observation on 08/26/2025 at 10:48 AM in the dry storage room revealed: a) One bag of graham cracker crumbs stored in a clear plastic bag tied at the top in a half knot with a piece of plastic wrap b) One opened bag of sandwich cookie crumbs, stored in the original bag, tied at the top in a half knot with a piece of plastic wrap c) One opened 5 lb. paper bag of cherry cake mix with approximately 1/3 left in the bag, rolled down and stuffed inside a zipper-lock bag with approximately 1/3 of the cake mix bag protruding outside the zipper-lock bag d) One opened 4.5 lb. paper bag of white frosting, rolled down, not sealed in a zipper-locked bag or storage container. During an interview on 08/26/2025 at 10:49 AM, the DM stated the graham cracker crumbs, cookie crumbs, cake mix and frosting should have all been stored in sealed bags or storage containers to prevent potential contamination from rodents and pests. All dietary staff storing food in the dry storage room were trained on how to properly store food in the dry storage room upon hire and from in-services throughout the year. 4. Observation on 08/26/2025 at 10:55 AM in the kitchen revealed one 9-oz. bag of cheese flavored snacks and one bag, size unknown, of cookies resembling vanilla wafers on a shelf above the preparation table. Both bags had been opened with approximately half the product used in each bag and both bags were rolled down and closed with a binder clip.During an interview on 08/26/2025 at 10:56 AM, the DM stated the bags of snacks and cookies should have been stored in sealed bags or storage containers to prevent contamination and product deterioration. 5. Observation on 08/26/2025 at 10:58 AM in the dish room revealed the facility used a chemical sanitizing, door-type dishwasher. Record review of the Dish Machine Temperature Log Sheet for August 2025 hanging on a clipboard in the dish room revealed the facility recorded only the temperatures of the machine during the wash and rinse cycles two times a day, for breakfast and lunch. There was no documentation indicating the level of chemical sanitizer solution strength of the machine for any day to ensure it was the proper concentration.Observation on 08/26/2025 at 11:05 AM revealed [NAME] A tested the chlorine level of the water in the dish machine by placing a chlorine test strip in the water. The color of the strip changed to dark lavender, indicating a chlorine level between 50-100 ppm when compared to the color chart on the container of the test strips, and was within the acceptable range.During an interview on 08/26/2025 at 11:04 AM, the DM stated the facility tested the concentration of chemical sanitizer in the machine three times a day and should have been using a log with columns to document the concentration level of chemical sanitizer every time it was checked. The DM further stated it was important to monitor the concentration of sanitizer in the machine to prevent potential foodborne illness by properly sanitizing dishes and utensils.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.Record review of the facility policy, Dry Storage, reviewed January 2023, revealed 9. If an item is opened, the food must be tightly sealed.if using large bags to seal open items in their original packaging.bags must be sealed. Record review of the facility policy, Sanitation, revised January 2024, revealed, The food service area shall be maintained in a clean and sanitary manner. I. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302 Preventing food and ingredient contamination. 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the facility policy, Dishwashing Machine Use, dated October 2022, revealed, Food Service staff required to operate the dish washing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. 4. Dish washing machine chemical sanitizer concentrations and contact times will be as follows:Type of Solution Minimum Concentration Contact TimeChlorine 50-100 ppm 10 seconds 5. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM] or mL/L) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log.6. Corrective action will be taken immediately if sanitizer concentrations are too low. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness.A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart. mg/L pH 10 or Less pH 8 or Less25-49 120 degrees F 120 degrees F50-99 100 degrees F 75 degrees F (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 degrees C (75 degrees F), (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, and(3) Be used only in water with 500 MG/L hardness or less or in waterhaving a hardness no greater than specified by the EPA-registered label use instructions4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration.Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 49) reviewed for oxygen in that: The facility failed on 8/26/2025to ensure that Resident #49's nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings included: Record review of Resident #49's face sheet, dated 8/16/25, revealed an [AGE] year old male admitted to facility on 3/1/2025 with the diagnosis that included: Benign Prostatic Hyperplasia ( an enlarged prostate ), Type 2 diabetes ( is a chronic condition where your body either doesn't use insulin properly, leading to high blood sugar levels) and Pleural effusion,(is the buildup of excess fluid in the pleural space between the lungs and chest wall) Record review of Resident #49's Quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated intact cognition Record review of Resident #49's Physician monthly orders dated August 2025 revealed an order start date of 08/17/25: Albuterol Sulfate Inhalation Solution for nebulization 0.5 mg -3mg twice a day for 7 days. Observation on 08/26/24 at 10:50 a.m. revealed that Resident #49's nebulizer tubing was unbagged on the bedside table. In an interview with Resident #49 on 08/26/25, at 11:05 a.m., he stated they only bag the nebulizer tubing at this facility every once in a while, depending on the nurse. In an interview with LVN B on 08/26/25, at 11:38 a.m., LVN B stated she was the assigned nurse for Resident #49. It was revealed that it was every nurse's responsibility to change and bag the nebulizer tubing weekly. However, she did not know why the tubing was not being bagged. LVN B stated Resident # 49 was at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. During an interview with the DON on 08/26/25 at 1:00 p.m., it was revealed that Resident #49 should have had their nebulizer tubing changed and bagged by the nurse administering the nebulizer treatment. The DON mentioned that she needed to determine why the nebulizer tubing was not bagged for Resident #49. The DON also stated that she oversaw this task and assured that she would monitor it for compliance. The DON stressed that Resident #49 was at risk of a possible respiratory infection due to the outdated and unbagged nebulizer tubing. Record review of the facility's policy, Administering Medications through a small-volume hand-held Nebulizer, 2001, revealed When equipment is dry, store in a plastic bag.

Based on observations, interviews, and record reviews, the facility failed to ensure that for a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 12 residents (Residents #49 and #52) reviewed for indwelling catheters and perineal/incontinent care, in that: The facility failed to ensure Resident #49's and Resident #52's indwelling catheter tubing were not attached to leg straps to prevent pulling or tugging on the urethra on 08/26/25. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings included: 1.Record review of Resident #49's face sheet, dated 8/16/25, revealed an [AGE] year old male admitted to facility on 3/1/2025 with the diagnosis that included: Benign Prostatic Hyperplasia ( an enlarged prostate ), Type 2 diabetes (is a chronic condition where your body either doesn't use insulin properly, leading to high blood sugar levels) and Pleural effusion,(is the buildup of excess fluid in the pleural space between the lungs and chest wall) Record review of Resident's #49's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 which indicated intact cognition, and under section H Bowel and Bladder, an indwelling catheter was selected. Record review of Resident #49's care plan, dated 03/03/25, revealed the resident's care plan addressed the resident's urinary catheter with interventions, Check leg strap for placement . Observation on 08/26/25 at 10:48 a.m. revealed that Resident #49 had an indwelling Foley catheter without a leg strap. During an interview with Resident #49 on 08/26/25 at 11:00 a.m., the resident stated, They never give me that thing to keep this from pulling out. 2. Record review of Resident #52's face sheet, dated 8/26/2025, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: Dementia is the loss of cognitive functioning that interferes with a person's daily life and activities. Atrial fibrillation (is an irregular heart rhythm), and Benign Prostatic Hyperplasia (an enlarged prostate). Record review of Resident's #52's Quarterly MDS, dated [DATE], revealed a BIMS score of 04 which indicated moderate cognitive impairment, and under section H Bowel and Bladder, an indwelling catheter was selected. Record review of Resident #52's care plan, dated 04/24/25, revealed the resident's care plan addressed the resident's urinary catheter with interventions, Check leg strap for placement . Observation on 08/26/25 at 11:10 a.m. revealed that Resident #52 had an indwelling Foley catheter without a leg strap. During an interview with Resident #52 on 08/26/25 at 11:11 a.m., the Interview was unable to be completed due to cognition. During an interview with LVN B on 08/26/25 at 11:30 a.m., LVN B stated she was the nurse for Resident #49 and Resident # 52 and confirmed that both residents were supposed to be wearing a secure device to prevent the urinary catheter from pulling on the resident's urethra. LVN B stated she did not know why Resident #49 and Resident # 52 were not wearing a leg strap but lack of wearing such devices risked both Residents having foley catheter pulled out. During an interview with the DON on 08/26/25 at 12:45 p.m., the DON stated Resident #49 and Resident # 52 should have been wearing a leg strap to prevent the urinary catheter from possibly dislodging. The DON stated she expected that all residents with a urinary catheter wear a secure device to prevent the catheter from pulling or becoming dislodged. Record review of the facility's policy titled, Catheter Care Urinary, March 2024, revealed, Secure catheter using a leg band

Based on observation, interview, and record review, the facility failed to ensure that in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 of 3 residents (Resident #58) reviewed for medication storage in that: The facility failed on 8/26/25 to ensure medications were not left on Resident #58's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings included: Record review of Resident #58's face sheet, dated 8/26/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Hypertension (is when the force of blood pushing against your artery walls is consistently too high) , Depression (persistent feeling of sadness and loss of interest), and Spinal Cord Infarction (Injury to the spinal cord ) Record review of Resident #58's Quarterly MDS Assessment, dated 5/09/25, revealed a BIMS score of 15, which indicated cognition was intact. Record review of Resident #58's Patient medication summary for August 2025 did not reveal an order to self-administer medications. Observation on 08/26/25 at 11:45 a.m. in Resident #58's room revealed morning medication in a plastic cup on bed side table. Interview with Resident #58 on 8/26/25 at 11:50 a.m., the resident stated, the MA left the medications there on bed side table for her to take when she was ready as she liked to take her time . Interview with MA C on 8/26/25 at 12:30 PM confirmed she was the MA assigned to pass out medications and revealed that, due to facility culture, she left Resident #58's morning medication on her bedside table this morning. Interview with the DON on 08/26/25 at 1:30 p.m., she reported that no self-medication assessment had been completed for Resident #58 and emphasized that no medications should be left at the bedside for any resident unless the interdisciplinary care planning team and physician had made that decision. The DON was unaware the MA C had left medications out on the bedside table for Resident #58. The DON expressed concern that Resident #58 might self-administer more medication than prescribed by the physician, by the MA C leaving medications on the bedside table. The DON also stated that her ADON would conduct weekly monitoring of bedside medications, while she would oversee this process monthly. Record review of the facility's policy titled, Medication Administration, dated June 2005, revealed, Residents may self-administer their own medications only if permitted by the attending physician, in conjunction with the interdisciplinary care planning team, who has determined that they have the decision-making capacity to do so .

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 2 of 3 Dumpsters (Dumpsters #1 and #3) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 had a drainage plug and Dumpster #3 was free of gaps. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 08/28/2025 at 10:17 AM revealed Dumpster #1 was missing a drainage plug. Observation on 08/28/2025 at 10:18 AM revealed the bottom of the left side of Dumpster #3 had a gap approximately 9 in length and 1 in height due to rust. During an interview on 08/28/2025 at 10:19 AM, the DM stated she was unaware Dumpster #1 was missing a drainage plug and Dumpster #3 had the gap caused by rust at the bottom, and it was important for both dumpsters to be completely sealed to prevent leakage and for the proliferation of rodents. Record review of the facility policy Food-Related Garbage and Refuse Disposal, dated October 2022, revealed, Food-related garbage and refuse are disposed of in accordance with state laws. 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 (LPN A) staff reviewed for staff qualifications. The facility failed to ensure LPN A's nursing license was not expired between [DATE] and [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse. The findings included: Record review of the staff roster for the facility indicated LPN A had been employed at the facility since [DATE]. Record review of the Texas Board of Nursing license verification, dated [DATE], indicated LPN A was originally issued a LVN/LPN license on [DATE] and current expiration date was [DATE]. During an interview on [DATE] at 04:26 p.m., the ADMIN revealed LPN A was notified of LPN A's expired license on [DATE]. LPN A was suspended until her license was renewed. The ADMIN revealed LPN A had only worked one or two shifts between Saturday, [DATE] and Friday, [DATE]. During an interview on [DATE] at 05:16 p.m., LPN A revealed she had just been notified by the facility her license was expired. She revealed she had set an alarm to re-renew on [DATE] but must have just forgotten to re-apply. She revealed she worked two shifts since [DATE], the date her licensed expired. She revealed the facility provided continuing education which ensured her continuing education was sufficient for her re-application. She revealed she re-applied the same day she was notified her license was expired, [DATE]. She revealed she did not believe her expired license impacted her ability to do her job because her education was current. Record review of the facility's policy titled, Guidelines for Credentialing Staff, dated revised 10/2022, reflected License and Certification Verification 1. All candidates extended an offer of employment for a certified or licensed position will be credential based on their credentials for the role. a. Nurses will be verified through the Board of Nursing .i. In addition, all nurses will be verified through Nursys, a national repository database, to check for board orders and out of state licensure status .4. Review all licenses and certifications monthly communicating upcoming expiration dates with the associate. 5. If the certification or license is not active by the expiration date the associate will be suspended without pay for up to 2 weeks, but no longer than 30 days, until the certification or license is reinstated.

Based on observation, interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's weights were documented in his medical record for 4 of 5 weeks (weeks of 03/13/2025, 03/20/2025, 03/27/2025, and 04/03/2025) reviewed. This failure could place residents at risk of not receiving the care and services needed. Findings included: Record review of Resident #1's admission Record, dated 06/03/2025, reflected an [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 06/03/2025, reflected a principal diagnosis of cerebral infarction (a disruption in the brain's blood flow) due to embolism (a clot related to foreign material that reduces blood flow) of right anterior cerebral artery (artery that supplies blood to the front part of the brain), an admission diagnosis of muscle wasting and atrophy (shrinking of muscle or nerve tissue), and an admission diagnosis of lack of coordination. Record review of Resident #1's Quarterly MDS, dated [DATE] and signed as completed on 05/21/2025, reflected assessment observation end date of 05/08/2025. Resident #1 had a BIMS score of 14, which indicated he was cognitively intact. He required partial/moderate assistance to roll left and right on the bed and substantial/maximal assistance for transferring from lying to sitting on the side of the bed or sitting to standing. He was documented as not having had or it was unknown if he had weight loss or weight gain in the last month or 10% loss or gain in the last 6 months. Record review of Resident #1's Order Recap Report for Order Date: 03/01/2025- 06/30/2025, dated 06/03/2025, did not reflect an order for weights to be taken. Record review of Resident #1's Weight Summary, accessed 06/06/2025, reflected Resident #1's initial weight (193.8 pounds) was documented as dated 03/06/2025 at 11:03 a.m. Resident #1's second weight (179.0 pounds) was documented as dated 04/24/2025 at 02:44 a.m. Resident #1's third weight (184.0 pounds) was documented as dated 04/24/2025 at 12:50 p.m. Resident #1's fourth weight (177.0 pounds) was documented as dated 04/30/2025 at 01:02 p.m. Record review of [facility name] Weights and Vitals Exceptions, dated 06/03/2025, reflected Resident #1 triggered for a 7.5% weight loss change on 04/24/2025 and on 04/30/2025 when the weights documented on those dates were compared to Resident #1's weight documented on 03/06/2025. Record review of Resident #1's Progress Notes from 03/01/2025 to 04/24/2025 did not reveal notes regarding Resident #1's weights or regarding alternative documentation of Resident #1's weights. Record review of Resident #1's Nutritional Therapy Evaluation, dated 03/17/2025, reflected Resident #1's meal intake varied from 50- 100%, he was at moderate risk for malnutrition, was obese, and was at risk for weight changes due to having edema (swelling caused by excess fluid trapped in the body's tissues) and was taking a diuretic (type of medication that increases urine production to help reduce fluid buildup and lower blood pressure). During an interview with Resident #1 on 06/03/2025 at 03:36 p.m., Resident #1 revealed he did not know if he had lost weight since his admission to the facility. He revealed he believed he could probably use some weight loss. During an interview on 06/06/2025 at 04:12 p.m., the DON revealed resident weights were to be taken when they first admitted , weekly for up to four weeks, and then monthly if the resident's weight was stable. She revealed residents continued to be weighed weekly if their weight was unstable. She revealed Resident #1 was weighed, but she would have to look for the weights documented on paper. She revealed the only reason for his weights to not be in the EMR was if she had forgotten to enter them into the system. She revealed at the time, she was working on her own for this task, since the ADON had not started yet. She revealed she did not believe the resident's care would have been impacted by his weights not having been recorded in the EMR. She revealed the nurses would have still had known Resident #1's weight because they received copies of the weights documented on paper. During an interview on 06/06/2025 at 04:37 p.m., the ADMIN revealed weights not entered into the EMR would impact how the facility determined if a resident had weight loss or weight gain. She revealed the reports the facility ran for weight triggered, weight loss and weight gain, used an algorithm based on the weights entered into the EMR. Record review of the facility's handwritten weight documentation, received 06/06/2025, reflected: - Weekly Weights, dated 03/10/2025, included Resident #1's name and a weight, - documentation listing resident names and weights, dated 03/19/2025, included Resident #1's name and a weight, - March Weights, undated, included Resident #1's name and a weight, and - Weekly Weights, dated April 2025, included Resident #1's name and a weight. Record review of the facility's policy, Weight Management, dated reviewed 12/09/2024, reflected: Procedure .2. New admits will be weighed weekly for the first 4 weeks to establish baseline weights, after which they will be weighed monthly .4. Facility will ensure that weights are recorded in the EMR and use paper documentation if the EMR system is down.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and supervision, in that: The facility failed to provide adequate supervision and assistive devices to prevent accidents when Resident #1 was confused and required assistance to ambulate. A fall mat was not in place and the bed was not in a low position, and Resident #1 fell out of bed and sustained a left femoral neck hip fracture. An IJ was identified on 11/26/2024. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 11/27/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. These failures placed the resident at risk for accidents and serious injuries. Findings included: Record review of Resident #1's Admission Record, dated 11/07/2024, indicated Resident #1 was initially admitted on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male. He was noted to have discharged on [DATE] to an acute care hospital, Hospital A. His diagnoses included: altered mental status, delirium (a change in mental abilities that results in confused thinking and a lack of awareness of someone's surroundings) due to known physiological condition, unspecified lack of coordination, age-related osteoporosis (brittle and fragile bones), and spina bifida (a birth defect that occurs when the spine and spinal cord do not form properly). Record review of Resident #1's Quarterly MDS assessment, dated 10/07/2024, indicated Resident #1 had a BIMS score of 04 indicating he was severely cognitively impaired. Resident #1 required substantial/maximal assistance with rolling left or right from lying on his back in bed and was dependent on staff assistance for chair/bed-to-chair transfers. He used a wheelchair; however, his ability to use was not attempted due to his medical condition or safety concerns. Record review of Resident #1's Care Plan, accessed 11/07/2024, indicated the following focuses: - The resident has had an actual fall with no injury r/t Poor Balance, Unsteady gait, initiated on 05/24/2023 and revised on 09/18/2023. Interventions/Tasks for the focus included: - 1:1 inservice [sic] with cna [sic] and nurse on fall mat for resident, initiated and created 11/02/2024, and - fall mat, initiated and created on 09/18/2023. - The resident is at risk for falls r/t Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, initiated on 10/27/2023 and revised on 10/27/2023. Interventions/Tasks for the focus included: - Follow facility fall protocol., initiated and created 10/27/2023, and - The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach), initiated, created, and revised 10/27/2023. Record review of Resident #1's Progress Note, dated 11/01/2024 at 10:39 p.m. by LPN B, revealed Note Text: went into room to check on resident. resident lying on floor on left side with legs crossed no internal or external rotation of lower extremities no active bleeding asked resident what happened resident stated I was trying to get in the car and fell to floor .sending to ER due to resident complaint of left side hurting . [sic]. Record review of Resident #1's Progress Note, dated 11/02/2024 at 04:49 a.m. by LPN B, revealed [hospital A] called [hospital A staff member name] stated impacted left femoral neck hip fracture [a fracture due to high-impact force in the neck of the left femur] notified DON and administrator of call from hospital called [facility's contracted physician group] talked with [name of nurse working with facility's contracted physician group] of new diagnosis impacted left femoral hip fracture and [hospital A] is moving resident to another hospital for ortho [orthopedics]. Record review of Resident #1's hospital documentation from Hospital A, dated 11/04/2024 revealed a diagnostic report on a CT scan of Resident #1's left hip without contrast. The report, dated 11/02/2024, revealed FINDINGS: Impacted left femoral neck fracture .IMPRESSION: 1. Impacted left femoral neck fracture. During an interview with CNA C on 11/07/2024 at 05:47 a.m., CNA C stated Resident #1's fall occurred close to 10:00 p.m. She stated that on the night of Resident #1's fall (11/01/2024), it was the first time she had seen Resident #1 that confused. She stated, every time I passed [his room], he was talking to someone that he said was sitting in the chair [chair in his room]. CNA C stated staff repeatedly tried to redirect Resident #1 and explain that he was the only person in his room. CNA C reported that she was the third staff member to respond after Resident #1 had fallen, and when staff asked him why he had gotten out of bed, he would reply that he was getting in his car to leave. CNA C reported Resident #1 was not on a fall mat when she observed him on the floor after his fall. CNA C stated she was not aware of Resident #1 having a fall mat but had heard later that he had fall mats. CNA C stated that due to staff knowing Resident #1 was confused, the staff were walking the hall consistently. During an interview with LPN B on 11/07/2024 at 02:38 p.m., LPN B stated she initially found Resident #1 on 11/01/2024 after his fall. LPN B stated Resident #1 said he was trying to get into the car and lost his footing. LPN B stated when she went into Resident #1's room after his fall, she observed that Resident #1 had moved his bedside table away from his bed. LPN B stated she didn't know if there was a fall mat in Resident #1's room but had observed that Resident #1 had not fallen onto a fall mat. LPN B stated she was unable to say if the fall mat had also been moved by Resident #1 because she was focused on providing care for Resident #1. LPN B stated staff would put Resident #1's bed in the low position; however, he would use his own bed controls and raise the bed back up. LPN B stated Resident #1 had been provided education about his safety, but he preferred to exercise his right to control his bed height. During an interview with the DON on 11/07/2024 at 04:52 p.m., the DON stated LPN B called and let her know Resident #1 had fallen around 09:48 p.m. on 11/01/2024. The DON stated staff did not report that they saw a fall mat in Resident #1's room, but staff had reported that Resident #1 had pushed items away from his bed prior to falling. The DON stated she was not notified that Resident #1 had fallen on a fall mat, but he was expected to have a fall mat in his room. During an interview with Resident #1's family member on 11/07/2024 at 06:22 p.m., the family member revealed Resident #1 was currently intubated at a local hospital following a partial hip replacement that occurred on the morning of 11/07/2024. The family member indicated Resident #1 was not available for interview or visitation at that time. During an interview with the DON on 11/08/2024 at 10:38 a.m., the DON stated she did a re-enactment yesterday, 11/07/2024 with LPN B and CNA C on Resident #1's fall. The DON stated CNA C told her that she had completed rounds with Resident #1 about 15 minutes prior to his fall (on 11/01/2024). The DON stated CNA C recalled that Resident #1 had his fall mat in place with his bed side table over him, as he preferred. The DON stated CNA C reported Resident #1's bed was in a lower position, but Resident #1 moved it back in a higher position himself after care was provided. The DON revealed LPN B recalled going into Resident #1's room to provide a medication and remembered almost tripping over Resident #1's fall mat. LPN B had believed that the fall mat must have moved when Resident #1 had pushed his bedside table away from his bed. LPN B revealed that this occurred at the same time as her finding Resident #1 on the floor and had immediately started providing emergency care. During an interview with CNA C on 11/08/2024 at 01:54 p.m., CNA C revealed she provided Resident #1 care prior to his fall on 11/01/2024. She stated she provided care, lowered his bed, and placed the bedside table and fall mat in place. CNA C revealed that as she was leaving Resident #1's room, he was raising his bed back up. CNA C stated she turned to him and reminded him of safety, to lower it, but said that he replied, I know but I want it up. CNA C stated Resident #1's bedside table and fall mat were in place when she left his room, but fifteen (15) minutes later the nurse found him on the floor and at that time, the bedside table and mat had been moved. Record review of facility policy Fall Prevention Program, dated as last reviewed 06/10/2024, revealed Policy: . specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. Definition: A fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident falls off any apparatus/equipment used for transfers. A. Procedure .2. Residents identified as being at risk will have interventions identified in their plan of care to minimize falls. 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury. .c. Bed maintained in low position with bedside mat .f. Resident teaching regarding safety .4. The resident's plan of care will be updated to reflect risk for falls, and appropriate interventions . An Immediate Jeopardy was identified on 11/26/2024. The Facility Corporate RN and DON were notified of the Immediate Jeopardy on 11/26/2024 at 4:45 PM and were given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 11/27/2024 at 12:04 PM and reflected the following: {Facility} Immediate Jeopardy Plan of Removal 11/26/2024 Quality of Care- F689 DON, in-serviced all nursing and CNA staff on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024 and completed on 11/27/2024. Competency was tested on Fall prevention protocols via quizzes conducted on 11/26/2024 and completed on 11/27/2024. DON/designee will ensure staff will not be able to work the floor until education is provided and competency tested . Staff will not be able to clock in until training is completed. Once resident is identified by staff of exhibiting behaviors, staff will ensure that resident is safe while immediately notifying DON/Designee to ensure fall prevention measures are updated/changed as needed. Concerns brought forward will be addressed immediately. This is included in education completed on 11/27/2024. All training material will be incorporated into new hire orientation by DON on 11/26/2024. Medical Director was notified by DON, 11/26/2024 regarding the Immediate Jeopardy involving Free of Accidents, Hazards, and Supervision. An audit of point of care tasks and care plans was completed by RN, Corporate Clinical Specialist, and DON on 11/26/2024, to ensure fall mitigation techniques were in place. The Director of Nursing/ Designee will perform random observations of fall risk residents 3 times weekly for 90 days and weekly thereafter to ensure proper interventions in place. DON/designee will monitor completion of POC task list 3 times a week for 90 days and weekly thereafter to ensure documentation is compliant. The facility QA Committee will meet weekly for the next 12 weeks to review compliance. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. The facility administrator will be responsible for ensuring that meetings occur weekly. The facility's POR Verification began on 11/27/2024 and was as follows: Interview on 11/27/2024 at 12:10 pm, facility DON stated she notified the facility Medical Director of the IJ on 11/27/2024. Interview on 11/27/2024 at 12:11 pm, facility DON stated she had in-serviced the ADONs and RN, Corporate Clinical Specialist, who assisted with in service training of all the facility nursing staff on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024 and completed on 11/27/2024. During an observation on 11/27/2024 at 9:20 am revealed 17/17 residents i(including Resident #1)(including Resident #1dentified as fall risk, in facility, with fall mats in place. Record review on 11/27/2024 of 17/17 residents (including Resident #1)EMRreflected care plan, POC and TAR have documentation of falls and fall interventions to include fall mats. TAR has nurse sign off to be done on 6a-6p shift and 6p-6a shift each day to indicate fall mat in place. 1. During an interview on 11/27/2024 at 11:23 am RN A stated she works 6a-6p shift and had received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 2. During an interview on 11/27/2024 at 11:24 am LVN CC stated she works 6a-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 3. During an interview on 11/27/2024 at 11:25 am CNA DD stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 4. During an interview on 11/27/2024 at 11:26 am CNA D stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 5. During an interview on 11/27/2024 at 11:27 am CNA E stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 6. During an interview on 11/27/2024 at 11:28 am CNA F stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 7. During an interview on 11/27/2024 at 11:42 am Medication aide G stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 8. During a telephone interview on 11/27/2024 at 12:54 pm LVN H stated she works 6a-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 9. During a telephone interview on 11/27/2024 at 11:54 am LVN B stated she works 6pm-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 10. During a telephone interview on 11/27/2024 at 12:32 pm CNA I stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 11. During an interview on 11/27/2024 at 1:52 pm CNA J stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 12. During a telephone interview on 11/27/2024 at 1:00 pm MA K stated she works 6a-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 13. During a telephone interview on 11/27/2024 at 12:45 pm LVN L stated she works 6a-6p and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 14. During a telephone interview on 11/27/2024 at 2:00 pm CNA M stated she works 6a-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 15. During a telephone interview on 11/27/2024 at 12:54pm CNA N stated he works 6p-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 16. During a telephone interview on 11/27/2024 at 12:29 pm CNA O stated she works 6p-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 17. During a telephone interview on 11/27/2024 at 12:31 pm CNA P stated she works 6p-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 18. During a telephone interview on 11/27/2024 at 12:46 pm RN Q stated she works 6a-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 19. During a telephone interview on 11/27/2024 at 12:17 pm CNA R stated she works 6p-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 20. During a telephone interview on 11/27/2024 at 12:50 pm CNA S stated she works 6p-6am received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 21. During a telephone interview on 11/27/2024 at 1:00 pm CNA T stated he works 6p-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 22. During a telephone interview on 11/27/2024 at 1:02 pm CNA U stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 23. During a telephone interview on 11/27/2024 at 2:30 pm LVN V stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 24. During a telephone interview on 11/27/2024 at 2:35 pm LVN W stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 25. During a telephone interview on 11/27/2024 at 3:00 pm LVN X stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 26. During a telephone interview on 11/27/2024 at 2:55 pm LVN Y stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 27. During a telephone interview on 11/27/2024 at 3:36pm LVN Z stated she works 6pm-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 28. During a telephone interview on 11/27/2024 at 3:40pm LVN AA stated she works 6pm-6am and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. 29. During a telephone interview on 11/27/2024 at 3:44pm CNA BB stated she works 6am-6pm and received in service training on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024. Record review on 11/27/2024 of Inservice conducted on 11/26/2024 by DON; 51of 51 in-serviced all nursing and CNA staff on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024 and completed on 11/27/2024. o Competency was tested on Fall prevention protocols via quizzes conducted on 11/26/2024 and completed on 11/27/2024 . Record review on 11/27/2024 of 51 of 51 nursing employees signed testing.all nursing and CNA staff on fall prevention protocols, including the proper use and placement of fall mats, maintaining beds in low positions, where and how to check off in POC task that fall interventions were in place, and what to do if residents start having behaviors such as removing fall mats, increased agitation etc. on 11/26/2024 and completed on 11/27/2024. o DON/designee will ensure staff will not be able to work the floor until education is provided and competency tested . Staff will not be able to clock in until training is completed. Interview on 11/27/2024 at 12:55 pm DON stated the DON/designee will ensure staff will not be able to work the floor until education is provided and competency tested . Staff will not be able to clock in until training is completed. o Once resident is identified by staff of exhibiting behaviors, staff will ensure that resident is safe while immediately notifying DON/Designee to ensure fall prevention measures are updated/changed as needed. Concerns brought forward will be addressed immediately. This is included in education completed on 11/27/2024. Interview on 11/27/2024 at 12:55 pm DON stated once resident is identified by staff of exhibiting behaviors, staff will ensure that resident is safe while immediately notifying DON/Designee to ensure fall prevention measures are updated/changed as needed. Concerns brought forward will be addressed immediately. This is included in education completed on 11/27/2024. o All training material will be incorporated into new hire orientation by DON on 11/26/2024. Interview on 11/27/2024 at 12:55 pm DON stated All training material will be incorporated into new hire orientation by herself DON on 11/26/2024. o Medical Director was notified by, DON, 11/26/2024 regarding the Immediate Jeopardy involving Free of Accidents, Hazards, and Supervision. Record review of statement by DON that Medical Director was notified on 11/26/2024 regarding the Immediate Jeopardy involving Free of Accidents, Hazards, and Supervision. During an interview on 11/27/2024 at 2:45 pm Medical Director voiced that he had been briefed on the IJ and that he would be participating in QAPI as planned. o An audit of point of care tasks and care plans was completed by RN Corporate Clinical Specialist, and DON on 11/26/2024, to ensure fall mitigation techniques were in place. Record review done on 11/27/2024 by investigator of audit of point of care tasks and care plans which was completed by RN, Corporate Clinical Specialist, and DON on 11/26/2024, to ensure fall mitigation techniques were in place. Record review of audit.100% complete. Interview on 11/27/2024 at 12:55 pm with DON and RN, Corporate Clinical Specialist, of audit of point of care tasks and care plans which was completed by Corporate Clinical Specialist, and DON on 11/26/2024, to ensure fall mitigation techniques were in place. They both voiced the audit was 100% accurate with point of care tasks and care plans updated for residents with fall interventions such as fall mats. o The Director of Nursing/ Designee will perform random observations of fall risk residents 3 times weekly for 90 days and weekly thereafter to ensure proper interventions in place. DON/designee will monitor completion of POC task list 3 times a week for 90 days and weekly thereafter to ensure documentation is compliant. Interview on 11/27/2024 at 12:55 pm DON stated she -the Director of Nursing/ Designee will perform random observations of fall risk residents 3 times weekly for 90 days and weekly thereafter to ensure proper interventions in place. DON/designee will monitor completion of POC task list 3 times a week for 90 days and weekly thereafter to ensure documentation is compliant. o The facility QA Committee will meet weekly for the next 12 weeks to review compliance. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. The facility administrator will be responsible for ensuring that meetings occur weekly. Interview on 11/27/2024 at 12:55 pm DON stated the facility QA Committee will meet weekly for the next 12 weeks to review compliance. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. The facility administrator will be responsible for ensuring that meetings occur weekly. On 11/27/2024 at 4:42 PM the DON and RN Corporate Clinical Specialist were notified the IJ was removed. While the IJ was removed on 11/27/2024 at 4:42 PM, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #1) of 6 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency, an incident of neglect regarding Resident #1, after he had an unwitnessed fall in his room with a possible injury to his hip that occurred on 11/01/2024. The unwitnessed fall later revealed through CT scan (a scan to create cross sectional images of organs, bones, and other tissues), Resident #1 had a left femoral hip fracture, and it was not reported to the state as of 11/06/2024. This failure could place facility residents at risk of hard due to delays in reporting allegations of injury of unknown origin, abuse, and neglect. Findings included: Record review of Resident #1's Admission Record, dated 11/07/2024, indicated Resident #1 was initially admitted on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male. He was noted to have discharged on [DATE] to an acute care hospital, Hospital A. His diagnoses included: altered mental status, delirium (a change in mental abilities that results in confused thinking and a lack of awareness of someone's surroundings) due to known physiological condition, unspecified lack of coordination, age-related osteoporosis (brittle and fragile bones), and spina bifida (a birth defect that occurs when the spine and spinal cord do not form properly). Record review of Resident #1's Quarterly MDS assessment, dated 10/07/2024, indicated Resident #1 had a BIMS score of 04, indicating he was severely cognitively impaired. Resident #1 required substantial/maximal assistance with rolling left or right from lying on his back in bed and was dependent on staff assistance for chair/bed-to-chair transfers. He used a wheelchair; however, his ability to use was not attempted due to his medical condition or safety concerns. Record review of Resident #1's Care Plan, accessed 11/07/2024, indicated the following focuses: - The resident has had an actual fall with no injury r/t Poor Balance, Unsteady gait, initiated on 05/24/2023 and revised on 09/18/2023. Interventions/Tasks for the focus included: - 1:1 inservice [sic] with cna [sic] and nurse on fall mat for resident, initiated and created 11/02/2024, and - fall mat, initiated and created on 09/18/2023. - The resident is at risk for falls r/t Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, initiated on 10/27/2023 and revised on 10/27/2023. Interventions/Tasks for the focus included: - Follow facility fall protocol., initiated and created 10/27/2023, and - The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach), initiated, created, and revised 10/27/2023. Record review of Resident #1 Progress Note, dated 11/01/2024 at 10:39 p.m. by LPN B, revealed Note Text: went into room to check on resident. resident lying on floor on left side with legs crossed no internal or external rotation of lower extremities no active bleeding asked resident what happened resident stated I was trying to get in the car and fell to floor .sending to ER due to resident complaint of left side hurting . [sic]. Record review of Resident #1 Progress Note, dated 11/02/2024 at 04:49 a.m. by LPN B, revealed [hospital A] called [hospital A staff member name] stated impacted left femoral neck hip fracture [a fracture due to high-impact force in the neck of the left femur] notified DON and administrator of call from hospital called [facility's contracted physician group] talked with [name of nurse working with facility's contracted physician group] of new diagnosis impacted left femoral hip fracture and [hospital A] is moving resident to another hospital for ortho [orthopedics; branch of medicine concerned with the correction of injuries of the skeleton and associated structures]. Record review of Resident #1 hospital documentation from Hospital A, dated 11/04/2024 revealed a diagnostic report on a CT scan of Resident #1's left hip without contrast. The report, dated 11/02/2024, revealed FINDINGS: Impacted left femoral neck fracture .IMPRESSION: 1. Impacted left femoral neck fracture. Record Review of TULIP (an online platform for long term care licensing and credentialing) on 11/06/2024 for the facility did not indicate a self-report was submitted to report the serious bodily injury of Resident #1. During an interview with CNA C on 11/07/2024 at 05:47 a.m., CNA C stated Resident #1's fall occurred close to 10:00 p.m. She stated that on the night of Resident #1's fall (11/01/2024), it was the first time she had seen Resident #1 that confused. She stated, every time I passed [his room], he was talking to someone that he said was sitting in the chair [chair in his room]. CNA C stated staff repeatedly tried to redirect Resident #1 and explain that he was the only person in his room. She reported that she was the third staff member to respond after Resident #1 had fallen, and when staff asked him why he had gotten out of bed, he would reply that he was getting in his car to leave. CNA C stated that when EMS [Emergency Services personnel] had arrived, Resident #1 was asked where he was, and he replied that he was on the third floor of [local hospital]. During an interview with LPN B on 11/07/2024 at 02:38 p.m., LPN B stated she reported Resident #1's fall to the DON, the administrator, and a physician for [facility's contracted physician group]. LPN B stated Resident #1 was his own resident representative, but she also notified the next contact on his face sheet of his transfer to the hospital. During an interview with the DON on 11/07/2024 at 04:52 p.m., the DON stated LPN B called and let her know Resident #1 had fallen around 09:48 p.m. on 11/01/2024. She then stated that LPN B left her a voice message at around 04:00 a.m. about Resident #1's diagnosed fracture. The DON stated at around 08:00 a.m. on 11/02/2024 she notified the Reg Admin that Resident #1 had a fracture. The DON revealed she was not aware if Resident #1's injury had been reported to the state and does not know why it was not reported. The DON stated the Reg Admin would have been responsible for reporting the incident. She stated that the facility administrator was typically responsible for reporting incidents to the state, but because the administrator was out on leave, she was letting the regional team know of any incidents. During an interview with Resident #1's family member on 11/07/2024 at 06:22 p.m., the family member revealed Resident #1 was currently intubated at a local hospital following a partial hip replacement that occurred on the morning of 11/07/2024. The family member indicated Resident #1 was not available for interview or visitation at that time. During an interview with the DON on 11/08/2024 at 11:00 a.m., the DON stated she did not do a self-report to HHSC (Health and Human Services Commission) because she did not know how. She stated she sent the report to her Reg Admin, who is covering for the current administrator. The facility administrator was on leave and unavailable for interview. During an interview with the Reg Admin on 11/08/2024 at 02:55 p.m., the Reg Admin stated she did not do a self-report because we knew what happened to the resident. He was able to tell us what happened and did not change his story. She further revealed that she had read the guidelines for falls and accidents and determined Resident #1's fall on 11/01/2024 was not a reportable incident. Record review of facility policy Policy for Resident Incident and Visitor Accident Report, dated as last revised 07/23/2018 and last reviewed 06 2024, revealed Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations. Record review of facility policy Abuse Prohibition Policy, dated as last reviewed 01/01/2024, revealed POLICY: . 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. and under Reporting/Response: . 2.The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.

Based on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (11/05/2024 and 11/06/2024) of 3 days reviewed. The facility did not post the required current nurse staffing information for 11/05/2024 and 11/06/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. Findings included: During an observation on 11/06/2024 at 04:25 p.m., a document labeled Daily Nurse Staffing Report dated 11/04/2024, was posted in a plastic sheet protector and taped next to the nurses' station and at the entry to the resident 200-hall. During an observation and interview on 11/06/2024 at 04:40 p.m., the DON stated the night nursing shift was typically responsible for posting the daily census and nurse staffing document. The DON was observed removing the document dated 11/04/2024 and stated, let me see if I can find it [referring to the current, 11/06/2024 posting]. The DON was observed searching through two binders and stated she did not find the current document and that she was going to ask the ADON. The DON confirmed the posted document was dated 11/04/2024 and revealed she did not know why the posting for 11/05/2024 or the current day's posting was posted. The DON revealed she did not see any harm for the posting not being updated because the facility reviewed staffing regularly and the resident families were familiar with the facility staffing schedule. During an observation and interview with the ADON on 11/07/2024 at 09:02 a.m., the ADON was observed to bring in the Daily Nurse Staffing Reports dated 11/05/2024 and 11/06/2024. The ADON stated the documents were in her schedule book because she was putting in the scheduled hours. The ADON stated the Daily Nurse Staffing Report was not posted on 11/06/2024 because it was in her schedule book. The ADON did not state why the Daily Nurse Staffing Reports were not posted for 11/05/2024 or 11/06/2024. Record review of facility policy, Posting Direct Care Daily Staffing Numbers, dated reviewed 3-2023, revealed Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .7. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the director of nursing services' office and filed as a permanent record.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards in that water temperatures were not correctly monitored and maintained within a safe temperature range to keep residents free of accident hazards for 4 of 8 residents' rooms observed during the survey (Room 304, 308, 309, and 310) and in 1 of 4 hall showers (300 Hall) for 17 cognitively impaired residents of 23 residing on the 300 Hall. 1. During initial rounds, the 300 Hall shower room temperature was 141.3?F. 2. During initial rounds room # 309 was occupied by two residents who were able to self-propel to their bathroom sink. The water temperature was 139?F. 3. During initial rounds, room # 308 was occupied by two residents. One resident was cognitively impaired with communication difficulties and both were able to self-propel to the bathroom sink. The water temperature was 134.3?F 4. During initial rounds room # 310 was occupied by two residents who were able to self-propel to the bathroom sink. The water temperature was 128.1?F. 5. During initial rounds room # 304 was occupied by two cognitively impaired residents. The water temperature was 126?F 6. The facility's Maintenance Director tested hot water temperatures of the residents' bathroom sinks and shower rooms with an electronic (digital) thermometer used for humans which recorded sublingual (under the tongue) temperatures only to 111?F instead of a thermometer used to measure water temperatures. An Immediate Jeopardy (IJ) was identified on 1/3/12. While the ImmediateJeopardy was removed prior to exit on 1/5/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not Immediate Jeopardy and a scope of Pattern due to the plan of removal was still being monitored for implementation and compliance. Failure to ensure the hot water remained at a safe temperature could result in serious burns and injury and could affect 17 cognitively impaired residents on the 300 hall. The findings were: A. Observation during the initial tour of the facility on 1 /3/12 at 10:17 a.m. revealed the hot water temperature in the 300 Hall shower room was 141.3?F. B. Observation during initial rounds 1/3/12 at 9:49 a.m. room # 309 was occupied by two residents who were able to self-propel to the bathroom sink. The water temperature was 139?F. C. Observation during initial rounds on 1/3/12 at 9:45 a.m. room # 308 was occupied by two residents. One resident was cognitively impaired with communication difficulties and both were able to self-propel to themselves to the bathroom sink. The water temperature was 134.3?F D. Observation during initial rounds on 1/3/12 at 10:02 a.m. room # 310 was occupied by two residents who were able to self-propel to the bathroom sink. The water temperature was 128.1?F. E. Observation during the initial rounds on 1/3/12 at 9:20 a.m. room # 304 was occupied by two cognitively impaired residents. The water temperature was 126?F Interview at the end of initial rounds with LVN W on 1/3/12 at 10:20 a.m. revealed she was not aware that water temperatures were that hot. Interview with the Maintenance Director on 1/3/12 at 10:40 a.m. revealed he used a thermometer that was in his maintenance office. The surveyor observed a digital oral thermometer used to take resident temperatures sublingually (under the tongue). He stated the thermometer was what he had been using to take water temperatures ever since he came to work at the facility in August, 2011. He stated the thermometer had not registered above 110?F. Review of the facility's Daily Water Temperature Log from 9/12/11 through 12/16/11 revealed no temperatures above 111?F. Interview with the Maintenance Director on 1/3/12 at 10:55 a.m. revealed the circulating pump of the water system may have been out and he would check on it. Observation on 1/3/12 at 10:55 a.m. revealed resident # 13 being showered by CNA S in the 300 Hall shower. Interview with the resident at that time revealed the water gets really hot when only the hot water is on. Interview with the D.O.N. on 1/3/12 at 11:10 a.m. revealed she was not aware of the high hot water temperatures in the 300 hall and not aware of the thermometer the Maintenance Director was using to take hot water temperatures. She verified the oral thermometer was not the correct thermometer for taking hot water temperatures and that it was an oral thermometer used to take residents' temperatures under the tongue. Interview with LVN W on 1/3/12 at 11:40 a.m. revealed the shower on the 300 hall had not been working and was just repaired yesterday. She stated she thought there was a problem with the water pipe and the knobs in the shower. Interview with Resident #32 on 1/3/12 at 11:43 a.m. revealed the water is sometimes too hot in his bathroom sink. He could not tell how hot it was but stated it was "too hot, it was just really hot". He stated the facility was trying to fix the shower. He thought the shower had not been working for about a week and the residents were going to Hall 200 to take showers. Interview on 1/3/12 at 11:50 a.m. with the Regional Nurse revealed someone had gone to purchase a thermometer that would measure hot water temperatures for the Maintenance Director. Interview on 1/3/12 at 11:55 a.m. with M.A. Y revealed resident #12 complained last week that the temperature was too hot to give her a shower on the 300 Hall. Interview with Resident #12 on 1/5/12 at 10:28 a.m. revealed 2 days ago (1/3/12) the water was "very, very hot". The resident gestured with her right hand, pulled the right hand back very quickly, to indicate that she was not able to keep her hand under the hot water. The resident reported she noticed the water was hot when she went to brush her teeth in her bathroom sink and thought it had been hot since the new year started. The resident reported one day she was showered with hot water and her shower days were on Tuesday, Thursday, and Saturday. Observation on 1/3/12 at 12:03 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the bathroom sink of Room 309 was 134.0?F. Observation on 1/3/12 at 12:07 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the bathroom sink of Room 310 was 137.6?F. Observation on 1/3/12 at 12.09 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the 300 Hall shower room was 136.4 ? Interview on 1/3/12 at 12:40 p.m. with the Administrator, revealed the staff on Hall 300 had been in-serviced regarding the hot water temperatures about 30 minutes ago and the Regional Engineer was on his way to the facility to check out the problem. Further interview on 1/3/12 at 2:00 p.m. with the Administrator revealed in the same in-service (30 minutes ago) the facility staff had been in-serviced on not letting residents on the 300 hall use the hot water and the Regional Engineer was on his way to the facility. On 1/3/12 at 2:05 p.m. after the temperatures were verified by the Maintenance Director with the new thermometer, the Administrator was informed of the Immediate Jeopardy situation. The Administrator reported during the lunch period the water had been flushed out of the hot water heater and the temperature had been turned down. The Administrator reported she would have the Maintenance Director turn off the hot water immediately. Interview on 1/3/12 at 2:17 p.m. with resident #8 revealed the water was "hot, boiling hot, it was hot hot." Interview on 1/3/12 at 2:25 p.m. with the Maintenance Director revealed 20 minutes ago (2:05 p.m.) he started draining the hot water out of the pipes and flushing them with cold water. Observation on 1/04/12 between 8:53 a.m.-9:30 a.m. the Maintenance Director took water temperatures in residents' bathrooms and the hall shower. The sink and water temperatures were: Room 304-Water temperature-77.0 Room 308-Water temperature-76.0 Room 309-Water temperature-77.0 Room 310-Water temperature-76.9 Shower-Water temperature-76.8 Interview with the Maintenance Director on 1/04/12 at 9:35 a.m. he stated he was hired by the facility in August 2011 and was not trained on how to take water temperatures at the facility. He stated he found the thermometer he was using to take water temperatures in the desk in the maintenance office. He stated he found the water temperature logs in the maintenance office and had been taking water temperatures in residents' room and showers and recording the temperatures in the log book since August 2011 using the oral thermometer. He stated he did not know the thermometer he was using was an oral thermometer until 1/03/12 when the survey team told him this. He stated the Regional Maintenance Director turned off the hot water heater and unplugged the circulating pump on 1/03/12 and ordered a new circulating pump which should be at the facility today. Observation on 1/05/12 between 10:05 a.m.-10:35 a.m. water temperatures in residents' bathrooms and the hall shower were re-checked and verified by the surveyor. The sink and shower water temperatures were: Room 304- Water temperature-105.4 Room 308- Water temperature-107.4 Room 309-Water temperature-105.8 Room 310-Water temperature-105.8 Shower-Water temperature-107.6 Interview with the Administrator on 1/05/12 at 12:10 p.m. revealed the facility Maintenance Director should have been trained by the Regional Maintenance Director once the Maintenance Director was hired to work at the facility. She stated she should have received information from Regional Maintenance Director that the facility Maintenance Director was trained, but could not recall if she had received this information. The Administrator stated she would check to verify if the Maintenance Director had received training on taking water temperatures at the facility and if not she would request the Maintenance Director be trained by the Regional Maintenance Director. Interview with the Regional Maintenance Director on 1/05/12 at 2:10 p.m. revealed he trained the Maintenance Director for 2 days as to the operations of the facility and had not provided the Maintenance Director with a thermometer or trained him on taking water temperatures at the facility. The Regional Maintenance Director stated he normally would spend a full week training a newly hired Maintenance Director; however he supervised 16 facilities for the Corporation and at times was pulled away from a facility depending on the needs of the other facilities. The Regional Maintenance Director stated he sent the Maintenance Director to another facility owned by the same corporation that was a few miles away and instructed the Maintenance Director at that facility to train the Maintenance Director for a week. The Regional Maintenance Director stated he was not aware if the facility Maintenance Director had been trained on taking water temperatures by the other facility Maintenance Director. The Regional Maintenance Director stated he did not provide documentation to the facility that he had trained the Maintenance Director, although he had provided this information to other facilities when he trained their Maintenance Directors. Interview on 1/6/12 at 10:42 a.m. with the manufacturer's customer service representative for the oral thermometer used by the facility revealed the thermometer measured temperatures between 89.6 - 111.2 degrees F. The facility submitted an action plan to remove the immediacy dated 1/3/12 at 5:52 p.m. consisting of the following actions: 1. The facility immediately shut off the hot water supply at the hot water heater for the 300 hall after being informed by the survey team of the Immediately Jeopardy. (Prior to that, the facility had only lowered the temperature setting on the hot water heater when informed by the surveyor of the high hot water temperatures and were waiting for a corporate maintenance person to arrive). 2. Residents on the 300 wing were assessed for any burn injuries; none were found. 3. A plan was implemented to shower/bath residents on one of the other wings which were not affected. 4. Night shift was informed of the situation so as not to attempt to turn the hot water heater back on. 5. Water temperatures were checked on all halls with use of an appropriate thermometer. 6. The Immediate Jeopardy was considered removed on 1/3/12, approximately 5:52 p.m. after verification by the survey team that the hot water had been shut off to that wing and staff informed. Verification of Plan: 1. A new thermometer was purchased by the facility that would record temperatures greater than 111?F. 2. The new thermometer was used to record the high hot water temperatures in various residents' room and verified with the surveyor making rounds with the Maintenance Director measuring water temperatures. 3. Each resident was assessed for any injuries related to hot water temperatures by the nursing staff and surveyor. 4. In-services were conducted for all staff working on Hall 300. Interviews were conducted on 1/3/12 and 1/4/12 with the facility staff to confirm in-services were conducted. 5 A new circulating pump for the water heater was installed on 1/4/12 and the administrator provided a copy of the invoice for the circulating pump. "Hot Water Burn Prevention" downloaded from http://www/cms/index.cfm?app=div_fireservices&currID=1018... on 01/20/2012 stated: "Water temperatures Time it takes to cause a third degree burn: 150 degrees 2 seconds 140 degrees 5 seconds 130 degrees 30 seconds 120 degrees 10 minutes Our skin becomes thinner, our reaction time may become slower and some medication conditions can put us at risk for a burn injury." Review of the facility census report, dated 1/4/12, revealed 23 residents resided on the 300 hall.

Based on observations, interviews and record review the administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently and to ensure that the resident-use water temperatures were correctly monitored and maintained within a safe temperature range to keep residents free of accident hazards range and to ensure the highest practicable physical well-being of their residents. The Administrator failed to: 1) Supervise the Maintenance Director to ensure he was trained on safe water temperature ranges to ensure residents well-being. 2) Ensure the Maintenance Director was provided with the appropriate equipment to take water temperatures at the facility. Failure to ensure the hot water temperatures remained at a safe temperature could result in [MEDICAL CONDITION] injury and could affect 17 cognitively impaired residents on the 300 hall. These failures resulted in an Immediate Jeopardy which was identified 1/03/12. While the Immediate Jeopardy was removed on 1/03/12 the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm at a pattern that was not Immediate Jeopardy as the plan of removal was still being monitored for implementation and compliance. : The findings were: A. Observation during initial tour of the facility on 1/3/12 at 10:17 a.m. revealed the hot water temperature in the 300 Hall shower room was 141.3?F. B. Observation during initial rounds 1/3/12 at 9:49 a.m. room # 309 was occupied by two residents who were able to self-propel to the bathroom sink. The water temperature was 139?F. C. Observation during initial rounds on 1/3/12 9:45 a.m. room # 308 was occupied by two residents. One resident was cognitively impaired with communication difficulties and both were able to self-propel to the bathroom sink. The water temperature was 134.3?F D. Observation during initial rounds on 1/3/12 at 10:02 a.m. room # 310 was occupied by two residents who were able to self-propel to the bathroom sink. The water temperature was 128.1?F. E. Observation during initial rounds on 1/3/12 at 9:20 a.m. room # 304 was occupied by two cognitively impaired residents. The water temperature was 126?F Interview at the end of initial rounds with LVN W on 1/3/12 at 10:20 a.m. revealed she was not aware that water temperatures being that hot. Interview with the Maintenance Director on 1/3/12 at 10:40 a.m. revealed he used a thermometer that was in his maintenance office. This surveyor observed a digital oral thermometer used to take resident temperatures sublingually (under the tongue). He stated the thermometer was what he had been using to take water temperatures ever since he came to work at the facility in August, 2011. He stated the thermometer had not registered above 110?F. Review of the facility's Daily Water Temperature Log from 9/12/11 through 12/16/11 revealed no temperatures above 111?F. Interview with the Maintenance Director on 1/3/12 at 10:55 a.m. revealed the circulating pump of the water system may have been out and he would check on it. Observation on 1/3/12 at 10:55 a.m. of resident # 13 being showered by CNA S in the 300 Hall shower. In an interview with resident # 13 revealed the water gets really hot when only the hot water is on. Interview with the D.O.N. on 1/3/12 at 11:10 a.m. revealed she was not aware of the high hot water temperatures in the 300 hall and not aware of the thermometer the Maintenance Director was using to take hot water temperatures. She verified the oral thermometer was not the correct thermometer for taking hot water temperatures and that it was an oral thermometer used to take residents' temperatures under the tongue. Interview with LVN W on 1/3/12 at 11:40 a.m. revealed the shower had not been working and was just repaired yesterday. She stated she thought there was a problem with the water pipe and the knobs in the shower. Interview on 1/3/12 at 11:43 a.m. with Resident #32, revealed the water in his bathroom sink was sometimes too hot. He could not tell how hot it was but stated it was "too hot, it was just really hot". He stated the facility was trying to fix the shower. He thought the shower had not been working for about a week and the residents were going to Hall 200 to take showers. Interview on 1/3/12 at 11:50 a.m. with the Regional Nurse revealed someone had gone to purchase a new thermometer that would measure hot water temperatures for the Maintenance Director. Interview on 1/3/12 at 11:55 a.m. with M.A. Y revealed Resident #12 complained last week that the temperature was too hot to give her a shower. Interview with Resident #12 on 1/5/12 at 10:28 a.m. revealed 2 days ago (1/3/12) the water was "very, very hot". The resident gestured with her right hand, pulled the right hand back very quickly, to indicate that she was not able to keep her hand under the hot water. The resident reported she noticed the water was hot when she went to brush her teeth in the bathroom sink and thought it had been hot since the new year started. The resident reported one day she was showered with hot water and her shower days were on Tuesday, Thursday, and Saturday. Observation on 1/3/12 at 12:03 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the bathroom sink of room [ROOM NUMBER] was 134.0?F. Observation on 1/3/12 at 12:07 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the bathroom sink of room [ROOM NUMBER] was 137.6?F. Observation on 1/3/12 at 12.09 p.m. with the Maintenance Director's new thermometer revealed the hot water temperature in the 300 Hall shower room was 136.4?F. Interview on 1/3/12 at 12:40 p.m. with the Administrator, revealed the staff on Hall 300 had been in-serviced regarding the hot water temperatures and the Regional Engineer was on his way to the facility to check out the problem. Further interview on 1/3/12 at 2:00 p.m. with the Administrator revealed that in the same in-service (30 minutes ago) the facility staff had been in-serviced on not letting residents on the 300 hall use the hot water and the Regional Engineer was on his way to the facility. At 2:05 p.m. the Administrator was informed of the Immediate Jepodary situation. The Administrator reported during the lunch period the water heater had flushed out the hot water from the water heater and the temperature had been turned down. The Administrator reported she would have the Maintenance Director turn off the hot water immediately. Interview on 1/3/12 at 2:17 p.m. with resident #8, revealed the water was "hot, boiling hot, it was hot hot." Interview on 1/3/12 at 2:25 p.m. with the Maintenance Director revealed 20 minutes ago (2:05 p.m.) he started draining the hot water out of the pipes and flushing them with cold water. Observation on 1/04/12 between 8:53 a.m.-9:30 a.m. the Maintenance Director took water temperatures in resident's bathrooms and the hall shower. The sink and water temperatures were: room [ROOM NUMBER]-Water temperature-77.0 room [ROOM NUMBER]-Water temperature-76.0 room [ROOM NUMBER]-Water temperature-77.0 room [ROOM NUMBER]-Water temperature-76.9 Shower-Water temperature-76.8 Interview with the Maintenance Director on 1/04/12 at 9:35 a.m. revealed he was hired by the facility in August 2011 and was not trained on how to take water temperatures at the facility. He stated he found the thermometer he was using to take water temperatures in the desk in the maintenance office. He stated he found the water temperature logs in the maintenance office and had been taking water temperatures in resident's room and showers and logging in the temperatures in the logs since August 2011 using the oral thermometer. He stated he did not know the thermometer he was using was an oral thermometer until 1/03/12 when the survey team told him this. He stated the Regional Maintenance Director turned off the hot water heater and unplugged the circulating pump on 1/03/12 and ordered a new circulating pump which should be at the facility today. Observation on 1/05/12 between 10:05 a.m.-10:35 a.m. water temperatures in resident's bathrooms and the hall shower were re-checked and verified by the surveyor. The sink and shower water temperatures were: room [ROOM NUMBER]- Water temperature-105.4 room [ROOM NUMBER]- Water temperature-107.4 room [ROOM NUMBER]-Water temperature-105.8 room [ROOM NUMBER]-Water temperature-105.8 Shower-Water temperature-107.6 Interview with the Administrator on 1/05/12 at 12:10 p.m. revealed the facility Maintenance Director should have been trained by the Regional Maintenance Director once the Maintenance Director was hired to work at the facility. She stated she should have received information from Regional that the Maintenance Director was trained, but could not recall if she had received this information. The Administrator stated she would check to verify if the Maintenance Director had received training on taking water temperatures at the facility and if not she would request the Maintenance Director be trained by the Regional Maintenance Director. Interview with the Regional Maintenance Director on 1/05/12 at 2:10 p.m. revealed he trained the Maintenance Director for 2 days as to the operations of the facility and had not provided the Maintenance Director with a thermometer or trained him on taking water temperatures at the facility. The Regional Maintenance Director stated he normally would spend a full week training a newly hired Maintenance Director; however he supervised 16 facilities for the Corporation and at times was pulled away from a facility depending on the needs of the other facilities. The Regional Maintenance Director stated he sent the Maintenance Director to another facility owned by the same corporation that was a few miles away and instructed the Maintenance Director at that facility to train the Maintenance Director for a week. The Regional Maintenance Director stated he was not aware if the facility Maintenance Director had been trained on taking water temperatures by the other facility Maintenance Director. The Regional Maintenance Director stated he did not provide documentation to the facility that he had trained the Maintenance Director, although he had provided this information to other facilities when he trained their Maintenance Directors. The facility submitted an action plan to remove the immediacy dated 1/3/12 at 5:52 p.m. consisting of the following actions: 1. The facility immediately shut off the hot water supply at the hot water heater for the 300 hall after being informed by the survey team of the IJ. (Prior to that, the facility had only lowered the temperature setting on the hot water heater when informed by the surveyor of the high hot water temperatures and were waiting for a corporate maintenance person to arrive). 2. Residents on that wing were assessed for any burn injuries; none were found. 3. A plan was implemented to shower/bath residents on one of the other wings which were not affected. 4. Night shift was informed of the situation so as not to attempt to turn the hot water heater back on. 5. Water temperatures were checked on all halls with use of an appropriate thermometer. 5. The Immediate Jeopardy was considered removed on 1/3/12, approximately 5:52 p.m. after verification by the survey team that the hot water had been shut off to that wing and staff informed. Verification of Plan: 1. A new thermometer was purchased by the facility that would record temperatures greater than 111?F. 2. The new thermometer was used to record the high hot water temperatures in various residents' room and verified with the surveyor making rounds with the Maintenance Director measuring water temperatures. 3. Each resident was assessed for any injuries related to hot water temperatures by the nursing staff and surveyor. 4. In-services were conducted for all staff working on Hall 300. Interviews were conducted on 1/3/12 and 1/4/12 with the facility staff to confirm in-services were conducted. 5. A new circulating pump for the water heater was installed on 1/4/12 and the administrator provided a copy of the invoice for the circulating pump. Interview on 1/6/12 with the manufacturer's customer service representative for the oral thermometer used by the facility revealed the thermometer measured temperatures between 89.6 - 111.2 degrees F. Review of the facility census report, dated 1/4/12, revealed 23 residents resided on the 300 hall. The facility submitted an action plan to remove the immediacy dated 1/3/12 at 5:52 p.m. consisting of the following actions: 1. The facility immediately shut off the hot water supply at the hot water heater for the 300 hall after being informed by the survey team of the Immediate Jeopardy (Prior to that, the facility had only lowered the temperature setting on the hot water heater when informed by the surveyor of the high hot water temperatures and were waiting for a corporate maintenance person to arrive). 2. Residents on that wing were assessed for any burn injuries; none were found. 3. A plan was implemented to shower/bath residents on one of the other wings which were not affected. 4. Night shift was informed of the situation so as not to attempt to turn the hot water heater back on. 5. Water temperatures were checked on all halls with use of an appropriate thermometer. 5. The Immediate Jeopardy was considered removed on 1/3/12, approximately 5:52 p.m. after verification by the survey team that the hot water had been shut off to that wing and staff informed. Verification of Plan: 1. A new thermometer was purchased by the facility that would record temperatures greater than 111?F. 2. The new thermometer was used to record the high hot water temperatures in various residents' room and verified with the surveyor. 3. Each resident was assessed for any injuries related to hot water temperatures. 4. In-services were conducted for all staff working on Hall 300. 5. Interviews were conducted on 1/3/12 and 1/4/12 with the facility staff to confirm in-services were conducted. 6. A new circulating pump for the water heater was installed on 1/4/12 and the administrator provided a copy of the invoice for the circulating pump. Interview on 1/6/12 with the manufacturer's customer service representative for the oral thermometer used by the facility revealed the thermometer measured temperatures between 89.6 - 111.2 degrees F. "Hot Water Burn Prevention" downloaded from http://www.city.greatersudbury.on.ca/cms/index.cfm?app=div_fireservices&currID=1018... on 01/20/2012 stated: "Water temperatures Time it takes to cause a third degree burn: 150 degrees 2 seconds 140 degrees 5 seconds 130 degrees 30 seconds 120 degrees 10 minutes Our skin becomes thinner, our reaction time may become slower and some medication conditions can put us at risk for a burn injury." Review of the facility census report, dated 1/4/12, revealed 23 residents resided on the 300 hall.