Every finding on record at Quitman Wellness & Rehabilitation

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to develop and implement a Baseline Care Plan within forty-eight hours of admission that included the instructions for resident care needed to provide effective and person-centered care for 5 of 12 residents reviewed for new admissions. (Resident #15, Resident #64, Resident #47, Resident # 67 and Resident #69). 1. The facility failed to ensure Resident #15, Resident #64, Resident #47, Resident #67, and Resident #69's baseline care plan was completed within 48 hours of admission to the facility. 2. The facility failed to ensure Resident #67's baseline care plan was signed off or reviewed by an RN. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #15's face sheet dated 5/05/26 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Non-ST elevation myocardial infarction (serious heart attack caused from a partial blockage of blood flow and damages heart muscle), bacteremia (bacteria found in the bloodstream), muscle weakness, retention of urine, hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath), and acute and subacute infective endocarditis(IE) (infection of the heart lining or heart valves, acute IE comes on rapidly and subacute IE progresses slowly, but both require prompt targeted antibiotics (medications to treat infections)). Record review of Resident #15's admission MDS assessment dated [DATE] revealed she admitted to the facility on [DATE] from a short-term general hospital. The MDS indicated Resident #15 had a BIMS score of 9 which indicated she had moderate cognitive impairment. Resident #15 required moderate to substantial assistance completing most ADLs. The MDS indicated Resident #15 had an indwelling catheter (tube inserted into the bladder to drain urine) and she was always incontinent of bowel. The MDS indicated Resident #15 had shortness of breath when lying flat. The MDS indicated Resident #15 required mechanically altered diet. The MDS indicated Resident #15 was at risk for developing pressure ulcers. The MDS indicated Resident #15 received high-risk medications: antibiotics, diuretics (used to reduce fluid levels in the body and lowered blood pressure and reduced swelling), antiplatelet (used to prevent blood clots, could increase risk of bleeding and bruising). The MDS indicated Resident #15 used oxygen continuously and received intravenous (directly into the vein/bloodstream) antibiotics. The MDS indicated Resident #15 had a PICC (Peripherally Inserted Central Catheter) line (thin, flexible tube inserted into a vein in the arm and threaded to a large vein near the heart for long-term intravenous medication administration). Record review of Resident #15's Baseline Care Plan dated 04/25/26 revealed there were no care areas completed and it had not been signed. During an interview on 05/06/26 at 2:50 PM, the ADON said the purpose of the baseline care plan was to initiate the resident's care for anything that they needed to initiate the resident's care. The ADON said things such as a resident having a urinary catheter, a PICC line, and incontinence, would be things that should be included in the baseline care plan. 2. Record review of Resident #64's face sheet dated 05/06/26 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including ataxic cerebral palsy (rare, non-progressive neurological disorder which causes shaky, unsteady movements, poor balance, and difficulties with precise coordination), hypertension (high blood pressure), hypercholesterolemia (high cholesterol in the blood), major depressive disorder (serious mental health disorder which causes persistent, severe sadness, loss of interest in activities, significantly impairing daily life), and dementia (decline in cognitive function, such as in memory, thinking, and behaviors that interfere with daily life). Record review of Resident #64's admission MDS assessment indicated it was not due to be completed. Record review of Resident #64's Baseline Care Plan revealed it had been signed on 05/05/26 as completed, which was approximately 96 hours after admission. During an interview on 05/05/26 at 2:30 PM, the ADON looked in Resident #64's EHR and said Resident #64 had a baseline care plan filled out but it had not been signed as completed. The ADON said she would sign it at that time. The ADON looked in Resident #15's EHR and said Resident #15's baseline care plan had been opened on 04/25/26, but it had not been filled out or completed. The ADON said the baseline care plan should be completed within 72 hours of admission, she believed. During an interview on 05/06/26 at 3:09 PM, the DON said the purpose of the baseline care plan was, so they knew how to do the continuity of care for the resident. The DON said she opened the baseline care plans, and it had to be signed off by an RN. The DON said she opened the baseline care plan for Resident #15 on 04/25/26 and it was signed as completed on 05/5/26. The DON said Resident #64's baseline care plan was filled out and she saw it was not signed until 05/5/26. The DON said the baseline care plan should be completed within 48 hours of the resident's admission. During an interview 05/06/26 at 3:32 PM, the ADM said the purpose of the baseline care plan, in layman's terms, was to get to know how to take care of your resident and gave a baseline of where to go from. The ADM said the baseline care plan would include urinary catheters, PICC lines, incontinent status, and code status. The ADM said the baseline care plan should be completed within 48 hours of the resident's admission. The ADM said if the baseline care plan was not completed, the staff would not know how to take care of the resident. The ADM said they were currently in-servicing the nursing staff that baseline care plans had to be completed within 48 hours of the resident's admission. 3. Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication. Record review of the admission MDS assessment, dated 04/27/26, reflected Resident #47 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #47's baseline care plan, signed as completed by the DON on 05/05/26, reflected Resident #47 admitted to the facility on [DATE]. The baseline care plan was completed and signed 11 days (approximately 264 hours) after admission. 4. Record review of the face sheet, dated 05/06/26, reflected Resident #67 was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnoses of ventricular tachycardia (a fast, abnormal heart rhythm exceeding 100 beats per minute, originating in the heart's lower chambers (ventricles)). Record review of the MDS list in the electronic charting system, undated, reflected Resident #67's MDS assessments were not due to have been completed. Record review of Resident #67's baseline care plan, signed as completed by LVN E on 05/04/26, reflected Resident #67 admitted to the facility on [DATE]. The baseline care plan was completed and signed 3 days (approximately 72 hours) after admission. There was no RN signature. 5. Record review of the face sheet, dated 05/06/26, reflected Resident #69 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of lung transplant status (meaning he had a lung transplant), squamous cell carcinoma of skin of other parts of face (skin cancer), and chronic obstructive pulmonary disease (chronic, progressive lung disease that makes it difficult to breathe due to damaged airways or sacs). Record review of the MDS assessment list in the electronic charting system, undated, reflected Resident #69's MDS assessments were not due to have been completed. Record review of Resident #69's baseline care plan reflected the following: 1. The DON signed and completed Section 1 on 05/05/26, which was 4 days (approximately 96 hours) after admission. 2. LVN E signed and completed Section 2, 3, 4, and 5 on 05/04/26, which was 3 days (approximately 72 hours) after admission. During an interview on 05/06/26 beginning at 2:25 PM, the ADON stated baseline care plans were the nursing staff's responsibility to complete. She said the admitting nurse was responsible for initiating the baseline care plan because it had to be completed within 48 hours. She stated she or the DON monitored baseline care plan completion by looking in the electronic charting system under assessments. She stated she and the DON discussed the baseline care plan system last week during training as they were both new to the facility and were learning the systems. She was unsure why Resident #47, Resident #67, or Resident #69's baseline care plans were not completed within 48 hours. She stated it was not a policy of the company for RNs to sign off on baseline care plans. She stated it was important to ensure baseline care plans were completed within 48 hours because it was a starting point for the staff to be able to provide the appropriate care and services each resident needed. She stated it was important to ensure an RN was involved in the baseline care planning completion and review because it was regulatory. During an interview on 05/06/26 beginning at 2:36 PM, the DON stated she was instructed by the company that RNs did not have to open the baseline care plan. She stated that the admitting nurse was responsible for initiating the baseline care plan. She stated the nursing staff was responsible for ensuring the baseline care plans were completed within 48 hours of admission to the facility. She said she or the ADON were responsible for monitoring to ensure the baseline care plans were completed. She stated she was unsure why Resident #47, Resident #67, or Resident #69's baseline care plan was not completed within 48 hours. She stated the RN should have been signing off and locking the baseline care plan as it was reviewed. She stated it was important to ensure the baseline care plan was completed within 48 hours and an RN signed off on the baseline care plan, so the residents received the proper care and services they needed. During an interview on 05/06/26 beginning at 3:25 p.m., LVN E stated she was not the admitting nurse for Resident #67 or Resident #69. LVN E stated she was asked to complete Resident #67 and Resident #69's baseline care plans by the DON. She stated baseline care plans should have been completed within 48 hours of admission. She stated it was important to ensure baseline care plans were completed within 48 hours, so the staff knew what care and services to provide for each resident. During an interview on 05/06/26 at 10:56 AM, LVN D said she had worked at the facility for about five years. LVN D said the admitting nurse does the admission and the admission was completed as a team and was broken down into sections and three shifts to be completed with 36 hours. LVN D said the baseline care plan would be completed during the last section of the admission process by the third shift. LVN D said the baseline care plan was to put in place precautions such as the resident being a fall risk, having a urinary catheter, was a risk of elopement, skin break risks, diet, and to find out what the resident needed. LVN D said the baseline care plan should be completed within 48 hours of admission. LVN D said she could fill out the baseline care plan, but the RN had to sign off on it. LVN D said if the baseline care plan was not completed, then you would not have a true baseline of what the resident needed, and it could hinder moving forward with care the resident needed and/or could delay the resident's treatment. During an interview on 05/06/26 beginning at 3:55 p.m., the Administrator stated she expected baseline care plans to have been opened and completed within 48 hours of admission. She stated she expected the baseline care plan to have been reviewed and closed by an RN. She said the DON was responsible for monitoring to ensure baseline care plans were completed timely and reviewed by an RN. She stated it was important to ensure baseline care plans were completed timely, so the nursing staff had a care map for the residents. Record review of the Care Planning policy, dated 06/2020, reflected .A Licensed Nurse will initiate the Care Plan.The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission.

Based on observation, interview, and record review the facility failed to ensure an accurate MDS assessment was completed for 2 of 19 residents (Resident's #11 and #47) reviewed for MDS accuracy. 1. The facility did not ensure Resident #11's admission MDS assessment was accurately coded to reflect her tobacco use. 2. The facility did not ensure Resident #47's admission MDS assessment was accurately coded to reflect her indwelling catheter. These failures could place residents at risk of not receiving care and services to meet their needs.The findings included: 1. Record review of the face sheet, dated 05/06/26, reflected Resident #11 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of benign neoplasm of meninges (slow-growing noncancerous brain tumor) and tobacco use. Record review of Resident #11's smoking assessment, dated 02/20/26, reflected Resident #11 smoked and was safe to smoke with minimal supervision. Record review of the admission MDS assessment, dated 03/19/26, reflected Resident #11 had clear speech, was understood, and was usually able to understand others. She had a BIMS score of 13, which indicated no cognitive impairment. The MDS reflected Resident #11 was not coded for current use of tobacco products. Record review of the comprehensive care plan, dated 03/18/2026, reflected Resident #11 used tobacco products, smoking, chewing, or snuff. During an observation and interview on 05/04/26 beginning at 11:27 a.m., Resident #11 was lying in her bed with the head of the bed elevated slightly. Resident #11 stated she smoked during the scheduled smoking times at the facility. During an observation on 05/05/26 at 3:30 p.m., Resident #11 was in the smoking area with staff members. She was smoking a cigarette. 2. Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication and urinary retention (holding urine in the bladder). Record review of the admission MDS assessment, dated 04/27/26, reflected Resident #47 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #47 was not coded for indwelling catheter. Record review of Resident #47's baseline care plan, signed as completed by the DON on 05/05/26, reflected Resident #47 had an indwelling urinary catheter. During an observation on 05/04/26 at 3:16 p.m., Resident #47 was lying in bed facing the window. Resident #47's urinary catheter drainage bag was hanging on the side of the bed. There was a large amount of clear, yellow urine the tubing and bag. During an interview on 05/06/26 beginning at 2:17 p.m., Regional MDS Coordinator G stated she had been completing MDS assessments for the facility over the last month because they were in between MDS Coordinators. She stated Regional MDS Coordinator H had also been helping complete MDS assessments. She stated the MDS Coordinator completing the MDS assessment was responsible for making sure the MDS was completed accurately. Regional MDS Coordinator G stated she completed Resident #11's MDS assessment. She stated Resident #11 had been discharged from the facility and readmitted sometime in March of 2026. She stated when she completed the MDS assessment, the smoking assessment had not been re-done, and the progress notes did not indicate Resident #11 smoked. She stated she did not ask Resident #11 if she was smoking as the MDS assessments were being completed remotely. Regional MDS Coordinator G stated she was unsure why Regional MDS Coordinator H missed coding Resident #47's indwelling catheter. She stated it was important to ensure MDS assessments accurately reflected the resident's status for continuation of care and to ensure the facility and state had an accurate representation of the residents. During an interview on 05/06/26 beginning at 3:55 p.m., the Administrator stated she expected MDS assessments to have been completed accurately. The Administrator stated the Regional MDS Coordinators have been filling in until the ADON resumed the role. She stated the Regional MDS Coordinator and DON were responsible for monitoring to ensure the MDS assessments were completed accurately. She stated it was important to ensure MDS assessments were completed accurately for payment purposes and to ensure the facility staff knew how to serve the residents. The policy on MDS accuracy was requested. The Administrator stated the Care Planning policy was what the facility used for MDS accuracy. Record review of the Care Planning policy, dated 06/2020, did not address MDS accuracy. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2024, reflected J1300: Current Tobacco Use. Steps for Assessment. 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they had used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. H0100: Appliances. Steps for Assessment.1. Examine the resident to not the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances.

Based on observation, interview, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for the right to be informed. (Resident #47) The facility failed to ensure Resident #47 or her representative provided informed consent prior to taking fluoxetine (an antidepressant medication). These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication and major depressive disorder (serious mental health condition characterized by at least two weeks of persistent, severe low mood, loss of interest in activities, and low energy). Record review of the admission MDS assessment, dated 04/27/26, reflected Resident #47 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 5, which indicated severe cognitive impairment. Resident #47 had little interest and pleasure in doing things and felt down, depress, or hopeless 2 - 6 days during the 14 day look-back period. The MDS reflected Resident #47 had an active diagnosis of depression and took an antidepressant medication during the 7-day look-back period. Record review of Resident #47's baseline care plan, signed as completed by the DON on 05/05/26, reflected Resident #47 was taking psychotropic medications and a current list was provided and reconciled with the representative. Record review of the Order Summary Report, dated 05/06/26, reflected Resident #47 had an order, which started on 04/24/26, for fluoxetine 40 mg - Give one capsule by mouth one time a day related to depression. Record review of the MAR, dated April 2026, reflected Resident #47 received fluoxetine 40 mg on 04/25/26, 04/26/26, 04/27/26, 04/28/26, 04/29/26, and 04/30/26. Record review of the MAR, dated May 2026, reflected Resident #47 received fluoxetine 40 mg on 05/01/26, 05/02/26, 05/03/26, and 05/04/26. Resident #47 refused her medication on 05/05/26 and 05/06/26. Record review of Resident #47's Psychotropic Medication Consent form, effective 05/06/26, reflected consent was given by Resident #47 in person/written. The form was printed on 05/06/26 by Regional MDS Coordinator G but the ADON manually signed the form and dated it for 04/24/26. During an observation and attempted interview on 05/04/26 at 9:55 a.m., Resident #47 was lying in her bed with the head of her bed elevated slightly. She was unable to answer questions appropriately as evidenced by confused conversation. During an interview on 05/06/26 beginning at 2:17 p.m., Regional MDS Coordinator G stated she was asked to provide a psychotropic consent form for Resident #47. She stated she printed the form earlier in the morning on 05/06/26. She stated she was unsure who completed or signed the form. During an interview on 05/06/26 beginning at 2:25 p.m., the ADON stated she was asked to sign Resident #47's psychotropic consent form for her antidepressant and date it for 04/24/26. The ADON stated she signed the form on 05/06/26 earlier in the morning. She stated she was unable to remember who asked her to sign the form. The ADON stated the consent was not obtained from the resident but was unable to remember if she spoke with the family. The ADON stated the admitting nurse was responsible for obtaining the psychotropic consent forms before a medication was given. She stated the nurse management was responsible for monitoring to ensure psychotropic consent forms were obtained. She was unsure why Resident #47's consent form was not obtained. She stated it was important to ensure psychotropic consent forms were obtained prior to receiving the psychotropic medication because the medication was mind-altering and the family and representative needed to be aware of the risks and benefits. During an interview on 05/06/26 beginning at 2:36 p.m., the DON stated she expected psychotropic consent forms to have been obtained prior to administering the psychotropic medication. She stated the ADON was responsible for monitoring to ensure psychotropic consent forms were obtained. She stated it was important to ensure psychotropic consent forms were obtained so the resident or family understood the risks or benefits of the mind-altering drug. The DON stated she was unaware Resident #47's consent was not obtained for her antidepressant. During an interview on 05/06/26 at 2:51 p.m., Resident #47's responsible party was called on the telephone with no response. A brief message was left with a call back number but was not returned upon exit of the facility. During an interview on 05/06/26 at 3:42 p.m., the ADON stated she reviewed Resident #47's electronic chart and believed Resident #47 had not received her antidepressant medication since being admitted to the facility. She stated Resident #47 had been refusing at least since 04/29/26 according to the progress notes. She stated the MAR reflected she had been getting the medication, but the progress notes clearly reflected that she was refusing. Record review of Resident #47's progress notes, dated between 04/06/26 and 05/06/26, reflected no progress notes regarding refusal of medications or behaviors. Record review of Resident #47's fluoxetine medication card (blister pack) that was received on 04/24/26, reflected there were 8 missing doses. During an interview on 05/06/26 beginning at 3:46 p.m., the Treatment Nurse stated she worked the floor at times. She stated Resident #47 had been receiving and taking her antidepressant medication. During an interview on 05/06/26 beginning at 3:55 p.m., the Administrator stated she expected psychotropic consent forms to have been completed upon admission, prior to receiving the medication. She stated the DON was responsible for monitoring to ensure psychotropic consent forms were completed. She stated it was important to ensure consent forms were obtained so the resident or family knew and agreed to what they were taking. Record review of the Psychotherapeutic Drug Management policy, dated 01/2025, reflected .G. The Licensed Nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the Attending Physician form the resident and/or surrogate decision maker, unless it is an emergency situation.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 24 residents reviewed for ADLs (Residents #54.)The facility failed to provide Resident #54 with a shower the week of 4/27/26-5/03/26.This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included:Record review of Resident #54's face sheet dated 5/05/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #54 had diagnoses which included Parkinson's disease (movement disorder), right knee pain, difficulty walking, dementia (forgetfulness), chronic pain syndrome and osteoarthritis (degenerative joint disease that breaks down the cartilage and underlying bone, causing pain, stiffness, and reduced mobility).Record review of Resident #54's annual MDS dated [DATE] indicated she understood others and was understood. Resident #54 had a BIMS with a score of 13, which indicated she was cognitively intact. The MDS indicated Resident #54 did not reject care. Resident #54 required moderate staff assistance with shower/bathing and most ADLs including personal hygiene.Record review of Resident #54's undated care plan indicated she had an ADL self-care deficit related to weakness and required partial/moderate assist by one staff with shower and personal hygiene.Record review of the facility's shower schedule sheet updated 3/23/26 indicated Resident #54 was scheduled for a shower on Tuesdays, Thursdays, and Saturdays before breakfast.Record review of Resident #54's CNA Shower Forms dated from 4/28/26-5/05/26 indicated the resident refused showers on 4/28/26 and 4/30/26. There was no Shower Form for Resident #54 on 5/02/26. There was a Shower Form for Resident #54 dated 5/05/26 indicating she was showered on 5/05/26.During an observation and interview on 5/04/26 at 12:05 PM, Resident #54 was sitting up in her wheelchair in her room. Resident #54 appeared well groomed and no odors were noted. Resident #54 said the staff treated her good and usually answered her call light timely. Resident #54 said the staff did the best they could and she thought they were short staffed. Resident #54 said she had not had a shower in over a week and had asked for one on her scheduled days and still did not get it. Resident #54 said they had moved her from the Monday, Wednesday, and Friday shower schedule to the Tuesday, Thursday, and Saturday schedule not long ago because there were too many showers for the shower aide to give on Monday, Wednesday, and Fridays. Resident #54 said she enjoyed a good shower.During an observation and interview on 5/05/26 at 10:00 AM, Resident #54 was sitting in her recliner, dressed and appeared well groomed. Resident #54 said she still had not had a shower in over a week. Resident #54 said she was supposed to receive her showers on Tuesday, Thursdays, and Saturdays, and she should receive a shower today (5/05/26).During an observation and interview on 5/05/26 at 3:07 PM, Resident #54 said she still had not received her shower and today (5/05/26) was supposed to be her day. Resident #54 asked Do you reckon I will get a shower today? Resident #54 said she had asked several staff about getting her shower after not receiving a shower on her scheduled days and they told her they would try to give her a shower if they had time. Resident #54 said she did not refuse showers and enjoyed a good shower.During an observation and interview on 5/06/26 at 9:49 AM, Resident #54 was sitting up in her recliner with damp hair and was using a hair pick to comb her hair. Resident #54 said she received a shower that morning but did not get it on her scheduled day yesterday (Tuesday, 5/05/26). Resident #54 said she did not want her hair dried and preferred it to dry naturally.During an interview on 5/06/2026 at 9:55 AM, CNA A said he had worked at the facility for about seven months. CNA A said there were two aides for approximately 37 residents and shower aides were supposed to work every day except Sundays. CNA A said there was a shower sheet with what residents were on what days. CNA A said the aides got the residents ready with their clothes and took the resident to the shower room and then the shower aide bathed the resident and would bring the resident back to their room when done. CNA A said the residents would sure let them know if they did not get their showers. CNA A said then they had to tell the resident they would try to work them in for a shower if they get caught up with keeping everyone changed. CNA A said Resident #54 said she had not had a shower in a week that morning and they got her one today (5/06/26). CNA A said Resident #54 should have had a shower Saturday (5/02/26) and yesterday (5/05/26). CNA A said the CNAs, nurses and everyone were responsible for ensuring the residents were bathed. CNA A said if the residents were not getting their showers, it could make them feel neglected.During an interview on 5/06/26 at 10:27 AM, CNA J said she was the shower aide on Mondays, Wednesdays, and Fridays and was planning to pick up an extra day starting Thursday next week. CNA J said she filled out a paper shower form for each shower she gave. CNA J said sometimes some residents would refuse but she was able to knocked out most of her residents. CNA J said the CNAs were responsible for ensuring the residents were showered. CNA J said the aides on the floor got the residents ready and brought the residents to her at the shower, unless the resident was walkie talky and she would grab them herself. CNA J said she has had some residents say they did not get their showers. CNA J said she had some residents refuse today (5/06/26) and she was able to give Resident #54 a shower today (5/06/26). CNA J said it mentally bothered the residents when they did not get their showers, and some residents had told her that nobody cared about them and were upset about it. CNA J said she picked up extra showers when she could. CNA J said she did not complete documentation in the EHR but gave the completed shower forms to the nurse and then the nurse signed it and then turned it in to either the ADON or DON.During an interview on 5/06/26 at 10:50 AM, the ADON said the shower aide for Tuesdays, Thursdays, and Saturdays had been out last week and this week. The ADON said she did not know who the DON had doing showers while the shower aide had been off.During an interview on 5/06/2026 at 10:46 AM, CNA C said she had worked at the facility for a little over a year and normally worked the day shift (6 AM- 6 PM). CNA C said they had enough staff to complete her tasks and care for the residents. CNA C said residents have told her about not getting their showers, usually every other day. CNA C said the residents usually complain on the days CNA J was not there, so it would be the Tuesday, Thursday, ant Saturday residents. CNA C said she reported to the DON and ADM when residents told her they had not received their shower. CNA C said if she had time, she would get the resident a shower when they told her they had not had a shower or wanted a shower. CNA C said there were only two aides managing the floor (keeping everyone turned, incontinent care, getting residents up for meals, laying residents down, ect.) CNA C said she wished they had a 3rd person because, if the shower aide did not show up, then they do not have enough time to do showers on top of caring for almost 40 residents. CNA C said if it was her and she was missing showers, then she would feel dirty. CNA C said residents normally should be receiving three showers a week, unless they refuse.During an interview on 5/06/2026 at 10:56 AM, LVN D said she had worked at the facility for about five years. LVN D said the nurses were responsible for ensuring the residents receive their showers. LVN D said their shower aide gave them the completed shower sheets and then they compared it to the list of who was supposed to have been showered. LVN D said if she found out that a resident was not showered, she would ask the shower aide and aides what happened and report it to the DON. LVN D said she knew there had been an issue with having 40 residents for one shower aide and she could not provide showers to all the residents if there was not another shower aide. LVN D said it could affect the resident's mood, skin integrity, and their quality of life if not receiving their showers. During an interview on 5/06/26 at 2:27 PM, CNA K said she had worked at the facility for about eight years and normally worked the 6 AM - 6 PM shift and every other weekend. CNA K said they have a shower list to go by to know who was supposed to be showered and when. CNA K said they had a shower aide, CNA J, for Mondays, Wednesdays, and Fridays and CNA J came faithfully. CNA K said they did not have a Tuesday, Thursday, and Saturday shower aide at this time. CNA K said then it was if someone wanted to work extra to do showers on Tuesday, Thursday, and Saturdays, or it was left to the aides on the floor to do the showers on those days. CNA K said there were only two CNAs and a shower aide, on the days they have one. CNA K said there were about 38-40 residents on her end (South end). CNA K said she tried to do the showers that she could but could not get everyone's showers completed. CNA K said she told the nurse when showers were not completed. CNA K said the department heads knew there was not a shower aide there on Tuesdays, Thursdays, and Saturdays and did not know what they expected them to do. CNA K said Resident #54 was scheduled for Tuesdays, Thursdays, and Saturday showers but they did not have a shower aide yesterday and she did not get a shower. CNA K said she did not work Resident #54's hall 5/05/26) but if she had to guess Resident #54 probably asked to have a shower. CNA K said CNA L was actually assigned to Resident #54's hall, but herself and CNA L work a lot as a team due to several residents required two people. CNA K said it could cause skin issues if the resident was not receiving showers and could make them feel neglected. On 5/06/26 at 2:37 PM and 4:10 PM, called CNA L. There was no answer and a detailed voicemail was left requesting a return call. CNA L did not return the call prior to the surveyor exiting the facility.During an interview on 5/06/26 at 2:50 PM, the ADON said the DON got other people to fill in when the shower aide was not there. The ADON said when all the staff were there, everything ran smoothly. The ADON said the shower aide had not been completing the documentation for the showers in the EHR and was filling out the paper forms. The ADON said with herself and the DON having to work the floor a lot in the month they had been there; they had not been able to go through the shower sheets to see who had gotten showers and who had not. The ADON said going forward the shower aide would complete her own documentation in the EHR then they could pull reports to be able to follow up. The ADON said everyone liked to be clean. The ADON said the resident would probably be upset about not getting their showers and it could affect their self-worth or something.During an interview on 5/06/26 at 3:09 PM, the DON said she had been the DON at the facility for about a month. The DON said the shower aide for Tuesday, Thursday, and Saturday was out last week and this week. The DON said if the shower was scheduled on the weekends, the aides were expected to do their own showers. The DON said they did have agency staff last Saturday. The DON said their policy said to bathe the residents at a minimum of once a week, but they scheduled the residents' showers for three times a week and if they requested a shower. The DON said the residents needed their showers for dignity issues and continuity of care. During an interview on 5/06/26 at 3:32 PM, the ADM said their policy was for the residents to have a minimum of one shower a week. The ADM said they scheduled the resident showers three days a week in hopes to get at least one shower completed weekly. The ADM said they tried to accommodate the best they could when residents asked for showers. The ADM said CNA J, the shower aide on Monday, Wednesday, and Fridays had a heavy schedule. The ADM said if the shower aide was not able to bathe the resident and the resident requested a shower; she would expect the resident to get a shower. The ADM said if the resident did not receive their shower, it could cause the resident to feel unclean.Record review of the facility's undated policy titled Showering a Resident, indicated . a shower bath is given to the resident to provide cleanliness, comfort and prevent body odors . residents are offered a shower at a minimum of once weekly and given per resident request .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary clean, comfortable, and homelike environment for 1 of 19 residents reviewed for environment. (Resident #3) 1.The facility failed to replace missing pieces from Resident #3's window blinds. This failure could place residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.Findings included: 1. Record review of Resident #3's face sheet, dated 5/6/26, reflected she was a [AGE] year-old female, initially admitted on [DATE] and re-admitted to the facility on [DATE]. Her diagnosis included anxiety disorder, muscle wasting and atrophy not elsewhere classified, right shoulder, muscle weakness, need for assistance with personal care, cognitive communication deficit and dementia (a decline in mental ability). Record review of Resident #3's comprehensive MDS assessment, dated 3/23/26, reflected that she had a BIMS score of 9, which indicated moderate cognitive impairment. Record review of Resident #3's care plan, dated 3/21/24, reflected Resident #3 has an ADL self-care performance deficit related to left hemiplegia weakness and incontinence. During an observation and interview on 5/4/26 at 3:09 PM, revealed the blinds in Resident #3's room were damaged and sunlight was shining in with the blinds closed. Resident #3 stated the damaged blinds bothered her when the sun shined into her eyes. During an observation on 5/5/26 at 2:55 PM, revealed Resident #3 was lying in bed. Resident #3's blind continued to be damaged. During an interview on 5/5/26 at 2:57 PM, a Family Member of Resident #3 was in the resident's room. The Family Member stated that the blinds in the resident's room had been damaged ever since the resident had been in the room. She stated she could see how the damaged blind could affect Resident #3 during the day, because the light shined in on the resident even when the blinds were closed. She stated she had not told anyone in the facility about the damaged blinds. During an observation on 5/6/26 at 9:29 AM, revealed Resident #3 was lying in be watching television. Resident #3's blinds on window were still damaged and sunlight continued to shine in the room while the blinds were closed. During an interview on 5/6/26 at 11:41 AM, CNA C stated usually she closed the curtain in Resident #3's room, so she did not get too much sunlight from the damaged blinds. She stated she honestly did not know if maintenance was aware of the damaged blinds. She stated maintenance was responsible for replacing the blinds. She stated a negative effect of the damaged blinds was that if the resident was trying to sleep during the day it was too much light coming in. She stated they all liked to sleep with the lights off. During an interview on 5/6/26 at 11:46 AM, the ADON stated she had not noticed the blinds in Resident #3's room. She stated she had not been in Resident #3's room. She stated she expected the residents' blinds to be functionable for the residents' preference. She stated Maintenance was responsible for replacing the blinds, but it was everyone's responsibility for reporting the blinds if they were damaged. She stated a negative effect of the damaged blinds was it could possibly exacerbate the residents' behaviors. She stated if the resident did not get her rest, it could cause behaviors. During an interview on 5/6/26 at 12:12 PM, the Maintenance Director stated he was just notified of the blinds in Resident #3's room about 10 minutes ago. He stated he was responsible for replacing the damaged blinds. He stated he did a walk through of the facility checking the rooms. He stated a negative effect of the damaged blinds was that there was light coming in the room where it should not be and it affects the residents' privacy. During an interview on 5/6/25 at 2:45 P.M., the Director of Nursing stated she expected the residents' blinds to be suitable to block out the sunshine when light comes through for their comfort. She stated maintenance was responsible for repairing or replacing the blinds. She stated a negative effect of the damaged blinds was that the residents may not be able to get rest due to the damaged blinds. During an interview on 5/6/26 at 3:06 P.M., the Administrator said she would agree that the light coming in during the day, with the damaged blinds, was a homelike environment issue. She stated as soon as the facility was made aware of the issue, they addressed it and fixed it. She stated she expected damaged blinds to be replaced. She stated maintenance was responsible for replacing damaged blinds. She stated a negative effect was that the blinds were unsightly. Record review of a facility policy titled, Resident Rooms and Environment date revised 08/2020. To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 1. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: C. Lighting that is comfortable (minimum glare) yet adequate (suitable to the task) .

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 19 (Resident #14) reviewed for medications in room. 1 of 3 medication carts reviewed (Nurse medication cart for the Front Halls) 1.The facility failed to ensure Resident #14 did not have over the counter medication Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in room on 5/4/26, 5/5/26 and 5/6/26. The facility failed to ensure LVN B secured and locked the nurse medication cart for Front Halls. 2.This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions. Findings included: 1.Record review of Resident #14's face sheet dated 5/6/26 indicated Resident #14 was an 82-years-old female initially admitted on [DATE] and readmitted on [DATE] to the facility. Resident #14 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe) and chronic respiratory failure with hypoxia (a long-term, serious condition where the lungs cannot adequately transfer oxygen into the blood, resulting in consistently blood oxygen levels). Record review of Resident #14's quarterly MDS assessment dated [DATE] indicated Resident #14 was usually understood and usually had the ability to understand others. Resident #14 had a BIMS score of 5 which indicated severe cognitive impairment. Pulmonary indicated chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe). Pain assessment indicated pain present. Record review of Resident #14's care plan dated 8/8/25 indicated over-the-counter medication will sometimes be found in room that was provided by family. Intervention included education provided to Resident #14 and family. Record review of Resident #14's care plan dated 8/8/25 indicated altered respiratory status/ difficulty breathing related to chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe). Interventions included administer medication/puffers as ordered. Monitor for effectiveness and side effects. Record review of Resident #14's order summary report dated 5/4/26 indicated oxygen at 2-4 liters via nasal cannula continuous every shift continuous. Start date 7/31/25. Further review revealed there was no physician order for Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms). During an observation on 5/4/26 at 11:01 AM, Resident #14 was not in room. Resident #14 had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on her bed and she used an oxygen concentrator. During an observation on 5/4/26 at 2:49 PM, Resident was not in room but had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on her bed. During an observation on 5/5/26 at 2:30 PM, Resident #14 had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on bed. Resident sitting up in wheelchair with oxygen in place. Resident #14 said she used the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) for her nose. Resident #14 said with her being on oxygen; the nasal cannula made her nose dry and hard, but the ointment reduces the hardness and dryness. During an observation on 5/6/26 at 9:33 AM, Resident #14 was lying in bed asleep with her oxygen in place with Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) on bed. During an observation on 5/6/26 at 10:47 AM, Resident #14 was not in room. Resident had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) lying on the bed. During an interview on 5/6/26 at 11:08 AM, CNA B said he was not aware of the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in Resident #14's room. He said if he found medication in a resident's room, he would have notified the nurse immediately of what he found. He said a negative effect of the medication in the resident's room was she could have too much of the medication at one time. During an interview on 5/6/26 at 11:12 AM, the Director of Nursing stated all staff were responsible for ensuring the residents do not have medications in their rooms. She stated she expected all medications to be administered by the nurse. She stated the negative effect of Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in the resident's possession was it had petroleum in it and the resident was on oxygen. She stated petroleum with oxygen could be a fire hazard. 2. Record review of a Daily Census provided by the facility on 5/4/26 indicated a census of 50. During an observation on 5/5/26 at 12:30 PM, it was revealed while walking on the Front Hall that the nurse cart was unlocked in front of the nurse's station. During an interview and observation on 5/6/26 at 12:32 PM, LVN B stated she was responsible for Front hall nursing cart. She came from the nurses' station to the cart and noticed the cart was unlocked, then she said she was responsible for the unlocked medication cart. She said the nurse assigned to the cart was responsible for ensuring the cart was locked. She said a negative effect of the cart unlocked was that a resident could get into the cart. During an interview on 5/6/26 at 11:46 AM, the ADON said she did not see the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) medication in Resident #14's room. She said the staff does ambassador rounds to check the residents' rooms. She stated the negative effect was that the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) could blow up the resident's room, because the petroleum ointment and oxygen used together is flammable.She said the nurse who was assigned to the cart was responsible for ensuring the cart was locked. She said a negative effect of the cart being unlocked was that demented residents or anyone could get into the cart and take the medication. During an interview on 5/6/26 at 2:50 PM, the Director of Nursing said she expected the nurses to have the medication carts locked while not in use. She said the nurse with the keys meant that the cart was assigned to them was responsible for ensuring the medication cart was locked. She said a negative effect of the unlocked medication cart was that anyone could get into it. During an interview on 5/6/26 at 3:07 PM, the Administrator said Resident #14 liked to keep things tucked under her while in bed. She said she expected residents to not have medications in their rooms. She said staff educated her Resident #14 about not having medications in her room, but she was not going to remember. She said staff would be educating the family on not bringing medications to Resident #14. She stated the negative effect of the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in Resident #14's room was that she cannot use it with oxygen, because it could cause a fire. She said as soon as the surveyor noticed the medication cart was unlocked; she was in serviced the nurse right away. She said she expected the nurses to keep the medication carts locked when not in use. She said the nurses were responsible for ensuring the medication carts were locked. She said a negative effect of the unlocked medication cart was it could be medications missing from it. Review of the facility Medication Storage Policy revised dated 01/2026 indicated, To establish standards that safeguard residents by preventing unauthorized access to medications and ensuring compliance with applicable federal and state pharmacy regulations. Medication carts must remain locked and always secured unless under direct and continuous supervision of authorized personnel during medication administration. These standards are required to ensure resident safety and regulatory compliance. Security & Access: Medication rooms, carts, and cabinets must remain locked at all times. 1. Locking Requirements: When turning away from the cart. When more than arm's reach from the cart. After completing a medication pass.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 19 residents (Resident #47) reviewed for resident rights. The facility failed to ensure Resident #47's catheter drainage bag was in a privacy bag. This failure could place residents at an increased risk of embarrassment and a diminished quality of life. The findings included: Record review of the face sheet, dated 05/06/26, reflected Resident #47 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of zoster (also known as shingles, is a painful, blistering rash caused by the reactivation of the dormant varicella-zoster virus which also causes chickenpox) without complication and urinary retention (holding urine in the bladder). Record review of the admission MDS assessment, dated 04/27/26, reflected Resident #47 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #47's baseline care plan, signed as completed by the DON on 05/05/26, reflected Resident #47 had an indwelling urinary catheter. During an observation and attempted interview on 05/04/26 at 9:55 a.m., Resident #47 was lying in her bed with the head of her bed elevated slightly. She was unable to answer questions appropriately as evidenced by confused conversation. Resident #47's urinary catheter drainage bag was hanging on the side of the bed with no privacy cover. There was a large amount of clear, yellow urine in the tubing and bag that was visible from the hallway. During an observation on 05/04/26 at 3:16 p.m., Resident #47 was lying in bed, turned on her right side facing the window. Resident #47's urinary catheter drainage bag was hanging on the side of the bed with no privacy cover. There was a large amount of clear, yellow urine the tubing and bag that was visible from the hallway. During an observation on 05/06/26 at 10:03 a.m., Resident #47 was lying in her bed with the head of her bed slightly elevated. Resident #47's urinary catheter drainage bag was hanging on the side of the bed with no privacy cover. There was a small amount of clear, yellow urine in the tubing and bag that was visible from the hallway. During an interview on 05/06/26 beginning at 2:06 p.m., CNA F stated she was aware Resident #47 did not have a privacy cover on her catheter drainage bag and had reported it to the nurse. She stated she had been trying to keep the catheter drainage bag in a pillowcase, but when therapy brought her back to her room earlier in the day (05/06/26), the therapy staff did not replace the catheter drainage bag inside the pillowcase. CNA F stated she placed the drainage bag back inside the pillowcase when she was passing ice. CNA F stated it was important to ensure Resident #47 had a privacy bag on her catheter drainage bag to maintain her dignity. During an interview on 05/06/26 beginning at 2:10 p.m., LVN B stated she was unaware Resident #47 did not have a privacy cover for her catheter drainage bag. She stated everyone was responsible for ensuring catheter drainage bags had a privacy cover. She stated whoever noticed the privacy cover was missing should have reported it to the nurse. She stated it was important to ensure catheter drainage bags had a privacy cover to maintain the resident's dignity. During an interview on 05/06/26 beginning at 2:36 p.m., the DON stated she expected the nursing staff to ensure catheter drainage bags had a privacy cover. The DON stated whoever noticed a privacy cover was missing was responsible for notifying the nurse, who then supplied a privacy cover out of the central supply. She stated nursing management was responsible for monitoring to ensure catheter drainage bags had privacy covers. She stated it was important to ensure catheter drainage bags had a privacy cover to maintain a resident's dignity. During an interview on 05/06/26 beginning at 3:55 p.m., the Administrator stated she expected facility staff to ensure a catheter drainage bag had a privacy cover at all times. She stated CNAs were responsible for monitoring to ensure catheter drainage bags had a privacy cover. She stated the therapy staff returned Resident #47 to her room earlier in the day (05/06/26). She said the therapy staff believed that a catheter drainage bag did not require a privacy cover while the residents were in their rooms. She stated in-service education was provided to the therapy staff on 05/06/26. The Administrator stated it was important to ensure catheter drainage bags had a privacy cover to maintain the residents' dignity. Record review of the Privacy and Dignity policy, dated 01/2026, reflected .Staff assist residents in maintaining self-esteem and self-worth. The policy did not address privacy covers on a catheter drainage bag.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 19 (Resident #14) reviewed for adequate supervision and assistive device to prevent accidents. The facility failed to ensure Resident #14 did not use Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) while nasal canula delivering oxygen was in place. These failures could place residents at an increased risk for injury.Findings included: Record review of Resident #14's face sheet dated 5/6/26 indicated Resident #14 was an 82-years-old female initially admitted on [DATE] and readmitted on [DATE] to the facility. Resident #14 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe) and chronic respiratory failure with hypoxia (a long-term, serious condition where the lungs cannot adequately transfer oxygen into the blood, resulting in consistently blood oxygen levels). Record review of Resident #14's quarterly MDS assessment dated [DATE] indicated Resident #14 was usually understood and usually had the ability to understand others. Resident #14 had a BIMS score of 5 which indicated severe cognitive impairment. Pulmonary indicated chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe). Pain assessment indicated pain present. Record review of Resident #14's care plan dated 8/8/25 indicated over-the-counter medication will sometimes be found in room that was provided by family. Intervention included education provided to Resident #14 and family. Record review of Resident #14's care plan dated 8/8/25 indicated altered respiratory status/ difficulty breathing related to chronic obstructive pulmonary disease with (acute) exacerbation (a progressive, treatable lung disease that restricts airflow, making it hard to breathe). Interventions included administer medication/puffers as ordered. Monitor for effectiveness and side effects. Record review of Resident #14's order summary report dated 5/4/26 indicated oxygen at 2-4 liters via nasal cannula continuous every shift continuous. Start date 7/31/25. Further review revealed there was no physician order for Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms). During an observation on 5/4/26 at 11:01 AM, Resident #14 was not in room. Resident #14 had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on her bed and she used an oxygen concentrator. During an observation on 5/4/26 at 2:49 PM, Resident was not in room but had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on her bed. During an observation on 5/5/26 at 2:30 PM, Resident #14 had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) on bed. Resident sitting up in wheelchair with oxygen in place. Resident #14 said she used the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) for her nose. Resident #14 said with her being on oxygen; the nasal cannula made her nose dry and hard, but the ointment reduces the hardness and dryness. During an observation on 5/6/26 at 9:33 AM, Resident #14 was lying in bed asleep with her oxygen in place with Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) on bed. During an observation on 5/6/26 at 10:47 AM, Resident #14 was not in room. Resident had Mentholatum original ointment (topical rub to relieve minor aches, pains and cold symptoms) lying on the bed. During an interview on 5/6/26 at 11:08 AM, CNA B said he was not aware of the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in Resident #14's room. He said if he found medication in a resident's room, he would have notified the nurse immediately of what he found. He said a negative effect of the medication in the resident's room was she could have too much of the medication at one time. During an interview on 5/6/26 at 11:12 AM, the Director of Nursing stated all staff were responsible for ensuring the residents do not have medications in their rooms. She stated she expected all medications to be administered by the nurse. She stated the negative effect of Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in the resident's possession was it had petroleum in it and the resident was on oxygen. She stated petroleum with oxygen could be a fire hazard. During an interview on 5/6/26 at 11:46 AM, the ADON said she did not see the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) medication in Resident #14's room. She said the staff does ambassador rounds to check the residents' rooms. She stated the negative effect was that the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) could blow up the resident's room, because the petroleum ointment and oxygen used together is flammable. During an interview on 5/6/26 at 3:07 PM, the Administrator said Resident #14 liked to keep things tucked under her while in bed. She said she expected residents to not have medications in their rooms. She said staff educated her Resident #14 about not having medications in her room, but she was not going to remember. She said staff would be educating the family on not bringing medications to Resident #14. She stated the negative effect of the Mentholatum ointment (topical rub to relieve minor aches, pains and cold symptoms) in Resident #14's room was that she cannot use it with the oxygen, because it could cause a fire. Record review of a facility's Oxygen Administration policy revised 01/2026 indicated, To provide guidelines for the safe and effective administration of oxygen to prevent or reverse hypoxemia and ensure adequate tissue oxygenation. Safe Handling of Oxygen/ Equipment: C. Oil, alcohols, and petroleum products are not to be used around the resident's face .

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure foods stored in the kitchen walk-in refrigerator were thrown away when expired. 2. The facility failed to ensure foods stored in the kitchen walk-in freezer were thrown away when expired. 3. The facility failed to ensure a mixing bowl with a pink and white substance was labeled and dated. 4. The facility failed to properly store raw meat in the kitchen walk-in refrigerator. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation on [DATE] at 09:08 AM, an initial tour of the kitchen was conducted. The following items were observed: 1) 1 mixer bowl half-full of a white and pink frozen substance in the freezer. It was not covered, labeled or dated. 2) 1 container labeled peas in the freezer, dated [DATE], expiration date of [DATE]. 3) 1 container labeled pinto beans in the freezer, dated [DATE], expiration date of [DATE]. 4) 1 container labeled cottage cheese in the refrigerator, expiration date of [DATE]. 5) 1 pan of raw bacon found in the refrigerator. The pan was on the top shelf of the refrigerator above bags of bread and cooked meat on the shelf. During an interview on [DATE] at 9:15AM, [NAME] A said that she was not sure why the items were in the freezer and refrigerators. She pulled the items out of the freezer and refrigerator and threw them away. She also moved the raw bacon to the bottom shelf. During an interview on [DATE] at 12:47 PM, the Dietary Manager said she expected the expired foods to be thrown away when they were found. She said she expected the raw meat to be kept on the bottom shelf. She said everyone that worked in the kitchen was responsible for throwing out the expired food. She said she usually checked the kitchen Monday and Friday mornings for expired foods. she was not working on [DATE] and was unable to check the kitchen. During an interview on [DATE] at 01:44 PM, the Administrator said his expectation was that food be labeled and dated and raw meat should have been on the bottom shelf. He said the risk was foodborne illness. Record review of the Facility's policy, Food Storage, dated 2018, stated: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines . .Procedure: . .2. Refrigerators . .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. f. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat food . .3. Freezers . .e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated .

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 17 residents reviewed for care plans, (Resident #4). Resident #4 was not have a care planned for her DNR (a medical order instructing healthcare providers not to perform CPR or other resuscitative measures if a patient's heart or breathing stops). Her care plan indicated she was a full code. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the undated face sheet indicated Resident #4 was a [AGE] year-old female that admitted [DATE] and readmitted [DATE]. The face sheet indicated she had diagnoses that included: cerebral infarction (blood flow to the brain is interrupted, causing tissue to die), heart failure (the heart does not pump blood as well as it should), and vascular dementia with behaviors (blood flow disruptions to the brain causing changes in behavior and mood including depression, agitation, and anger, along with difficulties in thinking, memory, and daily activities.) Record review of the physician's orders dated [DATE] for Resident #4 indicated: [DATE] DNR Record review of the quarterly MDS dated [DATE] indicated Resident #4 had unclear speech, rarely understood others, and was rarely understood. The MDS indicated she had short- and long-term memory problems. Record review of the Care Plan dated [DATE] indicated Resident #4 had impaired cognitive function with impaired thought processes related to dementia. The care plan indicated she was a Full Code status with an initiated date of [DATE] and a revision date of [DATE]. Record review of an OOH-DNR dated [DATE] indicated Resident #4 was a DNR. During an interview on [DATE] at 9:50 AM, LVN B looked in the electronic health record for Resident #4. LVN B said Resident #4 was a DNR. He looked at her care plan and said it indicated she was a full code and that was wrong. He said the care plan should indicate she was a DNR. He said the care plan should have been updated when Resident #4 got the DNR order and signed the OOH-DNR. During an interview on [DATE] at 9:55 AM, the ADON checked Resident #4's electronic chart and said Resident #4 was a DNR. She looked at the care plan and said the care plan indicated she was a DNR and had been updated today ([DATE]). The ADON was shown Resident #4's care plan from earlier today that indicated she was a full code. The ADON said a full code was wrong for Resident #4. She said the care plan for Resident #4 should have been updated on [DATE] when she got the order for the DNR and the OOH-DNR. During an interview on [DATE] at 10:28 AM, the MDS nurse looked at Resident 4's electronic chart and said she was a DNR. She looked at the care plan and said her care plan had been updated to a DNR today, [DATE]. She said she only worked 2 days per week. She said if the care plan indicated a full-code, it was wrong. She said the care plan should have indicated a DNR from the date Resident #4 got the DNR, ([DATE]). She said she was responsible for the mistake and should have caught it. She said the SW usually updated advance directives. She said she usually found out about a change from the DON or SW verbally or by email. The MDS nurse did not remember anyone telling her or sending an email indicating Resident #4 got a DNR on [DATE]. During an interview on [DATE] at 10:33 AM, the SW said she worked 2 days per week. She said if she had assisted with an advance directive, she would have care planned it. She said the DON or ADON would usually notify her if there was a change in a resident's advance directive. She said she did not know Resident #4 had gotten a DNR. She said she was responsible for making sure the advance directive was correct in the care plan. She said she did not work [DATE] and no one notified her of the change from a full code to a DNR. She said the person that assisted with the advance directive, the DON or ADON, should have let her know about a change. She said the DON would double check care plans to make sure they were correct. During an interview on [DATE] at 12:52 PM, the DON said she agreed that when surveyors entered the building the care plan for Resident #4 indicated a full code and that was wrong. She said she corrected the care plan on [DATE]. She said the care plan should have been changed to a DNR as soon as Resident #4 became a DNR on [DATE]. She said the person responsible for making sure the care plan was correct was her. She said she, the MDS nurse, and the SW worked on the care plans and somehow Resident #4's DNR got missed. She said there was not really a risk to the resident if the care plan was wrong because the book on the crash cart was correct and when her electronic record was pulled up it indicated Resident #4 was a DNR. She said in the event of a code (resident stopped breathing) nurses would not go to the care plan to check her status because they used the book on the crash cart which indicated she was a DNR. During an interview on [DATE] at 1:04 PM, the ADM said Resident #4's care plan should have been updated on [DATE], when she got the DNR. He said there was really not a risk to the resident, but the care plan documentation was incorrect. He said the crash cart book had her DNR correctly identified, and her electronic chart showed she was a DNR. He said if a resident coded, the nurses would look at the crash cart book which indicated she was a DNR. He said the final responsibility for the care plan being correct was the DON. Record review of a Care Plans, Comprehensive, Person Centered policy with a revised date of [DATE], provided by the ADM indicated: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 13. Assessments of residents are ongoing and care plans are r revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met .

Based on observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was properly secured in his wheelchair during transport, in which Resident #1 fell forward onto his hands and knees when CNA A hit the brakes on 08/20/2024. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 08/20/2024 and ended on 08/21/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury/death from a vehicle accident and decreased quality of life. Findings Include: Record review of the face sheet dated 10/02/2024, indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] and discharged from the facility on 08/27/2024, with diagnoses including pneumonia, unspecified organism (pneumonia caused by an organism, that was not specified) left bundle-branch block, unspecified (a heart condition that occurs when the electrical impulse that controls the heartbeat was disrupted), emphysema, unspecified (a progressive chronic lung condition in which the tiny air sacs (alveoli) are damaged or destroyed). Record review of the MDS assessment, dated 08/23/2024, revealed Resident # 1 had a BIMS score of 15, indicating resident #1 was cognitively intact. The MDS indicated Resident #1 required supervision only with bed mobility, and transfers. Record review of the care plan dated 09/03/2024, intervention: indicated Resident #1 was independent to transfer, encourage the resident to participate in exercise, physical activity for strengthening and improved mobility between surfaces. Ensure that the resident was wearing appropriate footwear and describe correct client footwear when ambulating or mobilizing in wheelchair. During an attempted interview on 1/012024 at 10;59 a.m., surveyor place a call to Resident # 1 with no answer and no return call. During an interview and observation on 10/01/2024 at 1:48 p.m., the Administrator stated he was trained by the Maintenance Supervisor by watching a video and demonstration of skills. The Administrator demonstrated how to correctly load and secure a resident in a wheelchair into the facility's van for transportation. During an interview and observation on 10/01/2024 at 2:30 p.m. the Maintenance Supervisor stated he was responsible for training new staff who would be doing transportation. The Maintenance Supervisor said he was trained by the corporate office. The Maintenance Supervisor said he watched videos and performed demonstrations to become trained. The Maintenance Supervisor said when he trains a new transportation aide, they watched the required videos and then performed safety demonstrations on securing residents who were in wheelchairs and who ambulate, using the lift, securing loose items, and driving the facility van. The Maintenance Supervisor demonstrated how to correctly load and secure a resident in a wheelchair into the facility's van for transportation. During an interview on 10/01/2024 at 3:02 p.m., CNA A stated she worked for a sister facility for several years but had been helping that facility for a couple of weeks when the incident happened. CNA A stated she picked up Resident #1 from the hospital and was on her way back to the facility. CNA A stated she came over a hill and a truck was stopped in the middle of the road. CNA A stated she hit the brakes and Resident #1 fell out of his wheelchair onto his hands and knees. CNA A stated Resident # 1's wheelchair was locked in, but she did not put the shoulder strap on because she did not think it would reach across him. CNA A stated she was terminated from both facilities for neglect. During an interview on 10/01/2024 at 3:20 p.m., the ADON stated she was notified on 08/20/2024 at 1:53p.m. by CNA A of the incident. The ADON stated she was informed Resident #1 had a scrape on his knee and a skin tear to his finger. The ADON stated following the phone call, she notified the DON and the Administrator of the incident. During an interview on 10/02/2024 at 12:50 p.m., the DON stated she was notified by the ADON of the incident. The DON stated when assessing Resident #1 he stated he was not wearing a seatbelt until after the incident. The DON stated Resident #1 had an abrasion to the right knee, and a bruise and skin tear on left hand. During an interview on 10/02/2024 at 1:25 p.m. the Administrator stated he and the Maintenance Supervisor were the only staff currently doing transportations. The Administrator stated only one resident in a wheelchair should be transported due to the van only being equipped to safely secure one wheelchair. The Administrator stated CNA A was terminated after an investigation was conducted. Record review of a facility's undated policy Vehicle Transportation and Safety of Residents indicated secure down all wheelchairs using the secure strap equipment. Always secure the strap to the frame of the wheelchair not the armrest or wheels. Place seatbelt around all residents including those in wheelchairs The facility's course of action prior to surveyor entrance included: Record review of the provider investigation report dated 08/20/2024 indicated Resident #1 was being transported by the facility van from the hospital to the facility when the transportation aide made a sudden stop and Resident # 1 fell out of his wheelchair. The provider investigation report indicated Resident #1 had an abrasion to the right knee, bruise and skin tear on left hand. X-rays were immediately ordered with results of no break, fracture or dislocation to the bruised area. The provider investigation report indicated CNA A was found negligent in her actions when failing to properly secure Resident #1in his wheelchair and was terminated following the investigation by the facility. Record review of an in-service dated 08/20/2024, topic: Abuse, and Neglect, description: all suspected, alleged, or actual abuse was to be reported immediately to the Abuse Coordinator, who was the Administrator. If for some reason staff are unable to reach the Abuse Coordinator, they are to notify he Director of Nurses. The in-service was signed by 31 employees. Record review of an in-service dated 08/21/2024 indicated the Administrator had been in-serviced on Vehicle Transportation and Safety of Residents, and hands on demonstration. Record review of a QAPI sign in sheet dated 08/22/2024 was signed by: Medical Director Administrator DON ADON Administrative Social Services Dietary Manager Record review of an in-service dated 08/27/2024 indicated the Maintenance Supervisor had been in-serviced on Vehicle Transportation and Safety of Residents, and hands on demonstration. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 08/20/2024 and ended on 08/21/2024. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised after she had a change in mental status and told staff she was leaving the facility, which resulted in her leaving the facility in her wheelchair and going two buildings down the street (on the same side of the road approximately 800 feet) away from the facility on 03/17/2024 without the facility staff's knowledge. An IJ was identified on 04/01/2024. The IJ began on 03/17/2024 and removed on 03/17/2024. While the IJ was removed on 03/17/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring after a change in condition. This failure could place residents at risk of potential accidents, injuries, harm or death. Findings included: Record review of a face sheet dated 03/20/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 made herself understood and understood others. Resident #1 had a BIMs score of 15, which indicated she was cognitively intact. The MDS assessment indicated Resident #1 did not exhibit wandering. The MDS assessment indicated Resident #1 required partial/moderate assistance with toileting hygiene, upper/lower body dressing, personal hygiene and transfers. The MDS assessment indicated Resident #1 used a manual wheelchair. Record review of Resident #1's care plan with a target date of 04/25/24 indicated she required assist of 1 person with transfers, dressing, toileting, personal hygiene, and limited assistance with toileting. The care plan did not indicate resident wandered, had a history of wandering or elopement. Resident #1's care plan indicated Resident #1 had an actual fall with interventions to complete fall documentation packet per facility protocol, wear nonskid footwear with all transfers, ask for assistance from staff, monitor for changes in condition and document and report to MD/NP. Record review of Resident #1's Wandering Risk Scale dated 01/10/2024 indicated Resident #1 could move without assistance while in a wheelchair, had no history of wandering, and had no reported episodes of wandering in the past 6 months. Resident #1 was at low risk for wandering. Record review of Resident #1's After Visit Summary from the ER visit date 03/16/2024 indicated the discharge diagnoses included a urinary tract infection. The After Visit Summary indicated instructions x-rays showed a nondisplaced tibial plateau fracture (fracture occurs around the knee joint) and possible compression fractures to the spine to apply ice for 20 minutes every 2 hours while awake to the areas that were sore and wear the knee brace and do not put full weight on the knee brace to use a wheelchair. The Physician's Orders indicated see ER discharge instructions, non-weight bearing to right knee, and ice back and knee for 20 minutes every 2 hours while awake. Record review of the Order Summary Report with active orders as of 03/19/2024 indicated Resident #1 had an order for place ice pack to back and right knee for 20 minutes every 2 hours related to pain every 2 hours as needed for pain and swelling while awake with a start date of 03/17/2024. The Order Summary Report did not indicate orders for non-weight bearing to the right knee or for the knee brace to right lower leg. Record review of the Neurological Assessments (tool used to assess neurological status) dated from 03/12/2024-03/17/2024 indicated they were completed per facility protocol. On 03/17/2024 Resident #1 was on 8-hour checks with the last 8 hour check completed at 11:30 AM. Record review of Resident #1's progress notes indicated: 03/16/2024 at 5:18 PM, .Resident #1 was showing signs and symptoms of confusion. NP notified and was given referral to have psych evaluation. Signed by LVN A. 03/16/2024 at 9:00 PM, Was called to resident's room due to CNA on duty overheard resident state oh oh I am falling. When this nurse entered the room, the resident was sitting on the floor propping self-up with both arms. Denies hitting head. Stated she fell forward while attempting to pick up glasses off the floor. Denies any pain and discomfort. Range of motion to upper and lower extremities within the normal limits. No abnormal alignments noted to upper or lower extremities. Assisted resident off the floor. Initiated fall protocol. Notified NP on call for the physician, who ordered resident to be sent out to the local hospital for further evaluation due to this being her second fall in 3 days. Signed by LVN B 03/17/2024 at 3:35 PM, received a phone call from a [NAME] that a person in a wheelchair was rolling down the street. Nurse ran to vehicle and rushed to resident's aide. No visible injuries were observed. Resident alert and oriented. Resident refused to get into vehicle with nurse and to return to facility. Resident continued attempt to enter road as nurse held wheelchair to keep her safely in parking lot. Resident's safety maintained. Resident stated, I'm leaving and going to the gas station. Nurse called 911, upon arrival, resident agreed to go to the hospital via EMS. Resident remained alert and oriented while being question by EMS, transferred to gurney with 1 person assist. Signed by LVN A. During an interview on 03/20/2024 at 11:25 AM, LVN A said she was in the middle of administering medications when she heard the facility phone ring, and it was a citizen that was driving down the road. LVN A said the citizen told her they thought one of the facility's residents was wheeling down the road. LVN A said she immediately notified the other nurse she was leaving to get the resident. LVN A said she called the DON when she got in the car to go get the resident. LVN A said she found Resident #1 two buildings away from the facility (on the same side of the road approximately 800 feet away from the facility). LVN A said she could not convince Resident #1 to return to the facility with her because she was insisting on going across the road to the gas station. LVN A said she asked the DON what to do and was told to call 911. LVN A said when EMS arrived, Resident #1 agreed to go to the ER with them, and Resident #1 remained hospitalized . LVN A said she did not know when Resident #1 left the facility, but she had just seen her 5-10 minutes prior to receiving the phone call that there was a resident in a wheelchair on the road. LVN A said she knew she had seen her 5-10 minutes prior because Resident #1 had requested assistance with getting her purse, and she had assisted her with that. LVN A said recently Resident #1 had been confused probably since Friday or Saturday (03/15/2024 or 03/16/2024) due to a UTI that was diagnosed from an ER visit Resident #1 had on 03/16/2024. LVN A said Resident #1 was able to respond appropriately when asked the place and time, but she was having some confusion. LVN A said Resident #1 was able to transfer herself and was able to wheel herself around manually in her wheelchair. LVN A said Resident #1 had not tried to elope from the facility before. LVN A said in the past Resident #1 had been allowed to sign herself out of the facility. LVN A said the day Resident #1 eloped she had not signed herself out. LVN A said she received a call from the ER after Resident #1 arrived at theER on [DATE] from her elopement. LVN A said she was told by the ER that Resident #1 had fractures to her back and to her right knee, but they were old fractures. LVN A said she had not received that information from LVN B in report, after Resident #1 returned to the facility from her ER visit on 03/16/2024. LVN A said she did not know if the ER had sent discharge paperwork with Resident #1 when she discharged from theER on [DATE]. During an interview on 03/20/2024 at 11:52 AM, the Administrator said he received a call from the DON around 2:25 PM on Sunday 03/17/2024, reporting someone in the community had called the nurse on duty to report a resident in a wheelchair on the road, and the nurse had gone to get the resident. The Administrator said he was told the nurse attempted to have the resident return to the facility for safety reasons, but the resident refused, 911 was called, and the resident was taken by EMS to the hospital where she remained hospitalized . The Administrator said Resident #1 had no history of wandering or any previous incidents of elopement. The Administrator said the front and back doors stay unlocked. The Administrator said they did not have any residents who wandered, and if they had a resident that wandered, they would have to be put on one-on-one supervision until they could send them to a different facility where their needs could be met because the facility was not equipped to care for residents that were at risk for wandering/elopement. The Administrator said according to the location where Resident #1 was found she was probably out of the facility for approximately 5-7 minutes. During an interview on 03/20/2024 at 12:44 AM, the DON said prior to Resident #1's elopement from the facility, LVN A had notified her Resident #1 was not herself. The DON said resident #1 was usually alert and oriented, but on Thursday (03/14/2024) Resident #1 was noticed to have a change in her cognition. Resident #1 was sent out to the hospital on 03/14/2024 due to having abnormal movements to her body that she could not control. The DON said Resident #1 did not have a history of elopement and she did not display exit seeking behaviors. The DON said the front door was locked from the outside but not from the inside. The DON said the true front door was used as a back door and the back door was used as the front door. The DON said the back door (used as the front door) was kept unlocked during the day, and then the night shift locked it at 9 PM and around when it was time for shift change at 6 AM the door was unlocked. The DON said they did not have any residents that wandered. The DON said LVN A had called her when she was on her way to find Resident #1, and she stayed on the phone with her to provide assistance. The DON said Resident #1 did not want to return to the facility because she insisted on going to the gas station across the street. The DON said she instructed LVN A to tell Resident #1 she would take her, but Resident #1 refused. The DON said LVN A then called for EMS services, and Resident #1 was taken to the ER, and was admitted to the hospital and was still hospitalized . During an interview on 03/20/2024 at 1:08 PM, Anonymous Staff Member #1 said on Sunday (03/17/24) Resident #1 had told everybody she was going to leave the facility. Anonymous Staff Member #1 said they could tell Resident #1 was mad. Anonymous Staff Member #1 said Resident #1 told them LVN B had told her she did not want to watch her when she returned from the ER Saturday (03/16/2024) night. Anonymous Staff Member #1 said Resident #1 told them because of that she was leaving the facility. Anonymous Staff Member #1 said they reported it to LVN A, and Resident #1 had reported it to LVN A as well. Anonymous Staff Member #1 said they were not aware when Resident #1 left the facility. Anonymous Staff Member #1 said the last time they had seen Resident # 1 was after lunch when they picked up her lunch tray. Anonymous Staff Member #1 said Resident #1 smoked, and she went to her smoke breaks and had never attempted to leave the facility. During an observation on 03/20/2024 at 2:00 PM, the gas station Resident #1 was attempting to go to was on the opposite side of the road from the facility. For Resident #1 to get to the gas station she would have had to wheel herself across the 4-lane state highway with a speed limit of 50 miles per hour. During an interview at the hospital on 03/20/2024 at 2:09 PM, Resident #1 was alert and oriented to person and place, but Resident #1 had confusion. Resident #1 was asked a question and started her response according to the question that was asked, but then veered off topic. During the interview Resident #1 asked surveyor to verify which city she was currently in. Resident #1 had a brace on her right lower extremity. Resident #1 said she had injured her right leg after a fall at the facility. Resident #1 said she wheeled herself out of the facility and made it two buildings down from the facility before they came and got her. Resident #1 stated she was trying to get to the gas station. Resident #1 said she left because the head night nurse, the night she had a fall, told her she needed to go, and she did not want her at the facility. Resident #1 said she told LVN A before she left that she wanted to leave the facility because LVN B did not want her at the facility. Resident #1 said LVN A had told her she could not leave the facility. Resident #1 said she thought she was out of the facility for a couple of hours. During an interview with Hospital RN C on 03/20/2024 at 2:33 PM, Hospital RN C said Resident #1's current mental status was altered. Hospital RN C said Resident #1 was alert and oriented to person and place and could remember some things, but when she started having a conversation with her, she could tell she was confused. Hospital RN C said Resident #1 was admitted to the hospital with a diagnosis of altered mental status, and the doctors were still trying to figure out the cause for her altered mental status and there was no discharge date at that time. During an interview on 03/20/2024 at 3:35 PM, LVN A said Resident #1 had not mentioned to her that LVN B told her she did not want to watch her. LVN A said Resident #1 did not mention to her wanting to leave the facility due to this. LVN A said Resident #1 asked her for her purse and told her I have to leave this team of teenage girls. LVN A said she asked Resident #1 for clarification and Resident #1 repeated the same thing. LVN A said that's how she knew Resident #1 was confused. LVN A said the CNAs and herself were rounding more frequently on Resident #1 due to her confusion. During an interview on 03/20/2024 at 3:56 PM, LVN B said she would not tell Resident #1 that she did not want to take care of her. LVN B said when she sent Resident #1 to the ER Saturday evening (03/16/2024) after she fell , initially Resident #1 did not want to go to be evaluated by the ER, but she was able to convince her to go. LVN B said when Resident #1 returned from her ER visit on 03/16/2024 she noticed she had a knee brace on. LVN B said she was not told in the report she received from the ER the evening of 03/16/2024 that Resident #1 had fractures to her back or right knee. During an interview on 03/20/2024 at 5:22 PM, LVN A said all the staff were responsible for monitoring the residents to ensure they knew where they were and to ensure their safety. LVN A said it was important to provide adequate supervision to the residents to know who was in the facility and where they were. LVN A said Resident #1 was confused at the time of her elopement and it was not safe for her to be out of the facility on her own, and she could have gotten hit by a car. During an interview on 03/20/2024 at 6:05 PM, the DON said all of the staff were responsible for ensuring residents were supervised to prevent accidents and hazards. The DON said they ensured the residents were supervised by rounding on them frequently and encouraging them to participate in the activities at the facility. The DON said she felt like the staff was providing more supervision to Resident #1 due to her confusion. The DON said she was not notified about Resident #1's fractures, and she had asked LVN B if she was aware and LVN B had told her no. During an interview on 03/20/2024 at 6:24 PM, the Administrator said all staff were responsible for supervising/monitoring the residents. The Administrator said he expected the staff to monitor the residents closely if they noticed an onset of confusion. The Administrator said Resident #1's elopement from the facility placed her and other residents at risk for accidents or injury. During an interview on 03/29/2024 at 8:52 AM, LVN A said one of the CNAs was saying Resident #1 told her she was leaving the facility. LVN A said she thought she would address it when Resident #1 told her she was leaving because she was able to go out on pass if she wanted to, she could not keep her at the facility. LVN A said she was monitoring Resident #1 closely not because she said she was leaving, but because she had a fall. LVN A said Saturday, before Resident #1 eloped she was having confusion that evening. LVN A said they were doing neuro checks on Resident #1 per the facility protocol due to her falls. LVN A said she had charted she was alert because even though Resident #1 had confusion, she was alert and oriented to person and place. LVN A said she did not think there was a place on the neuro checks to document the confusion. During an interview on 03/29/2024 at 10:51 AM, the DON said if the nurse was aware Resident #1 was saying she wanted to leave the facility, she should have notified her, the NP and should have increased supervision to every 15-minute checks on paper (15 minute checks were not performed prior to Resident #1's elopement). The DON said if the residents had any change in condition the nurses should document it in the electronic health record, place it on the 24-hour report to communicate it to the other nurses, monitor the resident closely, notify the MD and notify her. During an interview with the Medical Director on 03/29/2024 at 11:55 AM, he said the staff was updating him on Resident #1's changes. The Medical Director said he had given the staff instructions to monitor her closely and to monitor her mental status, and to send her back to the ER if she was still having issues. The Medial Director said Resident #1 was her own representative and she did not normally wander. The Medical Director said Resident #1 had days where she was very lucid and answering questions appropriately and then there were episodes when she was not able to make decisions appropriately. The Medical Director said from what he recalled from the ER she was alert and oriented and answering question, but she was having paranoia. The Medical Director said if Resident #1 had told the staff she wanted to leave the facility they should have increased supervision on her. The Medical Director said from what he understood the staff was monitoring Resident #1 closely, they just were not documenting throughout the day. During an interview on 04/01/2024 at 12:40 PM, the Administrator said Resident #1 had returned from the hospital on 03/26/2024. The Administrator said Resident #1 was on 15-minute checks upon her return from the hospital until they could determine if it was safe for Resident #1 to remain in the facility or what the next steps would be for her safety. Record review of 33 Wandering Risk Scale assessments indicated no residents were at high risk for elopement. Record review of the facility's policy revised March 2022, titled, Wandering and Elopements, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .

Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 3 residents (Resident #1) reviewed for admission physician orders. The facility failed to ensure Resident #1 had a physician order to wear her knee brace and to not bear weight on her right knee. This failure could place residents at risk for not receiving appropriate care, treatment, and services. Findings included: Record review of a face sheet dated 03/20/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with delayed healing (fracture of the spine with delayed healing), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had a BIMs score of 15, which indicated she was cognitively intact. The MDS assessment indicated Resident #1 did not exhibit wandering. The MDS assessment indicated Resident #1 required partial/moderate assistance with toileting hygiene, upper/lower body dressing, personal hygiene and transfers. The MDS assessment indicated Resident #1 used a manual wheelchair. Record review of Resident #1's care plan with a target date of 04/25/24 indicated she required assistance of 1 person with transfers, dressing, toileting, personal hygiene, and limited assistance with toileting. Resident #1's care plan indicated Resident #1 had an actual fall with interventions to complete fall documentation packet per facility protocol, wear nonskid footwear with all transfers, ask for assistance from staff, monitor for changes in condition and document and report to MD/NP. Record review of Resident #1's After Visit Summary from the ER visit dated 03/16/2024 indicated instructions x-rays showed a nondisplaced tibial plateau fracture (fracture occurs around the knee joint) and possible compression fractures to the spine to apply ice for 20 minutes every 2 hours while awake to the areas that were sore and wear the knee brace and do not put full weight on the knee brace to use a wheelchair. The Physician's Orders indicated see ER discharge instructions, non-weight bearing to right knee, and ice back and knee for 20 minutes every 2 hours while awake. Record review of the Order Summary Report with active orders as of 03/19/2024 indicated Resident #1 had an order for place ice pack to back and right knee for 20 minutes every 2 hours related to pain every 2 hours as needed for pain and swelling while awake with a start date of 03/17/2024. The Order Summary Report did not indicate orders for non-weight bearing to the right knee or for the knee brace to right lower leg. During an interview on 03/20/2024 at 11:25 AM, LVN A said she received a call from the ER after Resident #1 arrived at theER on [DATE] from her elopement. LVN A said she was told by the ER that Resident #1 had fractures to her back and to her right knee, but they were old fractures. LVN A said she had not received that information from LVN B in report, after Resident #1 returned to the facility from her ER visit (the previous night) on 03/16/2024. LVN A said she did not know if the ER had sent discharge paperwork with Resident #1 when she discharged from the ER (the night before) on 03/16/2024. During an observation and interview at the hospital on 03/20/2024 at 2:09 PM, Resident #1 had a brace on her right lower extremity. Resident #1 was alert and oriented to person and place but had confusion. Resident #1 said she had injured her right leg after a fall at the facility. During an interview on 03/20/2024 at 3:56 PM, LVN B said when Resident #1 returned from her ER visit on 03/16/2024 she noticed she had a knee brace on. LVN B said she was not told in the report she received from the ER the evening of 03/16/2024 that Resident #1 had fractures to her back or right knee. LVN B said the ER had sent paperwork after Resident #1's ER visit, but she had not seen the instructions or the orders for the knee brace or non-weight bearing status. LVN B said it was an error on her part and she should have looked over the discharge paperwork more thoroughly. LVN B said she should have let the other nurses, DON, ADON, and doctor know that Resident #1 had come back with fractures, and she should have put in the orders into the electronic health record. LVN B said when a resident admitted or readmitted the nurse that received the discharge orders was responsible for putting them into the computer. LVN B said it was important for the orders to be put in the electronic health record to ensure the doctor's orders were followed and the resident's received the treatments they needed. During an interview on 03/20/2024 at 6:05 PM, the DON said the nurse on duty when the resident arrives to the building was responsible for putting the physician's order into the electronic health record. The DON said Monday-Friday before 5 PM she reviewed the admissions and ER records, after 5 PM on Friday the weekend RN should review the admissions orders, and depending on the time of admission over the weekend if the DON reviewed them on Monday or the weekend RN reviewed them. The DON said even though the RN over the weekend reviewed orders she also reviewed them on Mondays. The DON said she was not notified about Resident #1's fractures, and she had asked LVN B if she was aware and LVN B had told her no. The DON said LVN B should have reviewed the ER records from 03/16/2024 not only for new orders or medication changes, but also for other orders and diagnoses, and if she needed clarification, she should have called the ER. The DON said it was important for new orders to be put in the electronic health record so orders and diagnoses did not get missed and the treatment plans did not get missed. During an interview on 03/20/2024 at 6:24 PM, the Administrator said the charge nurses were responsible for putting in orders upon a resident's admission, and he expected for the nurses to review records for new orders and to follow the physician's orders to ensure the residents received the care they required. Record review of the facility's undated Morning Meeting-Administrative/Clinical Stand-up, indicated, .During Morning Meeting (work concurrently to review PCC (point click care electronic medical record system), then discuss the areas listed below) . Run Order Summary Report select Order Date Range and include yesterday's date (include weekend on Monday), review active and discontinued orders to confirm they are entered correctly . discuss any critical events, accidents/incidents that occurred since morning meeting that require immediate action or notification .

Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 (Resident #25) who were reviewed for respiratory care. 1. The facility failed to ensure Resident #25 had an oxygen sign placed on her door. 2. The facility failed to ensure Resident #25's nasal cannula tubing was dated and, in a bag, when not used. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #25's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), chronic obstructive pulmonary disease {COPD}(a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Depression (sadness). Record review of Resident #25's quarterly MDS assessment, dated 01/26/24, indicated Resident #25 understood and understood others. The MDS assessment indicated she had a BIMS score of 15 indicating intact cognition. Resident #25 required, extensive assistance with bathing, limited assistance with toileting, dressing, bed mobility, and set-up assistance with personal hygiene, and eating. The MDS indicated she required oxygen. Record review of Resident #25's physician's order dated 09/26/22 indicated Oxygen at 2 l/m to 5 l/m per nasal cannula every shift. Record review of Resident #25's physician's order dated 09/26/22 indicated change, date, and bag oxygen tubing every Sunday night. Record review of Resident #25's comprehensive care plan, dated 10/12/22, indicated Resident #25 required oxygen therapy related to Ineffective gas exchange. The intervention of the care plan was for staff to provide oxygen as ordered. During an observation on 02/05/24 at 10:22 a.m., Resident #25 was in her bed with the head bed up. She had oxygen on at 2lvia n/c (liters per nasal cannula). The oxygen tubing was not dated, and no oxygen sign was noted outside her door. During an observation on 02/06/24 at 09:07 a.m., Resident #25 was sitting up on the side of her bed eating breakfast. She had oxygen on at 2lvia n/c. The oxygen tubing was not dated, and no oxygen sign was noted outside her door. During an interview on 02/07/24 at 4:03 p.m., the ADON said oxygen tubing should be changed and dated weekly on Sunday nights. She said oxygen tubing should be bagged when not in use. She said oxygen signs should be hung on each resident who required oxygen for their safety. She said oxygen tubing should be dated and, in a bag, when not in use for infection control issues. During an observation and interview on 02/07/24 at 5:41 p.m., LVN B went into Resident #25's room and noted oxygen tubing on the floor and oxygen tubing not dated. She said the oxygen tubing should be dated weekly on Sunday nights and the oxygen should be bagged when not in use. She said it could lead to infection control issues. She said she would apply new oxygen tubing and date it. During an interview on 02/07/24 at 5:49 p.m., the DON said the charge nurses were responsible for ensuring the oxygen tubing was changed and dated weekly on Sunday nights. She said oxygen tubing should not be on the floor. She said when oxygen was not used it should be in a bag. She said the ADON did oxygen checks on Monday morning because they were due to be changed on Sunday nights. She said oxygen signs should be placed on residents who required oxygen to alert staff and visitors of potential hazards. She said oxygen tubing should be changed and dated for infection control purposes. During an interview on 02/07/24 at 06:11 p.m., the Administrator said he was not clinical and did not know all the requirements. He said he would not expect the tubing to be on the floor for the cleanliness and safety of the resident Record review of the facility policy titled, Oxygen Administration, indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guideline #1 Oxygen therapy is administered by way of an oxygen mask and nasal cannula. Steps in procedure: I. Place an Oxygen in Use sign on the outside of the room entrance door .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 15 residents reviewed for comprehensive care plans (Resident #31 and Resident #24). 1. The facility failed to ensure Resident #31's care plan accurately reflected the use of a sling. 1a. The facility failed to have a physician order for Resident #31's sling to her right arm. 2. The facility failed to ensure Resident #24's care plan reflected she had PTSD (post-traumatic stress disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and her triggers. These failures placed residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care. Findings included: 1.Record review of Resident #31's face sheet dated 02/07/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses displaced fracture of the lateral end of right clavicle, depression, seizure disorder, high blood pressure, and cerebral cysts (fluid like sacs on the brain). Record review of Resident #31's admission MDS dated [DATE] indicated she had a BIMS score of 10 which indicated moderately impaired cognition. The MDS also indicated that Resident #31 required moderate assistance from staff for bathing, toileting, maximum assistance with transfers, and setup with eating. Record review of the order summary report dated 02/07/24 did not indicate an order for Resident #31's sling to be in place for her fracture. Record review of the care plan dated 02/07/24 after surveyor intervention indicated resident had potential for acute/chronic pain related to fracture of right clavicle and resident was supposed to wear sling. During an observation on 02/05/24 at 11:23 a.m. Resident #31 had a sling on her right arm. During an observation on 02/06/24 at 9:20 a.m. Resident #31 was in her wheelchair sitting in her room with sling on right arm. During an observation and interview on 02/07/24 at 12:58 p.m. Resident #31 was sitting in her wheelchair in the doorway to her room with sling on her right arm. Resident said she was instructed by her doctor to have the sling on her right arm. Resident #31 said she was supposed to wear the sling on her right arm for about 3 months and then schedule a surgery, she thought but was not sure, but she said she wore it every day. During an interview on 02/07/24 at 1:04 p.m., LVN E said she was unsure of the orders for Resident #31's sling. LVN E said Resident #31 had follow up appointments, but the doctor had not said exactly when the sling was to be removed. LVN E said usually when a resident required a sling, a physician order would be put it in place. LVN E said she was going to call therapy and call the orthopedic doctor to confirm the order for use of the sling. LVN E said the diagnosis for her fracture and her use of the sling should have been on her care plan. LVN E said any nurse who admits the resident can input a care plan and the RN ensured all problems and interventions were included in the resident's care plan. She said the failure could cause new nurses or agency nurses who came in to work to be unaware of resident diagnosis of the fractured right clavicle and how and when she should have been using the sling. During an interview on 02/07/24 at 1:36 p.m. the DON said Resident #31 should have had an order for the sling in place. The DON said the diagnosis and the use of the sling should have been included in Resident #31's care plan. She said every nurse was responsible for inputting care plans and the weekend supervisor, DON, ADON, and MDS ensure acute care plans were in place. The DON said it was important for the diagnosis and the use of the sling to have been placed on the care plan so nurses will know how to properly care for the resident. During an interview on 02/07/24 at 1:44 p.m. the ADON said she was unaware of how long Resident #31's sling was supposed to be in place, but she was trying to find out. She said there should have been an order in place if resident was using a sling and the charge nurse was responsible for ensuring the orders were in the computer and the ADON and DON followed up on the orders. She said it was important for the diagnosis and use of the sling to be on the care plan to ensure the resident was being cared for correctly and to determine if she should have had the sling or not. During an interview on 02/07/24 at 3:49 p.m. the Administrator said he expected the diagnosis and use of the sling will be placed in the care plan as well as orders to have been in place for the use of the sling. The Administrator said the nursing staff were responsible for ensuring orders for the sling was input and the ADON and DON should have followed up ensure the order was in place and the sling was on Resident #31's care plan. The failure placed an agency staff or a new nurse at risk of not being aware of the resident's need for the sling and what it was being used for. 45879 2.Record review of Resident #24's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included PTSD (intense, disturbing thoughts and feelings related to their experience that lasted long after the traumatic event has ended), Depression( a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of Resident #24's quarterly MDS assessment, dated 11/14/23, indicated Resident #24 was understood and understood by others. The MDS assessment indicated he had a BIMS score of 13 indicating cognitively intact. The MDS indicated she had trouble concentrating on things and felt depressed and hopeless. Resident #24 required supervision with bathing, dressing, bed mobility, personal hygiene, toileting, and eating. Record review of Resident #24's comprehensive care plan, dated 11/14/23, did not indicate Resident #24's diagnosis of PTSD, goals, intervention, or triggers. During an interview on 02/07/24 at 8:21 a.m., Resident #24 said she had PTSD and she said it was because of the death of her dad. Resident #24 became silent and then said she tries to stay around people but when she was alone or felt isolated it brought up the memories. She said she was on medication and seeing psychiatric services and then went silent again. During an interview on 02/07/24 at 8:44 a.m., LVN D said she worked both halls and was not aware of any resident who had PTSD. During an interview on 02/07/24 at 10:02 a.m., the MDS coordinator said she was aware Resident #24 had a diagnosis of PTSD and was receiving psychiatric services at the facility. She said she was not aware of her triggers but felt they needed to be on her care plan so that staff would know how to help her if she had an episode. She said she and the DON were responsible for care plans. She said care plans were done so staff would know how to care for residents. During an interview on 02/07/24 at 4:03 p.m., the ADON said care plans were a team effort. She said she was aware Resident #24 had PTSD but was not aware of why she had PTSD or her triggers. She said it was important to know her triggers to prevent or minimize them. She said she was not aware of why her PTSD was not care planned but knew it should have been care planned. She said a resident care plan was done to let staff know about the kind of care to provide. During an interview on 02/07/24 at 5:49 p.m., the DON said she was not aware of Resident #24's triggers. She said Resident #24 did not talk about her traumatic events. She said she had never asked her about what caused her to have PTSD. She said the only thing she knew was Resident #24 complained about not sleeping well at night. She said they should have addressed her diagnosis of PTSD, her triggers, and something about her goals and interventions such as psychiatric services or allowing her to express her feelings. During an interview on 02/07/24 at 6:11 p.m., the Administrator said all disciplinaries work together to complete a resident's care plan. He said the DON was the overseer. He said Resident #24 should have the diagnosis of PTSD and things to help her listed on her care plan. He said care plans were generated to provide each resident with the best care. Record review of the facility policy titled, Care Plan Comprehensive Person-Centered, revised December 2016, indicated, Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy: #1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. #8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems k. Reflect treatment goals, timetables, and objectives in measurable outcomes; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels . #12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Record review of the facility policy titled, Trauma-Informed and Culturally Competent Care, revised August 2022, indicated, The purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Resident Care Planning #1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. #2. Identify and decrease exposure to triggers that may re-traumatize the resident. #3. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). #4. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms, and values.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 halls (Hall 800) and 1 of 3 shower rooms (Hall 800) reviewed for accidents and supervision. 1. The facility failed to ensure water was at a safe temperature for hall 800. 2. The facility failed to ensure Hall 800 shower room was securely closed and free from hazardous liquid. These failures could place residents at risk of falls, entrapment, burns, or injury. Findings Include: During an observation on 02/05/24 at 10:16 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation on 02/05/24 at 10:18 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation on 02/05/24 at 10:28 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation on 02/05/24 at 10:25 a.m., revealed room [ROOM NUMBER] on hall 800 water in the bathroom sink felt hot to the surveyor's hand. During an observation and interview on 02/05/24 at 10:31 a.m., revealed room [ROOM NUMBER] water was hot in the bathroom. Resident # 24 said her water was hot, but she knew how to adjust the water by turning on both the hot and cold faucets. She said the staff (unknown) was aware the water was hot. During an observation and interview on 02/05/24 at 10:39 a.m., the Housekeeping Supervisor went into room [ROOM NUMBER] on hall 800 and tested the water with her hands, within seconds said the water was getting hot, and after a minute said the water was very hot. She said she usually wore gloves when cleaning and never noticed the water being that hot but could see it being too hot for a resident. During an interview on 02/05/24 at 11:03 a.m., the Maintenance Supervisor said he had adjusted the water (unknown time ago) due to complaints about the water in the shower room being too cold. He said he would check the water temperature in the rooms on hall 800. During an interview on 02/05/24 at 11:10 a.m., CNA A tested the water with her hands in room [ROOM NUMBER] on hall 800 and she said the water was extremely hot and her fingertips were burning in less than a minute. She said she gave showers on her assigned workdays and had not had any residents complain to her about the shower water being too cold or too hot. She said she was not aware of anyone getting burnt by the hot water. During an observation on 02/05/24 at 11:12 a.m., the Maintenance Supervisor tested the water temperature with a thermometer in room [ROOM NUMBER] and it read 130. During an interview and observation on 02/05/24 at 11:13 a.m., the Maintenance Supervisor tested the water temperature with a thermometer in room [ROOM NUMBER] and it read 127. He said he did not know why the temperature was so hot. He said he had checked the water temperature last week and had no issues. He said he would pull his TELS (a system used for services to help with day-to-day maintenance work). He said he was not aware of anyone getting burnt by the hot water. He said it was not hot when he tested the water last week. A policy for water temperature was requested but not provided. During an interview on 02/05/24 at 11:23 a.m., Resident # 15 located in room [ROOM NUMBER] on hall 800 said her bathroom water was hot but she knew to turn on the cold water, so it was not much of a deal to her. Record review of the facility incidents report log dated 02/05/24 did not reveal any concerns regarding burns. Record review of TELS revealed water temperatures were tested on [DATE] and were in normal range. During an interview on 02/07/24 at 8:44 a.m., LVN D said she had worked at this facility for about 6 years as the 6-2 nurse. She said she had heard the water was hot on yesterday (02/06/24) but had not had any complaints about the hot water before. She said she usually turned on both water faucets (hot and cold) and the water temperature was good for her. During an interview on 02/07/24 at 8:54 a.m., LVN E said she had been at the facility for about a year. She said she had not received any complaint from residents about the water being too hot. She said she usually turned on both faucets (hot and cold) when she washed her hands. Record review of Resident #29's face sheet, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), chronic obstructive pulmonary disease {COPD}( a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident #29's quarterly MDS assessment, dated 01/26/24, indicated Resident #29 was usually understood and usually understood by others. The MDS assessment indicated he had a BIMS score of 11 indicating moderately impaired cognition. Resident #29 required, extensive assistance with bathing, limited assistance with dressing, bed mobility, and set-up assistance with personal hygiene, toileting, and eating. Record review of Resident #29's comprehensive care plan, dated 10/18/23, indicated Resident #29 required ADL's self-care related to weakness and confusion at times. The intervention of the care plan was for staff to assist with bathing. During an observation and interview on 02/05/24 at 10:13 a.m., revealed the shower room door on hall 800 had a key inside the door and the door was able to open without having to unlock the door. The shower room had 2 spray bottles with yellow solution in them sitting on the side rail. The bottle read keep out of reach of children. After the surveyor had walked out of the shower room and partially down hall 800 hallway, Resident #29 walked into the shower room on hall 800. While in the shower room Resident, #29 was attempting to get out as evidenced by the knob turning backward and forward and Resident #29 banging on the door. Resident #29 opened the door and said he was looking for staff so he could receive his shower. He said the door would not open at first, but he was able to get the door opened. During an interview on 02/05/24 at 10:20 a.m., CNA A opened the shower door on hall 800 without using the key to push another resident into the shower. During an interview on 02/05/24 at 11:10 a.m., CNA A said she left the key in the shower room door on hall 800. She said she was only gone a few minutes to get another resident for their shower. She said she was aware she left the chemicals out and the door opened. She said she would usually remove the key from the door and put the chemical up in the locked cabinet after she had completed her showers for the day or went to lunch. She said she was not aware Resident #29 had gone into the shower room and had some difficulty getting out of the shower room door. She said she could see the potential of him getting the chemical since she did leave the door open, and the chemicals were out. She said the chemicals could be hazardous. During an interview on 02/07/24 at 8:44 a.m., LVN D said the shower doors should be locked to prevent residents from wandering into the shower room, she said she had never seen a resident wander into the shower room but there was a potential. She said the shower room contained chemicals that could be harmful to the residents. During an interview on 02/07/24 at 8:54 a.m., LVN E said they had 3 shower rooms in the facility but only one had been used the most on hall 800. She said she did not expect the shower room door to be unlocked when not in use. She said she expected for the chemicals to be put up in the locked cabinet in the shower room. She said if the shower room door were left open any resident could go in, get locked behind the door, drink the chemicals, or spray themselves in the face with the chemicals. During an interview on 02/07/24 at 4:03 p.m., the ADON said she heard about the hot water issues only after the surveyor mentioned it to the maintenance supervisor. She said she had not had anyone say anything about the water being hot. She said a water temperature of 130 was too hot and could cause injury to a resident. She said the maintenance supervisor was responsible for checking the water temperatures and the Administrator was the overseer. She said the shower room doors should be locked when not in use. She said she expected the shower doors locked and the chemicals to be locked up for the safety of the residents. During an interview on 02/07/24 at 5:49 p.m., the DON said the maintenance supervisor should be assessing the water temperatures weekly. She said she had not had any complaints about the water being too hot but had heard the water was cold in the shower room at times. She said a water temperature of 130 was not safe and could have been a potential for burns and injury. She said the Administrator was the overseer of maintenance. The DON said the shower room doors were supposed to be closed when not in use. She said everyone was responsible for ensuring they were closed. She said the chemicals should not be left out but should be secured in the cabinet. She said with the shower door being unlocked and opened and the chemicals left out it could be a risk for injury related to the chemicals and the potential for falls because the floor could have been wet. A policy for accident prevention was requested but not provided. During an interview on 02/07/24 at 06:11 p.m., the Administrator said the maintenance supervisor checked the water temperatures weekly. He said the water temperature was checked on 01/29/24 and had no issues. He said a water temperature of 130 was not safe and could cause burns. He said after the maintenance supervisor was aware of the water temperatures, he took immediate action to adjust the temperature and then called in a plumber. He said the water temperature issue was resolved on 02/06/24. He said he usually reviewed TELS monthly. He said it would be in red if the maintenance supervisor had not completed TELS weekly and it was not. The Administrator said he expected the shower doors to be closed when not in use. He said he expected the shower doors to be locked and the chemicals to be locked up for safety. Record review of the contracted plumber receipt dated 02/07/24 revealed they replaced the single-handle shower cartridge and trim kit. Adjusted the mixing value to correct the water temperature to 106 degrees. Record review of the facility policy titled, Hazard Material, did not indicate anything about the storage of hazardous material. Record review of the MSDS titled, Safety Data Sheet, dated 02/11/21 on Peroxide Multi Surface Cleaner and Disinfectant, indicated Conditions for safe storage: Keep out of reach of children. Store in safe suitable labeled containers. During an email on 02/08/24 at 1:16 p.m., the DON indicated she could not locate a policy on accidents and incidents or safe water temperature.

Based on interviews and record reviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 6 residents (Resident #24) reviewed for trauma-informed care. The facility did not ensure Resident #24's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Record review of Resident #24's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included PTSD (intense, disturbing thoughts and feelings related to their experience that lasted long after the traumatic event has ended), Depression( a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of Resident #24's quarterly MDS assessment, dated 11/14/23, indicated Resident #24 was understood and understood by others. The MDS assessment indicated he had a BIMS score of 13 indicating cognitively intact. The MDS indicated she had trouble concentrating on things and felt depressed and hopeless. Resident #24 required supervision with bathing, dressing, bed mobility, personal hygiene, toileting, and eating. Record review of Resident #24's comprehensive care plan, dated 11/14/23, did not indicate Resident #24's diagnosis of PTSD and/or her triggers. Record review of the facility's EMR (electronic medical records) on 02/06/24 revealed Resident #24's trauma assessment was not in there. During an interview on 02/06/24 at 5:00 p.m., the Social Worker said she started working at the facility sometime in June of 23. She said she was responsible for doing trauma assessments on all new admissions. During an interview on 02/07/24 at 8:21 a.m., Resident #24 said she had PTSD and she said it was because of the death of her dad. Resident #13 became silent and then said she tries to stay around people but when she was alone or felt isolated it brought up the memories. She said she was on medication and seeing psychiatric services and then went silent again. During an interview on 02/07/24 at 10:15 a.m., the Social Worker reviewed Resident #24's EMR and could not locate a trauma assessment. She said since she started working at the facility, she had completed all trauma screens on all new admits. She said Resident #24 came before she started working at the facility and she did not realize a trauma assessment had not been completed. She said she was unaware of who was responsible for completing the trauma assessments before she started working at the facility. The Social Worker said without these assessments the staff would not be familiar with the resident's triggers and what to implement to prevent the triggers. During an interview on 02/07/24 at 4:03 p.m., the ADON said the social worker did the trauma assessments. She said they should be done on admission. She said she did not know why Resident #24's trauma assessment was not done. She said looking back they were without a social worker for some time or it could have been a computer system error where the trauma assessment did not populate but she could not say why it was missed. She said she and the DON reviewed UDAs(User-Defined Assessments that eliminate paper assessments and put the information in residents' Electronic Health Records) the following morning but missed the trauma assessment. She said the trauma assessments should be completed to know whether a resident had a history of past trauma. During an interview on 02/07/24 at 5:49 p.m., the DON said the social worker was responsible for the trauma assessments. She said she was not aware Resident #24 did not have a trauma assessment done on admission. She said trauma assessments were supposed to trigger in their EMR system. She said trauma assessments were done to see if a resident had a traumatic event in their past and what might trigger them in some way. She said the purpose of the trauma assessments was to prevent any triggers or bad experiences the resident might have had. During an interview on 02/07/24 at 06:11 p.m., the Administrator said he was not aware of their policy on trauma assessment but said the social worker completed them. He said trauma assessments were done to make sure the staff was aware of any traumatic events a resident might have experienced and to try not to bring up any stressful events. Record review of the facility policy titled, Trauma-Informed and Culturally Competent Care, revised August 2022, indicated, The purpose: To guide staff in providing care that culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident Screening #1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. #2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant, and sensitive. #3. Screening may include information such as: a. trauma history, including type, severity, and duration; b. depression, trauma-related or dissociative symptoms; c. risk for safety (self or others); d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal, or developmental concerns; and #4 Utilize initial screening to identify the need for further assessment and care. Resident Assessment: #1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. #2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. #3. Use assessment tools that are facility-approved and specific to the resident population.

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for the front lobby, and 1 of 4 halls ( hall 800) reviewed for a clean and homelike environment. The facility failed to ensure the lobby and hall 800 were without odors. This failure could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: During an observation on 02/05/24 at 10:08 a.m., Hall 800 and the front lobby smelled of strong urine. During an observation on 02/06/24 at 8:14 a.m., Hall 800 and the front lobby smelled of strong urine. During an interview on 02/07/24 at 8:54 a.m., LVN E said she had noticed an odor on hall 800 for an unknown amount of time but all staff were aware to try to keep the odor down as much as possible. She said Resident #13 often urinated on himself and staff was supposed to help him every 2 hours to the bathroom. She said the staff was supposed to monitor his room for any urine on the floor and in the bathroom. She said Resident #13's bathroom smelled of urine and she noticed the strong urine smell as soon as she walked toward hall 800. During an interview on 02/07/24 at 9:10 a.m., CNA C said she had worked at the facility a long time. She said hall 800 smelled like urine because Resident #13 was incontinent, and he would often urinate on the floor. She said they attempted to toilet him every 2 hours but sometimes he would say he did not have to go and shortly afterward he would urinate on the floor or himself. She said some days were worse than others and staff would want to close all the doors because of the strong urine odor. She said Resident #13 had been on hall 800 for an unknown amount of time. During an interview on 02/07/24 at 9:41 a.m., housekeeper F said she noticed Hall 800 smelling of urine and did not like the smell. She said she had told her supervisor and she instructed her to use a deodorizer and peroxide. She said she asked about remodeling Resident #13's whole room but did not know the decision and could not remember how long ago that was. During an interview on 02/07/24 at 3:12 p.m. the Housekeeping Supervisor said she was aware of the odor on hall 800 and in the lobby area. She said the smell of urine came mostly from Resident #13. She said all the administration staff was aware because they had talked about it in the morning meeting. She said she had ordered an odorized with an apple scent because the one they had was not doing the job. She said they needed to remove the tile in his bathroom because she believed his urine had gone into the cracks. She said if she were to visit, she would turn around because of the smell or have a negative feeling about the facility and the care they provide. During an interview on 02/07/24 at 4:03 p.m., the ADON said she knew about the odor on hall 800 and lobby area. She said Resident #13 often urinated anywhere. She said housekeeping cleaned his room and he received his showers. She said the facility might be able to resurface his tile but she was not aware of any plans. She said she did not like the smell of urine in the resident's home. During an interview on 02/07/24 at 5:49 p.m., the DON said she was aware of the odors in the lobby and Resident #13's room. She said the housekeepers try to clean the facility thoroughly. She said Resident #13's urinates everywhere so they must watch him closely. She said all staff took a part in ensuring the facility was clean and odor-free. She said she wanted this home to be free from odors as much as possible. During an interview on 02/07/24 at 6:11 p.m., the Administrator said he was aware of the odors and that housekeeping staff was trying to clean it more. He said they were cleaning the rooms more often. He said he had discussed with the housekeeper that they might need to work a little better. He said he would not like to live with urine odor in his house. Record review of facility policy titled, Homelike Environment, revised February 2021, indicated, Policy statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy: 2. The community team members and management maximize, to the extent possible, the characteristics of the community that reflect a personalized, home-like setting. These characteristics include a. clean, sanitary, and orderly environment; f. pleasant, neutral scents .

Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #58) reviewed for psychoactive medications. The facility failed to obtain an informed consent based on the information of the benefits and risks for Resident #58 prior to administering Seroquel, an antipsychotic, used to treat schizophrenia, bipolar disorder, and depression. This failure could place residents at risk for receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status. Findings included: Record review of Resident #58's face sheet, dated 02/07/2024, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in your blood), Metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), chronic obstructive pulmonary disease (no air flow for breathing), myocardial infarction (heart attack), urinary tract infection, dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #58's admission MDS assessment, dated 02/02/24, indicated Resident #58 was understood and usually understood others. Resident #58's BIMS score was 15, which indicated she was cognitively intact. The MDS did not indicate Resident #58 rejected care or had behavior problems. The MDS indicated Resident #58 required supervision with toileting bed mobility, dressing, personal hygiene, transfers, and set up assistance for eating. Record review of Resident #58's medication administration recordorder summary rreport, dated 02/07/2024, indicated the resident had an order, dated 01/30/2024, for Seroquel Oral Tablet 25 MG (Quetiapine Fumarate). Give 1 tablet by mouth at bedtime for antipsychotic. Record review of Resident #58's medication administration record, dated 02/07/2024, indicated the resident had received Seroquel Oral Tablet 25 MG (Quetiapine Fumarate). Give 1 tablet by mouth at bedtime for antipsychotic for the last 67days (01/30/24 - 02/07/24. Record review of the baseline care plan dated 01/31/2024 indicated, Resident #58 used antipsychotic medications related to inability to sleep and depression. The intervention of the care plan indicated staff would give medication as ordered, staff would monitor for side effects, staff would monitor for behavior, pharmacy consultant would monitor for reduction needs as needed. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Record review of Resident #58's consents for use of psychotropic medication, Seroquel was not documented in her chart. During an interview on 02/07/2024 at 2:12 p.m., LVN D said consents should be obtained for all psychotropic medication prior to being given. LVN D said Resident #58 was given, Seroquel for sleep but did not know her consent was not done until mentioned by the State Surveyor. LVN D said the consent was usually obtained during the admission process by the charge nurse. LVN D said psychotropic medications could change a resident's demeanor and this was why their responsible party should be aware of all medications and the possible side effects from the medications. During an interview on 02/07/2024 at 2:26 p.m., the ADON said Resident #58 took Seroquel for sleeping purposes. The ADON said the consent for psychotropic medications was completed prior to the resident receiving the medication unless the resident came into the facility already taking the medication. The ADON said if the resident were already taking the psychotropic medication, the facility would obtain the consent as soon as possible. The ADON said they normally got consents for all psychotropic medication because these types of medications could alter the mind and could cause other risks. The ADON said the nurse who received the order was responsible for getting the consents. The ADON said it was important for the family to know about potential side effects and what medication their loved ones were taking. The ADON said failure to get consent could lead to a side effect and the family would not know why. During an interview on 02/07/2024 at 3:03 p.m., the DON said consents should be signed prior to medication being administered. The DON said one reason consents were obtain was to inform the family about the risk and benefits prior to receiving medications. The DON said the charge nurse who received the order was responsible to obtain consents and the ADON confirmed receipt of consent as well as herself. The DON said the pharmacist when at facility would also look for consents. The DON said failure to obtain consents could cause families not to have a choice about resident's care. During an interview on 02/07/2024 at 03:50 p.m., the Administrator said consents should be done to inform families of risk and/or benefits of medication or a choice to decline. The Administrator said the ADON, and the DON was in charge of this process. The Administrator said failure to get consents could lead to families not having a voice in resident care. During an interview on 02/07/2024 at 4:00 p.m., Resident #58 said she takes a lot of medicine after the heart attacks and was unsure of all the names. During an attempted telephone interview on 02/07/2024 at 04:30 p.m. Resident #58's Responsible Party was unable to reach. Left a message and requested call back. During an attempted telephone interview on 02/07/2024 at 05:30 p.m. Resident #58's Responsible Party was unable to be reached. Left a message and requested call back. Record review of the facility's undated policy titled; Psychotropic Medication Use did not address consents for Psychotropic Medications.

Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #85) reviewed for baseline care plans. The facility failed to ensure Resident #85 had a baseline care plan completed within 48 hours of admission that included the use of a sling for the diagnosis of displaced fracture of shaft of left clavicle (shoulder). This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #85's face sheet, dated 02/07/2024 indicated Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included sepsis (life threatening complications of an infection), acute cystitis (burning, pain upon urination), metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood), acute kidney failure (a condition when the kidneys cannot filter), displaced fracture of shaft of left clavicle (fracture of left shoulder), chronic obstructive pulmonary disease (limited breathing airflow). Record review of Resident #85's Admission MDS assessment - Resident Assessment and Care Screening, dated 02/02/2024, indicated Resident #85's MDS had not been completed. Record review of Resident #85's Admission and Baseline Care plan with an initiated date of 02/03/2024 did not address displaced fracture of shaft of left clavicle (fracture of left shoulder) and sling. Record review of Resident #85's Order Summary Report dated 02/07/2024 did not indicate she had an order for a sling related to her displaced fracture of shaft of left clavicle (fracture of left shoulder). During an interview on 02/07/2024 at 2:12 p.m., LVN D said the admitting nurse was responsible for completing the baseline care plan. LVN D said the baseline care plan should be completed within 48 hours of admission. LVN D said she was not aware Resident #85's's baseline care plan was not completed. LVN D said it was important for the care plan to be completed appropriately to address the resident's needs to ensure continuity of care between staff especially since the facility was using agency staff. LVN D said agency staff did know the residents and their daily care routines. LVN D said she learned of Resident #85 requiring a sling because the previous nurse told her about it. LVN D said she had not verified the information in Resident #85's care plans regarding the use of the sling. During an interview on 02/07/2024 at 2:26 p.m., the ADON said she was responsible for ensuring the baseline care plans were completed. The ADON said she did not know how she had missed that Resident #85's baseline care plan was not completed to include use of the sling. The ADON said it was important to complete the baseline care plan because all the staff needed to know how to take care of the residents. During an interview on 02/07/2024 at 3:03 p.m., the DON said she was responsible for overseeing the baseline care plans. The DON said the baseline care plans should be completed within 48 hours of admission. The DON said she had missed Resident #85's baseline care plan not being completed. The DON said it was important for the baseline care plan to be completed within 48 hours of admission for continuity of care. During an interview on 02/07/2024 at 3:50 p.m., the Administrator said the DON and the ADON were responsible for overseeing that the baseline care plans were completed within 48 hours of admission. The Administrator said he expected for the baseline care plan to be completed within 48 hours of admission, and for it to be signed by the RN. The Administrator said it was important for the baseline care plan to be completed within 48 hours of admission because it was a state and federal requirement. The Administrator stated it was important for the baseline care plans to be completed timely, so the staff would know how to take care of the residents. Record review of the facility's policy titled, Care Plan-Baseline, last revised December 2016, indicated, . a baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within 48 hours of admission .

Based on observation, interview, and record review, the facility did not ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 2 of 4 residents reviewed for pressure injuries (ulcers). (Resident #16, 29, 7 and 30) The facility did not prevent the development of pressure injuries on Resident #29's left inner thigh, heel, buttock, and gluteal folds. The facility did not prevent the development on Resident #30's right heel. Skin assessments were not timely for Resident #30. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: 1. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated Resident #29 had intact cognition and was always incontinent of bladder and bowel. She required the extensive assistance of 2 staff for bed mobility and was totally dependent with transfers, and toilet use. The MDS did not indicate any pressure ulcers or skin issues. The care plan dated 10/3/20 indicated Resident #29 was totally dependent on staff for all ADL's. She had stage 2 blisters to the left inner thigh, right heel, left buttock, sacrum, and coccyx. A Weekly Pressure Injury Evaluation form dated 10/16/20 indicated Resident #29 had a stage 2 pressure ulcer to her right buttock and was 4.0 cm x 1.5 cm x 0.1 cm. A stage 2 pressure ulcer to her upper gluteal fold that was 0.7 cm x 0.1 cm x 0.1 cm. A stage 2 pressure ulcer to her mid gluteal fold that was 1.0 cm x 0.5 cm x 0.2 cm. Two stage 2 pressure ulcers to her left inner thigh that were 1.0 cm x 0.7 cm and 1.0 cm x 0.5 cm. A Weekly Pressure Injury Evaluation form dated 10/22/20 indicated Resident #29 had a stage 2 pressure ulcer to her upper gluteal fold that had merged to the stage 2 mid gluteal fold pressure ulcer. The merged wound was 1.8 cm x 0.5 cm x 0.2 cm. A stage 2 pressure ulcer to the right inner buttock that was 0.4 cm x 0.5 cm x less than 0.1 cm. A stage 2 pressure ulcer to her left upper thigh distal that was 3.0 cm x 3.0 cm. During an observation and interview on 10/22/20 at 11:15 a.m., RN H performed wound care on Resident #29's coccyx and inner thigh. She said the wound to the resident's coccyx was 1.8 cm x 0.5 cm and had no drainage or odor. She said the wounds to the resident's inner thigh were 3 cm x 1 cm for blister #1 and .04 cm x 1.1 cm for blister #2. Both blisters were dry and had no drainage or odor. The blister to the resident's inner heel was resolved. A Residents with Pressure Ulcers list provided by the DON on 10/22/20 indicated: Resident #29 was moved into the COVID-19 unit on 9/9/20 and left the COVID-19 unit on 9/21/20. The list indicated Resident #29 had her last skin assessment on the COVID-19 unit on 9/24/20. The list indicated she had her first skin assessment since being off the COVID-19 on 10/4/20. The list indicated a pressure ulcer was identified 10/14/20. During an interview on 10/22/20 at 9:05 a.m., the DON said Resident #29's wounds were healing. He said the pressure injuries increased because the facility morning meetings were intermittent and not daily. He said Resident #29's skin was not assessed for 10 days because the facility had a skin book that listed resident room numbers and who to assess for that day. The facility's electronic charting also had a system for what skin assessments to perform on certain days. He said agency staff utilized the electronic charting system and facility staff utilized the skin book. He said due to these different tracking systems, there was a lapse in skin assessments for Resident #29. The DON said the treatment nurse, MDS nurse, and the charge nurses initiated a 3 day skin sweep where they assessed all resident's skin. He said the process could have been quicker than 3 days for 37 residents. During an interview on 10/23/20 at 8:46 a.m., LVN J said he was unaware of any pressure injuries to Resident #16, 29, 7 and 30 before they were sent to the COVID-19 unit. He said Resident's #16 and #7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he was notified of Resident #16 and #29's pressure ulcers when they were found, but the residents were not under his care at that time. He said all 4 residents need turning and repositioning. Resident #16 was frequently up and down but had a drastic decline since contracting COVID-19. During an interview on 10/23/20 at 9:00 a.m., CNA K said she was the daily shower aide. She said she was unaware of any pressure injuries to Resident's #16, 29, 7 and 30 before they contracted COVID-19. She said she noticed pressure injuries on Resident #30 and #16. She said she put her findings on the shower sheets for the residents, but she was unaware if the facility did anything for the resident's skin. During an interview on 10/23/20 at 9:30 a.m., LPN L said she was an agency nurse who had begun working in the facility on 9/28/20. She said she was unaware of any skin issues with Resident #16, #29, #7 or #30. She said Resident #16 readmitted on [DATE] or 10/11/20 and had a dark mark to his right knee. Resident #30 had an issue with her right heel. She said she did not notice any skin issues with Resident #7 until she saw an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 had orders dated 10/13/20, cleanse right heel with normal saline/wound cleanser, pat dry and apply skin prep daily and as needed. 10/14/20, Float heels on pillows at all times when in bed. Heels are not to touch pillows or mattress. Complete pressure relief. Nurse to verify. Low air loss mattress to help alleviate pressure. Nurse to verify function at least every shift. The MDS dated [DATE] indicated Resident #7 had severe cognitive impairment and was always incontinent of bladder and bowel. The MDS indicated she required the total assistance of 2 or more staff for bed mobility, and she had only transferred once or twice but required the total assistance of 2 or more staff. The MDS indicated she did not have any pressure injuries and had a pressure reducing device for her bed. The care plan dated 9/12/20 indicated Resident #7 had dementia and impaired cognitive function. The care plan indicated she required the extensive assistance of 2 staff for bed mobility and transfer, and had bilateral plantarflexion of her lower extremities. The care plan indicated on 10/13/20 she had fluid filled blisters to right heel. A Residents with Pressure Ulcers list provided by the DON on 10/22/20 indicated: Resident #7 was moved to the COVID-19 unit on 9/9/20 and left the COVID-19 unit on 9/22/20. The list indicated Resident #7 had her last skin assessment on the COVID-19 unit on 9/20/20. The list indicated she had her first skin assessment since being off the COVID-19 on 9/27/20 and did not have another skin assessment until 10/13/20 (17 days later). The list indicated a pressure ulcer was identified 10/13/20. Progress notes for Resident #7 indicated: *9/22/20 Resident #7 received new orders to transfer off the COVID-19 unit and return to a regular room. *10/14/20 Skin/wound note for Resident #7 indicated notified dietician regarding new wound. New orders to float heels on pillows at all times in bed and low air loss mattress to help alleviate pressure, low air loss mattress ordered ROM company to be delivered today. *10/15/20 Bilateral lower extremities offloaded. A weekly skin assessment dated [DATE] indicated Resident #7 had no skin conditions or pressure injuries. A weekly skin assessment dated [DATE] indicated Resident #7 had no skin conditions or pressure injuries. A weekly skin assessment dated [DATE] indicated Resident #7 had no skin conditions or pressure injuries. A weekly skin assessment dated [DATE] indicated Resident #7 had a State 2 pressure injury to her right heel measuring 2.0 cm x 2.0 cm x nm (not measurable). A Braden Scale for Predicting Pressure Ulcer Risk dated 10/13/20 indicated Resident #7 had a score of 6 indicating a very high risk. A weekly skin assessment dated [DATE] indicated Resident #7 had an unstageable DTI (deep tissue injury) to her right heel measuring 0.4 cm x 0.3 cm x nm (not measurable). A Braden Scale for Predicting Pressure Ulcer Risk dated 10/20/20 indicated Resident #7 had a score of 10 indicating a high risk. An undated weekly skin assessment schedule provided by the DON on 10/23/20 indicated Resident #7 was to have her weekly skin assessment on Thursday of every week on the 6:00 p.m. to 6:00 a.m. shift. A Weekly Pressure Injury Evaluation dated 10/21/20 indicated Resident #7 had a stage 2 pressure injury to her right heel measuring 4.0 cm x 2.0 cm x unable to determine. The evaluation indicated she had no tunneling or undermining, the surface was closed, no exudate, no odor, no paid, and the peri wound was normal. The evaluation indicated to cleans the pressure injury with normal saline, apply skin prep, and leave open to air daily. Offload heels at all times in bed. The evaluation indicated Resident #7 was on a low air loss mattress. A wound evaluation and management summary dated 10/20/20 indicated Resident #7 had a DTI (deep tissue injury) with intact skin measuring 0.4 cm x 0.3 cm x nm (not measurable). The summary indicated the treatment plan was to apply skin prep daily for 30 days. During an observation on 10/21/20 at 10:35 a.m. RN H and CNA B entered Resident #7's room. RN H measured the wound to Resident #7's right heel to be 2 cm x 2 cm with no depth. RN H said the wound was closed with no drainage. She said the wound had good improvement. 3. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated Resident #30 did not speak, rarely understood others and was rarely understood. The MDS indicated she had short and long term memory deficits with inattention that was continuously present. The MDS indicated she required the total assistance of 2 or more staff for bed mobility and transfer and was always incontinent of bladder and bowel. The care plan dated 10/13/20 indicated Resident #30 required the total assistance of 2 staff for bed mobility and transfer and had impaired cognitive function and thought processes. The care plan indicated she had a pressure ulcer, a fluid filled blister to her right heel. During an observation on 10/21/20 at 8:15 a.m. Resident #30 was in her bed on her left side. She had pillows between her knees and a tent over her legs and feet. Feet appeared to be offloaded but she was covered. During on observation on 10/22/20 at 8:02 a.m. Resident #30 was on her left side. She had pillows between her knees and a tent over her legs and feet. Feet appeared to be offloaded but she was covered. During an observation and interview on 10/21/20 at 10:51 a.m. RN H provided wound care to Resident #30. LVN F assisted. Resident #30's heel was wrapped with gauze and her foot was in a multi-purpose heel lift to prevent pressure at heel. Both heels were propped on pillow not touching the low air loss mattress that was set on 2 and float. Resident #30 had a wedge under her left side and a pillow between knees. RN H removed the wrap and non-adherent dressing. The non-adherent was difficult to remove from her heel. The proximal end of the wound had approximately 40% reabsorbed, with a normal skin color and had a surrounding border. The distal end of the wound had a 60% fluid filled blister. RN H measured the wound at 5 cm x 4 cm x unable to determine. RN H said the wound was a stage 2 pressure injury with the surrounding tissue within normal limits. She said there was no redness, warmth, [CONDITION(S)] or odor. RN H cleansed the wound with normal saline, patted dry, and applied [MEDICATION(S)]. RN H said since the [MEDICATION(S)] was stuck on Resident #30's heel she will leave the wound open to air and call the MD to see if he will discontinue the [MEDICATION(S)]. She applied the heel lift boot that did not touch the wound. LVN F called the MD and received a new order to leave the wound open to air. The dietary note dated 10/16/20 indicated Resident #30 weighed 141 lbs. and had a weight gain. The note indicated she had a stage 2 to her right heel. Diet: NPO/2 Calorie HN (one carton/can every 6 hours/flush with 200 ml every 6 hours .Currently at 120% of her IBW (ideal body weight), BMI (body mass index) was 24. There was a beneficial gain for this resident. Estimated protein needs were 1.2 grams per kilogram-79 grams per day. Enteral feeding provides exactly 79grams per day. Recommendation, were to add 30 milliliters of liquid protein via peg daily for 30 days. A Residents with Pressure Ulcers list provided by the DON on 10/22/20 indicated: Resident #30 was moved to the COVID-19 unit on 9/9/20, left the COVID-19 unit on 9/21/20. The list indicated Resident #30 had her last skin assessment on the COVID-19 unit 9/13/20. The list indicated she had her first skin assessment since being off the COVID-19 on 10/10/20 and the list indicated a pressure ulcer was identified on 10/10/20. Progress notes for Resident #30 indicated: *9/25/20 Braden Evaluation for Resident #30 with a score of 9, indicating very high risk. *10/10/20 Resident #30 had a fluid filled raised blister on her right heel measuring 5 cm x 5 cm. Braden Evaluation for Resident #30 with a score of 11, indicating high risk. *10/13/20 Nurse informed of a skin issue to right heel measuring 5.0 cm x 4.0 cm x 0.1 cm. *10/21/20 .New order received for Resident #30 to cleanse with normal saline, apply [MEDICATION(S)] and leave open to air. Use heel lift boot at all times with wedge pillow to offload heels at all times. Wound stable . A Weekly Skin assessment dated [DATE] indicated Resident #30 had no skin conditions or pressure injuries. A Weekly Skin assessment dated [DATE] indicated Resident #30 had a fluid filled blister to her right heel measuring 5 cm x 5 cm. A Braden Scale for Predicting Pressure Ulcer Risk dated 10/10/20 for Resident #30 was a score of 11 indicating a very high risk. A Wound Evaluation and Management Summary dated 10/13/20 indicated Resident #30 had a stage 2 pressure injury of the right heel measuring 5 cm x 4 cm x 0.1 that was a blood-filled blister with no exudate. The treatment plan indicated apply [MEDICATION(S)] once daily for 30 days, gauze roll, apply one daily for 30 days, elevate legs, and float heels in bed. A Weekly Pressure Injury Evaluation dated 10/14/20 indicated Resident #30 had a stage 2 pressure injury on her right heel measuring 5 cm x 4 cm x 0.1 cm with a closed surface completely covered with epithelium. A Weekly Pressure Injury Evaluation dated 10/18/20 indicated Resident #30 had a blister noted to her right heel. No measurements were documented. A Wound Evaluation and Management Summary dated 10/20/20 indicated Resident #30 had a stage 2 pressure injury of the right heel measuring 5 cm x 4 cm x 0.1 that was a blood-filled blister with no exudate. The treatment plan indicated apply [MEDICATION(S)] once daily for 30 days, gauze roll, apply one daily for 30 days, elevate legs, and float heels in bed. Wound progress indicated no change. A Weekly Pressure Injury Evaluation dated 10/21/20 indicated Resident #30 had a stage 2 pressure ulcer on her right heel measuring 5 cm x 5 cm x unable to determine, with a closed surface, completely covered with epithelium. A new order was noted for to leans with normal saline and leave open not air daily. Use heel lift boot and wedge to offload heels. An undated weekly skin assessment schedule provided by the DON on 10/23/20 indicated Resident #30 was to have her weekly skin assessment on Sunday of every week on the 6:00 a.m. to 6:00 p.m. shift. During an interview on 10/20/20 at 9:06 a.m. the DON said residents were not turned as much as they should have been in the COVID unit. He said they were using agency staff in the COVID unit and they had none of their regular staff in the COVID unit. He said he did observation rounds in the COVID unit at the end of the day before he went home. He said because residents had pressure wounds he believed had to do with turning and repositioning being a contributing factor. He said his opinion was the turning and repositioning was a potential contributing factor to the negative outcome among other contributing factors. He said they were adequately staffed the entire time. He said they were using agency staff only in the COVID unit that were trained and onboarded. He said he noted a high incidence of pressure related areas on post COVID patients. He said the staff told them they were doing rounds every 2 hours. He said he did not know if they were turned properly because he was not there and only went into the COVID unit daily before he left for the day. During an interview on 10/21/20 at 3:11 p.m. the DON said he only became aware of the pressure ulcers when residents came of the COVID Unit. He said 2 or 3 residents came off the COVID Unit and they did the weekly skin sweep finding pressure ulcers on each of these residents. He said the weekly skin assessments by the (agency) nurses in the COVID Unit did not indicate any skin breakdown. He said as soon as they were aware of the pressure ulcers they did a facility skin sweep that took place [DATE]-16, 2020 and were done by the treatment nurse. He said when they did the skin sweep they found more pressure ulcers with a total of 5. The DON said he found out about wounds when the treatment nurse had found 2-3 during the weekly skin assessment. During an interview on 10/21/20 at 4:01 p.m. the DON said he did not call the agency to ask any questions regarding the nurses on the COVID Unit or follow up with any questions regarding the pressure ulcers. During an interview on 10/22/20 at 9:05 a.m. the DON said every resident should have a skin assessment every week. He said it was the responsibility of the ADON to make sure the skin assessments were done. He said they go over the skin assessments every morning at the morning meeting. He said there is a schedule at the nurse's station that a certain resident should get a skin assessment on a certain day. He said then they fill out the skin assessment on PCC (Point Click Care-a computer program). He said the ADON brings any issues to the morning meeting. He said the skin assessments were missed because of COVID-19 The morning meetings were not every morning, they were intermittent. He said Resident #7 had a skin assessment 9/27/20 and then did not have another skin assessment until 10/13/20. He said Resident #30 had a skin assessment 9/13/20 and did not have another one until 10/10/20. He said residents should have had a skin assessment every week. He said there was a problem with the oversight component. He said once it was brought to his attention he made an action plan and ensured there was a daily meeting regardless of the situation. He said they did a skin sweep that lasted from 10/14/20 - 10/16/20. He said the skin sweep should not have taken 3 days. He said it should have been done more quickly. During an interview on 10/22/20 at 9:45 a.m. LVN F and the DON said there is not a skin assessment book, it is in the computer. They provided a schedule indicating room numbers and certain days. During an interview on 10/22/20 at 9:55 a.m. the ADON said she and the DON were responsible for making sure the skin assessments were done. She said the administrator stopped the morning meetings at some point because she and the DON were working the floor and they were so busy because staff had been out sick with COVID. She said things like skin assessments got missed. She said the skin assessments not being done timely is unacceptable. She said several of the nurses were counseled for missing the assessments. During an interview on 10/22/20 at 10:12 a.m. RN H said she did not help with the skin sweep assessments. She said she oversaw the treatment nurse at the time do the skin sweep. She said 3 days was too long to take for a skin sweep with a census of 35-37 residents. She said she did not know if the DON or the ADON helped with the skin sweep but she thought it was just the treatment nurse. She said she did not know about residents having pressure ulcers until it was put in PCC. She said PCC will trigger a skin assessment but if you click on the assessment it closes it and it will not show past due so is difficult to track it. She said charge nurses should do skin assessments weekly and it is not acceptable to miss them. She said sometime in September of 2020 the DON or the administrator stopped the morning meetings but she does not remember which who stopped the meetings. She said the morning meetings were stopped so they could focus on infection control related to COVID-19. She said they would have morning meetings intermittently. During an interview on 10/22/20 at 10:28 AM the administrator said he stopped the morning meetings on September 10, 2020 because 22 staff were out with COVID-19. He said the ADON and the DON are responsible for making sure the skin assessments are done. He said it is not acceptable for residents to miss their weekly skin assessment. During an interview on 10/22/20 at 10:42 a.m. the ADON said the last morning meeting was held on 9/1/20. A Skin Integrity Monitoring System - Pressure/Non-Pressure policy dated 3/2020 provided by the DON on 10/23/20 indicated: It is the policy of this center that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed, and preventative measures will be in place to prevent the development of pressure injuries/ulcers . Assessment and Monitoring: 3 .The weekly skin assessment will be documented on the weekly skin assessment in the clinical software Goals: 1. Prevent the development of pressure injury by performing routine skin ad risk assessments on all residents at admission and specified intervals with appropriate intervention as per policy to prevent tissue destruction. Guideline: 3. All residents with disruption of skin integrity (Stage 1 through 4, unstageable or Deep Tissue Injury) will be evaluated on a weekly basis with specific attention given to the evaluation, treatment, and management of the skin alteration(s). This evaluation will be documented using the clinical software and placed on the Weekly Pressure Injury Evaluation . An undated Skin System Policy provided by the DON 10/23/20 indicated: Weekly Skin Surveillance Form: Complete and give a copy to the DON, MDS Coordinator, Dietician, and administration every Friday. The Action Plan dated 10/14/20 indicated: Problem: 1. Acute increase in the occurrences of new pressure related wounds on g-tube patients. a. 4 Patients were noted to have been recently identified status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #'s 7, 11, 16, and 30. 2. Contributing factors: a. Use of agency exclusively to staff COVID unit created difficulty for management to perform oversite rounds in order to ensure compliance of daily ADL (activities of daily living) care rounds. b. Acute medical disease process limited mobility, oxygenation, and nutritional intake with patient's normal levels of function. i. Creating decreased oxygenation availability to the tissues. ii. Creating decreased nutrient intake. iii. Creating decreased circulation to tissue. Action: Goal: For the next 30 days was management implement daily spot check with scheduled compliance rounds, a direct care staff re-education in-service to incorporate a turning schedule to remind staff and agency that residents are to be offloaded and repositioned every 2 hours. 1. Nurse management (DON, ADON, and RN H) will each perform daily rounds on unit at periodic (changing) times throughout the day during week to ensure compliance with turning schedule over the next 30 days. 2. Nurse management will implement re-education in-service on the expectation in order to facilitate desired working routines from direct care staff. 3. Nurse management will train a treatment nurse to be oriented and scheduled through the next 2 weeks to ensure proper assessment, management, documentation, and progress of the care of the new wounds are being properly addressed. 4. Nurse management will refer these 4 newly noted patients to the dietician for nutritional recommendations. 5. Nurse Management will refer to therapy services for screen and/or evaluation to address any functional ADL needs as indicated. 6. Patients primary care physician or wound care physician will be consulted for wound care evaluation, and orders. Resolution/Evaluation/Conclusion: 10/14/20 Action plan initiated. Weekly evaluation notes will be ongoing to monitor responses/outcomes to action put in place. Initial projections for 4 weeks to form direct care staff routines of facility desired improved expectations/outcomes. 10/16/20 Nurse management performed ADL care in-services 2 times this week on 10/14/20 and 10/16/20 on various ADL tasks. 10/16/20 Nurse management performed multiple random checks on spot ADL care round checks and observed incontinent care performed by direct care staff. 10/16/20 Implemented new nurse position (Treatment Nurse) due to recent increase in pressure related wounds to facilitate optimal wound care outcomes. 10/14/20 - 10/16/20 Skin sweep of all residents were performed by the treatment nurse in order to identify any other areas of concern. One new patient, Resident #29 was identified as having a pressure related skin condition. 10/16/20 Regular dietician reviewed all 5 patients and recommendations are under review by PCP (primary care physician.) 10/14/20 All 4 patients were referred to therapy department and to RNP (Restorative Nursing Program) Manager for review and care coordination. 10/14/20 All 4 patients were referred to a wound care specialist this week. Reviewed in-services: 10/15/20 Resident's are to be turned and repositioned every 2 hours. Heels offloaded and repositioning aides used to reduce pressure. Nurses are to check residents every to hours to ensure repositioning is properly achieved. 10/16/20 Nurse's aides are responsible for reporting any new skin issues to the charge nurse or treatment nurse. Report all issues and do not assume it has already been reported. Always report. 10/16/20 Incontinent and charge nurse rounds. Turning and repositioning are to be done on hall at the very beginning of shift and at the least every 2 hours after. Provide incontinent care to all residents that need assistance. Report any refusals to the charge nurse. The charge nurse should immediately go and speak with that resident, explain the potential negative outcomes that will arise from being non-compliant with care, and complete a progress note that the resident has been educated and they understand. 10/16/20 24 hour reports and dashboard review at the beginning of shift. Review dashboard and 24 hour reports printed by the 10:00 p.m. to 6:00 a.m. shift by room number. Know what is going on with each of your residents prior to the 8:00 a.m. nurses meeting. On 10/23/20 at 1:15 p.m. reviewed QA Pressure Compliance Rounds dated 10/14/20 through 10/23/20. On 10/23/20 at 1:20 p.m. reviewed Point Click Care weekly skin assessments indicating the weekly skin assessments were caught up through today. According to the NPIAP website, https://npiap.com/page/PreventionPoints, accessed on 10/27/20, the following was noted: .4. Repeat the risk assessment at regular intervals and with any change in condition. Base the frequency of regular assessments on acuity levels: 2. Long term care: Weekly for 4 weeks, then quarterly Repositioning and Mobilization 1. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments . 6. Ensure that the heels are free from the bed . .13. Use heel offloading devices or [MEDICATION(S)] foam dressings on individuals at high-risk for heel ulcers . The surveyor determined the facility was in non-compliance from 10/13/2020 to 10/16/2020. The facility took the following actions to correct the non-compliance: *An in-service dated 10/15/2020 indicated residents would be turned and repositioned every 2 hours. Heels offloaded and repositioning aides used to reduce pressure. Nurses would check residents every two hours to ensure they were repositioned. 10/16/20 Nurse's aides would be responsible for reporting any new skin issues to the charge nurse or treatment nurse. Wound care notes dated 10/14/20 indicated Residents #16, 29, 7 and 30 were referred to the wound care physician for evalaution and treatment. Interviews on 10/22/2020 with 1 RN, 2 LVNs, 1 LPN, and 2 CNAs indicated they were in-serviced on skin assessments, repositioning residents, pressure injury interventions identifying and reporting wounds. They were able to identify the in-services.

Based on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was provided in accordance with professional standards of practice for 1 of 5 residents reviewed for CPR. (Resident # 1) The facility did not immediately provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event his heart or breathing stopped) when the resident was found without vital signs. LVN A assessed Resident #1 and determined the resident did not have a pulse or respirations. LVN A was instructed over the phone by the DON to start CPR and she refused. The resident was pronounced dead approximately 1.50 hours later by the DON. An Immediate Jeopardy (IJ) situation was determined to have existed from [DATE] to [DATE]. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who had a full code status at risk of death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged on [DATE], she expired in the facility. Her [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was a full code. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 made her needs known and understood others. She required extensive assistance with ADLs. She was incontinent of bowel and bladder. A care plan dated [DATE] indicated Resident #1 was a full code and interventions included to ensure a full code order was on the resident's chart, begin CPR after absence of vital signs, call 911, notify physician, and notify responsible party/family. A skilled evaluation dated [DATE] at 12:03 a.m., completed by LVN A indicated Resident #1's blood pressure was ,[DATE], pulse was 72, temperature was 99.3, respirations were 20 breaths a minute, and oxygen saturation was 94% on room air. The resident moaned out upon movement and incontinent care was provided as needed. Resident #1 participated in therapy services and was assisted with ADLs. During an interview on [DATE] at 12:21 p.m., LVN A said on [DATE] about 12:15 a.m., she went into Resident #1's room to administer her scheduled [MEDICATION NAME] medication. She said she woke the resident up and she did not think the resident looked well. LVN A said Resident #1 took her medication with no issues and she also took the resident's vital signs. She said the vital signs were in normal range. She said around 2:20 a.m., she stepped into Resident #1's room while CNA B and CNA C were repositioning the resident. She said Resident #1 was not hollering at that time, but she received [MEDICATION NAME] a little earlier. She said around 4:50 a.m., she heard one of the CNAs hollering for her to come to Resident #1's room. LVN A said Resident #1 was positioned on her left side with her eyes opened and fixed. She said Resident #1's mouth was open, and her neck was hyperextended. She said Resident #1 was unresponsive and she had no blood pressure or pulse. She said Resident #1's nail beds and lips were blue in color. LVN A said Resident #1's left arm was a little cool and she saw mottling on the resident's feet, she said she sent one of the CNAs to check Resident #1's code status. LVN A said the CNA returned and indicated she was a full code. LVN A said she thought Resident #1 had been dead for about an hour and did not initiate CPR or call 911. She said she overstepped her scope and if she could do it over again, she would have initiated CPR and called 911. LVN A said she called the DON, the DON asked if she had initiated CPR and she told the DON that the resident was already gone. She said she called the NP and notified her that Resident #1 died . She said the NP did not ask if the resident was a full code. LVN A said she also called Resident #1's husband. During an interview on [DATE] at 2:13 p.m., CNA B said she and CNA C went into Resident #1's room on [DATE] around 12:00 a.m. CNA B said Resident # 1 was sleeping, she said they checked her brief and she was dry, she said when they repositioned her she hollered out. She said it was normal for the resident to holler out when she was repositioned. CNA B said around 2:20 a.m., she and CNA C went back to Resident #1's room to check her brief and reposition her, she said the resident was dry and she did not holler out like she normally did when she was moved. CNA B said she groaned when she was moved, she said she knew LVN A had administered pain medication and she thought the resident was sleeping well. CNA B said around 4:50 a.m., she and CNA C entered Resident #1's room and the resident was not responsive. She said they called the resident's name and shook her, but she did not respond. CNA B said they called for LVN A to come to the room, she said LVN A attempted to get vital signs, but the resident did not have a blood pressure or pulse. CNA B said LVN A asked her to check the resident's code status, she said she went to the kiosk and saw Resident #1 was a full code. CNA B said she came back to the room and told LVN A she was a full code. She said LVN A told her and CNA C to make Resident #1 presentable and LVN A left the room and called the DON, NP, and family. She said LVN A did not initiate CPR or call 911. She said Resident #1's arms, face, and shoulders were cool but her back was still warm. During an interview on [DATE] at 8:16 a.m., CNA C said she came to work on [DATE] at 10:00 p.m. and she, CNA B, and the off-going CNA completed a walk through with the residents around 10:00 p.m. She said Resident #1 was in her bed sleeping as usual. She said around 12:00 a.m., she and CNA B checked Resident #1's brief and repositioned her. Resident #1 hollered out and cussed at them as she normally did. She said about 2:20 a.m., she and CNA B entered Resident #1's room and Resident #1 was sleeping. She said they checked her brief and she was dry. CNA C said they repositioned Resident #1 and she groaned when they moved her. She said about 4:50 a.m., she and CNA B entered Resident #1's room and Resident #1 was lying in bed with her eyes open and she was not responding to them. She said they called her name and shook her, and she did not respond. CNA C said they called for LVN A who immediately came to the room. She said LVN A had her pulse oximetry and blood pressure cuff and attempted to get the resident's vitals but there were no readings. She said LVN A tried calling the resident's name and shook the resident with no response. She said they pulled back the covers and Resident #1's feet, face, and hands were cool but that was normal for the resident. She said Resident #1's back was warm to touch, and the resident was not stiff. She said LVN A checked Resident #1's feet for mottling and looked at her nail beds. She said LVN A asked CNA B to check Resident #1's code status. CNA C said CNA B came back to the room and said Resident #1 was a full code. She said LVN A continued to call Resident #1's name and tried to arouse her, she said the resident was gone. CNA C said LVN A said she was going to make some phone calls and asked her and CNA B to stay with Resident #1 and get her presentable for her family. She said LVN A did not initiate CPR or call 911. During an interview on [DATE] at 4:05 p.m., Resident #1's NP said she was notified on [DATE] by a nurse that Resident #1 died . She said she was not notified Resident #1 was a full code and CPR was not initiated. She said Resident #1 had a history of [REDACTED]. She said it was not up to the nurse to decide if the resident was clinically dead. During an interview on [DATE] at 9:11 a.m., the DON said LVN A called her on [DATE] at 4:50 a.m. and told her Resident #1 died . She said she asked LVN A if she called a code and LVN A said she did not because she was dead. The DON said she told LVN A twice she had to initiate CPR because the resident was a full code. She said LVN A continued to say the resident was dead, had no vitals, and was cyanotic around her mouth. The DON said she told LVN A she was headed to the facility, she said she lived 45 minutes away and when she arrived LVN A had not initiated CPR. She said Resident #1's eyes were opened and fixed and her mouth was open, she said the resident was blue around her mouth, nose, and neck. The DON said mottling was seen from the resident's feet to above her knees, blood had pooled to her buttocks and back. She said Resident #1's hands were stiff and her fingers were spread out. The DON said Resident #1 had no blood pressure, pulse, or respirations, she said she pronounced Resident #1 deceased at 6:25 a.m. She said she called the funeral home to pick up Resident #1. The DON said LVN A was suspended for not initiating CPR and an investigation was started. She said they began in-servicing staff on their CPR policy and code status. She said all residents' charts were audited to ensure the correct code status was reflected in the paper chart and computer charting system. She said all resident's' care plans were audited to include their code status. The DON said an audit was completed to ensure all licensed staff had a current CPR certification. She said the AED and crash cart were checked for function and supplies. She said they performed mock code drills where she was the resident and she held up signs with different code scenarios and staff acted out what they would do in that situation. She said they hosted a CPR class for staff that needed CPR certification. The DON said the social worker, the medication aides, and transportation staff received their CPR certification. The DON said many CNAs and kitchen staff said they wanted to be CPR certified, she said they planned to host another CPR class in the near future. She said the facility used agency nurses and asked the agency to provide current CPR certifications for nurses that work in their facility. A provider investigation report dated [DATE] indicated on [DATE] at 4:50 a.m., Resident #1 was found unresponsive. LVN A was called and assessed the resident. Resident #1 was noted to be without a blood pressure, pulse, and oxygen saturation. LVN A asked the CNA to check the resident's code status. The CNA said Resident #1 was a full code. LVN A evaluated Resident #1's blood pressure, carotid pulse and attempted to arouse the resident. LVN A notified the DON about Resident #1 and the DON instructed LVN A twice to initiate CPR, LVN A said the resident was dead. LVN A notified the NP and received an order for [REDACTED].#1's husband was notified of the resident's death. The DON arrived at the facility approximately 1.5 hours later and assessed the resident. Resident #1 had no vital signs, was cyanotic around her mouth and nose, mottling noted from feet to knees, cyanotic nail beds, and mottling noted to hands. Resident #1's body was cool. Resident #1 was pronounced dead at 6:25 a.m. LVN A was suspended on [DATE] and terminated on [DATE]. In-services were initiated on CPR policy, full code and DNR status, change in resident's condition, and abuse/neglect. Resident's charts were audited for advanced directives and care plans were audited to ensure code status. An audit was completed to ensure current CPR certifications on licensed nurses. The AED and crash cart were checked for function and ample supplies. A mock code drill was completed, and a CPR class was conducted at the facility. The employee file for LVN A indicated she was hired on [DATE]. LVN A's CPR certification was current. LVN A was suspended on [DATE] and terminated on [DATE] for failing to perform CPR. The facility's cardiopulmonary resuscitation policy dated (MONTH) 2019 indicated .if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/basic life support) shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (rigor mortis) . If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support sequence of events (chest compressions, airway, breathing). According to www.heart.org, accessed on [DATE], CPR administered immediately after [MEDICAL CONDITION] can double or triple the chances of survival. The DON and business office manager were notified on [DATE] at 1:55 p.m., that a past non-compliance IJ situation existed from [DATE] to [DATE] was identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on [DATE]. The facility implemented the following interventions: *LVN A was suspended on [DATE] and terminated on [DATE]; *staff were in-serviced on code status, CPR policy and protocol, change of condition, and abuse/neglect on [DATE]; *resident paper and computer charts were audited for advanced directives and current code status on [DATE]; *resident care plans were audited to reflect code status; *AED and crash cart checked for function and supplies on [DATE]; *mock code drills were performed on [DATE] and [DATE]; *CPR class conducted on [DATE]. During interviews with 16 staff (DON, 4 LVNs, 3 MAs, 7 CNAs, and 1 social worker) they were able to appropriately define full code status and DNR status, identify the location of the AED and crash cart, provided the procedure for a resident found unresponsive with no vital signs that was a full code. Chart reviews were completed and reflected code status. Resident care plans included their code status. The crash cart was observed to have ample supplies and staff signed daily that the crash cart was checked.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary and safe environment. The facility did not prevent the septic system from backing up, causing a foul smelling black substance to come through the drains seeping into the kitchen floor in close proximity to food preparation areas, or prevent rain water from leaking onto a functional light fixture into the food preparation area in the kitchen. The facility continued to serve food to the residents from the kitchen. The facility did not prevent the grease trap in the courtyard from back up causing a strong odor. The facility did not have the correct sanitizing chemicals for the dishwasher and three compartment sink. The facility did not have floors in the kitchen that were not a trip hazard. An Immediate Jeopardy (IJ) was identified on 01/31/19. The administrator was notified. The IJ was not removed due to the facility's failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. This failure could place residents at risk for eating contaminated food and increased fire risk due to electrical problems. Findings included: During an observation on 01/31/19 at 10:16 a.m., a 4-foot rectangular shaped fluorescent light fixture was mounted to the kitchen ceiling. The light fixture hung above a food preparation table and gas fryer. There was faint brown staining on the ceiling where the light fixture's electrical wiring entered the light fixture. An 8 foot by 1-foot area of ceiling was visibly bowed downward approximately 4 inches. A 3-foot by 2-foot area of tile floor near the food preparation table was raised 0.5 inches from the floor and flexed when walked on. There was a sign taped to the dish machine that warned staff not to use the dish machine. During an observation on 01/31/19 at 11:02 a.m., while water was running in the 3-compartment sink and the garbage disposal was on, a black liquid visibly spewed onto the kitchen floor from the floor drain near the 3-compartment sink. Small puddles of the black greasy substance began forming on the floor near the floor drain. The black liquid had a foul odor and a greasy appearance. The floor drain was approximately 2-feet from the dish machine and 3-compartment sink, where dishes were sanitized. Cornbread for the lunch meal was sitting on top of the stove that was approximately 10 feet away from the floor drain. During an observation on 01/31/19 at 12:43 p.m., residents were in the dining room eating lunch on Styrofoam plates and drinking from plastic cups. Residents were using metal utensils. During an observation and interview on 02/01/19 at 12:48 p.m., there was a kitchen drain line that was connected to the grease trap and was located outside in the courtyard. There was standing water in the pipe approximately 2 feet from the top of the pipe. The maintenance supervisor said the drain line often overflowed in the courtyard, near the exit door of the facility. The courtyard was open to residents and visitors. During an observation and interview on 02/01/19 at 12:49 p.m., there was a grease trap pipe located in the courtyard. A light brown greasy substance was observed in the pipe approximately 3 feet from the top of the pipe. A strong foul odor emitted from the pipe. The maintenance supervisor said the grease trap needed to be pumped but since corporate (the facility owner) did not pay the vendor from pumping the grease trap last year, the vendor said they would not come back until they were paid. The courtyard was open to residents and visitors. A work order dated 01/14/19 indicated the vendor that pumped the grease trap was owed $264 from services dated 02/16/18 and stated the facility must pay up front before the vendor would perform the service. During an interview on 01/31/19 at 8:11 a.m., the administrator said the grease trap needed to be pumped but the corporate office would not pay the upfront payment needed to initiate the service. She said the sewer was backing up through the kitchen floor drain and the corporate office (owners) would not make the upfront payment needed for a plumber to come out. She said the roof leaked when it rained, causing rain to drip on equipment in the kitchen. She said the dish machine was out of the sanitizing agent, disinfecting pellets, and testing strips. She said corporate (the owners) only ordered enough chemicals for a week after they were cited previously for not having them. She said residents were eating from disposable plates. During an interview on 01/31/19 at 10:09 a.m., the maintenance supervisor said the black liquid had been coming up through the kitchen floor drain for a month. He said the black liquid would splatter up through the floor drain and puddle on the kitchen floor around the floor drain. He said anytime the kitchen staff turned on the water in the kitchen sinks, the black sewer water spilled out in the kitchen floor. The maintenance supervisor said the sewer water had a pungent odor. He said they attempted to call several plumbers, but no plumbers would come out to the facility without being paid first due to the facility's history of non-payment. He said corporate (the owner of the facility) was aware of the black liquid but still had not approved payment to hire a plumber. He said the grease trap had not been pumped due non-payment from the last time the vendor pumped the grease trap. He said the last time the grease trap was pumped was (MONTH) (YEAR). The maintenance supervisor said when it rained, water leaked into the kitchen through the ceiling. He said the rain water seeped through the ceiling, ran down the light fixtures onto food preparation tables and the fryer. He said corporate (the facility owner) was notified and told him to get bids for a new roof. He said he received several bids and sent them to corporate (facility owners) twice, but never heard a response. He said the last time he sent in bids for a new roof was late (MONTH) (YEAR). During an interview on 01/31/19 at 10:13 a.m., the dietary manager said every time it rained, the rain water leaked through the ceiling and ran down the light fixtures. She said the rain water dripped onto the food preparation tables, into the fryer, and onto the floors. She said they did their best to prepare the food in a dry area. She said they did not use the fryer when it rained. She said they moved trash cans under the leaks in an attempt to contain the rain water. She said rain water leaked into the kitchen for almost a year and the administration and corporate (the owners) were aware of the leaks. She said there was a bowed area in the kitchen ceiling where rain water pooled. She said when they turned on the water in the sink, a black liquid splattered out of the floor drain in the kitchen. She said the odor smelled like sewage and was almost unbearable but was contained to the kitchen. She said the tile was not adhered to the floor near the food preparation table, causing a trip hazard. She said they had been out of dish machine chemicals for more than 6 months because corporate (the owners) would not approve orders for the chemicals, but were aware the facility was out of the required chemicals. She said they did not have the correct chemicals for the 3-compartment sink and were using a household dish liquid and bleach. She said for months, they had served food to residents on disposable plates. The dietary manager said there were no testing strips to ensure the dishes were sanitized. She said corporate (the facility owner) was aware of everything they needed. The Texas Food Establishment Rules dated (MONTH) (YEAR) accessed 02/03/19 indicated the following .a food establishment shall immediately discontinue operations and notify the regulatory authority if an imminent health hazard may exist because of an emergency such as a fire, flood, extended interruption of electrical or water service, sewage backup, misuse of poisonous or toxic materials, onset of an apparent foodborne illness outbreak, gross insanitary occurrence or condition, or other circumstance that may endanger public health . The ADM, ADON, BOM, Maintenance Supervisor, Housekeeping Supervisor, Laundry Supervisor, Medical Records, and Social Worker were notified that an Immediate Jeopardy situation was identified on 1/31/19 at 3:53 p.m. due to the above failures. The facility presented the surveyors with a plan to remove the IJ on 2/01/19 at 12:50 p.m. The plan of removal included the following: Starting (MONTH) 31st the Vice President of Operations will be notified of any needed supplies or specialty equipment rentals, with the items needed, the cost of the items and what the payment arrangements will be. The VP will then notify, Joe Newman CEO, of the request and if necessary, approval will be obtained. Requests for items needed will be monitored by the, Administrator or Administrative designee, on a daily basis to find out when the items are ordered or that money was funded on the facility card so purchases can be made. On (MONTH) 31, 2019, continuous Fire Rounds were started and employees brought in to do just these checks specifically. Staff were in-serviced by the Maintenance Director on how the Fire Rounds should be made and documented. On (MONTH) 31, 2019, HFCO Fire Alarm Company was contacted and services our Fire Panel on (MONTH) 1, 2019. All Life Safety Fire Alarm requirements are up to date and current as of (MONTH) 1, 2019. On (MONTH) 31, 2019, the plumber was contacted to come and look at the kitchen area with regards to the sewage backing up in the kitchen. They will be here on (MONTH) 1, 2019 to fix the issue and find out what is causing this to happen. Bids will be sent back up to the Corporate Office Level, for the leaks in the kitchen area to stop the water from running into the light fixture and on the steam table. Administrator will continue to follow up on bid emails and plans are for this to be done by (MONTH) 7, 2019. In the section titled Administration and Governing Body, the plan of removal indicated the facility would address contracts to be updated or developed as needed by 02/07/19 in the areas of laboratory testing, x-ray, pharmacy consultant, dietician, fire alarm monitoring, medical records consultant, plumbing, chemical supply company for dietary, housekeeping and laundry, and medical equipment. The plan stated the administrator would work with the corporate owners of the facility and VP of Operations to restore contracts and services to the facility, with daily follow up and a completion date of 02/07/19. The plan of removal also addressed the lack of a required DON as follows: RN hours will be covered at 8 hours per day to make sure the facility if covered since we do not have a DON at this time. Advertisement will be made in local papers, facebook, craigslist, Texas Work Force and filled as soon as we can. The Administrator and/or the Corporate Regional Nurse will interview candidates as soon as we receive applications. The plan was not accepted because at the time of exit, the black liquid remained on the kitchen floor. The plan did not introduce any new policy or procedure, while evidence demonstrated the existing procedures were ineffective, causing widespread system failure. Required services and supplies were not purchased timely, and required staff were not employed or contracted, despite numerous attempts from the administrator to obtain approvals and payments for the delinquent services. Most local vendors placed the facility on vendor hold until payment made in advance due to the facility's history of late and non-payment, and while the plan of removal stated they would bring in the necessary plumbers and contractors, they did not address the delinquent payments or specify if any plumber / contractor would agree to service the facility.

Based on observation, interview, and record review, the administration failed to ensure resources were administered effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for each resident. 1.The administration did not obtain services to maintain the fire monitoring system, sewage system, and grease trap due to lack of financial resources available. 2. The administration did not prevent rain water from leaking onto electrical light fixatures in the kitchen, food preparation areas and onto equipment in the therapy department, threatening residents' health, safety and psychosocial well-being. not making repairs to the facility roof, ceilings and other essential equipment. 3. The administration did not obtain services for resident care due to lack of financial resources available. An Immediate Jeopardy (IJ) was identified on 01/31/19. The administrator was notified. The IJ was not removed due to the facility's failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. These failures placed the residents at risk for compromised safety, comfort, and medical care. Findings included: 1.During an interview on 01/31/19 at 8:11 a.m., the administrator said she had been at the facility since the end of November. She said from the first day she arrived, she battled corporate with paying bills. She said she was constantly sending emails or making phone calls about vendor holds, non-payments, payments that bounced, and the refusal of corporate (the facility owner) paying for supplies. She said the grease trap needed to be pumped but corporate (the owner) would not pay the upfront payment needed for the truck to come out. She said the sewer was backing up through the kitchen floor drain and the facility owner would not make the upfront payment needed for a plumber to come out. She said the roof leaked when it rained and leaked in the kitchen causing rain to drip on equipment. She said the dish machine was out of the sanitizing agent, disinfecting pellets, and testing strips. She said the corporate office ordered the sanitizing agent one time after they were cited. She said residents were eating from disposable plates. She said the facility's fire monitoring was placed on vendor hold due to non-payment. She said the fire monitoring included quarterly inspections of the fire alarm system, sprinkler system, and they responded to any trouble signals. She said the fire monitoring also included inspections of the fire extinguishers. She said she emailed the corporate office on 12/05/18 about the non-payment and the owner told her that if the fire alarm went off, the fire department would be notified of the fire alarm going off. She said the corporate office paid the vendors and invoices when the state agency came in and cited. She said the facility was without a pharmacy consultant and registered dietician. She said they were on vendor hold with laboratory and x-ray services but the corporate office did pay the bill and they were receiving those services again. She said they were on vendor hold with the company that supplied specialty mattresses, [DEVICE], and Hoyer lifts. She said they were on vendor hold with the company that provided chemicals for dietary, housekeeping, and laundry. She said the corporate office was aware of all of the holds but had not paid any of the vendors. She said the mobile dental vendor had not been paid. She said she just found out her facility credit card was cancelled. She said payroll checks have bounced and many staff quit or walked out. She said the facility did not have a DON and were using agency staff to cover shifts. She said the weekend RN supervisor also quit. She said the wheelchair scale was last calibrated in (YEAR) and the facility owner would not pay to have it calibrated again. She said they did not have toner for the fax and have not been able to receive faxes from physicians or labs. The administrator said most bills were mailed directly to the corporate office and she was not aware of how many vendors the facility was not in good standing with. During an interview on 01/31/19 at 10:09 a.m., the maintenance supervisor said the black liquid had been coming up through the kitchen floor drain for a month. He said the black liquid would splatter up through the floor drain and puddle on the kitchen floor around the floor drain. He said anytime the kitchen staff turned on the water in the kitchen sinks, the black sewer water spilled out in the kitchen floor. The maintenance supervisor said the sewer water had a pungent odor. He said they attempted to call several plumbers, but no plumbers would come out to the facility without being paid first due to the facility's history of non-payment. He said the corporate office was aware of the black liquid but still had not approved payment to hire a plumber. He said the grease trap had not been pumped due non-payment from the last time the vendor pumped the grease trap. He said the last time the grease trap was pumped was (MONTH) (YEAR). The maintenance supervisor said when it rained, water leaked into the kitchen through the ceiling. He said the rain water seeped through the ceiling, ran down the light fixtures onto food preparation tables and the fryer. He said the corporate office was notified and told him to get bids for a new roof. He said he received several bids and sent them to corporate (the facility owners) twice, but never heard a response. He said the last time he sent in bids for a new roof was late (MONTH) (YEAR). During an interview on 01/31/19 at 10:13 a.m., the dietary manager said every time it rained, the rain water leaked through the ceiling and ran down the light fixtures. She said the rain water dripped onto the food preparation tables, into the fryer, and onto the floors. She said they did their best to prepare the food in a dry area. She said they did not use the fryer when it rained. She said they moved trash cans under the leaks in an attempt to contain the rain water. She said rain water leaked into the kitchen for almost a year and the administration and the owners were aware of the leaks. She said there was a bowed area in the kitchen ceiling where rain water pooled. She said when they turned on the water in the sink, a black liquid splattered out of the floor drain in the kitchen. She said the odor smelled like sewage and was almost unbearable but was contained to the kitchen. She said the tile was not adhered to the floor near the food preparation table, causing a trip hazard. She said they had been out of dish machine chemicals for more than 6 months because corporate (owner) would not approve orders for the chemicals, but were aware the facility was out of the required chemicals. She said they did not have the correct chemicals for the 3-compartment sink and were using a household dish liquid and bleach. She said for months, they had served food to residents on disposable plates. The dietary manager said there were no testing strips to ensure the dishes were sanitized. She said the corporate office was aware of everything they needed. During an observation on 01/31/19 at 10:16 a.m., a 4-foot rectangular shaped fluorescent light fixture was mounted to the kitchen ceiling. The light fixture hung above a food preparation table and gas fryer. There was faint brown staining on the ceiling where the light fixture's electrical wiring entered the light fixture. An 8 foot by 1-foot area of ceiling was visibly bowed downward approximately 4 inches. A 3-foot by 2-foot area of tile floor near the food preparation table was raised 0.5 inches from the floor and flexed when walked on. There was a sign taped to the dish machine that warned staff not to use the dish machine. During an observation on 01/31/19 at 11:02 a.m., while water was running in the 3-compartment sink and the garbage disposal was on, a black liquid visibly spewed onto the kitchen floor from the floor drain near the 3-compartment sink. Small puddles of the black greasy substance began forming on the floor near the floor drain. The black liquid had a foul odor and a greasy appearance. The floor drain was approximately 2-feet from the dish machine and 3-compartment sink, where dishes were sanitized. Cornbread for the lunch meal was sitting on top of the stove that was approximately 10 feet away from the floor drain. During an observation on 01/31/19 at 12:43 p.m., residents were in the dining room eating the lunch meal and were eating on Styrofoam plates and drinking from plastic cups. Residents were using metal utensils. During an observation on 02/01/19 at 12:48 p.m., there was a kitchen drain line that was connected to the grease trap and was located outside in the courtyard. There was standing water in the pipe approximately 2 feet from the top of the pipe. The maintenance supervisor said the drain line often overflowed in the courtyard, near the exit door of the facility. The courtyard was open to residents and visitors. During an observation and interview on 02/01/19 at 12:49 p.m., there was a grease trap pipe located in the courtyard. A light brown greasy substance was observed in the pipe approximately 3 feet from the top of the pipe. A strong foul odor emitted from the pipe. The maintenance supervisor said the grease trap needed to be pumped but since the corporate office did not pay the vendor from pumping the grease trap last year, the vendor said they would not come back until they were paid. The courtyard was open to residents and visitors. A work order dated 01/14/19 indicated the vendor that pumped the grease trap was owed $264 from services dated 02/16/18 and stated the facility must pay up front before the vendor would perform the service. During an interview on 01/31/19 at 10:06 a.m., the maintenance supervisor said when it rained, the water leaked into a storage room in the therapy department. He said the ceiling appeared to have mold. He said the ceiling would pool with water. He said the corporate office was aware of the leaky roof. He said corporate's response was always the same, get another bid. He said he collected bids for almost a year. He said he sent them to the corporate office and nothing had been done. A proposal for roofing services dated 03/01/18 presented bid for a new roof. There was no documented response to the proposal. A proposal for roofing services dated 03/06/18 presented bid for a new roof. There was no documented response to the proposal. A proposal for roofing services dated 11/26/18 presented bid to repair the roof. There was no documented response to the proposal. A proposal for roofing services dated 11/30/18 presented bid for a new roof. There was no documented response to the proposal. During an observation on 01/31/19 at 10:07 a.m., a storage room located in the therapy hall had a 2-foot diameter area on the ceiling that was littered with brown and black spots. There was a 1-foot circular piece of sheet rock that was pulled away from the ceiling and dangling. The 1-foot area of ceiling where the sheet rock once hung was littered with black and brown spots. There was therapy equipment in the room. During an interview on 01/31/19 at 10:22 a.m., the maintenance supervisor said the fire panel had a ground fault code came across the screen a month ago and he called the fire monitoring company and was told they could not counsel the facility on the code due to the non-payment status. He said he had not pulled the fire alarm during fire drills because he did not know if he would be able to turn off the fire alarm. He said the owner of the facility was aware of the ground fault code and said the fire department would still be notified when the fire alarm was engaged. He said he had not contacted the fire department to ask if the fire department would be notified if the fire alarm was activated. During an observation on 01/31/19 at 10:23 a.m., the fire panel's trouble light was flashing. The silenced light was lit up. During an interview on 01/31/19 at 12:26 p.m., the fire monitoring representative said they cancelled their contract with the facility due to their history of non-payment. He said a ground fault code was the worst of the worst codes because it could include any number of wires that typically got wet and touched a grounded item. He said the monitoring company would have to come out to inspect the system and find the problem. He said the facility did not have fire monitoring and it the facility activated the fire alarm, the fire department would not be notified. During an observation on 01/31/19 at 12:47 p.m., the maintenance supervisor tested the fire alarm, the alarm rang, the automatic doors closed, and the alarm was disengaged. During an interview on 01/31/19 at 12:48 p.m., the local fire department said did not receive an alert that the facility's fire alarm went off. During an interview on 01/31/19 at 12:51 p.m., the local sheriff's department said they did not receive an alert that the facility's fire alarm went off. A letter dated 12/03/18 from the fire monitoring company to the facility indicated no services were available for the facility due to non-payment. The balance due was $617. A fire protection and maintenance agreement dated 05/01/15 indicated the fire monitoring vendor would provide 4 maintenance inspections yearly, report any faults in the fire protection system, and provide fire monitoring (response to fire alarm and trouble signals). Inspections, maintenance, parts, and service called would be billed to the facility and payments terms were net 30 days. The agreement would automatically renew after 24 months then every 12 months unless terminated. 2.During an interview on 01/31/19 at 9:43 a.m., the housekeeping supervisor said the housekeeping staff did not have the correct chemicals to clean and disinfect the facility. She said the corporate office had not paid the vendor and they had not received any chemicals. She said she used the last hand soap refill today and did not know what she would do when she needed more. She said they did not have toilet bowl cleaner or disinfectant for the showers. She said they did not the correct chemicals for cleaning the floors. She said the staff have bought their own chemicals from local stores but the housekeeping supervisor said the chemicals purchased locally do not clean as well as the chemicals from the vendor. During an interview on 01/31/19 at 10:57 a.m., LVN A said the facility usually received laboratory or x-ray results through the fax machine. He said the fax machine did not have toner and he had to call the laboratory service vendor to get the results. He said about 2 weeks ago the facility was on vendor hold with laboratory and x-ray services due to non-payment. During an interview on 01/31/19 at 10:59 a.m., the nurse practitioner (NP) said she was frustrated with the corporate office (the owners) because she was told she could not order Unna boots (compression dressing to promote healing of wounds and ulcers) with infused [MEDICATION NAME] lotion for residents at risk for pressure injuries. She said she knew the residents' needs and knew what worked best for them. She said the ADON notified her that corporate (the facility owner) said she could not order the Unna boots. The NP said she had not received any pharmacy recommendations or dietary recommendations since (MONTH) (YEAR). She said one resident lost 22 pounds in the last year and there were no dietary recommendations for her. She said the resident should have dietary recommendations in place. She said the last dietary recommendations she received were from (MONTH) (YEAR). She said the medical director had not been paid in a long time but he continued to provide services to the facility. During an interview on 01/31/19 at 2:23 p.m., the sales representative for the laboratory and x-ray services said as of today, the vendor no longer had an account with the facility. He said the facility was placed on vendor hold a few weeks ago and the vendor received a check from the corporate office. He said the hold was lifted and he was notified on 01/30/19 that the check was insufficient, and their account was cancelled. He said the facility would have to find another laboratory and x-ray vendor. He said the facility had a history of [REDACTED]. An agreement dated 02/01/15 indicated the x-ray vendor would provide x-ray, cardiac, and ultrasound services to the residents of the facility and the facility agreed to pay each x-ray vendor invoice in full within 30 days of the invoice date. The agreement would be automatically renewed yearly unless a written termination was provided by either party. A laboratory services agreement was unavailable. During an interview on 01/31/19 at 6:11 p.m., the pharmacy consultant said she last came to the facility at the end of (MONTH) (YEAR). She said she was told that the pharmacy consultant company would not return to the facility due to non-payment. She said when she was at the facility in (MONTH) she provided the facility with her pharmacy recommendations. Pharmacy recommendations dated 11/26/18 indicated residents' medications were reviewed and recommendations were provided. A pharmacist agreement dated 04/03/18 indicated the pharmacy consultant would provide medication review every 30 days and monthly drug destruction monthly or as deemed necessary. The pharmacy consultant would be compensated on or by the last day of the month. The agreement indicated the term of the agreement was monthly ending on 04/30/18. During an interview on 02/01/19 at 11:33 a.m., the ADON said the last time the pharmacy consultant destroyed drugs was on 10/17/18. Dietary recommendations dated 10/31/18 indicated the dietician reviewed resident records and provided dietary recommendations. A dietician agreement dated 01/07/19 indicated a registered dietician would provide consultation to staff, assist in nutritional care plans, and provide nutritional assessments of residents. Payment was due at the time of service and consultant services may be immediately withheld due to lack of payment. The agreement would continue unless a written notice was given by either party. An email from the administrator to corporate (the facility owner) dated 01/30/19 indicated the dietician consultant needed to be paid $840 before she would come out to the facility. During an interview on 01/31/19 at 10:47 a.m., the social worker said the mobile dental vendor was in the facility on 01/14/19 and 01/31/19 providing care. She said the dental vendor usually visited the facility every 2 weeks. A mobile dental invoice dated 01/28/19 indicated the facility owed $ .87 and included $7149.49 that was more than 90 days past due. A mobile dental agreement dated 03/25/15 indicated the dental vendor would provide facility residents with dental care and treatment services. The facility agreed to process and pay all invoices for dental services provided to facility residents. The agreement would continue yearly unless either party provided a written letter of termination. An invoice from an equipment supply vendor dated 11/06/18 indicated $2755.33 was due on 12/06/18. The invoice included bed frames, pressure reducing mattresses, oxygen concentrators, and a geri chair. An invoice from an equipment supply vendor dated 01/03/19 indicated $2403.50 was due on 02/02/19. The invoice included bed frames and pressure reduction mattresses. Times sheets dated (MONTH) 2019 indicated the former DON worked 01/07/19 and 01/08/19. There was not a DON in the facility for the rest of (MONTH) 2019. RN coverage was not provided for 8 consecutive hours on 01/01/19, 01/02/19, 01/03/19, 01/14/19, 01/15/19, and 01/16/19. During an interview on 01/31/19 at 10:47 a.m., the social worker said her paycheck dated 01/15/19 was deposited in her bank and on 01/23/19 she was notified that the check did not clear. She said corporate (the facility's owner) wired the money into her account but had not offered to pay for the insufficient fund fees that she accrued. During an interview on 01/31/19 at 9:33 a.m., the business office manager said on 01/29/19, facility staff received their payroll checks. She said corporate (the facility owner) had an account at a local bank and staff began going to the bank to cash their checks. She said about half of the staff were able to cash their checks then the rest of the staff were turned away because there was not enough money in the account to cover the entire payroll. She said the payroll budget for 2 weeks was $ and corporate (the owner) only deposited $ into the account. The business office manager said all the payroll checks were eventually covered. She said payroll checks had a history of [REDACTED]. She said staff have quit and the facility was using agency staff to cover shifts. The ADM, ADON, BOM, Maintenance Supervisor, Housekeeping Supervisor, Laundry Supervisor, Medical Records, and Social Worker were notified that an Immediate Jeopardy situation was identified on 1/31/19 at 3:53 p.m. due to the above failures. The facility presented the surveyors with a plan to remove the IJ on 2/01/19 at 12:50 p.m. The plan of removal included the following: Starting (MONTH) 31st the Vice President of Operations will be notified of any needed supplies or specialty equipment rentals, with the items needed, the cost of the items and what the payment arrangements will be. The VP will then notify, Joe Newman CEO, of the request and if necessary, approval will be obtained. Requests for items needed will be monitored by the, Administrator or Administrative designee, on a daily basis to find out when the items are ordered or that money was funded on the facility card so purchases can be made. On (MONTH) 31, 2019, continuous Fire Rounds were started and employees brought in to do just these checks specifically. Staff were in-serviced by the Maintenance Director on how the Fire Rounds should be made and documented. On (MONTH) 31, 2019, HFCO Fire Alarm Company was contacted and services our Fire Panel on (MONTH) 1, 2019. All Life Safety Fire Alarm requirements are up to date and current as of (MONTH) 1, 2019. On (MONTH) 31, 2019, the plumber was contacted to come and look at the kitchen area with regards to the sewage backing up in the kitchen. They will be here on (MONTH) 1, 2019 to fix the issue and find out what is causing this to happen. Bids will be sent back up to the Corporate Office Level, for the leaks in the kitchen area to stop the water from running into the light fixture and on the steam table. Administrator will continue to follow up on bid emails and plans are for this to be done by (MONTH) 7, 2019. In the section titled Administration and Governing Body, the plan of removal indicated the facility would address contracts to be updated or developed as needed by 02/07/19 in the areas of laboratory testing, x-ray, pharmacy consultant, dietician, fire alarm monitoring, medical records consultant, plumbing, chemical supply company for dietary, housekeeping and laundry, and medical equipment. The plan stated the administrator would work with the corporate owners and VP of Operations to restore contracts and services to the facility, with daily follow up and a completion date of 02/07/19. The plan of removal also addressed the lack of required staff as follows: RN hours will be covered at 8 hours per day to make sure the facility if covered since we do not have a DON at this time. Advertisement will be made in local papers, facebook, craigslist, Texas Work Force and filled as soon as we can. The Administrator and/or the Corporate Regional Nurse will interview candidates as soon as we receive applications. The plan was not accepted because it did not introduce any new policy or procedure, while evidence demonstrated the existing procedures were ineffective, causing widespread system failure. Required services and supplies were not purchased timely, and required staff were not employed or contracted, despite numerous attempts from the administrator to obtain approvals and payments for the delinquent services. Most local vendors placed the facility on vendor hold until payment made in advance due to the facility's history of late and non-payment, and while the plan of removal stated they would bring in the necessary plumbers and contractors, they did not address the delinquent payments or specify if any plumber / contractor would agree to service the facility.

Based on observation, interview, and record review, the facility failed to ensure the governing body established and implemented policy regarding the operation of the facility. 1.The facility owners failed to ensure residents' health, safety and psychosocial well-being by refusing to pay timely for repairs to the facility roof, ceilings and other essential equipment. 2. The facility owners failed to ensure residents' health, safety and psychosocial well-being by not meeting their financial obligations for staff, which included the medical director, and other vendors at the time they were due. An Immediate Jeopardy (IJ) was identified on 01/31/19. The administrator was notified. The IJ was not removed due to the facility's failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. These failures placed the residents at risk for compromised safety, comfort, and medical care. Findings included: 1.During an interview on 01/31/19 at 8:11 a.m., the administrator said she had been at the facility since the end of November. She said from the first day she arrived, she had battled corporate with paying bills. She said she was constantly sending emails or making phone calls about vendor holds, non-payments, payments that bounced, and the refusal of the corporate office paying for supplies. She said the grease trap needed to be pumped but the corporate office would not pay the upfront payment needed for the truck to come out. She said the sewer was backing up through the kitchen floor drain and the corporate office would not make the upfront payment needed for a plumber to come out. She said the roof leaked when it rained and leaked in the kitchen causing rain to drip on equipment. She said the dish machine was out of the sanitizing agent, disinfecting pellets, and testing strips. She said the corporate office ordered the sanitizing agent one time after they were cited. She said residents were eating from disposable plates. She said the facility's fire monitoring was placed on vendor hold due to non-payment. She said the fire monitoring included quarterly inspections of the fire alarm system, sprinkler system, and they responded to any trouble signals. She said the fire monitoring also included inspections of the fire extinguishers. She said she emailed the corporate office on 12/05/18 about the non-payment and the corporate office told her that if the fire alarm went off, the fire department would be notified of the fire alarm going off. She said the corporate office paid the vendors and invoices when the state agency came in and cited. She said the facility was without a pharmacy consultant and registered dietician. She said they were on vendor hold with laboratory and x-ray services but the corporate office did pay the bill and they were receiving those services again. She said they were on vendor hold with the company that supplied specialty mattresses, [DEVICE], and Hoyer lifts. She said they were on vendor hold with the company that provided chemicals for dietary, housekeeping, and laundry. She said the corporate office was aware of all of the holds and the corporate office had not paid any of the vendors. She said the mobile dental vendor had not been paid. She said she just found out her facility credit card was cancelled. She said payroll checks have bounced and many staff quit or walked out. She said the facility did not have a DON and were using agency staff to cover shifts. She said the weekend RN supervisor also quit. She said the wheelchair scale was last calibrated in (YEAR) and the corporate office would not pay to have it calibrated again. She said they did not have toner for the fax and have not been able to receive faxes from physicians or labs. The administrator said most bills were mailed directly to the corporate office and she was not aware of how many vendors the facility was not in good standing with. During an interview on 01/31/19 at 10:09 a.m., the maintenance supervisor said the black liquid had been coming up through the kitchen floor drain for a month. He said the black liquid would splatter up through the floor drain and puddle on the kitchen floor around the floor drain. He said anytime the kitchen staff turned on the water in the kitchen sinks, the black sewer water spilled out in the kitchen floor. The maintenance supervisor said the sewer water had a pungent odor. He said they attempted to call several plumbers, but no plumbers would come out to the facility without being paid first due to the facility's history of non-payment. He said the corporate office was aware of the black liquid but still had not approved payment to hire a plumber. He said the grease trap had not been pumped due non-payment from the last time the vendor pumped the grease trap. He said the last time the grease trap was pumped was (MONTH) (YEAR). The maintenance supervisor said when it rained, water leaked into the kitchen through the ceiling. He said the rain water seeped through the ceiling, ran down the light fixtures onto food preparation tables and the fryer. He said the corporate office was notified and told him to get bids for a new roof. He said he received several bids and sent them to the corporate office twice, but never heard a response. He said the last time he sent in bids for a new roof was late (MONTH) (YEAR). During an interview on 01/31/19 at 10:13 a.m., the dietary manager said every time it rained, the rain water leaked through the ceiling and ran down the light fixtures. She said the rain water dripped onto the food preparation tables, into the fryer, and onto the floors. She said they did their best to prepare the food in a dry area. She said they did not use the fryer when it rained. She said they moved trash cans under the leaks in an attempt to contain the rain water. She said rain water leaked into the kitchen for almost a year and the administration and the corporate office were aware of the leaks. She said there was a bowed area in the kitchen ceiling where rain water pooled. She said when they turned on the water in the sink, a black liquid splattered out of the floor drain in the kitchen. She said the odor smelled like sewage and was almost unbearable but was contained to the kitchen. She said the tile was not adhered to the floor near the food preparation table, causing a trip hazard. She said they had been out of dish machine chemicals for more than 6 months because the corporate office would not approve orders for the chemicals, but were aware the facility was out of the required chemicals. She said they did not have the correct chemicals for the 3-compartment sink and were using a household dish liquid and bleach. She said for months, they had served food to residents on disposable plates. The dietary manager said there were no testing strips to ensure the dishes were sanitized. She said the corporate office was aware of everything they needed. During an observation on 01/31/19 at 10:16 a.m., a 4-foot rectangular shaped fluorescent light fixture was mounted to the kitchen ceiling. The light fixture hung above a food preparation table and gas fryer. There was faint brown staining on the ceiling where the light fixture's electrical wiring entered the light fixture. An 8 foot by 1-foot area of ceiling was visibly bowed downward approximately 4 inches. A 3-foot by 2-foot area of tile floor near the food preparation table was raised 0.5 inches from the floor and flexed when walked on. There was a sign taped to the dish machine that warned staff not to use the dish machine. During an observation on 01/31/19 at 11:02 a.m., while water was running in the 3-compartment sink and the garbage disposal was on, a black liquid visibly spewed onto the kitchen floor from the floor drain near the 3-compartment sink. Small puddles of the black greasy substance began forming on the floor near the floor drain. The black liquid had a foul odor and a greasy appearance. The floor drain was approximately 2-feet from the dish machine and 3-compartment sink, where dishes were sanitized. Cornbread for the lunch meal was sitting on top of the stove that was approximately 10 feet away from the floor drain. During an observation on 01/31/19 at 12:43 p.m., residents were in the dining room eating the lunch meal and were eating on Styrofoam plates and drinking from plastic cups. Residents were using metal utensils. During an observation on 02/01/19 at 12:48 p.m., there was a kitchen drain line that was connected to the grease trap and was located outside in the courtyard. There was standing water in the pipe approximately 2 feet from the top of the pipe. The maintenance supervisor said the drain line often overflowed in the courtyard, near the exit door of the facility. The courtyard was open to residents and visitors. During an observation and interview on 02/01/19 at 12:49 p.m., there was a grease trap pipe located in the courtyard. A light brown greasy substance was observed in the pipe approximately 3 feet from the top of the pipe. A strong foul odor emitted from the pipe. The maintenance supervisor said the grease trap needed to be pumped but since the corporate office did not pay the vendor from pumping the grease trap last year, the vendor said they would not come back until they were paid. The courtyard was open to residents and visitors. A work order dated 01/14/19 indicated the vendor that pumped the grease trap was owed $264 from services dated 02/16/18 and stated the facility must pay up front before the vendor would perform the service. During an interview on 01/31/19 at 10:06 a.m., the maintenance supervisor said when it rained, the water leaked into a storage room in the therapy department. He said the ceiling appeared to have mold. He said the ceiling would pool with water. He said the corporate office was aware of the leaky roof. He said corporate's response was always the same, get another bid. He said he collected bids for almost a year. He said he sent them to the corporate office and nothing had been done. A proposal for roofing services dated 03/01/18 presented bid for a new roof. There was no documented response to the proposal. A proposal for roofing services dated 03/06/18 presented bid for a new roof. There was no documented response to the proposal. A proposal for roofing services dated 11/26/18 presented bid to repair the roof. There was no documented response to the proposal. A proposal for roofing services dated 11/30/18 presented bid for a new roof. There was no documented response to the proposal. During an observation on 01/31/19 at 10:07 a.m., a storage room located in the therapy hall had a 2-foot diameter area on the ceiling that was littered with brown and black spots. There was a 1-foot circular piece of sheet rock that was pulled away from the ceiling and dangling. The 1-foot area of ceiling where the sheet rock once hung was littered with black and brown spots. There was therapy equipment in the room. During an interview on 01/31/19 at 10:22 a.m., the maintenance supervisor said the fire panel had a ground fault code came across the screen a month ago and he called the fire monitoring company and was told they could not counsel the facility on the code due to the non-payment status. He said he had not pulled the fire alarm during fire drills because he did not know if he would be able to turn off the fire alarm. He said the corporate office was aware of the ground fault code and said the fire department would still be notified when the fire alarm was engaged. He said he had not contacted the fire department to ask if the fire department would be notified if the fire alarm was activated. During an observation on 01/31/19 at 10:23 a.m., the fire panel's trouble light was flashing. The silenced light was lit up. During an interview on 01/31/19 at 12:26 p.m., the fire monitoring representative said they cancelled their contract with the facility due to their history of non-payment. He said a ground fault code was the worst of the worst codes because it could include any number of wires that typically got wet and touched a grounded item. He said the monitoring company would have to come out to inspect the system and find the problem. He said the facility did not have fire monitoring and it the facility activated the fire alarm, the fire department would not be notified. During an observation on 01/31/19 at 12:47 p.m., the maintenance supervisor tested the fire alarm, the alarm rang, the automatic doors closed, and the alarm was disengaged. During an interview on 01/31/19 at 12:48 p.m., the local fire department said did not receive an alert that the facility's fire alarm went off. During an interview on 01/31/19 at 12:51 p.m., the local sheriff's department said they did not receive an alert that the facility's fire alarm went off. A letter dated 12/03/18 from the fire monitoring company to the facility indicated no services were available for the facility due to non-payment. The balance due was $617. A fire protection and maintenance agreement dated 05/01/15 indicated the fire monitoring vendor would provide 4 maintenance inspections yearly, report any faults in the fire protection system, and provide fire monitoring (response to fire alarm and trouble signals). Inspections, maintenance, parts, and service called would be billed to the facility and payments terms were net 30 days. The agreement would automatically renew after 24 months then every 12 months unless terminated. 2.During an interview on 01/31/19 at 9:43 a.m., the housekeeping supervisor said the housekeeping staff did not have the correct chemicals to clean and disinfect the facility. She said the corporate office had not paid the vendor and they had not received any chemicals. She said she used the last hand soap refill today and did not know what she would do when she needed more. She said they did not have toilet bowl cleaner or disinfectant for the showers. She said they did not the correct chemicals for cleaning the floors. She said the staff have bought their own chemicals from local stores but the housekeeping supervisor said the chemicals purchased locally do not clean as well as the chemicals from the vendor. During an interview on 01/31/19 at 10:57 a.m., LVN A said the facility usually received laboratory or x-ray results through the fax machine. He said the fax machine did not have toner and he had to call the laboratory service vendor to get the results. He said about 2 weeks ago the facility was on vendor hold with laboratory and x-ray services due to non-payment. During an interview on 01/31/19 at 10:59 a.m., the nurse practitioner (NP) said she was frustrated with the corporate office because she was told she could not order Unna boots (compression dressing to promote healing of wounds and ulcers) with infused [MEDICATION NAME] lotion for residents at risk for pressure injuries. She said she knew the residents' needs and knew what worked best for them. She said the ADON notified her that the corporate office said she could not order the Unna boots. The NP said she had not received any pharmacy recommendations or dietary recommendations since (MONTH) (YEAR). She said one resident lost 22 pounds in the last year and there were no dietary recommendations for her. She said the resident should have dietary recommendations in place. She said the last dietary recommendations she received were from (MONTH) (YEAR). She said the medical director had not been paid in a long time but he continued to provide services to the facility. During an interview on 01/31/19 at 2:23 p.m., the sales representative for the laboratory and x-ray services said as of today, the vendor no longer had an account with the facility. He said the facility was placed on vendor hold a few weeks ago and the vendor received a check from the corporate office. He said the hold was lifted and he was notified on 01/30/19 that the check was insufficient, and their account was cancelled. He said the facility would have to find another laboratory and x-ray vendor. He said the facility had a history of [REDACTED]. An agreement dated 02/01/15 indicated the x-ray vendor would provide x-ray, cardiac, and ultrasound services to the residents of the facility and the facility agreed to pay each x-ray vendor invoice in full within 30 days of the invoice date. The agreement would be automatically renewed yearly unless a written termination was provided by either party. A laboratory services agreement was unavailable. During an interview on 01/31/19 at 6:11 p.m., the pharmacy consultant said she last came to the facility at the end of (MONTH) (YEAR). She said she was told that the pharmacy consultant company would not return to the facility due to non-payment. She said when she was at the facility in (MONTH) she provided the facility with her pharmacy recommendations. Pharmacy recommendations dated 11/26/18 indicated residents' medications were reviewed and recommendations were provided. A pharmacist agreement dated 04/03/18 indicated the pharmacy consultant would provide medication review every 30 days and monthly drug destruction monthly or as deemed necessary. The pharmacy consultant would be compensated on or by the last day of the month. The agreement indicated the term of the agreement was monthly ending on 04/30/18. During an interview on 02/01/19 at 11:33 a.m., the ADON said the last time the pharmacy consultant destroyed drugs was on 10/17/18. Dietary recommendations dated 10/31/18 indicated the dietician reviewed resident records and provided dietary recommendations. A dietician agreement dated 01/07/19 indicated a registered dietician would provide consultation to staff, assist in nutritional care plans, and provide nutritional assessments of residents. Payment was due at the time of service and consultant services may be immediately withheld due to lack of payment. The agreement would continue unless a written notice was given by either party. An email from the administrator to the corporate office dated 01/30/19 indicated the dietician consultant needed to be paid $840 before she would come out to the facility. During an interview on 01/31/19 at 10:47 a.m., the social worker said the mobile dental vendor was in the facility on 01/14/19 and 01/31/19 providing care. She said the dental vendor usually visited the facility every 2 weeks. A mobile dental invoice dated 01/28/19 indicated the facility owed $ .87 and included $7149.49 that was more than 90 days past due. A mobile dental agreement dated 03/25/15 indicated the dental vendor would provide facility residents with dental care and treatment services. The facility agreed to process and pay all invoices for dental services provided to facility residents. The agreement would continue yearly unless either party provided a written letter of termination. An invoice from an equipment supply vendor dated 11/06/18 indicated $2755.33 was due on 12/06/18. The invoice included bed frames, pressure reducing mattresses, oxygen concentrators, and a geri chair. An invoice from an equipment supply vendor dated 01/03/19 indicated $2403.50 was due on 02/02/19. The invoice included bed frames and pressure reduction mattresses. Times sheets dated (MONTH) 2019 indicated the former DON worked 01/07/19 and 01/08/19. There was not a DON in the facility for the rest of (MONTH) 2019. RN coverage was not provided for 8 consecutive hours on 01/01/19, 01/02/19, 01/03/19, 01/14/19, 01/15/19, and 01/16/19. During an interview on 01/31/19 at 10:47 a.m., the social worker said her paycheck dated 01/15/19 was deposited in her bank and on 01/23/19 she was notified that the check did not clear. She said the corporate office wired the money into her account but had not offered to pay for the insufficient fees that she accrued. During an interview on 01/31/19 at 9:33 a.m., the business office manager said on 01/29/19, facility staff received their payroll checks. She said the corporate office had an account at a local bank and staff began going to the bank to cash their checks. She said about half of the staff were able to cash their checks then the rest of the staff were turned away because there was not enough money in the account to cover the entire payroll. She said the payroll budget for 2 weeks was $ and the corporate office only deposited $ into the account. The business office manager said all the payroll checks were eventually covered. She said payroll checks had a history of [REDACTED]. She said staff have quit and the facility was using agency staff to cover shifts. The ADM, ADON, BOM, Maintenance Supervisor, Housekeeping Supervisor, Laundry Supervisor, Medical Records, and Social Worker were notified that an Immediate Jeopardy situation was identified on 1/31/19 at 3:53 p.m. due to the above failures. The facility presented the surveyors with a plan to remove the IJ on 2/01/19 at 12:50 p.m. The plan of removal included the following: Starting (MONTH) 31st the Vice President of Operations will be notified of any needed supplies or specialty equipment rentals, with the items needed, the cost of the items and what the payment arrangements will be. The VP will then notify, Joe Newman CEO, of the request and if necessary, approval will be obtained. Requests for items needed will be monitored by the, Administrator or Administrative designee, on a daily basis to find out when the items are ordered or that money was funded on the facility card so purchases can be made. On (MONTH) 31, 2019, continuous Fire Rounds were started and employees brought in to do just these checks specifically. Staff were in-serviced by the Maintenance Director on how the Fire Rounds should be made and documented. On (MONTH) 31, 2019, HFCO Fire Alarm Company was contacted and services our Fire Panel on (MONTH) 1, 2019. All Life Safety Fire Alarm requirements are up to date and current as of (MONTH) 1, 2019. On (MONTH) 31, 2019, the plumber was contacted to come and look at the kitchen area with regards to the sewage backing up in the kitchen. They will be here on (MONTH) 1, 2019 to fix the issue and find out what is causing this to happen. Bids will be sent back up to the Corporate Office Level, for the leaks in the kitchen area to stop the water from running into the light fixture and on the steam table. Administrator will continue to follow up on bid emails and plans are for this to be done by (MONTH) 7, 2019. In the section titled Administration and Governing Body, the plan of removal indicated the facility would address contracts to be updated or developed as needed by 02/07/19 in the areas of laboratory testing, x-ray, pharmacy consultant, dietician, fire alarm monitoring, medical records consultant, plumbing, chemical supply company for dietary, housekeeping and laundry, and medical equipment. The plan stated the administrator would work with the corporate owners and VP of Operations to restore contracts and services to the facility, with daily follow up and a completion date of 02/07/19. The plan of removal also addressed the lack of required staff as follows: RN hours will be covered at 8 hours per day to make sure the facility if covered since we do not have a DON at this time. Advertisement will be made in local papers, facebook, craigslist, Texas Work Force and filled as soon as we can. The Administrator and/or the Corporate Regional Nurse will interview candidates as soon as we receive applications. The plan was not accepted because it did not introduce any new policy or procedure, while evidence demonstrated the existing procedures were ineffective, causing widespread system failure. Required services and supplies were not purchased timely, and required staff were not employed or contracted, despite numerous attempts from the administrator to obtain approvals and payments for the delinquent services. Most local vendors placed the facility on vendor hold until payment made in advance due to the facility's history of late and non-payment, and while the plan of removal stated they would bring in the necessary plumbers and contractors, they did not address the delinquent payments or specify if any plumber / contractor would agree to service the facility.

Based on observation interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility did not maintain the fire alarm system. The fire alarm did not alert the fire department or sheriff's department if the system was activated. An Immediate Jeopardy (IJ) was identified on 01/31/19. The administrator was notified. The IJ was not removed due to the facility's failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. The facility did not prevent rain water from leaking into the therapy hall This failure placed the residents at risk for alterations in safety, comfort and well-being. Findings included: During an interview on 01/31/19 at 10:22 a.m., the maintenance supervisor said the fire panel had a ground fault code came across the screen a month ago and he called the fire monitoring company and was told they could not counsel the facility on the code due to the non-payment status. He said he had not pulled the fire alarm during fire drills because he did not know if he would be able to turn off the fire alarm. He said corporate (the facility owner) was aware of the ground fault code and said the fire department would still be notified when the fire alarm was engaged. He said he had not contacted the fire department to ask if the fire department would be notified if the fire alarm was activated. During an observation on 01/31/19 at 10:23 a.m., the fire panel's trouble light was flashing. The silenced light was lit up. During an interview on 01/31/19 at 12:26 p.m., the fire monitoring representative said they cancelled their contract with the facility due to their history of non-payment. He said a ground fault code was the worst of the worst codes because it could include any number of wires that typically got wet and touched a grounded item. He said the monitoring company would have to come out to inspect the system and find the problem. He said the facility did not have fire monitoring and it the facility activated the fire alarm, the fire department would not be notified. During an observation on 01/31/19 at 12:47 p.m., the maintenance supervisor tested the fire alarm, the alarm rang, the automatic doors closed, and the alarm was disengaged. During an interview on 01/31/19 at 12:48 p.m., the local fire department said did not receive an alert that the facility's fire alarm went off. During an interview on 01/31/19 at 12:51 p.m., the local sheriff's department said they did not receive an alert that the facility's fire alarm went off. A letter dated 12/03/18 from the fire monitoring company to the facility indicated no services were available for the facility due to non-payment. During an interview on 01/31/19 at 8:11 a.m., the administrator said the facility's fire monitoring was placed on vendor hold due to non-payment. She said she emailed the corporate office on 12/05/18 about the non-payment and the corporate office told her that if the fire alarm went off, the fire department would be notified of the fire alarm going off. She said corporate (the facility owner) paid the vendors and invoices when the state agency came in and cited. During an observation on 01/31/19 at 10:07 a.m., a storage room located in the therapy hall had a 2-foot diameter area on the ceiling that was littered with brown and black spots. There was a 1-foot circular piece of sheet rock that was pulled away from the ceiling and dangling. The 1-foot area of ceiling where the sheet rock once hung was littered with black and brown spots. There was therapy equipment in the room. During an interview on 01/31/19 at 10:06 a.m., the maintenance supervisor said when it rained, the water leaked into a storage room in the therapy department. He said the ceiling appeared to have mold. He said the ceiling would pool with water. He said corporate (the owner of the facility) was aware of the leaky roof. He said the corporate office's response was always the same, get another bid. He said he collected bids for almost a year. He said he sent them to the corporate office and nothing had been done. A proposal for roofing services dated 03/01/18 presented bid for a new roof. A proposal for roofing services dated 03/06/18 presented bid for a new roof. A proposal for roofing services dated 11/26/18 presented bid to repair the roof. A proposal for roofing services dated 11/30/18 presented bid for a new roof. The ADM, ADON, BOM, Maintenance Supervisor, Housekeeping Supervisor, Laundry Supervisor, Medical Records, and Social Worker were notified that an Immediate Jeopardy situation was identified on 1/31/19 at 3:53 p.m. due to the above failures. The facility presented the surveyors with a plan to remove the IJ on 2/01/19 at 12:50 p.m. The plan of removal included the following: Starting (MONTH) 31st the Vice President of Operations will be notified of any needed supplies or specialty equipment rentals, with the items needed, the cost of the items and what the payment arrangements will be. The VP will then notify, Joe Newman CEO, of the request and if necessary, approval will be obtained. Requests for items needed will be monitored by the, Administrator or Administrative designee, on a daily basis to find out when the items are ordered or that money was funded on the facility card so purchases can be made. On (MONTH) 31, 2019, continuous Fire Rounds were started and employees brought in to do just these checks specifically. Staff were in-serviced by the Maintenance Director on how the Fire Rounds should be made and documented. On (MONTH) 31, 2019, HFCO Fire Alarm Company was contacted and services our Fire Panel on (MONTH) 1, 2019. All Life Safety Fire Alarm requirements are up to date and current as of (MONTH) 1, 2019. On (MONTH) 31, 2019, the plumber was contacted to come and look at the kitchen area with regards to the sewage backing up in the kitchen. They will be here on (MONTH) 1, 2019 to fix the issue and find out what is causing this to happen. Bids will be sent back up to the Corporate Office Level, for the leaks in the kitchen area to stop the water from running into the light fixture and on the steam table. Administrator will continue to follow up on bid emails and plans are for this to be done by (MONTH) 7, 2019. In the section titled Administration and Governing Body, the plan of removal indicated the facility would address contracts to be updated or developed as needed by 02/07/19 in the areas of laboratory testing, x-ray, pharmacy consultant, dietician, fire alarm monitoring, medical records consultant, plumbing, chemical supply company for dietary, housekeeping and laundry, and medical equipment. The plan stated the administrator would work with the corporate owners and VP of Operations to restore contracts and services to the facility, with daily follow up and a completion date of 02/07/19. The plan of removal also addressed the lack of required staff as follows: RN hours will be covered at 8 hours per day to make sure the facility if covered since we do not have a DON at this time. Advertisement will be made in local papers, facebook, craigslist, Texas Work Force and filled as soon as we can. The Administrator and/or the Corporate Regional Nurse will interview candidates as soon as we receive applications. The plan was not accepted because it did not introduce any new policy or procedure, while evidence demonstrated the existing procedures were ineffective, causing widespread system failure. Required services and supplies were not purchased timely, and required staff were not employed or contracted, despite numerous attempts from the administrator to obtain approvals and payments for the delinquent services. Most local vendors placed the facility on vendor hold until payment made in advance due to the facility's history of late and non-payment, and while the plan of removal stated they would bring in the necessary plumbers and contractors, they did not address the delinquent payments or specify if any plumber / contractor would agree to service the facility.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of and worsening of pressure injuries for 3 of 7 residents reviewed for pressure injuries. (Residents #1, #5, and #6) *The facility did not provide pressure relief to prevent the development, or treatment to prevent the worsening of two Stage 2 pressure injuries for Resident # 1. *The facility did not prevent the development of one facility acquired Stage 3 pressure injury for Resident #5, and did not provide accurate assessments or pressure relief for his heels. *The facility did not provide pressure relief to prevent the development of two Stage 2 and one Stage 1 facility acquired pressure injuries for Resident # 6. *The wound treatment nurse did not have specific training for identification and treatment of [REDACTED].#s 1, 5, and 6. These failures could place 11 residents with pressure injuries at risk for developing new pressure injuries and a decline in existing pressure injuries. Findings included: 1. Consolidated physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED].#1's foot would be offloaded to avoid pressure. A nursing note dated 9/6/01 indicated Resident #1 was admitted without pressure injuries. A readmit evaluation dated 9/18/16 indicated Resident #1 did not have pressure injuries to his ischium (right lower buttock) or right foot. The care plan initiated on 10/4/16 indicated Resident #1 required total assistance of two persons with bed mobility, transfers, toileting and hygiene. The care plan indicated Resident #1 had potential for pressure injury development related to immobility, incontinence, and diabetes. The care plan indicated staff would monitor and report skin changes to the physician and Resident #1 would receive weekly skin checks to monitor for pressure injuries and new conditions would be reported to the physician. The care plan initiated on 10/21/16 indicated Resident #1 had a Stage 2 pressure injury to the right foot (base of the right fifth toe). The care plan indicated staff would monitor and document the location, size, and treatment of [REDACTED]. The care plan indicated staff would reposition Resident #1 frequently and lay Resident #1 down after meals. Lab work dated 12/7/16 indicated Resident #1 had a total protein of 5.7 (normal range 6.4-8.9) and an [MEDICATION NAME] of 3.4 (normal range 3.5-5.7). The care plan initiated 2/14/17 indicated Resident #1 had a pressure injury to his right ischium. The care plan indicated staff would provide treatment as ordered and turn and reposition Resident #1 every 2 hours and as needed. Weekly skin assessments for Resident #1 indicated: 2/22/17 - The wound to right ischium had a beefy red wound bed with a small amount of drainage. The edges were attached, no tunneling or undermining were present. 3/1/17 - The wound to the right ischium had a pale red wound bed with no drainage. The edges were attached and no tunneling was present. 3/8/17 - The wound to the right ischium was shallow in nature with a pink wound bed. New tissue to the edges was noted. 3/13/17 - The wound to the right ischium was reddened. A wound care report dated 3/16/17 by the wound treatment nurse for Resident #1's right ischium indicated the Stage 2 wound to the right ischium was first observed on 3/16/17 and was not present on admission. (The wound report did not indicate two Stage 2 areas to the ischium and did not indicate which wound it was referring to) The wound measured 0.1 x 0.3 cm; no exudate; no odor; granulation tissue in the wound bed with normal edges; surrounding tissue was pink; no tunneling; no pain; [MEDICATION NAME] every shift; no care plan update. Weekly skin assessments for Resident #1 indicated: 3/22/17 - Open areas to ischium are 0.5 x 0.5 cm and 0.4 x 0.4 cm; red and no drainage noted. A wound care report for Resident #1's right ischium by the wound treatment nurse indicated: *3/23/17 - The wound measured 0.5 x 0.4 cm.; no exudate; no odor; granulation tissue in the wound bed with normal edges; surrounding tissue was pink; no pain; [MEDICATION NAME] every shift; wound has deteriorated; no care plan update. *3/30/17 - The wound measured 0.1 x 0.1 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was pink; no tunneling; no pain; [MEDICATION NAME] every shift; wound has improved; no care plan update. The most recent MDS dated [DATE] indicated Resident #1 rarely understood others and was rarely understood. The MDS indicated Resident #1 required extensive assistance of two persons for bed mobility and was totally dependent on staff for transfers, toileting, and bathing. The MDS indicated Resident #1 had one Stage 2 pressure injury and one Stage 3 pressure injury. The MDS did not indicate the location of the pressure injuries. Weekly skin assessments for Resident #1 indicated: 3/29/17 - Open areas to ischium are 0.5 x 0.5 cm and 0.4 x 0.4 cm; no drainage A wound care report for Resident #1's right ischium by the wound treatment nurse indicated: *3/30/17 - The wound measured 0.1 x 0.1 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was pink; no tunneling; no pain; [MEDICATION NAME] every shift; wound has improved; no care plan update. Weekly skin assessments for Resident #1 indicated: 4/5/17 - Open areas to ischium are 0.4 x 0.4 cm and 0.4 x 0.4 cm. 4/12/17 - Open areas to ischium are 0.4 x 0.4 cm and 0.4 x 0.4 cm. 4/19/17 - Open areas to ischium are 1.2 x 0.6 cm and 1.2 x 0.4 cm. A wound care report for Resident #1's right ischium by the wound treatment nurse indicated: *4/19/17 - The wound measured 1.2 x 0.6 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was pink; continue [MEDICATION NAME] every shift; wound has deteriorated. 4/26/17 - Open area to right ischium was red, 0.8 x 0.4 cm. Second area was pink, 0.6 x 0.2 cm. Skin barrier cream applied. A wound care report for Resident #1's right ischium by the wound treatment nurse indicated: *4/27/17 - The wound measured 0.8 x 0.8 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was pink; [MEDICATION NAME] every shift; wound has improved. *5/3/17 - The wound measured 0.8 x 0.4 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was pink; no tunneling; no pain; [MEDICATION NAME] every shift; no change in the wound. Weekly skin assessments for Resident #1 indicated: 5/3/17 - Wound to the ischium was closed with new skin, 0.8 x 0.4 cm and 0.6 x 0.4 cm. 5/10/17 - Ischium wound was beefy red, 0.8 x 0.4 cm. and 0.6 x 0.4 cm. A wound care report for Resident #1's right ischium by the wound treatment nurse indicated: *5/11/17 - The wound measured 0.8 x 0.4 cm; no exudate; no odor; [MEDICATION NAME] tissue in the wound bed with normal edges; surrounding tissue was bright; no tunneling; no pain; [MEDICATION NAME] every shift; no change to the wound. During an observation on 5/15/17 at 2:09 p.m., Resident #1 was lying flat in bed. Resident #1's heel protectors were lying at the foot of his bed and Resident #1's feet were not offloaded. During an observation on 5/15/17 at 3:21 p.m., Resident #1 was sitting upright in his Broda chair. Resident #1 was wearing his heel protectors but his feet were not offloaded. Resident #1's feet were propped directly on the pillow. During an observation on 5/16/17 at 10:38 a.m., Resident #1 was lying flat in bed. Resident #1's heel protectors were lying at the foot of the bed and his feet were not offloaded. Weekly skin assessments for Resident #1 indicated: 5/16/17 - Areas to ischium were sealed over with new skin and red. Areas were combined, 1.5 cm. x 1.0 cm. During an interview on 5/16/17 at 10:41 a.m., the wound treatment nurse said Resident #1 should wear his heel protectors at all times and his feet should always be offloaded. The wound treatment nurse said Resident #1 had 2 Stage 2 pressure injuries to his ischium and 1 Stage 2 pressure injury to his right foot. She said the pressure injuries were acquired at the facility. The wound treatment nurse said the pressure injury on Resident #1's right foot was healing, but the 2 areas on his ischium would start looking better, then get worse. She said Resident #1's pressure injuries to the ischium would be closed on Friday when she left but when she came back in on Monday, the pressure injuries would be open again. The wound treatment nurse said a wound care specialist from a medical supply group comes in once a month and helped her stage the pressure injuries. The wound treatment nurse said she was responsible for skin assessments, staging, wound treatments, and reporting changes to the physician. The wound treatment nurse said she had not had any formal wound care training. The wound treatment nurse said the weekend charge nurse was responsible for wound treatments on the weekend. During an observation and interview on 5/16/17 at 10:46 a.m., the wound treatment nurse provided care for Resident #1's pressure injury to his right foot. She rolled Resident #1 to his side and looked at the pressure injuries to his ischium. The areas were closed and healing. The wound treatment nurse did not measure the areas on the ischium or apply the barrier cream. The wound treatment nurse said the aides were going to get Resident #1 changed, so they would apply the barrier cream. The wound treatment nurse said she had already measured the wounds earlier that morning. During observation of Resident #1 on 5/16/17 at: 1:46 p.m. - The resident was lying flat in bed with heel protectors on. His feet were not offloaded. 2:16 p.m. - The resident was lying flat in bed with heel protectors on. His feet were not offloaded. During observation of Resident #1 on 5/17/17 at: 9:14 a.m. - The resident was reclined in his broda chair. His feet were not offloaded and the heel protector on the left foot was positioned incorrectly. The heel protector was turned upside down and lying on top of his foot, leaving his heels exposed. 9:30 a.m. - The resident was reclined in his Broda chair. His feet were not offloaded and the heel protector on the left foot was positioned incorrectly. The heel protector was turned upside down and lying on top of his foot, leaving his heels exposed. 9:48 a.m. - The resident was reclined in his Broda chair. His feet were not offloaded and the heel protector on the left foot was positioned incorrectly. The heel protector was turned upside down and lying on top of his foot, leaving his heels exposed. 10:30 a.m. - The resident was lying flat in bed. His feet were not offloaded and the heel protector on the left foot was positioned incorrectly. The heel protector was turned upside down and lying on top of his foot, leaving his heels exposed. 11:00 a.m. - The resident was lying flat in bed. He was wearing his heel protectors and they were positioned correctly. His feet were not offloaded. 1:29 p.m. - The resident was lying flat in his bed. The heel protectors were lying at the foot of the bed. During an interview on 5/17/17 at 10:36 a.m., CNA K said Resident #1 should wear his heel protectors at all times. She said they turn him every two hours when he is in the bed. CNA K said she had not noticed Resident #1's heel protector being positioned incorrectly this morning. CNA K said she was in a hurry and forgot to offload Resident #1's heels. During an interview on 5/17/17 at 10:42 a.m., CNA H said Resident #1 should wear his heel protectors all the time. She said she had not noticed Resident #1's heel protectors being positioned incorrectly. During an observation and interview on 5/17/17 at 10:00 a.m., the wound treatment nurse provided wound care to Resident #1. A new wound was noted to the right outer heel. The wound was reddened with the top layer of skin removed. There was no drainage. The wound treatment nurse measured the wound and said she called this a Stage 1 pressure injury measuring 2.5 x 1 cm. The wound treatment nurse measured the pressure injury to the right ischium and said the 2 pressure injuries had combined and was now one. She measured the right ischium pressure injury to be 3 x 2 cm. A new wound was noted to the left ischium. The wound treatment nurse said she would call this a Stage 2 pressure injury measuring 3 x 1.5 cm. A nursing note dated 5/17/17 indicated Resident #1 had 2 Stage 2 pressure injuries. The right ischium measured 3.0 cm x 2.0 cm and the left ischium measured 3.0 x 1.5cm. New orders were received to clean the area with normal saline, pat dry, and apply hydrogel sheet and cover with dressing daily. The nursing note did not address the new pressure injury to Resident #1's right outer heel. During an interview on 5/17/17 at 3:00 p.m., the wound treatment nurse said she reported the new pressure injury on the left ischium to the physician. She said she received new orders for treatment. The wound treatment nurse said she forgot to report the new pressure injury to the right outer heel. During an interview on 5/18/17 at 11:10 a.m., LVN S said she was the weekend charge nurse. LVN S said she had not looked at the wounds on Resident #1's ischium because he only had orders for barrier cream. She said she had not been informed the wounds were deteriorating on the weekend. LVN S said she had not noticed a new wound to Resident #1's right outer heel this past weekend. LVN S said Resident #1 wore his heel protectors at all times and his feet were offloaded. She said she made frequent rounds to ensure CNAs were implementing these interventions. During an interview on 5/17/17 at 3:08 p.m., the DON said she was aware of Resident 1's pressure injuries to his right ischium and right foot. She said she was aware the pressure injuries to Resident #1's ischium worsened on the weekends. She said this had been happening for the last few weeks. The DON said the weekend charge nurse was responsible for wound treatments on the weekend. She said she had worked the weekend and Resident #1's pressure injury did not deteriorate. She said she did not know what was happening and they were trying to figure it out. The DON said she had talked to her weekend staff about making sure treatments were done and residents were repositioned frequently. The DON said she did not know if the treatment nurse notified the physician when the pressure injuries opened back up. The DON said she expected the treatment nurse to notify the physician of any changes to the wound. She said she expected the staff to make sure Resident #1's heel protectors are in place and positioned correctly. She said she expected staff to offload Resident #1's heels. The DON said she was responsible for following up on wounds and making sure interventions were in place and staff were implementing the interventions. During an observation on 5/17/17 at 3:36 p.m., Resident #1 was reclined in his Broda chair. Both heel protectors were on and positioned correctly. The resident's feet were not offloaded. The resident's feet were lying directing on the pillow. During an interview on 5/17/17 at 3:40 p.m., CNA P said she had positioned Resident #1 in his Broda chair. CNA P said she put Resident #1's heel protector on and then placed a pillow directly under his feet. She said she thought propping the feet directly on a pillow was offloading. She said she had always offloaded resident's feet this way. She said she had not been trained to offload feet another way. During an interview on 5/17/17 at 4:00 p.m., the DON said she expected staff to offload resident's heels correctly. She said they should put pillows or cushions under the resident's ankles or legs to ensure the resident's heels are not touching the surface of the bed or the chair. The DON said propping a resident's feet directly on pillows was not correct offloading. She said she had not in-serviced staff on the proper way to offload a resident's heels. 2. Consolidated physician orders [REDACTED].#5 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated the only supplements Resident #5 received was a multivitamin. An admission care plan dated 1/10/17 indicated for staff to follow facility skin care protocol for Resident #5, and to report to the charge nurse any redness or skin breakdown. The care plan indicated turning the resident every two hours was an option, but was not checked as part of Resident #5's care plan. An admission MDS dated [DATE] indicated Resident #5 could make his needs known and understand others. The MDS indicated Resident #5 required extensive one to two person assist with all ADLs. The MDS indicated Resident #5 was at risk of developing pressure injuries and was admitted without any pressure injuries. The most recent MDS dated [DATE] indicated Resident #5 could make his needs known and understand others. The MDS indicated Resident #5 required extensive to total two person assist with ADLs. The MDS indicated Resident #5 was at risk of developing pressure injuries and had one unstageable pressure injury. An admission skin evaluation tool dated 1/11/17 indicated Resident #5 was admitted without any issues in skin integrity. A weekly skin assessment dated [DATE] for Resident #5 indicated there were no open areas. A progress note dated 1/18/17 at 12:56 p.m. for Resident #5 indicated he had a blood blister on the outside of his left heel, without drainage. His physician was notified and new orders were received. A Braden pressure injury risk assessment (is a tool for Predicting Pressure injury Risk.) indicated Resident #5 was at high to very high risk of developing a pressure injury from the first assessment on 1/19/17 through 4/25/17. The weekly skin assessment dated [DATE] for Resident #5 indicated he had a blood blister to his left lateral heel that was drying. An updated care plan dated 1/26/17 indicated Resident #5 required a 1-2 person extensive assist with ADLs. The care plan indicated Resident #5 had an impairment to his left heel and the interventions were to educate Resident #5 on the causative factors and measures to prevent the injury, encourage good nutrition and hydration, follow the facility protocol for the injury, and draw a pre [MEDICATION NAME] ([MEDICATION NAME] is a plasma protein that identifies patients at risk for malnutrition and monitors nutritional support.) and provide vitamin and protein supplements per protocol. Weekly skin assessment for Resident #5 indicated the following: *2/13/17- blood blister remains intact and dry; *2/20/17- blood blister remains dry and firm and maroon in color; Laboratory results indicated Resident #5 had a pre-[MEDICATION NAME] level drawn on 2/24/17 with a level of 22.4. (this was his first level drawn, normal is 17-40) A weekly skin assessment dated [DATE] for Resident #5 indicated his left heel had tan/brown eschar not attached to the wound edges, and the wound had a slight odor with a small amount of tan drainage. Resident #5's order sheet dated 3/7/17, from the wound care certified nurse (a wound care supplier) indicated his left heel was a full thickness unstageable pressure injury measuring 2.5 cm x 2.7 cm with minimal exudate (secretion). The clinically unavoidable pressure injury check off sheet, signed by the DON on 3/8/17, indicated Resident #5's pressure injury was unavoidable due to a Braden scale score of 12, dementia, depression, and diabetes. A weekly skin assessment dated [DATE] for Resident #5 did not mention the wound on his left heel. A wound care report dated 3/16/17, provided by the treatment nurse, for Resident #5's left heel indicated the first observation date for the unstageable pressure injury was 3/16/17 and indicated the wound measured 1.5 cm x 1.5 cm with a small amount of serosanguineous drainage (Serosanguineous drainage is pink (light red), watery, and a mixture of serum and blood) with a slight odor, and the wound bed was brown/black in color. Resident #5 had another pre-[MEDICATION NAME] level drawn on 3/20/17 that indicated a level of 14. (Reference range is 17.0 - 40.0) A weekly skin assessment dated [DATE] for Resident #5 indicated the wound on his left heel measured 2.0 cm x 1.5 cm. The wound was open with yellow slough, and had a small amount of drainage with no odor. A wound care report dated 3/23/17, provided by the treatment nurse indicated Resident #5's wound on his left heel measured 2.0 cm x 1.8 cm x 0.1 cm, with a moderate amount of serosanguineous drainage and a slight odor. The wound bed had slough in it. A weekly skin assessment dated [DATE], indicated Resident #5's left heel was a Stage 2, with yellow slough and a moderate amount of brown drainage and no odor. A revision to the care plan dated 3/29/17 indicated Resident #5 had an unavoidable pressure injury to his left heel, related to a Braden score of less than 19. The interventions were to administer medications and treatments as ordered, assess the wound weekly, avoid positioning on the pressure injury, float heels, monitor the dressing to ensure it was intact and adhering, to monitor the resident's nutritional status, and obtain and monitor labs as ordered. A wound care report dated 3/30/17, provided by the treatment nurse, indicated the pressure injury on Resident #5's left heel measured 2.0 cm x 1.8 cm x 0.1 cm with a moderate amount of serous drainage. The wound bed had slough in it. A weekly skin assessment dated [DATE] for Resident #5 indicated the pressure injury on his left heel was Stage 2 with yellow slough and a moderate amount of brown drainage. Resident #5's order sheet dated 4/4/17 from the wound care certified nurse (a wound care supplier) indicated Resident #5's left heel was a full thickness unstageable pressure injury measuring 2.00 cm x 1.8 cm with minimal exudate. A weekly skin assessment dated [DATE] for Resident #5's left heel indicated the heel was improving with red granulation tissue noted and a small amount of yellow drainage. A wound care report dated 4/19/17 provided by the treatment nurse for Resident #5's left heel indicated the pressure injury measured 1.8 cm x 1.5 cm x 0.1 cm, with moderate amount of serosanguinous drainage and no odor. The wound bed had granulation tissue in it. A weekly skin assessment dated [DATE] for Resident #5's left heel indicated the pressure injury measured 1.8 cm x 1.2 cm with a small amount of bloody drainage. A wound care report provided by the treatment nurse for Resident #5's left heel indicated: *4/27/17- 1.7 cm X 1.4 cm X 0.1 cm with small amount of serosanguinous drainage and no odor. The wound bed had granulation tissue in it; and *5/3/17- 1.7 cm X 1.4 cm X 0.2 cm with small amount of serosanguinous drainage and no odor. The wound bed had granulation tissue in it. Resident #5's order sheet dated 5/3/17 from the wound care certified nurse (a wound care supplier) indicated the pressure injury on his left heel was a full thickness unstageable pressure injury measuring 1.7 cm x 1.4 cm x 0.2 cm with minimal exudate. A dietary note dated 5/4/17 indicated the dietician recommended vitamin C, [MEDICATION NAME] 1 packet two times daily for 60 days, and protein liquid 30 ml twice daily for 60 days. A weekly skin assessment dated [DATE], for Resident #5 indicated he had an unstageable area to his left heel measuring 1.7 cm x 1.2 cm with no drainage or odor. Wound care reports provided by the treatment nurse for Resident #5's left heel indicated the following: *5/11/17-1.7 cm X 1.4 cm X 0.1 cm with scant amount of serousanguinous drainage and no odor. The wound bed had granulation tissue in it. *5/15/17- left heel is a Stage 3 measuring 1.5 cm x 1.1 cm x 0.2 cm, area is red with no drainage. During an observation on 5/15/17 at 12:45 p.m., Resident #5 ate lunch and consumed 75% of his meal. Resident #5 had a nutritional supplement ordered two times a day. During an observation on 5/16/17 at 7:18 a.m., Resident #5 ate breakfast and consumed 75% of his meal. During an observation on 5/16/17 at 9:08 a.m., Resident #5 was sitting up in his Geri chair with his feet dangling off the end. Resident #5 had on blue lift boots with the heel area removed. During an observation on 5/16/17 at 9:15 a.m., the treatment nurse provided wound care and measured Resident #5's unstageable pressure injury to his left heel. The pressure injury to his left heel was covered with black eschar. There was no drainage or odor noted. The area measured 1.0 cm x 2.0 cm. The treatment nurse said Resident #5 was lying on a regular foam mattress. During an observation and interview on 5/17/17 at 10:35 a.m., Resident #5 was lying in bed on his back, his feet were not elevated, and he wore lift boots on both feet. Resident #5 said he did not get the lift boots until he acquired the pressure injury to his left heel, and he said staff never placed pillows under his legs or elevated his feet off of his mattress. Resident #5 was lying on a regular mattress. During an observation on 5/17/17 at 12:48 p.m., Resident #5 was sitting up in bed eating lunch and his feet were not elevated off of the bed. During an observation on 5/17/17 at 3:45 p.m., Resident #5 was lying in bed on a regular mattress with blue lift boots on. His feet were not elevated off of the bed. During an interview on 5/17/17 at 3:00 p.m., CNA P said she had worked at the facility for 3 days. CNA P said she checked Resident #5 and #6 every two hours and turned them. She said she offloaded their feet with pillows. CNA P said if she wanted specific instructions to care for a resident with a pressure injury, she would ask the charge nurse. During an interview on 5/17/17 at 3:08 p.m., CNA Q said she turned Resident #5 and #6 every two hours and offloaded their feet with pillows. CNA Q said if she needed to know about the care of a resident, she would ask the charge nurse. During an interview on 5/17/17 at 3:18 p.m., the treatment nurse said she communicated with Resident #5's physician monthly. The treatment nurse said she had not received any formal wound care training. During an interview on 5/17/17 at 3:45 p.m., RN A said staff were offloading Resident #5's heels at one time. RN A said staff would put Resident #5's lift boots on and he would remove them. During an interview on 5/17/17 at 3:55 p.m., LVN D said she had only worked at the facility about a week and did not know the resident very well. She said Resident #5 should have his feet offloaded and turned every 2 hours and put a pillow under his legs to offload his feet. During an interview on 5/18/17 at 9:10 a.m., LVN R said Resident #5 got the pressure injury on his left heel from a pair of cowboy boots he wore, after he was admitted to the facility. She said Resident #5 could propel himself in a wheelchair when he was admitted . LVN R said she was not aware of any interventions in place for Resident #5 when he was admitted to help prevent pressure injuries. During an interview on 5/17/17 at 10:50 a.m., the DON said Resident #5 was a high risk resident to develop pressure injuries. The DON said if a resident's Braden score indicated they were at high risk to develop a pressure injury, staff should offload their feet, check the type of mattress they are on, get vitamins and nutritional supplements for them, and use a draw sheet to reposition them in bed. The DON said those interventions should be care planned. The DON said Resident #5 had a low air loss mattress and did not wear lift boots. The DON said the treatment nurse did not have any formal wound care training. The DON said a wound care nurse from their wound care supply company came monthly to evaluate some of the residents and the treatment nurse made rounds with her. The DON said Resident #5's care plan was incomplete. The DON said Resident #5's pressure injury was unavoidable based on the clinically unavoidable pressure injury check off sheet. 3. Consolidated physician orders [REDACTED].#6 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An admission care plan dated 4/11/17 indicated for staff to report to the charge nurse any redness or skin breakdown immediately. There were no other interventions to prevent pressure injuries. An admission evaluation dated 4/11/17 indicated Resident #6's heels were red and soft. laboratory results dated [DATE] indicated Resident #6's [MEDICATION NAME] level was 3.9. (Range is 3.5 - 5.7) The most recent care plan with an initiated date of 5/5/17 indicated Resident #6 had a DTI (deep tissue injury) to her left heel. The interventions were to educate the resident of the causative factors and measures to prevent skin injuries, encourage good nutrition and hydration, monitor and document location, size, and treatment on the skin injury, report failure to heal, and the resident is to wear lift boots at all times. The care plan indicated Resident #6 had impaired cognitive function. The most recent MDS dated [DATE] indicated Resident #6 could make her needs known and usually understood others. Resident #6 required extensive to total 2 person assistance with ADLS. The MDS indicated Resident #6 had a Stage 2 pressure injury acquired in the facility on 5/5/17. A progress note for Resident #6 dated 5/5/17 at 8:46 a.m., indicated Resident #6 had a DTI to her left heel measuring 6.0 cm x 3.0 cm. The heel was padded with a dressing and lift boots were applied. A wound care report dated 5/5/17 on Resident #6's left heel provided by the treatment nurse indicated the pressure injury measured 6.0 cm x 3.0 cm with [MEDICATION NAME] tissue to the wound bed, with no drainage or odor. A wound care report provided by the treatment nurse, dated 5/11/17 for Resident #6's left heel indicated the pressure injury measured 6.0 cm x 3.0 cm with [MEDICATION NAME] tissue to the wound bed, with no drainage or odor During an observation and interview on 5/16/17 at 1:50 p.m., the treatment nurse measured Resident #6's wound to her left heel. The wound was a fluid filled purple blister, measuring 7.0 cm x 4.0 cm. When the treatment nurse removed the padded boot to her left foot Resident #6 had a new DTI (deep tissue injury) to her left inner ankle that was dark purple in color and measured 3.0 cm x 3.0 cm. Resident #6 had a red quarter size non-blanchable area to her left upper buttock. The treatment nurse confirmed the area was n

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 5 residents reviewed for neglect. (Resident #10) The facility did not prevent Resident #10 from sustaining a serious injury of unknown origin on her breast and did investigate to determine how or when Resident #10 sustained the injury of unknown origin. Resident #10 was found with a large hematoma and extensive bruising to her left breast. The resident's physician and the emergency room physician said the extensive injury was caused by [MEDICATION NAME] force trauma. As of 6/8/16 the facility had not performed a thorough investigation to try to determine the cause of the injury of unknown origin. An Immediate Jeopardy situation was identified on 06/08/16. The Immediate Jeopardy was removed on 06/09/16. The facility remained out of compliance at isolated actual harm. This failure could place the census of 70 residents at risk for neglect, serious injury and even death. Findings included: A face sheet dated 6/08/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted [DATE] with the [DIAGNOSES REDACTED]. Physician orders [REDACTED].#10 was required to be transferred using a Hoyer (mechanical) lift. An MDS dated [DATE] indicated Resident #10 usually understood others, could be understood, and had problems with recall. Resident #10 required extensive assistance of two staff with bed mobility, transfers, locomotion, dressing, and personal hygiene. She required total assistance of two staff for toileting, and total assistance of one staff with bathing. A care plan dated 2/22/16 indicated Resident #10 was to be mechanically lifted, the goal was she would not sustain injuries during mechanical lifting with the intervention of 2 staff members at all times. The care plan indicated Resident #10 required extensive assistance of 2 staff with transfers, dressing, grooming, toileting, and total assistance of 1 staff with bathing. A skin sheet dated 6/01/16 at 7:13 a.m., indicated Resident #10 had warm, dry skin, with pale colored scattered dark purple areas to both upper extremities, and injection bruising to her abdomen. A nursing note dated 6/04/16 at 9:46 a.m., indicated LVN J was called to the shower room where she noted Resident #10 had a large bruise to her left breast. The note indicated the resident's left breast had yellow discoloration to the top half of the breast in an angled pattern that faded to the bottom half of the breast. The areola region was blue and purple colored measuring 5 cm (centimeters) x 2 cm. A large knot above the left breast area measured 8 cm x 9 cm. Resident #10 denied pain but complained of tenderness. The note indicated Resident #10 said, My daughter accidently did that while I was out on pass to Dallas with my family. LVN J said she called the daughter and the daughter said she had not been to see her mother in 10 days. LVN J notified the physician. The note indicated the physician questioned LVN J of any possible falls or injuries to the site. The physician recommended a sonogram. LVN J documented she notified the DON. A nursing note dated 6/4/16 at 9:04 p.m., indicated LVN J monitored the knot and bruising to Resident #10's left breast. Resident #10 complained of discomfort to her breast. During an interview on 6/08/16 at 2:15 p.m., LVN J said she was called to the shower on 6/04/16 between 8:30 a.m. to 9:00 a.m. to evaluate Resident #10. LVN J said Resident #10 had yellow colored bruising to the top of her left breast, and eggplant colored discoloration to the lower part of the left breast and knot was below the collar bone. LVN J said she asked Resident #10 how the injury occurred. LVN J said Resident #10 said her daughter accidently bumped her. LVN J said she called the daughter and the daughter told her she had not been to the facility in 10 days. LVN J said she notified the administrator of the bruised area. LVN J said on 6/5/16 the left breast had red streaking and was warm to touch. LVN J said she notified the physician. LVN J said the physician assessed the bruising and sent Resident #10 to the local emergency room . LVN J said the daughter called her and said the emergency room physician asked who could have hurt her mother. LVN J said she relayed the daughter and ER physician's concerns to the DON. During an interview on 6/08/16 at 1:00 p.m., the ADON said she was the charge nurse on duty on 6/03/16 from 10:00 p.m. to 6:00 a.m. She said she did not have a reason to assess Resident #10's breast. (bruise not discovered until 9:46 a.m. on 6/4/16) The ADON said she did not think the bruise was caused by abuse, but did not investigate to determine how the injury of unknown origin could have occurred on her shift. During an interview on 6/8/16 at 1:55 p.m., CNA O said on Sunday 6/5/16 around midnight she noticed Resident #10's left breast was purple and swollen. CNA O said she reported it to the ADON who was working and she nodded her head like she acknowledged her and did not say anything. CNA O said no administrative personnel interviewed her about Resident #10's swollen/bruised breast. A nursing note dated 6/5/16 at 1:50 a.m., indicated the ADON documented Resident #10 had a knot and a bruise to the left breast. The note indicated the physician would visit on Monday 6/06/16 to consider further treatment. A nursing note dated 6/05/16 at 11:30 a.m., indicated Resident #10's left breast had redness to the mass and was warm to touch. A nursing note dated 6/05/16 at 11:34 a.m., indicated LVN J notified the DON of the changes to the left breast knot. The note indicated the physician would be notified. A nursing note dated 6/05/16 at 12:18 p.m. indicated the physician would evaluate Resident #10 at 2:00 p.m. on 6/5/16. A physician progress notes [REDACTED].#10's left breast. The note indicated the left breast had a maroon healing bruise covering the lateral side from the 6 o'clock position to the 3 o'clock position. There was a lemon sized mass with [DIAGNOSES REDACTED] and warmth to the touch at the 11 o'clock position. There was red streaking extending from the mass upward. The nipple appeared yellow and crusted. There was a yellow healing bruise near the mass. The physician documented impressions of a breast mass, [MEDICAL CONDITION], and unexplained bruising. The physician's plan was to send the resident to the local emergency room for further evaluation. During an interview on 6/08/15 at 3:55 p.m., Resident #10's physician said she received a call from the facility on 6/4/16 saying Resident #10 had a yellow bruise with a mass to her left breast. The physician said she received a call again on 6/5/16 from the facility nurse stating the mass had streaking going toward the head. The physician said she went to the facility and assessed the area of concern. The physician said the mass measured 6 x 3 cm and was approximately the size of a lemon, with bruising to the entire breast. The physician said she ordered to send Resident #10 to the local emergency room for further evaluation. The physician said the CT scan revealed a hematoma and not a mass. The physician said Resident #10 sustained [MEDICATION NAME] force trauma to her left breast. The physician said she had multiple conversations with nurses at the facility in which she conveyed she felt this injury should be reported. The physician said she spoke to the DON on 6/06/16 concerning the injury. A physician order [REDACTED].#10 to the local emergency room by ambulance. A nursing note dated 6/05/16 at 2:23 p.m. indicated Resident #10 was transferred by EMS to the local emergency room . An emergency department physician note dated 6/05/16 at 3:06 p.m., indicated Resident #10 presented to the emergency room for the evaluation of a mass with redness to the left breast. The note indicated the unknown onset of the breast area, there was swelling and moderate pain to the breast. The physician indicated Resident #10 was a poor historian due to dementia. The skin assessment documented dark purple bruising to her left upper breast with various stages of healing bruises. A hematoma was documented below the clavicle (collar bone). The ER physician ordered a CT (computed tomography) of the chest. Photographic wound documentation from the emergency room dated 6/08/16 indicated Resident #10 had a hematoma of the left breast with massive bruising which was unable to be measured. An emergency department medication order dated 6/05/16 at 3:55 p.m., indicated Resident #10 received medication for pain. The documented pain score for Resident #10 was 8 out of 10 and considered severe level. A CT scan dated 6/5/16 at 5:46 p.m., indicated Resident #10 had a left anterior chest wall abnormality most consistent with a left pectorals intramuscular hematoma measuring 6.1 x 4.9 x 7.2 cm. There was surrounding soft tissue [MEDICAL CONDITION]. During an interview on 6/09/16 at 12:32 p.m., the emergency room physician said he received a call from Resident #10's physician for an evaluation of the left breast on 8/5/16. The emergency room physician said the CT scan indicated a hematoma to the left chest wall. He said Resident #10's injury was due to [MEDICATION NAME] force trauma to her left breast. The emergency room physician said he questioned the family extensively on how this type injury could have occurred. The physician said Resident #10's [MEDICATION NAME] (anticoagulant) and aspirin therapy had not contributed much to the breast bruising. A nursing note dated 6/05/16 at 5:29 p.m., indicated the daughter (responsible party) notified LVN J the emergency room physician had inquired who at the facility could have hurt Resident #10. A nursing note dated 6/05/16 at 5:48 p.m., indicated LVN J documented a telephone conversation with the daughter indicating Resident #10 said she scratched her breast. LVN J documented the daughter did not think scratching caused the bruising. A nursing note dated 6/05/16 at 8:36 p.m., indicated Resident #10 returned to the facility via the nursing home van with two staff members. During an interview on 6/08/16 at 11:40 a.m., the administrator said he was notified on 6/4/16 by LVN J of the bruise to Resident #10's breast. The administrator said he told the DON she was responsible for investigating and staying in contact with the nursing staff. The administrator said he was told Resident #10 might [MEDICAL CONDITION]. During an interview on 6/08/16 at 4:15 p.m., the daughter (responsible party) said she was notified on 6/04/16 of the bruising to Resident #10's left breast. The daughter said the emergency room doctor expressed concern that Resident #10 had a traumatic injury and asked how it could have occurred. The daughter said the emergency room doctor asked many questions, such as, had there been a fall, or could her room-mate have caused the injury. The daughter said she relayed these concerns to LVN J. The daughter said more times than not, she has witnessed staff transferring Resident #10 underneath her arms. The daughter said most recently the two nurse aides who transferred her on 6/05/16 transferred her mother under the arms from the hospital bed to the wheelchair, then back again. The daughter said her mother cried out when they transferred her underneath her arms. A nursing note dated 6/05/16 at 8:46 p.m., indicated Resident #10 had left arm bruising measuring 2 cm x 1 cm, and upper left arm 6 cm x 1 cm. Her left upper chest had purple bruising that measured 10 cm x 8 cm, bruising to sternum measured 5 cm x 1 cm, purple bruising from left side of areola that measured 18 cm x 6 cm and to the right side of areola measured 9 cm x 8 cm. The hematoma measured 15 cm x 16 cm with red and purple discoloration. A skin sheet dated 6/08/16 indicated Resident #10 had bruising and discoloration to her left chest, flank and side area. The note indicated swelling of her left breast and scattered bruises to her right forearm from laboratory and IV sticks. There were tiny bruises to her abdomen from insulin injections. During an observation on 6/08/16 at 4:10 p.m., Resident #10's entire left breast was discolored with yellow and purple bruising. The bruising extended under her arm and around onto her back. Her breast was grossly [MEDICAL CONDITION]. Resident #10's right breast had a small dark purple bruise and her left upper arm had a large purple and with yellow bruise. During an interview on 6/08/16 at 1:24 p.m., CNA C said she cared for Resident #10 on 6/3/15. CNA C said there was no bruising to Resident #10's breast. CNA C said Resident #10 was transferred by a mechanical lift. During an interview on 6/08/16 at 1:40 p.m., RN F said the physician told her on 6/5/16 she had concerns with the unexplained bruising to Resident #10's breast. She said the physician asked her if she had knowledge of any co-workers who could have caused the injury. RN F said any bruise of that size and in the breast area would be suspicious in nature. RN F said she did not report the suspicious bruise to the state agency because she thought the administration had. RN F said she had not investigated to determine how the injury of unknown origin could have occurred. During an interview on 6/08/16 at 1:58 p.m., NA Q said she worked on 6/02/16 and 6/03/16. NA Q said she and CNA P were in orientation those nights. NA Q said they transferred Resident #10 using a mechanical lift. During an interview on 6/8/16 at 3:10 p.m., CNA P said she was new to the facility. She said she and NA Q did not transfer Resident #10 with a mechanical lift. She said they transferred Resident #10 using a two person pivot technique and a gait belt on 6/2/16 and 6/3/16. CNA P said she had not looked in the kiosk (electronic station with resident care instructions) to review how to transfer Resident #10. During an interview on 6/08/16 at 12:20 p.m., the DON said she was notified of Resident #10's bruised breast on 6/04/16 by LVN J. The DON said the incident report completed by LVN J was the investigation. The DON said she had not investigated to determine the cause of the injury of unknown origin. The DON said Resident #10 said she and her daughter were playing around which caused the bruise to the left breast. The DON said on Sunday she was notified of Resident #10 having a knot on her bruised breast and that the physician was notified. The DON said she was aware Resident #10 was transferred to the local emergency room for an evaluation of the bruised breast. The DON said she did not believe the bruised breast was reportable because Resident #10's bruised breast could have been caused by her contracted left arm, the resident scratching, or the mechanical lift. The DON said she had been in contact with the physician. The DON said no one abused Resident #10, and the hematoma and bruising of the breast was not suspicious in nature and did not require further investigation and was not reportable. During an interview on 6/9/16 at 1:15 p.m., the administrator said he was not thoroughly informed regarding the injury of unknown origin to Resident #10. The administrator said he would have investigated and reported the injury if he had known the information he was given later. A revised Abuse Prevention Policy and Procedure dated 1/2005 indicated the facility will assure that all residents are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. (E)(1) Investigation: All suspicious injuries to a resident, or allegation of abuse will be thoroughly investigated by the administrator and or the director of nurses. (E) (3) The administrator and or the director of nurses will determine the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation and if so, will report the incident to the DADS state office in Austin. (E) (4) The administrator will follow the Guidelines for the Reporting Incidents in accordance with the licensure act and the State standards. (F)(2) The facility will assure that the resident remains protected from harm while any investigation is being undertaken. (G)(1) The administrator will report all alleged violations and all substantiated incidents to the DADS Austin agency and all other agencies required. A Safe Lifting and Movement of Residents policy and procedure dated December 2013 indicated the policy was in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. (2) Manual lifting of residents shall be eliminated when feasible. The administrator and DON were notified on 06/08/16 at 5:45 p.m., an Immediate Jeopardy situation was identified in the area of neglect. The facility's Plan of Removal was accepted on 06/08/16 at 8:18 p.m. and included: *Investigation of this incident and report it to appropriate agency to determine how the injury occurred. *In-service all staff in the building on appropriate procedure of reporting Abuse, Neglect, and Misappropriation/Exploitation (failure to investigate and failure to report) by administrator or designee: 1. 2-10 shift, June 8th (In-service tonight) 2. 10-6 shift, June 8th to 9th (In-service tonight) 3. 6-2 shift and morning shift June 9th (In-service tomorrow morning by 9:00 a.m.) 4. All other staff: in-service by phone or before the next time they come to work *Staff involved in resident transfers will be in-serviced on proper techniques *Residents that are able to be interviewed in the building, will be interviewed by staff regarding staff treatment with questionnaire by 10:00 a.m. tomorrow *All residents that are not able to communicate or not able to be interviewed, will be given a skin assessment head to toe by 10:00 a.m. tomorrow. On 6/09/16 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: 5 LVNs, 11 CNAs, 1 RN, 1 AD, 1 SW, 1 DON, 1 driver, 3 housekeepers, 1 maintenance person, 1 laundry aide and the administrator said the abuse coordinator was the administrator. In the event he is unavailable the DON should be contacted. Abuse can be reported by anyone. The facility staff were responsible to protect the residents. Reportable suspicious bruising to the neck, wrists, inner thighs, buttocks, and feet were not the usual vulnerable trauma areas. The staff verbalized understanding if they were unsure if something was reportable just report and then follow up with the abuse coordinator to ensure proper response. The administrator and DON were notified on 06/09/16 at 2:00 p.m. that the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and monitor the effectiveness of its corrective actions. The CMS for 672 dated 6/06/2016 indicated a census of 70.

Based on observation, interview, and record review, the facility failed to ensure an injury of unknown origin of suspicious nature was investigated and reported to the regulatory agency for 1 of 5 residents reviewed for abuse/neglect. (Resident #10) The facility did not investigate to determine how or when Resident #10 sustained an injury of unknown origin and did not report the incident to the regulatory agency. Resident #10 was found with a large hematoma and extensive bruising to her left breast. The resident's physician and the emergency room physician said the extensive injury was caused by [MEDICATION NAME] force trauma. As of 6/8/16 the facility had not performed an investigation to try to determine the cause of the injury of unknown origin. An Immediate Jeopardy situation was identified on 06/08/16. The Immediate Jeopardy was removed on 06/09/16. The facility remained out of compliance at isolated actual harm. This failure could place the census of 70 residents at risk for neglect, serious injury and even death. Findings included: A face sheet dated 6/08/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted [DATE] with the [DIAGNOSES REDACTED]. Physician orders [REDACTED].#10 was required to be transferred using a Hoyer (mechanical) lift. An MDS dated [DATE] indicated Resident #10 usually understood others, could be understood, and had problems with recall. Resident #10 required extensive assistance of two staff with bed mobility, transfers, locomotion, dressing, and personal hygiene. She required total assistance of two staff for toileting, and total assistance of one staff with bathing. A care plan dated 2/22/16 indicated Resident #10 was to be mechanically lifted, the goal was she would not sustain injuries during mechanical lifting with the intervention of 2 staff members at all times. The care plan indicated Resident #10 required extensive assistance of 2 staff with transfers, dressing, grooming, toileting, and total assistance of 1 staff with bathing. A skin sheet dated 6/01/16 at 7:13 a.m., indicated Resident #10 had warm, dry skin, with pale colored scattered dark purple areas to both upper extremities, and injection bruising to her abdomen. A nursing note dated 6/04/16 at 9:46 a.m., indicated LVN J was called to the shower room where she noted Resident #10 had a large bruise to her left breast. The note indicated the resident's left breast had yellow discoloration to the top half of the breast in an angled pattern that faded to the bottom half of the breast. The areola region was blue and purple colored measuring 5 cm (centimeters) x 2 cm. A large knot above the left breast area measured 8 cm x 9 cm. Resident #10 denied pain but complained of tenderness. The note indicated Resident #10 said, My daughter accidently did that while I was out on pass to Dallas with my family. LVN J said she called the daughter and the daughter said she had not been to see her mother in 10 days. LVN J notified the physician. The note indicated the physician questioned LVN J of any possible falls or injuries to the site. The physician recommended a sonogram. LVN J documented she notified the DON. A nursing note dated 6/4/16 at 9:04 p.m., indicated LVN J monitored the knot and bruising to Resident #10's left breast. Resident #10 complained of discomfort to her breast. During an interview on 6/08/16 at 2:15 p.m., LVN J said she was called to the shower on 6/04/16 between 8:30 a.m. to 9:00 a.m. to evaluate Resident #10. LVN J said Resident #10 had yellow colored bruising to the top of her left breast, and eggplant colored discoloration to the lower part of the left breast and knot was below the collar bone. LVN J said she asked Resident #10 how the injury occurred. LVN J said Resident #10 said her daughter accidently bumped her. LVN J said she called the daughter and the daughter told her she had not been to the facility in 10 days. LVN J said she notified the administrator of the bruised area. LVN J said on 6/5/16 the left breast had red streaking and was warm to touch. LVN J said she notified the physician. LVN J said the physician assessed the bruising and sent Resident #10 to the local emergency room . LVN J said the daughter called her and said the emergency room physician asked who could have hurt her mother. LVN J said she relayed the daughter and ER physician's concerns to the DON. During an interview on 6/08/16 at 1:00 p.m., the ADON said she was the charge nurse on duty on 6/03/16 from 10:00 p.m. to 6:00 a.m. She said she did not have a reason to assess Resident #10's breast. (bruise not discovered until 9:46 a.m. on 6/4/16) The ADON said she did not think the bruise was caused by abuse, but did not investigate to determine how the injury of unknown origin could have occurred on her shift. During an interview on 6/8/16 at 1:55 p.m., CNA O said on Sunday 6/5/16 around midnight she noticed Resident #10's left breast was purple and swollen. CNA O said she reported it to the ADON who was working and she nodded her head like she acknowledged her and did not say anything. CNA O said no administrative personnel interviewed her about Resident #10's swollen/bruised breast. A nursing note dated 6/5/16 at 1:50 a.m., indicated the ADON documented Resident #10 had a knot and a bruise to the left breast. The note indicated the physician would visit on Monday 6/06/16 to consider further treatment. A nursing note dated 6/05/16 at 11:30 a.m., indicated Resident #10's left breast had redness to the mass and was warm to touch. A nursing note dated 6/05/16 at 11:34 a.m., indicated LVN J notified the DON of the changes to the left breast knot. The note indicated the physician would be notified. A nursing note dated 6/05/16 at 12:18 p.m. indicated the physician would evaluate Resident #10 at 2:00 p.m. on 6/5/16. A physician progress notes [REDACTED].#10's left breast. The note indicated the left breast had a maroon healing bruise covering the lateral side from the 6 o'clock position to the 3 o'clock position. There was a lemon sized mass with [DIAGNOSES REDACTED] and warmth to the touch at the 11 o'clock position. There was red streaking extending from the mass upward. The nipple appeared yellow and crusted. There was a yellow healing bruise near the mass. The physician documented impressions of a breast mass, [MEDICAL CONDITION], and unexplained bruising. The physician's plan was to send the resident to the local emergency room for further evaluation. During an interview on 6/08/15 at 3:55 p.m., Resident #10's physician said she received a call from the facility on 6/4/16 saying Resident #10 had a yellow bruise with a mass to her left breast. The physician said she received a call again on 6/5/16 from the facility nurse stating the mass had streaking going toward the head. The physician said she went to the facility and assessed the area of concern. The physician said the mass measured 6 x 3 cm and was approximately the size of a lemon, with bruising to the entire breast. The physician said she ordered to send Resident #10 to the local emergency room for further evaluation. The physician said the CT scan revealed a hematoma and not a mass. The physician said Resident #10 sustained [MEDICATION NAME] force trauma to her left breast. The physician said she had multiple conversations with nurses at the facility in which she conveyed she felt this injury should be reported. The physician said she spoke to the DON on 6/06/16 concerning the injury. A physician order [REDACTED].#10 to the local emergency room by ambulance. A nursing note dated 6/05/16 at 2:23 p.m. indicated Resident #10 was transferred by EMS to the local emergency room . An emergency department physician note dated 6/05/16 at 3:06 p.m., indicated Resident #10 presented to the emergency room for the evaluation of a mass with redness to the left breast. The note indicated the unknown onset of the breast area, there was swelling and moderate pain to the breast. The physician indicated Resident #10 was a poor historian due to dementia. The skin assessment documented dark purple bruising to her left upper breast with various stages of healing bruises. A hematoma was documented below the clavicle (collar bone). The ER physician ordered a CT (computed tomography) of the chest. Photographic wound documentation from the emergency room dated 6/08/16 indicated Resident #10 had a hematoma of the left breast with massive bruising which was unable to be measured. An emergency department medication order dated 6/05/16 at 3:55 p.m., indicated Resident #10 received medication for pain. The documented pain score for Resident #10 was 8 out of 10 and considered severe level. A CT scan dated 6/5/16 at 5:46 p.m., indicated Resident #10 had a left anterior chest wall abnormality most consistent with a left pectorals intramuscular hematoma measuring 6.1 x 4.9 x 7.2 cm. There was surrounding soft tissue [MEDICAL CONDITION]. During an interview on 6/09/16 at 12:32 p.m., the emergency room physician said he received a call from Resident #10's physician for an evaluation of the left breast on 8/5/16. The emergency room physician said the CT scan indicated a hematoma to the left chest wall. He said Resident #10's injury was due to [MEDICATION NAME] force trauma to her left breast. The emergency room physician said he questioned the family extensively on how this type injury could have occurred. The physician said Resident #10's [MEDICATION NAME] (anticoagulant) and aspirin therapy had not contributed much to the breast bruising. A nursing note dated 6/05/16 at 5:29 p.m., indicated the daughter (responsible party) notified LVN J the emergency room physician had inquired who at the facility could have hurt Resident #10. A nursing note dated 6/05/16 at 5:48 p.m., indicated LVN J documented a telephone conversation with the daughter indicating Resident #10 said she scratched her breast. LVN J documented the daughter did not think scratching caused the bruising. A nursing note dated 6/05/16 at 8:36 p.m., indicated Resident #10 returned to the facility via the nursing home van with two staff members. During an interview on 6/08/16 at 11:40 a.m., the administrator said he was notified on 6/4/16 by LVN J of the bruise to Resident #10's breast. The administrator said he told the DON she was responsible for investigating and staying in contact with the nursing staff. The administrator said he was told Resident #10 might [MEDICAL CONDITION]. During an interview on 6/08/16 at 4:15 p.m., the daughter (responsible party) said she was notified on 6/04/16 of the bruising to Resident #10's left breast. The daughter said the emergency room doctor expressed concern that Resident #10 had a traumatic injury and asked how it could have occurred. The daughter said the emergency room doctor asked many questions, such as, had there been a fall, or could her room-mate have caused the injury. The daughter said she relayed these concerns to LVN J. The daughter said more times than not, she has witnessed staff transferring Resident #10 underneath her arms. The daughter said most recently the two nurse aides who transferred her on 6/05/16 transferred her mother under the arms from the hospital bed to the wheelchair, then back again. The daughter said her mother cried out when they transferred her underneath her arms. A nursing note dated 6/05/16 at 8:46 p.m., indicated Resident #10 had left arm bruising measuring 2 cm x 1 cm, and upper left arm 6 cm x 1 cm. Her left upper chest had purple bruising that measured 10 cm x 8 cm, bruising to sternum measured 5 cm x 1 cm, purple bruising from left side of areola that measured 18 cm x 6 cm and to the right side of areola measured 9 cm x 8 cm. The hematoma measured 15 cm x 16 cm with red and purple discoloration. A skin sheet dated 6/08/16 indicated Resident #10 had bruising and discoloration to her left chest, flank and side area. The note indicated swelling of her left breast and scattered bruises to her right forearm from laboratory and IV sticks. There were tiny bruises to her abdomen from insulin injections. During an observation on 6/08/16 at 4:10 p.m., Resident #10's entire left breast was discolored with yellow and purple bruising. The bruising extended under her arm and around onto her back. Her breast was grossly [MEDICAL CONDITION]. Resident #10's right breast had a small dark purple bruise and her left upper arm had a large purple and with yellow bruise. During an interview on 6/08/16 at 1:24 p.m., CNA C said she cared for Resident #10 on 6/3/15. CNA C said there was no bruising to Resident #10's breast. CNA C said Resident #10 was transferred by a mechanical lift. During an interview on 6/08/16 at 1:40 p.m., RN F said the physician told her on 6/5/16 she had concerns with the unexplained bruising to Resident #10's breast. She said the physician asked her if she had knowledge of any co-workers who could have caused the injury. RN F said any bruise of that size and in the breast area would be suspicious in nature. RN F said she did not report the suspicious bruise to the state agency because she thought the administration had. RN F said she had not investigated to determine how the injury of unknown origin could have occurred. During an interview on 6/08/16 at 1:58 p.m., NA Q said she worked on 6/02/16 and 6/03/16. NA Q said she and CNA P were in orientation those nights. NA Q said they transferred Resident #10 using a mechanical lift. During an interview on 6/8/16 at 3:10 p.m., CNA P said she was new to the facility. She said she and NA Q did not transfer Resident #10 with a mechanical lift. She said they transferred Resident #10 using a two person pivot technique and a gait belt on 6/2/16 and 6/3/16. CNA P said she had not looked in the kiosk (electronic station with resident care instructions) to review how to transfer Resident #10. During an interview on 6/08/16 at 12:20 p.m., the DON said she was notified of Resident #10's bruised breast on 6/04/16 by LVN J. The DON said the incident report completed by LVN J was the investigation. The DON said she had not investigated to determine the cause of the injury of unknown origin. The DON said Resident #10 said she and her daughter were playing around which caused the bruise to the left breast. The DON said on Sunday she was notified of Resident #10 having a knot on her bruised breast and that the physician was notified. The DON said she was aware Resident #10 was transferred to the local emergency room for an evaluation of the bruised breast. The DON said she did not believe the bruised breast was reportable because Resident #10's bruised breast could have been caused by her contracted left arm, the resident scratching, or the mechanical lift. The DON said she had been in contact with the physician. The DON said no one abused Resident #10, and the hematoma and bruising of the breast was not suspicious in nature and did not require further investigation and was not reportable. During an interview on 6/9/16 at 1:15 p.m., the administrator said he was not thoroughly informed regarding the injury of unknown origin to Resident #10. The administrator said he would have investigated and reported the injury if he had known the information he was given later. A revised Abuse Prevention Policy and Procedure dated 1/2005 indicated the facility will assure that all residents are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. (E)(1) Investigation: All suspicious injuries to a resident, or allegation of abuse will be thoroughly investigated by the administrator and or the director of nurses. (E) (3) The administrator and or the director of nurses will determine the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation and if so, will report the incident to the DADS state office in Austin. (E) (4) The administrator will follow the Guidelines for the Reporting Incidents in accordance with the licensure act and the State standards. (F)(2) The facility will assure that the resident remains protected from harm while any investigation is being undertaken. (G)(1) The administrator will report all alleged violations and all substantiated incidents to the DADS Austin agency and all other agencies required. A Safe Lifting and Movement of Residents policy and procedure dated December 2013 indicated the policy was in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. (2) Manual lifting of residents shall be eliminated when feasible. The administrator and DON were notified on 06/08/16 at 5:45 p.m., an Immediate Jeopardy situation was identified in the area of neglect. The facility's Plan of Removal was accepted on 06/08/16 at 8:18 p.m. and included: *Investigation of this incident and report it to appropriate agency to determine how the injury occurred. *In-service all staff in the building on appropriate procedure of reporting Abuse, Neglect, and Misappropriation/Exploitation (failure to investigate and failure to report) by administrator or designee: 1. 2-10 shift, June 8th (In-service tonight) 2. 10-6 shift, June 8th to 9th (In-service tonight) 3. 6-2 shift and morning shift June 9th (In-service tomorrow morning by 9:00 a.m.) 4. All other staff: in-service by phone or before the next time they come to work *Staff involved in resident transfers will be in-serviced on proper techniques *Residents that are able to be interviewed in the building, will be interviewed by staff regarding staff treatment with questionnaire by 10:00 a.m. tomorrow *All residents that are not able to communicate or not able to be interviewed, will be given a skin assessment head to toe by 10:00 a.m. tomorrow. On 6/09/16 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: 5 LVNs, 11 CNAs, 1 RN, 1 AD, 1 SW, 1 DON, 1 driver, 3 housekeepers, 1 maintenance person, 1 laundry aide and the administrator said the abuse coordinator was the administrator. In the event he is unavailable the DON should be contacted. Abuse can be reported by anyone. The facility staff were responsible to protect the residents. Reportable suspicious bruising to the neck, wrists, inner thighs, buttocks, and feet were not the usual vulnerable trauma areas. The staff verbalized understanding if they were unsure if something was reportable just report and then follow up with the abuse coordinator to ensure proper response. The administrator and DON were notified on 06/09/16 at 2:00 p.m. that the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and monitor the effectiveness of its corrective actions. The CMS for 672 dated 6/06/2016 indicated a census of 70.

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 1 of 5 residents reviewed for neglect. (Resident #10) The facility did not prevent Resident #10 from sustaining an injuy of unknown origin and did not investigate to determine how or when Resident #10 sustained an injury of unknown origin, did not report the incident to the regulatory agency. Resident #10 was found with a large hematoma and extensive bruising to her left breast. The resident's physician and the emergency room physician said the extensive injury was caused by [MEDICATION NAME] force trauma. As of 6/8/16 the facility had not performed an investigation to try to determine the cause of the injury of unknown origin. An Immediate Jeopardy situation was identified on 06/08/16. The Immediate Jeopardy was removed on 06/09/16. The facility remained out of compliance at isolated actual harm. This failure could place the census of 70 residents at risk for neglect, serious injury and even death. Findings included: A revised Abuse Prevention Policy and Procedure dated 1/2005 indicated the facility will assure that all residents are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. (E)(1) Investigation: All suspicious injuries to a resident, or allegation of abuse will be thoroughly investigated by the administrator and or the director of nurses. (E) (3) The administrator and or the director of nurses will determine the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation and if so, will report the incident to the DADS state office in Austin. (E) (4) The administrator will follow the Guidelines for the Reporting Incidents in accordance with the licensure act and the State standards. (F)(2) The facility will assure that the resident remains protected from harm while any investigation is being undertaken. (G)(1) The administrator will report all alleged violations and all substantiated incidents to the DADS Austin agency and all other agencies required. A Safe Lifting and Movement of Residents policy and procedure dated December 2013 indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. (2) Manual lifting of residents shall be eliminated when feasible. A face sheet dated 6/08/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted [DATE] with the [DIAGNOSES REDACTED]. Physician orders [REDACTED].#10 was required to be transferred using a Hoyer (mechanical) lift. An MDS dated [DATE] indicated Resident #10 usually understood others, could be understood, and had problems with recall. Resident #10 required extensive assistance of two staff with bed mobility, transfers, locomotion, dressing, and personal hygiene. She required total assistance of two staff for toileting, and total assistance of one staff with bathing. A care plan dated 2/22/16 indicated Resident #10 was to be mechanically lifted, the goal was she would not sustain injuries during mechanical lifting with the intervention of 2 staff members at all times. The care plan indicated Resident #10 required extensive assistance of 2 staff with transfers, dressing, grooming, toileting, and total assistance of 1 staff with bathing. A skin sheet dated 6/01/16 at 7:13 a.m., indicated Resident #10 had warm, dry skin, with pale colored scattered dark purple areas to both upper extremities, and injection bruising to her abdomen. A nursing note dated 6/04/16 at 9:46 a.m., indicated LVN J was called to the shower room where she noted Resident #10 had a large bruise to her left breast. The note indicated the resident's left breast had yellow discoloration to the top half of the breast in an angled pattern that faded to the bottom half of the breast. The areola region was blue and purple colored measuring 5 cm (centimeters) x 2 cm. A large knot above the left breast area measured 8 cm x 9 cm. Resident #10 denied pain but complained of tenderness. The note indicated Resident #10 said, My daughter accidently did that while I was out on pass to Dallas with my family. LVN J said she called the daughter and the daughter said she had not been to see her mother in 10 days. LVN J notified the physician. The note indicated the physician questioned LVN J of any possible falls or injuries to the site. The physician recommended a sonogram. LVN J documented she notified the DON. A nursing note dated 6/4/16 at 9:04 p.m., indicated LVN J monitored the knot and bruising to Resident #10's left breast. Resident #10 complained of discomfort to her breast. During an interview on 6/08/16 at 2:15 p.m., LVN J said she was called to the shower on 6/04/16 between 8:30 a.m. to 9:00 a.m. to evaluate Resident #10. LVN J said Resident #10 had yellow colored bruising to the top of her left breast, and eggplant colored discoloration to the lower part of the left breast and knot was below the collar bone. LVN J said she asked Resident #10 how the injury occurred. LVN J said Resident #10 said her daughter accidently bumped her. LVN J said she called the daughter and the daughter told her she had not been to the facility in 10 days. LVN J said she notified the administrator of the bruised area. LVN J said on 6/5/16 the left breast had red streaking and was warm to touch. LVN J said she notified the physician. LVN J said the physician assessed the bruising and sent Resident #10 to the local emergency room . LVN J said the daughter called her and said the emergency room physician asked who could have hurt her mother. LVN J said she relayed the daughter and ER physician's concerns to the DON. During an interview on 6/08/16 at 1:00 p.m., the ADON said she was the charge nurse on duty on 6/03/16 from 10:00 p.m. to 6:00 a.m. She said she did not have a reason to assess Resident #10's breast. (bruise not discovered until 9:46 a.m. on 6/4/16) The ADON said she did not think the bruise was caused by abuse, but did not investigate to determine how the injury of unknown origin could have occurred on her shift. During an interview on 6/8/16 at 1:55 p.m., CNA O said on Sunday 6/5/16 around midnight she noticed Resident #10's left breast was purple and swollen. CNA O said she reported it to the ADON who was working and she nodded her head like she acknowledged her and did not say anything. CNA O said no administrative personnel interviewed her about Resident #10's swollen/bruised breast. A nursing note dated 6/5/16 at 1:50 a.m., indicated the ADON documented Resident #10 had a knot and a bruise to the left breast. The note indicated the physician would visit on Monday 6/06/16 to consider further treatment. A nursing note dated 6/05/16 at 11:30 a.m., indicated Resident #10's left breast had redness to the mass and was warm to touch. A nursing note dated 6/05/16 at 11:34 a.m., indicated LVN J notified the DON of the changes to the left breast knot. The note indicated the physician would be notified. A nursing note dated 6/05/16 at 12:18 p.m. indicated the physician would evaluate Resident #10 at 2:00 p.m. on 6/5/16. A physician progress notes [REDACTED].#10's left breast. The note indicated the left breast had a maroon healing bruise covering the lateral side from the 6 o'clock position to the 3 o'clock position. There was a lemon sized mass with [DIAGNOSES REDACTED] and warmth to the touch at the 11 o'clock position. There was red streaking extending from the mass upward. The nipple appeared yellow and crusted. There was a yellow healing bruise near the mass. The physician documented impressions of a breast mass, [MEDICAL CONDITION], and unexplained bruising. The physician's plan was to send the resident to the local emergency room for further evaluation. During an interview on 6/08/15 at 3:55 p.m., Resident #10's physician said she received a call from the facility on 6/4/16 saying Resident #10 had a yellow bruise with a mass to her left breast. The physician said she received a call again on 6/5/16 from the facility nurse stating the mass had streaking going toward the head. The physician said she went to the facility and assessed the area of concern. The physician said the mass measured 6 x 3 cm and was approximately the size of a lemon, with bruising to the entire breast. The physician said she ordered to send Resident #10 to the local emergency room for further evaluation. The physician said the CT scan revealed a hematoma and not a mass. The physician said Resident #10 sustained [MEDICATION NAME] force trauma to her left breast. The physician said she had multiple conversations with nurses at the facility in which she conveyed she felt this injury should be reported. The physician said she spoke to the DON on 6/06/16 concerning the injury. A physician order [REDACTED].#10 to the local emergency room by ambulance. A nursing note dated 6/05/16 at 2:23 p.m. indicated Resident #10 was transferred by EMS to the local emergency room . An emergency department physician note dated 6/05/16 at 3:06 p.m., indicated Resident #10 presented to the emergency room for the evaluation of a mass with redness to the left breast. The note indicated the unknown onset of the breast area, there was swelling and moderate pain to the breast. The physician indicated Resident #10 was a poor historian due to dementia. The skin assessment documented dark purple bruising to her left upper breast with various stages of healing bruises. A hematoma was documented below the clavicle (collar bone). The ER physician ordered a CT (computed tomography) of the chest. Photographic wound documentation from the emergency room dated 6/08/16 indicated Resident #10 had a hematoma of the left breast with massive bruising which was unable to be measured. An emergency department medication order dated 6/05/16 at 3:55 p.m., indicated Resident #10 received medication for pain. The documented pain score for Resident #10 was 8 out of 10 and considered severe level. A CT scan dated 6/5/16 at 5:46 p.m., indicated Resident #10 had a left anterior chest wall abnormality most consistent with a left pectorals intramuscular hematoma measuring 6.1 x 4.9 x 7.2 cm. There was surrounding soft tissue [MEDICAL CONDITION]. During an interview on 6/09/16 at 12:32 p.m., the emergency room physician said he received a call from Resident #10's physician for an evaluation of the left breast on 8/5/16. The emergency room physician said the CT scan indicated a hematoma to the left chest wall. He said Resident #10's injury was due to [MEDICATION NAME] force trauma to her left breast. The emergency room physician said he questioned the family extensively on how this type injury could have occurred. The physician said Resident #10's [MEDICATION NAME] (anticoagulant) and aspirin therapy had not contributed much to the breast bruising. A nursing note dated 6/05/16 at 5:29 p.m., indicated the daughter (responsible party) notified LVN J the emergency room physician had inquired who at the facility could have hurt Resident #10. A nursing note dated 6/05/16 at 5:48 p.m., indicated LVN J documented a telephone conversation with the daughter indicating Resident #10 said she scratched her breast. LVN J documented the daughter did not think scratching caused the bruising. A nursing note dated 6/05/16 at 8:36 p.m., indicated Resident #10 returned to the facility via the nursing home van with two staff members. During an interview on 6/08/16 at 11:40 a.m., the administrator said he was notified on 6/4/16 by LVN J of the bruise to Resident #10's breast. The administrator said he told the DON she was responsible for investigating and staying in contact with the nursing staff. The administrator said he was told Resident #10 might [MEDICAL CONDITION]. During an interview on 6/08/16 at 4:15 p.m., the daughter (responsible party) said she was notified on 6/04/16 of the bruising to Resident #10's left breast. The daughter said the emergency room doctor expressed concern that Resident #10 had a traumatic injury and asked how it could have occurred. The daughter said the emergency room doctor asked many questions, such as, had there been a fall, or could her room-mate have caused the injury. The daughter said she relayed these concerns to LVN J. The daughter said more times than not, she has witnessed staff transferring Resident #10 underneath her arms. The daughter said most recently the two nurse aides who transferred her on 6/05/16 transferred her mother under the arms from the hospital bed to the wheelchair, then back again. The daughter said her mother cried out when they transferred her underneath her arms. A nursing note dated 6/05/16 at 8:46 p.m., indicated Resident #10 had left arm bruising measuring 2 cm x 1 cm, and upper left arm 6 cm x 1 cm. Her left upper chest had purple bruising that measured 10 cm x 8 cm, bruising to sternum measured 5 cm x 1 cm, purple bruising from left side of areola that measured 18 cm x 6 cm and to the right side of areola measured 9 cm x 8 cm. The hematoma measured 15 cm x 16 cm with red and purple discoloration. A skin sheet dated 6/08/16 indicated Resident #10 had bruising and discoloration to her left chest, flank and side area. The note indicated swelling of her left breast and scattered bruises to her right forearm from laboratory and IV sticks. There were tiny bruises to her abdomen from insulin injections. During an observation on 6/08/16 at 4:10 p.m., Resident #10's entire left breast was discolored with yellow and purple bruising. The bruising extended under her arm and around onto her back. Her breast was grossly [MEDICAL CONDITION]. Resident #10's right breast had a small dark purple bruise and her left upper arm had a large purple and with yellow bruise. During an interview on 6/08/16 at 1:24 p.m., CNA C said she cared for Resident #10 on 6/3/15. CNA C said there was no bruising to Resident #10's breast. CNA C said Resident #10 was transferred by a mechanical lift. During an interview on 6/08/16 at 1:40 p.m., RN F said the physician told her on 6/5/16 she had concerns with the unexplained bruising to Resident #10's breast. She said the physician asked her if she had knowledge of any co-workers who could have caused the injury. RN F said any bruise of that size and in the breast area would be suspicious in nature. RN F said she did not report the suspicious bruise to the state agency because she thought the administration had. RN F said she had not investigated to determine how the injury of unknown origin could have occurred. During an interview on 6/08/16 at 1:58 p.m., NA Q said she worked on 6/02/16 and 6/03/16. NA Q said she and CNA P were in orientation those nights. NA Q said they transferred Resident #10 using a mechanical lift. During an interview on 6/8/16 at 3:10 p.m., CNA P said she was new to the facility. She said she and NA Q did not transfer Resident #10 with a mechanical lift. She said they transferred Resident #10 using a two person pivot technique and a gait belt on 6/2/16 and 6/3/16. CNA P said she had not looked in the kiosk (electronic station with resident care instructions) to review how to transfer Resident #10. During an interview on 6/08/16 at 12:20 p.m., the DON said she was notified of Resident #10's bruised breast on 6/04/16 by LVN J. The DON said the incident report completed by LVN J was the investigation. The DON said she had not investigated to determine the cause of the injury of unknown origin. The DON said Resident #10 said she and her daughter were playing around which caused the bruise to the left breast. The DON said on Sunday she was notified of Resident #10 having a knot on her bruised breast and that the physician was notified. The DON said she was aware Resident #10 was transferred to the local emergency room for an evaluation of the bruised breast. The DON said she did not believe the bruised breast was reportable because Resident #10's bruised breast could have been caused by her contracted left arm, the resident scratching, or the mechanical lift. The DON said she had been in contact with the physician. The DON said no one abused Resident #10, and the hematoma and bruising of the breast was not suspicious in nature and did not require further investigation and was not reportable. During an interview on 6/9/16 at 1:15 p.m., the administrator said he was not thoroughly informed regarding the injury of unknown origin to Resident #10. The administrator said he would have investigated and reported the injury if he had known the information he was given later. The administrator and DON were notified on 06/08/16 at 5:45 p.m., an Immediate Jeopardy situation was identified in the area of neglect. The facility's Plan of Removal was accepted on 06/08/16 at 8:18 p.m. and included: *Investigation of this incident and report it to appropriate agency to determine how the injury occurred. *In-service all staff in the building on appropriate procedure of reporting Abuse, Neglect, and Misappropriation/Exploitation (failure to investigate and failure to report) by administrator or designee: 1. 2-10 shift, June 8th (In-service tonight) 2. 10-6 shift, June 8th to 9th (In-service tonight) 3. 6-2 shift and morning shift June 9th (In-service tomorrow morning by 9:00 a.m.) 4. All other staff: in-service by phone or before the next time they come to work *Staff involved in resident transfers will be in-serviced on proper techniques *Residents that are able to be interviewed in the building, will be interviewed by staff regarding staff treatment with questionnaire by 10:00 a.m. tomorrow *All residents that are not able to communicate or not able to be interviewed, will be given a skin assessment head to toe by 10:00 a.m. tomorrow. On 6/09/16 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: 5 LVNs, 11 CNAs, 1 RN, 1 AD, 1 SW, 1 DON, 1 driver, 3 housekeepers, 1 maintenance person, 1 laundry aide and the administrator said the abuse coordinator was the administrator. In the event he is unavailable the DON should be contacted. Abuse can be reported by anyone. The facility staff were responsible to protect the residents. Reportable suspicious bruising to the neck, wrists, inner thighs, buttocks, and feet were not the usual vulnerable trauma areas. The staff verbalized understanding if they were unsure if something was reportable just report and then follow up with the abuse coordinator to ensure proper response. The administrator and DON were notified on 06/09/16 at 2:00 p.m. that the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and monitor the effectiveness of its corrective actions. The CMS for 672 dated 6/06/2016 indicated a census of 70.

Based on interview and record review, the facility failed to ensure residents were provided the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for 1 of 6 residents reviewed for change in condition. (Resident #1) Resident #1 had diminished breath sounds and abnormal (rubs) lung sounds, rapid respirations, low blood pressure, and was less responsive. The facility did not consult with the physician for 16 hours after Resident #1 experienced a change in mental and respiratory status on 9/24/14, and did provide appropriate interventions. Resident #1 was transferred to the emergency room and diagnosed with [REDACTED]. This failure contributed to Resident #1 not receiving timely medical intervention. This failure could place the census of 63 residents at risk for a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 was cognitively impaired and dependent on staff for ADLs, transfers, and bed mobility. The care plan dated 4/17/14 indicated Resident #1 was at risk for dehydration related to diuretic therapy. The resident would be free from signs/symptoms of dehydration. A nursing note dated 9/23/14 at 1220 a.m. indicated Resident #1 denied any pain or discomfort, B/P was 90/50, and temperature 99.2. A nursing note dated 9/23/14 at 8:00 a.m. indicated her B/P was 80/45, she was more alert this a.m., and her blood pressure medication was held. Nursing notes dated 9/24/14 indicated: -2:15 a.m. Resident #1 ' s B/P was 110/85; pulse was 28, and temperature 99. Resident #1's respirations were even and rapid. Oxygen was applied because the resident was not as alert as normal. -8:00 a.m., Resident #1 ' s B/P was 105/59, and her blood pressure medication was held. Called and left message for physician. -11:00 a.m. another message left for the physician and the physician did not return the call. A nursing note dated 9/24/14 at 10:50 p.m. indicated Resident #1's vital signs were; B/P 86/44, pulse 79, respirations 28 and temperature 99.3. Resting quietly in bed, will awaken to verbal stimuli and answer questions but goes right back to sleep. Lung sounds had rubs in upper lobes and diminished breath sounds in both lower lungs. There was a change in the resident's condition with alertness and response to staff. Oxygen saturation was 96% on oxygen @ 2 liters per minute per nasal cannula with very shallow rapid breathing. The head of the bed was elevated. Will continue to monitor closely. Nursing notes dated 9/25/14 indicated: -5:45 a.m. Resident #1 continued to respond to verbal and tactile stimuli. Would try to talk but just mumbled random words. Would wake up and go right back to sleep. Oxygen saturation was 95% on room air. No urinary output all night. -6:00 a.m., attempted to notify the physician, no answer, message left. -6:15 a.m., b/p 77/44, pulse 70, respirations 28 and temperature 96.8. The daughter was notified and 911 was called to transport Resident #1 to the emergency room . A hospital transfer form dated 9/25/14 indicated the resident had a change in condition, not responding well, with a low blood pressure. Resident #1's hospital records indicated labs performed in the emergency room were abnormal, as follows: *BUN 157 critical value, (normal 7.0-18), *Sodium 158 high value, (norm 136-145), *Potassium 8.2 critical value, (normal 3.5-5.1), *Creatinine 10.2 high value, (normal 0.6-1.3), *AST (SGOT) 56 high value, (normal 10-37) *ALT (SGPT) 91 high value, (normal 14-59) The x-ray report indicated poor lung expansion. The emergency room report indicated the resident was in critical condition. She was admitted with severe dehydration, [MEDICAL CONDITIONS]/[MEDICAL CONDITION] and a urinary tract infection. During an interview on 10/28/14 at 10:00 p.m., LVN A said Resident #1's blood pressure had been running low for the past couple of days and her blood pressure medication had been held and she ran a low grade temperature for a couple of days prior to going to the hospital. She said the physician did not like to be called unless it was an emergency. LVN A said she monitored Resident #1 closely and attempted to notify the physician the next morning. LVN A said Resident #1 had a change in her mental and respiratory status. During an interview on 10/28/14 at 2:15 p.m., LVN B said Resident #1's blood pressure medication had to be held because her blood pressure was low and she ran a low grade temperature for a couple of days prior to going to the hospital. During an interview on 10/28/14 at 02:00 p.m., the DON said the nurses were to notify the physician immediately when there was a change in condition. She did not feel Resident #1 had a change in condition. The Physician Notification policy dated 3/10/05 indicated the following: " ...Immediate Notification- the physician should be informed at the time the event occurs , calling the on-call physician if appropriate.) ... - if there is no response from the physician and an immediate action is needed, your responsibility does not end, notify the attending physician, or the on call physician or the medical director........".... -"for situations requiring immediate action, contact the hospital emergency room and request transport......................"..... The CMS 672 dated 10/28/14 indicated there were 63 residents.

Based on observation, interview, and record review, the facility failed to consult with the physician for a change of condition that could require physician intervention for 1 of 6 residents reviewed for change in condition. (Resident #1) Resident #1 had diminished breath sounds and abnormal (rubs) lung sounds, rapid respirations, low blood pressure, and was less responsive. The facility did not consult with the physician for 16 hours after Resident #1 experienced a change in mental and respiratory status on 9/24/14. This failure contributed to Resident #1 not receiving timely medical intervention. This failure could place the census of 63 residents at risk for a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 was cognitively impaired and dependent on staff for ADLs, transfers, and bed mobility. The care plan dated 4/17/14 indicated Resident #1 was at risk for dehydration related to diuretic therapy. The resident would be free from signs/symptoms of dehydration. A nursing note dated 9/23/14 at 1220 a.m. indicated Resident #1 denied any pain or discomfort, B/P was 90/50, and temperature 99.2. A nursing note dated 9/23/14 at 8:00 a.m. indicated her B/P was 80/45, she was more alert this a.m., and her blood pressure medication was held. Nursing notes dated 9/24/14 indicated: -2:15 a.m. Resident #1's B/P was 110/85; pulse was 28, and temperature 99. Resident #1's respirations were even and rapid. Oxygen was applied because the resident was not as alert as normal. -8:00 a.m., Resident #1's B/P was 105/59, and her blood pressure medication was held. Called and left message for physician. -11:00 a.m. another message left for the physician and the physician did not return the call. A nursing note dated 9/24/14 at 10:50 p.m. indicated Resident #1's vital signs were; B/P 86/44, pulse 79, respirations 28 and temperature 99.3. Resting quietly in bed, will awaken to verbal stimuli and answer questions but goes right back to sleep. Lung sounds had rubs in upper lobes and diminished breath sounds in both lower lungs. There was a change in the resident's condition with alertness and response to staff. Oxygen saturation was 96% on oxygen @ 2 liters per minute per nasal cannula with very shallow rapid breathing. The head of the bed was elevated. Will continue to monitor closely. Nursing notes dated 9/24/14 (sic) indicated: -5:45 a.m. Resident #1 continued to respond to verbal and tactile stimuli. Would try to talk but just mumbled random words. Would wake up and go right back to sleep. Oxygen saturation was 95% on room air. No urinary output all night. -6:00 a.m., attempted to notify the physician, no answer, message left. -6:15 a.m., b/p 77/44, pulse 70, respirations 28 and temperature 96.8. The daughter was notified and 911 was called to transport Resident #1 to the emergency room . A hospital transfer form dated 9/25/14 indicated the resident had a change in condition, not responding well, with a low blood pressure. Resident #1's hospital records indicated labs performed in the emergency room were abnormal, as follows: *BUN 157 critical value, (normal 7.0-18), *Sodium 158 high value, (norm 136-145), *Potassium 8.2 critical value, (normal 3.5-5.1), *Creatinine 10.2 high value, (normal 0.6-1.3), *AST (SGOT) 56 high value, (normal 10-37) *ALT (SGPT) 91 high value, (normal 14-59) The x-ray report indicated poor lung expansion. The emergency room report indicated the resident was in critical condition. She was admitted with severe dehydration, [MEDICAL CONDITIONS]/[MEDICAL CONDITION] and a urinary tract infection. During an interview on 10/28/14 at 10:00 p.m., LVN A said Resident #1's blood pressure had been running low for the past couple of days and her blood pressure medication had been held and she ran a low grade temperature for a couple of days prior to going to the hospital. She said the physician did not like to be called unless it was an emergency. LVN A said she monitored Resident #1 closely and attempted to notify the physician the next morning. LVN A said Resident #1 had a change in her mental and respiratory status. During an interview on 10/28/14 at 2:15 p.m., LVN B said Resident #1's blood pressure medication had to be held because her blood pressure was low and she ran a low grade temperature for a couple of days prior to going to the hospital. During an interview on 10/28/14 at 02:00 p.m., the DON said the nurses were to notify the physician immediately when there was a change in condition. She did not feel Resident #1 had a change in condition. The Physician Notification policy dated 3/10/05 indicated the following: " ...Immediate Notification- the physician should be informed at the time the event occurs , calling the on-call physician if appropriate.) ... - if there is no response from the physician and an immediate action is needed, your responsibility does not end, notify the attending physician, or the on call physician or the medical director........".... -"for situations requiring immediate action, contact the hospital emergency room and request transport......................"..... The CMS 672 dated 10/28/14 indicated there were 63 residents.