Every finding on record at Richardson Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents (Residents #1) reviewed for respiratory care. The facility failed to ensure Resident #1's breathing treatment masks were properly stored on 08/19/26. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's face sheet dated 08/19/26 revealed a [AGE] year-old male admitted to the facility on [DATE], he had diagnosis of Acute Respiratory Failure with Hypoxia (your lungs suddenly stop working well. They cannot pull enough oxygen from the air into your blood) Record review of Resident #1's Quarterly MDS Assessment, dated 07/02/26, revealed a BIMS of 12 (mild to moderate cognitive impairment). The MDS Assessment revealed the resident needed supervision and setup for his ADLs. The MDS revealed he was coded for respiratory failure. Record review of Resident #1's physician order dated 05/09/26 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours as needed for SOB/Congestion. During an observation and interview on 08/19/26 at 11:30 a.m. Resident #1 was not in his room, his breathing treatment mask was observed hanging from the light fixture in his room. LVN C stated that Resident #1 went for his dialysis treatment. LVN C stated that the breathing treatment was as needed. LVN C stated that the breathing treatment mask should be bagged after every treatment. He stated that the Resident should be monitored and observed during and after treatment to ascertain the effectiveness of the treatment by a nurse. He stated that he was not sure of the last time the treatment was given since they don't have access to the EMR system, he stated the paper MAR does not reflect any administration of the nebulizer medication since 08/16/26. He stated that the nurses are responsible for making sure the nebulizer mask is bagged. He stated that if it is not bagged, it could be infected with germs, he stated that it is rinsed after each treatment and bagged to prevent contamination. He stated that the resident could get an infection if the nebulizer mask gets infected. He stated that he has been trained in nebulizer administration and assessment. During an interview on 08/19/26 at 2:40 p.m. with the DON and the Regional Resource Nurse, He stated that the breathing treatment mask should be changed weekly and stored in a dated bag when not in use. He stated that the orders should be verified before administration and make sure that the mask is bagged before use, rinsed after each use and bagged and the nurse needs to remain with the resident during the administration. He stated that the nursing management team and the nurses are responsible for making sure that the steps for administration of the breathing treatment are followed. He stated that they provide skill check offs for the nurses and they provide in service when a lack of competency is observed. He stated that they will provide education to Resident #1 to make sure he does not take the mask out of the bag and store it elsewhere. Record review of the Facility's Policy dated October 2010 for Administering Medications through a Small Volume (Handheld)Nebulizer revealed: 23. Administer therapy until medication is gone.24. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup.25. Wash and dry hands.26. Obtain post-treatment pulse, respiratory rate and lung sounds.27. Rinse and disinfect the nebulizer equipment according to facility protocol, or:a. wash pieces with warm, soapy water;b. rinse with hot water;c. place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes;d. rinse all pieces with sterile water (NOT tap, bottled, or distilled); ande. allow to air dry on a paper towel.28. Wash and dry hands.29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.30. Change equipment and tubing every seven days, or according to facility protocol.31. Disinfect outside of the compressor between residents, according to manufacturer's instructions.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's care plan related to her recent fall. These failures could place the residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's Face Sheet, dated 07/27/26, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning and communication skills). Record review of Resident #1's Quarterly MDS Assessment, dated 06/30/26, revealed the resident had severe cognitive impairment with a BIMS score of 02. The quarterly MDS Assessment indicated that the resident had inattention and disorganized thinking. Record review of Resident #1's Comprehensive Care Plan, dated 12/17/25, revealed that the resident did not have a care plan for falls. Record review of the incident report dated 07/31/26 revealed Resident #1 had an unwitnessed fall on 07/28/26 at 9:40 a.m. Record review of Resident #1's fall risk evaluation late entry date 07/28/26 revealed that the resident has not had a fall in the past 3 months with a fall risk score of 6.0. Record review of Resident #1's progress note dated 07/28/26 revealed that Resident #1 repeatedly refused to remain seated despite staff encouragement. Redirection was attempted six times without success. Resident continued to ambulate in the hallways. Nursing will continue to monitor the resident closely, provide frequent redirection, and implement fall prevention interventions as appropriate. Record review of Resident #1's progress note dated 07/28/26 revealed Resident #1 was assessed following a fall. Resident #1 denied pain or discomfort during the assessment. A cast to the left arm and hand remains intact with no visible concerns noted.Resident #1 was ambulatory throughout the hallways with an unsteady gait observed. During an observation and interview on 07/30/2026 at 9:30 a.m., Resident #1 was observed ambulating in her room, Resident #1 was observed with cast to left arm, she stated she fell, unable to describe how it happened. She appeared clean and well-groomed and denied any pain. During an interview on 07/31/26 at 2:15 a.m., the DON stated that Resident #1 had never had a fall in the facility and had no history of falls. She stated that everyone who is admitted is assessed for falls and a care plan for fall intervention is put in place, but the resident did not have one. She stated that with the recent fall there should have been a care plan update to include a fall risk and interventions to prevent falls. She stated that it was unintentional oversight that the fall care plan was not initiated. She stated that she has put a care plan in place with interventions for falls. She stated that she or the MDS nurses update the care plans. She stated that the fall was unwitnessed and the resident came to her that she had fallen and she was sent to the hospital and X-ray reports showed a fracture to the left wrist, and she had a cast put on. She stated that in services have been completed on best practice on how to document falls and keep the resident care plans updated. During an interview on 07/31/26 at 3:09 p.m., LVN G stated that Resident #1 came to report a fall and demonstrated how she fell. She stated the fall was not witnessed. She stated that an assessment was completed and her wrist looked twisted, the Nurse practitioner was contacted, and an order was given to send her to the ER. She stated that the protocol is to notify the physician, DON and family, she stated she placed an ice pack on her wrist while she waited to be picked up by the paramedics. She stated that the care plan should have been updated for falls risk, she stated that the DON and RN's update the care plans. She stated that she notified the DON of the fall. She stated that she is not sure why the care plan was not updated. She stated that she has been doing her nursing protocol follow up since the resident came back from the hospital. She stated that if the residents' care plan is not updated it could result in another fall. She stated that if the resident falls it will result in injuries and unnecessary hospitalization. Record review of the facility's policy Comprehensive Care Plans 2025 revision revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for eachresident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident'smedical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident'scomprehensive assessment and meet professional standards of quality. Record Review of the facility's policy Fall Risk Assessment 2025 revision revealed It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents.1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified.2. The risk assessment will contain the following components:a. Identify environmental hazards and individual risks, including the need for supervisionb. Evaluate and analyze hazards and risks3. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly.4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident.5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

Based on observation, interviews, and record review, the facility failed to ensure the residents environment remained free of accidents and hazards for all residents reviewed for hazards. The facility failed to ensure that a gas-powered lawn [NAME] containing active liquid fuel was not stored inside a vacant area in the 2400 hall currently designated as a temporary storage area within an active renovation zone. This failure placed residents, visitors and staff at risk of harm and injury in the event of anfire. Findings include: During an interview and observation on 07/30/26 at 1:15 p.m., with the Maintenance supervisor it was observed that a lawn [NAME] with half a tank of gas was stored in the 2400 hall that was under renovation. The maintenance supervisor stated that the lawn [NAME] was not supposed to be parked inside the building and should be outside next to the dumpster 25-30 feet from the building. He stated that the lawn [NAME] is normally stored outside but was not sure how it got into the building. He stated that it was a safety hazard to have the lawn [NAME] stored inside the building, he stated that it could leak gas or oil and become a fire risk to the whole facility. He stated that he is responsible for making sure the [NAME] is stored properly outside and not in the building. He stated that he makes daily rounds to make sure the whole building is safe and secure and checks all exits to make sure they are secure but had not done so today due to having an emergency to fix a call light in a resident's room. He stated that he would move it outside immediately. During an interview on 07/31/26 at 4:45 p.m., the administrator stated that the lawn [NAME] should not be stored in the building but next to the dumpster for safety. She stated that Maintenance worker H does the land scaping, she stated that he stated that he left the lawn [NAME] outside next to the dumpster the last time he cut the lawn. She stated that they make rounds to ensure hazards are stored properly. She stated that they do rounds weekly but will be rounding daily to check for any safety issues going forward. She stated it is a fired hazard for a lawn [NAME] with a tank full of gas to be stored in the building. Record review of the facility's policy 2012 edition K-923 Health Care Facilities Code Requirements Gas Equipment -Cylinder and Container Storage revealed: 3,000 cubic feetStorage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.> 300 but <3,000 cubic feetStorage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. 300 cubic feetIn a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.

Based on observation, interview and record review the facility failed to ensure receiving services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 4 of 9 residents (Residents #2, #3, #4 and #5) reviewed for the resident rights. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #3's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #4's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #5's room was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: 1. Record review of Resident #2's Face Sheet, dated 04/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included History of Falling, and Repeated falls. Record review of Resident #2's Quarterly MDS assessment, dated 02/22/26, revealed the resident had a BIMS of 6 indicating severe cognitive impairment, history of falling. Record review of Resident #2's active care plan dated 01/08/26 revealed the resident is at risk for falls Deconditioning,Gait/balance problems, Vision/hearing problems with intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. It revealed the resident had an unwitnessed fall on 08/01/25. 2. Record review of Resident #3's Face Sheet, dated 04/23/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), Fracture of left Acetabulum (a break in the socket portion of your left hip join), and Fracture of left Pubis (a break or crack in the bone located at the front of the pelvis (hip area) on the left side). Record review of Resident #3's Quarterly MDS assessment, dated 01/21/26, revealed the resident had a BIMS of 5 indicating severe cognitive impairment, lack of coordination (The inability of different parts of a system or body to work together effectively). Record review of Resident #3's active care plan dated 02/20/26 revealed the resident is at risk for falls with intervention to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 3. Record review of Resident #4's Face Sheet, dated 04/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, and unsteadiness on feet. Record review of Resident #4's Quarterly MDS assessment, dated 02/22/26, revealed the resident has a BIMS of 3 indicating severe cognitive impairment, diagnosis of Alzheimer's disease and unsteadiness on feet. Record review of Resident #4's active care plan dated 01/08/26 revealed the resident is at risk for falls confusion, deconditioning,Gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with intervention to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. It revealed the resident had a fall with injury on 02/17/23 and fall with no injury on 03/08/24. 4. Record review of Resident #5's Face Sheet, dated 04/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it hard to breathe), Lack of coordination (The inability of different parts of a system or body to work together effectively), Abnormalities of gait and mobility (an unusual or irregular way of walking), and Osteoporosis (a disease that makes bones weak, thin, and brittle, significantly increasing the risk of fractures). Record review of Resident #5's Quarterly MDS assessment, dated 02/22/26, revealed the resident had a BIMS of 15 (cognitively intact), lack of coordination (The inability of different parts of a system or body to work together effectively), muscle weakness (a noticeable lack of strength where your muscles do not respond the way they are supposed to). Record review of Resident #5's active physician's orders evealed active orders for: 1) Administer oxygen 2.0 liter/min via nasal cannula as needed for shortness of breath as needed for SOB dated 1210/2024 and Oxygen tubing change weekly label each componentwith date and initials. every night shift every Sunday Label each component with date and initials dated 01/10/2025. Record review of Resident #5's active care plan dated 01/08/26 revealed 1) The resident is at risk for falls Gait/balance problems, hx of falls, difficulty in walking, muscle weakness, osteoporosis with intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 2) Resident is at risk for shortness of breath, respiratory distress, increased anxiety due to DX of COPD with interventions to a) Encourage and remind resident to use call light to ask for and provide assistance as needed, b) Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are notEffective, c) Provide O2 as ordered and indicated. During an observation on 04/23/26 at 9:27 a.m., Residents #2 and #3 were observed lying in their beds. Resident #2's call light was observed on the floor lying on the left side of her oxygen concentrator, and Resident #3's call light was observed hanging on to the headboard, out of reach of resident.During an observation and interview on 04/23/26 at 9:31 a.m., Residents #4 and #5 were observed lying in their beds. Resident #4's call light was observed wrapped and hanging off the wall on the left side of the resident's bed; Resident #5's call light was observed on the floor, lying behind the headboard. Resident #5 stated she was very independent and would usually go to the nurses station if her call bell was not answered in a timely manner to ask for help.During an interview on 04/23/26 at 10:51 a.m., with DON, she stated that the call light should be within reach of every resident and readily available for them to call for help. She stated that the risk of not having the call bell within reach was a risk of falls, the resident may not be able to call for hydration when needed and if they are needing to use the restroom. During an interview on 04/23/26 at 11:28 a.m. with LVN H, she stated that the call light should be within reach of all residents and clipped to their beds with the provided clip to keep it secured. She stated that the risk of not having the call bell within reach is that the residents will not be able to call if they are having an emergency. During an interview on 04/23/26 at 1:25 p.m. with CNA G, she stated that the call bell should always be within reach for all residents. She stated that the risk of not having the call bell within reach could be bad, she stated that resident will not get assistance in a timely manner and could result in them falling if they try to act independently without assistance. A record review of the facilities Call light: Accessibility and Timely Response dated 05/16/2025: Revealed: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at eachresidents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights willdirectly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines:1. All staff will be educated on the proper use of the resident call system, including how the systemworks and ensuring resident access to the call light.5. Staff will ensure the call light is within reach of resident and secured, as needed.6. The call system will be accessible to residents while in their bed or other sleeping accommodationswithin the resident's room.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 8 residents (Resident s#5 and #6) reviewed for respiratory care. The facility failed to ensure Resident #5's nasal cannula connected to the oxygen concentrator (medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen) was properly stored. The facility failed to ensure Resident #6's nasal cannula connected to the oxygen concentrator was properly stored. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #6's Face Sheet, dated 04/23/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it hard to breathe), SOB, Lack of coordination (The inability of different parts of a system or body to work together effectively), and Dependence on supplemental oxygen. Record review of Resident #6's active physician's orders date 05/28/2025 revealed active orders for: Oxygen at 2 liters per nasal cannula every shift and Change oxygen tubing every night shift every 7 day(s). Record review of Resident #6's Quarterly MDS assessment, dated 02/22/26, revealed the resident had a BIMS of 15 (cognitively intact). Record review of Resident #6's active care plan dated 01/08/26 revealed 1) Noted behaviors such as removing nasalcannula from face with intervention to Document behaviors in the clinical record. 2) Requires supplemental oxygen forcardo/pulmonary (refers to the combined, interdependent functions of the heart and lungs) health/respiratory condition related to COPD with interventions to a) Monitor for complications related to oxygen use (ears, nose, dry mucous membranes)follow up with preventative measures as ordered by physician, b) Oxygen tubing changed per facility protocol. 2. Record review of Resident #5's Face Sheet, dated 04/23/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease - COPD (a progressive, long-term lung disease that makes it hard to breathe), Lack of coordination (The inability of different parts of a system or body to work together effectively), Abnormalities of gait and mobility (an unusual or irregular way of walking), and Osteoporosis (a disease that makes bones weak, thin, and brittle, significantly increasing the risk of fractures). Record review of Resident #5's active physician's orders dated 12/10/2024 revealed active orders for: Administer oxygen 2.0 liter/min via nasal cannula as needed for shortness of breath as needed for SOB and Oxygen tubing change weekly Label each componentwith date and initials every night shift every Sunday Label each component with date and initials. Record review of Resident #5's Quarterly MDS assessment, dated 02/22/26, revealed the resident had a BIMS of 15 (cognitively intact). Record review of Resident #5's active care plan dated 01/08/26 revealed 1) The resident is at risk for falls Gait/balance problems, hx of falls, difficulty in walking, muscle weakness, osteoporosis with intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 2) Resident is at risk for shortness of breath, respiratory distress, increased anxiety due to DX of COPD with interventions to a) Encourage and remind resident to use call light to ask for and provide assistance as needed, b) Observe for SOB, respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD if interventions are notEffective, c) Provide O2 as ordered and indicated. During an observation on 04/23/26 at 9:38 a.m., revealed Resident #6's nasal cannula connected to oxygen concentrator was observed lying on the floor, under his bed, while he was in bed. During an observation and interview on 04/23/26 at 12:34 p.m. Residents #5's nasal cannula connected to oxygen concentrator was observed hanging on her concentrator while the resident was sitting on her bed. The resident stated that she used her oxygen at night only. She stated she took the oxygen off in the morning. She stated she was told the oxygen tube should be bagged. She stated the staff came to check to make sure it was bagged but they had not come around yet. She stated that it should be bagged to keep it clean. During an interview on 04/23/26 at 10:51 a.m. with DON, she stated when not in use the nasal cannula should be stored in a bag and dated. She stated the CNAs and nurses during their rounds are responsible for making sure of placement on the residents' nostrils when in use and were bagged and dated when not in use. She stated if the nasal cannula was not bagged, it could become a risk for infection and airway complications. During an interview on 04/23/26 at 11:28 a.m. with LVN H, she stated that the nasal cannula should always be bagged to keep it clean and prevent the risk of any infection. During an interview on 04/23/26 at 1:25 p.m. with CNA G, she stated that the nasal cannula should be bagged when not in use to prevent risk of contamination. She stated that the risk of not having it bagged could lead to contamination which could cause infection to the residents. During a record review of the Facility's Oxygen Administration Policy Dated 05/16/2025 it revealed: Policy:Oxygen is administered to residents who need it, consistent with professional standards of practice, thecomprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines:4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident'sassessment and orders, such as, but not limited to:e. Keep delivery devices covered in plastic bag when not in use.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of eight (resident #7) residing on two of four halls (Hall 100 and 200) reviewed for infection control.The facility failed to ensure personal items were not stored on the medication carts located on hall 100 The facility failed to ensure that CNA M had on PPE when providing high contact care for Resident #7. This failure could place the residents at risk of an infection during medication administration and care. Findings included: During an interview and observation on 04/23/26 at 9:20 a.m., MA B was observed with a personal phone, 2 portable fans and deodorant spray on top of the medication cart on 100 hall. She stated the phone was her personal phone for her to see who was calling. She stated the fans were to keep her cool as she passes medications and that the deodorant spray was for when it smells bad on the hallways. She stated she was not sure of the facility policy for personal items on the medication cart. She stated she guessed it should not be on the cart due to risk of infection to the residents. During an interview and observation on 04/23/26 at 9:49 a.m. CNA M was observed providing care for Resident #7 who had an EBP signage on his room door alone. She stated that she was new and in training. She stated that she should have the proper PPE such as gloves and a protective gown. She stated that not having the proper PPE could result in transmitting infection from one resident to another and to herself. During an interview on 04/23/26 at 10:51 a.m. with DON she stated that all staff providing care should have the proper PPE for all residents on EBP and observe standard precautions for all others, she stated that now donning the proper PPE will result in transmission of infection to the residents in the facility. She stated that no personal items are allowed on the cart due to the risk of infection to the residents. During an interview on 04/23/26 at 10:53 a.m. with ADON, she stated that a protective gown, gloves and a mask should be worn when providing high contact care for residents on EBP by all staff providing care. She stated the risk of not having the proper PPE on would result in transmitting infection from resident to resident. During an interview on 04/23/26 at 11:26 a.m. with LVN A, she stated that personal items were not allowed in or on the medication carts. She stated personal items should be stored in designated staff areas. She stated that the risk of having personal items on the cart could result in infection transmission since no one knew where the items had been. During an interview on 04/23/26 at 11:28 a.m. with LVN H, she stated that all staff providing personal care to residents on EBP should have the proper PPE as directed to reduce the spread of infections. During an interview on 04/23/26 at 1:25 p.m. with CNA G, she stated that proper PPE should be worn by staff providing high contact care for all residents that have EBP sign outside their rooms. She stated that not having the proper PPE on would result in a spread of infection to the residents. During a record review of the facility's Infection Prevention and Control Program dated 04/11/25 revealed: Policy:This facility has established and maintains an infection prevention and control program designed to provide a safe,sanitary, and comfortable environment and to help prevent the development and transmission of communicablediseases and infections as per accepted national standards and guidelines.Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, otherswho provide care and services to residents on behalf of the facility, and students in the facility's nurse aide trainingprograms or from affiliated academic institutions.Policy Explanation and Compliance Guidelines:2. All staff are responsible for following all policies and procedures related to the program.4. Standard Precautions:a. All staff shall assume that all residents are potentially infected or colonized with an organism that couldbe transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c. All staff shall use personal protective equipment (PPE) according to established facility policygoverning the use of PPE.10. Equipment Protocol:a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall becleaned in accordance with our current procedures governing the cleaning and sterilization of soiled orcontaminated equipment. d. Staff will decontaminate equipment with a germicidal detergent prior to storing for reuse.11. Supplies Protocol:16. Staff Education:a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding thefacility's infection prevention and control program, including policies and procedures related to theirjob function.b. All staff shall demonstrate competence in relevant infection control practices.c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.

Based on observation, interview and record review the facility failed to have complete and accurately documented medical records for one of eight Resident (Resident #9) whose clinical record was reviewed for accuracy. The facility failed to record on the TAR wound care provided to the resident on 04/17/26, 04/18/26, 04/19/26, 04/20/26, and 04/21/26. This failure could affect all residents at risk for inaccurate or incomplete clinical records and place residents at risk for her wound care not being done as ordered.Findings included: Record review of Resident #9's Face Sheet, dated 04/23/2026, revealed a [AGE] year-old female, admitted [DATE]. The resident has diagnosed that included Diabetes ((high blood sugar levels) and Peripheral vascular disease (a slow, progressive circulation disorder that occurs when blood vessels outside of the heart and brain become narrowed, blocked, or spasm). Record review of Resident #9's physician's order, dated 04/21/2026, revealed an order for: Povidone-Iodine Solution 10 % Apply to sacrum (a large, triangular-shaped bone located at the very base of the spine, just above the tailbone (coccyx) and between the two hip bones ) topically every day shift for treatment cleanse with saline or wound cleanser, pat dry apply betadine and calcium alginate with dry dressing. Record review of Resident #'9s active initial care plan date 04/16/2026 reflected no care plan problem goals, or intervention related to the resident's wound care. Record review of Resident #'9s MDS dated [DATE] reflected no problem goals, or intervention related to the resident's wound care Record review of Resident #9's progress dated 04/16/26 revealed that the wound to the sacrum was present on admission. Record review of Resident #9's TAR for April 2026 revealed no documented evidence that wound care was provided for April 17th, 18th, 19th, 20th and 21st. During an observation and interview on 04/23/26 at 1:35 p.m. with Resident #9 and the Wound Nurse, it was observed that the old wound dressing was not dated and initialed for the date wound care was performed, the dressing was soiled with brownish discharge. The Wound Nurse stated that the wound care was performed last night by the night nurse and that the night nurse sent her a text to let her know the wound care was done. She stated that the wound care was scheduled for the 6 a.m. to 2 p.m. shift. She stated that the wound dressing should be dated and initialed by the nurse at the time it was done. She stated that the risk of not dating the wound dressing could result in not having the wound care performed as scheduled and could lead to worsening of the wound and possible infection. During an interview on 04/23/26 at 2:13 p.m. with the DON, she stated that the wound dressing should always be dated with every dressing change. She stated if the dressing was not dated it could result in skipped wound care and possible infection or make already existing infection worse. During a record review of the facilities Wound Treatment Management dated 05/15/2025 revealed: Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-basedtreatments in accordance with current standards of practice and physician orders. Treatment selection will considerwound etiology, condition, resident preferences, and risk factors. Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type ofdressing, and frequency of dressing change.3. Dressing changes may be provided outside the frequency parameters in certain situations:a. Feces has seeped underneath the dressing.b. The dressing has dislodged.c. The dressing is soiled otherwise, or is wet.6. Guidelines for dressing selection may be utilized in obtaining physician orders (See Wound Treatment Guidelines).c. The facility will follow specific physician orders for providing wound care.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 2 of 9 residents (Resident #1 and #7) reviewed for dignity. Resident #1 was observed lying in bed and his catheter bag could be observed hanging from his bed without a privacy cover. Resident #7 was observed sitting on his bed and his catheter bag could be observed laying on the floor without a privacy cover. These deficient practices could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect.Findings include: Record review of Resident #1's Face Sheet, dated 04/23/26, revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included Neuromuscular Dysfubction of Bladder (a condition where the nerves that carry messages between the brain and the bladder are damaged, causing a loss of bladder control) . Record review of Resident #1's active physician's order as of revealed the following orders: 1) Change catheter and bag once a month every day shift every Sunday for Neuromuscular Dysfunction of the bladder dated 10/27/2024, 2) Ensure dignity cover is in place and covering catheter bag every shift for Neuromuscular Dysfunction of the bladder dated 02/04/2023. Record review of Resident #1's comprehensive care plan dated 04/26/24 revealed a care plan for Suprapubic Catheter related to Neurogenic bladder, with intervention to Position catheter bag and tubing below the level of the bladder 2. Ensure catheter bag is covered to maintain dignity of Resident #1 Monitor and ensure that catheter securing device is in place to reduce excessive tension on tubing/facilitate urine flow. Record review of Resident #7's Face Sheet, dated 04/23/26, revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included Neuromuscular Dysfunction of Bladder (a condition where the nerves that carry messages between the brain and the bladder are damaged, causing a loss of bladder control). Record review of Resident #7's active physician's order as of 04/23/26 revealed the following order: Change suprapubic Catheter 24Fr (catheter size) every 10th of the month every night shift every 1 month(s) starting on the 10th for 1 day(s) for catheter care related to neuromuscular dysfunction of bladder, unspecified Record review of Resident #7's comprehensive care plan dated 07/26/24 revealed a care plan for a 24Fr suprapubic catheter related to neuromuscular dysfunction of bladder, unspecified and is at increased risk for complication During an interview and observation on 04/23/26 at 9:18 a.m., with Resident #1, revealed he was lying in his bed awake. His Foley catheter drainage bag was noted hanging on the bed frame without privacy cover on it. Resident #1 stated that the drainage bag was not usually covered and that it had always been that way and that no one told him it should be covered. He stated that it would be nice if it was covered. During an interview and observation on 04/23/26 at 9:43 a.m., with Resident #7, revealed his Foley catheter drainage bag was noted on the floor and without a privacy cover. He stated that he was about to get a shower and have the bag changed with the assistance of CNA M in a few minutes. He stated that the bag should not be lying on the floor to prevent infection, but that it would be changed today. During an interview on 04/23/26 at 10:51 a.m. with DON, she stated that that the foley catheter drainage bags should always be covered to maintain residents' dignity. She stated that most residents came from the hospital with no privacy cover over the drainage bag and they changed them when the resident was admitted to the facility. She stated that if the drainage bags were not covered it would be a dignity and privacy issue and the residents could feel violated. During an interview on 04/23/26 at 11:28 a.m. with LVN H, she stated that the foley catheter bag should be covered and not touching the floor and should be placed below the waist level. She stated that the risk of not having the bags covered was that other residents could see what was going on with the residents without a catheter privacy cover and talking about them to others which would be a HIPAA violation. During an interview on 04/23/26 at 1:25 p.m. with CNA G, she stated that the foley catheter drainage bag should be covered at all times. She stated the risk of not having the catheter bag covered could result in a loss of dignity and the resident could be embarrassed and sad. Review of the facility's policy on Catheter care dated 05/02/2025 revealed: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.3. Privacy bags will be changed out when soiled, with a catheter change or as needed.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 (Residents #8) reviewed for medication storage. The facility failed to ensure that Resident #8 did not have zinc oxide in his room. The failure could place residents at risk of accidental overdose, misuse of medications, and possible adverse reactions. Findings included: 1. Record review of Resident #8's Face Sheet, dated 04/23/2026, revealed a [AGE] year-old male, admitted [DATE]. The resident has diagnosed that included Allergic Rhinitis commonly known as hay fever or allergies, is a reaction that causes sneezing, a runny or stuffed-up nose, and itchy eyes or throat), and Hypertension (high blood pressure) Record review of Resident #8's physician's order, dated 02/20/2026, revealed an order for: Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to buttocks topically every 24 hours as needed for Redness Record review of Resident #8's Comprehensive MDS Assessment, dated 03/05/2026, revealed that the resident has a BIMS score of 15 (cognitively intact). Record review of Resident #8's Comprehensive Care Plan, dated 04/23/2026, revealed the resident expresses desire to keeppersonal cream at bedside for frequent with the following interventions: 1) Educate resident on proper use, frequency , and potential risk (overuse, skin irritation, infection), 2) Ensure proper hand hygiene before and after application, 3) Evaluate resident's cognitive status and ability to safely self-administer. During an observation and interview on 04/23/26 at 9:48 a.m., Resident #8 was in her bed, awake. A tube of zinc oxide cream was observed on resident's bedside table. The resident stated that it was part of his ordered medications. He stated it was originally ordered for the rash on his face. He stated he now used it for the rash in his groin area, scrotum, belly and his buttocks. He stated the nurse knew he had it and the staff used it when they cleaned him. During an interview on 04/23/26 at 10:51 a.m. with the DON, she stated that no medication should be in the resident's room. She stated it could be a hazard risk to the resident if not supervised by a qualified nurse. The DON stated that they will assess Resident #8 for possible ability to self-administer his Zinc Oxide. During an interview on 04/23/26 at 11:28 a.m. with LVN H, she stated that she was not aware the resident had the zinc oxide in his possession. She stated that all medications should be stored in the medication cart unless the resident has been assessed and an order written by a physician for self-administration. She stated that the risk of self-administration was possible allergic reaction and improper administration. During an interview on 04/23/26 at 1:25 p.m. with CNA G, she stated that the residents should not have medications on them. She stated that if she found any medication in the resident's room, she took it to the charge nurse. She stated that the residents having medications on them, unsupervised, could cause a risk of the residents not using them as prescribed and to other residents who could walk in and use it, they could get sick from using medications not meant for them. Record review of the facility's Medication storage policy dated 06/15/25 revealed: Policy:It is the policy of this facility to ensure all medications housed on our premises will be stored in thepharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient toensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines1. General Guidelines:a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts,cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.b. Only authorized personnel will have access to the keys to locked compartments.c. During a medication pass, medications must be under the direct observation of the personadministering medications or locked in the medication storage area/cart.

Based on observation, interview and record review, the facility failed to ensure coordination of care with the Hospice agency, specific to each patient, for 1 (Resident #1) of 5 residents reviewed for hospice services. Resident #1 was sent to the hospital on [DATE] after her g-tube was dislodged and needed to be replaced. The facility failed to report this hospital transfer to the hospice agency. This failure could affect residents who received Hospice services by placing them at risk for services and treatments not being coordinated. Findings included: Record review of Resident #1's Annual MDS Assessment, dated 12/13/26, reflected an [AGE] year-old female, admitted [DATE] and readmitted [DATE]. Resident #1 did not have a BIMS score calculated, but was noted to have short and long-term memory problems along with severely impaired cognitive skills. Resident #1's active diagnoses included Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), aphasia (a disorder that results from damage to areas of the brain responsible for language, affecting a person's ability to comprehend or formulate language), and stroke (a sudden interruption of blood flow to the brain, which can lead to brain damage and other serious complications). Record review of Resident #1's Order Summary Report, dated 03/14/26, reflected the following: Admit to [Hospice Company] DX: Alzheimer's Disease, Unspecified, Start of Care 6/30/2023 Record review of Resident #1's undated Care Plan reflected the following: [Resident #1] has chosen to admit to [Hospice Company] DX: Alzheimer's Disease, Unspecified, Start of Care 6/30/2023 [sic]. Record review of Resident #1's eINTERACT Transfer Form, dated 03/12/26 reflected her hospice company was not contacted about the transfer. Record review of Resident #1's Progress Notes reflected the following:LVN A wrote, Resident pulled her G-tube. MD notified with new order to send her to ER for g-tube replacement. Called [Ambulance Company] and scheduled transportation with ETA of 1 Hour [sic]. On 03/12/26 at 11:21 PM.LVN B wrote, Resdt [sic] transported to [Hospital Name] for G/Tube [sic] replacement via [Ambulance Company] EMS, stable, denies pain at this time, V/S 97.6, 78, 18, 98/64. Report called in and given to hosp [sic] ER via [phone number]. Family- [Resident #1's RP] notified via [phone number]. On 03/13/25 at 1:15 AM. During an observation on 03/14/26 at 12:45 PM, Resident #1 was in the hospital, lying in bed, and not able to respond to the surveyor's questions due to her condition as she was only able to look at the surveyor but was not able to verbally communicate or physically respond to the questions the surveyor was asking. During a telephone interview on 03/14/26 at 10:25 AM, Resident #1's Family Member revealed she was sent to the hospital the other night (she was unsure of the date) because she pulled out her g-tube. During an attempted telephone interview on 03/14/26 at 11:05 a.m., LVN B did not answer or call back prior to exit. A message was left with contact information and a request for a return call was made. During a telephone interview on 03/14/26 at 12:06 PM, a Hospice Representative revealed she spoke with Resident #1's RN Case Manager and said the hospice company was not informed of Resident #1's transfer to the hospital after her g-tube was pulled out. The Hospice Representative said she expected the facility to communicate with them when Resident #1 went to the hospital but they did not. During an interview on 03/14/26 at 2:37 PM, the DON revealed all nurses knew when a resident was on hospice and had a change in condition or was sent to the hospital, their hospice agency was supposed to be notified. The DON said the purpose of that was because they were part of the IDT team, provided care for residents, and needed to know what was going on with them. The DON said the nurse on duty would have been responsible for communicating those changes with the hospice agency. The DON said she was not aware Resident #1's hospice agency did not know she had gone to the hospital and were not notified of the transfer. The DON said the nurse managers normally would go back and check that all necessary parties were notified of Resident #1's hospital transfer but that was not done. The DON said if a resident's hospice agency was not notified of changes regarding a resident's care, they might not be able to continue with their plan of care. During a telephone interview on 03/14/26 at 3:43 PM, LVN A revealed when he was doing the last round of his shift when he was told Resident #1 pulled her g-tube out on 03/12/26. LVN A said he assessed Resident #1 and called the doctor to get the order to send her to the ER. LVN A said he also called the ambulance service to come pick her up and he communicated with LVN B ,who worked the next shift, to call the hospice agency and let them know about Resident #1 being transferred to the hospital. LVN A said he assumed since he communicated with LVN B, she would notify hospice. Record review of the facility's policy, revised 06/10/25, titled, Coordination of Hospice Services reflected, 10. The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in resident's status, clinical complications or emergent situations.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for five of eighteen residents (Residents #3, #5, #61, #73, and #79) reviewed for privacy and confidentiality. 1. The facility failed to ensure MA G secured Residents #3, #61, #73, and #79's medical information before leaving her cart on 03/11/2026. 2. The facility failed to provide privacy during Resident #5's transfer via mechanical lift on 03/10/2026.These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided, which could result in the residents feeling uncomfortable during treatment and having their personal and medical record exposed to unauthorized individuals.Findings included: 1. Record review of Resident #3's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #61's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #73's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #79's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. During an observation on 03/11/2026 at 6:41 AM revealed a small notebook was left on top of the MA's cart parked in the hallway. It was observed that on one page of the notebook were Residents #79, #3, and #73's vital signs written respectively. The nurse's cart was unattended and was facing the hallway with several staff and residents passing by the cart. During an observation on 03/11/2026 at 6:43 AM revealed MA G came out of one the resident's room and went straight to the rack to get a blanket and went back to a resident's room. Residents #79, #3, and #73's vital signs were still exposed. During an observation on 03/11/2026 at 6:44 AM revealed MA G came out of the resident's room and started to assist a resident in a wheelchair to the dining area. Residents #79, #3, and #73's vital signs were still exposed. During an observation on 03/11/2026 at 6:54 AM revealed MA G went inside Resident #61's room to get the resident's vital signs. After getting the vital signs, MA G wrote it on the page of the notebook where Residents #79, #3, and #73's vital signs were written. After writing Resident #61's vital signs, MA G prepared Resident #61's medications, and went inside Resident #61's room to administer his medications. Residents #79, #3, #73, and #61's vital signs were left exposed on top of the cart. During an interview on 03/11/2026 at 7:30 AM, MA G said she would usually cover her notebook every time she would leave her cart. She said maybe she got busy and forgot to do so. She said she should have flipped her notebook or placed it under her laptop so that whatever medical information written on it would not be exposed to everyone to see. She said vital signs were medical information and should be secured to prevent any HIPAA violations. During an interview on 03/11/2026 at 7:36 AM, the Infection Nurse said the residents' vital signs should not be left exposed because they were confidential information and should only be available to individuals that had something to do with the residents' care, like the nurses, physicians, responsible party, and therapists. She said the staff could also input the vital signs as soon as they had them, so the staff would not need to write the vital signs down. She said she would start an in-service about confidentiality of records. 2. Review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Review of Resident #5's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 01/06/2026, reflected the resident was cognitively intact (resident may need additional support and monitoring) with a BIMS (screening tool used to assess cognitive status) score of 15. The Quarterly MDS Assessment indicated the resident was dependent on staff transfer from bed-to-chair transfer. Review of Resident #5's Care Plan, dated 02/27/2026, reflected the resident required extensive assistance by two staff with mechanical lift (devices used to move a person from one position to another). The plan did not indicate that the resident preferred to be transferred from the hallway to her room. During an observation on 03/10/2026 at 2:37 PM revealed CNA D and CNA E were about to transfer Resident #5 from wheelchair to the resident's bed via mechanical lift. While in the hallway, both CNAs hooked the sling, that was underneath the resident, to the mechanical lift and started to raise the mechanical lift. After the resident was up in the air, in the hallway, the CNAs started to push the mechanical lift towards the room of the resident and lowered the resident to her bed. During an interview on 03/10/2026 at 2:49 PM, CNA E said he did not know that a resident could not be transferred from the hallway. He said, though the resident was fully clothed, everybody could see that she was dependent on the staff for transfer. During an interview on 03/10/2026 at 2: 51 PM, CNA D said the resident was transferred from the hallway because the room was small. She said it did not occur to her that it was a dignity issue. During an interview on 03/11/2026 at 6:22 AM, Resident #5 said nobody talked to her about being transferred inside the room. She said it made sense that transfer should be done inside the room because everybody saw that she was aided by a mechanical lift to be transferred, was hanging in the air, and that as if she was too heavy to be transferred without the help of the mechanical lift. She said she might be fully clothed but other individuals could see that she was heavy. She said staff only talked to her about the transfer on the afternoon of 03/10/2026, Tuesday, when somebody was asking why she was being transferred from the hallway. During an interview on 03/12/2026 at 6:59 AM, the ADON said transferring the resident in the hallway could be a dignity issue because everybody could see the mode the resident was being transferred as well as the resident's inability to do the transfer herself. She said they talked to Resident #5 last 03/10/2026, Tuesday afternoon and that was the only time she knew that the resident preferred to be transferred from the hallway. She said because nobody talked to her about the transfer then it was a dignity and privacy issue because everybody could see how she was being transferred. She said the issue should have been addressed when staff saw that the resident was seen being transferred from the hallway. The ADON said medical information of any resident was confidential and should not be left unattended. She said the incident could be a HIPAA violation because other residents and visitors might see the information, or even staff that had nothing to do with the care of the residents. She said the staff should have secured it somewhere before leaving the cart. She said the notebook could have been turned over, left under the laptop, left inside the cart, or the staff could bring it with them. She said the expectation was for the staff to secure all confidential information before leaving their cart. She said the DON already started an in-service about privacy and confidentiality of records. During an interview on 03/12/2026 at 7:28 AM, the DON said she talked to Resident #5 last 03/10/2026, Tuesday afternoon, regarding being transferred from the hallway. She said she saw before that the resident was being transferred from the hallway and should have asked the resident and the staff about it. She said residents should be given privacy when being transferred. The DON said the vital signs written in the notebook were confidential information and should be protected. She said leaving the information exposed and unattended could be a HIPAA violation because unauthorized individuals might see them. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said if the confidential information was exposed, non-nursing staff, other residents, and visitors might be able to see it. She said all staff, including her, were expected to provide confidentiality of all the residents' personal and medical information. The DON stated she had already started an in-service about privacy and confidentiality of medical records.During an interview on 03/12/2026 at 9:25 AM, the Administrator said the expectation was for the staff to have secured the residents' medical information before leaving their carts. She said the DON already started an in-service about confidentiality of records, but she would still coordinate with the DON to closely monitor if the staff understood the in-service regarding confidentiality of medical records. Record review of the facility's policy, HIPAA Security Measures The Compliance Store, undated, reflected Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information. Record review of the facility's policy, Resident Rights The Compliance Store, revised June 15, 2025, reflected Policy: The facility will inform the resident both orally and in writing . of his or her rights . 7. Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . Personal privacy includes . personal care.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for four of twelve residents (Residents #14, #15, #19, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #14 was care planned for oxygen therapy. 2. The facility failed to ensure Resident #15 was care planned for congestive heart failure. 3. The facility failed to ensure Resident #19 was care planned for her AVAPS. 4. The facility failed to ensure Resident #29's care plan reflected an intervention for her bed to be in the lowest position for fall prevention and a plan of care for Enteral feeding. These failures could place the residents at risk of not receiving the necessary care and services. Findings included: 1. Record review of Resident #14's Face Sheet, dated 03/10/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with weakness. Record review of Resident #14's Comprehensive MDS Assessment, dated 01/29/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated that the resident had muscle weakness. Record review of Resident #14's Comprehensive Care Plan, dated 02/09/2026, reflected that the resident did not have a care plan for oxygen therapy. Record review of Resident #14's Physician Order, dated 02/26/2026, reflected Oxygen at 2 liters per minute via Nasal Cannula or Mask. every shift for SOB. Record review of Resident #14's Progress Notes, dated 12/02/2025, reflected Monitor . Oxygen therapy protocol. Record review of Resident #14's Progress Notes, dated 12/21/2025, reflected Monitor . Oxygen Therapy. Record review of Resident #14's Progress Notes, dated 12/25/2025, reflected Monitor . Oxygen Therapy. Record review of Resident #14's Progress Notes, dated 01/24/2026, reflected Patient on O2@2-3L/m. Record review of Resident #14's Progress Notes, dated 02/11/2026, reflected on 3 liter of oxygen via N/C. Record review of Resident #14's Progress Notes, dated 10/26/2025, reflected Resident is on continuous oxygen therapy at 2 L. During an observation and interview on 03/10/2026 at 9:21 AM revealed Resident #14 was in her bed, awake. It was observed that the resident was using oxygen. When asked how long she had been using oxygen, the resident did not reply. During an interview on 03/10/2026 at 9:28 AM, CNA F said Resident #14 was using oxygen since she was admitted to the facility. During an observation and interview on 03/11/2026 at 1:07 PM, LVN C said the nurses were responsible in making the acute care plan. He said if Resident #14 came back from the hospital using the oxygen, then it should have been care planned by the admitting nurse. He said, but if the resident had been using oxygen since last year, then it should have been care planned since last year. He said he would check the resident's care plan and would make one for the resident's oxygen. 2. Record review of Resident #15's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs). Record review of Resident #15's Quarterly MDS Assessment, dated 12/31/2025, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had congestive heart failure. Record review of Resident #15's Comprehensive Care Plan, dated 01/11/2026, reflected that the resident was not care planned for congestive heart failure. Record review of Resident #15's Physician's Order, dated 12/29/2025, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day for SOB/Congestion. During an observation and interview on 03/10/2026 at 9:10 AM revealed Resident #15 was in her bed, awake. It was observed that a nebulizer machine was on top of the resident's side table. The resident said she had breathing treatments to help with her congestion. 3. Review of Resident #19's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #19's Comprehensive MDS Assessment, dated 02/02/2026, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate that the resident was using a non-invasive mechanical ventilator. Review of Resident #19's Comprehensive Care Plan, dated 02/02/2026, reflected that the resident did not have a care plan for a non-invasive mechanical ventilator. Review of Resident #19's Physician Order, dated 01/26/2026, reflected AVAPS settings Max-35, min-15, Peep +10, Rate - 26, 430 ML, 2L O2. Record review of Resident #19's Pulmonary Notes, dated 01/21/2026, reflected . wearing her AVAPS mask upon provider arrival . denies complaints associated with AVAPS. During an observation on 03/10/2026 at 9:12 AM revealed Resident #19 was not inside her room. It was observed that the resident had AVAPs at the bedside. During an interview on 03/10/2026 at 10:43 AM, CNA F stated Resident #19 had been using her AVAPs since she was admitted to the facility and would use it every night. During an interview on 03/11/2026 at 12:12 PM, the MDS Nurse said Resident #19's AVAPs did not have a care plan because there was no documentation about the AVAPs. During an interview on 03/11/2026 at 12:24 PM, LVN A said Resident #19 had been using an AVAPs since she was admitted to the facility. She said she was the one taking it off every morning. She said the respiratory department even taught her how to use the AVAPs. During an observation and interview on 03/11/2026 at 12:46 PM, the MDS Nurse checked Resident #19's Progress Notes from the resident's admission to present and saw that the resident was using her AVAPs. She said if the resident was using an AVAPs, which was a form of a non-invasive mechanical ventilator, since admission, then there should be a care plan for the AVAPs. She then checked Resident #14's care plan and saw the resident did not have a care plan for her oxygen. She said if the resident was using oxygen when the resident was re-admitted to the facility, then there should be an acute care plan done for the resident. She said the nurses were responsible for the acute care plan. She said if a resident had a congestive heart failure, there should be a care plan for congestive heart failure. She said she would check Resident #15's care plan and would make a care plan for congestive heart failure. She said care plans should be in place, so the staff would know the interventions and goals for the resident and would be in sync in terms of the care to be provided. She said it was an oversight and she would fix it. During an interview on 03/12/2026 at 6:59 AM, the ADON said the care plan should be in place to protect the residents and the facility. She said the care plan reflected the needs of the residents that needed to be addressed. She said the care plan served as the facility's agreement with the resident in terms of the care and services that the facility would be providing. She said she would coordinate with the DON and the MDS nurse to fix the care plan and audit the care plans of the other residents. During an interview on 03/12/2026 at 7:28 AM, the DON said care plans were extensions of the care given to the residents. She said the care plans were to reassure that the residents were being taken care of. She said care plans should be in place and should reflect realistic goals and interventions and assess as well if the expectations were being met. She said the care plan should also be done if the resident had a fall, came back with an order for antibiotics, or was declining. She said if the resident was using oxygen, then there should be a care plan for oxygen. She said if the resident was using an AVAPs or had a congestive heart failure, then there should be care plan for both. She said she would coordinate with the MDS Nurse regarding the issue. During an interview on 03/12/2026 at 9:25 AM, the Administrator said the expectation was that all the residents were care planned appropriate to their needs. She said the care plans should indicate the care and services being provided. She said care plans should be in place so that the individuals providing care for the resident would be in sync. She said she would coordinate with the MDS nurse and the DON regarding the issues. 4. Record review of Resident #29's Face Sheet, dated 03/11/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses of lack of coordination and malnutrition.Record review of Resident #29's Quarterly MDS Assessment, dated 01/08/26, reflected the resident's BIMS indicated an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of lack of coordination and malnutrition.Record review of Resident #29's Physician orders, dated 03/11/26, reflected Enteral Feeding for evening meals.Record review of Resident #29's Comprehensive Care Plan, dated 03/10/26, reflected no plan of care for the resident receiving Enteral feeding and Resident #29's plan of care for fall prevention did not include an intervention for the resident's bed to be in the lowest position.During an interview and observation on 03/10/26 at 2:15 p.m. LVN C observed Resident #29's bed in a low position. He stated he was unsure why the resident's bed was low. Resident #29 stated her bed was low because she had fallen out of bed about a year ago and had broken her knee cap. She stated she wanted her bed in the lowest position.During an interview on 03/10/26 at 2:20 p.m. LVN C and the ADON was informed by the Surveyor of Resident #29 not having an intervention for her bed to be in the lowest position for fall prevention, The ADON stated Resident #29 was a fall risk and her bed was to be in the lowest position so if she fell it could reduce the risk of injury. The ADON stated the resident's bed being in the lowest position should have been an intervention included in the resident's plan of care for fall prevention so staff would be aware of her plan of care. The ADON stated the DON and MDS nurse were responsible for updating the resident's care plan. During an interview and record review on 03/11/26 at 01:15 p.m., the DON was informed of Resident #29 not being care planned for her evening eternal feed. She reviewed the resident's care plan and stated the resident should have been care planned for the eternal feed because it was part of her plan of care. She stated it was the MDS nurse and her responsibility to update the resident's care plan. She was also informed of Resident #29 not being care planned for her bed being in the lowest position. She stated she was informed of this by the ADON and she had updated the resident's care plan to include this intervention. During an interview on 03/11/26 at 02:15 p.m., the MDS nurse stated she was informed by the DON of Resident #29 not being care planned for her bed being in the lowest position and the resident receiving eternal feeding. She stated it was her and the DON's responsibility to update the resident's plan of care to ensure the resident received the care needed.Record review of the facility's policy, Comprehensive Care Plans the Compliance Store revised May 05, 2025 reflected Policy: It is the policy of this facility 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 and services that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines . 1. The care planning process will include an assessment of the resident's strengths and needs . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 11 of 20 Resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), and two of the six carpeted floor halls (2100 and 2500) observed for cleanliness. The facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 7 (Resident #15) reviewed for misappropriation of property. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were thoroughly cleaned and sanitized.The facility failed to ensure the carpeted floor halls on 2100 and 2500 were thoroughly cleaned and sanitized.The facility failed to protect Resident #15's property (Stainless steel bedpan) from loss. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life and could negatively impact Resident #15's quality-of-life and self-esteem.Findings included: An observation on 03/10/26 at 10:06 a.m., revealed the carpet on the 2100 hallway had dark stains all over it. One area of the hall had a 15-inch circular dark gray stain. An observation on 03/10/26 at 10:15 a.m., of room [ROOM NUMBER], reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The air conditioning unit cover was hanging off the unit. An observation on 03/10/26 at 10:16 a.m., revealed the carpet on the 2500 hallway had a large dark stain, approximately four feet long, near the middle of the resident hallway. An observation on 03/10/26 at 10:20 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. An observation on 03/10/26 at 10:25 a.m., of room [ROOM NUMBER], reflected the entryway of the room floor had a thick yellowish stain. The floor had built up dirt in the corners and light grayish stains near the resident bed and in front of the mini fridge. The bedside table had dust and light grayish stains all over the lower frame. An observation on 03/10/26 at 10:28 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. An observation on 03/10/26 at 10:33 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. Some of the vents on the air conditioning unit were broken. The bathroom floor under the toilet had a large white stain circling a drain hole. An observation on 03/10/26 at 10:38 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor under the toilet had a large white stain and grayish stains. A whiteboard on a wall, above a chest of drawers, had brownish stains An observation on 03/10/26 at 10:41 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents An observation on 03/10/26 at 10:45 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet. The room floor had built up dirt and dark stains near the closet door and along the door entrance. An observation on 03/10/26 at 10:49 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. An observation on 03/10/26 at 10:51 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. Some of the vents on the air conditioning unit were broken. The air conditioning unit filter appeared broken and was partially hanging out of the unit.An observation on 03/10/26 at 11:04 a.m., of room [ROOM NUMBER], reflected the air conditioning unit had black dirt and dust all over the front of the unit and between the vents. The bathroom floor had dark substances all over the center portion of the floor, the corners of the floor, and around the toilet. The room floor had dark stains all over the floor.During an interview on 03/12/26 at 11:12 a.m., Housekeeping T stated she had been at the facility for 3 years. She stated she cleaned the 2100 and 2500 halls. She stated they were responsible for cleaning the entire resident room. She was shown photos of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. She stated they were responsible for cleaning the areas mentioned and they must inform their supervisor of areas of the floor they were unable to clean. She stated not cleaning the areas mentioned could cause the spread of germs. During an interview on 03/12/26 at 11:27 a.m., Housekeeping S stated she had been at the facility almost a month. She stated her peers trained her to clean the resident rooms. She stated they were to clean the entire resident room. She stated she cleaned all halls and was not assigned to any particular hall. She was showed photos of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. She stated if the areas were not properly cleaned, residents could get sick. During an interview on 03/12/26 at 11:43 a.m., the Housekeeping Supervisor was informed of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, Hall 2100, and Hall 2500. He stated they scrubbed the floors, but the stains did not come out. He stated the floors were old. He stated he in-serviced the staff on cleaning the rooms last month. He stated he is unsure of the impact the cleanliness of the resident rooms would have on the residents and would need to speak with a nurse to see what kind of impact it would have on them. During an interview on 03/12/26 at 12:10 p.m., the Administrator was informed of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, Hall 2100, and Hall 2500. She stated she expected the resident rooms to be thoroughly cleaned. She stated they completed rounds with leadership and one of the check offs was to check for cleanliness. She stated the housekeeping supervisor should be checking the rooms to ensure they were properly cleaned. She stated not cleaning the rooms thoroughly could have respiratory concerns for residents. Record review of Resident #15's face sheet revealed she was a [AGE] year-old originally admitted to the facility on [DATE] with diagnoses which included but not limited to Depression, Bipolar Disorder, Non-Pressure chronic ulcer of Abdomen, Morbid obesity.Record review of Resident #15's MDS dated [DATE] revealed that the resident had a BIMS score of 15 (means the person has intact cognitive function).Record review of care plan dated 01/08/26 stated Resident #15 needs Toileting assistance of 1 staff with bedpan.Observation and interview on 03/11/26 at 8:50 am. Resident #15 was in bed resting, and when asked she stated she was doing well. However, her stainless-steel bed pan was lost when she moved rooms on 03/05/26 and is still missing. She stated the facility staff is using a plastic one which does not hold her urine and spills on the bed and pinches her skin when she is on it.Interview with Social Worker on 03/11/26 at 9:00 am, she stated a stainless-steel bed pan has been ordered.Interview with Resident #15 on 03/11/26, at 10:55 am, she stated that she was informed a replacement stainless steel bed pan has been ordered.Interview with Administrator on 03/11/26 at 11:00 am, she stated that a replacement stainless steel bed pan has been ordered on 03/11/26.Interview with Administrator on 03/12/26 at 9:50 am, she stated that she was not sure of what happened to the bed pan; it may have been taken by visitors or other residents. She confirmed that a new bed pan like what Resident #15 had was ordered from Walmart on 03/11/26. She confirmed that facility staff were aware Resident #15 had a stainless-steel bed pan that she prefers to use. She stated that they keep an inventory of resident belongings during admission and while they are residing at the facility. She stated that the facility investigates if any resident belongings come up missing and document it on the grievance log.Interview with Social Worker on 03/12/26 at 10:10 am, she stated that the protocol to move is the nurses / staff inform her of the move and why and she informs the resident about the move and why. Housekeeping moves the resident and belongings, but she was not sure if inventory is done before and after the move. She stated that she was informed by Resident #15 about the missing bed pan last week, not sure of the date, and the Administrator was made aware of it. She stated that Resident #15 not having her preferred bedpan could result in emotional distress since they have very little belongings and have no control over the little, they have left.Interview with Housekeeping Supervisor on 03/12/26 at 10:20 am. He stated the Protocol is he takes a picture of resident's belongings before and after moving rooms. He stated he tries his best to arrange the resident's belongings as they were in the previous room and to residents' preference. He usually reports missing Items to the nurses if medical and others to the administrator. He stated he found out about the missing bedpan from CNA D on 03/05/26 and told the nurse on duty about it. Record review of the facility Policy on Resident Personal Belongings, (undated) reflected: It is the policy of this facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. The facility will ensure that personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative, in the event of the resident's death or discharge from the facility. All resident possessions, regardless of their apparent value to others, will be treated with respect.All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing.The facility will exercise reasonable care for the protection of the resident's property from loss or Theft.Inventories of all items are to be reviewed and examined by Social Services designee and the resident's representative. Recipients of such personal items at the time of discharge or death shall signoff with their legal signature, acknowledging receipt of all personal belongings presented. Review of the facility's policy on Resident Environmental Quality (undated) revealed It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.

Based on observation, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three of eight residents (Residents #2, #5, and Resident #19) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #2's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was admitted to hospice. 2. The facility failed to ensure Resident #5's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. 3. The facility failed to ensure Resident #19's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was using an AVAPS. These failures could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.Findings included: 1. Record review of Resident #2's Face Sheet, dated 03/11/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills) with a late onset. Record review of Resident #2's Comprehensive MDS Assessment, dated 01/21/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 05. The Comprehensive MDS Assessment did not indicate that the resident was receiving hospice care. Record review of Resident #2's Comprehensive Care Plan, dated 01/13/2026, reflected that the resident had chosen hospice services and one of the interventions was to work cooperatively with the hospice team. Record review of Resident #2's Physician Order, dated 09/25/2024, reflected . HOSPICE . DX ALZHEIMERS DISEASE WITH LATE ONSET. 2. Record review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic pulmonary edema (too much fluid in the lungs) and heart failure. Record review of Resident #5's Quarterly MDS Assessment, dated 01/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy. Record review of Resident #5's Quarterly Care Plan, dated 02/27/2026, reflected that the resident had heart failure and one of the interventions was to administer oxygen as ordered. The Care Plan indicated that the resident started using oxygen on 08/07/2024. Record review of Resident #5's Physician Order, dated 02/26/2026, reflected Oxygen at 2 liters per minute via Nasal Cannula. every shift for SOB During an observation on 03/10/2026 at 2:37 PM revealed Resident #5 was in her wheelchair in the hallway. It was observed that the resident was on oxygen via a nasal cannula connected to the oxygen tank at the back of her wheelchair. During an observation and interview on 03/11/2026 at 6:22 AM revealed Resident #5 was in her wheelchair at the reception area of the facility. It was observed that the resident was using oxygen. She said she had been using oxygen for years and would use it night and day. 3. Review of Resident #19's Face Sheet, dated 03/12/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #19's Comprehensive MDS Assessment, dated 02/02/2026, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment did not indicate that the resident was using a non-invasive mechanical ventilator. Review of Resident #19's Comprehensive Care Plan, dated 02/02/2025, reflected that the resident did not have a care plan for a non-invasive mechanical ventilator. Review of Resident #19's Physician Order, dated 01/26/2026, reflected AVAPs (non-invasive ventilation mode that automatically adjust the air moving in and out of the lungs) settings Max-35, min-15, Peep +10, Rate - 26, 430 ML, 2L O2. Record review of Resident #19's Pulmonary Notes, dated 01/21/2026, reflected . wearing her AVAPS mask upon provider arrival . denies complaints associated with AVAPS. During an observation on 03/10/2026 at 9:12 AM revealed Resident #19 was not inside her room. It was observed that the resident had AVAPs at the bedside. During an interview on 03/10/2026 at 10:43 AM, CNA F stated Resident #19 had been using her AVAPs since she was admitted to the facility and would use it every night. During an interview on 03/11/2026 at 12:12 PM, the MDS Nurse said Resident #19's AVAPs was not coded in her MDS because there was no documentation about the AVAPs. During an interview on 03/11/2026 at 12:24 PM, LVN A said Resident #19 had been using an AVAP since she was admitted to the facility. She said she was the one taking it off every morning. She said the respiratory department even taught her how to use the AVAP. During an observation and interview on 03/11/2026 at 12:46 PM, the MDS Nurse checked Resident #19's Progress Notes from the resident's admission to present and saw that the resident was using her AVAPS. She said if the resident was using an AVAPS, which was in the form of a non-invasive mechanical ventilator, since admission, then it should have been coded in the resident's MDS. The MDS Nurse said, the same was applicable to the resident who was admitted to the hospice and the resident who was using some oxygen. She checked on Resident #2's MDS and saw that the resident was not coded for hospice. She then checked Resident #5's MDS and saw the resident was not coded for her oxygen use. She said it was an oversight on her part and said she would fix it. She said the MDS was a form of a clinical assessment to determine the needs of the residents. She said if the assessment was not accurate, then there could be a probability that the needs would not be met. She said she would also audit the MDS of the other residents. During an interview on 03/12/2026 at 6:59 AM, the ADON said she was not familiar with the MDS but if the MDS needed to reflect that residents were using oxygen and AVAPs, then it should be in the MDS. She said the same with the resident receiving Hospice care. During an interview on 03/12/2026 at 7:28 AM, the DON said she was not familiar with the MDS but would coordinate with the MDS nurse to audit the MDS of the residents to make sure what should be coded was reflected in the MDS. During an interview on 03/12/2026 at 9:25 AM, the Administrator said the MDS of the resident should have been triggered if the resident was in hospice or were using oxygen and AVAPs. She said she would coordinate with the DON and the MDS Nurse about the issue. Record review of the facility's policy Conducting an Accurate Resident Assessment The Compliance Store revised May 05, 2025, reflected Policy: The purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . Policy Explanation and Compliance Guidelines . 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status.

Based on observations, interviews, and record reviews the facility failed to assess the resident for appropriateness and review the risks and benefits of grab/assist bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for 4 (Resident #1, Resident #13, Resident #76, Resident #91) of 7 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consents for Resident #1, Resident #13, Resident #76, and Resident #91 for grab/enabler bars to be placed on the bed. The facility failed to have evidence of assessments for Resident #1, Resident #13, Resident #76 and Resident #91, for risk of entrapment and ability to safely use the grab/enabler bars. These failures could affect residents who used grab/assist bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, and assessments not being completed for appropriateness which could lead to injury, entrapment, feelings of restraint, or death of the resident. Findings included: Record review of Resident #1's admission Record, dated 3/11/2026, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Metabolic Encephalopathy (syndrome of brain dysfunction caused by systemic illness, organ failure, or toxin accumulation affecting consciousness, cognition and motor function) and other diagnoses including Adult Failure to Thrive, Acute Kidney Failure, Cognitive Communication Deficit, Bipolar II Disorder (chronic mental health condition characterized by a pattern of depressive episodes and hypomanic episodes, but never full manic episodes), Anxiety Disorder (excessive, persistent, and uncontrolled worry or fear that interferes with daily life), Post-Traumatic Stress Disorder (mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events), and Dystonia (neurological movement disorder characterized by involuntary, sustained, or repetitive muscle contractions that cause twisting, repetitive movements abnormal postures). Resident #1 had diagnoses such as Unspecified Dementia (A group of symptoms that affects memory, thinking and interferes with daily life), Alkalosis (condition where body fluids have excess base [alkali] or too little acid causing blood pH to rise), Shortness of Breath, and Chronic Obstructive Pulmonary Disease (progressive, long term lung disease causes obstructed airflow, making breathing difficult) added during stay at the facility. Record review of Resident #1's Care Plan, last updated on 01/02/2026, revealed a Focus area of The resident has an ADL self-careperformance deficit Activity Intolerance, Fatigue, Impaired balance, Limited Mobility with Interventions that included .BED MOBILITY: The resident requires extensive assist by 1 staff for bed mobility. Resident #1 had Focus area of [Resident] is at Risk for injury r/t 1/4 side rail to enable assistance with bed mobility/transfers, safety with Interventions of Call light within reach. Complete appropriate assessment for enabler/side rail per facility policy. Review for continued need for side rail per facility policy. Record review of Resident #1's Annual MDS, dated [DATE], revealed a BIMS was unable to be conducted. Staff Assessment for Mental Status was conducted and resulted in a status of Severely Impaired (never/rarely made decisions). Resident #1 had self-care functional abilities rated at partial/moderate assistance required for eating, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Self-care functional abilities rated at substantial/maximal assistance required were oral hygiene, toileting hygiene, and shower/bathe self. Resident #1 had mobility functional abilities rated at supervision or touching assistance required for roll left and right, sit to lying, and laying to sitting on side of bed. Resident #1 had mobility functional ability rated at partial/moderate assistance required for sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. Record Review of Resident #1's Assessment list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Record review of Resident #1's Miscellaneous list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Observation of Resident #1's bed on 3/10/2026 at 10:40 AM revealed bilateral grab bars on the Resident's bed. The resident was not in the room; the bed was made for the day and call light was placed on the bed. Record review of Resident #13's admission Record, dated 3/11/2026, revealed a 51-year-olf female who originally admitted to the facility on [DATE] and most recent readmission on [DATE]. Resident #13 had diagnoses that included Quadriplegia (partial or total loss of function in all four limbs), Chronic Respiratory Failure with Hypoxia (long term condition where lungs cannot adequately oxygenate the blood), Chronic Obstructive Pulmonary Disease (progressive, long term lung disease causes obstructed airflow, making breathing difficult), Muscle Weakness, Altered Mental Status, Senile Degeneration Of Brain (progressive deterioration of mental abilities including memory, reasoning, and judgement associated with aging), Unspecified Intellectual Disabilities, Other Specified Extrapyramidal and Movement Disorders (range of neurological conditions including restless leg syndrome, stiff-man syndrome, writers cramp, and medication induced tremor), and Unspecified Lack of Coordination. Record review of Resident #13's Care Plan, last updated on 02/20/2026, revealed a focus area of [Resident] has an ADL self-care performance deficit with interventions last updated on 02/07/2025 including .BED MOBILITY: The resident requires total assistance by (1) staff to turn and reposition in bed. Bed rails as an enabler for turning and repositioning in bed. Bilateral 1/4 enabler bars per residents' preference. TRANSFER: The resident requires total assistance by (2) staff to move between surfaces. Record review of Resident #13's Quarterly MDS, dated [DATE], revealed a BIMS score of 9 indicating moderate impairment. Resident #13 was assessed as being completely dependent for all self-care and mobility functional abilities as she has a total loss of function in all four limbs. Record Review of Resident #13's Assessment list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Record review of Resident #13's Miscellaneous list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Observation of Resident #13's bed on 3/10/2026 at 10:05 AM revealed the resident in bed, covered with blankets, and watching tv. The resident's bed had a scoop mattress and there were bilateral grab bars observed on the bed. Record review of Resident #76's admission Record, dated 3/12/2026, revealed a [AGE] year-old male who originally admitted to the facility on [DATE]. Resident #76 had diagnoses including Anemia (blood disorder marked by a deficiency of healthy red blood cells reducing oxygen transport to body tissues), Major Depressive Disorder (mental health condition characterized by persistent, severe sadness, low mood, and loss of interest), Obstructive Sleep Apnea (disorder where upper airway collapses during sleep, causing breathing to repeatedly stop and restart), and Alcohol Abuse; no Primary admitting diagnosis was listed. Record review of Resident #76's Care Plan, last updated on 02/20/2026, revealed a focus area of Resident #76 is at Risk for injury r/t 1/4 side rail to enable assistance with bed mobility/transfers, safety and interventions of Call light within reach. Complete appropriate assessment for enabler/side rail per facility policy. Review for continued need for side rail per facility policy. Record review of Resident #76's Entry MDS, dated [DATE], revealed the resident was admitted from a short-term general hospital. No information on functional or mental status was included. Record Review of Resident #76's Assessment list, dated 03/12/2026, revealed no assessment or consent related to bed rails or grab bars. A BIMS assessment listed a score of 15 indicating resident was cognitively intact. Record review of Resident #76's Miscellaneous list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Observation of Resident #76's bed on 3/10/2026 at 10:20 AM revealed the resident in bed asleep. The resident's bed was observed with bilateral grab bars raised. The call light was within easy reach for the resident. Record review of Resident #91's admission Record, dated 3/12/2026, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] with most recent readmission on [DATE]. Resident #91 was noted to have diagnoses including Epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), Senile Degeneration of Brain (progressive deterioration of mental abilities including memory, reasoning, and judgement associated with aging, Extrapyramidal and Movement Disorder (drug induced movement disorder often caused by dopamine-blocking agents like antipsychotics resulting in muscle spasms, rigidity, tremors, or restlessness), Chronic Respiratory Failure (long term condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), Unspecified Convulsions (sudden, involuntary, and sometimes temporary muscle contractions or jerking motions), Schizoaffective Disorder Bipolar Type (chronic mental health condition blending schizophrenia symptoms [hallucinations, delusions] with severe mood episodes [mania, depression]), Muscle Weakness (Generalized), Unspecified Abnormalities of Gait and Mobility, Abnormal Posture, and Other Muscle Spasm. Record review of Resident #91's Care Plan, last updated on 01/08/2026, revealed a focus area of [Resident] is at Risk for injury r/t 1/4 side rail to enable assistance with bed mobility/transfers, safety and interventions of Call light within reach. Complete appropriate assessment for enabler/side rail per facility policy. Educate him/her/family on risks regarding of use of side rail device. Record review of Resident #91's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating cognitively intact. Resident #91 was assessed for self-care functional abilities of partial/moderate assistance for lower body dressing and putting on/taking off footwear; supervision or touching assistance for toileting hygiene, shower/bathe self, personal hygiene, and upper body dressing. Assessment for mobility functional abilities for Resident #91 indicated partial/moderate assistance for sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer; supervision or touching assistance for roll left and right, sit to lying, lying to sitting on side of the bed, walking 10, 50, and 150 feet. Record Review of Resident #91's Assessment list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Record review of Resident #91's Miscellaneous list, dated 03/11/2026, revealed no assessment or consent related to bed rails or grab bars. Observation of Resident #91's bed on 3/10/2026 at 10:30 AM revealed bilateral grab bars raised on the resident's bed and the resident was in bed napping. The call light was next to the resident's hand. During an interview on 3/12/2026 at 9:56AM, Resident #13 stated she had been without the ability to move either her arms or legs for a long time. Resident #13 stated that the staff check on her often, ask if she wants the tv changed to a different show, or has any needs. Resident #13 reported that the staff had to come and reposition her and will every few hours. Resident #13 stated that when she is repositioned, sometimes the grab bars are in the way of the tv viewing. Resident #13 stated that staff use the grab bars to wrap things around but she has no ability to use call light or tv remote and is no longer able to use arms or hands to reposition herself or grab items. In an interview on 3/12/2026 at 10:48AM, ADON stated that for residents to have grab bars or bed trails on their bed there needed to be an assessment for safety and mobility of the residents. ADON stated that the residents' MDS assessment would also be reviewed and areas such as the BIMS would be considered. Before grab bars or bed rails were put on a bed, the family had to be notified, a progress note entered in the resident's chart, and for the bed rails/grab bars to be care planned. ADON stated that there was a consent form that was a part of the assessment and could also be noted if a family member or responsible party gave verbal consent. ADON stated that the bed rail/grab bar was in the baseline care plan that was completed at admission and realized it had been removed but not sure when. ADON shared that there could be a risk to residents who were not assessed to be safe with grab bars/bed rails of entanglement or other dangers. In an interview on 3/12/2026 at 11:15AM the Adm stated the process for grab bars or bed rails was for an assessment for appropriateness to be conducted by nursing or rehab staff, if approved a care plan entry would be made with a timeframe to reevaluate or if they grab bars were solely for repositioning then it would be indicated as indefinite use. Adm stated that consent should also be obtained from the resident or their responsible party; the assessment and consent were located in the EHR in the Assessment tab. Adm stated that residents could face a safety hazard if not appropriate for the grab bars or bed rails. Record review of Proper Use of Bed Rails revised 6/09/2025, revealed the policy It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails . The definition provided was: Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examplesof bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Further review revealed: Policy Explanation and Compliance Guidelines:Resident Assessment1. As part of the resident's comprehensive assessment, the following components will be considered whendetermining the resident's needs, and whether or not the use of bed rails meets those needs:a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms.f. Underlying medical conditionsg. Existence of deliriumh. Ability to toilet self safelyi. Cognition.k. Mobility (in and out of bed).Informed Consent6. Informed consent from the resident or resident representative may be obtained after appropriate alternativeshave been attempted prior to installation and use of bed rails. This information should be presented in anunderstandable manner, and consent given voluntarily, free from coercion.Appropriate Alternatives9. The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternativesinclude, but are not limited to.10. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions,symptoms or behavioral patterns for which a bed rail was considered.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. The facility failed to ensure the ice machine was thoroughly cleaned and sanitized. The facility failed to ensure the ice scoop holder was thoroughly cleaned and sanitized. The facility failed to ensure the ice chest on the 2500-hall was thoroughly cleaned and sanitized. The facility failed to ensure the tea dispenser was covered with a lid. The facility failed to ensure the rinse temperature on the dishwasher was at the manufacturers required operating temperature of 180 degrees. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: During Observation on 03/10/26 at 8:57 am, a tea dispenser in the facility kitchen was observed with tea in it without a lid on it. During observation on 03/10/26 at 8:59 am, a Styrofoam container with no date or name was noted in the refrigerator located in the facility kitchen. During observation on 03/10/26 at 9:05 am, the ice machine located in the kitchen was noted with black, greenish and red stains on the inside of the ice machine. During observation on 03/10/26 at 9:06 am, the Ice scoop holder in the kitchen had black discoloration on the base of it. During an observation on 03/10/26 at 09:14 a.m., an ice chest, located on the 2500-hall, had reddish and light brownish stains on the inside of the chest, which contained ice, and a metal ice scoop was sitting in the ice. During an interview on 03/10/26 at 11:40 am with [NAME] 1, he stated that he does not know who the food in the Styrofoam container belonged to. He stated that any premade food in the refrigerator should have a date on it to prevent expired food being served to the residents. During an interview on 03/10/26 at 11:43 am with Nutrition manager, he stated the tea dispenser should be closed when filled with tea to prevent contamination. He stated that the ice machine and the ice scoop holder were cleaned weekly. He stated the kitchen staff makes daily rounds to check for cleanliness of the ice machine and ice scoop holder. He stated that no staff personal or resident personal food should be in the kitchen fridge, He stated, they prepare food in advance for residents who need substitutes but that should be labelled with date and time. He stated that the ice machine and ice scoop holder not being sanitized properly could cause widespread sickness to all residents who use the ice, During an interview on 03/11/26 at 11:45 a.m., the Nutrition manager was shown a picture of the ice chest, located on the 2500-hall, which had reddish and light brownish on the inside of the chest. He stated the CNAs were to bring all the ice chests on the halls to the kitchen to be run through the dishwasher every morning and they refill it with ice. He stated it was up to the nursing staff to ensure they brought the ice chest to the kitchen to be cleaned. He stated that the ice scop should not be stored in the ice chest. He stated that not cleaning the ice chest and leaving the ice scoop in the chest could contaminate the ice and lead to residents getting sick. Observation on 03/11/26 at 12:06 pm, It was observed the dishwasher had a rinse temperature of 110 degrees when it was being run, 70 degrees lower than posted operating temperature of 180 degrees. Interview on 03/12/26 at 9:10 am with the Nutrition manager, he stated the dishwasher temperature was checked 3 times a day and temperature was logged in the temperature log. Since it was noted by the surveyor and kitchen staff that the rinse temperature was 70 degrees off the 180 degrees manufacturer's operating temperature, they had switched to a 3-compartment sink method to sanitize dishes as of 3/11/26. The Nutrition manager stated that If dishes were not properly sanitized, it will have left over food debris which could cause cross contamination of food types and make residents sick. Record review of the facility Policy on Use and Storage of Food Brought in by Family or Visitors states: It is the right of the residents of this facility to have food brought in by family or other visitors, however, The food must be handled in a way to ensure the safety of the residents. Record review of the facility policy on Date Marking for Food Safety states: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or Discarded.The individual opening or preparing a food shall be responsible for date marking the food at the time The food is opened or prepared.The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded.The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly.The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, anddocument accordingly. Corrective action shall be taken as needed.

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of fifteen residents (Residents #5, #29, and Resident #38) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E performed hand hygiene before transferring Resident #5 on 03/10/2026. 2. The facility failed to ensure LVN B wore a gown while administering Resident #29's medication via g-tube on 03/10/2026. 3. The facility failed to ensure CNA F performed hand hygiene and changed her gloves after touching the soiled draw sheet during Resident #38's incontinent care on 03/10/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1. Review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Review of Resident #5's Quarterly MDS Assessment, dated 01/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was dependent on staff for bed-to-chair transfer. Review of Resident #5's Care Plan, dated 02/27/2026, reflected the resident required extensive assistance by two staff with mechanical lift (devices used to move a person from one position to another). During an observation on 03/10/2026 at 2:37 PM revealed CNA D and CNA E were about to transfer Resident #5 from wheelchair to the resident's bed. Both CNAs took some gloves from a box of gloves from the wall and put them on. Both CNAs did not perform hand hygiene prior to putting the gloves on. During an interview on 03/10/2026 at 2:49 PM, CNA D said hand hygiene should have been performed before transferring Resident #5 to make sure the hands were clean before touching the resident to prevent infection. She said she should have sanitized her hands before putting the gloves on to make sure her hands were clean before touching the gloves to be worn. During an interview on 03/10/2026 at 2:51 PM, CNA E said he forgot to sanitize his hands before transferring Resident #5. He said hands should be washed or sanitized before putting on a pair of gloves to prevent cross contamination and infection. 2. Record review of Resident #29's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support) and irritable bowel syndrome (abdominal disorder characterized by bloating, abdominal pain, and diarrhea). Record review of Resident #29's Comprehensive MDS Assessment, dated 01/08/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #29's Comprehensive Care Plan, dated 01/10/2026, reflected the resident was on EBP related to g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) and one of the interventions was to the use of gowns and gloves during high-contact resident care. Record review of Resident #29's Physician Order, dated 02/03/2026, reflected Enteral Feed Order in the evening of Jevity 1.5 at 55 ml/hour via feeding tube. Up at 7pm, to run continuously until a total volume of 660 ml is administered. May remove for care and services. Record review of Resident #29's Physician Order, dated 02/03/2026, reflected Dicyclomine HCl Oral Tablet 20 MG (Dicyclomine HCl) Give 1 tablet via G-Tube four times a day for irritable bowel syndrome. Record review of Resident #29's Physician Order, dated 10/07/2026, reflected Enhanced Barrier Precautions for, (indwelling medical device) (GTube) Gown and Gloves required for HIGH-CONTACT Resident Care Activities. An observation on 03/10/2026 at 3:49 PM revealed LVN B was about to administer Resident #29's medication. She prepared the medication, crushed it, and dissolved it with water. She went inside the resident's room and administered the medication. She did not wear a gown while administering the medication. During an interview on 03/10/2026 at 4:37 PM, LVN B said it did not occur to her to put on a gown when she was administering Resident #29's medication. She looked at the sign outside the resident's door and saw the gown should be used during use of g-tube. She said gowns were needed in addition to the gloves to make sure that the staff were not transferring anything dirty to the residents with tubings. 3. Record review of Resident #38's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with weakness. Record review of Resident #38's Comprehensive MDS Assessment, dated 02/03/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #38's Comprehensive Care Plan, dated 12/11/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was to provide peri care after each incontinent episode. An observation on 03/10/2026 at 2:09 PM revealed CNA F was about to do Resident #38's incontinent care. During the process of incontinent care, CNA F rolled the soiled draw sheet of the resident, then took the new draw sheet followed by the new brief. She did not change her gloves and performed hand hygiene after she touched the soiled draw sheet. During an interview on 03/10/2026 at 2:29 PM, CNA F said she should have changed her gloves after touching the soiled draw sheet and before touching the new draw sheet and the new brief to make sure her hands and gloves were clean before touching the new draw sheet and brief. She said hand hygiene was important to prevent cross contamination and probable UTI. During an interview on 03/12/2026 at 6:59 AM, the ADON said staff should be mindful they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, after, and during any care. She said the staff should change their gloves after touching anything soiled to make sure the staff were not using soiled gloves when they touched the new draw sheet and brief. She said another way to prevent the spread of infection was to wear PPE when residents were on EBP. She said residents with g-tubes were on EBP to prevent any microorganism from the clothes of the staff from transferring to the residents and vice versa. She said the purpose of EBP was to prevent the spread of MDRO (Multi-Drug-Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics). She said the expectation was for the staff to practice infection control, hand hygiene, change gloves, sanitize between changing gloves, and to wear PPE when needed. She said they had already started an in-service about infection control. During an interview on 03/12/2026 at 7:28 AM, the DON said hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care, said gloves should be changed after touching anything soiled. She said if there was an EBP sign outside the residents' rooms, then staff were required to wear a gown in addition to gloves to protect the residents from cross contamination and probable infection. She said the expectation was for the staff to adhere to the policy of hand hygiene and infection control. She said she already started an in-service about hand hygiene and infection control. During an interview on 03/12/2026 at 9:25 AM, the Administrator said staff should always wash their hands before and after any care, change their gloves when needed, and put on a gown when the residents required EBP. She said the DON already started an in-service about infection control, EBP, and hand hygiene, but she would still coordinate with the DON to closely monitor if the staff understood the in-service regarding infection control, EBP, and hand hygiene. Record review of the facility's policy Enhanced Barrier Protection The Compliance Store revised April 10, 2025 reflected Enhanced barrier precautions (EBP) are used in conjunction with standard precautions and expands the use of PPE to donning of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . EBP is employed when performing the following high contact resident care activities . Device care or use . feeding tube. Record review of the facility's policy Hand Hygiene The Compliance Store revised April 10, 2025, reflected Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Policy Explanation and Compliance Guidelines . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens . Before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for ten of eleven residents (Residents #4, #7, #10, #11, #24, #31, #34, #74, #91, and #96) and for two of four LVNs (LVN B and LVN I) reviewed for accident hazards.1. The facility failed to ensure Resident #31 had her fall prevention interventions which included a fall mat to each side of bed every shift for safety. 2. The facility failed to ensure Residents #4, #10, #11, #24, #34, #74, #91, and #96 were properly supervised while smoking in the smoking area of the facility and that Resident #4, #10, #24, #34, #74, #91, and #96 had quarterly smoking assessments completed.3. The facility failed to ensure that LVN B did not leave a container of germicidal wipes on top of her cart unattended on 03/10/2026. 4. The facility failed to ensure LVN I did not leave a container of germicidal wipes on top of his cart unattended on 03/10/2026.These failures placed residents at risk of injury, pain, bruises, fractures, dislocation of joints, exposure to toxic chemicals, exposure to toxic chemicals, and/ or significant changes of condition. Findings included: 1. Record review of Resident #31's face sheet dated 03/10/26 revealed an [AGE] year-old admitted to the facility initially on 12/13/2010 with the following diagnoses: Type 2 Diabetes ((high blood sugar levels), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), Convulsions (sudden, uncontrollable shaking or jerking of the muscles), Epilepsy (recurrent, unprovoked seizures caused by temporary, abnormal electrical activity in the brain). Record review of Resident #31's MDS dated [DATE] revealed that the resident was coded for risk of developing pressure ulcers/injuries, had severely impaired decision skills, triggered for falls, he required extensive assistance for all ADL's and all his nutrition via a feeding tube. Review of Resident #31's Treatment Administration record dated 03/01/26 to 03/31/26 revealed an order for: Fall mat to each side of bed every shift for safety, intervention was signed off as being completedReview of Resident #31's care plan dated 01/02/26 revealed the resident is at risk for falls Gait/balance problems, Unaware of safety needs, history of falling, dx of unspecified lack of coordination. Intervention noted on care plan was fall matt to each side of bed. Resident #31 was noted laying on her floor mat on 06/24/23 and 07/08/24 with no injuries noted. Observation on 03/10/26 at 1:50 pm, Resident #31 was in bed sleeping, fall mat was noted only on the right side of the bed. Interview with LVN A on 03/10/26 at 2:00 pm, she stated Resident #31's Fall mats should be in place all the time if fall mats are not in place it will result in severe injury if the resident falls. She stated it should be checked during rounds by all care staff. Interview with CNA D on 03/10/26 at 2:15 pm she stated she was not aware Resident #31 needed to have fall mats one on both sides of the bed. Not having both fall mats in place could result in serious injury with any fall. Interview with the DON on 03/10/26 at 2;25 pm, she stated that Floor mats for Resident #31 should be in place per care plan and orders, not having both fall mats in place could result in injury with fall. She stated all care staff are responsible for checking to make sure the fall mats are in place. She stated she will conduct an audit and provide education to care staff on fall prevention and monitoring. 2. Record review of Resident #4's Face Sheet, dated 03/11/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and COPD. Record review of Resident #4's Quarterly MDS assessment, dated 01/29/26, reflected he had a BIMS score of 14 (intact cognitive response). For active diagnosis it reflected respiratory failure. For ADL care it reflected the resident dependent on staff to provide care. Record review of Resident #4's Comprehensive Care Plan, dated 03/02/26, reflected the resident was a smoker and an intervention was supervised smoking sessions. Record review of Resident #4's Smoking assessment revealed it was last completed on 09/04/25. Record review of Resident #10's Face Sheet, dated 03/11/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and COPD. Record review of Resident #10's Quarterly MDS assessment, dated 12/05/25, reflected he had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected respiratory failure. For ADL care it reflected the resident required supervision. Record review of Resident #10's Comprehensive Care Plan, dated 02/20/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #10's smoking assessment revealed it was last completed on 11/18/24. Record review of Resident #11's Face Sheet, dated 03/11/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included respiratory failure and lack of coordination. Record review of Resident #11's Quarterly MDS assessment, dated 12/03/25, reflected he had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected acute respiratory failure. Record review of Resident #11's Comprehensive Care Plan, dated 01/23/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #24's Face Sheet, dated 03/11/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizophrenia (severe brain disorder, and bipolar disease (mood swings) Record review of Resident #24's Quarterly MDS assessment, dated 02/11/26, reflected she had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected schizophrenia. Record review of Resident #24's Comprehensive Care Plan, dated 03/11/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #24's smoking assessment revealed it was last completed on 10/30/25. Record review of Resident #34's Face Sheet, dated 03/11/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and COPD (lung disease). Record review of Resident #34's Quarterly MDS assessment, dated 01/06/26, reflected he had a BIMS score of 13 (intact cognitive response). For active diagnoses it reflected lack of coordination and COPD. Record review of Resident #34's Comprehensive Care Plan, dated 01/07/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #34's smoking assessment revealed it was last completed on 09/06/24. Record review of Resident #74's Face Sheet, dated 03/11/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included COPD and lack of coordination. Record review of Resident #74's Quarterly MDS assessment, dated 02/16/26, reflected he had a BIMS score of 7 (severe cognitive impairment). For active diagnosis it reflected COPD. Record review of Resident #74's Comprehensive Care Plan, dated 02/27/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #74's smoking assessment revealed it was last completed on 09/06/24. Record review of Resident #91's Face Sheet, dated 03/11/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included acute respiratory failure and lack of coordination. Record review of Resident #91's Quarterly MDS assessment, dated 12/12/25, reflected he had a BIMS score of 15 (intact cognitive response). For active diagnosis it reflected COPD. Record review of Resident #91's Comprehensive Care Plan, dated 01/08/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #91's smoking assessment revealed it was last completed on 09/06/24. Record review of Resident #96's Face Sheet, dated 03/11/26, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included paralysis of left side of her body and lack of coordination. Record review of Resident #96's Quarterly MDS assessment, dated 02/01/26, reflected she had a BIMS score of 9 (moderate cognitive impairment). For active diagnosis it reflected lack of coordination. Record review of Resident #96's Comprehensive Care Plan, dated 02/20/26, reflected the resident was a smoker and an intervention was for the resident to be supervised while smoking for safety. Record review of Resident #96's smoking assessment revealed it was last completed on 12/09/24. During an observation and interview on 03/11/26 at 1:00 p.m., Floor Tech T was observed sitting in the dining area near the exit door looking out to the smoking area. Residents #4, #10, #11, #24, #34, #74, #91, and #96 were outside smoking tobacco products and Floor Tech T was observed looking at his phone and not observing the residents. He stated he was supposed to be monitoring the residents to ensure they did not harm themselves while smoking. During an interview on 03/11/26 at 12:55 p.m., the Social Worker was informed by the Surveyor of Resident #4, #10, #24, #34, #74, #91, and #96 not having a recent quarterly assessment on file. She stated it was the nursing staff responsibility to complete the quarterly assessments. She stated smoking assessments were needed to ensure the resident was safe while smoking. During an interview on 03/11/26 at 01:00 p.m., the DON was informed by the Surveyor of Resident #4, #10, #24, #34, #74, #91, and #96 not having a recent quarterly assessment on file. She stated it was the Social Worker's responsibility to ensure residents who smoke had quarterly smoking assessments completed to ensure the residents' conditions had not changed and it was safe for them to smoke. During an interview on 03/11/26 at 1:15 p.m., the Administrator was informed by the Surveyor of Floor Tech T being observed on his phone and not observing Resident #4, #10, #11, #24, #34, #74, #91, and #96 as they smoked their tobacco products. She stated staff were to observe residents while they smoked to ensure they did not harm themselves. She stated staff was not to be on their phones and distracted. The Administrator stated smoking assessments were to be completed quarterly for all residents that smoked to ensure it was safe for them to smoke and identify any risk for the residents. The Administrator was informed by the Surveyor of Resident #4, #10, #24, #34, #74, #91, and #96 not having quarterly smoking assessments completed. She stated it was the Social Worker's responsibility to complete quarterly assessments for residents who smoked to ensure they were smoking safely. 3. During an observation on 03/10/2026 at 3:49 PM revealed LVN B went inside a resident's room to administer medication. She closed the door when she went inside the resident's room. It was observed that a container of germicidal wipes (substance that destroys germs and microorganism) was on top of her cart that was left unattended when she closed the door. It was observed that several residents were passing by the hallway. During an interview on 03/10/2026 at 4:37 PM, LVN B said she should have placed the germicidal wipes inside the cart before leaving the cart unattended because there were confused residents and they might use them to clean their faces and eyes that could result in irritations. 4. During an observation on 03/10/2026 at 4:40 PM revealed an opened container of germicidal wipes was on top of a cart parked near the nurse's station. The cart was facing the hallway and was unattended. It was observed that there were no staff in the nurse's station. During an observation and interview on 03/10/2026 at 4:42 PM, the Infection Control Nurse told LVN B that the germicidal should be locked inside the cart before leaving the cart unattended. She then went to the other cart and took the open germicidal wipes and said LVN I was the one using the cart with an open container of germicidal wipes. She said the containers should be locked inside the carts because residents might mistakenly use them to wipe their faces. She said she would start an in-service about storing the germicidal wipes.During an interview on 03/11/2026 at 9:12 AM, LVN I said he was told about the open germicidal wipes he left on top of the cart. He said the wipes could be harmful to the residents, and he should have stored them properly before he left his cart. During an interview on 03/12/2026 at 6:59 AM, the ADON said the germicidal wipes should be stored inside the cart for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin. She said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She said the DON already started an in-service about not leaving the germicidal wipes on top of the carts. During an interview on 03/12/2026 at 7:28 AM, the DON said the germicidal wipes should be locked inside the carts and not left on top of the carts unattended. She said it should be secured inside the carts so that the residents would not be able to access the wipes that had chemicals on them. She said she was not sure what chemical was on the wipes but considering the wipes were used to disinfect, then the wipes could be harmful to the residents. She said confused residents might get hold of the wipes and wipe their face and body that could result in irritations. She said the expectation was for the staff to be mindful and never leave the germicidal wipes on top of the carts unattended. She said she already started an in-service about not leaving anything with chemicals unattended. During an interview on 03/12/2026 at 9:25 AM, the Administrator said the germicidal wipes should be placed somewhere not accessible to the residents. She said the wipes had chemicals in them that could be harmful when consumed or had contact with the eyes. She said the DON already started an in-service about not leaving the germicidal wipes unattended, but she would still coordinate with the DON to closely monitor if the staff understood the in-service. Record review of the facility's policy Medication Storage The Compliance Store revised June 15, 2025, reflected 3. External Products: Disinfectants and drugs for external use are stored separately. Record review of Safety Data Sheet (SDS) on 01/21/2026 reflected Safety Data Sheet Medline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity – oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children. Review of the facility's Fall Prevention Program dated 05/29/25 revealed: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Record review of facility's policy, Resident Smoking, undated, reflected It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of twelve residents (Residents #5, #6 and #15) reviewed for respiratory care. 1. The facility failed to ensure Resident #5's nasal cannula was stored properly when not in use on 03/10/2026. 2. The facility failed to ensure Resident #6's nasal cannula was stored properly when not in use on 03/10/2026. 3. The facility failed to ensure Resident #15's breathing mask was stored properly when not in use on 03/10/2026. These failures could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic pulmonary edema (accumulation of fluid in the lungs). Record review of Resident #5's Quarterly MDS Assessment, dated 01/06/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment did not indicate that the resident was on oxygen therapy. Record review of Resident #5's Quarterly Care Plan, dated 02/27/2026, reflected that the resident had pulmonary edema and one of the interventions was to administer oxygen as ordered. Record review of Resident #5's Physician Order, dated 02/26/2026, reflected Oxygen at 2 liters per minute via Nasal Cannula (flexible tube used to deliver oxygen to the nose through two prongs). Every shift for SOB. During an observation on 03/10/2026 at 2:37 PM revealed Resident #5 was in her wheelchair in the hallway and was about to be transferred to her bed. It was observed that the resident was on oxygen via a nasal cannula connected to the oxygen tank at the back of her wheelchair. When the resident was already in her bed, CNA D pulled the resident's nasal cannula from the resident's bed railing to replace the nasal cannula from her wheelchair. The nasal canula was not bagged. During an observation and interview on 03/10/2026 at 2:46 PM, CNA D said the nasal canula was not bagged and she would tell the nurse to replace it because it was already dirty. She said whoever transferred the resident should have bagged the nasal cannula. She said she did not know who transferred the resident earlier that day. During an observation and interview on 03/11/2026 at 6:22 AM revealed Resident #5 was in her wheelchair at the reception area of the facility. It was observed that the resident was using oxygen. She said she had been using oxygen for years and would use it night and day. 2. Record review of Resident #6's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure with hypoxia (insufficient amount of oxygen in the body). Record review of Resident #6's Quarterly MDS Assessment, dated 01/07/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #6's Comprehensive Care Plan, dated 01/19/2026, reflected the resident had oxygen therapy and one of the interventions was administered oxygen as ordered. Record review of Resident #6's Physician's Order, dated 10/07/2024, reflected O2 at 2-3 LPM via NC as needed for O2 Sats less than 90%. Document LPM used and O2 sats. During an observation on 03/10/2026 at 9:15 AM revealed Resident #6 was not inside his room. It was observed that a nasal canula was attached to an oxygen concentrator at the bedside. The nasal cannula was on top of the bed and was not bagged. During an observation and interview on 03/10/2026 at 9:17 AM, CNA D said Resident #6 was up early because he needed to go to his appointment. She saw the nasal cannula on top of the bed and said the nasal cannula should be bagged so that it would not get dirty. She said she would notify the nurse, so it be replaced with a new one. 3. Record review of Resident #15's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs). Record review of Resident #15's Quarterly MDS Assessment, dated 12/31/2025, reflected that the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had congestive heart failure. Record review of Resident #15's Comprehensive Care Plan, dated 01/11/2026, reflected that the resident did not have a care plan for congestive heart failure. Record review of Resident #15's Physician's Order, dated 12/29/2025, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day for SOB/Congestion. During an observation and interview on 03/10/2026 at 9:10 AM revealed Resident #15 was in her awake. It was observed that a nebulizer machine was on top of the resident's side table with a breathing mask attached to it. The breathing mask was on top of the nebulizer and was not bagged. The resident said the nurse administered her breathing treatment, and somebody had to take it off because she was unable to put it on the side table. She said somebody took it off, but she could not remember who took it off. During an observation and interview on 03/10/2026 at 9:20 AM, LVN A said she administered Resident #15's breathing treatment but had not checked on the resident yet. She went inside the room and saw the breathing mask was on top of the nebulizer. She disconnected the breathing mask and threw it in the trash can. She said she would get a new one. She asked the resident, and the resident told LVN A that somebody took it off. She said she was also notified of Resident #6's nasal canula, and she already changed it. She said the breathing mask and the nasal canula should be bagged to prevent cross contamination and possible respiratory infection. She said she would also talk to the CNAs that when they transfer a resident with a nasal canula, make sure to bag it. During an interview on 03/12/2026 at 6:59 AM, the ADON said the nasal canula and the breathing masks should be bagged when the residents were not using them to prevent probable infection. She said whoever transferred the resident should put the nasal cannula in a bag after taking them off the residents. She said whoever administered the breathing treatment should bag the breathing mask when the treatment was done. She said they had already started an in-service about respiratory care. During an interview on 03/12/2026 at 7:28 AM, the DON said the staff were responsible for making sure the nasal cannula and the breathing masks were bagged when not in use to prevent any respiratory infection. She said the staff who transferred the residents with nasal canula should have bagged the nasal canula, and the staff who administered the breathing treatment should have bagged the breathing mask after the treatment was done. She said she already started an in-service about bagging the nasal canula and the breathing masks. During an interview on 03/12/2026 at 9:25 AM, the Administrator said the expectation was for the staff to bag the nasal cannula and the breathing mask when not in use to prevent respiratory issues. She said she would coordinate with the DON about respiratory care. Record review of the facility's policy Oxygen Administration The Compliance Store revised May 16, 2025, reflected Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice . Policy Explanation and Compliance Guidelines . 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include . e. Keep delivery devices covered in plastic bag when not in use.

Based on interviews and record review the facility failed to ensure that the transfer or discharge was documented in the resident's medical record for one (Resident #105) of three residents reviewed for transfers and discharges.The facility failed to accurately document Resident #105's discharge on [DATE].This failure could prevent the resident or their caregivers from receiving necessary information about the resident's support needed for further care.Findings included:Review of Resident #105's Face Sheet, dated 03/11/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with heart failure and Type 2 Diabetes (high blood sugar levels). Record review of Resident #105's 's MDS Assessment, dated 02/17/26, reflected the resident's BIMS indicated an intact cognitive response. The MDS Assessment reflected the resident had active diagnoses of heart failure and Type 2 Diabetes.Record review of Resident #105's progress notes on 02/19/26 revealed Resident left AMA. After the Surveyor inquired about the resident's discharge, the Social Worker added the following progress notes on 03/11/26, Resident did not leave AMA. Resident and resident's [family member] spoke with SW one week prior of discharge; that resident would be discharging in a week. On day of discharge SW spoke with MD regarding discharge planning and arranging for home health for safe discharge. MD was in agreeance, signed order for home health; home health arranged. Resident discharged home with family. Discharge complete.Record review of Resident #105's Discharge document on 02/17/26, revealed discharged Against Medical Advice. During an interview and record review on 03/11/26 at 11:22 a.m., the Social Worker initially stated Resident #105 had discharged from the facility against medical advice and she had forgotten to have the resident sign the AMA form upon his discharge. She stated she was busy trying to get the resident set up on home healthcare and overlooked this process. The Social Worker then stated she was reminded by the Administrator that the resident's discharge was not against medical advice. She stated the resident had planned the discharge and was discharged home and set up with home health care. She was informed of the progress notes on 02/19/26 indicating the resident had left against medical advice. She stated the progress notes and discharge document was incorrect. During an interview on 03/11/26 at 11:30 a.m., the Administrator stated she was informed of Resident #105's discharge incorrectly documented as Against Medical Advice. She stated the Social Worker had forgotten the resident's physician had approved of the discharge. She stated it was important to ensure the resident's discharge was accurately documented.During an interview on 03/12/26 at 11:56 a.m., Physician O stated Resident #105 was discharged home with home health care and not AMA. He stated he had met with the Resident and the Resident's caregiver to discuss his discharge and provided his medication upon his discharge on [DATE]. Record review of facility's policy, Transfer and Discharge, undated, reflected It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards for one (Resident #1) of four residents reviewed for elopement behavior. Resident #1 had a documented history of wandering and/or exit seeking behavior on 07/16/2024. The facility failed to provide adequate supervision to Resident #1 who had a history of exit seeking behavior. The facility did not accurately re-assess his elopment risk assessment, monitor, or update the residents care plan after the incident. On 08/27/2024 around approximately 6:00 AM the resident was located by the facility's SLP outside the facility beyond the Therapy Services door. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. While the POR was accepted on 08/29/2024 at 12:04 PM and the IJ lifted at 08/29/2024 at 3:45 PM, the facility remained out of compliance at a severity level of potential for minimum harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal. This failure could place residents at risk of becoming lost, disoriented, injured, and/or death from exposure to environmental elements. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included dementia, major depressive disorder, generalized anxiety disorder, weakness, unsteadiness on feet, blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Quarterly Minimum Data Set (MDS,) dated 06/21/2024 revealed he was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 08. He was wheelchair bound and required partial/moderate assistance with shower/bathing and personal hygiene. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 was assessed as having adequate vision. Resident #1 was documented as not having wandering behavior at this time. Record review of Resident #1's Comprehensive Care Plan, dated 06/21/2024, revealed he was a full code, was at risk for falls related to deconditioning, gait/balance problems, psychoactive drug use, vision/hearing problems . and had impaired visual function related to blindness in right eye, macular degeneration . The care plan did not address the residents wandering, elopement, and/or exit seeking behavior. Record review of Resident #1's Progress Note by LPN Y, dated 08/27/2024, revealed: Resident eloped from facility, found in parking lot in the front of the building. no s/s of distress noted, V/S are normal, noted resident stated, I was looking for my brother, and my wife. resident found by facility staff member (therapy dept) nursing and all staff to closely monitor, report passed on to on-coming am nurse to f/u with pcp to for recommendations to obtain UA, rule out UTI, and notify Rp of elopement. Interview of LPN Y was attempted via telephone 08/28/2024 at 09:05 AM was unsuccessful. In interview with facility SLP on 08/28/2024 at 8:59 AM, she stated on 08/27/2024 at approximately shift change at 6:00 AM, when she was walking down the hall where the Therapy Service door was located, she stated she observed Resident #1 located outside of the facility ambulating beyond the curb. She stated she did not hear the door alarm. She stated she did not see Resident #1 exit the facility and was not certain how he got out of the facility. The SLP stated she was confident that Resident #1 did not know the door code. She stated that door was set to have an alarm go off if the code was not entered or when the door was left open for an extended amount of time. She stated she thought he perhaps followed a staff member out exiting the facility around shift change. The SLP stated when she went outside to see Resident #1, he was confused, and ambulating was without his wheelchair. She stated she then alerted nursing staff who came out to assess the resident. She stated she was not aware of any wandering or exit seeking behaviors from Resident #1 prior to this incident and was not aware of any previous elopement attempts. Record review of Resident #1's Progress Note authored by LVN X, dated 07/16/2024, revealed: Resident wheeled himself out of his room and pushed the 2100 hall door to outside and the door closed behind him and the CNA called this Nurse to open door for him, Resident stated that he wanted to get some fresh air. Notified ADON/DON of occurrence. Resident is back in his room safely. offered Resident snacks and fluids. call light within reach, bed in low position. An interview of LVN X was attempted via telephone 08/28/2024 at 11:18 AM and 08/29/2024 at 3:00 PM and was unsuccessful. An interview with facility's ADON on 08/28/2024 at 9:07 AM, he stated he was working on 07/16/2024. He recalled that the alarm was triggered by Resident #1 and we brought him back in. He stated the incident was not considered an elopement because the mechanisms in place worked. In interview with the facility's MDS nurse on 08/28/2024 at 9:21 AM, she stated she began employment at the facility on 07/08/2024 and was not aware of Resident #1's previous wandering behaviors prior to 08/27/2024. She stated she has not had the chance to review past documentation. She stated she had participated in multiple interdisciplinary meetings at the facility, but this specific incident was not reported to her in any of these meetings. She stated if had been reported to her, she would have updated Resident #1's MDS, created and implemented care interventions on Resident #1's Comprehensive Care Plan for wandering, exit seeking, and/or elopement behavior. She stated that after Resident #1's initial wandering and/or exit seeking behavior was exhibited, the facility should have re-assessed his risk level, implemented enhanced monitoring, and completed frequent documentation of where he was located. She stated these interventions were important to accurately reflect the care needs of the resident and for the safety of the resident. An interview and record review with the facility's DON on 08/28/2024 at 9:35 AM, she stated that Resident #1 has been at the facility quite a long time. She stated he was not one we were worried about eloping. She stated his episodes of confusion were related to the development of an UTI. She stated that her interpretation of the incident documented on 07/16/24the Progress Note was that he was never on the other side of the door. The DON stated after reviewing Resident #1's progress note from 07/16/2024, she did not consider this an elopement. She stated the resident has never left the building. She stated it was not an elopement, it was wandering, exit seeking, and/or elopement behavior and Resident #1 should have had an elopement reassessment, and the MDS and Care Plan should have been updated with interventions put in place. She stated it was the MDS nurse's responsibility to update these documents. The DON stated during this time the facility had a remote MDS nurse and that was the reason this was missed. She stated it was important for resident MDS and Comprehensive Care Plan to be updated when new behaviors were exhibited so the care was reflective of the resident needs. She stated she was aware of his confusion, did not think he was safe to be outside of the facility unsupervised, and it was ultimately her responsibility to ensure resident assessments and care plans were updated and accurate. Record review of Resident #1's Wandering/Elopement assessment dated [DATE] revealed he was scored as 1.0 - Low Risk for Wandering. Record review of Resident #1's All Inclusive Quarterly Screen dated 07/24/2024 revealed he was moderately impaired with limited vision and was a 2. Moderate Risk for elopement. Record Review of facility's Incident Report for July 2024, dated 08/28/2024, revealed no documentation of Resident #1's wandering, exit seeking, and/or elopement behavior/incident from 07/16/2024 Record review of facility's Incident Report for August 2024, dated 08/28/2024, revealed Resident #1 eloped 08/27/2024 at 5:30 AM. Record review of facility's Every 15 Minute Check Sheet provided by the DON on 08/28/2024 at 12:21 PM revealed sufficient staff documentation for monitoring of Resident #1 every 15 minutes 08/27/2024 and 08/28/2024. In interviews with Resident #1 on 08/27/2024 at 10:20 AM and 11:48 AM, he did not recall either incident, and a meaningful interview was not possible due to the resident's cognitive status and confusion. In interview with LVN C on 08/27/2024 at 10:27 AM, she stated Resident #1 was slightly confused and was not aware of any behaviors, accidents, or elopements. In interview with facility's Administrator on 08/28/2024 at 2:20 PM, he stated he was not aware of any wandering, exit seeking, and/or elopement behavior from Resident #1. He stated when he spoke with the facility's DON the morning of 08/27/2024, she reported to him that Resident #1 was seen outside of the building, but it was not considered an elopement. Upon further interview, Administrator declined to comment further at this time. Record review and Interview on 08/28/2024 at 1:00 PM with facility's DON, she provided a document that revealed Resident #1's Elopement Risk Assessments, dated 08/28/2024, that revealed his elopement risk was documented as Low Risk on 08/27/2024 and Moderate Risk on 08/28/2024. When asked how his risk could be low or moderate after an actual documented elopement, she stated she would get back with me on that. Record review on 08/28/2024 at 1:30 PM the facility's DON, provided a document that revealed Resident #1 Elopement Risk Assessment, dated 08/28/2024 at 1:00 PM, that revealed his elopement risk was documented now a High Risk. Supplementary comments on the document revealed Incident isolated. Resident has never attempted to leave the facility or open a door. Facility suspects UTI. Resident will be monitored closely until evaluated by MD. In Interview with facility's Administrator on 08/29/2024 at 2:52 PM he stated that he did not consider the incident on 08/27/2024 an elopement and declined to further comment. Record review of facility policy Care Plans, Comprehensive Person-Centered rev. 03/2023 revealed, 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 . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintained the residents highest practicable physical, mental, and psychosocial well-being . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . 11. Assessments of residents are ongoing and care plans revised as information about the residents and the residents condition change. Record review of facility policy Resident-to-Resident Altercations, rev. 12/2016 revealed, Policy Statement . All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator . 2. If two residents are involved in an altercation, staff will: f. make any necessary changes in the care plan approaches to any or all of the involved individuals; g. document in the resident's clinical record all interventions and their effectiveness . Record review of facility policy, Wandering and Elopement Policy, rev. 03/2019 revealed, The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm . 1. If identified as a risk for wandering, elopement . the resident's care plan will include strategies and interventions to maintain the resident's safety . 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: 3. Document all events, interventions and outcomes in the resident record f. Review the event details during the QUAPI meeting to determine root cause and preventative measures. Record review of facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program rev. 04/2021 revealed Policy Statement . Residents have the right to be free from abuse, neglect . 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment . 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. Record review of facility policy, Resident Assessments, rev. 03/2022 revealed A comprehensive assessment of every resident's needs is made at intervals . are federal mandated, and therefore must be performed for al residents of Medicare and/or Medicaid . provide information about the clinical condition . in order to be reimbursed . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate assessments and reviews according to . Admission assessment . Quarterly assessment Annual assessment . Significant change in Status Assessment An Immediate Jeopardy (IJ) situation was identified due to the above failures and presented to the Administrator on 08/28/2024 at 4:10 PM and an IJ template was provided.The POR was accepted on 08/29/2024 at 12:04 PM and indicated: The facility's Plan of Removal (POR) stated: PLAN OF REMOVAL Name of facility: [Facility] Date: 08/28/2024 F 689 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on 08/28/2024 at 3:30pm. Resident #1 continues to be a current resident at the facility. A head-to-toe assessment was completed on 08/27/2024 with no injuries or adverse effects noted. The resident was placed on Q15 checks on 08/27/2024 x 48 hours and will then be monitored hourly x 5 days. Psych Services saw the resident on 08/28/2024 and recommended that the resident be moved to a room closer to the nurse's station. Official report pending. The resident's elopement assessment was updated this evening and shows high risk. An off-cycle Significant Change MDS was opened with an ARD of 08/29/2024. The Care Plan was updated 08/28/2024 4:30 pm to reflect High Risk status with personalized interventions noted. If at any time the resident is determined to require a locked unit, the facility will seek placement elsewhere with the assistance of family and social services. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 6pm on 08/28/2024. The following plan was implemented on 08/28/2024 to prevent residents from leaving the facility unsupervised. PLAN TO IMPROVE THE FACILITY ELOPEMENT RESPONSE 1. Educate and Inservice staff on the: Importance of accurate and timely elopement assessments Accurate and timely MDS and care plan updates Elopement Binder, contents, and location Elopement definition including elopement behaviors How to respond when a resident exhibits said behaviors Notifications if an elopement occurs (Admin/ DON, MD, RP, HHSC reporting if criteria is met) 2. An Elopement Drill is scheduled for 08/28/2024 for evening and night shift and 08/29/2024 for day shift to shift to ensure all staff know how to respond to elopements. 3. The Elopement Binder will be reviewed and updated accordingly once the Elopement Assessments have been completed. The Elopement Binder contents include the face sheet, resident pictures and Department Manager Contact Info). Elopement Binders are located at the reception desk and Nurses Station. The DON and/or designee will review the binder monthly to ensure that all new admissions and any Elopement Status changes have been captured. 4. The MDS and Care Plan will be updated with any significant change and/or quarterly or annual assessments depending on which assessment is required. The MDS Coordinator will ensure accuracy by reviewing the most recent Elopement Assessment. The DON will review the MDS prior to signing to ensure the information is accurate. MDS and Care Plan supporting documentation is located in the Resident's Electronic Medical Record. Facility Plan to Ensure Compliance Quickly Education was provided to the Administrator, and Director of Nurses by Divisional VP of Clinical Operations on the following items: Importance of accurate and timely elopement assessments Accurate and timely MDS and care plan updates Elopement Binder, contents (Face Sheet, Resident Pictures, Department Manager Contact Info), and location binder stored Elopement definition including elopement behaviors How to respond when a resident exhibits elopement behaviors (interventions) Notifications if an elopement occurs (Admin/ DON, MD, RP, HHSC reporting if criteria is met) Education will be provided to all current staff / all disciplines by the Administrator and DON on the Elopement Management Process and policies, Elopement Binder and contents, Elopement definition including elopement behaviors and how to respond when a resident exhibits said behaviors and notifications if an elopement occurs. Nurse Management including DON, ADON, MDS Coordinator and Unit Managers will be educated on policies including the importance of accurate and timely elopement assessments with MDS and care plan updates by the [NAME] President of Clinical Reimbursement The target date for training completion is Thursday, 08/29/2024 at 6 pm. New employees (all employees/ all disciplines) and agency nurses (if used) will be educated on the Elopement Management Process which includes the importance of accurate and timely elopement assessments with MDS and care plan updates; Elopement Binder and contents, Elopement definition including elopement behaviors and how to respond when a resident exhibits said behaviors and notifications if an elopement occurs. A mass text was sent to ALL employees regarding the required education/ in-servicing on the Elopement Management Process which must be received prior to returning to work for their next shift. Competency Testing must be completed and successfully passed before returning to work on their next shift. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and care planned with personalized interventions in place. The Administrator will audit new admissions in Morning Meeting with IDT to ensure the Elopement Assessment is completed, care planned and personalized. Elopement Risk Audits will be completed and reviewed by the Director of Nurses and/ or designee with each admission, readmission and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and to ensure that compliance and standards are met. Training on Elopement Management Process will be completed by Thursday 08/28/24 at 6 pm and will be provided to the staff by the Administrator and Director of Nurses and consist of the following action items: 1. If a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: 3. Attempt to prevent the resident from leaving in a non-threatening courteous manner 4. Request assistance from other staff member in the immediate vicinity as needed 5. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. 6. If a resident is missing, initiate the Elopement Management Process: 7. Determine if the resident is out on an unauthorized leave of absence. 8. If the resident was not authorized to leave, initiate a thorough search of the facility, grounds, and immediate areas surrounding the building. 9. If the resident is not located, notify the Administrator, the Director of Nursing, the Physician, the family/responsible party and law enforcement officials. 10. Follow HHSC's reporting guidelines. 11. When the resident returns to the facility, the director of nursing services or charge nurse shall: 12. Notify staff and examine the resident for injuries 13. Notify the physician and medical director of the resident return and assessment findings 14. Notify the family/ responsible party 15. Notify law enforcement 16. Document all events, interventions and outcomes in the resident record 17. Review the event details during the QAPI meeting to determine root cause and preventative measures. Re-education will be completed with the staff if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. Facility Monitoring Included: Record review of facility in-service training report, educational material, comprehension quiz, and sign in sheet for Administrator and DON, Elopement Management Protocols, dated 08/28/2024 conducted by Divisional [NAME] President of Clinical Operations (DVP) revealed Contents or summary training . 1. Ensure elopement assessments are accurate and timely for all residents. 2. Accurate and timely MDS and Care Plan updates. 3. Elopement binder, contents, and location. 4. Elopement definition and behaviors. How to respond to elopement behaviors (interventions) and notifications should an elopement occur (Admin, DON, MD, RP, HHSC.) In Interviews on 08/29/2024 between 11:16 AM and 2:52 PM with facility Administrator and DON revealed sufficient understanding of in-services related to: Elopement Coordinator role and scope; any attempts to leave the facility MUST be reported to the Elopement Coordinator; risk factors for wandering, elopement, exit seeking; behavioral triggers for wandering, elopement, exit seeking; examples of behaviors of wandering, elopement, exit seeking; what to do if one notices these behaviors; location and contents of Elopement Risk Form and Elopement Binder; interventions for residents that are high risk for wandering, elopement, exit seeking; what to do if a resident is missing; and information and confirmation of elopement drills. Record review of facility in-service training report, educational material, and sign in sheet for all staff, Wandering and Elopement Policy/Elopement Drill, dated 08/28/2024 conducted by Administrator and DON revealed: Contents or summary of training . facilities Elopement Coordinator is Administrator . Any attempts to leave the facility MUST be reported to the Elopement Coordinator. This includes when a resident opens or attempts to open an outside door . Elopement definition and behaviors. How to respond to elopement behaviors and interventions. In Interviews on 08/29/2024 between 11:16 AM and 2:19 PM with ADON A, ADON B, LVN C, LVN D, LVN E, LVN F, LVN V, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CMA M, MDS, Admission Coordinator, Activity Director, DOR, SLP N, SLP O, PT P, PT Q, OT R, OT S, COTA, PTA T, and PTA U revealed sufficient understanding of in-services related to: Elopement Coordinator role and scope; any attempts to leave the facility MUST be reported to the Elopement Coordinator; risk factors for wandering, elopement, exit seeking; behavioral triggers for wandering, elopement, exit seeking; examples of behaviors of wandering, elopement, exit seeking; what to do if one notices these behaviors; location and contents of Elopement Risk Form and Elopement Binder; interventions for residents that are high risk for wandering, elopement, exit seeking; what to do if a resident is missing; and information related to elopement drills. In Interviews on 08/29/2024 between 11:16 AM and 2:19 PM with ADON A, ADON B, LVN C, LVN D, LVN E, LVN F, LVN V, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CMA M, MDS, Admission Coordinator, Activity Director, DOR, SLP N, SLP O, PT P, PT Q, OT R, OT S, COTA, PTA T, and PTA U revealed they had participated in the simulation of an elopement drill either 08/28/2024 or 08/29/2024 conducted by the Administrator or DON. Observation and record review on 08/29/2024 at 2:30 PM revealed located at the front desk and nurses station of and determined sufficient contents of the facility's Elopement Binder(s). In observation of Resident #1 on 08/29/2024 at 2:45 PM he was in his room resting. Review on 08/29/2024 at 2:35 PM revealed Resident #1's MDS and Comprehensive Care Plan updated by 08/29/2024 2:30 PM to reflect resident's current behaviors and elopement risk. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. While the POR was accepted on 08/29/2024 at 12:04 PM and the IJ lifted at 08/29/2024 at 3:45 PM, the facility remained out of compliance at a severity level of potential for minimum harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of four residents reviewed for Comprehensive Care Plans. The facility failed to devise and implement any Comprehensive Care Plan goals and/or interventions for Resident #1's documented wandering, exit seeking, and/or elopement behavior on 07/16/2024 to prevent an incident of elopement by Resident #1 on 08/27/2024. Additionally, Resident #1 had a documented history of physical aggression on 07/16/2024 at 9:20 PM that necessitated the relocation of his roommate but was not updated on his Comprehensive Care Plan. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. While the POR was accepted on 08/29/2024 at 12:04 PM and the IJ lifted at 08/29/2024 at 3:45 PM, the facility remained out of compliance at a severity level of potential for minimum harm and scope of isolated/pattern, due to the facility's continued monitoring of the effectiveness of their plan of removal. This failure could place residents at risk of inappropriate, unsafe, and/or insufficient care based on insufficient Comprehensive Care Plans. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included dementia, major depressive disorder, generalized anxiety disorder, weakness, unsteadiness on feet, blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Quarterly Minimum Data Set (MDS,) dated 06/21/2024 revealed he was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 08. He was wheelchair bound and required partial/moderate assistance with shower/bathing and personal hygiene. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1 was assessed as having adequate vision. Resident #1 was documented as not having wandering behavior at this time. Resident #1's MDS was assessed has having no evidence of an acute changes in mental status from resident's baseline, and behavior was not present for disorganized thinking . unclear or illogical flow of ideas . Additionally, Resident #1 was scored as behavior not exhibited for physical behavioral symptoms directed toward others ( . hitting .) and behavior not exhibited for any rejection of care. Record review of Resident #1's Comprehensive Care Plan, dated 06/21/2024, revealed he was a full code, was at risk for falls related to deconditioning, gait/balance problems, psychoactive drug use, vision/hearing problems . and had impaired visual function related to blindness in right eye, macular degeneration . Resident #1 was non-adherent to treatment plan . refuses meals and [does not] allow staff to weigh him. He also had impaired cognitive function and impaired thought process r/t dementia. Further review revealed there was no evidence of aggressive behaviors, wandering, elopement, and/or exit seeking behavior was documented. Record review of Resident #1's Comprehensive Care Plan history on 08/28/2024 at 10:15 Am revealed there were no revisions that referenced aggressive behaviors, wandering, elopement, and/or exit seeking behavior. Record review of Facility's Provider Investigation Report, authored by facility DON, dated 07/16/2024, revealed that facility staff observed [Resident #1] hitting his roommate . residents were separated immediately . and his roommate was relocated to another room . [Resident #1] had bruising noted to bilateral hands with no complaints of pain . and [Resident #1] was placed on frequent monitoring until evaluated by MD and/or psych . Record Review of Resident #1's Psychiatric Provider Visit Notes, dated 07/22/2024, revealed [Resident #1] recently had his roommate move out due to an altercation between them, he is unable to recall it but states he knows something happened . Staff reports he and previous roommate were in an altercation necessitating someone moving out . Upon examination, patient exhibited illogical thoughts . [Resident #1] obtained a score of 9 out of 15 on the BIMS score indicating moderate impairment . Record review of Resident #1's Progress Note authored by LVN X, dated 07/16/2024, revealed: Resident wheeled himself out of his room and pushed the 2100 hall door to outside and the door closed behind him and the CNA called this Nurse to open door for him, Resident stated that he wanted to get some fresh air. Notified ADON/DON of occurrence. Resident is back in his room safely. offered Resident snacks and fluids. call light within reach, bed in low position. Interview of LVN X was attempted via telephone 08/28/2024 at 11:18 AM and 08/29/2024 at 3:00 PM and was unsuccessful. Record review of Resident #1's Progress Note by LPN Y, dated 08/27/2024, revealed: Resident eloped from facility, found in parking lot in the front of the building. no s/s of distress noted, V/S are normal, noted resident stated, I was looking for my brother, and my wife. resident found by facility staff member (therapy dept) nursing and all staff to closely monitor, report passed on to on-coming am nurse to f/u with pcp to for recommendations to obtain UA, rule out UTI, and notify Rp of elopement. Interview of LPN Y was attempted via telephone 08/28/2024 at 09:05 AM was unsuccessful. An interview with facility SLP on 08/28/2024 at 8:59 AM, she stated on 08/27/2024 at approximately shift change at 6:00 AM, when she was walking down the hall where the Therapy Service door was located, she stated she observed Resident #1 located outside of the facility ambulating beyond the curb. She stated she did not hear the door alarm. She stated she did not see Resident #1 exit the facility and was not certain how he got out of the facility. SLP stated she was confident that Resident #1 did not know the door code, but that door was set to have an alarm go off if the code was not entered or when the door was left open for an extended amount of time. She stated she was not aware of any wandering or exit seeking behaviors from Resident #1 prior to this incident and was not aware of any previous elopement attempts. Record Review of facility's Incident Report for July 2024, dated 08/28/2024, revealed no documentation of Resident #1's wandering, exit seeking, and/or elopement behavior/incident from 07/16/2024. Record review of facility's Incident Report for August 2024, dated 08/28/2024, revealed documentation that Resident #1 eloped 08/27/2024 at 5:30 AM. Record review of facility's Every 15 Minute Check Sheet provided by the DON on 08/28/2024 at 12:21 PM revealed sufficient staff post-elopement monitoring documentation of Resident #1 every 15 minutes between 08/27/2024 and 08/28/2024. In interviews with Resident #1 on 08/27/2024 at 10:20 AM and 11:48 AM, revealed he did not recall any of the incidents, denied having any of aggressive behaviors, wandering, elopement, and/or exit seeking behaviors. Further interview was not successful due to the resident's cognitive status and confusion. In interview with Resident #1's nurse for the day, LVN C, on 08/27/2024 at 10:27 AM, she stated he was slightly confused and was not aware of any behaviors, accidents, or elopements. In interview with ADON A on 08/28/2024 at 9:07 AM, he stated he was aware of Resident #1's aggressive, wandering, elopement, and/or exit seeking behaviors. He stated was working on 07/16/2024 but was not certain of any follow-up re-assessments and/or interventions ADON A stated Resident #1's MDS and Comprehensive Care Plan should have been updated in response to these behaviors as it was significant change, that it was the MDS nurse's responsibility, stated it was important for resident MDS and Comprehensive Care Plans were updated as new resident behaviors were exhibited, to ultimately ensure accuracy and to reflect resident care needs. In interview with the facility's MDS nurse on 08/28/2024 at 9:21 AM, she stated she began employment at the facility on 07/08/2024 and was not aware of Resident #1's previous behaviors of aggression, wandering, elopement, and/or exit seeking; but stated she had not had the chance to review past documentation. She stated she had participated in multiple interdisciplinary meetings at the facility, but none of these behaviors were reported to her in any of these meetings. She stated if had been reported to her, she would have updated Resident #1's MDS, created and implemented care interventions on Resident #1's Comprehensive Care Plan for aggression, wandering, exit seeking, and/or elopement behaviors. She stated that after Resident #1's initial aggression, wandering and/or exit seeking behavior was exhibited, the facility should have re-assessed his risk level, implemented enhanced monitoring, and completed frequent documentation of where he was located. She stated these interventions were important to accurately reflect the care needs of the resident and for the safety of the resident. In interview and record review with the facility's DON on 08/28/2024 at 9:35 AM, she stated that while the incident on 07/16/2024 was not an elopement, it was wandering, exit seeking, and/or elopement behavior and Resident #1 should have had an elopement reassessment, and the MDS and Comprehensive Care Plan should have been updated with interventions put in place. She also stated that she was not sure if his incident of aggression should have triggered revision of his Comprehensive Care Plan because again, she stated it was related to his development of a UTI. She stated it was the MDS nurse's responsibility to update these documents and to ensure interventions were implemented at the facility. The DON stated last month the facility had a remote MDS nurse and that was the reason the various assessments, revisions, and/or updates to resident documents were missed. She stated it was important for resident MDS and Comprehensive Care Plans to be updated when new behaviors were exhibited so the care was reflective of the resident needs. She stated it was ultimately her responsibility to ensure resident assessments, revisions, and/or any updates to resident documents were completed and accurate to best reflect resident care needs. Record review of facility policy Care Plans, Comprehensive Person-Centered rev. 03/2023 revealed, 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 . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintained the residents highest practicable physical, mental, and psychosocial well-being . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . 11. Assessments of residents are ongoing and care plans revised as information about the residents and the residents condition change. Record review of facility policy Resident-to-Resident Altercations, rev. 12/2016 revealed, .staff will: f. make any necessary changes in the care plan approaches to any or all of the involved individuals; g. document in the resident's clinical record all interventions and their effectiveness . Record review of facility policy, Wandering and Elopement Policy, rev. 03/2019 revealed, The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm . 1. If identified as a risk for wandering, elopement . the resident's care plan will include strategies and interventions to maintain the resident's safety . 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: 3. Document all events, interventions and outcomes in the resident record f. Review the event details during the QUAPI meeting to determine root cause and preventative measures. Record review of facility policy, Resident Assessments, rev. 03/2022 revealed A comprehensive assessment of every resident's needs is made at intervals . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate assessments and reviews according to . Admission assessment . Quarterly assessment Annual assessment . Significant change in Status Assessment An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. While the POR was accepted on 08/29/2024 at 12:04 PM and the IJ lifted at 08/29/2024 at 3:45 PM, the facility remained out of compliance at a severity level of potential for minimum harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal. The facility's Plan of Removal (POR) stated: PLAN OF REMOVAL Name of facility: [Facility] Date: 08/28/2024 F 656 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on 08/28/2024 at 3:30pm. Resident #1 continues to be a current resident at the facility. A head-to-toe assessment was completed on 08/27/2024 with no injuries or adverse effects noted. The resident was placed on Q15 checks on 08/27/2024 x 48 hours and will then be monitored hourly x 5 days. Psych Services saw the resident on 08/28/2024 and recommended that the resident be moved to a room closer to the nurse's station. Official report pending. The resident's elopement assessment was updated this evening and shows high risk. An off-cycle Significant Change MDS was opened with an ARD of 08/29/2024. The Care Plan was updated 08/28/2024 4:30 pm to reflect High Risk status with personalized interventions noted. If at any time the resident is determined to require a locked unit, the facility will seek placement elsewhere with the assistance of family and social services. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 6pm on 08/28/2024. The following plan was implemented on 08/28/2024 to prevent residents from leaving the facility unsupervised. PLAN TO IMPROVE THE FACILITY ELOPEMENT RESPONSE 1. Educate and Inservice staff on the: Importance of accurate and timely elopement assessments Accurate and timely MDS and care plan updates Elopement Binder, contents, and location Elopement definition including elopement behaviors How to respond when a resident exhibits said behaviors Notifications if an elopement occurs (Admin/ DON, MD, RP, HHSC reporting if criteria is met) 2. An Elopement Drill is scheduled for 08/28/2024 for evening and night shift and 08/29/2024 for day shift to shift to ensure all staff know how to respond to elopements. 3. The Elopement Binder will be reviewed and updated accordingly once the Elopement Assessments have been completed. The Elopement Binder contents include the face sheet, resident pictures and Department Manager Contact Info). Elopement Binders are located at the reception desk and Nurses Station. The DON and/or designee will review the binder monthly to ensure that all new admissions and any Elopement Status changes have been captured. 4. The MDS and Care Plan will be updated with any significant change and/or quarterly or annual assessments depending on which assessment is required. The MDS Coordinator will ensure accuracy by reviewing the most recent Elopement Assessment. The DON will review the MDS prior to signing to ensure the information is accurate. MDS and Care Plan supporting documentation is located in the Resident's Electronic Medical Record. Facility Plan to Ensure Compliance Quickly Education was provided to the Administrator, and Director of Nurses by Divisional VP of Clinical Operations on the following items: Importance of accurate and timely elopement assessments Accurate and timely MDS and care plan updates Elopement Binder, contents (Face Sheet, Resident Pictures, Department Manager Contact Info), and location binder stored Elopement definition including elopement behaviors How to respond when a resident exhibits elopement behaviors (interventions) Notifications if an elopement occurs (Admin/ DON, MD, RP, HHSC reporting if criteria is met) Education will be provided to current staff by the Administrator and DON on the Elopement Management Process and policies, Elopement Binder and contents, Elopement definition including elopement behaviors and how to respond when a resident exhibit said behaviors and notifications if an elopement occurs. Nurse Management including DON, ADON, MDS Coordinator and Unit Managers will be educated on policies including the importance of accurate and timely elopement assessments with MDS and care plan updates by the [NAME] President of Clinical Reimbursement. The target date for training completion is Thursday, 08/29/2024 at 6 pm. New employees (all employees/ all disciplines) and agency nurses (if used) will be educated on the Elopement Management Process which includes the importance of accurate and timely elopement assessments with MDS and care plan updates; Elopement Binder and contents, Elopement definition including elopement behaviors and how to respond when a resident exhibits said behaviors and notifications if an elopement occurs. A mass text went out to ALL employees regarding the required education/ in-servicing on the Elopement Management Process which must be received prior to returning to work for their next shift. Competency Testing must be completed and successfully passed before returning to work on their next shift. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and care planned with personalized interventions in place. The Administrator will audit new admissions in Morning Meeting with IDT to ensure the Elopement Assessment is completed, care planned and personalized. Elopement Risk Audits will be completed and reviewed by the Director of Nurses and/ or designee with each admission, readmission and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and to ensure that compliance and standards are met. Training on Elopement Management Process will be completed by Thursday 08/28/24 at 6 pm and will be provided to the staff by the Administrator and Director of Nurses and consist of the following action items: 1. If a resident is identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: 3. Attempt to prevent the resident from leaving in a non-threatening courteous manner 4. Request assistance from other staff member in the immediate vicinity as needed 5. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. 6. If a resident is missing, initiate the Elopement Management Process: 7. Determine if the resident is out on an unauthorized leave of absence. 8. If the resident was not authorized to leave, initiate a thorough search of the facility, grounds, and immediate areas surrounding the building. 9. If the resident is not located, notify the Administrator, the Director of Nursing, the Physician, the family/responsible party and law enforcement officials. 10. Follow HHSC's reporting guidelines. 11. When the resident returns to the facility, the director of nursing services or charge nurse shall: 12. Notify staff and examine the resident for injuries 13. Notify the physician and medical director of the resident return and assessment findings 14. Notify the family/ responsible party 15. Notify law enforcement 16. Document all events, interventions and outcomes in the resident record 17. Review the event details during the QAPI meeting to determine root cause and preventative measures. Re-education will be completed with the staff if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. Facility Monitoring Included: Record review of facility in-service training report, educational material, and sign in sheet for Administrator, DON, MDS, ADON A, ADON B, DOR, and Activity Director MDS/SIG Change/Timely Completion of Assessments dated 08/28/2024 conducted by [NAME] President of Clinical Reimbursement (VPCR) revealed Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In Interviews on 08/29/2024 between 11:16 AM and 2:52 PM with facility Administrator, DON, MDS, ADON A, ADON B, DOR, and Activity Director revealed sufficient understanding of in-services related to: Contents and importance of Care Plans, Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In Interviews on 08/29/2024 between 11:16 AM and 2:19 PM with LVN C, LVN D, LVN E, LVN F, LVN V, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CMA M, Admission Coordinator, SLP N, SLP O, PT P, PT Q, OT R, OT S, COTA, PTA T, and PTA U revealed sufficient understanding of in-services related to: Contents and importance of Care Plans, Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. Record Review on 08/29/2024 at 2:35 PM revealed Resident #1's MDS and Comprehensive Care Plan were updated to reflect resident's current behaviors and elopement risk. In observation of Resident #1 on 08/29/2024 at 2:45 PM he was in his room resting. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. While the IJ was lifted at 08/29/2024 at 3:45 PM, the facility remained out of compliance at a severity level of potential for minimum harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 1 (Resident #1) reviewed for accident hazards. The facility failed to ensure appropriate supervision were provided to Resident #1 to prevent her from sustaining hot liquid burn. DA B gave Resident #1 coffee with a cup that had no lid. Resident #1 dropped coffee on her thighs causing an injury with blisters on her right thigh and redness on her left thigh. An Immediate Jeopardy (IJ) was identified to have existed from 04/19/22 to 04/19/22 . The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could place residents requiring supervision at risk for [CONDITION(S)], serious injury and death. Findings included: Review of Resident #1's Face Sheet revealed she was a 67year old female with an original admitted [DATE]. Resident #1's diagnoses included: type 2 diabetes without complications, lack of coordination, muscle weakness, unspecified dementia with behavior disturbance, muscle wasting and atrophy. Record Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed, her BIMS (Brief Interview of Mental Status) was 15 indicating that she was cognitively intact. Her functional status indicated that resident needed set up help while eating, she required supervision with eating and drinking, she had no behavioral issues and she required extensive assistance with mobility. Other ADLS were not assessed during this MDS evaluation. Record review of Incident Report dated 04/19/2022 revealed the following: Resident #1 was awaiting an orthopedic appointment on 04/19/22 at approximately 6:25AM. She was assisted to the front lobby to wait for transportation. In the meantime, she wheeled herself to the kitchen to request a cup of coffee prior to her appointment. DA B gave her a half- cup full of coffee. The cup did not have a lid. Resident#1 was attempting to propel her wheelchair while holding her coffee causing a coffee spill. DA B encouraged Resident#1 to report to the nurse for evaluation after the spill, but she declined, twice. She was transported to her to her appointment. Upon return, Resident#1 was assessed, and the following skin interruptions were noted: redness to the left thigh and blisters to the right inner thigh with redness. No measurements were given for this assessment. Additional training provided to nursing staff and dietary staff. The Resident#1 did not require any treatment other than in-house treatment and management. Record review of Resident #1's medical record revealed, nurses' notes entry by LVN P dated 04/19/22 revealed Resident #1 had redness to left inner thigh and redness and blisters to her right thigh. Review of Physician Orders dated 04/19/22 not timed, received verbally from Physician E by LVN P revealed, Redness to left inner thigh redness and blisters to right thigh apply [MEDICATION(S)] Cream BID and leave open to air until resolved Additional review of Resident #1's nurses' notes dated 04/21/22 indicated an open blister on the right inner thigh, a verbal was given by Physician E to LVN P to Right inner thigh open blister apply [MEDICATION(S)] cream and cover with a dry dressing. Review of Resident # 1's MAR and TAR on 04/27/22 revealed the physicians orders were in place and being followed . Record Review of the facility kitchen's coffee temperature log for April 19, 2022 revealed morning coffee temperatures in degrees F, 1159.3, Lunch coffee temperatures in degrees F, 158.4,. Supper coffee temperatures in degrees F 161. In an interview with Resident #1 on 04/26/22 at 4:55PM, Resident #1 stated that she needed coffee the morning of 04/19/22. DA B told her there were no lids for the coffee cups. Resident #1 stated that she insisted, and DA B gave her half a cup of coffee with no lid. Resident #1 stated that she should have used a cup with a lid. She also stated that she had tremors. Resident #1 stated that it was hurting bad that day, but she was feeling better at the time of the interview. Resident #1 had a dressing to her right thigh that was clean dry and intact. During an interview on 04/27/22 at 9:30AM, DA B stated that Resident #1 came to the kitchen door asking for coffee. She said Resident #1 was in her wheelchair and she propelled herself to the kitchen. DA B told her she could not give her coffee because there were no lids. DA B stated Resident #1 started crying and screaming and kicking and demanded to have coffee. She said Resident #1 requested to have even a half cup of coffee. DA B stated she gave Resident #1 a half cup of coffee, the cup had no lid. When the aide turned back Resident #1 stated that she had spilled the coffee on her lap. Resident #1 refused to go to the nurse. DA B then pushed Resident #1 in her wheelchair to the front desk, MA F was at the front. DA B told MA F that Resident #1 needed to go to the nurse, but Resident#1 said she had an appointment. DA B stated that at the time of the interview, they had tall black reusable coffee cups in the kitchen, but there were no lids. They also had white and pink cups for coffee, but residents didn't bring the lids back. DA B also stated that when residents were given coffee, the cups were supposed to have lids on them. She stated that it was unusual for Resident #1 to ask for coffee at that time of the morning, she usually asked for lemonade. DA B stated that if you gave a resident coffee without a lid, 9 times out of 10 they would burn themselves. She also said that even when they had lids they could burn if they were not supervised. The temperature of the coffee on the morning of 04/19/22 was 159.3 degrees Fahrenheit. Further interview revealed that DA B stated Resident#1's wheelchair had no cup holder, and that Resident#1 was propelling herself with coffee in her hands. DA B stated she knew she should not have given Resident #1 the coffee cup with no lid. In an interview on 04/27/22 at 9:50, LVN G stated that she was the nurse assigned to Resident#1's care on 04/19/22. She stated that Resident#1 had an appointment on 04/19/22 at 6:30AM with her orthopedist outside the facility. She told CNA H to take Resident#1 to the front door. Resident #1 came back from appointment at about 11AM. NP D who was in the building, informed LVN G that Resident#1 had blisters. NP D told LVN G to have the facility wound care nurse assess the burned area and obtain orders for treatment from the wound care physician. LVN G went to talk to Resident#1, and Resident #1 stated that she spilled coffee on herself. LVN G stated when residents needed coffee, they were given with cups that had lids all the time. LVN G said she did not know if Resident#1's coffee cup had lid that day. LVN G said she did not know about the burn until the NP D notified her. During an Interview on 04/27/22 at 10:22AM, MA F stated that Resident #1 was sitting at the front waiting to go for appointment. Resident #1 stated she needed coffee, MA F told her to go and get it. Resident #1 then went to the kitchen to retrieve her own cup of coffee. While she was gone, the driver came, and MA F went to get Resident #1. DA B was pushing Resident#1 to the front area. DA B said Resident#1 refused to go to the nurse. An interview on 04/27/22 at 10:26am, DA B stated that previously, they had a lot of lids in the kitchen but in the recent past there were only a few. She said residents were taking the cups with lids but when they brought them back there no lids.DA B stated that when residents requested coffee, the dietary staff was giving the residents coffee in cups without lids even thought the dietary staff was aware that residents would likely be burned by the hot coffee. In a telephone interview on 04/27/22 at 1:32 PM, NP D stated all she knew was that Resident #1 had an appt. NP D saw Resident #1 at the nurses' station and Resident #1 told her she spilled coffee on herself that day. Resident #1 showed NP D the site and she saw that she had blisters. She told the nurse, ADON and Administrator. She also stated that wound care nurse was informed to contact wound care physician to get orders. Physician E followed Resident #1r later. Physician E stated thought it was second degree burn because of the blisters to the area upon his assessment of the area. She stated that Resident #1 did not have a condition that could have caused her to spill. She had not mentioned any tremors to her. She also said that she was shocked that Resident #1 had not reported to anyone. Physician E stated that Resident #1denied pain. In a telephone interview on 04/27/22 at 2:58pm, physician E stated that NP D had seen Resident #1 that morning after appointment. He was told that Resident #1 was scheduled for an appointment, and she was at the front to wait. She wheeled herself to the kitchen and asked for coffee, they told her there were no lids. She asked for half a cup, and it ended up spilling. DA B wanted to bring her back to the nurse, but she refused. Resident#1 did not tell anyone. She was trying to rush to her appointment, she was told there were no lids. He thought they discussed that they should have had a lid. When the physician was asked about prior incidents, he stated that there was a resident he was taking care of last year. She was a [CONDITION(S)] resident and while she was in her bed, she spilled coffee on herself. Previously they were supposed to check the temperature, or reduce the temperature of the coffee, and use lids. Interview and observation on 04/28/22 at 7:30AM, DM A stated that residents didn't usually eat in the dining room at breakfast and dinner, they only ate lunch at the dining. A meal cart was observed with breakfast trays that had empty cups with lids on them. DM A stated that they put the cups on the trays so that nursing staff would pour coffee for the residents when passing the trays. She also stated that the cups were only for those residents identified at risk. DM A provided a resident's meal ticket form the cart that stated to use a sippy cup and another ticket for a different resident stated to use a cup with a lid. DM A said would also be checking the coffee temperature for each cart that they sent to the halls. An interview on 04/28/22 at 11:56AM, Speech Therapist J stated that she received in-service about procedure for coffee that morning. Speech Therapist J stated if residents requested coffee, they could not get it from the kitchen. Nursing staff had to get it for them. If there was an emblem of coffee next to the resident's name on the door, they had to use a non-spill cup or a cup with a lid. An interview on 04/28/22 at 12:PM, CNA K stated she received an in-service on 04/27/22 about coffee spills. CNA K stated nursing staff had to give residents lids, especially residents who were shaky or using one hand. They had to make sure coffee was not too hot and put a lid on the cup. Certain residents who could not drink coffee by themselves needed assistance. The kitchen staff would check the temperature before giving it out. An interview on 04/27/22 at 1:10PM, DM A stated she had cups with lids, and would make sure she had ten extra cups than the 50 people on the high risk for spills list. DM A stated if the number of cups was less than required, she won't serve coffee until she obtained more. She would check temperatures for coffee to make sure it was at 160 degrees F or less. She did in-service with dietary dept about hot coffee. The staff who were absent would get in-service prior to their next shift. She also stated that residents were no longer allowed to get caffeine by themselves from the kitchen. An interview on 04/27/22 at 3:46PM, DON stated measures that were put in place previously and at the time of the previous citation were not implemented and monitored. She stated she understood what monitoring was required for her dept. She had conducted in-services with nursing staff and would continue re-educating staff. Interview on 04/27/22 at 6:58PM, revealed, LVN L received in-service on how to identify residents who were at risk of getting burnt from hot coffee. LVN L stated these residents would include those with behaviors, contractures, mood swings, and cognition issues. They were given an assessment tool to use for the residents. Once they identified the residents, they would report to dietary staff and other nursing staff to make them aware. They also had a coffee sign by the door against residents' names to identify those at risk. Nursing staff had to monitor the residents while eating or drinking for safety. Residents could not drink hot liquids while lying in bed, they had to be in upright position. They had to use non-spill and insulated to prevent spills or [CONDITION(S)]. In an interview on 04/28/22 at 07:03PM, Administrator revealed,he had put in place cup identifiers on the door against residents' names. Nurses would do assessment upon admission or re-admission to identify residents at risk for hot liquid injury. Also, dietary staff will be given a list of those residents at risk for spills to ensure they use appropriate cups. He had bought plenty of cups with lids and he would continue to monitor supplies with DM A to ensure there were always enough lids available. Administrator would review hot beverage temperature logs no less that four times weekly for three weeks. In an interview on 04/28/22 at 7:45pm, ADON C in-serviced nursing staff to conduct hot beverages assessment every 90 days and as needed. Nursing staff would assess residents for risk for hot beverage injury by checking functional ability, cognitive ability, presence of contractures, and ability to realize that coffee was hot. After assessment, they would generate a list for identified residents that will be shared with dietary staff, nursing staff, therapy department and anyone involved in resident care. They would put identifiers on the residents' door next to their names, kitchen would ensure temperatures were appropriate but maintaining a daily log, nursing staff would ensure coffee was safe to serve when passing trays. All staff would make sure the cups had lids before serving residents coffee, and if there were no lids, no coffee would be served. DM A would make sure they always had enough stock of cups with lids for residents. An interview on 4/29/2022 at 11:00AM, LVN P revealed that she received training from leadership staff regarding hot liquids. LVN P stated the training provided included the following residents should be assessed for risk for spills upon change in conditions, admission, and as needed. Nurses would conduct the assessments. Risk factors for spills were residents with cognitive deficits, tremors, and limited mobility. Every resident who drank coffee had to use a cup with a lid. There were coffee cups with lid decals located at each resident's door on the room label to identify those at risk. All spills should be reported to the charge nurse. Charge nurses would check liquids on food carts before CNAs would serve. Dietary staff would check the coffee temperature before the carts left the kitchen. Resident should not be allowed to get coffee directly from the kitchen. An interview on 4/29/22 at 11:15AM, .MA Q stated that she attended an in-service on 4-27-2022 and again on 4-29-22 on the safety of residents and hot beverages. She stated all residents in the nursing home should be supervised and assessed, as conditions change. She stated that residents who drank coffee were being assessed for, tremors, behaviors, cognition, and contractures. MA Q stated there was a picture of a coffee cup on the name tag of residents that had been used to identify residents at risk for spills. Coffee should never be hotter than 160° F. Dietary staff and nurses were checking temperatures for appropriate levels before CNA's would serve to residents. Resident should not be allowed to go to the dining room to get coffee. All spills and any concerns would be directly reported to charge nurses. An interview on 4/29/22 at 1:15 PM, CNA N confirmed verbally that she received training for hot beverages. CNA N stated residents at risk for injury included those with tremors, behavior problems, memory problems, and unsteadiness. They should be assessed for hot liquids because these were the factors that contribute to accidents. Residents at risk had been identified and symbol with a cup with a lid had been put by their names on the door. The list was at the nursing station. Charge nurse were checking coffee temperature before aides distributed to residents. Residents would not go to the kitchen to get coffee independently. An interview on 4/29/22 at 1:25 PM, CNA O stated he received training on hot beverages. CNA O risk factors included residents with memory lost, limited range in motion, contractures. These should be assessed for hot beverages injuries. All residents who drank coffee were assessed for spill risk and a list was located at the nursing station. Spills would be reported to the charge nurse immediately for them to assess. Coffee should be served in a cup with a lid. He would report any concern to the administration. In an interview on 04/29/22 at 1:30 PM, housekeeping supervisor M said he received in- service with other staff. Housekeeping Supervisor M stated hot beverages should be monitored and assessed with residents. Residents that were bedbound, had cognitive problems, tremors or unsteadiness were at risk. Residents who drank coffee would be given a cup with a lid on top. Hot beverage spills would be reported to the charge nurses. Charge nurses would check residence coffee temperatures before they left the cart. An interview on 04/29/22 at 1:45PM, DM A said she would be taking coffee temperatures three times a day and would keep a log. DM A appropriate temperature range should be between 155 F and 175F. She had a list of residents in the kitchen that drank coffee using coffee cups with lids. Additional cups with were in the kitchen and administrator's office in the event some got misplaced. Cups were to be filled halfway with coffee. Nursing and dietary staff would work together to pick up cups from the residents' rooms to assure ongoing coffee support. In addition, no residents should be getting coffee directly from the kitchen. An interviewing on 04/29/22 at 2:15PM, DON said that nursing staff would be assessing all residents for risk for spills. THE DON stated she would conduct ongoing assessment and training with staff on the safety of hot beverages. Leaderships staff would continue to monitor staff and train for consistency with care and protection of residents. The Administrator would be checking temperatures in the kitchen several times a day. Additional cups with lids were in the administrator's office. All residents should have a cup with a lid and coffee cups decals were located on each door for staff to identify. DON would teach staff on how to recognize and identify risk and concerns. Spills would be immediately reported to nurses in charge. An interview on 04/29/22 at 2:45PM, the Administrator stated that he was checking temperatures in the kitchen and comparing it with dietary staff. The admininstrator stated he would assure that the kitchen staff comprehend and communicate the importance of hot beverage safety as well as healthcare staff. Monitoring and training will be ongoing. Coffee times have been limited to meal and snack times only to allow supervision and monitoring. All residents would be assessed for hot liquids safety. Residents with underlying mobility issues and cognitive issues should be especially supervised when receiving hot liquids. Additional cups had been ordered and if any cups were lost, staff would be notified of where to locate additional cups. Administrator would be checking coffee temperatures several times a day to ensure they were at appropriate. He would be interviewing healthcare staff throughout the day for accuracy in the routine for protecting residents from hot liquid injuries. All incidents of hot liquids and spilled would be reported immediately to the administrator and medical attention proved. Record Review of an in-service dated 04/19/22 revealed it was given by the DON titled, hot liquid burn high risk. Staff to identify residents on high risk of hot liquid burn. Place identifiers (cup with lid) resident's name by the door. Ensure residents who are identified as high risk have adequate supervision. Communicate with dietary for changes. Charge nurses to check each meal tray to ensure compliance, with 31 staff attending. Review of the List of Residents identified by the facility as being High Risk for Spills on 04/27/22 revealed that Resident#1 had been added to the list as of 04/19/22 Record Review of an in-service dated 04/19/22 was given by the DM A regarding hot beverage policy. Coffee should only be served from the urn, not coffee machine. Before serving HOT liquid, must be checked twice and should be 160 or below, with 7 employees who worked in the kitchen attending. Review of facility policy titled nutrition policies and procedures dated 08/01/2020, it revealed that Precautions shall be implemented to limit the risk of [CONDITION(S)] from hot beverages (coffee, tea, etc.) procedure, patients or residents should not carry hot beverages without a lid while walking or moving in a wheelchair when serving hot beverages to patients or residents with behavior or medical conditions that put them at risk* for spills: evaluate the president's ability to manage hot beverages independently, provide assistance and/or supervision as needed, consider providing a lid for coffee cup or travel mug, allow hot beverage to coo before serving. Residents who may be at greater risk may include, but are not limited to, those with tremors, poor hand control, visual impairment or behavioral issues. Record review from the reference link below reveals: Hot beverages such as coffee are frequently served at temperatures between 160 degrees F and 185 degrees F. Brief exposures to liquids in this temperature range can cause significant scald [CONDITION(S)]. https://pubmed.ncbi.nlm.nih.gov/ 454/ PMID: 454 DOI: 10.1016/j.[CONDITION(S)].2007.09.012. accessed 04/27/22. An ad hoc Quality Assurance Performance Improvement Committee meeting was held on 4/19/2022 at the time of initial discovery.

Based on interview and record review, based on the comprehensive assessment of a resident, the facility must ensure that a resident with pressure ulcer receives necessary treatment and services, consistent with professional stands of practice, to healing, prevent infection and prevent new ulcers for one (Resident#1) of four Residents reviewed for pressure ulcers. 1. LVN A failed to perform treatment on Resident #1's pressure injury with necrotic tissue to the left foot for 5 days of 12 days when Resident#1 went to [MEDICAL TREATMENT]. 2. LVN B failed to assess, document and notify physician of change in condition and obtain treatment for [REDACTED].#1's back. 3. The facility failed to identify two pressure injuries to Resident #1 right foot. 4. The facility failed to obtain a referral appointment on 04/13/18 with an alternative wound care clinic that coordinated with Resident #1's [MEDICAL TREATMENT] schedule. An Immediate Jeopardy (IJ) was identified on 05/18/18 at 5:45 P.M., While the IJ was removed on 05/23/18 at 9:50 A.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the seven residents with pressure injuries by placing them at risk for not receiving wound care, delayed healing, wound infections and mental anguish. Findings included: Review of Resident#1's MDS dated [DATE] revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 01/17/18 revealed he goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. He is at risk for skin breakdown related to impaired bed mobility and incontinent of bowel and bladder. He has a pressure ulcer to his left medial foot, unstageable, left lateral foot unstageable and Right Medial foot unstageable. An interview on 05/02/18 at 2:10 PM, Resident #1's family member revealed, she stated, she had informed LVN B on 04/30/18 of a sore on his back. She stated LVN B observed the sore on his back and gave the family member a tube of Triple antibiotic ointment and told family member to put it on the sore. On Wednesday 05/02/18, she informed LVN B that there was blood on his bed sheets from the sore on his back. She stated the facility has not been treating the wound on his back and the pressure ulcer on his right foot and he was not receiving daily wound care to his left foot. She stated the physician at the hospital had made a referral see to a specific Dr. for his left foot pressure ulcer, that would see him on his off days from [MEDICAL TREATMENT], but the facility had not made the appointment. Observation of wound on Resident #1's back on 05/03/18 at 10:00 A.M with Family member revealed, a stage two pressure on the left medial aspect on the back there was an open area approximately 1cm x 1 cm with a pink center without drainage. The surrounding tissue was natural in color with [MEDICAL CONDITION]. Review of Resident #1's Physician orders for the month of (MONTH) (YEAR) and (MONTH) (YEAR) reflected to treat the left medial foot with [MEDICATION NAME] every day for 14 days then re-evaluate, treat left medial heel with skin prep, every day for 14 days then re-evaluate, treat left medial first toe with skin prep, every day for 14 days then re-evaluate. There were no orders to treat the back wound with the Triple antibiotic. There was no physician order to treat the wound on his back or wounds on his right foot for (MONTH) (YEAR) or (MONTH) (YEAR). Review of Resident #1's Treatment Administration Record treatment for [REDACTED]. the treatment had been performed. There was no treatment for [REDACTED]. Observation on 05/04/18 at 8:30 A.M of Resident #1's right foot with LVN A, wound care nurse, revealed two unidentified pressure injuries, one stage two on the tip of the right great toe, measured approximately 0.5 cm x 0.5cm, center dark and superficial in depth, no drainage. The right heel Deep Tissue Injury measured approximately 0.1cm x1 cm, round shape and color dark and superficial in depth, no drainage. LVN A stated she had not seen the new pressure injuries on his right foot, and there were no orders for treatment. Review of Resident #1's Weekly Skin Integrity record signed by LVN A, dated 03/13/18 through 04/25/18 did not reveal any pressure injuries to the right foot. Interview on 05/03/18 at 3:00 P.M. LVN D revealed she worked the evening shift Monday through Friday. She stated she did not treat Resident #1's left foot. The wound care treatment is not on the Medication Administration Book. The wound care is in the Treatment book and she didn't look at the treatment book. She stated there were a couple of times the family had asked her to treat his left foot. Review of Wound Care Physicians V, initial evaluation dated 03/13/18, Resident#1's left, medial foot wound measured 3.0cm by 3.0cm unstageable, treatment skin- prep every day. On 03/21/18 revealed patient not seen due to a non-wound hospitalization since last visit. LVN B wound care nurse stated, Wound Care physician V came in on Tuesday 03/13/18 but the scheduled visit days for the facility was every Wednesday, since resident goes to [MEDICAL TREATMENT] on Wednesday the wound care physician can't see him once a week. Review of Progress notes from LVN A wound care nurse revealed, 0n 03/28/18, 04/04/18, 04/11/18 and 04/18/18 Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Then on 04/25/18 Wound Care Physician V seen him. The Left medial foot pressure injury measurements were 2.5cm x2.0 unstageable, necrosis thick adherent black necrotic tissue, eschar. Apply [MEDICATION NAME] once a day. Then on 05/02/18, Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Interview on 05/03/18 at 10:00 A.M. LVN A wound care nurse revealed, she had written the word [MEDICAL TREATMENT] on the dates of 04/12/18, 04/20/18, 04/27/18, 04/30/18 and 05/01/18. She stated the treatments were not done. Resident #1 left for [MEDICAL TREATMENT] before she enters the facility each day and has not returned from [MEDICAL TREATMENT] until after she leaves for the day. The evening shift nurses don't do the treatments on the days he goes to [MEDICAL TREATMENT]. She stated when she enters an order into the computer system for daily treatment's the system requires a specific time or shift. She stated she would change the treatment time to the evening shift on the day he goes to [MEDICAL TREATMENT]. Interview on 05/03/18 at 9:50 A.M. with LVN A, wound care nurse, revealed LVN B informed her on 04/30/18 of the open wound on Resident #1's back around noonish, but he goes to [MEDICAL TREATMENT] on Mondays, Tuesdays and Wednesdays around 9:30 A.M. returned after she leaves for the day around 5:00 P.M. Then on 05/01/18, she went to Resident#1's room to assess the wound, but he had gone to [MEDICAL TREATMENT]. She stated Resident #1 was feeling ill on 04/30/18 and didn't go to [MEDICAL TREATMENT], but she was not informed he was in the facility. He had gone to [MEDICAL TREATMENT] on Tuesday and she was not able to assess the wound on his back. She stated he was out for a Doctor's appointment and she would take care of his wound when he returns. Interview on 05/03/18 at 11.00 A.M, LVN B revealed, she had been informed by a family member on 4/30/18 Resident #1 had a wound on his back. She stated she looked at the wound it was on the inner part of his back close to his spine. It looked like a blister was there and the top came off. She reported the wound to LVN A (wound Care Nurse) around lunch time. She stated she didn't initiate care or document the wound and didn't notify the physician of the change of condition because she thought LVN B would take care of it since she does all the wounds. She stated she don't treat Resident#1's pressure injuries to his foot before his go to [MEDICAL TREATMENT] because it was the wound care nurses that done his wounds and she was off duty before he returned from [MEDICAL TREATMENT]. Review of Resident#1's telephone order for 05/03/18 revealed Back- cleanse with NS, pat dry with 4x4, apply skin prep leave open to air qd x 14 days, then re-evaluate. Observation on Resident #1's telephone order dated 05/04/18 revealed wound care to be done daily, on days of [MEDICAL TREATMENT], wound care to be done on 2-10 shift. Review on Resident #1's Physician telephone dated 05/04/18 revealed an order to treat the Right great toe -apply skin prep, leave open to air qd x14 days, then re-evaluate. Right heel-apply apply skin prep, leave open to air qd x14 days, then re-evaluate. Interview on 05/03/18 at 11:15 A.M., the DON stated the facility had wound care services with Physician V, that came every Wednesday for the facilities residents needing wound care. Observation on 05/04/18 at 8:30 A.M, with LVN A of wound care and measurement of pressure ulcer by LVN A, revealed the measurement of the left medial foot was 5cmx4cm hard black cap over the wound bed, with 1.5cmx1.5cm open area to left lateral edge of the wound with scant serous drainage. The pressure injury on the back measured 1cm x 1 cm with a pink center without drainage, no redness or [MEDICAL CONDITION] to the surrounding tissue. Interview on 05/04/18 at 9:45 A.M. with NP revealed, he had not been notified of the pressure injury on Resident #1's back. He was not notified of Resident #1 not getting his daily wound care treatment to his left foot. He stated he can't address changes in his status unless he has been notified. He stated had to go through the family to find out about any changes in his condition. A second Interview on 05/19/18 at 11:00 A.M. with NP revealed he had made a referral on 03/31/18 after communicating with DR. V that she was not able to see Resident #1 consistently because of his [MEDICAL TREATMENT] schedule. He visited with the Resident #1 on 04/13/18, the left medial Metatarsal foot pressure ulcer was worsening. Resident #1 was about to leave for [MEDICAL TREATMENT] and he told him to go ahead to [MEDICAL TREATMENT]. He spoke with a Vascular Physician. Resident #1 left the [MEDICAL TREATMENT] and was transport to the emergency room for evaluation by physician CC and was advised to follow-up with physician AA, a wound care specialist. The appointment was not made until 05/17/18. Review of Discharge Instruction from physician BB on 04\13\18 revealed, Resident#1 had a referral for Physician F for wound care to the left foot. Interview on 05/19/18 with Wound care Physician V revealed she had communicated Resident #1's primary physician on 03/30/18 to make a referral for another wound care physician or wound clinic related to the schedule not coinciding with Resident [MEDICAL TREATMENT] Schedule. The referral was written on 03/30/18 for a wound care consult, but it was not followed through. She received one set of pictures of Resident's left foot pressure injury on 04/13/18 and no other time from LVN A. She communicated with LVN A (wound Care nurse) on multiply occasions for Resident #1 to see another wound physician because she was unable to see him on consistently related to his [MEDICAL TREATMENT] schedule. She stated she was at the facility on Wednesdays only. She communicated with Resident #1's primary physician on 03/30/18. She stated she could not treat pressure ulcers on pictures alone. She revealed if the pressure injury stayed dry that it would take extended amount of time to heal even if ever would heal, but if the wound became soft, draining signs of infection it would have to be debrided for it to possibly heal. Review of Progress notes dated 05/17/18 from Physician F, Wound Care Specialist, revealed on 05/03/18, Resident #1 was seen by Physician BB. The patient underwent Angiogram with atherectomy and the wound has improved. Physician BB recommended follow-up for wound care at the Wound Care Clinic. It took the facility three weeks to get him scheduled. Integumentary: revealed, open wound of left medical foot at first metatarsal head; wound #1 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound with etiology of pressure ulcer and is located on the left, medial metatarsal head first. The wound measured 3cm length x2.9 cm width x 0.1 cm. depth. There was medium amount of serous drainage. There was a large 67percent to 100 percent of necrotic within the wound bed including eschar and adherent slough. Right foot: planter heel with Deep tissue injury. Pressure ulcer of other sites, unstageable. Wound #1: selective debridement of portion of eschar and exudate; large amount of eschar. Vascular: palpable left distal pulse. Interview on 05/03/18 at 3:45 P.M., LVN C unit Manager revealed she was not aware Resident #1's pressure injuries were not being done on the days he went out for [MEDICAL TREATMENT]. She was not aware of the referral request on 04\13\18. She stated any nurse can do his treatment before he went out to [MEDICAL TREATMENT] or after he returned from [MEDICAL TREATMENT]. Interview on 05/03/18 at 3:48 P.M., DON revealed she was not aware Resident #1's pressure injuries were not being treated on his [MEDICAL TREATMENT] days and the nurse should do the wound care before he left for [MEDICAL TREATMENT] or after he returned as long as his wound care was done daily. She was not informed of the referral on 04/13/18 not being followed up with, but the appointment will be done. She was not aware Wound Care physician was not seeing him because he was out for [MEDICAL TREATMENT]. The Administrator was notified on 05/18/18 at 5:45 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The Medical Director was notified on 05/18/18 at 8:00 P.M. of the IJ. A meeting with the facility to discuss failure to identify, communicate, and perform an assessment for wounds for [MEDICAL TREATMENT] resident including failure to complete orders treatments and follow physician orders. The facility's Plan of Removal was accepted on 05/19/18 at 3:20 P.M. and included: 1. The licensed nurse identified in the Immediate Jeopardy was terminated on 05/04/18. The Wound care Nurse LVN A was suspended based on the information provided regarding allegation of Neglect pending on the investigation and reported to HHSC per policy on 05/19/18. 2. Resident #1 Physician and responsible were notified and further evaluation and treatment completed at the facility 05/04/18. 3. Resident#1 was sent to outside wound clinic for evaluation and treatment on 05/17/18. 4. The facility ordered pressure relieving boots on 05/19/18 to wear continuously and at [MEDICAL TREATMENT]. 5.The Director of Nursing will/designee complete will completed a skin assessment, measure, classify/stage the wound and add the resident to the weekly wound log for tracking. The DIRECTOR OF NURSING will review the skin assessment and care plan the findings. 6.All facility resident had a wound sweep completed by nursing on 05/19/18. The Director of Nursing/designee complete will completed a skin assessment 7. Director of Nursing was educated on 05/18/18 on wound care /policy/management and communication follow-up. 8. All licensed nurses will be re-educated on Wound care by the Director of Nursing by 12pm on 05/21/18 for all regular staff nurses. PRN licensed nurse who has not received the re-education will not be allowed to perform wound care until they have received the education. The content of the re-education is as follows: a. Facility policy and procedure for completing weekly skin assessments. b. Identify of pressure ulcers and wounds. c. Timely notification to the physician, responsible party, and Director of Nursing/designee. d. Communication of new pressure ulcers and wounds to the Director of nursing/designee, wound care nurse. e. Following physician's and treatment orders. f. Nursing assessments for pressure ulcers and wounds. g. Education to License Nurses on evaluating, identifying, and following treatment orders for new skin and wound concerns. h. Completing wound treatments in the absence of the wound care nurse. I. Communicate with the [MEDICAL TREATMENT] center weekly regarding residents with active wound and residents that are at risk for skin breakdown, ensure appropriate pressure relieving interventions are implemented by [MEDICAL TREATMENT] clinic. j. Perform skin assessment on residents returning form [MEDICAL TREATMENT]. k. If a treatment is not completed, nurse to complete treatment error report, notify physician/family/Director of Nursing. 9. All clinical staff will be educated on Abuse, neglect and exploration by 05/21/18. 10. The Director of Nursing/designee or wound care nurse will reconcile residents with active wounds and compare with wound care physician notes weekly. 11. Wound treatment will be evaluated by the Director of Nurses/designee every 14 days for appropriateness and accuracy. 12. Residents identified as having a Braden score of 18 or less will have a skin risk analysis assessment completed by a RN and at risk care plan will be performed 13. Resident at risk will have a daily skin checks completed by the Certified Nurse Aids on the point of Care System. 14. Certified Nurse Aids will receive re-education by the Director of Nurses/designee on skin checks completed by 05/21/18. 15. All residents will be assigned a day/shift for skin assessments completion. New admissions will be assigned day/shift for skin evaluation to be completed by the LVN or RN. Any skin abnormalities identified will be added to the 24-hour report and a progress note written. The director of Nurses/RN designee will review the 24-hour report in the morning clinical meeting for further assessment needs. 16. The Director of Nursing/RN will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. 17. The week-end RN will be responsible for new admissions on the week-end and the Director of Nurses /RN/designee will stay after hours for new admissions and complete the assessment. 18. the Director of Nurses/ designee will review all skin assessments, weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance and Performance Improvement meeting. 19. Audit treatment book to ensure all treatments have been completed by 05/12/18. 20. Full facility sweeps with assessments will be completed quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. An In-service dated 05/18/18, Objective of the in-service; Neglect is the failure of the facility, it's employees or services providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. An In-service dated 05/18/18, Objective of the in-service; Skin integrity and wound management. An In-service dated 05/18/18, Objective of the in-service; education on evaluation, identifying and following treatment orders and communicating with the Director of nurses, auditing weekly skin assessments and initiating treatment, up-dating care plan. An In-service dated 05/18/18, Objective of the in-service; Communication with the [MEDICAL TREATMENT] center weekly regarding resident with wounds and residents that are at risk for wound to ensure proper pressure relieving interventions are implemented by the [MEDICAL TREATMENT] center. Nurse to perform skin assessments on resident returning from [MEDICAL TREATMENT] clinic. If treatments are not completed, fill out a treatment error report, and notify the physician, family and Director of nurses. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight Charge Nurses representing all three shifts (LVNs I, J, K, L, M, N, O, P and Q) all had training on wound care, and in serviced on the policy and procedure for completing weekly skin assessments, timely notification to the physician, responsible party and Director of Nursing. Following physician's and treatment orders. Nursing assessments and identification on pressure ulcers and wounds Completing wound treatment in absence of the wound care nurse and evaluating, identifying and following physician orders, communication of new pressure ulcers and wounds to the Director of Nursing and the wound care nurse. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight CNA's representing all three shifts and weekends (CNAs R, S, T, U, W, X, Y, and Z) revealed all had training on assessment and reporting changes in resident's skin on shower days and repositioning a resident. They were in-serviced on Abuse, Neglect and Exploration and understood when to report, types of abuse and the Administrator was the Abuse Coordinator. Interview on 05/21/18 at 2:50 P.M. with the Administrator revealed he supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting by going over all reports standup morning meeting. He understood the IJ occurred related to physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. Interviews on 05/19/18 at 1:00 P.M. with Director of Nurses revealed, she understood the IJ occurred related to poor communication between nursing staff, unit managers and the Director of Nurses. Resident #1's physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. If she would have been notified of Resident #1's treatments were not being done, and referral needed to be made, she would have addressed the issue with the wound care nurse, other licensed nurses and the unit managers. She expected the Licensed Nurses to communicate with the unit managers if any task cannot be completed on his or her shift and to assist the Licensed Nurses to complete the task as ordered by the physician. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. The CNA's are doing skin assessments on bath days and documenting on the bath sheet. The nurse is to sign the bath sheet. If a wound or pressure sore was identified the charge nurse is to assess, call the physician, family, initiate care and document in the clinical chart. If a wound is not healing in ten to fourteen days the charge nurse is to notify the physician and the wound care physician will assess and evaluate stage two wounds. She stated she will be monitoring if policy and procedures and physician orders are being followed by chart audit, review of the 24-hour end of shift report. She will attend morning clinical meeting with the nursing staff where issues are addressed such as change in status, weight loss, falls, labs and skin. She will attend all Care Plan, Quality of Care and Nursing meeting. On 05/23/18 at 9:50 A.M. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. Review of Pressure Ulcers policy and procedures dated 06/01/15 (1.) Evaluate the pressure ulcer initially for location; stage, size (in cm) . (5) Re-evaluate pressure ulcers at least weekly, If the patients /resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2weeks), the treatment plan should be re-evaluated. (6) if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. Review of Wound Care Policies and procedures dated 06/01/15 components of wound documentation: Characteristics, Location, onset date for pressure ulcers, size and stage of Pressure Ulcer, color, odor, necrotic tissue (when present) Infection, surrounding tissue, pain and healing. Staging of pressure Ulcers National Pressure Ulcer Advisor Panel- NPUAP .Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and \or underlying tissue over a boney prominence, as a result of pressure in combination with shear and /or friction. Nursing policy and procedures: Physician Communication/change in Conditions dated 07/01/16, reflected, Notify the physician of the change in medical condition . The DON provided a list dated 05/23/18 of seven residents with pressure injuries.

Based on interviews and record reviews, the facility failed to provide services in accordance of professional standards by one (LVN A) of three licensed nurses with each resident's written plan of care for one (Resident #1) of four residents reviewed for Physician Orders 1. LVN A failed to perform treatment on Resident #1's pressure injury with necrotic tissue to the left foot for 5 days of 12 days when Resident#1 went to [MEDICAL TREATMENT]. 2. The facility failed to obtain a referral appointment on 04/13/18 with an alternative wound care clinic that coordinated with Resident #1's [MEDICAL TREATMENT] schedule. An Immediate Jeopardy (IJ) was identified on 05/18/18 at 5:45 P.M., While the IJ was removed on 05/23/18 at 9:50 A.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the seven residents with pressure injuries by placing them at risk for not receiving wound care, delayed healing, wound infections and mental anguish. Findings included: Review of Resident#1's MDS dated [DATE] revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 01/17/18 revealed he goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. He is at risk for skin breakdown related to impaired bed mobility and incontinent of bowel and bladder. He has a pressure ulcer to his left medial foot, unstageable, left lateral foot unstageable and Right Medial foot unstageable. An interview on 05/02/18 at 2:10 PM, Resident #1's family member revealed, she stated, she had informed LVN B on 04/30/18 of a sore on his back. She stated LVN B observed the sore on his back and gave the family member a tube of Triple antibiotic ointment and told family member to put it on the sore. On Wednesday 05/02/18, she informed LVN B that there was blood on his bed sheets from the sore on his back. She stated the facility has not been treating the wound on his back and the pressure ulcer on his right foot and he was not receiving daily wound care to his left foot. She stated the physician at the hospital had made a referral see to a specific Dr. for his left foot pressure ulcer, that would see him on his off days from [MEDICAL TREATMENT], but the facility had not made the appointment. Observation of wound on Resident #1's back on 05/03/18 at 10:00 A.M with Family member revealed, a stage two pressure on the left medial aspect on the back there was an open area approximately 1cm x 1 cm with a pink center without drainage. The surrounding tissue was natural in color with [MEDICAL CONDITION]. Review of Resident #1's Physician orders for the month of (MONTH) (YEAR) and (MONTH) (YEAR) reflected to treat the left medial foot with [MEDICATION NAME] every day for 14 days then re-evaluate, treat left medial heel with skin prep, every day for 14 days then re-evaluate, treat left medial first toe with skin prep, every day for 14 days then re-evaluate. There were no orders to treat the back wound with the Triple antibiotic. There was no physician order to treat the wound on his back or wounds on his right foot for (MONTH) (YEAR) or (MONTH) (YEAR). Review of Resident #1's Treatment Administration Record treatment for [REDACTED]. the treatment had been performed. There was no treatment for [REDACTED]. Observation on 05/04/18 at 8:30 A.M of Resident #1's right foot with LVN A, wound care nurse, revealed two unidentified pressure injuries, one stage two on the tip of the right great toe, measured approximately 0.5 cm x 0.5cm, center dark and superficial in depth, no drainage. The right heel Deep Tissue Injury measured approximately 0.1cm x1 cm, round shape and color dark and superficial in depth, no drainage. LVN A stated she had not seen the new pressure injuries on his right foot, and there were no orders for treatment. Review of Resident #1's Weekly Skin Integrity record signed by LVN A, dated 03/13/18 through 04/25/18 did not reveal any pressure injuries to the right foot. Interview on 05/03/18 at 3:00 P.M. LVN D revealed she worked the evening shift Monday through Friday. She stated she did not treat Resident #1's left foot. The wound care treatment is not on the Medication Administration Book. The wound care is in the Treatment book and she didn't look at the treatment book. She stated there were a couple of times the family had asked her to treat his left foot. Review of Wound Care Physicians V, initial evaluation dated 03/13/18, Resident#1's left, medial foot wound measured 3.0cm by 3.0cm unstageable, treatment skin- prep every day. On 03/21/18 revealed patient not seen due to a non-wound hospitalization since last visit. LVN B wound care nurse stated, Wound Care physician V came in on Tuesday 03/13/18 but the scheduled visit days for the facility was every Wednesday, since resident goes to [MEDICAL TREATMENT] on Wednesday the wound care physician can't see him once a week. Review of Progress notes from LVN A wound care nurse revealed, 0n 03/28/18, 04/04/18, 04/11/18 and 04/18/18 Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Then on 04/25/18 Wound Care Physician V seen him. The Left medial foot pressure injury measurements were 2.5cm x2.0 unstageable, necrosis thick adherent black necrotic tissue, eschar. Apply [MEDICATION NAME] once a day. Then on 05/02/18, Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Interview on 05/03/18 at 10:00 A.M. LVN A wound care nurse revealed, she had written the word [MEDICAL TREATMENT] on the dates of 04/12/18, 04/20/18, 04/27/18, 04/30/18 and 05/01/18. She stated the treatments were not done. Resident #1 left for [MEDICAL TREATMENT] before she enters the facility each day and has not returned from [MEDICAL TREATMENT] until after she leaves for the day. The evening shift nurses don't do the treatments on the days he goes to [MEDICAL TREATMENT]. She stated when she enters an order into the computer system for daily treatment's the system requires a specific time or shift. She stated she would change the treatment time to the evening shift on the day he goes to [MEDICAL TREATMENT]. Interview on 05/03/18 at 9:50 A.M. with LVN A, wound care nurse, revealed LVN B informed her on 04/30/18 of the open wound on Resident #1's back around noonish, but he goes to [MEDICAL TREATMENT] on Mondays, Tuesdays and Wednesdays around 9:30 A.M. returned after she leaves for the day around 5:00 P.M. Then on 05/01/18, she went to Resident#1's room to assess the wound, but he had gone to [MEDICAL TREATMENT]. She stated Resident #1 was feeling ill on 04/30/18 and didn't go to [MEDICAL TREATMENT], but she was not informed he was in the facility. He had gone to [MEDICAL TREATMENT] on Tuesday and she was not able to assess the wound on his back. She stated he was out for a Doctor's appointment and she would take care of his wound when he returns. Interview on 05/03/18 at 11.00 A.M, LVN B revealed, she had been informed by a family member on 4/30/18 Resident #1 had a wound on his back. She stated she looked at the wound it was on the inner part of his back close to his spine. It looked like a blister was there and the top came off. She reported the wound to LVN A (wound Care Nurse) around lunch time. She stated she didn't initiate care or document the wound and didn't notify the physician of the change of condition because she thought LVN B would take care of it since she does all the wounds. She stated she don't treat Resident#1's pressure injuries to his foot before his go to [MEDICAL TREATMENT] because it was the wound care nurses that done his wounds and she was off duty before he returned from [MEDICAL TREATMENT]. Review of Resident#1's telephone order for 05/03/18 revealed Back- cleanse with NS, pat dry with 4x4, apply skin prep leave open to air qd x 14 days, then re-evaluate. Observation on Resident #1's telephone order dated 05/04/18 revealed wound care to be done daily, on days of [MEDICAL TREATMENT], wound care to be done on 2-10 shift. Review on Resident #1's Physician telephone dated 05/04/18 revealed an order to treat the Right great toe -apply skin prep, leave open to air qd x14 days, then re-evaluate. Right heel-apply apply skin prep, leave open to air qd x14 days, then re-evaluate. Interview on 05/03/18 at 11:15 A.M., the DON stated the facility had wound care services with Physician V, that came every Wednesday for the facilities residents needing wound care. Observation on 05/04/18 at 8:30 A.M, with LVN A of wound care and measurement of pressure ulcer by LVN A, revealed the measurement of the left medial foot was 5cmx4cm hard black cap over the wound bed, with 1.5cmx1.5cm open area to left lateral edge of the wound with scant serous drainage. The pressure injury on the back measured 1cm x 1 cm with a pink center without drainage, no redness or [MEDICAL CONDITION] to the surrounding tissue. Interview on 05/04/18 at 9:45 A.M. with NP revealed, he had not been notified of the pressure injury on Resident #1's back. He was not notified of Resident #1 not getting his daily wound care treatment to his left foot. He stated he can't address changes in his status unless he has been notified. He stated had to go through the family to find out about any changes in his condition. A second Interview on 05/19/18 at 11:00 A.M. with NP revealed he had made a referral on 03/31/18 after communicating with DR. V that she was not able to see Resident #1 consistently because of his [MEDICAL TREATMENT] schedule. He visited with the Resident #1 on 04/13/18, the left medial Metatarsal foot pressure ulcer was worsening. Resident #1 was about to leave for [MEDICAL TREATMENT] and he told him to go ahead to [MEDICAL TREATMENT]. He spoke with a Vascular Physician. Resident #1 left the [MEDICAL TREATMENT] and was transport to the emergency room for evaluation by physician CC and was advised to follow-up with physician AA, a wound care specialist. The appointment was not made until 05/17/18. Review of Discharge Instruction from physician BB on 04\13\18 revealed, Resident#1 had a referral for Physician F for wound care to the left foot. Interview on 05/19/18 with Wound care Physician V revealed she had communicated Resident #1's primary physician on 03/30/18 to make a referral for another wound care physician or wound clinic related to the schedule not coinciding with Resident [MEDICAL TREATMENT] Schedule. The referral was written on 03/30/18 for a wound care consult, but it was not followed through. She received one set of pictures of Resident's left foot pressure injury on 04/13/18 and no other time from LVN A. She communicated with LVN A (wound Care nurse) on multiply occasions for Resident #1 to see another wound physician because she was unable to see him on consistently related to his [MEDICAL TREATMENT] schedule. She stated she was at the facility on Wednesdays only. She communicated with Resident #1's primary physician on 03/30/18. She stated she could not treat pressure ulcers on pictures alone. She revealed if the pressure injury stayed dry that it would take extended amount of time to heal even if ever would heal, but if the wound became soft, draining signs of infection it would have to be debrided for it to possibly heal. Review of Progress notes dated 05/17/18 from Physician F, Wound Care Specialist, revealed on 05/03/18, Resident #1 was seen by Physician BB. The patient underwent Angiogram with atherectomy and the wound has improved. Physician BB recommended follow-up for wound care at the Wound Care Clinic. It took the facility three weeks to get him scheduled. Integumentary: revealed, open wound of left medical foot at first metatarsal head; wound #1 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound with etiology of pressure ulcer and is located on the left, medial metatarsal head first. The wound measured 3cm length x2.9 cm width x 0.1 cm. depth. There was medium amount of serous drainage. There was a large 67percent to 100 percent of necrotic within the wound bed including eschar and adherent slough. Right foot: planter heel with Deep tissue injury. Pressure ulcer of other sites, unstageable. Wound #1: selective debridement of portion of eschar and exudate; large amount of eschar. Vascular: palpable left distal pulse. Interview on 05/03/18 at 3:45 P.M., LVN C unit Manager revealed she was not aware Resident #1's pressure injuries were not being done on the days he went out for [MEDICAL TREATMENT]. She was not aware of the referral request on 04\13\18. She stated any nurse can do his treatment before he went out to [MEDICAL TREATMENT] or after he returned from [MEDICAL TREATMENT]. Interview on 05/03/18 at 3:48 P.M., DON revealed she was not aware Resident #1's pressure injuries were not being treated on his [MEDICAL TREATMENT] days and the nurse should do the wound care before he left for [MEDICAL TREATMENT] or after he returned as long as his wound care was done daily. She was not informed of the referral on 04/13/18 not being followed up with, but the appointment will be done. She was not aware Wound Care physician was not seeing him because he was out for [MEDICAL TREATMENT]. The Administrator was notified on 05/18/18 at 5:45 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The Medical Director was notified on 05/18/18 at 8:00 P.M. of the IJ. A meeting with the facility to discuss failure to identify, communicate, and perform an assessment for wounds for [MEDICAL TREATMENT] resident including failure to complete orders treatments and follow physician orders. The facility's Plan of Removal was accepted on 05/19/18 at 3:20 P.M. and included: 1. The licensed nurse identified in the Immediate Jeopardy was terminated on 05/04/18. The Wound care Nurse LVN A was suspended based on the information provided regarding allegation of Neglect pending on the investigation and reported to HHSC per policy on 05/19/18. 2. Resident #1 Physician and responsible were notified and further evaluation and treatment completed at the facility 05/04/18. 3. Resident#1 was sent to outside wound clinic for evaluation and treatment on 05/17/18. 4. The facility ordered pressure relieving boots on 05/19/18 to wear continuously and at [MEDICAL TREATMENT]. 5.The Director of Nursing will/designee complete will completed a skin assessment, measure, classify/stage the wound and add the resident to the weekly wound log for tracking. The DIRECTOR OF NURSING will review the skin assessment and care plan the findings. 6.All facility resident had a wound sweep completed by nursing on 05/19/18. The Director of Nursing/designee complete will completed a skin assessment 7. Director of Nursing was educated on 05/18/18 on wound care /policy/management and communication follow-up. 8. All licensed nurses will be re-educated on Wound care by the Director of Nursing by 12pm on 05/21/18 for all regular staff nurses. PRN licensed nurse who has not received the re-education will not be allowed to perform wound care until they have received the education. The content of the re-education is as follows: a. Facility policy and procedure for completing weekly skin assessments. b. Identify of pressure ulcers and wounds. c. Timely notification to the physician, responsible party, and Director of Nursing/designee. d. Communication of new pressure ulcers and wounds to the Director of nursing/designee, wound care nurse. e. Following physician's and treatment orders. f. Nursing assessments for pressure ulcers and wounds. g. Education to License Nurses on evaluating, identifying, and following treatment orders for new skin and wound concerns. h. Completing wound treatments in the absence of the wound care nurse. I. Communicate with the [MEDICAL TREATMENT] center weekly regarding residents with active wound and residents that are at risk for skin breakdown, ensure appropriate pressure relieving interventions are implemented by [MEDICAL TREATMENT] clinic. j. Perform skin assessment on residents returning form [MEDICAL TREATMENT]. k. If a treatment is not completed, nurse to complete treatment error report, notify physician/family/Director of Nursing. 9. All clinical staff will be educated on Abuse, neglect and exploration by 05/21/18. 10. The Director of Nursing/designee or wound care nurse will reconcile residents with active wounds and compare with wound care physician notes weekly. 11. Wound treatment will be evaluated by the Director of Nurses/designee every 14 days for appropriateness and accuracy. 12. Residents identified as having a Braden score of 18 or less will have a skin risk analysis assessment completed by a RN and at risk care plan will be performed 13. Resident at risk will have a daily skin checks completed by the Certified Nurse Aids on the point of Care System. 14. Certified Nurse Aids will receive re-education by the Director of Nurses/designee on skin checks completed by 05/21/18. 15. All residents will be assigned a day/shift for skin assessments completion. New admissions will be assigned day/shift for skin evaluation to be completed by the LVN or RN. Any skin abnormalities identified will be added to the 24-hour report and a progress note written. The director of Nurses/RN designee will review the 24-hour report in the morning clinical meeting for further assessment needs. 16. The Director of Nursing/RN will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. 17. The week-end RN will be responsible for new admissions on the week-end and the Director of Nurses /RN/designee will stay after hours for new admissions and complete the assessment. 18. the Director of Nurses/ designee will review all skin assessments, weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance and Performance Improvement meeting. 19. Audit treatment book to ensure all treatments have been completed by 05/12/18. 20. Full facility sweeps with assessments will be completed quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. An In-service dated 05/18/18, Objective of the in-service; Neglect is the failure of the facility, it's employees or services providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. An In-service dated 05/18/18, Objective of the in-service; Skin integrity and wound management. An In-service dated 05/18/18, Objective of the in-service; education on evaluation, identifying and following treatment orders and communicating with the Director of nurses, auditing weekly skin assessments and initiating treatment, up-dating care plan. An In-service dated 05/18/18, Objective of the in-service; Communication with the [MEDICAL TREATMENT] center weekly regarding resident with wounds and residents that are at risk for wound to ensure proper pressure relieving interventions are implemented by the [MEDICAL TREATMENT] center. Nurse to perform skin assessments on resident returning from [MEDICAL TREATMENT] clinic. If treatments are not completed, fill out a treatment error report, and notify the physician, family and Director of nurses. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight Charge Nurses representing all three shifts (LVNs I, J, K, L, M, N, O, P and Q) all had training on wound care, and in serviced on the policy and procedure for completing weekly skin assessments, timely notification to the physician, responsible party and Director of Nursing. Following physician's and treatment orders. Nursing assessments and identification on pressure ulcers and wounds Completing wound treatment in absence of the wound care nurse and evaluating, identifying and following physician orders, communication of new pressure ulcers and wounds to the Director of Nursing and the wound care nurse. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight CNA's representing all three shifts and weekends (CNAs R, S, T, U, W, X, Y, and Z) revealed all had training on assessment and reporting changes in resident's skin on shower days and repositioning a resident. They were in-serviced on Abuse, Neglect and Exploration and understood when to report, types of abuse and the Administrator was the Abuse Coordinator. Interview on 05/21/18 at 2:50 P.M. with the Administrator revealed he supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting by going over all reports standup morning meeting. He understood the IJ occurred related to physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. Interviews on 05/19/18 at 1:00 P.M. with Director of Nurses revealed, she understood the IJ occurred related to poor communication between nursing staff, unit managers and the Director of Nurses. Resident #1's physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. If she would have been notified of Resident #1's treatments were not being done, and referral needed to be made, she would have addressed the issue with the wound care nurse, other licensed nurses and the unit managers. She expected the Licensed Nurses to communicate with the unit managers if any task cannot be completed on his or her shift and to assist the Licensed Nurses to complete the task as ordered by the physician. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. The CNA's are doing skin assessments on bath days and documenting on the bath sheet. The nurse is to sign the bath sheet. If a wound or pressure sore was identified the charge nurse is to assess, call the physician, family, initiate care and document in the clinical chart. If a wound is not healing in ten to fourteen days the charge nurse is to notify the physician and the wound care physician will assess and evaluate stage two wounds. She stated she will be monitoring if policy and procedures and physician orders are being followed by chart audit, review of the 24-hour end of shift report. She will attend morning clinical meeting with the nursing staff where issues are addressed such as change in status, weight loss, falls, labs and skin. She will attend all Care Plan, Quality of Care and Nursing meeting. On 05/23/18 at 9:50 A.M. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. Review of Pressure Ulcers policy and procedures dated 06/01/15 (1.) Evaluate the pressure ulcer initially for location; stage, size (in cm) . (5) Re-evaluate pressure ulcers at least weekly, If the patients /resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2weeks), the treatment plan should be re-evaluated. (6) if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. Review of Wound Care Policies and procedures dated 06/01/15 components of wound documentation: Characteristics, Location, onset date for pressure ulcers, size and stage of Pressure Ulcer, color, odor, necrotic tissue (when present) Infection, surrounding tissue, pain and healing. Staging of pressure Ulcers National Pressure Ulcer Advisor Panel- NPUAP .Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and \or underlying tissue over a boney prominence, as a result of pressure in combination with shear and /or friction. Nursing policy and procedures: Physician Communication/change in Conditions dated 07/01/16, reflected, Notify the physician of the change in medical condition . www.bon.texas.gov reflected, TAC Rule §217.11 reflected, (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same . (Retrieved 06/07/18) The DON provided a list dated 05/23/18 of seven residents with pressure injuries.

Based on interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #1) of 4 residents reviewed for neglect. 1. LVN A failed to perform treatment on Resident #1's pressure injury with necrotic tissue to the left foot for 5 days of 12 days when Resident#1 went to [MEDICAL TREATMENT]. 2. LVN B failed to assess, document and notify physician of change in condition and obtain treatment for [REDACTED].#1's back. 3. The facility failed to identify two pressure injuries to Resident #1's right foot. 4. The facility failed to obtain a referral appointment on 04/13/18 with an alternative wound care clinic that coordinated with Resident #1's [MEDICAL TREATMENT] schedule. An Immediate Jeopardy (IJ) was identified on 05/18/18 at 5:45 P.M., While the IJ was removed on 05/23/18 at 9:50 A.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the seven residents with pressure injuries by placing them at risk for not receiving wound care, delayed healing, wound infections and mental anguish. Findings included: Review of Abuse, Neglect and Misappropriation of Property policy and procedures revised 05/01/13 reflected under definitions .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident#1's MDS dated [DATE] revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 01/17/18 revealed he goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. He is at risk for skin breakdown related to impaired bed mobility and incontinent of bowel and bladder. He has a pressure ulcer to his left medial foot, unstageable, left lateral foot unstageable and Right Medial foot unstageable. An interview on 05/02/18 at 2:10 PM, Resident #1's family member revealed, she stated, she had informed LVN B on 04/30/18 of a sore on his back. She stated LVN B observed the sore on his back and gave the family member a tube of Triple antibiotic ointment and told family member to put it on the sore. On Wednesday 05/02/18, she informed LVN B that there was blood on his bed sheets from the sore on his back. She stated the facility has not been treating the wound on his back and the pressure ulcer on his right foot and he was not receiving daily wound care to his left foot. She stated the physician at the hospital had made a referral see to a specific Dr. for his left foot pressure ulcer, that would see him on his off days from [MEDICAL TREATMENT], but the facility had not made the appointment. Observation of wound on Resident #1's back on 05/03/18 at 10:00 A.M with Family member revealed, a stage two pressure on the left medial aspect on the back there was an open area approximately 1cm x 1 cm with a pink center without drainage. The surrounding tissue was natural in color with [MEDICAL CONDITION]. Review of Resident #1's Physician orders for the month of (MONTH) (YEAR) and (MONTH) (YEAR) reflected to treat the left medial foot with [MEDICATION NAME] every day for 14 days then re-evaluate, treat left medial heel with skin prep, every day for 14 days then re-evaluate, treat left medial first toe with skin prep, every day for 14 days then re-evaluate. There were no orders to treat the back wound with the Triple antibiotic. There was no physician order to treat the wound on his back or wounds on his right foot for (MONTH) (YEAR) or (MONTH) (YEAR). Review of Resident #1's Treatment Administration Record treatment for [REDACTED]. the treatment had been performed. There was no treatment for [REDACTED]. Observation on 05/04/18 at 8:30 A.M of Resident #1's right foot with LVN A, wound care nurse, revealed two unidentified pressure injuries, one stage two on the tip of the right great toe, measured approximately 0.5 cm x 0.5cm, center dark and superficial in depth, no drainage. The right heel Deep Tissue Injury measured approximately 0.1cm x1 cm, round shape and color dark and superficial in depth, no drainage. LVN A stated she had not seen the new pressure injuries on his right foot, and there were no orders for treatment. Review of Resident #1's Weekly Skin Integrity record signed by LVN A, dated 03/13/18 through 04/25/18 did not reveal any pressure injuries to the right foot. Interview on 05/03/18 at 3:00 P.M. LVN D revealed she worked the evening shift Monday through Friday. She stated she did not treat Resident #1's left foot. The wound care treatment is not on the Medication Administration Book. The wound care is in the Treatment book and she didn't look at the treatment book. She stated there were a couple of times the family had asked her to treat his left foot. Review of Wound Care Physicians V, initial evaluation dated 03/13/18, Resident#1's left, medial foot wound measured 3.0cm by 3.0cm unstageable, treatment skin- prep every day. On 03/21/18 revealed patient not seen due to a non-wound hospitalization since last visit. LVN B wound care nurse stated, Wound Care physician V came in on Tuesday 03/13/18 but the scheduled visit days for the facility was every Wednesday, since resident goes to [MEDICAL TREATMENT] on Wednesday the wound care physician can't see him once a week. Review of Progress notes from LVN A wound care nurse revealed, 0n 03/28/18, 04/04/18, 04/11/18 and 04/18/18 Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Then on 04/25/18 Wound Care Physician V seen him. The Left medial foot pressure injury measurements were 2.5cm x2.0 unstageable, necrosis thick adherent black necrotic tissue, eschar. Apply [MEDICATION NAME] once a day. Then on 05/02/18, Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Interview on 05/03/18 at 10:00 A.M. LVN A wound care nurse revealed, she had written the word [MEDICAL TREATMENT] on the dates of 04/12/18, 04/20/18, 04/27/18, 04/30/18 and 05/01/18. She stated the treatments were not done. Resident #1 left for [MEDICAL TREATMENT] before she enters the facility each day and has not returned from [MEDICAL TREATMENT] until after she leaves for the day. The evening shift nurses don't do the treatments on the days he goes to [MEDICAL TREATMENT]. She stated when she enters an order into the computer system for daily treatment's the system requires a specific time or shift. She stated she would change the treatment time to the evening shift on the day he goes to [MEDICAL TREATMENT]. Interview on 05/03/18 at 9:50 A.M. with LVN A, wound care nurse, revealed LVN B informed her on 04/30/18 of the open wound on Resident #1's back around noonish, but he goes to [MEDICAL TREATMENT] on Mondays, Tuesdays and Wednesdays around 9:30 A.M. returned after she leaves for the day around 5:00 P.M. Then on 05/01/18, she went to Resident#1's room to assess the wound, but he had gone to [MEDICAL TREATMENT]. She stated Resident #1 was feeling ill on 04/30/18 and didn't go to [MEDICAL TREATMENT], but she was not informed he was in the facility. He had gone to [MEDICAL TREATMENT] on Tuesday and she was not able to assess the wound on his back. She stated he was out for a Doctor's appointment and she would take care of his wound when he returns. Interview on 05/03/18 at 11.00 A.M, LVN B revealed, she had been informed by a family member on 4/30/18 Resident #1 had a wound on his back. She stated she looked at the wound it was on the inner part of his back close to his spine. It looked like a blister was there and the top came off. She reported the wound to LVN A (wound Care Nurse) around lunch time. She stated she didn't initiate care or document the wound and didn't notify the physician of the change of condition because she thought LVN B would take care of it since she does all the wounds. She stated she don't treat Resident#1's pressure injuries to his foot before his go to [MEDICAL TREATMENT] because it was the wound care nurses that done his wounds and she was off duty before he returned from [MEDICAL TREATMENT]. Review of Resident#1's telephone order for 05/03/18 revealed Back- cleanse with NS, pat dry with 4x4, apply skin prep leave open to air qd x 14 days, then re-evaluate. Observation on Resident #1's telephone order dated 05/04/18 revealed wound care to be done daily, on days of [MEDICAL TREATMENT], wound care to be done on 2-10 shift. Review on Resident #1's Physician telephone dated 05/04/18 revealed an order to treat the Right great toe -apply skin prep, leave open to air qd x14 days, then re-evaluate. Right heel-apply apply skin prep, leave open to air qd x14 days, then re-evaluate. Interview on 05/03/18 at 11:15 A.M., the DON stated the facility had wound care services with Physician V, that came every Wednesday for the facilities residents needing wound care. Observation on 05/04/18 at 8:30 A.M, with LVN A of wound care and measurement of pressure ulcer by LVN A, revealed the measurement of the left medial foot was 5cmx4cm hard black cap over the wound bed, with 1.5cmx1.5cm open area to left lateral edge of the wound with scant serous drainage. The pressure injury on the back measured 1cm x 1 cm with a pink center without drainage, no redness or [MEDICAL CONDITION] to the surrounding tissue. Interview on 05/04/18 at 9:45 A.M. with NP revealed, he had not been notified of the pressure injury on Resident #1's back. He was not notified of Resident #1 not getting his daily wound care treatment to his left foot. He stated he can't address changes in his status unless he has been notified. He stated had to go through the family to find out about any changes in his condition. A second Interview on 05/19/18 at 11:00 A.M. with NP revealed he had made a referral on 03/31/18 after communicating with DR. V that she was not able to see Resident #1 consistently because of his [MEDICAL TREATMENT] schedule. He visited with the Resident #1 on 04/13/18, the left medial Metatarsal foot pressure ulcer was worsening. Resident #1 was about to leave for [MEDICAL TREATMENT] and he told him to go ahead to [MEDICAL TREATMENT]. He spoke with a Vascular Physician. Resident #1 left the [MEDICAL TREATMENT] and was transport to the emergency room for evaluation by physician CC and was advised to follow-up with physician AA, a wound care specialist. The appointment was not made until 05/17/18. Review of Discharge Instruction from physician BB on 04\13\18 revealed, Resident#1 had a referral for Physician F for wound care to the left foot. Interview on 05/19/18 with Wound care Physician V revealed she had communicated Resident #1's primary physician on 03/30/18 to make a referral for another wound care physician or wound clinic related to the schedule not coinciding with Resident [MEDICAL TREATMENT] Schedule. The referral was written on 03/30/18 for a wound care consult, but it was not followed through. She received one set of pictures of Resident's left foot pressure injury on 04/13/18 and no other time from LVN A. She communicated with LVN A (wound Care nurse) on multiply occasions for Resident #1 to see another wound physician because she was unable to see him on consistently related to his [MEDICAL TREATMENT] schedule. She stated she was at the facility on Wednesdays only. She communicated with Resident #1's primary physician on 03/30/18. She stated she could not treat pressure ulcers on pictures alone. She revealed if the pressure injury stayed dry that it would take extended amount of time to heal even if ever would heal, but if the wound became soft, draining signs of infection it would have to be debrided for it to possibly heal. Review of Progress notes dated 05/17/18 from Physician F, Wound Care Specialist, revealed on 05/03/18, Resident #1 was seen by Physician BB. The patient underwent Angiogram with atherectomy and the wound has improved. Physician BB recommended follow-up for wound care at the Wound Care Clinic. It took the facility three weeks to get him scheduled. Integumentary: revealed, open wound of left medical foot at first metatarsal head; wound #1 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound with etiology of pressure ulcer and is located on the left, medial metatarsal head first. The wound measured 3cm length x2.9 cm width x 0.1 cm. depth. There was medium amount of serous drainage. There was a large 67percent to 100 percent of necrotic within the wound bed including eschar and adherent slough. Right foot: planter heel with Deep tissue injury. Pressure ulcer of other sites, unstageable. Wound #1: selective debridement of portion of eschar and exudate; large amount of eschar. Vascular: palpable left distal pulse. Interview on 05/03/18 at 3:45 P.M., LVN C unit Manager revealed she was not aware Resident #1's pressure injuries were not being done on the days he went out for [MEDICAL TREATMENT]. She was not aware of the referral request on 04\13\18. She stated any nurse can do his treatment before he went out to [MEDICAL TREATMENT] or after he returned from [MEDICAL TREATMENT]. Interview on 05/03/18 at 3:48 P.M., DON revealed she was not aware Resident #1's pressure injuries were not being treated on his [MEDICAL TREATMENT] days and the nurse should do the wound care before he left for [MEDICAL TREATMENT] or after he returned as long as his wound care was done daily. She was not informed of the referral on 04/13/18 not being followed up with, but the appointment will be done. She was not aware Wound Care physician was not seeing him because he was out for [MEDICAL TREATMENT]. The Administrator was notified on 05/18/18 at 5:45 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The Medical Director was notified on 05/18/18 at 8:00 P.M. of the IJ. A meeting with the facility to discuss failure to identify, communicate, and perform an assessment for wounds for [MEDICAL TREATMENT] resident including failure to complete orders treatments and follow physician orders. The facility's Plan of Removal was accepted on 05/19/18 at 3:20 P.M. and included: 1. The licensed nurse identified in the Immediate Jeopardy was terminated on 05/04/18. The Wound care Nurse LVN A was suspended based on the information provided regarding allegation of Neglect pending on the investigation and reported to HHSC per policy on 05/19/18. 2. Resident #1 Physician and responsible were notified and further evaluation and treatment completed at the facility 05/04/18. 3. Resident#1 was sent to outside wound clinic for evaluation and treatment on 05/17/18. 4. The facility ordered pressure relieving boots on 05/19/18 to wear continuously and at [MEDICAL TREATMENT]. 5.The Director of Nursing will/designee complete will completed a skin assessment, measure, classify/stage the wound and add the resident to the weekly wound log for tracking. The DIRECTOR OF NURSING will review the skin assessment and care plan the findings. 6.All facility resident had a wound sweep completed by nursing on 05/19/18. The Director of Nursing/designee complete will completed a skin assessment 7. Director of Nursing was educated on 05/18/18 on wound care /policy/management and communication follow-up. 8. All licensed nurses will be re-educated on Wound care by the Director of Nursing by 12pm on 05/21/18 for all regular staff nurses. PRN licensed nurse who has not received the re-education will not be allowed to perform wound care until they have received the education. The content of the re-education is as follows: a. Facility policy and procedure for completing weekly skin assessments. b. Identify of pressure ulcers and wounds. c. Timely notification to the physician, responsible party, and Director of Nursing/designee. d. Communication of new pressure ulcers and wounds to the Director of nursing/designee, wound care nurse. e. Following physician's and treatment orders. f. Nursing assessments for pressure ulcers and wounds. g. Education to License Nurses on evaluating, identifying, and following treatment orders for new skin and wound concerns. h. Completing wound treatments in the absence of the wound care nurse. I. Communicate with the [MEDICAL TREATMENT] center weekly regarding residents with active wound and residents that are at risk for skin breakdown, ensure appropriate pressure relieving interventions are implemented by [MEDICAL TREATMENT] clinic. j. Perform skin assessment on residents returning form [MEDICAL TREATMENT]. k. If a treatment is not completed, nurse to complete treatment error report, notify physician/family/Director of Nursing. 9. All clinical staff will be educated on Abuse, neglect and exploration by 05/21/18. 10. The Director of Nursing/designee or wound care nurse will reconcile residents with active wounds and compare with wound care physician notes weekly. 11. Wound treatment will be evaluated by the Director of Nurses/designee every 14 days for appropriateness and accuracy. 12. Residents identified as having a Braden score of 18 or less will have a skin risk analysis assessment completed by a RN and at risk care plan will be performed 13. Resident at risk will have a daily skin checks completed by the Certified Nurse Aids on the point of Care System. 14. Certified Nurse Aids will receive re-education by the Director of Nurses/designee on skin checks completed by 05/21/18. 15. All residents will be assigned a day/shift for skin assessments completion. New admissions will be assigned day/shift for skin evaluation to be completed by the LVN or RN. Any skin abnormalities identified will be added to the 24-hour report and a progress note written. The director of Nurses/RN designee will review the 24-hour report in the morning clinical meeting for further assessment needs. 16. The Director of Nursing/RN will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. 17. The week-end RN will be responsible for new admissions on the week-end and the Director of Nurses /RN/designee will stay after hours for new admissions and complete the assessment. 18. the Director of Nurses/ designee will review all skin assessments, weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance and Performance Improvement meeting. 19. Audit treatment book to ensure all treatments have been completed by 05/12/18. 20. Full facility sweeps with assessments will be completed quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. An In-service dated 05/18/18, Objective of the in-service; Neglect is the failure of the facility, it's employees or services providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. An In-service dated 05/18/18, Objective of the in-service; Skin integrity and wound management. An In-service dated 05/18/18, Objective of the in-service; education on evaluation, identifying and following treatment orders and communicating with the Director of nurses, auditing weekly skin assessments and initiating treatment, up-dating care plan. An In-service dated 05/18/18, Objective of the in-service; Communication with the [MEDICAL TREATMENT] center weekly regarding resident with wounds and residents that are at risk for wound to ensure proper pressure relieving interventions are implemented by the [MEDICAL TREATMENT] center. Nurse to perform skin assessments on resident returning from [MEDICAL TREATMENT] clinic. If treatments are not completed, fill out a treatment error report, and notify the physician, family and Director of nurses. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight Charge Nurses representing all three shifts (LVNs I, J, K, L, M, N, O, P and Q) all had training on wound care, and in serviced on the policy and procedure for completing weekly skin assessments, timely notification to the physician, responsible party and Director of Nursing. Following physician's and treatment orders. Nursing assessments and identification on pressure ulcers and wounds Completing wound treatment in absence of the wound care nurse and evaluating, identifying and following physician orders, communication of new pressure ulcers and wounds to the Director of Nursing and the wound care nurse. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight CNA's representing all three shifts and weekends (CNAs R, S, T, U, W, X, Y, and Z) revealed all had training on assessment and reporting changes in resident's skin on shower days and repositioning a resident. They were in-serviced on Abuse, Neglect and Exploration and understood when to report, types of abuse and the Administrator was the Abuse Coordinator. Interview on 05/21/18 at 2:50 P.M. with the Administrator revealed he supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting by going over all reports standup morning meeting. He understood the IJ occurred related to physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. Interviews on 05/19/18 at 1:00 P.M. with Director of Nurses revealed, she understood the IJ occurred related to poor communication between nursing staff, unit managers and the Director of Nurses. Resident #1's physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. If she would have been notified of Resident #1's treatments were not being done, and referral needed to be made, she would have addressed the issue with the wound care nurse, other licensed nurses and the unit managers. She expected the Licensed Nurses to communicate with the unit managers if any task cannot be completed on his or her shift and to assist the Licensed Nurses to complete the task as ordered by the physician. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. The CNA's are doing skin assessments on bath days and documenting on the bath sheet. The nurse is to sign the bath sheet. If a wound or pressure sore was identified the charge nurse is to assess, call the physician, family, initiate care and document in the clinical chart. If a wound is not healing in ten to fourteen days the charge nurse is to notify the physician and the wound care physician will assess and evaluate stage two wounds. She stated she will be monitoring if policy and procedures and physician orders are being followed by chart audit, review of the 24-hour end of shift report. She will attend morning clinical meeting with the nursing staff where issues are addressed such as change in status, weight loss, falls, labs and skin. She will attend all Care Plan, Quality of Care and Nursing meeting. On 05/23/18 at 9:50 A.M. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. Review of Pressure Ulcers policy and procedures dated 06/01/15 (1.) Evaluate the pressure ulcer initially for location; stage, size (in cm) . (5) Re-evaluate pressure ulcers at least weekly, If the patients /resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2weeks), the treatment plan should be re-evaluated. (6) if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. Review of Wound Care Policies and procedures dated 06/01/15 components of wound documentation: Characteristics, Location, onset date for pressure ulcers, size and stage of Pressure Ulcer, color, odor, necrotic tissue (when present) Infection, surrounding tissue, pain and healing. Staging of pressure Ulcers National Pressure Ulcer Advisor Panel- NPUAP .Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and \or underlying tissue over a boney prominence, as a result of pressure in combination with shear and /or friction. Nursing policy and procedures: Physician Communication/change in Conditions dated 07/01/16, reflected, Notify the physician of the change in medical condition . The DON provided a list dated 05/23/18 of seven residents with pressure injuries.

Based on interview and record review, the facility failed to ensure all residents were free from neglect for one (Resident #1) of four residents reviewed for neglect. 1. LVN A failed to perform treatment on Resident #1's pressure injury with necrotic tissue to the left foot for 5 days of 12 days when Resident#1 went to [MEDICAL TREATMENT]. 2. LVN B failed to assess, document and notify physician of change in condition and obtain treatment for [REDACTED].#1's back. 3. The facility failed to identify two pressure injuries to Resident #1's right foot. 4. The facility failed to obtain a referral appointment on 04/13/18 with an alternative wound care clinic that coordinated with Resident #1's [MEDICAL TREATMENT] schedule. An Immediate Jeopardy (IJ) was identified on 05/18/18 at 5:45 P.M., While the IJ was removed on 05/23/18 at 9:50 A.M., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the seven residents with pressure injuries by placing them at risk for not receiving wound care, delayed healing, wound infections and mental anguish. Findings included: Review of Resident#1's MDS dated [DATE] revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 01/17/18 revealed he goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday. He is at risk for skin breakdown related to impaired bed mobility and incontinent of bowel and bladder. He has a pressure ulcer to his left medial foot, unstageable, left lateral foot unstageable and Right Medial foot unstageable. An interview on 05/02/18 at 2:10 PM, Resident #1's family member revealed, she stated, she had informed LVN B on 04/30/18 of a sore on his back. She stated LVN B observed the sore on his back and gave the family member a tube of Triple antibiotic ointment and told family member to put it on the sore. On Wednesday 05/02/18, she informed LVN B that there was blood on his bed sheets from the sore on his back. She stated the facility has not been treating the wound on his back and the pressure ulcer on his right foot and he was not receiving daily wound care to his left foot. She stated the physician at the hospital had made a referral see to a specific Dr. for his left foot pressure ulcer, that would see him on his off days from [MEDICAL TREATMENT], but the facility had not made the appointment. Observation of wound on Resident #1's back on 05/03/18 at 10:00 A.M with Family member revealed, a stage two pressure on the left medial aspect on the back there was an open area approximately 1cm x 1 cm with a pink center without drainage. The surrounding tissue was natural in color with [MEDICAL CONDITION]. Review of Resident #1's Physician orders for the month of (MONTH) (YEAR) and (MONTH) (YEAR) reflected to treat the left medial foot with [MEDICATION NAME] every day for 14 days then re-evaluate, treat left medial heel with skin prep, every day for 14 days then re-evaluate, treat left medial first toe with skin prep, every day for 14 days then re-evaluate. There were no orders to treat the back wound with the Triple antibiotic. There was no physician order to treat the wound on his back or wounds on his right foot for (MONTH) (YEAR) or (MONTH) (YEAR). Review of Resident #1's Treatment Administration Record treatment for [REDACTED]. the treatment had been performed. There was no treatment for [REDACTED]. Observation on 05/04/18 at 8:30 A.M of Resident #1's right foot with LVN A, wound care nurse, revealed two unidentified pressure injuries, one stage two on the tip of the right great toe, measured approximately 0.5 cm x 0.5cm, center dark and superficial in depth, no drainage. The right heel Deep Tissue Injury measured approximately 0.1cm x1 cm, round shape and color dark and superficial in depth, no drainage. LVN A stated she had not seen the new pressure injuries on his right foot, and there were no orders for treatment. Review of Resident #1's Weekly Skin Integrity record signed by LVN A, dated 03/13/18 through 04/25/18 did not reveal any pressure injuries to the right foot. Interview on 05/03/18 at 3:00 P.M. LVN D revealed she worked the evening shift Monday through Friday. She stated she did not treat Resident #1's left foot. The wound care treatment is not on the Medication Administration Book. The wound care is in the Treatment book and she didn't look at the treatment book. She stated there were a couple of times the family had asked her to treat his left foot. Review of Wound Care Physicians V, initial evaluation dated 03/13/18, Resident#1's left, medial foot wound measured 3.0cm by 3.0cm unstageable, treatment skin- prep every day. On 03/21/18 revealed patient not seen due to a non-wound hospitalization since last visit. LVN B wound care nurse stated, Wound Care physician V came in on Tuesday 03/13/18 but the scheduled visit days for the facility was every Wednesday, since resident goes to [MEDICAL TREATMENT] on Wednesday the wound care physician can't see him once a week. Review of Progress notes from LVN A wound care nurse revealed, 0n 03/28/18, 04/04/18, 04/11/18 and 04/18/18 Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Then on 04/25/18 Wound Care Physician V seen him. The Left medial foot pressure injury measurements were 2.5cm x2.0 unstageable, necrosis thick adherent black necrotic tissue, eschar. Apply [MEDICATION NAME] once a day. Then on 05/02/18, Wound Care Physician V did not see him because he was out to [MEDICAL TREATMENT]. Interview on 05/03/18 at 10:00 A.M. LVN A wound care nurse revealed, she had written the word [MEDICAL TREATMENT] on the dates of 04/12/18, 04/20/18, 04/27/18, 04/30/18 and 05/01/18. She stated the treatments were not done. Resident #1 left for [MEDICAL TREATMENT] before she enters the facility each day and has not returned from [MEDICAL TREATMENT] until after she leaves for the day. The evening shift nurses don't do the treatments on the days he goes to [MEDICAL TREATMENT]. She stated when she enters an order into the computer system for daily treatment's the system requires a specific time or shift. She stated she would change the treatment time to the evening shift on the day he goes to [MEDICAL TREATMENT]. Interview on 05/03/18 at 9:50 A.M. with LVN A, wound care nurse, revealed LVN B informed her on 04/30/18 of the open wound on Resident #1's back around noonish, but he goes to [MEDICAL TREATMENT] on Mondays, Tuesdays and Wednesdays around 9:30 A.M. returned after she leaves for the day around 5:00 P.M. Then on 05/01/18, she went to Resident#1's room to assess the wound, but he had gone to [MEDICAL TREATMENT]. She stated Resident #1 was feeling ill on 04/30/18 and didn't go to [MEDICAL TREATMENT], but she was not informed he was in the facility. He had gone to [MEDICAL TREATMENT] on Tuesday and she was not able to assess the wound on his back. She stated he was out for a Doctor's appointment and she would take care of his wound when he returns. Interview on 05/03/18 at 11.00 A.M, LVN B revealed, she had been informed by a family member on 4/30/18 Resident #1 had a wound on his back. She stated she looked at the wound it was on the inner part of his back close to his spine. It looked like a blister was there and the top came off. She reported the wound to LVN A (wound Care Nurse) around lunch time. She stated she didn't initiate care or document the wound and didn't notify the physician of the change of condition because she thought LVN B would take care of it since she does all the wounds. She stated she don't treat Resident#1's pressure injuries to his foot before his go to [MEDICAL TREATMENT] because it was the wound care nurses that done his wounds and she was off duty before he returned from [MEDICAL TREATMENT]. Review of Resident#1's telephone order for 05/03/18 revealed Back- cleanse with NS, pat dry with 4x4, apply skin prep leave open to air qd x 14 days, then re-evaluate. Observation on Resident #1's telephone order dated 05/04/18 revealed wound care to be done daily, on days of [MEDICAL TREATMENT], wound care to be done on 2-10 shift. Review on Resident #1's Physician telephone dated 05/04/18 revealed an order to treat the Right great toe -apply skin prep, leave open to air qd x14 days, then re-evaluate. Right heel-apply apply skin prep, leave open to air qd x14 days, then re-evaluate. Interview on 05/03/18 at 11:15 A.M., the DON stated the facility had wound care services with Physician V, that came every Wednesday for the facilities residents needing wound care. Observation on 05/04/18 at 8:30 A.M, with LVN A of wound care and measurement of pressure ulcer by LVN A, revealed the measurement of the left medial foot was 5cmx4cm hard black cap over the wound bed, with 1.5cmx1.5cm open area to left lateral edge of the wound with scant serous drainage. The pressure injury on the back measured 1cm x 1 cm with a pink center without drainage, no redness or [MEDICAL CONDITION] to the surrounding tissue. Interview on 05/04/18 at 9:45 A.M. with NP revealed, he had not been notified of the pressure injury on Resident #1's back. He was not notified of Resident #1 not getting his daily wound care treatment to his left foot. He stated he can't address changes in his status unless he has been notified. He stated had to go through the family to find out about any changes in his condition. A second Interview on 05/19/18 at 11:00 A.M. with NP revealed he had made a referral on 03/31/18 after communicating with DR. V that she was not able to see Resident #1 consistently because of his [MEDICAL TREATMENT] schedule. He visited with the Resident #1 on 04/13/18, the left medial Metatarsal foot pressure ulcer was worsening. Resident #1 was about to leave for [MEDICAL TREATMENT] and he told him to go ahead to [MEDICAL TREATMENT]. He spoke with a Vascular Physician. Resident #1 left the [MEDICAL TREATMENT] and was transport to the emergency room for evaluation by physician CC and was advised to follow-up with physician AA, a wound care specialist. The appointment was not made until 05/17/18. Review of Discharge Instruction from physician BB on 04\13\18 revealed, Resident#1 had a referral for Physician F for wound care to the left foot. Interview on 05/19/18 with Wound care Physician V revealed she had communicated Resident #1's primary physician on 03/30/18 to make a referral for another wound care physician or wound clinic related to the schedule not coinciding with Resident [MEDICAL TREATMENT] Schedule. The referral was written on 03/30/18 for a wound care consult, but it was not followed through. She received one set of pictures of Resident's left foot pressure injury on 04/13/18 and no other time from LVN A. She communicated with LVN A (wound Care nurse) on multiply occasions for Resident #1 to see another wound physician because she was unable to see him on consistently related to his [MEDICAL TREATMENT] schedule. She stated she was at the facility on Wednesdays only. She communicated with Resident #1's primary physician on 03/30/18. She stated she could not treat pressure ulcers on pictures alone. She revealed if the pressure injury stayed dry that it would take extended amount of time to heal even if ever would heal, but if the wound became soft, draining signs of infection it would have to be debrided for it to possibly heal. Review of Progress notes dated 05/17/18 from Physician F, Wound Care Specialist, revealed on 05/03/18, Resident #1 was seen by Physician BB. The patient underwent Angiogram with atherectomy and the wound has improved. Physician BB recommended follow-up for wound care at the Wound Care Clinic. It took the facility three weeks to get him scheduled. Integumentary: revealed, open wound of left medical foot at first metatarsal head; wound #1 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound with etiology of pressure ulcer and is located on the left, medial metatarsal head first. The wound measured 3cm length x2.9 cm width x 0.1 cm. depth. There was medium amount of serous drainage. There was a large 67percent to 100 percent of necrotic within the wound bed including eschar and adherent slough. Right foot: planter heel with Deep tissue injury. Pressure ulcer of other sites, unstageable. Wound #1: selective debridement of portion of eschar and exudate; large amount of eschar. Vascular: palpable left distal pulse. Interview on 05/03/18 at 3:45 P.M., LVN C unit Manager revealed she was not aware Resident #1's pressure injuries were not being done on the days he went out for [MEDICAL TREATMENT]. She was not aware of the referral request on 04\13\18. She stated any nurse can do his treatment before he went out to [MEDICAL TREATMENT] or after he returned from [MEDICAL TREATMENT]. Interview on 05/03/18 at 3:48 P.M., DON revealed she was not aware Resident #1's pressure injuries were not being treated on his [MEDICAL TREATMENT] days and the nurse should do the wound care before he left for [MEDICAL TREATMENT] or after he returned as long as his wound care was done daily. She was not informed of the referral on 04/13/18 not being followed up with, but the appointment will be done. She was not aware Wound Care physician was not seeing him because he was out for [MEDICAL TREATMENT]. The Administrator was notified on 05/18/18 at 5:45 P.M. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The Medical Director was notified on 05/18/18 at 8:00 P.M. of the IJ. A meeting with the facility to discuss failure to identify, communicate, and perform an assessment for wounds for [MEDICAL TREATMENT] resident including failure to complete orders treatments and follow physician orders. The facility's Plan of Removal was accepted on 05/19/18 at 3:20 P.M. and included: 1. The licensed nurse identified in the Immediate Jeopardy was terminated on 05/04/18. The Wound care Nurse LVN A was suspended based on the information provided regarding allegation of Neglect pending on the investigation and reported to HHSC per policy on 05/19/18. 2. Resident #1 Physician and responsible were notified and further evaluation and treatment completed at the facility 05/04/18. 3. Resident#1 was sent to outside wound clinic for evaluation and treatment on 05/17/18. 4. The facility ordered pressure relieving boots on 05/19/18 to wear continuously and at [MEDICAL TREATMENT]. 5.The Director of Nursing will/designee complete will completed a skin assessment, measure, classify/stage the wound and add the resident to the weekly wound log for tracking. The DIRECTOR OF NURSING will review the skin assessment and care plan the findings. 6.All facility resident had a wound sweep completed by nursing on 05/19/18. The Director of Nursing/designee complete will completed a skin assessment 7. Director of Nursing was educated on 05/18/18 on wound care /policy/management and communication follow-up. 8. All licensed nurses will be re-educated on Wound care by the Director of Nursing by 12pm on 05/21/18 for all regular staff nurses. PRN licensed nurse who has not received the re-education will not be allowed to perform wound care until they have received the education. The content of the re-education is as follows: a. Facility policy and procedure for completing weekly skin assessments. b. Identify of pressure ulcers and wounds. c. Timely notification to the physician, responsible party, and Director of Nursing/designee. d. Communication of new pressure ulcers and wounds to the Director of nursing/designee, wound care nurse. e. Following physician's and treatment orders. f. Nursing assessments for pressure ulcers and wounds. g. Education to License Nurses on evaluating, identifying, and following treatment orders for new skin and wound concerns. h. Completing wound treatments in the absence of the wound care nurse. I. Communicate with the [MEDICAL TREATMENT] center weekly regarding residents with active wound and residents that are at risk for skin breakdown, ensure appropriate pressure relieving interventions are implemented by [MEDICAL TREATMENT] clinic. j. Perform skin assessment on residents returning form [MEDICAL TREATMENT]. k. If a treatment is not completed, nurse to complete treatment error report, notify physician/family/Director of Nursing. 9. All clinical staff will be educated on Abuse, neglect and exploration by 05/21/18. 10. The Director of Nursing/designee or wound care nurse will reconcile residents with active wounds and compare with wound care physician notes weekly. 11. Wound treatment will be evaluated by the Director of Nurses/designee every 14 days for appropriateness and accuracy. 12. Residents identified as having a Braden score of 18 or less will have a skin risk analysis assessment completed by a RN and at risk care plan will be performed 13. Resident at risk will have a daily skin checks completed by the Certified Nurse Aids on the point of Care System. 14. Certified Nurse Aids will receive re-education by the Director of Nurses/designee on skin checks completed by 05/21/18. 15. All residents will be assigned a day/shift for skin assessments completion. New admissions will be assigned day/shift for skin evaluation to be completed by the LVN or RN. Any skin abnormalities identified will be added to the 24-hour report and a progress note written. The director of Nurses/RN designee will review the 24-hour report in the morning clinical meeting for further assessment needs. 16. The Director of Nursing/RN will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. 17. The week-end RN will be responsible for new admissions on the week-end and the Director of Nurses /RN/designee will stay after hours for new admissions and complete the assessment. 18. the Director of Nurses/ designee will review all skin assessments, weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance and Performance Improvement meeting. 19. Audit treatment book to ensure all treatments have been completed by 05/12/18. 20. Full facility sweeps with assessments will be completed quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. An In-service dated 05/18/18, Objective of the in-service; Neglect is the failure of the facility, it's employees or services providers to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. An In-service dated 05/18/18, Objective of the in-service; Skin integrity and wound management. An In-service dated 05/18/18, Objective of the in-service; education on evaluation, identifying and following treatment orders and communicating with the Director of nurses, auditing weekly skin assessments and initiating treatment, up-dating care plan. An In-service dated 05/18/18, Objective of the in-service; Communication with the [MEDICAL TREATMENT] center weekly regarding resident with wounds and residents that are at risk for wound to ensure proper pressure relieving interventions are implemented by the [MEDICAL TREATMENT] center. Nurse to perform skin assessments on resident returning from [MEDICAL TREATMENT] clinic. If treatments are not completed, fill out a treatment error report, and notify the physician, family and Director of nurses. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight Charge Nurses representing all three shifts (LVNs I, J, K, L, M, N, O, P and Q) all had training on wound care, and in serviced on the policy and procedure for completing weekly skin assessments, timely notification to the physician, responsible party and Director of Nursing. Following physician's and treatment orders. Nursing assessments and identification on pressure ulcers and wounds Completing wound treatment in absence of the wound care nurse and evaluating, identifying and following physician orders, communication of new pressure ulcers and wounds to the Director of Nursing and the wound care nurse. Interviews on 05/21/18 from 9:00 A.M. to 3:55 P.M revealed eight CNA's representing all three shifts and weekends (CNAs R, S, T, U, W, X, Y, and Z) revealed all had training on assessment and reporting changes in resident's skin on shower days and repositioning a resident. They were in-serviced on Abuse, Neglect and Exploration and understood when to report, types of abuse and the Administrator was the Abuse Coordinator. Interview on 05/21/18 at 2:50 P.M. with the Administrator revealed he supervised the staff and Director of Nurses to ensure the policies and procedures were followed by attending the Quality of Care meeting by going over all reports standup morning meeting. He understood the IJ occurred related to physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. Interviews on 05/19/18 at 1:00 P.M. with Director of Nurses revealed, she understood the IJ occurred related to poor communication between nursing staff, unit managers and the Director of Nurses. Resident #1's physician orders were not followed, pressure ulcers/wounds were not identified on Resident #1's back and right foot, wound clinic referral was not made, and treatments were not being done on [MEDICAL TREATMENT] days. If she would have been notified of Resident #1's treatments were not being done, and referral needed to be made, she would have addressed the issue with the wound care nurse, other licensed nurses and the unit managers. She expected the Licensed Nurses to communicate with the unit managers if any task cannot be completed on his or her shift and to assist the Licensed Nurses to complete the task as ordered by the physician. The following changes were made to prevent the re-occurrence, re-education, training on all staff, Licensed Nurses and CNA's. The CNA's are doing skin assessments on bath days and documenting on the bath sheet. The nurse is to sign the bath sheet. If a wound or pressure sore was identified the charge nurse is to assess, call the physician, family, initiate care and document in the clinical chart. If a wound is not healing in ten to fourteen days the charge nurse is to notify the physician and the wound care physician will assess and evaluate stage two wounds. She stated she will be monitoring if policy and procedures and physician orders are being followed by chart audit, review of the 24-hour end of shift report. She will attend morning clinical meeting with the nursing staff where issues are addressed such as change in status, weight loss, falls, labs and skin. She will attend all Care Plan, Quality of Care and Nursing meeting. On 05/23/18 at 9:50 A.M. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated of actual harm due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. Review of Abuse, Neglect and Misappropriation of Property policy and procedures revised 05/01/13 reflected under definitions .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Pressure Ulcers policy and procedures dated 06/01/15 (1.) Evaluate the pressure ulcer initially for location; stage, size (in cm) . (5) Re-evaluate pressure ulcers at least weekly, If the patients /resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2weeks), the treatment plan should be re-evaluated. (6) if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. Review of Wound Care Policies and procedures dated 06/01/15 components of wound documentation: Characteristics, Location, onset date for pressure ulcers, size and stage of Pressure Ulcer, color, odor, necrotic tissue (when present) Infection, surrounding tissue, pain and healing. Staging of pressure Ulcers National Pressure Ulcer Advisor Panel- NPUAP .Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and \or underlying tissue over a boney prominence, as a result of pressure in combination with shear and /or friction. Nursing policy and procedures: Physician Communication/change in Conditions dated 07/01/16, reflected, Notify the physician of the change in medical condition . The DON provided a list dated 05/23/18 of seven residents with pressure injuries.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) of 35 sampled residents had proper supervision and was free of accident hazards. Resident #25 was provided a hot pack for his back that resulted in second and third degree burns. The facility failed: 1. To provide proper layering between the hot pack and the resident's skin. The hot pack of wrapped with two towels instead of six; 2. Position the resident properly. The resident was lying directly on the hot pack instead of the hot pack being placed on top of the area; and 3. Monitor the resident and provide timely intervention. The hot pack remained in place for greater than the 25-30 minutes, as recommended. These failures resulted in Resident #25's serious burns and could affect the twenty-four other residents who received "Modalities" from the Rehab Department for hot packs. Findings included: 1 .Review of Resident #25's admission MDS Resident Assessment and Care Screening dated 10/27/11 revealed he was a [AGE] year-old male admitted on [DATE]. His admitting active [DIAGNOSES REDACTED]. On 10/31/11 at 10:30 AM during the initial tour with RN/ADON I, Resident #25 was described as a new admission from out-of-state who was interviewable. RN/ADON I revealed the resident was receiving in-house dialysis and was admitted with a wound. RN/ADON I stated Resident #25 had a [DEVICE] for nutrition and an indwelling urinary catheter (Foley). He was incontinent of bowel and required total care. RN/ADON I said the resident used a wheelchair for mobility, propelled by staff. On 11/02/11 at 12:45 PM, Resident #25 was observed in his room, in his bed. He was awake and alert, wearing a hospital gown and when asked how he was, he replied, "Not so good." He explained, "I burnt my back yesterday." When queried further he stated, "Put a hot pad on it." At that time, LVN J and COTA P entered the room and informed Resident #25 they were going to look at the burns on his back. LVN J instructed Resident #25 to attempt to turn to his right side. COTA P was on the resident's right and LVN J was on his left side. and they both helped turn him to his right side. When he was on his side the surveyor saw one large, first degree burn on Resident #25's mid back, measuring approximately 10 inches by 8 inches. Within this first degree burn were two second to third degree burns; one was on the upper left side of his spine and approximately 5 cm X 4 cm and was red and raw with a small area of purple to black noted to the left upper edge. The second advanced burn was approximately two to three inches below and to the right of the first. It was midline to his spine and extended to the right and was approximately 5 cm X 4 cm. The burned skin was dark, reddish raw with an area which appeared whitish in the center. When queried on how this had happened COTA P informed the surveyor a therapist had put a hot pad on him the previous day. LVN J and COTA P did not measure the burned areas. When LVN J and COTA P finished looking at the burns, they positioned Resident #25 back onto his back with a pillow under the left side and left the room. After LVN B and COTA P left the room, Resident #25 revealed his back "really hurt" the previous night. He stated he thought the heating pad had been left on for one and a half hour the previous morning. On 11/02/11 at 1:00 PM, COTA P stated she had worked with Resident #25 "yesterday and had found it" (burns). She said the area was red and she told the Rehab Director. She stated an Incident Report was completed and all the therapists had been in-serviced on the use of the heat pad. Resident #25's nurses note dated 11/01/11 at 10:50 AM and signed by UM K reflected, "Pt was in therapy (and) received a hot pack for his back. Therapist put hot pack on resident's back (and) wheeled pt to room after therapy was done (and) therapist had forgotten to take off hotpack (sic). Pt started to complain of back pain (and) hot pack was then removed, physician (and) family notified of incident. 2 small blisters were noted on back #1 was filled with clear serous fluid, measures 6 cm X 5 cm (and) #2 is also filled (with) clear serous fluid (and) measures 5 cm X 4 cm, wound tx nurse evaluated pt (and) (symbol for 'no') N/O were written @ this time, WCTM (will continue to monitor) for any (changes) in condition." Resident #25's Pain Flow Sheet with the only entry of 11/01/11 at 12:00 PM reflected Resident #25 complained of back pain with an intensity of 8 out of 10 (10 being the worst and 1 being the least). It reflected he received one Tylenol 325 mg (milligram) and was re-positioned. Resident #25's Daily Skilled Nurse's Note dated 11/01/11 at 2:00 PM and signed by LVN J reflected Resident #25's doctor was called and a message left on his voice mail regarding "resident's complain of pain in the back, due to burn from therapy...." Resident #25's Weekly Skin Documentation dated 11/01/11 untimed and signed by LVN O reflected, "#1 Serous fluid blister noted. Measures 6 cm X 4.5 cm. #2 Serous fluid blister noted. Measures 5 cm X 4 cm." On 11/02/11 at 1:50 PM during an interview with the DON, she revealed she had been informed of Resident #25 being burned the previous day. She was told by UM L and had instructed her to write an Incident Report, tell the Rehab Director to in-service her employees on hot packs, write a treatment order and get measurements. When informed there were no treatment orders written and no first aide had been administered, she called the West Treatment Nurse. On 11/02/11 at 2:05 PM, Resident #25 was asked for a description of his pain on a scale from 1 to 10 with 1 being the least and 10 being the worst. Resident #25 replied, "yesterday (10/31/11) it was a 9 and now it is a 7." UM L and NP M donned gloves and assisted him to turn to his left side and looked at the burns. NP M said the burns were partial thickness or 2nd degree burns; they almost looked like 3rd degree in areas. NP M said she would order Hydrocodone one to two every four hours as needed for pain. Resident #25 was asked if he had received anything for pain since the day before and he informed her, "Nothing all night; no pain medicine. They all went to bed...." An interview on 11/02/11 at 2:45 PM with the Administrator, Assistant Administrator and Corporate Nurse revealed the incident involving Resident #25 and the burns resulting from the hot packed would be reported to the state agency immediately. On 11/02/11 at 2:50 PM, the RD updated the surveyor on the investigation. The RD revealed Resident #25 had a swallow study and had been sitting up for a while. He complained that his back hurt so COTA P placed a hot pack on Resident #25's back. COTA P got the hot pack and wrapped it in towels prior to putting it on his back. She said COTA P had asked Resident #25 a few times if it was too hot and he had told her it was not. COTA P had to leave the resident's side but told other therapists Resident #25 had a hot pack. The RD revealed a CNA (unidentified) came and took the resident back to his room. DPT Q and the CNA were transferring Resident #25 back into his bed when they found the hot pack.. RD stated it had been determined the hot pack was on for no more than 20 minutes, explaining COTA P was with Resident #25 for 10 minutes before she left and it was about 10 minutes later when DPT Q came and told her about finding the hot pack. On 11/02/11 at 3:00 PM during an interview with COTA P, she revealed she placed the hot pack on Resident #25. She said she had been doing this type of work for five years and this had never happened before. COTA P said Resident #25 came back in from the swallow study and was sitting up in his w/c and complained of back pain. She said he had only been sitting for 15-20 minutes and as part of his therapy they were trying to get him to increase his time sitting up so she asked him if he would like a hot pack for his back pain. He said yes. She stated she covered the hot pack with two towels and the cover as well and placed it on his back. COTA P said they normally cool down in 15 minutes and she asked him several times if it was too hot. Resident #25 said it was okay. COTA P said Resident #25 kept saying he wanted to lie back down and he never complained of the pack being too hot. COTA P said she forgot she put a hot pack on Resident #25. She stated SLP R took the resident back to his room, as he had completed his speech therapy swallow study. COTA P did not know how long he sat up in his room before the hot pack was discovered. COTA P said it was about 10:30 AM when Resident #25 was with her and around 11:30 AM when she found out about the burn. COTA P said DPT Q informed her of Resident #25's burn; they both went to inform LVN J. She said they tried to get LVN J to give Resident #25 something for pain and he informed them he would have to contact the doctor. She and DPT Q went back and placed Resident #25 on his side. COTA P said Resident #25 kept asking, "Could we put something on it?" and she kept "bugging" LVN J and LVN C. LVN J said he would put something on it so she left and did not go back to check on Resident #25 until 3:00 PM to 3:30 PM. COTA P said Resident #25 had just had a shower and kept asking her to "please put something on it." COTA P said she went back to LVN C again and asked her to put something on the burn and LVN C told her she would. (Note: LVN C never gave Resident #25 anything for pain nor did she assess his pain or the burns.) On 11/02/11 at 3:23 PM, the UM L was observed during a treatment and assessment of Resident #25's burns. During the observation, UM L did not measure the reddened, first degree area and it still appeared to be approximately 10 inches by 8 inches. On the upper left side of his spine was an open area (Area #1) measured by UM L at 6.9 cm wide by 6.6 cm long and was bloody red, raw with a small area of purplish black noted to the left upper edge. The small purple area was not measured separately by UM L but it appeared to be approximately 1 cm by 1 cm. Approximately two to three inches below and to the right of Area #1, midline to his spine and extending to the right was Area #2 that measured at 8.3 cm wide by 5.4 cm long and was dark, reddish raw with a whitish center. UM L stated the area was oozing serous fluid. UM L did not measure this whitish area but it was approximately 1.5 cm wide by 1cm long. UM L then cleaned the burns with normal saline, dried them, placed Silvadene on the open areas with a sterile tongue depressor and covered the area with an 8 by 10 inch ABD (Abdominal) pad (Large dressing). On 11/02/11 at 3:50 PM, the DON revealed she first learned of the incident at lunch on 11/01/11. The DON stated, "I was told we had an incident; one of the therapists left a hot pack on too long...I was told they burned him." She said it was reported the resident sustained [REDACTED]. The DON stated she told them to do an in-service and told her nurses to "Go assess him; get an order for [REDACTED]." She stated she went back later in the afternoon and said to ADON I, UM K and UM L, "We have to have in-services." When queried whether she had checked Resident #25's wounds, the DON stated she focused on the inservices. She was told by her nurses, other staff were taking care of the resident. When queried whether the physician had been notified, the DON stated she was not sure. An interview on 11/02/11 at 4:54 PM, the Facility Wound Physician revealed he felt the burns to Resident #25 were partial thickness, second degree wounds and the treatment order was appropriate and he (Resident #25) should be fine. The Facility Wound Physician said, "Sometimes you have to just wait and see. It may go from partial thickness to full in the first 24 hours...Pain control for sure..." When queried about the purplish black area to Area #1 and the whitish area on Area #2, he stated he would be back to re-assess them the next day. He stated he could not see the complete wound beds due to the wound being covered with Silvadene, and he did not want to cause unnecessary pain to Resident #25 by completely cleaning them off. On 11/02/11 at 5:12 PM, during a meeting with administrative staff, the DON was queried regarding whether Resident #25 had a physician's orders [REDACTED]." When queried whether anyone could make the decision to apply a hot pack, the RD replied, "Yes." RD stated it was part of the order and pointed out an order for [REDACTED]. When queried whether a resident's risk for skin breakdown would factor in the decision to use heat, the RD replied, "That's a precaution, not a contraindication." When asked to clarify "precaution," she stated they would need to be monitored. When asked how often they would need to be monitored, the RD stated every two to three minutes at first, asking if it felt too hot. The Rehab Departments, Clinical Service Bulletin for Application of Hydrocollator (sic) Hot Packs dated 08/26/11 reflected under definition: "The hydrocollator hot packs contain inert silica gel, which absorbs and holds large quantities of water. This is a form of moist heat....The heat is released slowly over a period of approximately 30 minutes." And under precautions: "1. Elderly patients may need more toweling because of their fragile skin." Under application: "2. Remove clothing from the part to be treated and check the rest of the clothing for maximum comfort and freedom from restriction....5. Check sensation for light touch and hot/cold. 6. Place the patient in the appropriate position...7. Place 2-3 hot pack covers on top of each other(at least 6 layers of towels)...11. Place the pack on the area to be treated. It is recommended to place the hot pack on the patient versus allowing the patients weight to rest on the pack, as this can cause burns...14. Do not leave the patient unattended. Check the skin under the hot pack after the first 5 minutes to ensure it is not too hot; adjust number of towels as needed..15. Duration of the hot pack treatment is generally 15-25 minutes or to the patient's tolerance. Place the call bell in place and continue to supervision (sic) the care." Under documentation and coding: "2. ....However, the therapist must record the treatment through the mobile device and it is best practice to include hot packs in the treatment clarification order." Review of the Rehab Departments, Skilled Nursing Rehabilitation Policy and Procedures Manual for "Hot Pack" revealed under Procedure: "c. Position the patient comfortably and drape accordingly with the area to be treated exposed. d ...place pack in cloth cover or wrap in 6-8 towels. It is best to put the pack ON the patient rather that (sic) putting the patient on the pack. e...Skin must be checked every 5-10 minutes during the treatment....f. Duration of the hot pack treatment is generally 15-25 minutes or to the patient's tolerance...." On 11/03/11 at 9:38 AM, the DON said that around noon (on 11/01/11) UM K came to her and informed her Resident #25 had received a burn to his back and it had two little "0.5 cm tiny blisters" The DON said she instructed UM K to go to therapy and get a report of what happened, tell the RD to do in-services with all her therapists that worked with hot packs, complete an incident report, the burns were to be measured and a treatment order obtained. She said when she was queried by the surveyor on 11/02/11 she realized "the gravity of it." The DON said the ADON I, UM K, and the RD were given specific instructions and they "did not do what they were told...." She stated that UM K "charted something that she never went and assessed." The DON said the RD told her DPT Q helped transfer him to bed, but "That's not what happened." She informed the surveyors, COTA P had put the hot pad on Resident #25's back while she was actually caring for someone else, SLP R took him back to his room. The DON said when the aide "went to put him in the bed, she found it" and gave it to Therapy Tech DD. She said Therapy Tech DD took the hot pack to UM K and UM K "assumed" he was therapy. The DON said actually Therapy Tech DD used to be her CNA, and was nothing more than a "CNA Transporter" but had gone to work for the therapy department. When queried about who had placed Resident #25 back to bed, the DON said she did not know and was still trying to find out. The DON stated, "I completely agree that he was not cared for properly, I was horrified." On 11/03/11 at 12:00 PM, the Facility Wound Physician revealed he had been in to assess Resident #25's burns and he reported, "I think it's going to be full thickness, It's looking worse..." He described the wound beds as having some "blue/black darker areas." He stated, "It is unstageable, it's definitely second degree." He said he would come and check on it over the weekend and the following week. An interview with Therapy Tech DD on 11/03/11 at 12:30 PM revealed, "The aide handed me the hot pack." He said it was CNA T and when he received it there was a towel over it, a hot pack cover and then the hot pack. When queried about the time he replied it was before lunch "I clean the therapy gym during lunch." He also reported it was closer to lunch than breakfast and he had not seen CNA T. Review of the facility's Rehabilitation Services Policy and Procedures dated 08/2011 under position description for job title Occupational Therapy Assistant reflects under standard responsibilities: "2. Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment." Review of the facility's Rehabilitation Services Policy and Procedures dated 08/2011 under the competency checklist of performance criteria for use of hot packs/moist heat, "5. The patient/resident is draped and positioned appropriately with the area to be treated exposed...6. Moist heat pack is removed from the hydrocullator (sic) unit, placed in a terry cloth cover and wrapped in 3-4 layers of towels or more as indicated by patient tolerance or thickness of cover/towels if hot pack is placed on top of the patient/resident. 7. Hot packs are never placed under the patient. If the back is being treated, patient is positioned in side lying, as necessary... 9. Check the treated area after the first 5 minutes for excessive redness or signs of burning. 10. At the end of the treatment (15-25 minutes)...." Review of COTA P's Competency Assessment- Occupational Therapy Assistant with her hire date on the form revealed under Heat Application the date of 09/16/11 and the methods of observation being observation, repeat performance and previous experience that was documented. Review of Resident #25's Incident/Accident Investigation Worksheet dated and signed by UM K on 11/01/11 under "Describe patient's or resident's health condition at the conclusion of the investigation: Date: 11/2/11 Time 12:45" with AM checked and marked and UM K's initials beside and then PM checked (Note: This was the time the surveyor first learned and observed the open burns) and filled out by UM K. The worksheet revealed, "Pt is now resting comfortably in bed, blisters on back X (times) 2 still intact on back." Review of the facility's Record of In-Service dated 11/01/11, facilitated by the RD, with the subject "Hot Pack Protocols" revealed, "1) Place towels over the area where heat will be applied. 4-6 layers, 2) Place hot pack over area for 30 mins (minutes), 3) Once placed on pt. check back with pt. in 2 mins and check skin and ask pt if ok. 4) pt must be constantly monitored during treatment." Interview with UM K on 11/03/11 at 5:38 PM revealed she became aware of Resident #25's burns from someone in the therapy department, but could not remember who. LVN J was with her at the time. UM K stated they were told there was a burn from a "patch" that was put on his back. She stated she went and looked at Resident #25's back and saw two blisters. When asked what they looked like she stated she could not tell exactly but they were "not anything like they are now." She stated there was some redness and pink around the blisters. She said she had informed LVN J to continue to monitor his back and pain and to be sure and tell the next shift. When queried who called the physician, UM K stated she called the Medical Director, who is Resident #25's attending physician and left a message and called Resident #25's wife. On 11/04/11 at 10:05 AM, the surveyor observed UM M change the dressing to Resident #25's burns. After she cleaned the burns, Area #1's wound bed appeared dark blue, red, purple, black and very dry. Area #2 appeared as dark blue, red, purple, black and was very dried out as well. UM M described them as purple, maroon in color. Interview with CNA T on 11/04/11 at 1:15 PM revealed she entered Resident #25's room after her lunch break. CNA T stated "CNA U and CNA V had just put him back to bed. They were getting ready to remove the sling (used during a Hoyer lift transfer), I told them I would get the sling." CNA T stated she removed the sling and afterward, Resident #25 complained that his back was hot. When she asked him why, he stated he did not know. CNA T stated she checked and discovered the hot pack. When queried what she saw, CNA T stated there was the sling, then a pillow, then the hot pad in a sleeve and then two towels. She further stated she did not notice the pack when she removed the sling because there was a pillow placed over it inside the sling. When queried about the temperature of the pack when she removed it, CNA T stated "It was normal hot, like if you put a hot pack on you." CNA T stated she did not look at his skin at that time, "I just said 'okay' and took it off...later he still complained." CNA T stated it was later she saw the areas, the same time as UM L, She stated, "Therapy had already seen it." CNA T stated his whole back was red and there were two blisters. CNA T drew a circle approximately one centimeter in diameter to describe the size. When queried whether Resident #25 was complaining of pain at that time, CNA T replied, "yeah, he kept saying 'my back is hot'." On 11/04/11 at 2:35 PM during an interview with CNA JJ, she said she had taken care of Resident #25 and given him a shower on 11/01/11 around 3:00 PM. CNA JJ denied seeing any redness or blisters on his back. She said CNA KK assisted her in putting him back to bed and she denied Resident #25 ever complained of pain. CNA JJ said after he was back in bed she applied lotion to his back. (Note: In the interview with COTA P on 11/02/11 at 3:00 PM, she stated she checked on Resident #25 between 3:00 PM to 3:30 PM. on 11/01/11 and he had just had a shower and kept asking her to "please put something on it.") On 11/04/11 at 3:00 PM during an interview with LVN C, she revealed her supervisor UM K had informed her Resident #25 had blisters. During the medication pass at 4:30 PM she looked at his back and saw 3 little blisters, not open. Review of the facility's Resident Bed List Report dated 11/03/11 with residents who receive "Modalities" from the Rehab Department revealed 25 highlighted names so these 25 residents in the facility could be at risk for burns related to the modality of hot packs.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (Residents #25, #10 and #18) of 21 residents reviewed for pain/comfort as evidenced by: 1. Resident #25 received a full-thickness, 2nd degree burn on his mid back from a "moist heat" hot pack and went for greater than 24 hours without a continuous assessment of pain control or treatment for [REDACTED]. Following an assessment by the NP on 11/02/11, the resident was ordered to receive [MEDICATION NAME] 1-2 tablets every four hours for pain as needed and to clean [MEDICAL CONDITION] normal saline, apply [MEDICATION NAME] and cover with a dressing on a daily basis. These failures resulted in Resident #25 having uncontrolled pain, caused an increase in his medical cost, an increase in the time he must stay at the facility, an increase in the time he must stay away from his family and loved ones, and could result in the development of an infection to the burned areas. Twenty-five other residents who received "Modalities" from the Rehab Department could be at risk [MEDICAL CONDITION] to the modality of hot packs. Resident #25 received a serious burn to his mid back and went for more than 24 hours without a continuous assessment for pain control and/or treatment for [REDACTED]. 2. Resident #10 was not assessed or medicated for pain before, during or after a dressing change to her right outer ankle on 11/01/11, September 2011 or October 2011. This failure resulted in Resident #10 experiencing unnecessary pain and discomfort, dreading dressing treatments, transfers, refusal of treatments and transfers resulting in self-isolation, and could result in a decrease in her quality of life. 3. Resident #18 was not assessed before or after 86 of the 143 doses of PRN [MEDICATION NAME] (narcotic [MEDICATION NAME]) were administered. This failure could affect Resident #18 and placed her at risk for discomfort, ineffective pain management and unnecessary administration of narcotics, which could result in dependence upon the narcotic. These failures could affect the 67 residents on pain management programs and/or the 82 residents who received PRN pain medications and placed them at risk for potentially experiencing unnecessary pain and discomfort, ineffective pain management, developing dependence upon pain medications, and having a negative impact on their quality of life. Findings included: 1. Review of Resident #25's admission MDS Resident Assessment and Care Screening dated 10/27/11 revealed he was a [AGE] year-old male admitted on [DATE]. His admitting active [DIAGNOSES REDACTED]. On 10/31/11 at 10:30 AM during the initial tour with RN/ADON I, Resident #25 was described as a new admission from out-of-state who was interviewable. RN/ADON I revealed the resident was receiving in-house [MEDICAL TREATMENT] and was admitted with a wound. RN/ADON I stated Resident #25 had a [DEVICE] for nutrition and an indwelling urinary catheter (Foley). He was incontinent of bowel and required total care. RN/ADON I said the resident used a wheelchair for mobility, propelled by staff. At that time, it was observed the resident had a special mattress on his bed. On 11/02/11 at 12:45 PM, Resident #25 was observed in his room, in his bed, with the HOB elevated to 45 degrees. His feeding pump was on and infusing Nepro at 45 cc/hr. He had misted O2 per nasal cannula and his Foley catheter was draining dark yellow urine via gravity. He was awake and alert, wearing a hospital gown and when asked how he was, he replied, "Not so good." He explained, "I burnt my back yesterday." When queried further he stated, "Put a hot pad on it." At that time, LVN J and COTA P entered the room and informed Resident #25 they were going to look at [MEDICAL CONDITION] his back. LVN J put the HOB down to 15 degrees (With the feeding pump still infusing at 45 cc/hr), and instructed Resident #25 to attempt to turn to his right side. COTA P was on the resident's right and LVN J was on his left side. and they both helped turn him to his right side. When he was on his side the surveyor saw one large, first degree burn on Resident #25's mid back, measuring approximately 10 inches by 8 inches. Within this first degree burn were two second to third degree burns; one was on the upper left side of his spine and approximately 5 cm X 4 cm and was red and raw with a small area of purple to black noted to the left upper edge. The second advanced burn was approximately two to three inches below and to the right of the first. It was midline to his spine and extended to the right and was approximately 5 cm X 4 cm. The burned skin was dark, reddish raw with an area which appeared whitish in the center. When queried on how this had happened COTA P informed the surveyor a therapist had put a hot pad on him the previous day. LVN J and COTA P did not measure the burned areas. When LVN J and COTA P finished looking at the burns, they positioned Resident #25 back onto his back with a pillow under the left side and left the room. LVN J and COTA P did not raise Resident #25's HOB back up and never turned his feeding pump off so it was still infusing at 45 cc/hr. After LVN B and COTA P left the room, Resident #25 revealed his back "really hurt" the previous night. He stated he thought the heating pad had been left on for one and a half hour the previous morning. Resident #25 revealed he could not reach the controls for his bed to raise his HOB up. The surveyor informed him she would get the nurse to come back and raise the HOB, as his feeding pump was still infusing at 45 cc/hr. On 11/02/11 at 12:57 AM, LVN J was queried concerning where the HOB should be elevated while a resident had a feeding pump on and running. LVN J stated "mid fowlers" (around 30 degrees). LVN J revealed he had intentionally left Resident #25's head down because UM L and the NP/ RN M were coming to look at the resident's back. LVN J then went to Resident #25's room and turned the feeding pump off. On 11/02/11 at 1:00 PM, COTA P stated she had worked with Resident #25 "yesterday and had found it" (burns). She said the area was red, and she told the Rehab Director. She stated an Incident Report was completed and all the therapists had been in-serviced on the use of the heat pad. Resident #25's Physician order [REDACTED]. Resident #25's Physician's Telephone Orders from his admittance on 10/20/11 through 11/01/11 reflected no treatment orders [MEDICAL CONDITION] his back. Resident #25's nurses note dated 11/01/11 at 10:50 AM and signed by UM K reflected, "Pt was in therapy (and) received a hot pack for his back. Therapist put hot pack on resident's back (and) wheeled pt to room after therapy was done (and) therapist had forgotten to take off hotpack (sic). Pt started to complain of back pain (and) hot pack was then removed, physician (and) family notified of incident. 2 small blisters were noted on back #1 was filled with clear serous fluid, measures 6 cm X 5 cm (and) #2 is also filled (with) clear serous fluid (and) measures 5 cm X 4 cm, wound tx nurse evaluated pt (and) (symbol for 'no') N/O were written @ this time, WCTM (will continue to monitor) for any (changes) in condition." Resident #25's Pain Flow Sheet with the only entry of 11/01/11 at 12:00 PM reflected Resident #25 complained of back pain with an intensity of 8 out of 10 (10 being the worst and 1 being the least). The Pain Flow Sheet reflected he received one Tylenol 325 mg and was re-positioned. Resident #25's Enteral Meds PRN Flowsheet dated 11/01/11-11/30/11, revealed Tylenol 325 mg two tabs via the [DEVICE] every 6 hours as needed for pain was the only pain medicine ordered. There was one entry (initial) on 11/01/11 under PRN 1. There was PRN 1 through PRN 4 listed on each day for this pain medication. (Note: This meant he could have the Tylenol four times per day.) Resident #25's Daily Skilled Nurse's Note dated 11/01/11 at 2:00 PM and signed by LVN J reflected Resident #25's doctor was called and a message left on his voice mail regarding "resident's complain of pain in the back, due to burn from therapy...." Resident #25's Daily Skilled Nurse's Note dated 11/01/11 untimed and signed by LVN C reflected "...M.D. notified to monitor blister till open then tx (with) TAO leave open to air...." Resident #25's Weekly Skin Documentation dated 11/01/11 untimed and signed by LVN O reflected, "#1 Serous fluid blister noted. Measures 6 cm X 4.5 cm. #2 Serous fluid blister noted. Measures 5 cm X 4 cm." On 11/02/11 at 1:50 PM during an interview with the DON, she revealed she had been informed of Resident #25 being burned the previous day. She was told by UM L and had instructed her to write an Incident Report, tell the Rehab Director to in-service her employees on hot packs, write a treatment order and get measurements. When informed there were no treatment orders written and no first aide had been administered, she called the West Treatment Nurse. On 11/02/11 at 2:05 PM, Resident #25 was asked for a description of his pain on a scale from 1 to 10 with 1 being the least and 10 being the worst. Resident #25 replied, "Yesterday (10/31/11) it was a 9 and now it is a 7." UM L and NP M were at the doorway to Resident #25's room during the interview and came in when they heard what he rated his pain. They revealed they wanted to look at his back, but they asked the resident if he wanted to wait. He said, "I wish ya'll would. I felt that way all night." UM L asked if he had told anyone about his back and pain. Resident #25 replied, "They all went home at 7." UM L and NP M donned gloves and assisted him to turn to his left side and looked at the burns. NP M instructed UM L to clean [MEDICAL CONDITION] NS, dry, apply [MEDICATION NAME] and cover with a dry bandage every day. NP M said [MEDICAL CONDITION] partial thickness or 2nd degree burns; they almost looked like 3rd degree in areas. NP M said she would order [MEDICATION NAME] one to two every four hours as needed for pain. She then left to write the orders. UM L left to see if there was any [MEDICATION NAME] on hand. Resident #25 was asked if he had received anything for pain since the day before and he informed her, "Nothing all night. No pain medicine. They all went to bed...." On 11/02/11 at 2:25 PM, UM L returned to Resident #25's room with the DON. The DON revealed they were going to pre-medicate the resident prior to cleaning and dressing the wounds. An interview on 11/02/11 at 2:45 PM with the Administrator, Assistant Administrator and Corporate Nurse revealed the incident involving Resident #25 and [MEDICAL CONDITION] from the hot packed would be reported to the state agency immediately. On 11/02/11 at 2:50 PM, the RD updated the surveyor on the investigation. The RD revealed Resident #25 had a swallow study and had been sitting up for a while. He complained that his back hurt so COTA P placed a hot pack on Resident #25's back. COTA P got the hot pack and wrapped it in towels prior to putting it on his back. She said COTA P had asked Resident #25 a few times if it was too hot, and he had told her it was not. COTA P had to leave the resident's side but told other therapists Resident #25 had a hot pack. The RD revealed a CNA (unidentified) came and took the resident back to his room. DPT Q and the CNA were transferring Resident #25 back into his bed when they found the hot pack. RD stated it had been determined the hot pack was on for no more than 20 minutes, explaining COTA P was with Resident #25 for 10 minutes before she left, and it was about 10 minutes later when DPT Q came and told her about finding the hot pack. On 11/02/11 at 3:00 PM during an interview with COTA P, she revealed she placed the hot pack on Resident #25. She said she had been doing this type of work for five years, and this had never happened before. COTA P said Resident #25 came back in from the swallow study and was sitting up in his w/c and complained of back pain. She said he had only been sitting for 15-20 minutes and as part of his therapy they were trying to get him to increase his time sitting up so she asked him if he would like a hot pack for his back pain. He said yes. She stated she covered the hot pack with two towels and the cover as well and placed it on his back. COTA P said they normally cool down in 15 minutes and she asked him several times if it was too hot. Resident #25 said it was okay. COTA P said Resident #25 kept saying he wanted to lie back down and he never complained of the pack being too hot. Resident #25 kept having COTA P adjust his legs in the w/c, first up then down and then back up and kept saying he wanted to lie down. COTA P said she forgot she put a hot pack on Resident #25. She stated SLP R took the resident back to his room, as he had completed his speech therapy swallow study. COTA P did not know how long he sat up in his room before the hot pack was discovered. COTA P said it was about 10:30 AM when Resident #25 was with her and around 11:30 AM when she found out about the burn. COTA P said DPT Q informed her of Resident #25's burn; they both went to inform LVN J. She said they tried to get LVN J to give Resident #25 something for pain and he informed them he would have to contact the doctor. She and DPT Q went back and placed Resident #25 on his side. COTA P said Resident #25 kept asking, "Could we put something on it?" and she kept "bugging" LVN J and LVN C. LVN J said he would put something on it so she left and did not go back to check on Resident #25 until 3:00 PM to 3:30 PM. COTA P said Resident #25 had just had a shower and kept asking her to "please put something on it." COTA P said she went back to LVN C again and asked her to put something on the burn and LVN C told her she would. (Note: LVN C never gave Resident #25 anything for pain nor did she assess his pain or the burns.) On 11/02/11 at 3:15 PM, the surveyor queried NP M about whether she or the facility's Wound Physician had known about Resident # 25'[MEDICAL CONDITION] 11/02/11 and she said she had just heard about them after coming to the facility for a wound consult on Resident #10. On 11/02/11 at 3:23 PM, the UM L set up her clean field for the dressing change for Resident #25 on his over bed table. She informed the surveyor he had been medicated for pain with a [MEDICATION NAME] ([MEDICATION NAME]/ [MEDICATION NAME]) 5/325 (5 mg [MEDICATION NAME] and 325 mg [MEDICATION NAME]) at 2:30 PM. The surveyor asked Resident #25 to rate his pain on the scale of 1 - 10 and he said it was a 2 -3. UM L assisted Resident #25 to his right side after putting the HOB down (his feeding machine was off). UM L revealed she needed to measure [MEDICAL CONDITION] well. During the observation, UM L did not measure the reddened, first degree area and it still appeared to be approximately 10 inches by 8 inches. On the upper left side of his spine was an open area (Area #1) measured by UM L at 6.9 cm wide by 6.6 cm long and was bloody red, raw with a small area of purplish black noted to the left upper edge. The small purple area was not measured separately by UM L but it appeared to be approximately 1 cm by 1 cm. Approximately two to three inches below and to the right of Area #1, midline to his spine and extending to the right was Area #2 that measured at 8.3 cm wide by 5.4 cm long and was dark, reddish raw with a whitish center. UM L stated the area was oozing serous fluid. UM L did not measure this whitish area but it was approximately 1.5 cm wide by 1cm long. UM L then cleaned [MEDICAL CONDITION] normal saline, dried them, placed [MEDICATION NAME] on the open areas with a sterile tongue depressor and covered the area with an 8 by 10 inch ABD (Abdominal) pad (Large dressing). When UM L had completed the treatment she revealed she was going to assist the resident in changing his t-shirt, as it was wet from the open areas weeping serous fluid. UM L instructed Resident #25 on how often he could receive the pain medication, and raised his HOB back up. On 11/02/11 at 3:50 PM, the DON revealed she first learned of the incident at lunch on 11/01/11. The DON stated, "I was told we had an incident; one of the therapists left a hot pack on too long...I was told they burned him." She said it was reported the resident sustained [REDACTED]. The DON stated she told them to do an in-service and told her nurses to "Go assess him; get an order for [REDACTED]." When queried whether she had checked Resident #25's wounds, the DON stated she focused on the inservices. She was told by her nurses, other staff were taking care of the resident. When queried whether the physician had been notified, the DON stated she was not sure. An interview on 11/02/11 at 4:54 PM, the Facility Wound Physician revealed he felt [MEDICAL CONDITION] Resident #25 were partial thickness, second degree wounds and the treatment order was appropriate and he (Resident #25) should be fine. He revealed he would expect the nurses or staff to identify the burn, take away the heat source, provide pain control, watch it and treat it. The Facility Wound Physician said, "Sometimes you have to just wait and see. It may go from partial thickness to full in the first 24 hours...Pain control for sure..." When queried about the purplish black area to Area #1 and the whitish area on Area #2, he stated he would be back to re-assess them the next day. He stated he could not see the complete wound beds due to the wound being covered with [MEDICATION NAME], and he did not want to cause unnecessary pain to Resident #25 by completely cleaning them off. On 11/02/11 at 5:12 PM, during a meeting with administrative staff, the DON was queried regarding whether Resident #25 had a physician's orders [REDACTED]." When queried whether anyone could make the decision to apply a hot pack, the RD replied, "Yes." RD stated it was part of the order and pointed out an order for [REDACTED]. precaution, not a contraindication." When asked to clarify "precaution," she stated they would need to be monitored. When asked how often they would need to be monitored, the RD stated every two to three minutes at first, asking if it felt too hot. The Rehab Departments, Clinical Service Bulletin for Application of [MEDICATION NAME] Hot Packs dated 08/26/11 reflected under definition: "The [MEDICATION NAME] hot packs contain inert [MEDICATION NAME] gel, which absorbs and holds large quantities of water. This is a form of moist heat....The heat is released slowly over a period of approximately 30 minutes." And under precautions: "1. Elderly patients may need more toweling because of their fragile skin." Under application: "2. Remove clothing from the part to be treated and check the rest of the clothing for maximum comfort and freedom from restriction....5. Check sensation for light touch and hot/cold. 6. Place the patient in the appropriate position...7. Place 2-3 hot pack covers on top of each other(at least 6 layers of towels)...11. Place the pack on the area to be treated. It is recommended to place the hot pack on the patient versus allowing the patients weight to rest on the pack, as this can cause burns...14. Do not leave the patient unattended. Check the skin under the hot pack after the first 5 minutes to ensure it is not too hot; adjust number of towels as needed..15. Duration of the hot pack treatment is generally 15-25 minutes or to the patient's tolerance. Place the call bell in place and continue to supervision (sic) the care." Under documentation and coding: "2. ....However, the therapist must record the treatment through the mobile device and it is best practice to include hot packs in the treatment clarification order." Review of the Rehab Departments, Skilled Nursing Rehabilitation Policy and Procedures Manual for "Hot Pack" revealed under Procedure: "c. Position the patient comfortably and drape accordingly with the area to be treated exposed. d ...place pack in cloth cover or wrap in 6-8 towels. It is best to put the pack ON the patient rather that (sic) putting the patient on the pack. e...Skin must be checked every 5-10 minutes during the treatment....f. Duration of the hot pack treatment is generally 15-25 minutes or to the patient's tolerance...." On 11/03/11 at 9:38 AM, the DON revealed the incident was not called into the state agency when she was initially made aware of the burns. She said that around noon (on 11/01/11) UM K came to her and informed her Resident #25 had received a burn to his back, and it had two little "0.5 cm tiny blisters" The DON said she instructed UM K to go to therapy and get a report of what happened, tell the RD to do in-services with all her therapists who worked with hot packs, complete an incident report, [MEDICAL CONDITION] to be measured and a treatment order obtained. She said when she was queried by the surveyor on 11/02/11 she realized "the gravity of it." The DON said UM K charted about it happening but no intervention, no assessment. She reported to the surveyors she asked ADON I if she had gone down and assessed it as she was the "RN and ADON and should" but she had not. The DON said the ADON I, UM K, and the RD were given specific instructions and they "did not do what they were told..." She stated that UM K "charted something that she never went and assessed." The DON said the RD told her DPT Q helped transfer him to bed, but "That's not what happened." She informed the surveyors, COTA P had put the hot pad on Resident #25's back while she was actually caring for someone else, SLP R took him back to his room. The DON said when the aide "went to put him in the bed, she found it" and gave it to Therapy Tech DD. She said Therapy Tech DD took the hot pack to UM K and UM K "assumed" he was therapy. The DON said actually Therapy Tech DD used to be her CNA, and was nothing more than a "CNA Transporter" but had gone to work for the therapy department. When queried about who had placed Resident #25 back to bed, the DON said she did not know and was still trying to find out. The DON stated, "I completely agree that he was not cared for properly. I was horrified." On 11/03/11 at 12:00 PM, the Facility Wound Physician revealed he had been in to assess Resident #25'[MEDICAL CONDITION] he reported, "I think it's going to be full thickness, It's looking worse..." He described the wound beds as having some "blue/black darker areas." He stated, "It is unstageable, it's definitely second degree." He said he would come and check on it over the weekend and the following week. Review of the Facility Wound Physician's progress notes dated 11/03/11 at 11:00 AM revealed a description of the "Open back ulcers are now much darker, purple-blue...." An interview on 11/03/11 at 12:00 PM the ADM stated he was informed by the DON, the afternoon of 11/02/11 regarding the burn on Resident #25's back. (Note this was more than 24 hours later). The ADM stated his management team did not follow through on what they should have done for the resident. An interview with Therapy Tech DD on 11/03/11 at 12:30 PM revealed, "The aide handed me the hot pack." He said it was CNA T and when he received it there was a towel over it, a hot pack cover and then the hot pack. When queried about the time he replied it was before lunch "I clean the therapy gym during lunch." He also reported it was closer to lunch than breakfast and he had not seen CNA T. Review of the facility's Rehabilitation Services Policy and Procedures dated 08/2011 under position description for job title Occupational Therapy Assistant reflects under standard responsibilities: "2. Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment." Review of the facility's Rehabilitation Services Policy and Procedures dated 08/2011 under the competency checklist of performance criteria for use of hot packs/moist heat, "5. The patient/resident is draped and positioned appropriately with the area to be treated exposed...6. Moist heat pack is removed from the hydrocullator (sic) unit, placed in a terry cloth cover and wrapped in 3-4 layers of towels or more as indicated by patient tolerance or thickness of cover/towels if hot pack is placed on top of the patient/resident. 7. Hot packs are never placed under the patient. If the back is being treated, patient is positioned in side lying, as necessary... 9. Check the treated area after the first 5 minutes for excessive redness or signs of burning. 10. At the end of the treatment (15-25 minutes)..." Review of COTA P's Competency Assessment- Occupational Therapy Assistant with her hire date on the form revealed under Heat Application the date of 09/16/11 and the methods of observation being observation, repeat performance and previous experience that was documented. Review of Resident #25's Incident/Accident Investigation Worksheet dated and signed by UM K on 11/01/11 under "Describe patient's or resident's health condition at the conclusion of the investigation: Date: 11/2/11 Time 12:45" with AM checked and marked and UM K's initials beside and then PM checked (Note: This was the time the surveyor first learned and observed the open burns) and filled out by UM K. The worksheet revealed, "Pt is now resting comfortably in bed, blisters on back X (times) 2 still intact on back." Review of the facility's Record of In-Service dated 11/01/11, facilitated by the RD, with the subject "Hot Pack Protocols" revealed, "1) Place towels over the area where heat will be applied. 4-6 layers, 2) Place hot pack over area for 30 mins (minutes), 3) Once placed on pt. check back with pt. in 2 mins and check skin and ask pt if ok. 4) pt must be constantly monitored during treatment." Interview with UM K on 11/03/11 at 5:38 PM revealed she became aware of Resident #25'[MEDICAL CONDITION] someone in the therapy department, but could not remember who. LVN J was with her at the time. UM K stated they were told there was a burn from a "patch" that was put on his back. She stated she went and looked at Resident #25's back and saw two blisters. When asked what they looked like she stated she could not tell exactly but they were "not anything like they are now." She stated there was some redness and pink around the blisters. She informed LVN O to go measure them. UM K said she should have gone back and assessed them again after she got the measurements from LVN O as, "They hadn't looked that big when I saw them." When queried, UM K said she could not remember if LVN O had been with her when she saw the blisters. When queried about what the DON had told her to do, UM K replied, "Get inservices, get statements from the therapists, have him assessed. I told LVN O, if there are any treatments, you need to get an order." She also said she had informed LVN J to continue to monitor his back and pain and to be sure and tell the next shift. When queried who called the physician, UM K stated she called the Medical Director, who is Resident #25's attending physician and left a message and called Resident #25's wife. On 11/04/11 at 10:05 AM, the surveyor observed UM M change the dressing to Resident #25's burns. After she cleaned the burns, Area #1's wound bed appeared dark blue, red, purple, black and very dry. Area #2 appeared as dark blue, red, purple, black and was very dried out as well. UM M described them as purple, maroon in color. Interview with CNA T on 11/04/11 at 1:15 PM revealed she entered Resident #25's room after her lunch break. CNA T stated "CNA U and CNA V had just put him back to bed. They were getting ready to remove the sling (used during a Hoyer lift transfer), I told them I would get the sling." CNA T stated she removed the sling and afterward, Resident #25 complained that his back was hot. When she asked him why, he stated he did not know. CNA T stated she checked and discovered the hot pack. When queried what she saw, CNA T stated there was the sling, then a pillow, then the hot pad in a sleeve and then two towels. She further stated she did not notice the pack when she removed the sling because there was a pillow placed over it inside the sling. When queried about the temperature of the pack when she removed it, CNA T stated "It was normal hot, like if you put a hot pack on you." CNA T stated she did not look at his skin at that time, "I just said 'okay' and took it off...later he still complained." CNA T stated it was later she saw the areas, the same time as UM L, She stated, "Therapy had already seen it." CNA T stated his whole back was red and there were two blisters. CNA T drew a circle approximately one centimeter in diameter to describe the size. When queried whether Resident #25 was complaining of pain at that time, CNA T replied, "yeah, he kept saying 'my back is hot'." On 11/04/11 at 1:40 PM, The Medical director was interviewed via the telephone regarding Resident #25. The Medical Director stated, "I spoke with (Administrator) the day before yesterday and he asked if I had been called-I looked through my call log, I had not been called...It was pointed out to me that it was noted in the nurse's notes I was (called) but I was not." When queried what time he had spoken with the Administrator, the Medical Director stated it was Wednesday, early evening, approximately 5:00 PM. When queried whether he had ever given an order for [REDACTED]." On 11/04/11 at 2:15 PM during an interview with UM K, she revealed she had called the Medical Director and left a message. "He never called me back but I know he called back because someone got an order for [REDACTED]." She stated she used the phone number in their book with the doctors listed in it. On 11/04/11 at 2:35 PM during an interview with CNA JJ, she said she had taken care of Resident #25 and given him a shower on 11/01/11 around 3:00 PM. CNA JJ denied seeing any redness or blisters on his back. She said CNA KK assisted her in putting him back to bed and she denied Resident #25 ever complained of pain. CNA JJ said after he was back in bed she applied lotion to his back. (Note: In the interview with COTA P on 11/02/11 at 3:00 PM, she stated she checked on Resident #25 between 3:00 PM to 3:30 PM. on 11/01/11 and he had just had a shower and kept asking her to "please put something on it.") On 11/04/11 at 3:00 PM during an interview with LVN C, she revealed her supervisor UM K had informed her Resident #25 had blisters. During the medication pass at 4:30 PM she looked at his back and saw 3 little blisters, not open. When queried about speaking with the doctor, LVN C stated she did not speak to the doctor. When queried about why she wrote in her nurse's note, "MD notified" she replied UM K had told her she spoke with the doctor and "that's what I meant." The surveyor queried her on her nurse's note which stated, "monitor for blisters till open then tx (with) TAO- leave open to air." LVN C replied, "we can put TAO on small open areas...we do it all the time...a doctor didn't tell me...I never spoke to a doctor." Review of the facility's Resident Bed List Report dated 11/03/11 with residents who receive "Modalities" from the Rehab Department revealed 25 highlighted names so these 25 residents in the facility could be at risk [MEDICAL CONDITION] to the modality of hot packs. 2. Resident #10's MDS assessment dated ,[DATE]/