Every finding on record at Riverside Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 residents in the 400-hall. 3 of 3 residents reviewed for infection control1. The facility failed to ensure hand hygiene was completed when passing residents' breakfast trays to residents in the 400 hall.These failures could place residents at risk of disease and infection transmission. Findings include:Observation on 04/12/2025 at 8:40 AM revealed during breakfast service in the 400-hall dining room, CNA D was passing food trays to the residents. CNA D was not sanitizing her hands between handing out food trays for 3 residentsDuring an interview on 04/12/2026 at 11:36 AM with CNA D, she revealed she had worked at the facility for 9 months. CNA D stated she had been trained on infection control. CNA D stated that she was supposed to sanitize her hands between each tray given to residents. CNA D stated that failing to sanitize her hands could contaminate the food given to the residents. The CNA D stated that she has had in-service training on infection control, and the last time was 2 weeks ago. She stated that she forgot to sanitize her hands while passing out trays today, but she normally does sanitize her hands when passing out food trays. During an interview on 04/12/2026 at 12:37 PM with CNA E, he revealed that he had worked at the facility for 9 months. CNA E stated that when passing out food trays to residents, he double-checks the ticket. CNA E stated that he sanitizes his hands before passing out the first tray, and will sanitize his hands between each tray after that. CNA E stated that if he sees staff not sanitizing their hands, then he will remind them to do it. CNA E stated that it is important to sanitize hands while passing food trays to prevent infections in vulnerable residents. CNA E stated that he has had in-service training on hand hygiene, and the last time was about two weeks ago. During an interview on 04/12/2026 at 1:08 PM with LVN F, she revealed that she had worked at the facility for 1 year. LVN F stated that when passing out food trays, your hands should be cleaned in between passing food to each resident. LVN F stated that if she sees another staff member not sanitizing their hands while passing food to residents, she will remind them to do so. LVN F stated that she has not witnessed any staff failing to sanitize their hands while passing out food. LVN F stated that she has had in-service training on infection prevention and hand sanitizing. LVN F stated that the last time she had end-of-service training on infection control was about two weeks ago.During an interview on 04/12/2026 at 1:19 PM with CNA G, she revealed that he had worked at the facility for 1 year and 5 months. The CNA G stated that when passing out food trays, staff hands should be sanitized in between each tray passed out. CNA G stated that she has not witnessed any staff failing to sanitize their hands when passing out food to residents. CNA G stated if she did see staff not sanitizing their hands, she would mention it to them. CNA G stated that she had in-service training on hand sanitation and infection control two or three weeks ago. CNA G stated that if hands are not cleaned before passing out trays, residents could get an infection.During an interview on 04/12/2026 at 1:23 PM with DON H, she revealed that he had worked at the facility for 3 months.DON H stated that the expectations for staff to sanitize their hands in between each tray given to a resident. The DON stated that she has not witnessed any staff failing to sanitize their hands while passing out food trays. DON H stated that if she witnesses staff not sanitizing their hands correctly, she will correct them and have them sanitize their hands. DON H stated that she would start in-service training on hand hygiene and infection control if she sees staff not sanitizing their hands. DON H stated that if hands are not cleaned when passing food trays, it is an infection-control issue, and residents could get sick. DON H stated that she has received in-service training on infection control and hand sanitizing. The DON H stated that the last time she had in-service training was about two weeks ago.During an interview with ADM on 04/12/2026 at 1:41 PM, she revealed that it was her expectation that staff sanitize their hands while serving meals to residents. The ADM stated that if she sees staff not sanitizing their hands, she will remind them that they are supposed to do so and then start in-service training on hand sanitation and infection control. The ADM stated that if hands are not cleaned before passing out trays, it is an infection control issue and residents could get sick. The ADM stated that she had already started an in-service training after hearing that staff did not sanitize their hands while passing out food trays to residents. The ADM stated that prior to this incident, the last in-service training on hand sanitation and infection control was about two weeks ago.Record review:Policy titled, Policy/ Procedure - Nursing Clinical Meal, Serving reflected the following:3. Sanitize hands before and after touching each tray.Policy - Infection Prevention and Control Programb. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observation, interview, and record review, the facility failed to ensure all residents were free from physical abuse for 1 of 7 (Resident #1) residents reviewed for resident-resident altercations.The facility failed to ensure Resident #2 did not hit Resident #1 on 3/06/2026.This failure could place residents at risk for psychological and physical harm.The noncompliance was identified as PNC. The noncompliance began on 3/06/2026 and ended on 3/09/2026. The facility had corrected the noncompliance before the survey began.Resident #1A record review of Resident #1's face sheet dated 3/10/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure, cirrhosis (scarring) of the liver, type 2 diabetes (uncontrolled blood sugar), cognitive communication deficit (difficulty communicating), coagulation deficit, bipolar disorder (manic depression), major depressive disorder, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), chronic kidney disease, unspecified lack of coordination, vascular dementia (decreased blood flow to the brain), foot drop (right foot), and contracture (right hand).A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of 9, which indicated moderately impaired cognition. Section E reflected that Resident #1 had no verbal, physical, or other behaviors in the 7-day look-back period. Section GG reflected that Resident #1 was dependent on staff for toileting, lower body dressing, and putting on footwear.A record review of Resident #1's care plan last revised on 1/16/2026 reflected she had ADL self-care performance deficit related to CVA with hemiparesis and staff were to observe her skin for bruising.A record review of Resident #1's change of condition assessment dated [DATE] reflected No changes observed regarding her mental status evaluation and skin evaluation.A record review of Resident #1's psychological services progress note dated 3/09/2026 reflected the following: Provider obtain report from the facility, regarding an incident with another resident and this patient, met with patient at bedside and discussed incident and distress related.Patient's Response to Intervention: Patient laying in bed, presented calm and pleasant engaged with provider in session, patient described incident in dining room, reports she doesn't know the resident buthas seen him around before, reports when he hit her in the arms and that it didn't hurt her, but it was more shocking that it happened. Patient reports staff broke it up right away, report staff have been good to her and providing her with a feeling of safety since incident happened. Patient reports she has not seen the resident since the incident, but is scared of him and that if she does see him out in the common areas, she won't engage and she will go the other way or get staff. Patient describes the situation is frustrating as she has never had problems with anyone before. Patient reportsshe feels safe in the facility because she knows the staff care for her.A record review of Resident #1's assessment dated [DATE] reflected the following: Called by the staff to the dining room to witness the resident crying and the staff was consoling. From the staff the writer came to know that another resident hit the resident on her right arm for blocking the way to the kitchen. This resident was waiting in line to talk to the speech therapist.The staff separated both of them immediately before any escalation. Head to toe assessment completed. Skin is intact. No new skin issues noticed. Resident has old bruises to both rt and lt. arm from previous hospitalization. Vitals are stable. skin assessment every 3days.During an interview on 3/10/2026 at 2:07 PM, the ADON stated that she separated Resident #2 and Resident #1 after the incident on 3/06/2026 and talked with Resident #1. The ADON stated that both residents were referred to psych and that both had already been seen. The ADON stated that the SW met with both Resident #1 and Resident #2. The ADON said that the Psych NP visited with both residents that day (3/10/2026). The ADON said that the Psych NP told her that Resident #1 was okay. The ADON stated that prior to the Psych NP coming to the facility, the Psych NP had a tele-visit with Resident #1 and Resident #2 on 3/06/2026. Resident #2A record review of Resident #2's face sheet dated 3/10/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified sequelae of cerebral infarction (stroke), cognitive social or emotional deficit following cerebral infarction (stroke), cognitive communication deficit (difficulty communicating), intermittent explosive disorder (sudden episodes of unwarranted anger and violent outbursts), vascular dementia, severe, with mood disturbance, adjustment disorder with anxiety, epilepsy (seizure disorder), aphasia (language disorder) following cerebral infarction, and hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting right dominant side.A record review of Resident #2's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Section E reflected that Resident #1 had not exhibited any verbal, physical, or other behaviors in the 7-day lookback period. Section GG reflected that Resident #1 required substantial assistance with oral hygiene and dressing.A record review of Resident #2's care plan last revised on 3/10/2026 reflected that he demonstrated physical behaviors related to expressive aphasia. Resident #2's care plan reflected that he struck another resident on 4/19/2025 and on 3/06/2026. Resident #2's interventions included analyzing triggers, increasing monitoring, psych medication review, and redirecting the resident when stressed. Date Initiated: 04/22/2025A record review of Resident #2's progress note dated 3/09/2026 reflected the following: over the weekend, reports of pt hitting another resident aggressive outburst; attempted to have UA and labs taken to assess if 2/2 acute illness causing mood disturbance, but pt refusedA record review of Resident #2's psychiatric subsequent assessment dated [DATE] reflected that Resident #2 met with the Psych NP for agitation. The note reflected that Resident #2's behaviors, diagnoses, labs, triggers, and medications were reviewed. The note reflected the Resident #2 was back at his baseline and no other behavioral disturbances had been reported over the weekend. The note reflected that Resident #2 has aphasia, and the behavior may have been related to difficulty communicating his needs effectively.A record review of the facility's one-to-one monitoring log dated 3/06/2026-3/09/2026 reflected that Resident #2 was being monitored every 15 minutes.During an observation and interview on 3/10/2026 at 3:50 PM, Resident #2 was observed sleeping in bed. CNA B was in Resident #2's room monitoring him and she said that Resident #2 could not talk but could shake his head yes or no. Resident #2 was unavailable for interview.A record review of the facility's investigation report dated 3/06/2026, indicated the incident involving Resident #1 and Resident #2 reflected safe surveys were conducted with 12 residents with no concerns regarding abuse noted.During an interview on 3/10/2026 at 1:04 PM, the Administrator stated that abuse prevention started with education and in-services on de-escalation. The Administrator stated that residents should be separated immediately and after an incident and that responsible parties were notified. The Administrator stated that Resident #2 did not have a history of physical behaviors but that he had verbal behaviors and would grunt at times. The Administrator stated that Resident #1 was not injured as a result of the resident-resident incident on 3/06/2026.During an interview on 3/10/2026 at 1:28 PM, CNA A stated that Resident #1 and Resident #2 were in the dining room on 3/06/2026 when he heard Resident #1 crying out he hit me. CNA A stated that a housekeeper was there and intervened, but he did not know their name. CNA A said that he let Resident #1 know that it would not happen again. CNA A stated that they put Resident #2 on one-to-one monitoring. CNA A stated that he had never seen Resident #2 be physical before. CNA stated that . CNA A stated that since the incident, staff made sure to monitor Resident #2 and ensure he did not come close to Resident #1. CNA A stated, as soon as we see Resident #1, we make sure he's not near her and we are always observing them.During an interview on 3/10/2026 at 1:30 PM, CNA B stated that on 3/06/2026, she saw Resident #2 trying to get by Resident #1 in the dining room and she wasn't moving fast enough so Resident #2 tried to hit Resident #1. CNA B stated that RN C was the one who saw Resident #2 hit Resident #1. CNA B stated she did not hear Resident #1 state that she was in pain. CNA B stated that the residents were immediately separated and the facility did an in-service on abuse.During an observation and interview on 3/10/2026 at 1:41 PM, Resident #1 was observed sitting in her wheelchair in her room. Resident stated no she did not feel safe in the facility and started tearing up. Resident #1 stated the man did this and made a fist shape with her hand. Resident #1's left arm was observed to be bruised, but she said it was from the hospital. Resident #1 stated she did not know the man's name but when asked if it was Resident #2, she said it's him. Resident #1 then started crying and said that she was scared. Resident #1 pointed to her right arm and said this is what he did to me and said again that she was scared. Resident #1's right arm was observed to be bruised.During an interview on 3/10/2026 at 1:52 PM, RN C stated that on 3/06/2026 Resident #1 was waiting in the cafeteria to see the speech therapist and she was in Resident #2's way. RN C stated that Resident #1 could not move very quickly because she was a stroke patient and Resident #1 could not move her right side. RN C stated that Resident #2 was frustrated because Resident #1 could not move fast enough and he was pushing her chair out of the way. RN C stated Resident #2 raised his hand and started hitting Resident #1 on the right side of her arm as Resident #1 was yelling stop. RN C stated that by the time she got up from the nurses station, Resident #2 was already hitting Resident #1. RN C stated that Resident #1 had spasms on her right side, so it was painful for her to be struck on that side and Resident #1 was crying. RN C stated they separated the residents and Resident #2 started swinging at LVN D. RN C stated that Resident #2 had no history of physical aggression that she knew of.During an interview on 3/10/2026 at 2:22 PM, the SW stated that she visited with Resident #1 on 3/09/2026 about how she felt, if she was in pain, and if she felt safe.The SW stated that she did not visit with Resident #2 regarding the resident-resident incident, but that she spoke with his family member and they would have a care plan on 3/11/2026. The SW stated that Resident #1 was crying when she talked to her about the incident and she was scared but she felt safe. The SW said that the Psych NP saw Resident #1 the day prior (3/09/2026).During an interview on 3/10/2026 at 2:27 PM, the DON stated that the facility's policy on abuse included reporting allegations immediately to the Administrator, de-escalating, and investigating. The DON said that for resident-resident altercations, they put the perpetrator on one-to-one monitoring, do a change of condition assessment, monitor, and refer them to psych. The DON stated that staff were trained on prevention abuse verbally and through computer-based trainings. The DON stated that residents were monitored to ensure they were free from abuse all the time by CNAs, nurses, and all staff. The DON stated if residents experienced abuse, they could be depressed, they could cry or be secluded. The DON stated that she was aware of the bruising on Resident #1's arm and that some of the bruising was from a hospital visit. The DON stated she was aware that Resident #1 was tearful, and that was why she was scheduled to see a psychologist. The DON stated that MD saw both Resident #1 and Resident #2 on 3/09/2026. The DON stated yes, possibly that Resident #1 was affected by the altercation. The DON stated they would continue one-to-one monitoring with Resident #2 despite the Psych NP giving them the go ahead to take him off.During an interview on 3/10/2026 at 4:35 PM, the Administrator stated that residents were monitored by identifying aggression or anything out of the ordinary. The Administrator stated that Resident #1 had been upset following the incident with Resident #2, but that each time she talked with her family member, she seemed a little better.A record review of an in-service dated 3/06/2026 reflected that all staff were trained on types of abuse and reporting abuse and neglect.A record review of an in-service dated 3/06/2026 reflected that all staff were trained on resident-resident deescalation techniques. A record review of the facility's policy titled Abuse: Prevention of and Prohibition Against most recently reviewed in December of 2023 reflected the following: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, exploitation. and mistreatment.The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment withresulting physical harm, pain, or mental anguish. This includes the deprivation by an individual,including a caretaker, of goods or services that are necessary to attain or maintain physical, mental,and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physicalcondition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physicalabuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident received services with reasonable accommodation of the resident's needs and preferences for 1 of 5 residents (Resident #66) reviewed for resident rights. The facility failed to ensure Resident #66's call light was within reach on 01/13/2026. This failure could place residents at risk for unmet needs, delayed care, and injury.Findings included: Record Review of Resident #66's face sheet dated 01/15/2026 reflected the resident was an [AGE] year-old male admitted on [DATE]. His diagnoses included heart failure, atherosclerotic heart disease of native coronary artery (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), polyneuropathy (a condition that involves damage to multiple nerves throughout the body) and chronic pain. Record Review of Resident #66's Quarterly MDS dated [DATE] reflected Resident #66 had almost constant pain, received oxygen therapy, used a wheelchair, and required partial or moderate assistance for toileting, lower body dressing, oral and personal hygiene, bathing, and transfers. The MDS reflected Resident #66 had a BIMS score of 14 which indicated no cognitive impairment. Record review of the Resident #66's care plan dated 12/23/2025 reflected the resident was at high risk for falls r/t gait and balance problems. Interventions included: Be sure the call light is within reach . Furthermore, the resident had potential for pressure ulcer development r/t history of pressure ulcers and immobility. Interventions included: Call light within reach. Record review of Resident #66's orders dated 01/15/2026 reflected the resident was admitted to hospice care and received oxygen therapy and multiple pain medications, including Morphine Sulfate oral solution, Methadone, and Hydrocodone Acetaminophen. During an observation and interview on 01/13/2026 at 11:28 AM, Resident #66 was lying in bed with an oxygen nasal cannula in place. The resident stated he was in pain. The surveyor observed the resident's call light lying on the floor directly behind the bed and out of the resident's reach. The resident stated he did not know where his call light was, could not reach it, and would have to wait until staff passed by his room to get help. He stated he did not know how long the call light had been on the floor. In an interview on 01/13/2026 at 11:45 AM, CNA C stated all residents' call lights should always be within reach. He stated Resident #66 could not have reached the call light where it was lying on the floor when the surveyor saw it. He stated he had been in serviced on call light placement and that a call light out of reach could cause injury or delay in care. CNA C was observed picking up the call light and clipping it to the resident's bed sheet. He stated it was everyone's responsibility to check for call light placement. In an interview on 01/14/2026 at 9:10 AM, LVN E stated all residents' call lights should always be within reach. She stated a call light out of reach could cause a resident to fall or prevent the resident from alerting staff, resulting in unmet needs or delayed response. She stated Resident #66 could not have reached the call light where it was lying on the floor when the surveyor saw it.She stated she was trained in call light placement, and it was everyone's responsibility to check for call light placement. In an interview on 01/14/2026 at 3:39 PM, the ADON stated it was her expectation that all residents' call lights should always be within reach. She stated a call light out of reach could cause a resident to fall, become injured, or experience delayed care. She stated Resident #66 could not have reached the call light where it was lying on the floor when the surveyor saw it. She stated staff have been trained in call light placement, and it was everyone's responsibility to check for call light placement. In an interview on 01/15/2026 at 11:21 AM, the DON stated it was her expectation that all residents' call lights always be within reach. She stated that a resident unable to reach their call light could not communicate needs, which could result in injury, pain, or delayed care. She stated Resident #66 could not have reached the call light where it was lying on the floor when the surveyor saw it.She stated staff have been trained in call light placement and it was everyone's responsibility to check for call light placement during morning rounds. In an interview on 01/15/2026 at 11:44 AM, the ADM stated it was his expectation that all residents always had their call lights within reach. He stated a call light out of reach could cause anxiety or delay in receiving pain medication or other needed care. He stated a call light on the floor behind a resident's bed would be out of reach and did not meet his expectations. He stated it was everyone's responsibility to check for call light placement. Record review of the facility policy titled Call Light/Bell, dated 05/2007 (revised 2026), reflected: Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: 5. Place the call device within residents' reach before leaving the room. Record review of facility In Service Training dated 10/01/2025 and 10/08/2025 reflected staff were trained that Call lights should be placed in reach of all residents at all times.

Based on observation, interview, and record review the facility failed to ensure residents were given the appropriate treatment and services to carry out the activities of daily living (ADLs) for 1 of 6 residents (Resident #69) reviewed for ADL abilities, in that: Resident #69's nails were long, jagged, and dirty and had built-up dirt and grime underneath all fingernails on 01/13/26. This deficient practice could place residents who required assistance for trimming, cleaning, and filing their nails which could put residents at risk for infections and skin concerns. Findings included: Record Review of Resident #69's face sheet dated 01/15/26 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysarthria (a speech disorder that occurs when the muscles used for speech are weak or difficult to control, leading to slurred or slow speech that can be hard to understand. It is often caused by neurological injuries affecting the motor component of the speech system), and schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). Record review of Resident #69's modification of annual MDS dated [DATE] reflected Resident #69 had a BIMS score of 05 which reflected Resident #69 was severely cognitively impaired. MDS reflected Resident #69 required set-up or clean-up assistance with eating, substantial/maximal assistance with toileting, showering, upper and lower body dressing, and personal hygiene. Record review of Resident #69's care plan dated 01/28/25 reflected:Focus: Resident #69 was at risk for a communication problem r/t CVA, Dysarthria.Goal: Resident #69 will be able to make basic needs known dailythrough the review date.Interventions included: Anticipate and meet needs. Record review of Resident #69's care plan dated 01/28/25 reflected:Focus: ADL Self Care Performance Deficit r/t CVA.Goal: Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date.Interventions included: BATHING (SHOWER/BATHE SELF): I require x1 staff assistance with bathing/showering (FREQ) and as necessary. Resident's preference is to shower once a week on Mondays. PERSONAL HYGIENE/ORAL CARE (ORAL HYGIENE): Requires x1 staff participation with personal hygiene and oral care. In an interview and observation on 01/13/26 at 12:06 PM, Resident #69 stated he was doing ok and the staff treated him well. He stated he had been at the facility for a while. He stated he was getting his showers correctly. He stated he had a call light but had not used it or needed it so far. He stated the staff checked on him frequently and made sure he was ok. He stated he would like his nails trimmed and no one has offered to cut them or clean under them. He stated he had not been able to use his phone very well like this. Resident #69 demonstrated how his fingernails got in his way when he attempted to use the screen on his phone. Observed Resident #69's fingernails on left and right hands. Resident #69's fingernails were long, jagged, and dirty with built-up dirt and grime underneath each nail. In an interview on 01/14/26 at 2:57 PM, RN F stated he has worked in the facility for about a year and a half. He stated he was in-serviced on ADL care including nail care. He stated the nurse's aides were able to do the nail care of non-diabetic residents and nurses did the nail care for residents that were diabetic. He stated the CNAs should have offered to do nail care for residents, even those that were able to make their own personal hygiene decisions, during showers, shaving, and ADL care. He stated dirty, long, jagged fingernails could have caused skin tears or skin issues or could also hoard bacteria which could have caused an infection, and it could have also affected the resident's dignity. In an interview on 01/14/26 at 3:13 PM, LVN D stated she had worked in the facility for about 3-4 years off and on. She stated she was in-serviced on ADL care such as nail care. She stated the nurse's aides did the nail care for those residents which were not diabetic, and nurses do the nail care for residents that are diabetic. She stated the CNAs should have offered to do nail care during showers, shaving, and ADL care, even for those residents that are able to make their own personal hygiene decisions. She stated dirty, long, jagged fingernails could have caused skin tears, nail injuries, ingrown nails, or infection. In an interview on 01/14/26 at 3:40 PM, CNA A stated she had worked in the facility for about 3 years. She stated she was in-serviced on ADL care including fingernails. She stated even for residents that had long, dirty, jagged nails, she would have offered to trim, file, and clean the residents' nails. She stated if a resident had dirty, long, jagged fingernails, it could have caused skin tears. In an interview on 01/14/26 at 3:44 PM, CNA B stated she had worked in the facility for about a year. She stated she was in-serviced on ADL's including nail care. She stated for residents that had long, dirty, jagged nails, she would have offered to trim, file, and clean the residents' nails. She stated the CNAs did not trim the nails of residents with diabetes. She stated if a resident had dirty, long, jagged fingernails, it could have caused infections. In an interview on 01/15/26 at 11:12 AM, the DON stated she started working in the facility 9 days ago. She stated she was not sure when the staff were in-serviced last on ADL care including nail care but that was something she was going to implement as part of being a new DON. She stated for residents that they had long, dirty, jagged nails it was her expectation the staff offered to trim, file, and clean the residents' nails. She stated if a resident had dirty, long, jagged fingernails, it could have caused the spread of infection. In an interview on 01/15/26 at 11:39 AM, the ADM stated he had worked in the facility for about 6 months as the operations manager and he is now the Administrator. He stated he had in-serviced staff on ADL care such as nail care. He stated for residents that had long, dirty, jagged nails, it was his expectation that the staff offered to trim, file, and clean the residents' nails. He stated if a resident had dirty, long, jagged fingernails it could have caused a possible skin tear. Record review of facility policy titled Policy/ Procedure - Nursing Clinical Section: Licensed Nurse Procedures, Subject: Nails, Care of Finger and Toe and dated Revised 05/2007, Revised 11/2017, Reviewed 12/2025 reflected Policy: It is the policy of this facility to perform nail care to: 1. Clean the nail bed 2. Keep nail trimmed 3. Prevent infections. PROCEDURES: 1. Wash your hands thoroughly before and after completing the procedure. 2. If permitted, and to make trimming nails easier, allow nails to soak in warm soapy water for five (5) minutes. 5. Nails can be partially cleaned during bath care. 6. Nail care includes daily cleaning and regular trimming, during ADL care. 7. Proper nail care can aid in the prevention of skin problems around the nail bed. 8. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 9. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. 10. Stop and report to your charge nurse if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1), reviewed for pharmaceutical services. The facility failed to ensure that Resident #1 was administered her 2 tablets of Acetaminophen 325 MG crushed due to her diagnosis of Dysphagia and difficulty swallowing. The medication administered by RN B (2 tablets of acetaminophen non-crushed) caused the resident to cough uncontrollably. This failure could place residents at risk for not receiving medications as ordered, aspiration, psychosocial harm/fear, and decreased quality of life. The findings included: Review of Resident #1's face sheet dated 05/27/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction (stroke), generalized anxiety disorder (condition characterized by excessive worry), and major depressive disorder-recurrent-moderate (condition characterized by persistent feeling of sadness and loss of interest). Review of Resident #1's Quarterly MDS assessment reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG for functional abilities reflected Resident #1 was dependent-helper does ALL of the effort, resident does none of the effort to complete activity or the assistance of 2 or more helpers is required for the resident to complete the activity which was marked as such for oral hygiene, toileting hygiene, shower/bathe, dressing, personal hygiene, sit to lying and lying to sit, toilet transfer, tub/shower transfer, and chair to bed transfer. Section I for active diagnosis reflected Resident #1 was identified as having a diagnosis of a stroke, non-Alzheimer's dementia, and hemiplegia/hemiparesis. Review of Resident #1's care plan last revised 05/27/25 reflected a focus area swallowing problem related to Dysphagia, coughing or choking swallowing meds, swallowing assessment results with interventions all staff to be informed of residents special dietary and safety needs: CRUSH MEDICATION. Review of Resident #1's swallow study physician consult summary dated 01/16/25 reflected: Diagnosis- dysphagia, dysphagia following cerebral infarction, dysphagia following unspecified cerebral vascular disease. Chief complaint: coughing, feeding difficulties, difficulties swallowing. Recommendations: Meal Diet: Pureed, thin liquids Strategies for pills: Choking risk- crush meds. Pertinent positive swallowing history: Current diet: Solids- Pureed, Liquids-thin. Indication for Dysphagia consultation- life limiting or threatening dysphagia disorder with: feeding difficulties, complaints of difficulty or pain when swallowing, coughing, determine safe diet, determine least restrictive diet. Modified Barium Swallow Study Results: Strategies for pills: choking risk- crush meds Pill trial not provided due to choking risk. Review of Resident #1's EMR undated face sheet special instructions capture on 05/27/25 reflected Special instructions: crush medication as well as Diet: REGULAR diet, PUREED texture, THIN LIQUIDS consistency. Review of Resident #1's EMR undated face sheet special instructions capture on 05/28/25 reflected, Special instructions: **CRUSH MEDS** as well as Diet: REGULAR diet, PUREED texture, THIN LIQUIDS consistency. Review of Resident #1's physician orders reflected an order dated 09/22/22, may crush meds prn, empty capsules & mix with applesauce or Jello as indicated/desired/needed. Review of Resident #1's physician orders reflected an order dated 05/27/25, Crush meds, empty capsules & mix w/ applesauce or pudding unless contraindicated. Review of Resident #1's physician orders reflected an order dated 04/04/24, acetaminophen tablet 325 mg- Give 2 tablets by mouth every 4 hours as needed for pain. Review of Resident #1's medication administration note dated 05/27/25 at 11:18 AM entered by RN B reflected, acetaminophen tablet 325 mg- give 2 tablets by mouth every 4 hours as needed for pain 1-10 do not exceed 3G/day. Resident was complaining of pain in her right shoulder where she has a fracture and administered acetaminophen per orders. Arm in sling for comfort. Will continue to monitor. In an observation on 05/27/25 at 11:18 AM RN B was observed providing pain medication to Resident #1 and walked in her room with a clear pill container that contained 2 tablets not crushed. RN B asked Resident #1 if she required crushed medications, Resident #1's response to RN B was not heard. RN B provided the medication to Resident #1 and then Resident #1 was heard immediately coughing forcibly and uncontrollably. RN B was heard asking Resident #1 continuously if she was ok and if she required more water, attempted to provide her more water which Resident #1 refused as she continued to cough to clear her throat. In an interview and observation on 05/27/25 at 12:11 PM with RN B, he stated he did not know if Resident #1 required crushed medication. He stated he doesn't usually work this building. RN B stated he would have to check Resident #1's chart and was then observed logging into Resident #1's chart. RN B stated that Resident #1 did require her medications to be crushed as stated in the special instructions located on top of the face sheet/ medical record which is where he said he would look to find that information. He stated the special instructions give you the important stuff as soon as you log into the residents' chart, as an alert located at the top being one of the first things you see. RN B stated the last time he worked with Resident #1 was 6 months ago. He stated the medication he gave which were 2 acetaminophen tablets are able to be crushed and should have been. RN B stated he did not look at the chart to determine if Resident #1 required crushed medications prior to the administration of the acetaminophen tablets but should have done so to verify correct administration. RN B stated a potential negative outcome of not providing crushed medications to Resident #1 is the resident has the potential to choke on the medication. In an interview on 05/27/25 at 12:40 PM with the DON, she stated that if residents require crushed medications its communicated through special instructions on the residents chart. The DON stated that if the special instruction say to crush medications its her expectation that medications are crushed when provided to the resident. The DON stated that any staff member that is here can see the special instructions and said, PRN staff members, CNAs, everyone know its there, its quick and it shows up at the top so they can see it. The DON stated that a negative outcome to not reviewing the chart prior to providing care, staff could provide something that is not part of their plan of care. She stated failing to crush medication for a resident that required it has the potential to result in the resident not being able to swallow the medication appropriately. The DON stated Resident #1 has good recall but that she did not believe Resident #1 had the cognition to answer the question appropriately if asked if her medication needed to be crushed instead of her chart being reviewed by staff. In an interview on 05/27/25 at 01:14 PM with Resident #1 she stated she preferred her medication to be crushed. Resident #1 stated that when she was administered the medication in the morning, when she started to choke and cough it made her scared. In an interview on 05/27/25 at 04:04 PM in a follow up interview again with Resident #1, she was once again asked about the morning medication administration and stated she recalled the incident. Resident #1 stated it made her feel terrible. In an interview on 05/27/25 at 04:09 PM with SW, she stated she believed Resident #1 would be able to say if she was in pain or scared. She said if Resident #1 said she was scared she would take it seriously but would question if Resident #1 fully understood what that meant. She stated given Resident #1's cognitive stance she is more likely to recall events tied to a strong emotion like fear or pain. In an interview on 05/28/25 at 11:10 AM with ST, she stated that when there are concerns with a residents ability to swallow they will do a bedside swallow test or have a swallow study done. ST stated that after the swallow study is completed if there is anything on the residents chart that needs to be updated, they will do so based on the swallow study providers recommendations which comes from the third party provider. ST stated since Resident #1 is on a pureed diet there is a risk of choking to occur so they will recommend pills to be crushed as a precaution. ST stated that they have attempted a mechanical soft diet in the past with Resident #1 such as with pleasure feedings but she requires a lot of cueing and would still cough. ST stated that she has worked with Resident #1 for a while and that even with the pureed diet she appears to cough a lot and looks like she's choking which can appear scary. ST stated that Resident #1 has not done well enough on pleasure feedings with a mechanical soft diet to be upgraded from a full pureed texture. ST stated that based on the swallow studies and their work with her crushed medications would go down easier and be safer for her. In an interview on 05/28/25 at 02:31 PM with the DON she stated she made the updates to Resident #1's chart pertaining to the order from may crush medications to crush medications unless contraindicated in order to ensure more consistent care. In an interview on 05/28/25 at 02:55 PM with the ADM, he stated it was his expectation that physician orders and special instructions in a resident's medical record were reviewed prior to the administration of medication. He stated a potential negative outcome of not reviewing the chart prior to providing medications is there could be a medication error. The ADM stated that a negative outcome of not following a providers recommendation related to the swallow study would be it would depend on the order or recommendation provided. Record Review of the undated Medication and Treatment Administration policy reflected: Residents shall be identified prior to the administration of a medication or treatment. Record review of the Resident Rights policy last revised 2023 reflected: You have a right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record review, the facility failed to accommodate the needs and preferences for one(Resident #1) of five residents reviewed for accommodation of needs, in that: The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #1 the ability to safely call to staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Review of Resident #1's face sheet dated 05/27/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction (stroke), generalized anxiety disorder (condition characterized by excessive worry), and major depressive disorder-recurrent-moderate (condition characterized by persistent feeling of sadness and loss of interest). Review of Resident #1's Quarterly MDS assessment reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG for functional abilities reflected Resident #1 was dependent-helper does ALL of the effort, resident does none of the effort to complete activity or the assistance of 2 or more helpers is required for the resident to complete the activity which was marked as such for oral hygiene, toileting hygiene, shower/bathe, dressing, personal hygiene, sit to lying and lying to sit, toilet transfer, tub/shower transfer, and chair to bed transfer. Section I for active diagnosis reflected Resident #1 was identified as having a diagnosis of a stroke, non-Alzheimer's dementia, and hemiplegia/hemiparesis. Review of Resident #1's care plan included a section last revised 01/04/25 with a focus on ADL self-care performance deficit related to limited mobility, hemiplegia, impaired balance, dementia, stroke with interventions that included encourage to use call bell for assistance. An additional focus area last revised 01/04/25 also included Resident #1 is at high risk for falls related to gait/balance problems, incontinence, vision/hearing problems with interventions that included be sure call light is within reach and encourage to use it to call for assistance as needed. In an observation and interview on 05/27/25 at 11:07 AM in Resident #1's room, Resident #1 was observed lying in bed and stated she had right sided pain and was not able to call staff for help because she did not know where the call light was. Resident #1's right arm was observed in a sling supporting her arm near to her chest and the call light was observed wrapped around the right bed rail and dangling off the bed close to the floor. In an observation on 05/27/25 at 11:10 AM CNA A entered the room to ask Resident #1 if she needed assistance and Resident #1 stated she was in pain. CNA A stated she would let the nurse know and was observed leaving the room without adjusting the call light (which was still near the floor) to be used by Resident #1. In an observation on 05/27/25 at 11:18 AM RN B was observed entering Resident #1's room with a medicine cup to provide Resident #1 with pain medication. After RN B completed the medication administration, he was observed leaving the room without adjusting the call light (which was still near the floor) to be used by Resident #1. In an interview on 05/27/25 at 12:11 PM with RN B, he stated it is his responsibility to ensure call lights are on the bed with the resident and in reach where it can be used before leaving a resident's room after providing care. RN B stated he just had a moment and didn't notice it. RN B stated a negative outcome of the call light not being in reach would be the resident would not be able to call for help as needed. In an interview on 05/27/25 at 12:40 PM with the DON, she stated it was her expectation that call lights are within reach of the resident. The DON stated that Resident #1 has hemiparesis to the right side as well as her sling and she would expect for staff to place the call light in reach and on the side she is able to use. In an interview on 05/28/25 at 01:26 PM with CNA A she stated that it is the expectation of the facility that staff are to ensure call lights are in reach, bed are in the lowest position, and hands are sanitized. CNA A stated that a negative outcome of residents not having call lights in reach would be they would not get the assistance they need. CNA A stated Resident #1 can only use her left side and that call lights should be placed on her left side. In an interview on 05/28/25 at 02:55 PM with the ADM, he stated it was his expectation that staff place call lights within residents' reach. He stated some call lights are specialized and can be used with their chin; he stated the call lights should be placed on the resident's usable side. The ADM stated a potential negative outcome of not placing the residents call light within reach would be the resident would not be able to get the assistance they need or communicate their needs. Review of the facility Call Light/Bell policy last revised 05/2007 revealed: It is the policy of this facility to provide the resident a means of communicating with nursing staff.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility without staff's knowledge on 03/25/25 by following a contract worker out the front door. Resident #1 self-propelled to the driveway where she rolled down into and across the street to the median where she bumped into the curb and fell out of her wheelchair. An Immediate Jeopardy (IJ) existed on 03/25/25. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice could place residents at risk for elopements, falls, injuries, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, dementia, muscle wasting and atrophy (wasting away), and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 01/17/25, reflected a BIMS could not be conducted due to her rarely/never being understood. Section E (Behavior) reflected she had not exhibited wandering behaviors. Section GG (Functional Abilities and Goals) reflected she utilized a wheelchair for mobility. Section P (Restraints and Alarms) reflected she did not have a wander/elopement alarm. Review of Resident #1's quarterly care plan, revised 03/25/25, reflected was a high risk for elopement risk/wanderer related to disoriented to place, impaired safety awareness, and wandering aimlessly with an intervention of monitoring her wander guard placement on her right ankle. Review of Resident #1's Elopement/Wandering Evaluation, dated 02/25/25, reflected she was a low risk of elopement. Review of Resident #1's progress note, dated 03/25/25 at 2:50 PM and documented by LVN A, reflected the following: Reported to this nurse that staff member observed [Resident #1] at top of driveway. Staff member (HA B) followed behind her attempting to stop [Resident #1]. Staff member unable to reach resident d/t incline and momentum. [Resident #1] reached curb and fell as staff approached. Staff states resident did not strike head . Upon return to facility head to toe assessment completed by nurse, ADON, and WCN, noted with superficial abrasions to knee, pain assessment completed. No s/s of pain. Review of Resident #1's progress note, dated 03/25/25 at 9:15 PM and documented by LVN C, reflected the following: This nurse was given a verbal order by (doctor) to send [Resident #1] out to the hospital for further evaluation. [Resident #1] is alert x 1 and at baseline . Review of Resident #1's hospital records, dated 3/25/25, reflected the following: You were seen today for: FALL No obvious injury to the knees on ultrasound. Review of Resident #1's progress note, dated 03/26/25 at 12:11 AM and documented by LVN D, reflected the following: [Resident #1] arrived back to facility via (non-emergency medical transport) @ 0008 (12:08 AM). [Resident #1] transferred into bed by nursing staff. [Resident #1] is alert x 1 and at baseline. No s/s of pain or discomfort observed from resident during transfer. Review of Resident #1's Elopement/Wandering Evaluation, dated 03/25/25, reflected she was a high risk of elopement. Review of Resident #1's physician order, dated 03/25/25, reflected Monitor placement and functioning of wander guard q shift: Right ankle EXP date 1/20/28. Check skin under wander guard: Notify NP/MD if irritation occurs. Review of the facility's self-report to HHSC, dated 03/26/25 at 9:18 AM, reflected the ADM self-reported the incident with Resident #1 within the 24-hour timeframe: [Resident #1] exited the facility without staff knowledge and lost control of her wheelchair. A staff membber on the patio saw [Resident #1] and immediately went to intervene. However, she rolled down the driveway and fell out of her wheelchair before staff could reach her. Staff assisted her back into the facility. During an observation and interview on 03/26/25 at 10:24 AM revealed Resident #1 in the lobby. The ADM spoke to her in Spanish and asked if it was okay to take her to her room after the Surveyor requested to observe her knees. RN E attempted to explain to Resident #1 she was going to pull up her pant legs. RN E pulled up her left pant leg which revealed a small red abrasion. RN E began to pull up her right pant leg which revealed a wander guard on her right ankle. At that point, Resident #1 raised her arm and grunted, No!. RN E pulled down her pant leg and thanked Resident #1. RN E stated Resident #1 leaving the day before (03/25/25) was completely out of character for her. She stated she had never attempted to leave and had never even seen her at the entrance of the facility. She stated Resident #1 was unable to communicate or voice her needs but did let staff know when she did not want something or for care to be provided. She stated she was in-serviced yesterday (03/25/25) after the incident on the elopement process and abuse and neglect. She stated she was also in-serviced on the nursing staff being responsible for covering the front door after the Receptionist's shift had ended each day. During an interview on 03/26/25 at 10:34 AM, the MDSC stated she was in the conference room yesterday (03/25/25) when she heard commotion outside (front of facility). She stated she got up and saw through the window HA B moving fast towards the driveway where she saw Resident #1. She ran outside with the DON and ADON and ran after Resident #1. She stated they did not catch up to her as she rolled into the street and to the median. She stated HA B got the cars to stop. She stated when she got to the median she bumped into the curb and fell out of the wheelchair. She stated she was gotten up and was taken into the facility where she was assessed by a nurse. She stated she was in-serviced yesterday on abuse and neglect, the elopement process, which residents can leave the facility, and the elopement binders located at the Receptionist's desk and nurses' station. She stated there should always be someone manning the Receptionist's desk. During an interview on 03/26/25 at 10:39 AM, the HRD stated on 03/25/25 around 2:45 PM, she was in her office (which is close to the entrance of the facility) when she heard yelling and commotion coming from outside in the front. She stated she immediately went outside and saw everyone running so she took off running. She stated by the time she made it down the driveway, Resident #1 was already back in her wheelchair. She stated the Receptionist was their first line of defense when it came to determining if a resident should be exiting the facility or not. She stated she was supposed to ask if they were going out to smoke or going out on pass. She stated there was an elopement binder at her desk and the nurses' station that contained all residents that were a high risk for elopement. She stated they were in-serviced yesterday (03/25/25) on abuse and neglect, the elopement process and their policy. She stated if a resident was missing, they would check all rooms, all exit doors, and the perimeter of the facility. During an interview on 03/26/25 at 10:46 AM, the ADM stated he reviewed the video footage, and it revealed a contract worker exiting the facility around 2:50 PM and another resident in a powered wheelchair was able to catch the door before it closed completely. A third resident that was outside held the door and Resident #1 exited. He stated it was the Receptionist's responsibility to ask residents if they were going out on pass or if they were going outside to smoke. He stated if they were going out on pass, she would then need to verify it with the nurse and have the resident sign out. He stated because they have so many residents that were able to smoke independently, it was not unusual to have a lot of traffic at the front door. He stated after the incident, REC F quit. He stated he tried to interview her about what happened, but she did not give him a clear response. He stated since the contract worker did not utilize the keypad to exit, he assumed REC F used the remote to allow her to exit and did not verify or notice the other residents that were exiting. He stated if she needed to run an errand or go to the bathroom, his expectations were that she notified him so he could watch the door. He stated HA B exited the building approximately a minute after and saw Resident #1 self-propelling to the top of the driveway. He stated she immediately ran after her. He stated once she rolled to the bottom of the hill, the MDSC, DON, and ADON were seen running out of the facility and down to the resident. He stated once she hit the curb of the median, he was told the wheelchair bounced back and she fell out. He stated Resident #1 had no history of wandering or exit-seeking. He stated he had never seen her in the front lobby area. He stated she was sent to the ER and returned shortly after with no injuries. He stated she now had a wander guard and he and the DON completed and audit on all residents' elopement risk assessments as well as the elopement binders. He stated he ordered speed bumps that would be delivered that day (03/26/25) and would be installed across the driveway in order to assist in preventing a resident to go down it. He stated he also purchased a fish-eyed mirror to put in the foyer so the Receptionist would have an easier time seeing anyone that was near the door. He stated he began in-services the day prior (03/25/25) for all staff on abuse and neglect and their elopement policy. He stated they were also in-serviced on coverage of the front desk and that the nurses were responsible for covering who exited the facility after the Receptionist's shift had ended each day. He stated no one started their shift until they were in-serviced, and no one will be able to work going forward until they were. During an interview on 03/26/25 at 12:02 PM, REC G stated she had worked as an aide at the facility for a couple of months but was now working as the Receptionist. She stated she was trained before her shift on never using the remote to let someone out of the front door before ensuring residents were not exiting behind them. She stated she was to ask any resident that wanted to leave if they were going to smoke or going out on pass. She stated if they told her they were going out on pass, she would go verify that with their nurse and would have them sign out. She stated if she was unsure if a resident was able to exit the facility independently, she could ask a nurse or look in the elopement binder. She stated she was not to leave the front desk at any time unless she found a designee. During a telephone interview on 03/26/25 at 3:59 PM, HA B stated on 03/25/25 around 2:50 PM, she was coming outside after her lunch break and noticed Resident #1 going towards the driveway and then down the driveway. She stated she ran after her and tried to catch her, but her wheelchair kept picking up speed. She stated when she got to the bottom, she managed to get traffic to stop by waving her hands. She stated when her wheelchair hit the curb of the median, she fell out of her wheelchair onto her knees. She stated the MDSC, DON, and ADON arrived shortly after. She stated she was in-serviced that same day on abuse and neglect and their elopement policy. She stated it was the Receptionist's responsibility to ensure residents who were unable to leave the facility independently did not do so. She stated the Receptionist's desk should never be left unattended. On 03/26/25 at 11:22 AM and 1:48 PM, attempts were made to interview REC F. A returned call was not received prior to exit. Review of a Counseling/Disciplinary Notice, dated 03/10/25, reflected REC F was counseled by the ADM on the procedures and requirements of letting people out of the facility, indicating she had been trained prior to the incident with Resident #1 on 03/25/25. Review of a Counseling/Disciplinary Notice, dated 03/25/25, reflected REC F was provided education on expectations of the receptionist after [Resident #1] went out front door when receptionist should have been watching it. Review of receipts, dated 03/25/25, reflected two fish-eyed mirrors four 6-foot speed bumps had been purchased. Review of the facility's QAPI meeting minutes, dated 03/25/25, reflected the ADM, MD, DON, ADON, MDSC, BOM, SW, DM, AD, MAINTD, and DOR were in attendance. Review of the elopement binder at the front desk reflected Resident #1 and her information had been added. Three residents' information that were considered a high elopement risk were appropriately in the binder. Review of an in-service entitled Abuse and Neglect, dated 03/25/25 - 03/26/24, reflected staff from all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an in-service entitled Receptionist, dated 03/25/25 - 03/26/25, reflected staff from all shifts were in-serviced on the following: The front desk will be covered by the receptionist or designee. The receptionist will find coverage for all breaks and not leave the desk prior to having coverage. The receptionist/designee will visualize every resident exiting facility and inquire intention. The door should be locked at all times. The receptionist will notify nursing staff when leaving for the day and the nursing staff will be responsible for managing the front door and ensuring appropriateness of residents exiting. Review of an in-service entitled Elopement, dated 03/25/25 - 03/26/24, reflected staff from all shifts were in-serviced on the facility's Elopement Policy. Review of Elopement Quizzes, dated 03/25/25 - 03/26/25, reflected all staff members took a quiz with the following questions: 1. Location of elopement binder 2. What to do if possible elopement 3. Name 3 patients that are in the elopement binder. Review of the facility's Elopement/Unsafe Wandering Policy, revised 06/2018, reflected the following: It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . Elopement is when a resident leaves the facility premises or a safe area without authorization and/or any necessary supervision to do so. An Immediate Jeopardy (IJ) existed on 03/25/25. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to label, and date food stored in the walk-in refrigerator. 2. The facility failed to label, and date food stored in the walk-in freezer. 3. The facility failed to ensure food preparation areas and appliances, including equipment such as the fryer, microwave, toaster, blender, and ice machine were maintained clean and sanitary. 4. The facility failed to ensure handwashing supplies were stocked at the kitchen handwashing station (no paper towels). These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 01/07/25 at 10:30 AM the following was observed: - Upon entering and washing hands there were no paper towels observed stocked or in use at the handwashing station. A used rag from the food prep area was offered (and declined) by a dietary staff member to dry hands before the DM went out and returned to stock the handwashing station with paper towels. - In the walk-in refrigerator there was a plastic container of vegetable soup covered with plastic wrap with no label or dates as to when it was prepared and when it should be used by/ discarded. A separate plastic container containing chicken and pasta with a white sauce was observed not labeled or dated. A large clear container of tuna salad was observed not labeled or dated. In the walk-in freezer the following was observed: o 1 zip sealed bag containing breaded chicken filets not labeled or dated with the received date or use by date. o 1 zip seal bag containing raw chicken not labeled or dated with the received date or use by date. o 1 zip sealed bag containing raw beef burger patties not labeled or dated with the received date or use by date. o 1 approximately 10-pound clear tube of ground meat not labeled or dated with the received date or use by date. o 1 pie crust packed in a clear bag not labeled or dated with the received date or use by date. o 1 box containing tortilla wrapped taquitos not sealed, box was opened, and the contents exposed to open air. o 1 box containing a ripped bag of what appeared to be prepared omelets not labeled or dated with the received/ prepared date or use by date, not properly sealed and the contents exposed to open air. - The fryer was observed with a thick coat of dark grease surrounding the outside from all sides, and the inside door and bottom compartment below the temperature control. The fryer was not in use and uncovered. - The inside of the microwave was observed soiled in a yellow fluid on the round plate, and yellow/dark orange food splatters that appeared dry and stuck to the 3 inner walls, below the round rotating plate, and on the top 'ceiling' of the microwave. The microwave door was also observed covered in the dried yellow/dark orange, dried, stuck on substances. - The blender had a yellow-green residue stuck to the top element where the container sat on; it appeared dried and ran down to where the sides and buttons were located. - The toaster oven had a thick layer of oil residue and crumbs. - The inside of the ice machine was observed to be soiled. On the top plastic inner wall behind the lid just above the ice there was a slimy pink/yellow residue with smaller dark spots of an unknown substance that ran the entire length of the inner plastic above the ice. The inner back side of the lid was observed with a white powdery-like substance. - The kitchen floors were observed completely soiled. A puddle of a red juice and other dark fluids were observed in front of the drink machine which was also observed soiled in red stained and dark stained fluids. The floors in the food preparation area under the steamtable and 2 compartment sinks to the right of the steamtable were observed with sections of a dark black residue, there were cereal containers, plastic lids, packets of condiments and butter, and food that soiled the floors beneath the two areas. In an interview on 01/07/25 at 10:50 AM with the DM, he stated it was his expectation that all food items were labeled and dated with either the received or prepared date and the use by date when items are placed into the refrigerator/freezer. He stated it was his expectation that food items were always properly sealed in either a sealed container, zip seal bag, or if in a box sealed/closed and the food not exposed. He stated it was his expectation that dietary staff maintained a clean environment and said items not properly labeled or dated or an environment that was not clean could potentially result in residents getting sick. The DM stated he expected the necessary supplies to be stocked in order to follow hand hygiene guidelines . He stated it is the responsibility of anyone who notices that the paper towels are empty should replace them. In an interview on 01/07/25 at 5:45 PM with the ADM, he stated Food should be stored according to the regulation, and it needs to be followed. He stated it was his expectation that items were labeled/dated and sealed when stored in the refrigerator/freezer and if they were not sealed or closed off it could result in cross contamination or food spoilage. The ADM stated that cleaning should be done on an as needed basis and that if dietary staff see that items are soiled in between mealtimes, they should be cleaned. He stated failure to maintain a clean environment could result in cross contamination and spreading of germs. Record review of the facility Infection Prevention and Control Program last revised 10/2022 revealed: The infection prevention and control program is a facility- wide effort involving all disciplines and individuals as is an integral part of the quality assurance and performance improvement plan .it is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. - The facility will provide areas, equipment, and supplies to implement its infection control program with the goal of: o Readily available of hand cleaning supplies and paper towels at each sink. Record review of Dietary Services Meals and Food policy dated 06/2017 revealed: It is the policy of this facility to ensure dietary services are provided to our residents operating within the confines of Texas state regulations. - A dietary manager is responsible for the total food service of this facility. - Food purchased, stored, and serviced in this facility is labeled and dated according to all applicable food service regulations. - Food prepared for consumption by our residents is prepared according to all applicable food service regulations. Record review of Resident/ Personal Food Storage policy dated 06/2017 revealed: - Food storage areas shall be clean at all times. - All food stored in facility refrigerator will be labeled and discarded after being opened for three days. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or PACKAGE that does not bear a date or day; or 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 laundry facility reviewed for infection control. 1. The facility failed to ensure LS A was following handwashing and sanitation when working with soiled clothing and moving to clean clothing; and failing to keep items stocked and readily available for use in hand hygiene (paper towels). 2. The facility failed to ensure laundry staff was maintaining and cleaning the lint traps for both commercial sized tumble dryers in the clean laundry room side. This failure could place residents at risk for development of communicable diseases and infections. Findings include: During a tour of the laundry room on 01/07/25 at 02:50 PM the following was observed: - LS A was observed to be the only staff working in the laundry room at the time. She was observed working with soiled linen in the dirty or soiled linen side of the laundry area. LS A was observed rinsing her hands at the handwash station located on the wall across from the washing machines in the soiled linen side, and no soap was observed to be used. LS A was then observed moving to the clean room side as her hands dripped with water from not drying her hands, then grabbing the hand sanitizer, applying it to her dripping hands and then shaking her hands to dry. The paper towel dispenser at the handwashing station was observed empty . - The lint traps were checked on the commercial size tumble dryers which were observed with thick layers of lint. The lint cleaning log which was hanging on a wall near the dryers was reviewed and there was no documentation showing the lint trap was cleaned for any day in the month of January 2025. In an interview and observation on 01/07/25 at 03:05 PM with the HS, she stated it was her expectation that the lint traps were cleaned every time after the dryer has been used. She stated that laundry staff should also be logging each time it was cleaned on the log. The HS stated that failure to clean the lint traps posed a fire hazard and can be unsanitary. The HS was observed speaking to LS A providing education on cleaning the lint traps and LS A was observed asking questions about the cleaning log indicating that she was not aware of it and did not know how to complete it. The HS also stated that she expected that staff were washing their hands with soap and water before moving to the clean linen and completely drying their hands. She stated paper towels should be stocked and available. The HS stated that she personally provides training on the procedures and reminds staff that a negative outcome of not washing their hands would be possible contamination of cleaning clothing. In an interview on 01/07/25 at 04:20 PM with LS A, she stated that when working with soiled linen she should have been wearing gloves and washing her hands before moving to the clean linen. LS A stated that she was in-serviced that day on cleaning the lint traps on the dryers and stated that they should be cleaned after each cycle . LS A stated a negative outcome of not cleaning the lint traps was it is a fire hazard and can hold on to bacteria and stated failing to follow handwashing and sanitation could result in contamination of clean clothing. LS A stated she had been working at the facility for a month and was still learning the rules. In an interview on 01/07/25 at 05:45 PM with the ADM, he stated that handling linen in some instances would require the use of gloves, but that it was his expectation that staff were always washing their hands before moving to clean laundry after working with soiled linen. He stated it was his expectation that the handwash station remained stocked with the necessities such as soap, water, and paper towels in order to follow proper handwashing procedures. The ADM stated the lint traps should be cleaned as needed for the machines to be safe. He stated failure to keep the lint traps clean could result in improper function of the dryer. Record review of the facility Wellness Services Laundry Services policy dated 06/2017 revealed: It is the policy of this facility to ensure resident laundry is washed, dried, folded, or hung up by care staff in a way to prevent infection control issues. - Staff will empty the lint trap in each dryer as needed. Record review of the facility Infection Prevention and Control Program last revised 10/2022 revealed: The infection prevention and control program is a facility- wide effort involving all disciplines and individuals as is an integral part of the quality assurance and performance improvement plan .it is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. - Facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection. - The facility will provide areas, equipment, and supplies to implement its infection control program with the goal of: o Readily available of hand cleaning supplies and paper towels at each sink.

Based on observation, interview, and record review, the facility failed to provide safe, clean, comfortable, and homelike environment and to exercise reasonable care for the protection of the resident's property from loss or theft for 2 of 6 residents (Resident #1 and Resident #2) reviewed for personal belongings. 1. The facility failed to ensure Resident #1 and Resident #2's clothes and belongings were reasonably protected from loss or theft. These failures placed residents at risk of diminished quality of life. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility 11/10/17 with diagnoses that included Alzheimer's disease with late onset (neurodegenerative disease), major depressive disorder-recurrent-moderate (mood disorder that causes persistent feelings of sadness and loss of interest), age-related physical debility, and adjustment disorder with anxiety (a condition where a person experiences significant anxiety symptoms within three months of a specific life change or stressor- can involve worry, nervousness, irritability and other anxiety related symptoms). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #1's medical record revealed no inventory list. Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of upper outer quadrant of right female breast (cancerous tumor), systemic lupus erythematosus- unspecified (autoimmune disease that causes inflammation and damage in various organs and tissues), major depressive disorder-recurrent-moderate (mood disorder that causes persistent feelings of sadness and loss of interest), and generalized anxiety disorder (fear characterized by behavioral disturbances). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Record review of Resident #2's medical record revealed no inventory list. In an interview on 01/07/25 at 02:11 PM with Resident #1, he stated he has noticed he had less clothes and said he thought some shirts were missing but had not personally reported any. Resident #1 was not sure if facility staff took an inventory of his items when he arrived at the facility. In an interview and observation on 01/07/25 at 02:26 PM with Resident #2, she stated laundry was always losing her clothes. She stated laundry is taking too long to wash her clothing and when she gets it back, she is missing clothes or gets back items that don't belong to her. Resident #2 stated she is missing multiple pairs of panties, socks, and nightgowns. Resident #2 stated she received a bag from laundry after staff claimed to have found her stuff, but that the items they gave her were not hers. Resident #2 was observed pulling out a clear plastic bag filled with clothes that had her name written on it. She stated the handwriting on the bag was not hers and was written by someone from housekeeping she was unable to identify. From the plastic bag Resident #2 pulled out multiple oversized shirts and she stated they were not hers, 2 sets of female panties, one which was observed to have a different resident's name on it written in black permanent marker, and a pair of men's boxer briefs. Resident #2 stated the facility did not take inventory of her items, and said she is frustrated and upset at her clothes going missing and being given clothes that are not hers. In an interview on 01/07/25 at 03:05 PM with the HS, she stated that lately it was common that clothing would arrive to the laundry room with no name on it. She stated that every Thursday they would try to set up an area in the dining room with clothing to ask residents if they recognized any of it as being theirs to claim it. She stated that recently in November 2024 she implemented an audit where she would check 1 person's room in each hall to see if they had clothing missing. She said it started November 20th 2024 due to a lot of clothing coming with no names. She stated it was the CNAs responsibility to write the residents' names on the clothes and that she was also beginning to train staff on the use of the label press but that not everyone was yet trained on it. She stated that the negative outcome of not having the residents' clothes easily identified has resulted in lost items and frustration from some residents. In an interview on 01/07/25 at 04:48 PM with Resident #1's family, he stated Resident #1 has had a lot of clothing go missing. He stated he wanted Resident #1 to have nice clothing and personally went out to purchase multiple polo style shirts for him in mid November 2024 and soon realized they went missing. Resident #1's family stated that he filed a complaint with the facility which has not been resolved and stated when he asked Resident #1 where the shirts went, he was unable to say. Resident #1's family stated that to his knowledge the facility did not inventory the residents clothing and claimed when speaking to the ADM that he stated it would be addressed but hasn't been. Resident #1s family claimed that in addition to the polo style shirts, he has also had personal blankets go missing. In an interview on 01/07/25 with the ADM, he stated it was his expectation that both nursing/ direct care staff as well as laundry staff manage the inventory and labeling of resident clothing and that all items should be labeled with the resident's name. The ADM stated that due to the issues with missing laundry they have implemented a weekly audit system where the HS was to audit resident closets from each hall to ensure their names were being written on their clothes. He stated a negative outcome of not labeling or taking inventory of resident items would be they could be lost, and residents would not get them back. Record review of grievances for the month of November 2024 revealed 5 reports revealing residents missing clothing, and review of grievances for the month of December 2024 revealed 6 reports of residents with missing clothing, which included a report of Resident #1 's missing shirts. Record review of the facility 2023 Resident Rights policy revealed: Respect and dignity- you have the right to be treated with respect and dignity including the right to: - Retain and use personal possessions including furnishings, and clothing as space permits unless to do so would infringe upon the rights or health and safety of other residents. You have the right to a safe, clean, comfortable and homelike environment and use of your personal belongings to the extent possible.

Based on observation, interview, and record review, the facility failed to provide safe, clean, comfortable, and homelike environment and to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 24 residents (Resident #76) reviewed for personal belongings and 1 of 1 smoking area reviewed for cleanliness. 1. The facility failed to ensure Resident #76's clothes and belongings were reasonably protected from loss or theft. 2. The facility failed to ensure staff and residents disposed of cigarette butts in the designated receptacle in the facility smoking area and front porch/sidewalk on 10/29/24. These failures placed residents at risk of diminished quality of life. Findings included: 1. Review of Resident #76's face sheet revealed a [AGE] year-old man admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar type (a rare mental health condition that combines symptoms of schizophrenia and bipolar disorder), paranoid schizophrenia (type of schizophrenia that involves paranoia and delusions), and mild neurocognitive disorder (mild cognitive impairment). Review of Resident #76's quarterly MDS dated [DATE] revealed resident's BIMS score of 12 which indicated a mild cognitive impairment. Review of Resident #76 medical record revealed no inventory sheet listed. During an interview on 10/28/24 at 02:36 PM, Resident #76 stated that he is missing several items. Resident #76 stated he is missing several shirts and shoes. He stated he was unsure when the items were missing and that he had mentioned in passing to a staff and was unsure who. During a resident group interview on 10/29/24 at 11:00 AM, the group stated when they send clothes to the laundry, they do not always all come back. The group stated that sometimes they end up with other residents' clothes. The group stated the facility does not take inventory of new clothes, but they put their name in the clothing. The group stated they will sometimes find their clothing in other resident's rooms or see other residents' wearing their clothing. During an interview on 10/30/24 at 09:02 AM, CNA A stated that there should be a list in the resident's chart of items they [NAME] in. She stated that the CNAs and nurses were responsible for writing the information on the list. She stated that CNAs or central supply was responsible for writing the residents' name on their clothing. CNA A stated that if a resident stated they were missing clothing, the CNA would help them find their clothes in the laundry area. She stated she would also let other CNAs know what clothing the resident was missing incase it was in a different resident's room. She stated that if she could not find the clothing item she would notify the DON. During an interview on 10/30/24 at 09:23 AM, CNA B stated there is a list written down with the amount of clothing the resident has. CNA B stated they reviewed the list during orientation and she believed human resources was responsible for writing down the list. She stated that no residents are missing clothing because every piece of clothing is marked when it goes to the laundry. During an interview on 10/30/24 at 09:30 AM, RN C stated that there is an inventory sheet for when a new resident comes in and it was supposed to be completed every time there was a new resident. She stated that all items the resident had were supposed to get written down on the space. She stated that new items could also be added later. She stated that new items do not always get added. RN C stated the CNAs could write down resident's name in the clothes or the resident would. She stated normally the CNA was responsible for writing down the information on the inventory sheet. RN C stated if residents were missing clothes then they would go to the laundry room and look for it and let laundry staff know. RN C stated if they still could not find the item then they were supposed to do a grievance. RN C stated the facility may replace some items. RN C stated normally the CNAs write the information on the inventory list and the nurse would verify. RN C stated that if a resident was missing items they would sometimes be upset, but the facility tried to compensate for the missing items. During an interview on 10/30/24 at 09:38 AM, LVN D stated there was a new admission packet and an inventory sheet is in there. LVN D stated typically whoever nursing was completing the admission was responsible for writing the information on the inventory list. LVN D stated CNAs help out, but the nurse filled out the form. LVN D stated if they get new items while they are here, and was brought to the staff's attention then they could add it to the inventory. LVN D stated an inventory list was supposed to be done for every new admission to keep track of things. LVN D stated the inventory list was sent to medical records and it was filed or scanned into the resident's chart. LVN D stated if something was missing, he would notify CNA to let them look for it. LVN D stated if they could not find it, he will let DON know. LVD D stated that was as far as the nurses would go. During an interview on 10/30/24 at 11:33, the BSW stated that the CNAs were responsible for marking down items that the resident comes in with. The BSW stated that typically when items were reported missing, they would go through the grievance process which goes to the BSW. She stated once the grievance is filled out, it would go the appropriate party, such as missing clothing grievances would go to laundry. The BSW stated she got quite a few grievances on missing clothing, maybe 1-2 a week. The BSW stated she does not go and look for the inventory sheet and it would be more of searching for the item when it is reported missing. The BSW stated she generally trusted that the resident had them item since she would not check them inventory sheet. The BSW stated when residents were missing items that they may be worried about their items missing, but not overly upset and may be concerned, but it depended on the resident. Resident #76 let him know she was missing items. He has been talking about missing items for quite some time. The BSW stated that concerns from resident council were brought up to social worker and then they go through the grievance process and would get assigned to the appropriate department. During an interview on10/30/24 at 11:45 AM, HSK E she stated that nurses and CNAs were responsible for writing residents' names in their clothing. HSK E stated that there were a lot of clothes currently that do not have names on them. HSK E stated she had noticed an increase in clothing without resident names in the last few months. HSK E stated that sometimes laundry aides or CNAs would bring residents to the laundry area to look at the clothing without names if there were missing items. During an interview on 10/30/24 at 01:53 PM, the AD stated she attended every resident council meeting. The AD stated that she recorded the minutes from the meetings. AD stated that any concerns brought up during the meeting were put on a grievance form brought to morning meeting. AD stated she will hand the grievance to the responsible department. AD stated they will discuss in morning meeting the outcome or solution or how to better the concerns. The AD stated that the facility was trying to do new inventory sheets. The AD stated she believed inventory sheets will be done by marketing director, but she was unsure if CNAs or housekeeping would be responsible. The AD stated the facility does not have inventory sheets right now and stated that is how they are in the lost clothes situation. AD stated that during her four months of working here, missing clothing has been an issues during each of the resident council meetings. During an interview on 10/30/24 at 02:28 PM DON stated the activity director will go over concerns in morning meeting from resident council and then they go through grievance process. [NAME] stated sometimes resolutions were discussed in morning meetings from resident council concerns. DON stated they have discussed missing clothing concerns during morning meeting. [NAME] stated the staff discussed to ensure labeling is correct, that the labeling can be read by staff handing out clothing. DON stated missing clothes are put on a grievance form. DON stated it was a team effort for labeling clothing. DON stated the CNAs and laundry can also help with labeling. DON stated there was supposed to be an inventory sheet that is done upon admission. DON stated it was not being consistently. DON stated the inventory sheet was a part of the admission packet that the nurses completed. DON stated she was unsure who oversaw that labeling was being done. During an interview on 10/30/24 at 04:12 PM ADM stated that new admissions items brought in were supposed to be documented on the inventory sheets. ADM stated that concerns from resident council were documented on the grievance log and then given to each department to address. ADM stated that he was aware that almost monthly resident council minutes showed clothes are missing or not being return from laundry and stated that it was being addressed by upon admission writing names on clothing. ADM stated on admission, CNA, family or resident is responsible for labeling the clothing. ADM stated that inventory sheets were part of the admission process and medical records was responsible for uploading the inventory sheet as well. ADM stated that there was no facility policy regarding missing clothing or inventory. Review of facility in-services dated October 2023 to October 2024, no in-service completed on missing items, labeling items, inventory sheet. 2. Observation on 10/29/24 at 01:29 PM revealed a large white pop-up pavilion in facility parking lot in front of the building where residents smoked throughout the day in the presence of a staff member. 91 cigarette butts were observed on the sidewalk, patio, and landscaped area in front of the building and the area underneath the smoking pavilion. There were two metal ashtrays under the pavilion, both filled with cigarette butts. Three residents were under the pavilion smoking with the DSD present, supervising. During an interview on 10/29/24 at 01:29 PM, the DSD stated she did not usually supervise the smoking tent, but the regular full time smoking aide was coming in late that day. The DSD stated she did not know who was responsible for picking up cigarette butts on the ground or what process was in place to keep the grounds clean. During an interview on 10/29/24 at 02:35 PM, the ADM stated he was not sure who exactly should have ensured cigarette butts were picked up, but the residents were supposed to extinguish their own butts in the ashtray. He stated all the residents had smoking assessments and could smoke safely and independently. He stated the presence of cigarette butts on the ground outside the facility could be a quality of life for the residents. He stated he would not want to see cigarette butts all over his front porch, and the residents might feel the same way. Review of facility policy dated 2023 and titled Resident Rights reflected the following: You have the right to a safe, clean, comfortable, and homelike environment, and use of your personal belongings to the extent possible, including, but not limited to receiving treatment and supports for daily living safely. 42600 50872

Based on observation, interview, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 8 residents (Residents #100, 70, and 104) reviewed for care plans. The facility failed to ensure Residents #100, 70, and 104 had activities care plans that were person-centered and specific. This failure placed residents at risk of boredom and diminished quality of life. Findings included: 1. Review of the undated face sheet for Resident #100 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included neuromuscular dysfunction of bladder (the brain and nervous system cannot properly communicate with the bladder), pressure ulcer, polyarthritis (arthritis that affects more than five of your joints at the same time), chronic pain, acute embolism and thrombosis of deep veins of lower extremity (formation of blood clots in the blood vessels of the legs), colostomy status (surgical procedure that changes the way stool moves through the body), gastroesophageal reflux disease (chronic disease where liquid contents of the stomach reflux back into the esophagus), and congestive heart failure (a progressive disease that affects the pumping mechanism of the heart). Review of the admission MDS assessment for Resident #100 dated 09/27/24 reflected a BIMS score of 07, indicating severe cognitive impairment. The section for Activity Preferences reflected it was somewhat important to him to have books, newspapers, and magazines to read, to be around animals such as pets, do things with groups of people, and to participate in religious services or practices and very important to him to listen to music he liked, keep up with the news, and go outside to get fresh air when the weather is good. The section for ADL care reflected he was dependent on staff for all ADL care, including mobility. Review of the Admission Activity assessment dated [DATE] and completed by the AD reflected Resident #100 was currently interested in games, puzzles, arts/crafts/woodworking/ceramics, knitting/crocheting, drawing/painting, music/singing, reading/writing, spiritual/religious, trips outside the facility, walking/wheeling outdoors, watching television, gardening, exercise, talking/conversing, helping others/volunteering, parties, visits with pets, and reminiscing. Review of the care plan for Resident #100 dated 09/22/24 reflected no care planning related to recreational activities. Review of activity progress notes for Resident #100 reflected no notes from admission on 09/20/24. Review of activity task documentation for Resident #100 reflected no tasks documented from 09/30/24 to 10/30/24. 2. Review of the undated face sheet for Resident #70 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included pulmonary fibrosis (a disease in which the lungs become scarred (fibrosed) and damaged causing difficulty in breathing), hemiplegia and hemiparesis following cerebral infarction (paralysis on one side of the body following death to brain tissue), cognitive communication deficit (difficulty communicating due to cognitive impairment), lack of coordination, muscle wasting and atrophy, unsteadiness on feet, dementia, adult failure to thrive, major depressive disorder, anxiety disorder, and chronic pain. Review of the admission MDS assessment for Resident #70 dated 08/23/24 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences was not completed. Review of the care plan for Resident #70 dated 10/26/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t Cognitive deficits, Immobility, Physical Limitations. Will attend/participate in activities of choice by next review date. All staff to converse with resident while providing care. o Assistance with ADLs as required during the activity. o Assure that the activities attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. o Encourage ongoing family involvement. Invite family to attend special events, activities, meals. o Invite to scheduled activities. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. Review of activity progress notes for Resident #70 reflected no notes from admission on 08/19/24. Review of activity task documentation for Resident #70 reflected no tasks documented from 09/30/24 to 10/30/24. Observation and interview on 10/28/24 at 10:11 AM, revealed Resident #100 laying in bed in a hospital gown with his window open. He stated he liked to look out the window but had not done anything else in the facility. He stated he liked to do anything for fun. He stated he did not remember anyone inviting him to activities. Observation on 10/28/24 at 11:25 AM, 12:42 PM, 01:38 PM, and 02:50 PM, on 10/29/24 at 09:15 AM, 10:20 AM, 11:22 AM, 01:20 PM, 02:15 PM, 03:20 PM, and 04:34 PM, and 10/30/24 at 09:10 AM, 10:32 AM, 11:30 AM, 01:00 PM revealed Resident #100 was laying in his bed in a hospital gown with the window open and not engaged in any activities. There were no supplies or materials for any activity present in his room. 3. Review of the undated face sheet for Resident #104 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bilateral primary osteoarthritis of the carpometacarpal joints (arthritis in both wrists), muscle weakness, unsteadiness on feet, cognitive communication deficit (difficulty communicating due to cognitive impairment), need for assistance with personal care, bilateral (both sides) primary osteoarthritis of knee, spinal stenosis (spinal column narrowed and compressed the spinal cord), repeated falls, depression, low back pain, and malaise. Review of the admission MDS assessment for Resident #104 dated 09/02/24 reflected a BIMS score of 15, indicating intact cognition. The section for Activity Preferences reflected he was somewhat important to her to keep up with the news, and go outside to get fresh air when the weather is good, to be around animals such as pets, do things with groups of people, and to participate in religious services or practices and very important to her to have books, newspapers, and magazines to read, and to listen to music she liked. The section for ADL care reflected she was dependent on staff for transfers. Review of the Admission Activity assessment dated [DATE] and completed by the AD reflected she was currently interested in puzzles, arts/crafts/woodworking/ceramics, drawing/painting, music/singing, and reminiscing. Review of the care plan for Resident #104 dated 10/07/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t Cognitive deficits, Immobility. Will attend/participate in activities of choice by next review date. All staff to converse with resident while providing care. o Assistance with ADLs as required during the activity. o Encourage ongoing family involvement. Invite family to attend special events, activities, meals. o Invite to scheduled activities. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. There were no care plan items describing Resident #104's specific activity interests. Review of activity progress notes for Resident #104 reflected no notes from admission on 08/29/24. Review of activity task documentation for Resident #104 reflected no tasks documented from 09/30/24 to 10/30/24. Observation and interview on 10/28/24 at 11:35 AM, revealed Resident #104 was laying in bed in a hospital gown. She stated nobody from the facility had invited her to activities. There were no supplies or materials for any activity present in her room. Observation on 10/28/24 at 12:41 PM, 01:37 PM, and 02:49 PM, on 10/29/24 at 09:14 AM, 10:19 AM, 11:21 AM, 01:19 PM, 02:14 PM, 03:19 PM, and 04:33 PM, and 10/30/24 at 09:09 AM, 10:31 AM, 11:29 AM, 01:04 PM revealed Resident #104 was laying in her bed in a hospital gown and not engaged in any activities. During an interview on 10/30/24 at 10:52 AM, the MDSN stated she initiated the care plan items based on the MDS assessment, but the department heads, particularly the AD, were expected to go into the care plan and personalize it to reflect the specific needs of the resident. The MDSN stated the AD was new and might not have known she needed to update the care plans. The MDSN stated she did not know who was responsible for ensuring the AD updated the care plans to be personalized, but the ADM was the AD's direct supervisor. She stated the potential negative outcome of not having activities care plans personalized with specific resident interests was isolation. During an interview on 10/30/24 at 01:32 PM, the AD stated sat in the care plan meetings, asked if they liked activities, and took notes. She stated she had not learned how to update care plans to be personalized. She stated she did try to update the care plan if she discovered a specific activity a resident liked, but she was not aware until that day that she was fully responsible for that. She stated residents might feel forced to do something they did not like to do if their care plans weren't personalized with their specific activity preferences. During an interview on 10/30/24 at 02:27 PM, the DON stated she helped with care plans by initiating most of them, the MDSN added the care plan areas, and then some of the department heads added some specific information. She stated The AD was fairly new and was supposed to go train to learn more of her job, but the facility where she was supposed to train with that facility's activity director had HHSC enter for full book survey the day she was supposed to go there. The DON stated the care plan should have been person-centered and specific to the residents. During an interview on 10/30/24 at 03:50 PM, the ADM stated he monitored the activity program by having a one-to-one meeting with the AD each week. He stated she was responsible for making sure care plans were personalized and for making sure the activities program was compliant. He stated one one-to-one activity per month was not enough. The ADM stated he expected the AD to document resident activities, and specific resident interests should have been care planned. He stated a potential negative effect of residents not receiving activities or having their specific preferences care planned was it could diminish quality of life. Review of facility policy dated 01/2022 and titled Comprehensive Resident Centered Care Plans reflected the following: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives, and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 50872

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 24 residents (Residents #27, 100, and 104) reviewed for activities. The facility failed to ensure Residents #27, 100, and 104 received activities according to their preferences on their comprehensive assessments. This failure placed residents at risk of boredom and diminished quality of life. Findings included: 1. Review of Resident #27 face sheet revealed a [AGE] year-old woman admitted on [DATE] with diagnosis of senile degeneration of brain (progressive decline in cognitive functioning that can lead to memory loss, impaired thinking, and loss of independence) unspecified dementia (chronic condition that causes a decline in mental abilities such as thinking, remembering and reasoning that interferes with daily life), unspecified visual loss, unspecified sensorineural hearing loss (type of heading loss that occurs when there is no identifiable cause), absence of eye, major depressive disorder (mood disorder that causes a persistent low mood and loss of interest in activities) and anxiety disorder (mental illness that causes excessive and uncontrollable feelings of fear that can impact a person's daily life). Review of Resident #27's special instructions on her medical profile revealed she is blind, hard of hearing and enjoys listening to music or tv, religious practices, going outdoors or feeling the sun on her face. Review of Resident #27's care plan dated 12/11/2023 revealed activity preferences as relaxing to calming music with interventions to provide encouragement, reminds and transport to activities as needed. Review of Resident #27's quarterly activity assessment dated [DATE] revealed room visits were provided weekly with music therapy during meals. During an attempted interview on 10/28/2024 at 9:48 AM, Resident #27 did not respond to questions. Observation on 10/28/24 at 09:49 AM, revealed Resident #27 lying in bed. Observation on 10/28/2024 at 12:30 PM, revealed Resident #27 lying in bed. There was no music playing and the television was not on. Observation on 10/28/24 at 01:04 PM, revealed Resident #27 lying in bed. Observation on 10/28/2024 at 2:24 PM, revealed Resident #27 lying in bed. There was no music on and the television was not on. Observation on 10/29/24 at 09:23 AM, revealed Resident #27 lying in bed. Resident had no music on. Roommate's television was on, but not Resident #27's. Observation on 10/29/24 at 11:43 AM, revealed Resident #27 lying in bed. There was no music or television on. Observation on 10/29/24 at 01:02 PM, revealed Resident #27 lying in bed. There was no music or television on. Observation on 10/30/24 at 09:01 AM, revealed Resident #27 lying in bed. There was no music or television on. 2. Review of the undated face sheet for Resident #100 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included neuromuscular dysfunction of bladder (the brain and nervous system cannot properly communicate with the bladder), pressure ulcer, polyarthritis (arthritis that affects more than five of your joints at the same time), chronic pain, acute embolism and thrombosis of deep veins of lower extremity (formation of blood clots in the blood vessels of the legs), colostomy status (surgical procedure that changes the way stool moves through the body), gastroesophageal reflux disease (chronic disease where liquid contents of the stomach reflux back into the esophagus), and congestive heart failure (a progressive disease that affects the pumping mechanism of the heart). Review of the admission MDS assessment for Resident #100 dated 09/27/24 reflected a BIMS score of 07, indicating severe cognitive impairment. The section for Activity Preferences reflected it was somewhat important to him to have books, newspapers, and magazines to read, to be around animals such as pets, do things with groups of people, and to participate in religious services or practices and very important to him to listen to music he liked, keep up with the news, and go outside to get fresh air when the weather is good. The section for ADL care reflected he was dependent on staff for all ADL care, including mobility. Review of the Admission Activity assessment dated [DATE] and completed by the AD reflected he was currently interested in games, puzzles, arts/crafts/woodworking/ceramics, knitting/crocheting, drawing/painting, music/singing, reading/writing, spiritual/religious, trips outside the facility, walking/wheeling outdoors, watching television, gardening, exercise, talking/conversing, helping others/volunteering, parties, visits with pets, and reminiscing. Review of the care plan for Resident #100 dated 09/22/24 reflected no care planning related to recreational activities. Review of activity progress notes for Resident #100 reflected no notes from admission on 09/20/24. Review of activity task documentation for Resident #100 reflected no tasks documented from 09/30/24 to 10/30/24. Observation and interview on 10/28/24 at 10:11 AM, revealed Resident #100 laying in bed in a hospital gown with his window open. He stated he liked to look out the window but had not done anything else in the facility. He stated he liked to do anything for fun. He stated he did not remember anyone inviting him to activities. Observation on 10/28/24 at 11:25 AM, 12:42 PM, 01:38 PM, and 02:50 PM, on 10/29/24 at 09:15 AM, 10:20 AM, 11:22 AM, 01:20 PM, 02:15 PM, 03:20 PM, and 04:34 PM, and 10/30/24 at 09:10 AM, 10:32 AM, 11:30 AM, 01:00 PM revealed Resident #100 was laying in his bed in a hospital gown with the window open and not engaged in any activities. There were no supplies or materials for any activity present in his room. 3. Review of the undated face sheet for Resident #104 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included bilateral primary osteoarthritis of the carpometacarpal joints (arthritis in both wrists), muscle weakness, unsteadiness on feet, cognitive communication deficit (difficulty communicating due to cognitive impairment), need for assistance with personal care, bilateral (both sides) primary osteoarthritis of knee, spinal stenosis (spinal column narrowed and compressed the spinal cord), repeated falls, depression, low back pain, and malaise. Review of the admission MDS assessment for Resident #104 dated 09/02/24 reflected a BIMS score of 15, indicating intact cognition. The section for Activity Preferences reflected he was somewhat important to her to keep up with the news, and go outside to get fresh air when the weather is good, to be around animals such as pets, do things with groups of people, and to participate in religious services or practices and very important to her to have books, newspapers, and magazines to read, and to listen to music she liked. The section for ADL care reflected she was dependent on staff for transfers. Review of the Admission Activity assessment dated [DATE] and completed by the AD reflected she was currently interested in puzzles, arts/crafts/woodworking/ceramics, drawing/painting, music/singing, and reminiscing. Review of the care plan for Resident #104 dated 10/07/24 reflected the following: Dependent on staff for activities, cognitive stimulation, social interaction r/t Cognitive deficits, Immobility. Will attend/participate in activities of choice by next review date. All staff to converse with resident while providing care. o Assistance with ADLs as required during the activity. o Encourage ongoing family involvement. Invite family to attend special events, activities, meals. o Invite to scheduled activities. o Provide with activities calendar. Notify resident of any changes to the calendar of activities. There were no care plan items describing Resident #104's specific activity interests. Review of activity progress notes for Resident #104 reflected no notes from admission on 08/29/24. Review of activity task documentation for Resident #104 reflected no tasks documented from 09/30/24 to 10/30/24. Observation and interview on 10/28/24 at 11:35 AM, revealed Resident #104 was laying in bed in a hospital gown. She stated nobody from the facility had invited her to activities. There were no supplies or materials for any activity present in her room. Observation on 10/28/24 at 12:41 PM, 01:37 PM, and 02:49 PM, on 10/29/24 at 09:14 AM, 10:19 AM, 11:21 AM, 01:19 PM, 02:14 PM, 03:19 PM, and 04:33 PM, and 10/30/24 at 09:09 AM, 10:31 AM, 11:29 AM, 01:04 PM revealed Resident #104 was laying in her bed in a hospital gown and not engaged in any activities. During an interview on 10/30/24 at 01:33 PM, the AD stated she was not very familiar with Resident #27. The AD stated that Resident #27 does not come out of her room but that she gets one to one activities. The AD stated that Resident #27 listens to music and will get massage therapy and watch tv. AD was not aware that Resident #27 had a visual and auditory impairment. AD then stated Resident #27 listens to television. AD stated that Resident #27 gets out of her room when she works with therapy, but therapy is not at the facility on the weekends so Resident #27 does not come out of her room then. AD stated she will play whatever music is on the radio for Resident #27. AD stated that Resident #27 has one to one activities done once a month. She stated when Resident #27 does not get a one-to-one activity she is not sure what she does. She stated the CNAs will usually put on country music for Resident #27 but no checks to ensure that music is put on. The AD stated Resident #100 usually stayed in bed, so his activities were more one-on-one. She stated he liked to watch the bird feeders out the window. She stated Resident #104 did not like to come out of her room, and the AD tried to go get her, but she needed to do more with Resident #104. The AD stated that sometimes Resident #88 did gardening. AD stated that on the weekends they have university students come and they will bring math, history writing activities and cup pong. AD stated Resident #88 does not participate in that activity. AD stated Resident #88 does comes out for social activities. AD stated that he has not come out this week for any activities. AD stated she was not sure why he has not come out for activities. AD stated she would not consider watching television with no volume on activity. AD stated everyone is responsible for ensuring that the television is on with something they like and volume is on. The AD stated she did not log her activities anywhere and had no documentation of specific residents participating in specific activities. She stated the one-to-one activities were completed on the weekends, and she rotated a hall each weekend, so each resident who required one-to-one activities received them once every four weeks. During an interview on 10/30/24 at 02:27 PM, the DON stated before the AD, they had someone doing the activities program who did a terrible job, and the AD is so much better. The DON stated they had seen a liveliness return to the activities program as a result of the AD being there. The DON stated one activity per month was not enough. She stated she did not know what would be enough, but she would think one one-to-one activity per week at least was the minimum. During an interview on 10/30/24 at 03:50 PM, the ADM stated he monitored the activity program by having a one-to-one meeting with the AD each week. He stated the AD was responsible for making sure care plans were personalized and for making sure the activities program was compliant. He stated one one-to-one activity per month was not enough. The ADM stated he expected the AD to document resident activities, and specific resident interests should have been care planned. He stated a potential negative effect of residents not receiving activities or having their specific preferences care planned was it could diminish quality of life. He stated there was no written policy related to activities. 42600

Based on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, or preferences for 1 of 9 residents (Resident #24) reviewed for meal preferences. The facility failed to cut Resident #24's meat according to her meal ticket during lunch 10/28/24, dinner 10/29/24, and lunch 10/30/24 and failed to ensure she was not served squash, which her meal ticket reflected she disliked. This failure placed residents at risk of weight loss and diminished quality of life. Findings included: Review of the undated face sheet for Resident #24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included essential tremor (a nervous system condition, also known as a neurological condition, that causes involuntary and rhythmic shaking), lack of coordination, muscle weakness, and need for assistance with personal care. Review of the Functional Performance Observation (Section GG of the MDS assessment) for Resident #24 dated 10/30/24 reflected she required set up or clean up assistance with eating . Review of the BIMS assessment for Resident #24 dated 09/25/24 reflected a score of 15, indicating intact cognition. Review of the care plan for Resident #24 dated 05/02/24 reflected the following: ADL Self Care Performance Deficit r/t Limited Mobility. Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence through the review date. EATING: resident requires set up and supervision of staff to eat. Observation and interview on 10/28/24 at 12:25 PM, revealed Resident #24 revealed an aide delivered her lunch meal of fried chicken breast with gravy, mashed potatoes, and green beans. The chicken breast was whole, and the aide did not offer to cut it. Resident #24 presented her meal ticket, which had the words, Cut all meats at all meals printed on it. It also listed her dislikes as beans, beets, Mexican food, seafood, and squash. Resident #24 stated the staff never cut her meat at meals and often sent food out on her plate that her meal ticket indicated she disliked. Resident #24 stated she was capable of cutting her own meat, but it was hard for her, because her hands shook. She stated that it also made her feel unimportant that nobody at the facility paid attention to her meal ticket. Observation on 10/29/24 at 05:23 PM, revealed an aide served Resident #24 a dinner meal with a smothered pork chop, mashed potatoes, and greens. The pork chop was not cut up, and the aide did not offer to cut it up. Resident #24 cut her own pork chop slowly and with trembling hands. Observation and interview on 10/30/24 at 12:20 PM, revealed the ADOR served Resident #24 her lunch plate which had Swiss steak, rice, and mixed vegetables including squash. The ADOR did not cut the meat for Resident #24 or note that the tray had a vegetable on it that was listed in her dislikes. The ADOR stated she did not know who was responsible for cutting meat on the resident's plate if the resident's meal ticket reflected the resident's meat should be cut. The ADOR stated she did not know who should have looked at the ticket to ensure disliked foods were not served to the residents, but she thought it might have been the dietary staff. She offered to cut Resident #24's meat for her, and Resident #24 stated it was okay, and she would do it herself at that time. The ADOR walked away, and Resident #24 stated she did not like to bother people or complain but she wished they would read the ticket. During an interview on 10/30/24 at 01:40 PM, the DM stated he added resident likes and dislikes to the meal tickets and the aides, cooks, and nurses were supposed to look at follow the meal tickets as they were preparing and serving the meals. The DM stated he had not received any complaints from Resident #24. He stated the aides went around taking meal orders from the residents, and they would strike off anything the residents did not want, but the menu item that day was called Italian vegetables and it did not say what was in them. He stated someone in the process to get the meals out- dietary aides, cooks, and nursing staff- should have noticed there was food on the tray Resident #24 did not want, and that was a three-fold failure. He stated the people responsible for cutting Resident #24's meat according to her meal ticket were the staff who brought meals to the table. He stated that was the nursing staff, usually the CNAs. The DM stated a potential negative impact of the failure was Resident #24 was dissatisfaction. During an interview on 10/30/24 at 02:27 PM, the DON stated the responsibility for cutting meat according to the meal ticket was the responsibility of whoever served it. She stated the staff were trained to check the tickets and read what was on the meal ticket. She stated she could not remember when the last training was about the topic. She stated it could be a problem for residents if they did not get their meat cut by the staff serving the food. During an interview on 10/30/24 at 03:50 PM, the ADM stated the people responsible for ensuring the meal ticket was followed if it said to cut all meats were the staff who served the meals. He stated the ADOR had said Resident #24 declined to have her meat cut when served the tray, but he was aware that the offer came after the surveyor asked about the instructions on the meal ticket and why they had not been followed. The ADM stated it could lessen the residents' quality of life if the staff serving their meal trays ignored instruction on their meal tickets. Review of facility policy dated 2023 and title Resident Rights reflected the following: Self determination. You have the right to self-determination through support of your choice, including the right to: choose activities, schedules, healthcare, and providers of healthcare services, consistent with your interests, assessments, plan of care; make choices about aspects of your life and the facility that are significant to you.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 5 of 12 residents (Resident #7, Resident #16, Resident #47, Resident #104, and Resident #408) reviewed for infection control, as indicated by: The facility failed to ensure : 1. CNA G and CNA F performed clean practices during peri care for Resident # 104 and Resident 408 2. CNA J sanitized her hands between residents while passing meal trays to Residents in Hall #100. 3. MA I sanitized her hands before preparing medications, medical equipment after contact with Resident #7 , Resident #16 and Resident #47. These failures could place the residents at risk of transmission of diseases and infection. Findings included: 1. Record review of Resident #104's face sheet dated 10/29/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Her diagnoses were unsteadiness on feet, low back pain, cognitive communication deficit and need for assistance with personal care. Record review on 10/29/24 of Resident #104's initial MDS assessment, dated 09/11/24 revealed her BIMS was 15 indicating her cognition was intact. MDS indicated he needed support with ADLs. Record review on 10/29/24 of Resident #104's care plan dated 08/30/24 reflected the resident had ADL self-care performance deficit r/t pain, decreased mobility, and weakness and the relevant intervention was helping him with the ADLs. During an observation on 10/28/24 at 10:10 a.m., CNA G was performing peri care for Resident #104 with the help of CNA H. CNA G donned gloves without washing or sanitizing her hands. She then opened the brief and cleaned the fecal matters from the front and back with wet wipes that she took directly from the packet ,with her soiled gloves. After finishing the cleaning, she changed the gloves and applied the new brief . After the completion of the task, she saved the contaminated wet wipe packet with remaining wipes, on the side table; beside an incentive spirometer (A mechanical hand-held breathing device that gives the patient visual feedback on the volume of the inhalation), lotions, creams and shampoo. CNA G did not wash or sanitize her hands after the completion of the peri care. During an interview on 10/28/24 at 1:45 p.m., CNA G stated she thought she was following the infection control protocol while providing peri care., CNA G stated she should have washed her hands before and after the peri care. She stated she contaminated the wet wipe packet by handling it with gloves soiled with fecal matters. CNA G said since the wet wipe packet was contaminated , she should have thrown it away. CNA G said unhygienic practices caused contamination that eventually spread germs. CNA G said she started working at the facility about a month ago and received training on infection control during the orientation classes. 2. Record review of Resident #408's face sheet dated 10/29/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. His diagnoses was Sepsis, COPD, Cellulitis (deeper bacterial skin infection) of left upper limb, Type 2 diabetes, Muscle weakness and Unsteadiness on feet. Record review on 10/16/24 of Resident #408's initial MDS assessment, dated 10/04/24 revealed a BIMS of 14 indicating intact cognition. Record review on 10/29/24 of Resident #408's care plan dated 10/08/24 reflected the resident had chemotherapy r/t leukemia (Blood cancer) and relevant intervention was keeping the environment clean as he was at the risk for contracting infections due to chemotherapy. During an observation on 10/29/24 at 10:45 a.m., CNA F provided peri care to Resident #408. CNA F put on a new pair of gloves, he did not wash or sanitize his hands before donning the gloves. CNA F removed the old brief and cleaned Resident #408's front and back with wet wipes. During this process he handled the wet wipe packet with soiled gloves. After the completion of peri care he stored the contaminated wet wipe packet on the side table and left the room without washing or sanitizing his hands and moved on to the next resident. During an interview on 10/29/24 at 11:15 a.m., CNA F requested the investigator to walk through the peri care process that he did so that he would be able identify the mistakes. After the completion he said he should not have handled the wet wipe packet with dirty gloves. He stated he knew washing hands before and after the peri care was instructed at the facility however forgot to practice it at the time of peri care. He said his wrong practices could promote spreading various diseases. Record review of the in-service records revealed since 05/01/2024 there was one in service conducted on peri care. On 10/08/24 'Check off on peri care was conducted and CNA G and CNA F had not attended the in-service 3. Record review of Resident #7's face sheet dated 10/20/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia (difficulty with thinking processes), hypertension (high blood pressure), diabetes mellitus (inability to maintain blood sugars), and paroxysmal atrial fibrillation (an abnormal heart rhythm). Record review of Resident #7's quarterly BIMS assessment dated [DATE] revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #16's face sheet dated 10/29/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease (a progressive disease affecting the lungs and making it difficult to breathe), diabetes mellitus (inability to maintain blood sugars), cognitive communication deficit (difficulty communicating), and chronic kidney disease (the kidneys are not able to filter toxins as well). Record review of Resident #16's quarterly BIMS assessment dated [DATE] revealed a BIMS score of 12 which indicated mild cognitive impairment. Record review of Resident #47's face sheet dated 10/29/2024 revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses that included but were not limited to Diabetes Mellitus (inability to maintain blood sugars), dementia (difficulty with thinking processes), hypertension (high blood pressure), and chronic kidney disease (the kidney's inability to filter toxins in the blood). Record review of Resident #47's quarterly BIMS assessment dated [DATE] revealed a BIMS score of 6 which indicated moderate cognitive impairment. Observation on 10/28/2024 at 1:14 PM, revealed CNA J came out of a resident's room down the 100-hall with a dirty breakfast tray, set tray down on lower part of the meal cart, walked around to other side of the meal cart, pulled a lunch tray and delivered it to different room across the hall. Observation on 10/29/2024 at 7:47 AM, revealed MA I picked up wrist blood pressure cuff off top of medication cart, approached Resident #7 and checked blood pressure using wrist blood pressure cuff. MA I returned to medication cart, set the blood pressure down cuff on top of the cart (without sanitizing it or her hands), pulled keys from pocket, unlocked medication cart and proceeded to pull medication cards for Resident #7. MA I proceeded to gather scheduled medications for the resident. She returned the medication cards to the cart, locked the cart and returned to Resident #7 to administer medications (without sanitizing hands). MA I asked resident if he wanted his pain patch today. Resident stated yes. MA I returned to medication cart. Unlocked cart, pulled Lidocaine patch from cart, locked cart, then opened the package and dated the patch. MA I then put on gloves and returned to the resident to apply patch to lower back and took off gloves and threw them away. She then returned to the cart and sanitized her hand with hand sanitizer. Observation on 10/29/2024 at 7:57 AM, revealed MA I unlocked the medication cart, applied gloves, pulled out purple top sanitizing wipes from bottom drawer and sanitized the wrist blood pressure cuff, then took off gloves. MA I then approached Resident #16 and checked blood pressure. MA I then returned to medication cart and set blood pressure cuff down on top of cart (without sanitizing blood pressure cuff or hands), unlocked cart and pulled medication cards from the medication cart. MA I prepared scheduled medication then returned to Resident #16 (without sanitizing hands) to administer medication. After administering medications to Resident #16, MA I walked into the bathroom and washed hands with soap for approximately 5 seconds, hands dried and MA I returned to medication cart. Observation on 10/29/2024 at 8:07 AM, MA I applied gloves, unlocked medication cart, removed sanitizing wipes and proceeded to sanitize wrist blood pressure cuff and removed gloves, then locked cart. MA I approached resident and checked vital signs on Resident # 47. MA I returned to medication cart, set blood pressure cuff down on top of the cart, unlocked cart, took medications out of cart and prepared scheduled medications by putting tablets in a cup and a capsule in a separate cup. She then put all tablets into a pill crusher pouch and used the pill crusher to crush all tablets. The crushed tablets were poured into a plastic cup. MA I then applied gloves, opened the remaining capsule and poured it over the other crushed medications. She removed her gloves, grabbed a new container of vanilla pudding and opened it. With a new spoon she put a spoonful of pudding on top of the medications in the cup. MA I then dated the top of the pudding with a sharpie that way laying on top of the medication cart. She stirred the medications in with the pudding, locked the cart and returned to Resident # 47 and administered medications. After returning the medication cart MA I then sanitized her hands. Interview on 10/30/2024 at 12:13 PM, LVN D stated hands should be sanitized before preparing medication, before going into room to administer medications, and after administering medications. LVN D stated not doing so could cause infection or sickness. LVN D stated all medical equipment for checking vital signs should be sanitized before use and not doing so could cause cross contamination, skin infections by transferring bacteria and viruses. Phone Interview on 10/30/2024 at 3:37 PM, MA I stated hands should be sanitized between each resident and washed for a minute every third resident. She also stated that the blood pressure cuff should be sanitized prior to use. Stated that during medication pass she used hand sanitizer from her pocket but does not recall how long she washed her hands for. She stated she was unsure if blood pressure cuffs were to be sanitized after use or before use. MA I said she did not think about a cuff not being sanitized before setting on the cart could contaminate the cart and the medication does not touch the top of the cart. MA I stated not sanitizing her hands could cause contamination from resident to resident and transmit viruses and disease to others or ourself. Phone interview attempted on 10/30/2024 at 3:45 PM, with CNA J attempted, but phone number was not in service. Interview on 10/30/2024 at 2:08 PM, the DON stated she expected the staff to wash or sanitize their hands and clean the relevant surfaces before and after any nursing care like wound care, peri care, between passing food trays and when preparing and administering medications. The DON said medical equipment like the blood pressure cuff should be sanitized before and after use. She stated not sanitizing hands and equipment appropriately could cause spreading infections and diseases. Record review of Policy/Procedure named Infection Control: General Cleaning and Maintenance of Equipment dated 1/2024 stated It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Equipment will be cleaned and decontaminated according to manufacturer's recommendation. Procedures: All equipment and supplies will be cleaned and decontaminated immediately after use. Record review of policy named Specific Medication Administration Procedures dated 11/13/2018 states: 1. General procedures to follow for all medications. G. Cleanse hands before handling medication and before contact with resident. Record review of Policy/Procedure: Nursing Clinical revised in January 24 reflected: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. 50872

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility failed to provide an effective pest control program for flies and cockroaches in the facility. This deficient practice could place residents at risk of remaining in an environment that was not free of pests. The findings include: Observation on 10/29/2024 at 10:07 AM, in Resident #9's room of a dark brown cockroach (about the size of a quarter) crawled out from under the closet door, across the floor, and went under the bed. Interview on 10/29/2024 at 10:07 AM, with Resident #9 stated she has not seen a bug like that before in her room. Resident #9 stated she does not like the thought of having bugs in her room. During an observation and interview on 10/29/24 at 10:15 AM, in Resident #408's room there were 2 flies crawling on the side table, bed, and Resident #408's body. Resident #408 stated there were flies always in his room since his admission to the facility. He stated he complained to the staff numerous occasions however no actions taken. During an interview and observation on 10/29/24 at 10:45 AM, two flies was crawling on Resident #408. CNA F who was present in the room stated he saw the flies however did not report to anyone. He stated flies could spread diseases through contamination. Observation on 10/29/24 at 05:18 PM, in the dining room revealed a fly landed on the surveyor's leg during observations of the dinner meal. During interview on 10/30/2024 at 11:35 AM, with CNA L stated she had not seen any bugs in the facility but if she were to see one, she would inform the nurse on duty or housekeeping manager. Observation on 10/30/2024 at 12:13 PM, in 100-hall revealed a fly. The fly landed on top of the computer. During an interview on 10/30/24 at 1:30 PM, the ADM stated the pest control agency did the treatment twice a month and it was up to date. The ADM said the pest control treatment might not be fully effective since there were insect activities at the facility. The ADM stated he was committed to have a post-free facility as they were harmful to residents many ways like causing insect bites or spreading various diseases however no one reported to him about any insect activities at the facility. Record review of pest control records revealed the pest control agency visited the facility and did the treatment on 10/22/24. It was also revealed they visited the facility every 15 days for treatment. Record review of the facility's undated policy Pest Control reflected : Policy - It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with at least amount of contamination to the environment . 1. Report any pest sightings and file a report using the TELS system. 2. Document problems found during inspection and the remedial actions taken 3. Advise staff on preventive measure, unsanitary conditions, etc 4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment. Pest Identification: The following guidelines for pest identification: 1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures 2. Use pesticides only after all other channels of control are exhausted 3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls 4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information: a. Type of problem b. Location c. Person reporting and time reported

Based on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity during personal care for 2 of 4 residents (Resident #408 and Resident # 21) reviewed for respect and dignity in that: The facility failed to ensure LVN E provided privacy when providing Resident #21 with wound care. The facility failed to ensure CNA F provided privacy when providing Resident #408 with incontinent care. This failure could place residents at risk of emotional distress and low self esteem Findings included: 1. Record review of Resident #21's face sheet dated 10/29/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were COPD, Heart Failure, Obesity, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Lack of coordination, Weakness, and Dementia. Record review on 10/29/24 of Resident #21's initial MDS assessment, dated 10/16/24 revealed the assessment was not completed. Record review on 10/29/24 of Resident #21's care plan dated 10/22/24 reflected the resident had a Diabetic Ulcer r/t Diabetes and related intervention was carefully drying between toes but do not apply lotion between toes. During an observation on 10/28/24 at 12:10 p.m., LVN E provided wound care to Resident #21 while he was sitting on his wheelchair. LVN E did not close the door and drew the privacy curtain of Resident #21's room during the entire process. Resident #21's wound care was visible to the hallway. During an interview on 10/28/24 at 12:55 p.m., Resident #21 stated he did not notice if the door and privacy curtain was not closed properly. He said he would be visible to others if the door and the curtain was not closed properly. He said it would not make any difference for him personally. During an interview on 10/28/24 at 1:35pm LVN E stated, by not closing the door and the curtain, the privacy and dignity of Resident #21 was compromised as anyone passed by the room could see the wound care. When asked about the training she received on resident's rights, LVN E stated she was fully aware of resident right to have privacy, dignity, and respect and received in-service on resident's rights at least once a year. 2. Record review of Resident #408's face sheet dated 10/29/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. His diagnoses were Sepsis, COPD, Cellulitis of left upper limb, Infection of the skin and subcutaneous tissue, Type 2 diabetes, muscle weakness and Unsteadiness on feet. Record review on 10/16/24 of Resident #408's initial MDS assessment, dated 10/04/24 revealed a BIMS of 14 indicating intact cognition. Further review of MDS revealed Resident #408 was always incontinent with bowel. Record review on 10/29/24 of Resident #408's care plan dated 10/08/24 reflected the resident had an ADL Self Care Performance Deficit r/t weakness, cellulitis and debility and related intervention was supporting resident with his ADLs. During an observation on 10/29/24 at 10:45 a.m., CNA F provided peri care to Resident #408. Resident #408 shared the room with another resident and Resident #408's bed was next to the door. LVN F closed the door before commencing peri care however did not close the privacy curtain so that Resident #408's body was visible to anyone who tried to enter the room. During an interview on 10/29/24 at 11:05 a.m., Resident #408 stated he did not notice about the privacy curtain. When investigator asked him how he would have felt if his naked body was exposed to others Resident #408 stated, that would be very embarrassing. During an interview on 10/29/24 at 10:55 a.m., CNA F stated he forgot to close the privacy curtain of Resident #408 and did not noticed until the investigator pointed it out. He said by not closing the curtain he did not respect resident's privacy and dignity and need to be careful about it in the future. CNA F stated Resident #408's body would have been visible to anyone who entered the room as his bed was exposed to the door without the privacy curtain. During an interview 10/17/24 at 4:35 p.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #21 and Resident #408's room should have been closed completely by LVN E and CNA F. She said the trainings was ongoing process and resident rights was one of them. The DON stated the facility ensured all the new hires had gone through skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting resident's rights. During an interview on 10/17/24 at 3:30 p.m., the ADM stated the residents' rights at the facility should be maintained during nursing care. He said staff was expected to respect privacy and dignity by making sure doors to rooms were closed, privacy curtains fully drawn, and the window blinds was shut properly. During the review of facility's policy Quality of Life -Dignity revised in August 2009, reflected: Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interviews, and record review the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 7 (Resident #15) reviewed for dental services. The facility failed to assist Resident #15 with obtaining dental services in a timely manner when her bottom dentures broke sometime after May 2024. This deficient practice could affect residents by placing them at risk of not receiving necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being which could result in decreased quality of life. Findings included: Record review of Resident #15's face sheet dated 10/29/2024 with an admitted [DATE] reflected a [AGE] year-old female with diagnoses including but not limited to rotator cuff tear or rupture of left and right shoulders (damage to the shoulder muscle), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty communicating), muscle weakness, lack of coordination, major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), and peripheral vascular disease (disorder of the blood vessels in the legs causing decreased blood circulation). Record review of Resident #15's quarterly BIMS assessment dated [DATE] reflects a BIMS score of 15 which indicated no cognitive impairment at the time of assessment. Record review of Resident #15's quarterly MDS dated [DATE] reflected Resident #15 required setup or clean-up assistance for eating. Resident #15 was completely dependent on staff for showering, upper and lower body dressing and putting on and taking off footwear. The MDS also reflected Resident #15 required partial/moderate assistance for personal hygiene such as combing hair, washing and drying face, and washing hands. MDS reflected no weight loss of 5% in the last month or 10% or more in the last 6 months under the swallowing/nutritional status section. MDS reflected under oral/dental status, no broken or loosely fitting full or partial denture and no mouth or facial pain, discomfort, or difficulty chewing. Record review of Resident #15's orders dated 10/11/2024 reflected resident is on a regular diet with regular texture and thin liquid consistency. Record review or Resident #15's care plan dated initiated 10/7/2022 reflected Resident #15 had ADL self-care performance deficit related to impaired balance, limited ROM, OA to bilateral (both) shoulders and knees with interventions of staff assist for toilet use, bed mobility, bathing, dressing and transfers. Intervention reflected resident requires 1 staff to set up and assist with meals. Record review of Resident #15's dental visit progress noted dated 7/12/2024 indicated broken bottom dentures. Record review of dental progress note dated 8/13/2024 reflected insurance approval for repair of bottom denture and dentures sent off to lab for repair. Record review of dental progress note dated 9/26/2024 reflected Patient tells me she does not have her repaired denture, I contacted lab and they gave me tracking number from when it was delivered, shows 8/27/24 around 11am. I have spoken with receptionist, her nurse, another nurse nobody knows where it is. I have tried speaking to social worker but not available, not sure what to do at this time. Record review of emails between BSW and priority care specialist with dental office dated 10/2/2024 at 4:09 PM, stated Resident #15 turned in a pair of dentures to be fixed and asked for delivery details. Email response from dental office on 10/3/2024 at 10:17 AM provides tracking number and (wrong)date/time of delivery. Follow up email on 10/08/24 at 10:15 AM from BSW to dental office stated they were unable to locate the dentures and to set up appointment for resident to be fitted for new bottom dentures. Response from dental office to BSW on 10/08/2024 at 11:11 AM indicated resident was put on the schedule for 10/21/2024. Record review of dental progress note on 10/21/24 revealed Patient was scheduled to be treated today but was not treated. Reason: Patient was Not Due for treatment: patient doesn't have lower, I have tracking Number from ups that shows date, time and place it was left. nobody that I have spoken with seems to know, will include copy of tracking # in the fax. During observation and interview on 10/28/2024 at 12:11 PM, Resident #15 was sitting up in wheelchair with food tray on table. Food appeared untouched. Resident stated her dentures were broken and she wanted them repaired. Not having dentures make it uncomfortable to chew food. Resident also stated she is unaware of any process to find or replace her dentures at this time. Denied any communication from staff related to this issue. During interview on 10/29/2024 at 4:24 PM, with ADM stated that lost items was to go through the grievance process and if a resident stated that a package was delivered, and they did not receive it then a tracking number is needed to follow up to see when it was delivered, and cameras would be reviewed. The ADM also stated the social worker was supposed to find out what happened to the missing dentures, but stated he told the social worker if her dentures could not be found to order new ones for the resident. During interview on 10/30/2024 at 2:08 PM, the DON stated her expectation of staff for broken dentures are to notify her or the social worker to follow up. Stated having broken or missing dentures could put a resident a risk because they have no proper way to chew which could cause choking. The DON also stated not having bottom dentures could negatively affect a resident's dignity. During interview on 10/30/2024 at 3:01 PM, the BSW stated missing items were to go through the grievance process and she oversees that process. She stated the forms are outside of her door and she or any other staff can assist a resident in filling out the form as needed. The BSW stated if a missing article is not located then she works with the resident to come up with an appropriate agreement for the missing item. If a resident's dentures were reported broken to her then she schedules a dentist appointment for the resident to be seen as soon as possible. She stated that she contacted the dentist about the missing broken dentures and has gone back and forth in multiple emails since the dentures have not been located. The BSW stated Resident #15 has reported uncomfortable chewing since not having her bottom dentures. The BSW stated she would provide all emails and follow ups with the dental office related to the dentures. During interview on 10/30/2024 at 3:54 PM, the ADM revealed cameras reviewed for missing packages only go back for 30 day and he was unable to look back at when the package was delivered. He also stated if dentures were broken, he would expect for staff to document it in the resident's chart. The ADM stated he just reviewed the policy for dental care and realized he only has 3 days to start working on getting the resident seen by the dentist. Record review of facility Dental Services policy dated 1/1/2024 reflected under heading Policy: It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the facility to repair or replace dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. Under heading Procedure: 1.In the event that a Facility resident experiences loss or damage to his/her dentures, the Facility will: o Gather the necessary facts and information in order to make a determination as to whether the loss/damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. o If so, and absent some extenuating or unusual circumstance, the Facility will not be financially responsible for the repair or replacement. o If not, and absent some extenuating or unusual circumstance, the Facility will be financially responsible for the repair or replacement. o If it is determined that the Facility is responsible for the loss of or damage to the dentures, there will be no charge to the resident for the repair or replacement. Repair or replacement will be accomplished in a reasonable manner, with the goal of returning the resident to his/her dentition baseline pre-loss or damage. 2. In the event that a Facility resident requires emergency dental services, for the repair or replacement of dentures or otherwise, the Facility will: o Promptly and, in any event, no later than three (3) business days from the date of loss/damage, refer the resident for dental services. o Assist the resident in making the necessary dental appointments, when necessary or requested. o Arrange for transportation to and from the dental services appointment/location, using the lowest cost or no cost option to minimize the financial burden on the resident. 3. If a referral for dental services does not occur within three (3) business days from the date of the loss/damage, the Facility will: o Document what actions were taken to ensure the resident could eat, drink and communicate (if applicable) adequately while awaiting dental services. o Document the nature of the extenuating circumstances which led to the delay.

Based on interviews and record review, it was determined that the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 (Resident #1) of 10 Residents reviewed for resident rights. The facility did not allow Resident #1 to visit with a family member. This failure could place residents at risk of isolation, decreased emotional wellbeing, and diminished quality of life. Findings included: 1. Review of Resident #1's face sheet dated 09/25/2024 reflected that Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of alcoholic polyneuropathy (a neurological disorder in which peripheral nerves throughout the body malfunction simultaneously), Wernicke's encephalopathy (a type of brain injury), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), alcohol dependence (being unable to stop drinking without experiencing symptoms of withdrawal), in remission, and other psychoactive substance abuse (refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs). Review of Resident #1's quarterly MDS dated [DATE] reflected the resident had a BIMs score of 15 which indicated no cognitive impairment. Review of Resident #1's care plan revised on 02/05/2024 reflected that resident had verbally abusive behaviors towards staff related to substance use disorder. Approach for this care plan included assess resident's coping skills and support system. Resident #1 was at risk for unexpected weight loss or gain related to new admission, malnutrition, diabetes, depression, and other medical conditions. Interventions included encourage snacks between meals, honor resident rights to make personal dietary choices, monitor and report to doctor as needed for any symptoms of decreased appetite or unexpected weight loss, and monthly weights if stable. Care plan did not include any information regarding visitation limitations or concerns from the facility or Resident #1. Review of Resident #1's progress notes dated 07/26/2024 through 09/26/2024 did not include any information regarding visitation limitations or concerns from the facility or Resident #1. Review of Resident #1's progress notes dated 07/26/2024 through 09/26/2024 reflected no conversations with ADM regarding visitors/visitation. Review of Resident #1's psychological services progress note dated 09/04/2024 completed by LCSW, revealed Resident #1 reported feeling depressed because he had not seen his family member in several days and was worried because the family member was homeless. Review of Resident #1's psychiatric initial assessment dated [DATE] completed by PMHNP, revealed Resident #1 endorsed depression, sadness, loss of interest, fatigue, and guilt because his family member was banned from the facility, and he did not know why. Review of Resident #1's electronic medical record did not include any information regarding visitation limitations or concerns from the facility or other residents regarding Resident #1's family member. Review of Resident #1's weight records showed stable weight with no weight loss. During an interview on 09/24/2024 at 1:20 PM, the Ombudsman stated Resident #1 was upset because his family member could not visit him. Resident #1 stated that the ADM told him they had on video that the family member brought Resident #1 drugs and alcohol. Resident #1 denied this and had asked to see the video, but that request was denied. The Ombudsman stated that she talked to the ADM on 09/06/2024, who stated that Resident #1's family member had been banned from the facility because he was bringing drugs and alcohol into the facility. The ADM further stated that the family member was homeless, and Resident #1 had allowed family member to sleep in his bed, which was not allowed. The ADM told the Ombudsman that he called the police, but the family member left, and the police did not respond and there was not a no trespass order. The Ombudsman asked the ADM for proof or documentation of disruptive behaviors or suspected drug, and none was provided. The Ombudsman stated the ADM refused to allow supervised visitation between Resident #1 and the family member. The Ombudsman stated the ADM told her Resident #1 could transfer to another facility if he wanted to visit with his family member; otherwise, the ADM would start the discharge process because Resident #1 was not following the facility rules. During an interview on 09/25/2024 at 10:05 AM, LVN A stated family members can visit at any time. LVN A stated he observed Resident #1 at the nursing station complaining about his family member not being allowed to visit. LVN A had not seen Resident #1's family member in a few weeks and did not know why. LVN A had never seen Resident #1's family member bring alcohol or drugs into the facility, be disruptive, or aggressive. LVN A stated Resident #1 would allow the family member to sleep in resident's bed during the daytime when Resident #1 was not using the bed. LVN A stated the facility had a lot of social activities and family members came often to visit and engage in these activities. LVN A stated since Resident #1's family member had not been allowed to visit, Resident #1 appeared quieter and more withdrawn. LVN A stated he was not aware Resident #1's family member had been banned from the facility. During an interview on 09/25/2024 at 10:59 AM, Resident #1 stated the facility limited his visitors and that he was unable to visit with his family. Resident #1 stated he missed his family member and would like to see him. Resident #1 stated the ADM banned his family member from the facility because he had a video of the family member giving the resident alcohol. Resident #1 stated this was not true and he asked the ADM to view the video and his request was denied. Resident #1 stated he could get his own alcohol. He denied his family member being disruptive or causing any problems. Resident #1 stated he allowed his family member to sleep in his bed, during the daytime, never at night. Resident #1 stated the ADM never offered him supervised visitation with his family member or provided him anything in writing about the family member being banned. Resident #1 stated not allowing visits from his family member went against the facility's mission statement and against his resident rights. Resident #1 stated since his family member had been banned from the facility, he had lost his appetite, and was depressed as hell. Resident #1 stated since the family member was banned, he could not visit Resident #2 either. During an interview on 09/25/2024 at 12:00 PM, LVN B stated she was Resident #1's nurse. LVN B recalled an incident with Resident #1's family member about two months ago when Resident #1's family member yelled at her, Do you have a problem with me? You have a problem with me!. LVN B reported this to the ADM and the ADM stated he would talk to the resident and family member about this. LVN B had never observed any disruptive behaviors from Resident #1's family member prior to this and never had a problem with family visiting Resident #1. LVN B stated this was an isolated incident. LVN B stated she was never told Resident #1's family member was banned from the facility, and she does not know what the ADM did to address the situation. During an interview on 09/25/2024 at 12:15 PM, the OT stated that she had seen Resident #1's family member visit Resident #1, but not recently. The OT stated that she heard Resident #1's family member was not supposed to visit, but she did not know why. The OT had not observed any disruptive behaviors from Resident #1's family member. The OT stated that residents could have family member visit, but there might be restrictions on visiting hours. During an interview on 09/25/2024 at 12:20 PM, CNA B stated he found alcohol in Resident #1's backpack in his room and thought it might have been brought into the facility by Resident #1's family member. CNA B stated Resident #1's family member was always mad and yelled at staff, but he could not give specific dates of incidents or names of staff involved. He stated Resident #1's family member would sleep in Resident #1's bed and ate the food at the facility. CNA B stated he had not seen Resident #1's family member recently. During a telephone interview on 09/27/2024 at 8:35 AM Resident #1's family member A stated her family was mourning that family member B was not allowed to visit Resident #1 and Resident #2. She believed both Resident #1 and Resident #2 benefited from visits from family member B. Family member A stated she had never observed family member B be disruptive or disrespectful. She does not believe family member B would bring in alcohol or drugs into the facility as that was not the kind of person he was. Family member A stated she talked to both Resident #1 and family member B and they both denied family member B brought alcohol or drugs into the facility or was being disruptive and she believed them. 2. Review of Resident #2's face sheet dated 09/25/2024 revealed a [AGE] year-old female admitted on [DATE] with primary diagnoses of Huntington's Disease (an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die), Alcoholic cirrhosis (liver damage caused by chronic alcohol use) of the liver with ascites (buildup of fluid in the stomach), dysarthria (a speech disorder caused by problems controlling the muscles used for speech) and anarthria (the most severe form of dysarthria where the individual in unable to speak at all). Special instructions listed the resident enjoys spending time with her family. Review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 BIMS score selection was not completed. Resident was completely dependent for all functional abilities. Resident's speech was unclear and her ability to make herself understood and understand others was marked as sometimes. The cognitive patterns section had blanks and was not scored. Most items on the MDS were not scored. Review of Resident #2's care plan revised on 06/29/2023 reflected Resident #2 was identified as being at risk for delirium and impaired cognitive function/dementia due to Huntington's disease. Resident #2 was at risk for a communication problem related to hearing deficit, dementia, and aphasia. Under Activity Preferences, it was noted that resident would maintain involvement in cognitive stimulation such as outings with family and interventions included: Resident needed 11 beside/in-room visits and activities if she was unable to attend activities out of her room. Review of Resident #2's progress notes dated 08/26/2024 to 09/26/2024 reflected no conversations or requests regarding visitors/visitation. During an observation on 09/25/2024 at 3:05 PM, Resident #2 was observed lying in bed. Resident #2 was non-verbal but did respond to the surveyor calling her name and reached her hand out to shake the surveyor's hand. During an interview on 09/25/2024 at 12:57 PM, family member C stated Resident #2 was related to family member B. She had seen family member B at the facility when she went to visit Resident #2 and had not observed any disruptive behaviors. Family member C had never heard of facility staff or other residents complaining about Resident #1's family member. Family member C stated family member B primarily visited Resident #1, but also Resident #2. Family member C stated about a month ago, the ADM called her to inform her that Resident #1's family member had been banned from the facility. Resident #1 told her that the ADM had a video of family member B taking Resident #1 to buy alcohol. Family member C stated she had no concerns with family member B visiting Resident #2 and thought it was good for Resident #2 to see familiar family faces. She also had no concerns with the family member B visiting Resident #1. During an interview on 09/25/2024 at 9:46 AM, CNA A stated family members can visit all times of the day and she was not aware of any restrictions of family visiting residents. CNA A had not observed any disruptive family members or heard any complaints from residents about family members visiting. During an interview on 09/25/2024 at 11:37 AM, the SW stated residents could have family members visit any time 24 hours a day. The SW stated a potential negative outcome of a family member not being able to visit a resident was a change to their mental health. The SW stated Resident #1's family member was a regular visitor to Resident #1 until recently. The SW stated Resident #1's family member was suspected of bringing alcohol into the facility and he made LVN B feel uncomfortable and had been banned from the facility. The SW stated she had seen Resident #1's family member visiting and had never observed any disruptive behaviors. The SW described the family member as calm. The SW had observed Resident #1's family member sleeping in Resident #1's bed or on the floor during the daytime, but never at night. The SW stated residents could not have family members sleep overnight, but she was not aware of any policy that would prohibit that during the day. The SW stated Resident #2 was also impacted by Resident #1's family member not visiting, but she had never seen this family member visit Resident #2. There was one occasion when Resident #1 was upset after a visit from his family member and said they argued, and Resident # 1 did not want his family member to visit. The facility had a sign in sheet for the visitors, but it is not used or enforced or regulated. During an interview on 09/25/2024 at 1:15 PM, the DON stated that residents could have family members visit any time with no restrictions. Potential negative outcome of a family member not being able to visit a resident was psychosocial. The DON observed Resident #1's family member yelling at staff and sleeping in Resident #1's bed. The DON stated that based on family member B's presentation of red eyes and slurred speech, she thought he was under the influence of something. The DON stated that the ADM had spoken to both Resident #1 and family member B about these concerns and the facility restricted family member B's visitation for the safety of residents and staff. The DON stated that the ADM provided verbal discussion and that this was not documented anywhere. The DON was not aware of any documentation regarding family member B being banned from the facility. During an interview on 09/25/2024 at 1:35 PM, the ADM stated residents could have visitors 24 hours a day, but they could restrict visits if a visitor was disruptive to protect the safety of residents. Potential negative outcome of a family member not being able to visit was psychosocial harm. Resident #1 was very high functioning and would sign himself out on pass daily and when he would return to the facility, he appeared intoxicated. When Resident #1's family would visit, the resident appeared more intoxicated and would yell at staff. The ADM stated there were residents at the facility that did not want family member B to visit, and he needed to protect their rights. The ADM stated family member B would yell at the nurse or demand services (such as cleaning the room). The ADM talked to Resident #1 about not having his family member bring in substances. The ADM stated family member B was homeless and came into the facility to live there by sleeping on the bed and eating the food during the day when Resident #1 was not in the facility. The ADM educated Resident #1 on visitation rights and that the services were for residents and not his family. These conversations were not documented. The ADM stated family member B brought alcohol into the facility because he heard glass bottles when family member B walked by. The ADM denied having video or other proof that family member B brought in alcohol but suspected he had brought in illegal substances. The ADM stated family member B yelled at him because of this accusation, and he called the police, but family member B left the facility, and the ADM told the police not to respond. The ADM stated they did not have a police report or file number. The ADM stated he had not made any law enforcement referrals. The ADM stated he offered Resident #1 supervised visits with his family, but Resident #1 refused. The ADM stated the facility does not have a policy about family bringing alcohol into the facility nor about family members drinking alcohol while in the facility. Residents can drink alcohol in the facility but need a doctor's order. The ADM stated Resident #1's family member was also a family member of Resident #2. Family member B stated that he would go visit Resident #2 when he was at the facility. The ADM stated Resident #2's family did not want family member B to visit Resident #2. The ADM stated Resident #1 could leave on pass to visit his family member outside of the facility. The ADM stated he banned family member B from the facility and from visiting Resident #1 and Resident #2 because of these behaviors. The ADM stated he had not put any of this in writing or documented it anywhere. The ADM did not know family member B's name. The ADM stated staff had not been trained or given notice that family member B had been banned. The ADM could not recall when family member B was banned or how long that ban would last. The ADM stated that all of this was not documented in Resident #1 or Resident #2's electronic medical record nor anywhere else, because it was a family member and not a resident. During an interview on 09/25/2024 at 2:53 PM, the local Police Department stated they did not have any incident records for Resident #1 or his family member for the last two months. They did not have any records on file. During an interview on 09/25/2024 at 3:00 PM, CMA stated Resident #2's family visits often but had not seen family member B in a while and had never seen any problems with family member B's behavior. Review of facility grievance logs dated 06/03/2024 through 09/23/2024 revealed no complaints about visitation with family members. Review of facility policy titled Resident Rights and Responsibilities, Notice of dated November 2016 and revised in December 2023 reflected, It is the policy of the facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Review of facility policy titled Residents Rights dated 07/13/2017 reflected residents had the right to receive visitors of your choosing at the time of your choosing, subject to your right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Further review reflected residents had the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language you understand. Review of facility policy titled Visitation Rights of Residents dated November 2016 and revised in December 2023, reflected It is the policy of the facility to inform each resident and/or resident representative of the rights to receive visitors based on their preferences and any clinical or safety restrictions or limitations on these rights. The facility will respect the rights of a resident to consent to receive visitors of their choosing at the time of their choosing and the right to deny or withdraw consent for visitation at any time, when applicable, and in a manner that does not impose on the rights of another resident. Visitation will not be restricted, limited, or denied based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Further review reflected the resident had the right of immediate access to immediate family and visitation would be person-centered, consider the psychosocial well-being of the resident, and support their quality of life. Policy included The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences. And Notify resident and/or their representative of the facility policy regarding visitation, to include the resident right to consent to, withdraw consent for, or deny visitors and any potential limitation or restrictions for visitation. Further review reflected, Reasonable clinical and safety restrictions include a facility's policies, procedures, or practices that protect the health and security of all residents and staff. These may include, but are not limited to: o Denying access to individuals who are inebriated or disruptive; 1. If the resident exhibits signs or symptoms or triggers of illegal substance use, ask the resident whether they possess or have used an illegal substance. 2. If the facility determines illegal substances have been brought into the facility by a visitor: Make a referral to law enforcement. The facility may need to provide additional monitoring or supervision or resident and/or visitation restrictions.

Based on observation, interview and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation) of needs and preference for 4 of 5 (Resident #1, Resident #2, Resident #3 and Resident #4) who were reviewed for accommodation of needs. The facility failed to ensure on 09/11/2024 the call light was in place for Resident #1, Resident #2, and Resident #3. The facility failed to ensure there was an order to check functioning of Resident #3 and Resident #4's air mattresses. The facility failed to ensure the air mattress order dated 09/02/2024 was plugged in and functioning for Resident #1 on 09/11/2024. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency and at risk for malfunction of their air mattresses. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old woman admitted on [DATE] with diagnoses of cerebral palsy, autistic disorder, congenital malformation of brain. Review of physician orders for Resident #1 revealed an order dated 09/02/2024 that stated low air loss mattress with wings for skin maintenance and positioning and check placement and function. Review of Resident #1 quarterly MDS dated [DATE] revealed that resident was unable to complete the BIMS and indicated that Resident #1 was non-interviewable. Further review of quarterly MDS revealed that Resident #1 was at risk for developing pressure injuries. MDS revealed that Resident had pressure reducing device for bed. Review of Resident #1 care plan dated 11/02/2022 revealed that Resident #1 has contractures and weakness and interventions included to be sure call light is within reach and respond promptly to all requests for assistance. Further of care plan dated 11/10/2022 revealed Resident #1 has communication problem related to intellectual disability and that resident is nonverbal with intervention to ensure/provide a safe environment and have call light within reach. Care plan dated 11/10/2022 revealed that Resident #1 is a risk for falls and intervention included to ensure call light is within reach and have winged air mattress for positioning. Review of care plan dated 11/10/2022 revealed resident has potential for pressure ulcer development and intervention included that Resident #1 required pressure reliving/reducing device on bed (low air loss mattress). Observation on 09/11/2024 at 9:29 AM revealed Resident #1 asleep in bed with call light under fall mat and not within reach. Observation on 09/11/2024 at 11:37 AM revealed Resident #1 laying in bed with call light under fall mat. Further observation revealed Resident #1's air mattress appeared to be deflated. Observation revealed that the pump for the air mattress was not on. Review of Resident #2 face sheet revealed a [AGE] year-old woman admitted on [DATE] with diagnoses of unspecified dementia, contracture of right hand, muscle weakness and anxiety disorder. Review of Resident #2 quarterly MDS dated [DATE] revealed no BIMS score. MDS revealed that Resident #2 has impairment on one side for her upper and lower extremities. Review of Resident #2 care plan dated 01/24/2023 revealed resident has alteration in musculoskeletal status related to contractures to right wrist and right hand with intervention to be sure call light is within reach and respond promptly to all requests for assistance. Review of care plan dated 01/24/2023 revealed Resident #2 has communication problem with intervention to ensure/provide safe environment with call light in reach. Review of care plan dated 12/13/2022 revealed Resident #2 was a risk for falls and intervention included to be sure the call light is within reach. Observation 09/11/2024 at 9:29 AM revealed Resident #2 asleep in bed with call light cord wrapped around bed from on right side with call button laying on the floor and not within reach. Observation on 09/11/2024 at 11:37 AM revealed Resident #2 awake in bed and call light button remained on floor next to her bed out of reach. Review of Resident #3 face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Parkinsonism, unspecified dementia, unspecified intellectual disabilities and muscle weakness. Review of Resident #3 quarterly MDS date 07/01/2024 revealed BIMS score of 0 which indicated severe cognitive impairment. Review of Resident #3 care plan dated 03/22/2023 revealed Resident #3 was at risk for calls with interventions to be sure the call light was within reach. Further review of care plan dated 03/22/2023 revealed Resident #3 had potential for pressure ulcer development related to impaired mobility with intervention that Resident #3 required pressure relieving device. Review of Resident #3's physician orders dated 03/21/2023 to 09/11/2024 which revealed no order for monitoring function and placement or low air loss mattress. Observation on 09/11/2024 at 9:41 AM revealed Resident #3 was lying in bed on air mattress and the overhead light cord laid on his chest. Further observation revealed Resident #3's soft touch call light cord was wrapped around the bed rail and the call light button hung down. During an interview on 09/11/2024 at 9:42 AM, Resident #3 stated that he was unable to reach his call light. Review of Resident #4's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of spastic quadriplegic cerebral palsy, spinal stenosis, stiff-man syndrome and muscle weakness. Review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. Review of Resident #4 physician orders dated 11/02/2022 to 09/11/2024 which revealed no order for monitoring function and placement or low air loss mattress. Observation of Resident #4 on 09/11/2024 at 9:40 AM revealed Resident laying in bed with air mattress. Settings observed on pump for air mattress revealed they were turned up to if Resident weighed 1000 lbs. During an interview on 09/11/2024 at 9:40 AM Resident #4 stated that his bed deflates every two hours. Observation on 09/11/2024 at 11:30 AM revealed Resident #4's air mattress was still inflated, but observed staff adjusted settings on pump of air mattress. During an interview and observation on 09/11/2024 at 11:54 AM, CNA A stated that Resident #1's bed (air mattress) was not working. CNA A was observed to pick the plug up off the ground and stated that the bed was not plugged in. CNA A plugged the air mattress. CNA A was observed exiting the room and did not check call light placement for Resident #1 or Resident #2 before exiting the room. CNA A stated that Resident #1 and Resident #2's call lights were not within in reach and stated that residents should have their call light within reach. He stated that when doing rounds or assisting residents, staff should check that air mattresses are plugged in and that call lights are within reach. During an interview on 09/11/2024 at 11:57 AM, LVN B stated that residents who had a fall risk should have their bed in lower position and call lights in place. LVN B stated that staff should have checked that the call light was in place and that the air mattress worked. She stated that it was a problem if the air mattress was unplugged. She stated that depending on the health and nutrition status of the resident it could cause a pressure injury. She stated that setting for the air mattress were usually in the order and there should be an order for the air mattress because it is specialized equipment, and it is apart of the plan of care. During an interview on 09/11/2024 at 12:13 PM, CNA C stated that when you assist a resident you check to see if they are okay, wet and safe. She stated that staff should make sure they have their call light where they can reach. CNA C stated that if they have an air mattress staff should make sure its on the right setting and ensure its plugged in. She stated that if it is unplugged you should tell a nurse. During an interview and observation on 09/11/2024 at 12:23 PM, LVN D stated it was trial and error to get the correct settings with air mattresses and that the setting depends on the resident's preferences. She stated that Resident #4 wants his air mattress at a certain setting and prefers it to be firm. She stated there should be an order for the air mattress and usually there are settings on it. She stated that Resident #3 and Resident #4 should have an order for their air mattresses. During the interview, LVN D was observed viewing orders for Resident #3 and Resident #4. LVN D stated that she did not see an order for the air mattresses for Resident #3 or Resident #4. LVN D stated that the setting should match the weight of the residents and if it is too firm it could be uncomfortable, and the pressure could stay in one place. During an interview on 09/11/2024 at 12:24 PM, LVN E stated that staff should look to see that call lights are within reach and supposed to ensure air mattresses are plugged in and working. During an interview on 09/11/2024 at 1:14 PM, LVN F stated that she was also the wound care nurse. She stated that the nurses should have checked the settings of air mattresses daily and the setting depended on what the resident wanted. She stated that nurses should have checked to ensure that air mattresses were plugged in and on the correct setting. She stated that air mattresses should have had an order to ensure that the air mattress is inflated. She stated that this was usually on the MAR so that nurses could check off that they checked the settings. She stated that it was important to have an order for air mattresses to ensure there is a need for it or if the resident had wounds or unable to reposition themselves. LVN F stated that if there was not an order for the air mattress the nurse would not be able to tell if it was functioning. LVN F stated that the potential for harm is that the would be no way to know if the resident had an air mattress in their room to see that it was functioning, and it could be misplaced or harm the resident's skin. During an interview on 09/11/2024 at 2:06 PM, LVN G stated that normally there should have been an order for an air mattress. She stated that there is an order for the resident to have the mattress and an order to check the function. LVN G stated that staff are supposed to check call light placement for residents when they go in and assist. She stated that she has completed in-services with staff on placement and it should have been within reach of residents. She stated that if it is not within reach the resident would be unable to ask for assistance. During an interview on 09/11/2024 at 2:20 PM, the DON stated that she expected that staff ensure residents are met, they have needed items within reach, that the call light was in reach and that devices are functioning. She stated that residents should have an order for an air mattress to ensure function and placement each shift. During an interview on 09/11/2024 at 2:37 PM, the ADM stated that he expects that residents are being care for properly. ADM stated that he expected call lights to be within reach of residents and that specialized equipment and adaptive equipment be functioning. He stated that he did expect air mattresses to be plugged in and that the residents should have had an order to check the functioning of the mattress. The ADM stated that there was not a facility policy regarding air mattresses. Review of in-service dated 06/04/2024 was completed regarding call light placement and that call lights should be within reach for all residents. Review of facility in-service dated 07/11/2024 with subject on call lights stated call lights should be placed in reach at all times. Review of facility policy dated 05/2007 titled Policy/Procedure - Nursing Clinical with subject of Call Light/Bell revealed It is the policy of this facility to provide a resident a means of communication with nursing staff. Further review revealed to leave the resident comfortable and place the call light device within resident's reach before leaving the room.

Based on interview and record review, the facility failed to ensure the residents had the right to neglect for one (Resident #1) out of three residents reviewed for neglect, in that: The facility failed to pick up Resident #1 from his chemo treatment until three plus hours after his treatment had ended. Resident #1 had to wait outside while the facility was not answering his phone calls. He experienced increased frustration, humiliation, exhaustion, and harm to his psychosocial well-being. He stated he still felt frustrated and neglected. This failure placed residents at risk of experiencing humiliation, dehydration, and a decrease of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure, chronic heart failure, type II diabetes, chronic pain, major depressive disorder, stage II pressure ulcer of sacral region, and COPD (persistent respiratory symptoms like progressive breathlessness and cough). Review of Resident #1's quarterly MDS assessment, dated 07/29/23, reflected a BIMS of 15, indicating he was cognitively intact. Section I (Active Diagnoses) reflected he had a diagnosis of cancer. Section O (Special Treatments, Procedures, and Programs) reflected he was receiving chemotherapy treatments. Review of Resident #1's quarterly care plan, revised 08/02/23, reflected he had chemotherapy related to pancreatic cancer with an intervention of giving medications and treatments as ordered. Review of Resident #1's oncology notes, dated 04/18/23, reflected the following: 1. Pancreatic Cancer - Approximately 3 x 4 cm ill-defined hypo enhancing lesion at the head of the pancreas with associated narrowing of the pancreatic duct and portal vein confluence and sub centimeter adjacent lymph nodes, highly suspicious for malignancy (cancer). Review of Resident #1's oncology notes, dated 05/01/23, reflected the following: My Diagnosis: Primary pancreatic cancer My Stage at Diagnosis: Stage IIB Current Status of Disease: Metastatic (advanced or late-stage) Therapy Goal: Cure Prognosis: guarded Recommended Treatment: Abraxane D1 (on day one), 8 (on day 8), 15 (on day 15) + Gemcitabine D1, 8, 15 Q28D (for every 28-day cycle) Expected Response: shrinkage of tumor During an interview on 09/03/23 at 9:11 AM, Resident #1 stated he arrived at his chemotherapy appointment on 08/31/23 around 8:50 AM - 9:00 AM and his appointment was scheduled for 9:30 AM. He stated the facility did not send an aide to go with him as they normally did for the past couple of months. He stated he thought the van driver was going to stay with him at the appointment, but she left and never came back. He stated his treatment was completed around 3:00 PM, and he went to the parking garage to wait to be picked up. He stated he repeatedly called the facility without getting any answer. He stated he was extremely hot, sweaty , exhausted, and increasingly frustrated that he could not get ahold of anyone. He stated around 4:30 PM, the receptionist at the facility answered but she did not know what was going on with his transportation. He stated he finally got ahold of LVN A at the nurse's station, and she too had no idea what was going on with his transportation. He stated the staff at the Oncology clinic noticed him still waiting outside around 5:20 PM and brought him inside because they felt sorry for him. He stated he finally got ahold of the van driver on her cell phone around 6:00 PM. He stated she sounded very annoyed because she had to go back to the facility to get the van and then to the clinic to pick him up. He stated he went back outside once the clinic closed at 6:00 PM. He stated he was finally picked up by the van driver around 6:30 PM and brought back to the facility. He stated the whole situation made him extremely pissed off, embarrassed, and frustrated when he could not get ahold of anyone and no one knew what was going on. He stated the situation truly felt like it caused him mental anguish . He stated he did not suffer any physical ailments, such as dehydration, from the incident. Tearfully, he stated he still felt frusterated and upset over that sitation and was fearful the neglect he endured would happen again in the future. During an interview on 09/03/23 at 9:50 AM, the ADM stated she had not been informed of anything that occurred from Resident #1's last chemotherapy appointment on 08/31/23. She stated it would depend on the resident if they sent a staff member to accompany the resident to an appointment. She stated if a resident was cognitively impaired and not able to handle the process, a staff member would be sent with to assist. She stated, to her knowledge, no one accompanied Resident #1 to his appointments because he had a BIMS of 15. During an interview on 09/03/23 at 10:28 AM, the VD stated she stayed with residents at their appointments if she was able. She stated if their appointment was over two hours and she had to get another resident to their appointment, she would not be able to stay. She stated Resident #1 had been receiving chemotherapy one time a week for a few months now. She stated Resident #1's chemotherapy treatments usually last 2.5 - 3 hours. She stated they normally utilized a contracted transportation agency to transport him to his appointments and an aide always accompanied him. She stated she transported Resident #1 to his appointment on 08/31/23 because he notified her last minute of his appointment, and she did not have time to set up transportation with their contracted agency. She stated on 08/31/23 she had multiple resident appointments, so she reached out to the ADM and asked if they could get Resident #1 a (rideshare) to pick him up from his appointment. She stated she assumed it was taken care of until she received a call from Resident #1. She stated she picked him up from his appointment around 6:30 PM on 08/31/23. During an interview on 09/03/23 at 11:25 AM, the ADM stated the VD texted him on 08/31/23 at 2:36 PM asking if a (rideshare) could be arranged for Resident #1's pick-up. He stated he responded to her at 3:05 PM stating that he was out at a meeting and could not arrange one, but someone from the facility could arrange one as long as they met the (rideshare) at the clinic to ensure Resident #1 was picked up safely. He stated he did not have any further communication with the VD. He stated it was unacceptable that Resident #1 had to wait at the clinic for that long before getting picked up. A telephone call was made to LVN A on 09/03/23 at 11:39 AM. LVN A was Resident #1's nurse on 08/30/23 from 6:00 AM to 6:00 PM. A returned telephone call was not received prior to exiting the facility. A telephone call was made to LVN B on 09/03/23 at 11:42 AM. LVN B was Resident #1's nurse from 6:00 PM on 08/30/23 to 6:00 AM on 09/01/23. A returned telephone call was not received prior to exiting the facility. A telephone call was made to the Monday - Friday Receptionist on 09/03/23 at 11:45 AM. A returned telephone call was not received prior to exiting the facility. During an interview on 09/03/23 at 1:40 PM, the DON stated it was extremely important to ensure residents were dropped off and picked up in a timely manner for appointments. Shee stated the VD was ultimately responsible for ensuring that it happened. She stated it was inexcusable that Resident #1 had to wait at the clinic for over three hours after his chemotherapy treatment. She stated it could have caused him to become dehydrated, over-heated, or he could become so weak and exhausted that he could have fallen out of his wheelchair. She stated the only policy they had related to transportation, was a policy on transportation arrangements for dialysis. Telephone calls were made to the SW at the oncology clinic on 09/03/23 at 9:37 AM and 09/05/23 at 2:59 PM. A returned telephone call was not received prior to exiting the facility. Review of the facility's invoices from their contracted transportation agency, from 06/20/23 - 09/03/23, reflected they transported Resident #1 to/from his chemotherapy appointments on the following days: 06/22/23, 06/30/23, 07/07/23, 08/17/23, and 08/24/23. Review of the facility's undated Abuse, Neglect, and Exploitation policy, reflected the following: 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.

Based on interview, observation and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of (Resident # 1) four residents reviewed for falls and accidents. The facility failed to ensure a safe and practical room move for Resident #1. Resident #1 was visually impaired and was moved from her room in which she was acclimated to and into a room on a different hallway. The following day she fell in the threshold of her new room resulting in a wrist fracture and a traumatic subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain). An Immediate Jeopardy (IJ) was identified on 11/30/2022. The IJ began on 11/30/2022 and was removed on 12/16/2022. While the IJ was removed on 12/16/2022, based on review of the facility's actions taken, the facility remained out of compliance at a scope of isolated and a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents who are impaired at risk for accidents, falls, fractures, and a diminished quality of life. Findings included: Review of Resident#'1s face undated sheet revealed a [AGE] year-old female with an original admitted [DATE] and readmitted [DATE]. Her diagnoses included anxiety disorder, acquired absence of eye, repeated falls, dementia, traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, dysphagia following nontraumatic subarachnoid hemorrhage, unspecified fracture of the lower end of right radius, and subsequent encounter for closed fracture with routine healing. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, indicating no cognitive impairment. It further reflected Resident #1 required no assistance with feeding and Resident #1 ambulated via walker. Resident #1's vision was severely impaired, no fall since admissions. Review of Resident #1's care plan initiated 11/19/2022 revealed Resident #1 has ADLs self-care deficit related to fall and resident is blind. It also indicated Resident #1 is at risk for falls related to blindness and history of fall as evidence by fall with significant injury on 11/15/2022. Review of Resident #1's nursing progress notes written by RN B dated 11/14/2022 at 15:51 PM (3:51 PM) reflected: Room changed to 408A. Resident is adjusting with new room and roommate. Gave orientation to each part of the room and surrounding. Resident can't see. Call light is within reach and educated to use. Continue to monitor. Review of Resident #1's nursing progress notes reflected no notes to indicate why Resident #1 was being moved to another room. Review of Resident #1's Fall Risk Evaluation, dated 11/15/22, reflected a score of 10, indicating Resident #1 was a Medium Risk for falling and had experienced no falls within the past three months. Review of Resident #1's nursing progress notes written by RN B dated 11/15/2022 at 14:07 PM (2:07PM) reflected the following: Called by the staff to see the resident lying prone on the floor, unresponsive, head positioned on the 400 hallway and rest of the body in resident's room. Noticed blood on the floor from the head. Dentures were loose. After five minutes resident started moving her body. Called 911 . Review of Resident #1's NP Progress Note completed by the NP, dated 11/15/22, reflected the following: Pt seen today after an unwitnessed fall. Called to scene, EMS was already activated. Pt was face down on floor at the threshold of her rom. Pool of blood noted under head. Pt unresponsive, no movement noted . Large laceration noted to right forehead . Of note, pt was moved from her previous room to a new room on Monday. I had recommended against moving patient as she is blind and does take a while to reacclimate to her surroundings. She has been in her same room since her readmission to [facility] 05/2022. Her roommate was very helpful and also Spanish speaking and helped to advocate for her . Recommended against the transfer . but transfer was still made. Review of Resident #1's hospital discharge paperwork, dated 11/18/22, reflected the following: Right forearm x-ray- fracture of the distal right radial metaphysis (the neck portion of a long bone between the epiphysis and the diaphysis) with moderate dorsal later displacement of the distal fracture fragment. Head CT - there is a small amount of posttraumatic subarachnoid (bleeding) blood over the anterior margin of the superior frontal gyri (frontal lobe) . There is also a small amount of blood within the right lateral ventricle (an interconnecting fluid-filled cavity within the brain. Review of Resident #1's Fall Risk Evaluation, dated 11/19/22, reflected a score of 15, indicating she was a High Risk for falling and had experienced one - two falls within the past three months. Review of Resident #1's progress notes written by the AD dated 11/21/2022 reflected the Following: [Resident #1] returned from the hospital requiring total assist with all her needs. She used to be able to hold conversation but now it seems that she does not understand what is said to her. She responds with answers that have nothing to do with the question asked. When asked if she can hear me, she says yes. When asked to repeat three words back to me, she responds, I am happy. I restated the request a couple of times, and she said the same thing each time. Review of Resident #1's quarterly care plan, initiated 11/30/22, reflected she was at risk for falls related to blindness with an intervention of needing a safe environment. It further reflected she had an ADL self-care performance deficit related to a fall and that she was blind with an intervention of requiring assistance to eat. Further review of the care plan revealed there were no interventions to address safety awareness. During an observation and interview on 11/30/22 at 11:38 AM, Resident #1 was seen laying in her bed with her eyes closed and hands clasped. When Surveyor asked questions, she repeated the question. For example, she was asked how she was doing, and she quietly replied, How are you doing? During an interview on 11/30/22 at 11:08 AM with the DON, she stated she was not sure why Resident #1 had been moved to a different room but did know the layout of the new room was identical to her previous room. She stated she had not worked at the facility long and was not familiar with Resident #1 or knew that she was blind. She stated if she had known this information at the time, there was no way she would have allowed the move to happen. During an interview on 11/30/22 at 11:42 AM with the AD, he stated Resident #1 should have absolutely not have been moved rooms. He stated before the move, she had a BIMS of 14, was walking and talking, and went to activities. The AD stated she loved getting her nails painted weekly and they had a good rapport. He stated since she had returned from the hospital, a conversation could not be held, and she stayed in bed. The AD stated Resident #1 previous roommate looked out for her and would assist Resident #1 to activities by guiding her with her arm. The AD stated he believed moving Resident #1 to a new room had been a very poor choice. During an interview on 11/30/22 at 11:56 AM with the SW, she stated that Resident #1 was moved to a new room, from 107 to 408 because Resident #2 was having problems with her (then) roommate. She stated Resident #1's psychologist believed Resident #1 and Resident #2 would be a great match, so she suggested around 10/26/22 to swap Resident #1 with the (then) roommate of her new roommate. The SW stated she thought it was a great idea and saw no issue with the fact that Resident #1 was blind because the layout of the rooms were identical. The SW stated she was not sure why it took so long to move Resident #1, as the move did not happen until 11/14/22. The SW stated it was talked about in morning meetings often. She stated she did not know if Resident #1 had signed a consent form for the move. She stated she had not thought to get one signed during the weeks prior to the move. Later, on 01/11/2023 at 11:38 AM, the SW stated the room change on 11/14/2022 was done urgently due to Resident #2 having problems with her then roommate and the roommate had to room with another resident. When asked why Resident #2 was not moved instead of Resident #1 who was visually impaired, SW stated, Resident #3 had so much stuff to be moved and had stay longer in room [ROOM NUMBER]. When asked if there were other empty rooms, if so, why was Resident #2 not moved there? The SW stated, there were empty rooms on the 200 hall but the hall was not yet opened. The SW also stated the NP had spoken to her once in the hall and the NP told her it was not a good thing to do. The SW stated she thought the NP did not want Resident #1 to move in the room with Resident #2 due to personality changes, but the NP said she told her it was not safe due to Resident #1 being blind. A telephone interview was attempted with Resident #1's Psychologist on 11/30/22 at 12:22 PM; a message was left requesting a call back. During an interview on 01/11/2023 at 12:16 pm the Psychologist stated she treated Resident #1 and Resident #2. The Psychologist stated both Residents were requesting the same thing in a roommate. The Psychologist stated she introduced both Residents on 10/26/2022 and they both connected like they were old friends. The Psychologist stated she made the recommendation to the SW and the DON. The Psychologist stated the rooms lay out were the same, Resident #1 doesn't get out of bed. When asked if that was a safe room change knowing Resident #1 was visually impaired, the Psychologist stated, It was just a recommendation, I was not involved in the mechanics or the room to be moved to. Resident #1 is in her mid-90s, before the fall she was high functioning. Her blindness did not impair her. During an interview on 11/30/22 at 12:25 PM with Resident #1's NP, NP A, she stated she believed the facility moved Resident #1 because they wanted to get a better room situation for the resident that did not like her current roommate. The NP stated she had heard that Resident #1's Psychologist believed she would be a good match for Resident #2. The NP stated she absolutely did not agree with the room move as Resident #1 was extremely vulnerable and had been comfortable in her environment - moving her was setting her up for failure. The NP stated she could only remember voicing her concerns to the SW. The NP stated before the fall, Resident #1 was more independent and could feed herself, and now she was always in bed and required more assistance. Later on 01/11/2023 at 12:40 p.m., the NP stated, Resident #1 had been in the facility previously and was readmitted to the same room and roommate because the roommate Resident #3 would advocate for Resident #1. The NP stated she told the SW because she heard the SW talk about the room change in passing. The NP stated when the room change did not happen in October of 2022, she thought it was off the table because she had spoken to the SW. The NP stated, I was concerned about physical impairment. She takes a long time to get acclimated to her surroundings. If something is out of place it messes with her. I was not concerned about the personality issues. I think they should have moved someone to her room. She has dementia and blindness. I don't really have a say in the social aspect. I am concerned about the medical aspect; it was not a safe transfer. During a telephone interview on 11/30/22 at 2:45 PM with RN B, she stated she was Resident #1's nurse when she was relocated to room [ROOM NUMBER] on 11/14/22. She stated she acclimated Resident #1 to the new room by showing her (and having her touch) where everything was, such as the bathroom and her nightstand. During an interview on 11/30/22 at 2:51 PM with the DON, she again expressed that Resident #1 should have never been moved to another room. She stated the ADM was out sick and she had attempted to contact him to get more information on Resident #1's room move. She stated the resident that had been unhappy with her roommate should have been the one moved. She stated her expectations were that a consent to be transferred to a new room was signed by either the resident or the resident's RP. She stated Resident #1 did not have any family and there had not been a consent signed by the resident. She stated it was important to ensure all residents, especially the extra vulnerable residents, were well-acclimated to the new room and knew their way around. She stated room moves being conducted without her knowing all of the information (i.e., Resident #1 being blind) could result in resident harm or injury. She stated the facility did not have policies on room moves/transfers or physical environment. During an observation and interview on 01/11/2023 at 2:51 PM, revealed very bright light upon entering room [ROOM NUMBER]. Resident #1 was lying in bed with eyes closed, resident was in a scooped mattress. Resident #1 was nonresponsive to questions at first and later said multiple words that were unrelated to the questions and then Resident #1 was noted struggling to say the next word. She pounded her fist to the half side rail and seemed frustrated. Review of the facility's policy titled Room to Room Transfer with origin date of 11/2016 and revision date of 1/22 reflected: Where feasible, and the consent of the involved residents, the facility will make room to room transfer when requested by the resident or as may become necessary to meet the resident's physical mental, or psycho-social needs. Unless medically necessary or for the safety and well-being of the resident, a resident will be provided with advance notice of a room transfer. Prior to the transfer, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room transfer. Such notice will include the reason (s) why the move is rerecommended. Unless medically necessary or for the safety and well-being of the resident. Resident will receive notice, including the reason for the change, before the resident's room or roommate in the facility is changed. .Inquires concerning room to room transfer should be referred to the Administrator or the Director of Nursing. An Immediate Jeopardy was identified on 11/30/2022 due to the above failures. Although the IJ began on 11/30/2022, after administrative review, the DON and the Clinical Resource Nurse were notified of the Immediate Jeopardy and the IJ template was provided on 1/11/2023. The DON and the Clinical Resource Nurse expressed understanding of the Immediate Jeopardy. After administrative review, the IJ was determined to be lifted on 12/16/2023 based on the following actions: -- Resident #1 was transferred to the hospital on 11/15/22 by Nurse Practitioner. -- Resident #1 placed on palliative care with the Nurse Practitioner on 11/21/22. -- Nurse Practitioner assessed Resident #1 on 11/30/22 and added pain medication to the treatment regimen. -- New staff and agency staff are trained as part of new hire orientation and onboarding prior to accepting assignments for patient care. -- Licensed nurse completed a chart review and room inspection of residents with impaired vision on 12/15/223 and updated interventions if needed, no other residents were found to be affected by the alleged deficient practice. -- Direct care staff re-educated on fall prevention by Operations Manager on 11/18/22. -- Direct care staff re-education on Abuse and Neglect by the Operations Manager on 11/18/22. -- DON/Designee will review falls and room changes with the Interdisciplinary team during the morning meeting to ensure appropriate intervention for 3 months beginning on 12/19/2022. -- Operations Manager will review audits weekly during morning meeting with interdisciplinary Team for 3 months beginning 12/19/2022. -- Operations Manager will review audit findings in QAPI monthly for 3 months and modify plan if indicated. First QAPI meeting following state's exit took place on 12/21/2022, where findings were reviewed. Monitoring of the actions the facility had taken was completed from 01/12/2023 through 01/13/2023. Review of Facility's QAPI committee report dated 01/11/2023 revealed the following was discussed: Plan of Removal related to Immediate Jeopardy for 689. Visually Impaired resident #1 had a fall on 11/15/2022 after being moved from her original room on 11/14/2022 and was sent to local hospital where she was diagnoses with subarachnoid hematoma and a right radius/ulna fracture. Interview with the SW, AD, ADON, MDS nurse, RN B and 2 other LVNs all reflected they were trained and in serviced on room to room changed. They all were able to state who to contact when there was a need for from change in case of emergency. In an interview on 01/13/2023 at 10:26 am, the DON stated the facility put in place the IDT process when there needs to be a room move. The DON stated we have IDT form that everyone checks off on. The DON stated we put in place that if we must move a severely impaired resident, they are acclimated to the new room for 48 hours and make sure there are no hazards. The DON stated, we have in-serviced staff, we started with the IDT team, nurses, medication aides. Review of the facility's Inservice dated 01/12/2023 reflected the following: --Review Social Worker understanding of IDT process for room transfer. --Review understanding for scope and severity of IJ. ---Reviewed understanding of the facility intervention to ----immediacy. ---Reviewed understanding of communication deficit that leads to systemic failure. The Social worker, Operation Manager and Clinical Resource RN were all signatories to this document. Review of the facility's in-service titled Room Moves/Transfer dated 01/11/2023, 1/12/2023 and 1/13/2023 reflected the following. Who makes up the IDT? IDT is a minimum of the Operations Manager, DON, and the Medical Director or designee. Other team members may include the social worker, the MDS nurse, the ADONs, the Activities Director. All potential room moves must be discussed and agreed upon, prior to any resident moving to another room. Any afterhours room moves will be placed on a short-term hold until the IDT can meet, review, and discussed the potential room move. Residents that have been moved will be oriented to the new room and 1:1 monitoring will occur x48 hours, by a member of the nursing department, for any severely visually impaired resident that is moved to a different room. See policy and procedure for room transfers. On 01/12/20/2023 at 7:54 p.m. the Operations Manager and DON were notified that the IJ was removed on 12/16/2022 based on the actions completed by the facility. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy with a scope of isolated due to the facility need to evaluate the effectiveness of the Plan of Removal. 42949

Based on observation, interview and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 13 of 13 (LVN A, CNA B, CNA C, CNA L, CNA M, CNA N, Cook R, HK V, ADM, Receptionist, and three unidentified staff) and 11 of 15 Residents (Resident #1, #2, #3, #4, #5, #7, #8, #16, #17, #18, and #19) reviewed for infection control: The facility failed to appropriately screen visitors/staff per HHSC guidelines, prior to entering the building. LVN A and CNA B did not screen for symptoms by not having a screener taker their temperature, did not answer questions regarding symptoms of COVID-19, and did not document any information on the Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log when entering the building on 2/13/22 for their shift. CNA C did not answer questions regarding symptoms of COVID-19 on Symptom Monitoring Log when entering the building on 2/13/22 for her shift. Cook R and HK V failed to screen for symptoms by not having a screener taker her temperature, did not answer questions regarding symptoms of COVID-19, and did not document any information on the Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log when entering the building on 2/14/22 for her shift2/14/22. Investigator #1 and Investigator #2 were not screened for symptoms of COVID-19 upon entry to the facility on [DATE] due to no staff being present at the facility entrance to take their temperature or to ask questions regarding symptoms of COVID-19. The Receptionist filled in the questions regarding symptoms of COVID-19 with an N (No) for staff who drew a line through the answer areas on the monitoring log and falsely added temperatures for staff/visitors who did not have a documented temperature. The facility failed to ensure staff wore N95 masks per HHSC guidance CNA B and CNA C did not don a mask while working the night shift on 2/13/22. LVN A, CNA L, HK V, Cook R, and CNA M wore surgical masks in the facility. CNA B CNA C were not wearing a mask initially, however, they donned a surgical mask after HHSC Investigators entered the facility. The facility failed to ensure staff, who showed signs and symptoms of COVID-19, were assessed, tested , or prevented from working with non-positive COVID-19 residents. CNA B and CNA C provided care to residents while exhibiting symptoms of COVID-19. The facility failed to ensure staff donned proper PPE when providing care in the COVID unit. CNA N failed to don a gown and goggles/shield when providing care to a resident who tested positive for COVID-19. LVA A and CNA B walked into resident's rooms without downing full PPE in the COVID unit. The facility failed to monitor Resident #1, #2, #3, #4, #5, #7, and #8 for signs and symptoms of COVID daily including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. Six of seven residents (Resident #1, #2, #4, #5, #7, and #8) tested positive after not being monitored. The facility failed to conduct a root cause analysis for the COVID-19 outbreak beginning on 12/28/21. These failures placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , and/or death. An Immediate Jeopardy (IJ) was identified on 02/14/22 at 5:42 pm. While the IJ was removed on 02/18/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of widespread because the facility was still monitoring the effectiveness of their corrective systems. Findings Included: Review of the facility's COVID tracking report on 2/14/22 reflected the facility currently had 23 residents' who tested positive for COVID-19 and were on the COVID unit. Observations on 2/14/22 from 3:15 a.m. to 4:30 a.m. were made from the end of the 300 hall (COVID-19 hot unit) windows, looking from the outside in. Three staff, LVA A, CNA B, and CNA C, were observed walking Halls 100, 200, and 300 and entering resident rooms. CNA B and CNA C were not wearing masks and LVN A wore a surgical mask (100 and 200 halls are cold halls. Resident who are negative for COVID-19). An observation on 2/14/22 at 3:45 a.m. revealed CNA B walked into the COVID unit and did not don appropriate PPE. CNA B wore a surgical mask but did not don a gown, face shield, or goggles. CNA B walked into a resident's room for approximately three minutes and left the room. The observation was made from outside of the COIVD unit window from the parking lot. An observation on 2/14/22 at 4:30 a.m. revealed LVN A walked into the COVID unit and did not don appropriate PPE. LVN A wore a surgical mask but did not don a gown, face shield, or goggles. LVN A walked into a resident's room for approximately five minutes and left the room. The observation was made from outside of the COVID unit window in the parking lot. An observation on 2/14/22 at 4:45 a.m. revealed no staff available to screen HHSC Investigators #1 and #2. The Investigators were allowed into the facility by LVN A. LVN A appeared to push a button from the nurses' station which unlocked the front door of the facility. The investigators waited for approximately 5 minutes at the facility screening station before LVN A waved Investigators #1 and #2 to the nurses' station. Review of The Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log dated 2/13/22 was conducted on 2/14/22 at 4:55 a.m. The monitoring log reflected LVA A and CNA B did not appropriately screen per for COVID-19 symptoms prior to their shift on 2/13/22. LVN A and CNA B were not screened for symptoms of COVID-19 by a trained screener. LVN A and CNA B did not have their temperature taken, answer questions regarding symptoms of COVID-19, and did not document and information on the screening log. CNA C signed the monitoring log and documented a temperature but did not answer all the questions regarding symptoms of COVID-19. The last documented signature was CNA C at 9:51 pm. An observation on 2/14/22 at 5:00 a.m. revealed CNA C had a runny nose. She kept rubbing her nose and was not wearing a mask. After speaking to HHSC Investigators #1 and #2, CNA C donned a surgical mask. In an interview on 2/14/22 at 5:01 a.m. CNA C stated She checked her own temperature when she walked into the facility for her 10 p.m. to 6 a.m. shift on 2/13/22. She stated there is not always someone at the front door to conduct the screening. She stated when staff screen themselves the nurse follows up and verifies by asking if staff screened or not. She stated she and CNA B split the COVID-19- hall during her shift. She stated she is not the only staff to screen themselves. She stated she was not wearing a mask because it was hard to breathe. She also stated she had congestion, a runny nose, and a sore through. When asked if those were symptoms of COVID-19 that were listed on the monitoring log, she stated yes but she didn't think she needed to be tested . She stated she did not think it was COVID but was not sure. She stated if she has symptoms of COVID-19 she should have notified the nurse of those symptoms. She stated the facility's protocol requires staff to test for COVID-19 if they have symptoms. CNA C stated she did not have a mask on because she kept blowing her nose and her nose was dripping. She stated she screened herself prior to her shift. She stated she did not answer the questions regarding symptoms of COVID-19; however, she did not have those symptoms when she began her shift at 10:00 p.m. She stated she should probably have the nurse test her. She stated she was not assessed by the nurse and was not tested for COVID-19 during her shift. An observation on 2/14/22 at 5:05 a.m. revealed CNA B was without a mask at the nurses' station for approximately 10 minutes before donning a surgical mask. Prior to donning the surgical mask, CNA B pinched her nose to stop a sneeze and then got a Kleenex without performing had hygiene. CNA B touched the nurses station counter with her hands. An observation on 2/14/22 at 5:06 a.m. revealed Cook R entered the facility through the front entrance of the building and screened herself for symptoms of COVID-19. Cook R was not wearing an N95 mask. Cook R did not take her own temperature. In an interview on 2/14/22 at 5:06 a.m. Cook R stated she screens herself for symptoms of COVID-19 often because there is no screener present when she arrives for her morning shift. She stated she never takes her temperature, but she does answer the questions regarding symptoms on the monitoring log. She stated she recently had COVID-19 and felt she contracted the virus from the facility. She stated if she felt sick you would not come to work but could not voice any other procedures regarding COVID-19 screening. In an interview on 2/14/22 at 5:10 a.m., LVN A stated the night shift staff screen themselves. She stated when staff screen themselves a nurse should follow up at some point to ensure staff do not have symptoms. She stated she screened herself prior to her 10:00 p.m. to 6:00 p.m. shift on 2/13/22 but did not document her screening on the monitoring log. She stated she just forgot to document. She stated she took her own temperature but did not answer the questions regarding symptoms of COVID-19. She stated she was aware she should be screened for symptoms of COVID-19 by another staff, prior to entering the facility, however, if they are not present staff screen themselves. She stated she was aware CNA B and CNA C had symptoms, but she believed it was just allergies. She stated she believed the CNAs were screened by someone therefore she felt there were no concerns. She stated CNA B and CNA C worked the 100, 200, and 400 halls (cold halls) in addition to the 300 hall (warm/hot hall). She stated the aides check residents every two hours. She stated the aides probably should have been tested for COVID-19 and should not have worked with residents if they had symptoms of COVID-19. She stated staff should be screened for symptoms of COVID-19 to prevent the spread of the virus. LVN A stated she worked the COVID Unit as she was the only nurse after 4:00 a.m. on 2/14/22. She stated she did walk into the COVID unit but did not provide care. She stated she walked into a resident's room to check on them. She stated if she would have provided care, she would have donned a gown, shield/google, glove, and an N95 mask. She stated she only wore s surgical mask. She stated she is aware full PPE must be worn in the COVID Unit when you enter a resident's room to prevent the spread of the virus. An observation on 2/14/22 at 5:12 a.m. revealed CNA B went into resident's rooms on the 100 hall (cold hall) She sneezed a few times. She wore a regular surgical mask. CNA B remains in residents' room for 5 minutes. In an interview on 2/14/22 at 5:12 a.m. CNA B stated, she came on duty at 10:00 p.m. and worked all of the halls on her shift, including the hot and warm hall (Covid-19 positive and quarantined residents). She stated she screened herself prior to her shift on 2/13/22. When the investigator informed her there was no documented evidence that she screened for symptoms of COVID-19, CNA B stated she forgot to write on the monitoring log. She stated she checks on residents throughout her shift and helps reposition or provides incontinent care throughout the night. She stated she had just checked the residents for incontinence and to make sure they did not need to be repositioned. When asked about what appeared to be symptoms of COVID-19 she stated she believed she had allergies. She stated LVN A knew about her symptoms and she had not been tested for COVID-19 that day. She stated maybe she should have been tested before working with residents. She stated she provided care to the residents on several halls all evening. She stated she helps reposition resident and does rounds every two hours for to check on residents including incontinent care. She stated she was not assessed by the nurse and was not tested for COVID-19 during her shift. CNA B stated she previously checked on resident #4 in the Covid Unit to see what he wanted. She stated she should have worn a gown, shield or googles, and an N95 mask when she entered the resident's room because they are positive for COVID-19. She denied providing care to the residents. In an interview on 2/14/22 at 5:14 a.m., Central Supply Clerk Y stated when she arrives at the facility in the morning, she is responsible for screening staff prior to their shifts. She stated if she is not present at the front door, the person who allows entry to staff and visitors should screen them for symptoms of COVID-19. Central Supply stated no staff should ever screen themselves for symptoms of COVID-19 because staff may not accurately screen or answer questions. She stated it is important to ensure staff and visitors are screened to prevent the spread of COVID-19. HHSC Investigators informed Central Supply Clerk Y they had not been screened of symptoms of COVID-19. In a follow up interview on 02/14/22 at 10:55 a.m. Central Supply Y stated if a staff shows symptoms of COVID-19 including allergies they should be assessed by a nurse and should be tested for COVID-19. She stated the ADM is responsible for monitoring the screening logs to ensure they are completed accurately. She stated she was trained by a nurse to do screenings. An observation on 2/14/22 at 5:14 a.m. revealed Central Supply Clerk Y screened HHSC Investigators for Symptoms of COVID-19 (Twenty-nine minutes after they were in the facility). An observation and interview on 2/14/22 at 5:15 a.m. revealed CNA C walking in an out of the COVID unit. CNA C stated she was emptying a urinal for a resident on the 200 Hall (cold hall). CNA C stated she had been on duty since 10:00 p.m. and provided care to residents on all of the halls. CNA C continued to wear a surgical mask, not an N95 mask. An observation on 2/14/22 at 5:20 a.m. revealed CNA M wore a surgical mask when entering Resident #13's room. CNA helped the resident reposition. She sanitized her hands as she left the room. The resident was not wearing a mask. In an interview on 2/14/22 at 5:20 a.m. CNA M stated she never screens herself for Covid-19 symptoms but was aware some staff have screened themselves. CNA M stated if staff have symptoms of COVID-19 they are supposed to screen and get tested for COVID-19 prior to entering the facility for their shift. She stated some staff take their mask off often. She stated she wears an N95 mask only when she enters the COVID unit. She stated staff are trained to screen for signs and symptoms of COVID-19 prior to entering the facility. She stated staff should not work with residents if they have symptoms of COVID-19 without being tested or assessed by the nurse. During an observation and interview on 2/14/22 at 5:40 a.m. room [ROOM NUMBER] B (cold hall), CNA C stated she had provided incontinent care for Resident #5 at approximately 4:00 a.m. She further stated Resident #5 was a heavy wetter. Observation of Resident #5 revealed he was in bed and beginning to wake. CNA C asked if she could check his brief and then opened it and it was dry. CNA C was a surgical mask. In an interview on 2/14/22 at 5:50 a.m. LVN A stated they were going to test all staff prior to the end of their shift due to CNA B and CNA C having symptoms of COVID. An observation on 2/14/22 at 5:52 a.m. revealed HK V entered the facility through the back door. HK V was wearing a surgical mask and not wearing a N95 mask. HK V did not screen for symptoms of COVID-19. In an interview on 2/14/22 at 5:52 a.m. HK V stated laundry staff often enter through the back door of the facility. She stated she is aware she should screen appropriately at the front entrance of the building. She stated she was not screened prior to her 6:00 a.m. entrance. An Observation on 2/14/22 from 5:00 a.m. to 6:00 a.m. revealed no staff were tested for COVID-19 prior to leaving the facility at the end of their shift. An observation on 2/14/22 at 6:00 a.m. revealed CNA B ended her shift and proceeded to leave the building, however, she stopped at the front door and documented on the monitoring log. An observation on 2/14/22 at 6:00 a.m. revealed two unidentified staff walked in from the back hall. The staff wore a surgical mask. The staff were not screened prior to entering the facility. They did not go to the front of the building to screen. Further observation revealed CNA L donned a surgical mask when he entered the facility. A follow up review of The Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log dated 2/14/22 at 6:02 am reflected CNA B documented her name on the monitoring log with a date and time of 2/13/22 at 9:52 p.m. CNA B answered N (No) to all the questions regarding symptoms of COVID-19. (Review of this document on 2/14/22 at 4:55 a.m. reflected the last documented signature was CNA C at 9:51 p.m. An observation on 2/14/22 at 7:15 a.m. revealed Cook R was not wearing her mask while preparing breakfast. She was observed preparing food for approximately 15 minutes and never put her mask over her nose or mouth. Further observations revealed an unidentified dietary aide pouring drinks for breakfast also not wearing a mask. In an interview on 2/16/22 at 9:50 a.m. DM stated he was unaware staff were screening themselves for symptoms of COVID-19. He stated all staff are aware they should not screen themselves. He stated he is responsible for ensuring dietary staff wear a N95 mask appropriately. He stated staff the person conducting the screening should ensure staff screen appropriate for COVID-19. He stated staff are in-serviced on proper infection control procedures weekly. In an interview on 2/14/22 at 8:30 a.m. DA O stated all staff should enter the facility through the front entrance and should be screened for symptoms of COVID-19. She stated she was aware staff entered through the back doors and do not screen for COVID-19. She stated at times there is no one available to do the screening and staff have to screen themselves for symptoms of COVID-19. In an interview on 2/14/22 at 8:45 a.m. Resident #16 (on the 200-cold hall) was asked if staff wear masks while on duty and caring for him. He said for the most part, yes. Resident #16 said he was awake around 3:00 a.m. (on 2/14/22) and saw a CNA walking up and down the hall several times without a mask. He said he does not really know the names of the staff but provided a brief description. In an interview on 2/16/22 at 9:21 a.m. CNA N stated some staff screen themselves when they enter because no one is available to screen staff when they enter the facility. In an interview on 2/16/22 at 9:27 a.m. LVN F stated staff know better than to screen themselves, but they are in a hurry and do not wait for anyone to screen them for symptoms of COVID-19. She stated some staff enter through the back doors without screening. An observation on 2/14/22 at 1:50 p.m. revealed CNA N was providing care to Resident #4's roommate (on the warm hall). She touched his face and adjusted his linens and grabbed his meal tray. She was wearing an N95 mask. She had goggles that were placed on top of her head. She did not have the googles over her eyes for proper protection. The resident was in a high bed appeared to be eating lunch. CNA N was not wearing a gown. After providing care, she removed her gloves and left the room. CNA Left the warm unit and walked through the building to exit the front door. Her shift ended at 2:00 p.m. In an interview on 2/14/22 at 1:50 p.m. Resident #4 stated CNA N came to his room and helped his roommate. He stated she came in a couple of times and wore a mask but did not wear a gown or face shield. Resident #4 stated CNA N typically wears all her PPE including a gown and face shield. He stated CNA N may have been in a hurry this time. In an interview on 9:21 AM 2/16/22 CNA N stated she is trained to don PPE appropriately when entering a resident's room on the COVID-19 unit. She stated she dons a face shield/google, gown, and gloves prior to entering the resident's rooms. She stated all PPE is disposed of in the hazards box prior to exiting the resident's room. She stated she sanitized after each resident contact. She stated when Investigator #1 observed her without PPE, she had provided care to Resident #4 and doffed her PPE. She said she was leaving the room and felt Resident #4's roommate was getting out of his bed. She stated she repositioned him. She said she did sanitize her hands after. Review of the Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log dated from 1/13/22 - 2/13/22 reflected: o 1/13/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/14/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/15/22 - eight people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/16/22 - six people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/17/22 - six people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/18/22 - nine people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/19/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/21/22 - three people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/22/22 - four people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/23/22 -three people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/24/22 - three people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/25/22 - seven people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/26/22 - seven people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/27/22 - two people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/28/22 - 14 people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/29/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/30/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 1/31/22 - two people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/1/22 - 10 people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/2/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/3/22 - two people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/4/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/5/22 - 12 people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/6/22 - seven people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/7/22 - four people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/8/22 - eight people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/9/22 - four people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/10/22 - two people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/11/22 - seven people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/12/22 - five people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. o 2/13/22 - 10 people did not answer all the questions regarding symptoms of COVID-19 or did not have a temperature documented. Further review reflected from 1/13/22 to 2/13/22 there were 180 incomplete entries in the monitoring log. A follow up review of the Coronavirus Diseases 2019 (COVID-19) Symptom Monitoring Log dated from 1/13/22 - 2/13/22 reflected most of the blanks left in the screening log from 1/13/22 to 2/13/22 were filled in with a N (No) and temperatures were documented on the logs which was previously blank when reviewed at 4:55 a.m. on 2/14/22. The investigator obtained copies of both logs showing blanks were filled in after the Investigators identified the area of concern. In an interview on 2/14/22 at 11:00 a.m. the Receptionist stated she was responsible for screening all staff and visitors from 8:00 a.m. to 5:00 p.m. Monday through Friday. She stated she takes everyone's temperature and ask questions related to symptoms of COVID-19 or possible exposure. She stated no staff should screen themselves. She stated staff have been in serviced to screen appropriately. She stated the ADM and DON monitor the screening log daily. The Receptionist was informed that HHSC investigators made copies of the screening log and identified someone filled in the monitoring log for staff who did not screen appropriately. She stated she filled in the log that morning because she realized there were many empty areas in the questions and temperature. She stated she assumed all staff and visitors were screened, therefore she filled in the questions with an N (No). She stated she also put an N for staff who drew a line through the answer areas on the monitoring log. She stated she did not know if the staff or visitors had symptoms but knew there should be no blank spots on the log. She stated she should not have falsely documented temperatures for visitors or staff, and she should not have answered the questions regarding symptoms for visitors or staff. She stated she panicked when HHSC Investigators asked for copies of the Monitoring log. The Receptionist apologized and stated she realized that screening was the first step to preventing the spread of COVD-19 in the facility. She stated she was not aware of who conducts the screening on the weekends but believed anyone who lets you into the building should screen staff and visitors for COVID-19. In an interview on 2/17/22 at 9:22 a.m. the DON stated the 100, 200, and 400 halls were cold non-positive halls, and the 300 hall was the warm/hot unit. He stated 8 of the 78 residents were unvaccinated. The DON stated the nurses, administrative staff, and the receptionist are responsible for screening all staff and visitors prior to them entering the facility. He stated he has spoken to staff regarding screening procedures in the past few weeks. He stated the nurse is responsible for screening staff and visitors on the night shift. He stated he expected all staff and visitors to answer all questions related to symptoms of COVID-19 and to accurately document their temperature. He stated the screening monitoring logs are monitored by the ADM daily. The DON stated it was not acceptable for staff to screen themselves for symptoms of COVID-19. He stated it was not acceptable for staff to enter the facility through the back doors or to not screen for symptoms of COVID-19 prior to their shift. He stated it was unacceptable for the receptionist to fill in the screening log for staff and falsely document temperatures. He stated he was under the assumption that the night staff screened appropriately. He stated he should have monitored the night staff for screening. He stated the failure to screen for symptoms of COVID-19 could lead to the spread of the virus in the facility. The DON stated if staff develop symptoms during their shift, they should notify the nurse or the DON and get tested for COVID-19. He stated LVN A should have tested the two staff on the night shift, and they should have been wearing an N95 mask. He stated there was no reason for staff to walk around without mask and to provide care without being screened appropriately or wearing an N95 Mask. He stated he was under the assumption that the night staff screened appropriately. He stated the failure to screen for symptoms of COVID-19 could lead to the spread of the virus in the facility. The DON stated it was his expectation that staff on the COVID unit apply full PPE including eye protection, gown, and gloves every time they enter a resident's room. He stated the PPE must be discarded prior to exit and staff must wash or sanitize their hands. In an interview on 02/17/22 at 9:50 a.m. the ADM stated the 300 hall was the warm/hot COVID unit. He stated 8 residents were unvaccinated The ADM stated every person should be screened to make sure no one has any type of symptoms. He stated no one should screen themselves because staff could possibly have COVID-19 and spread the virus. He stated he did not assign anyone to monitor the screening monitoring log. He stated he supposes he was responsible for the monitoring. He stated he did look at the logs but did not notice any blank areas or that staff drew lines through the answer section. He staff should accurately document their temperature and answer all the questions related to symptoms truthfully to prevent the spread of COVID-19. He stated it was unacceptable for the receptionist to fill in the log sheet for staff and to falsely document temperatures. The ADM stated every person should be screened for symptoms of COVID-19 prior to entering the facility to make sure no one has any type of symptoms. He stated no one should screen themselves because staff could possibly have COVID-19 and spread the virus. He stated if staff develop symptoms of COVID-19 they should be assessed by a nurse and tested for COVID-19. He stated screening for COVID-19 is the first step in preventing the spread of the virus. He stated the facility follows HHSC guidelines for screening and testing. the ADM stated he expected all staff to wear full PPE when entering a resident's room in the COVID unit. He stated staff should wear a face shield or goggles, gown, and gloves. He stated the PPE should be doffed prior to leaving the resident's rooms and staff should hand wash or sanitize. He stated this should be repeated for every resident room in the COVID unit. He stated the facility did not have specific polices regarding the COVID-19 Disease. Record review of the facility's Protocols for persons Entering a Nursing Facility, undated, reflected: staff and visitors must be screened prior to entry. Review of the facility's Timeline Outbreak provided by the NFA on 2/16/22 reflected from 1/13/22 to 2/13/22 showed 35 residents tested positive for COVID-19. Review of Resident #1's face sheet reflected [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS dated [DATE] reflected BIMS of 3 - severe cognitive impairment. Review of Resident #1's undated Care plan reflected: Resident #1 at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers. Monitor for signs/symptoms of COVID-10 in[TRUNCATED]

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 92 of 92 residents (Residents #1 - 92) reviewed for infection control. 1. The facility failed to provide resident room notification for residents (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13) under droplet precautions. 2. The facility failed to establish an effective method of communicating COVID-19 positive status to staff. 3. The facility failed to isolate pending symptomatic residents from asymptomatic residents (Resident #17, Resident #19, Resident #22) which resulted in those residents becoming symptomatic and testing positive for COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. Findings included: 1. Review of the Face Sheet for Resident #1 reflected a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of progress note for Resident #1 dated [DATE], reflected that resident tested positive for COVID-19 and moved to resident room [ROOM NUMBER]b under isolation precautions. Review of the significant change MDS for Resident #1 dated [DATE] reflected a BIMS of 05 indicating severe impairment cognition. Further review of the significant change MDS Section I additional active [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #1 with a revision date [DATE] reflected interventions for positive results of COVID-19, which included contact/droplet precautions, observe signs/symptoms of COVID-19 document and report any signs of fever, coughing, sneezing sore throat, respiratory issues, change in vital signs. Resident #1's care plan reflected to keep door closed whenever possible and encourage resident to wear the mask. The care plan reflected to maintain resident in private room or cohort with other COVID-19 positive residents. Review of the Face Sheet for Resident #2 reflected a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview conducted on [DATE] at 1:14 p.m. LVN A stated that there should be see the nurse before entering the room sign on doors for positive and pending residents of COVID-19 test results. Review of the facility census for [DATE] reflected that Resident #1 was positive for COVID-19, Resident #2 and #21 were pending for COVID-19. Observations conducted in the 100 isolation hall on [DATE] at 1:14 p.m. revealed that Resident #1, Resident #21 and Resident #2's resident room door didn't have a see the nurse before entering the room sign. Review of resident roster dated [DATE] reflected Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13 were pending results for COVID-19. Observations conducted on [DATE] between 12:30 p.m. to 4:00 p.m., revealed that there were no signs on the door for resident rooms with COVID-19 pending residents (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13). Observations conducted on [DATE] at 10:00 a.m. revealed that there were no signs on the door for resident rooms with COVID-19 pending residents (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13). Observation conducted on [DATE] at 3:56 p.m. revealed transportation staff entering resident rooms [ROOM NUMBERS] without PPE on those resident rooms were occupied by pending residents. Resident rooms did not have signs on the door. During an interview on [DATE] at 3:57 p.m., transportation staff stated she didn't know which residents were pending. During an interview on [DATE] at 12:19, DON stated he communicates with staff verbally regarding who is pending so staff should be aware of who is pending COVID-19 test results and COVID-19 positive. DON further stated if they do not know who is pending or positive they can spread the infection. During an interview on [DATE] at 12:34 p.m., MA stated that when he started his shift there was no sign on the door for rooms occupied by residents with pending COVID-19 test results. During an interview conducted on [DATE] at 2:44 p.m., ICP stated that residents with COVID-19 pending results should be treated as positive, meaning they should be on droplet precautions, signs should be on doors until the results come back. Review of the facility COVID-19 Emergency plan Prevent the Spread of Respiratory Germs within your facility reflected Provide the right supplies to ensure easy and correct use of PPE, Post signs on the door or wall outside the resident room that clearly describe the type of precaution needed and required PPE. 2. Review of resident roster dated [DATE] reflected highlighted resident names for resident rooms 104, 206, 209, 213, 301, 303, 311, 312 which indicated that pending symptomatic residents occupied these resident rooms. DON highlighted these rooms when surveyor asked which residents were pending symptomatic residents. Review of resident roster dated [DATE] reflected highlighted resident names for resident rooms 104, 206, 209, 213, 301, 303, 311, 312, 404, 409 which indicated that pending symptomatic residents occupied these rooms. DON highlighted these rooms when surveyor asked which residents were pending symptomatic residents. During an interview on [DATE] at 2:47 p.m., CNA A stated that she does not know which residents were pending COVID-19 test results. CNA A stated that positive residents and symptomatic residents were only on the isolation wing. During an interview on [DATE] at 3:03 p.m., CNA B stated positive residents were on the isolation wing, she doesn't work that wing because she has kids. CNA B stated she has no idea which residents were pending COVID-19 test results because they had not informed her of this information. Observation conducted on [DATE] at 3:05 p.m., revealed the AD in resident room [ROOM NUMBER] painting Resident #3's nails. Resident was not wearing a facemask. Further observations revealed no indication that this resident was on droplet-precaution as there were no sign on the door. During an interview on [DATE] at 3:37 p.m., LVN B stated that she was not sure which residents were pending COVID-19 test results. LVN B stated the DON has the list but she wasn't sure who was tested . When surveyor asked if LVN B had a copy of the list, she stated she was new. During an interview on [DATE] at 9:21 p.m., HK stated that she does not know which residents were pending COVID-19 test results. During an interview on [DATE] at 12:22p.m, LA stated that all residents who have positive or pending COVID-19 test result were on the isolation wing. He stated that there were no residents pending COVID-19 test results or symptomatic residents in other halls. During an interview on [DATE] at 12:30 p.m., AD stated that he knew which residents were pending COVID-19 test results because of the red sign by the resident's door but added that he would not be able to identify which of the two residents was pending and which was asymptomatic. During an interview on [DATE] at 12:34 p.m., MA stated that he was sent from a sister facility to assist. He stated that no one informed him of who or where the COVID-19 positive or pending COVID-19 test results residents were. During an interview conducted on [DATE] at 2:44 p.m., ICP stated that the DON communicates with staff regarding who was pending for COVID-19 and the DON communicates with staff when there is a change to the list. She stated that CNAs should know which residents were pending COVID-19 test results and added that it was important for staff to know to take precautions and to prevent the spread of [MEDICAL CONDITION]. Review of the facility COVID-19 Emergency plan interim infection prevention and Control Recommendation for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings Implement mechanism and policies that promote situation awareness for facility staff including infection control, healthcare epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about known or suspected COVID-19 patient and facility plans for response 3. Review of the resident roster provided by the ADM on [DATE] revealed the total positive COVID-19 resident cases in the facility was 3 (Resident #1, Resident#14, Resident #15) and 2 pending (Resident #21 and Resident #24). On [DATE], the ADM sent an e-mail to surveyor stating that the total positive COVID-19 resident cases was 38 with 22 of those positive COVID-19 cases in the facility and five of those having expired. Review of the facility 24 hour Report Resident Test Status dated [DATE] Version 28 reflected 44 positive COVID-19 residents in the facility. 14 COVID-19 positive residents have expired. Observation conducted on [DATE] at 1:30 p.m., revealed Resident #5 who was symptomatic and pending COVID-19 test results sharing a resident room with Resident # 19 who was asymptomatic and not tested for COVID-19. Review of Resident #5's laboratory results with a collection date of [DATE] reflected resident was positive for COVID-19. Review of Resident # 19's Respiratory Therapy notes dated [DATE], reflected Breath sounds clear. Denies SOB. No cough or congestion. Review of Resident #19's nursing notes dated [DATE] reflected, Notified RP regarding positive COVID results. Observation conducted on [DATE] at 2:00 p.m. reflected Resident # 11 who was symptomatic and pending COVID-19 test results sharing a resident room with Resident #17 who was asymptomatic and not tested for COVID-19. Review of progress note for Resident # 11 dated [DATE], reflected that resident had diarrhea. Review of Resident # 11 's laboratory results with a collection date of [DATE], reflected that resident was positive for COVID-19. Review of physician's progress notes for Resident # 17 dated [DATE], reflected that resident had cough, diarrhea and fever and was tested for COVID-19. Review of the face sheet for Resident # 17 dated [DATE] reflected a [DIAGNOSES REDACTED]. Observation conducted on [DATE] at 2:34 p.m., revealed Resident #3 who was symptomatic and pending COVID-19 test results sharing a resident room with Resident # 22 who was asymptomatic and not tested for COVID-19. Review of a progress note for Resident #3 dated [DATE], reflected that resident had diarrhea. Review of progress note for Resident #3 dated [DATE], reflected that resident had elevated temperature of 99.7 F and poor appetite. Review of Cluster line list dated [DATE], reflected that Resident #3's collection date for COVID-19 test was [DATE] with an onset date of [DATE]. Review of NP's progress notes dated [DATE], reflected that Resident #3 tested positive on [DATE] and moved to the COVID-19 unit. Review of NP's progress notes for Resident # 22 dated [DATE], reflected that resident was positive for COVID-19, with an onset date of [DATE] presented symptoms of fever, diarrhea, myalgias. Review of NP's progress notes for Resident # 22 dated [DATE], reflected that resident was negative for COVID-19 on [DATE] and positive on [DATE]. Review of facility roster on [DATE] reflected 92 residents resided in the building. During an interview conducted on [DATE] at 1:08 p.m., when surveyor asked the DON which residents were pending COVID-19 test results and if he could provide a list, DON walked to his office, printed off a resident room roster dated [DATE] and brought back a resident roster with highlighted residents who were pending COVID-19 test results. DON stated residents showing signs and symptoms of the COVID-19 were tested but their roommates were not tested because they did not have COVID-19 symptoms. Review of the facility COVID-19 Emergency plan interim infection prevention and Control Recommendation for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings reflected Isolate symptomatic patients as soon as possible. Set up separate, well-ventilated triage areas, place patient with suspected or confirmed COVID-19 in private rooms with door closed and private bathroom (as possible) ADM was notified on [DATE] at 3:40 PM an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to ADM on [DATE] at 3:45 PM. The facility's first Plan of Removal (POR) was submitted by the ADM on [DATE] at 6:40 p.m. The following POR was accepted by the survey team on [DATE] at 8:11 p.m. Actions Taken/Plan included: DON / designee will reeducate facility staff regarding donning and doffing of PPE, expectations for COVID-19 wing and any resident on isolation/droplet precautions. Currently all residents who are symptomatic have been moved to the isolation wing or are already cohorted with another symptomatic resident in a room designated for droplet precaution isolation- these rooms are supplied with PPE and are noted/posted for staff . All staff working today will be reeducated and all staff oncoming reeducated prior to the start of their shift or via telephone prior to entering facility. The DON / designee will reeducate nursing staff to post See Nurse Prior to Entering Room signage on the doors to alert staff of residents that are on isolation precautions. If and when a resident becomes symptomatic, the resident will be re-assessed and treatment provided and noted in the medical record. Symptomatic resident(s) will be placed on droplet precaution isolation. Current staff and new staff will be made aware of residents on isolation precautions by hanging a sign of isolation needs on the residents door and a listing of Covid-positive and symptomatic/pending residents provided to the charge nurses via the 24 hour nurses report. DON/ designee will track Covid-positive residents and symptomatic/pending residents on the tracking log. Staff will be re-educated to communicate with charge nurse for residents becoming symptomatic/pending or positive Covid test result. on residents and to observe postings on residents' doors. PPE is readily available at resident rooms on isolation precautions. The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Observations from [DATE] through [DATE] revealed compliance with wearing PPE appropriately, positive and pending resident for COVID-19 results were placed on isolation/droplet precautions, the 24hrs report was used for staff to identify pending and positive residents for COVID-19 test results, signs and PPE were available at resident rooms on isolation precautions Review of in-services conducted from [DATE] through ,[DATE] /2020 regarding putting on and removing, wearing the PPE appropriately, positive and pending resident for COVID-19 results were placed on isolation/droplet precautions, the 24hrs report use identify pending and positive residents for COVID-19 test results, signs and PPE were available at resident rooms on isolation precautions. In-services were appropriate and contained all necessary information for staff. Observations conducted on [DATE] reflected that pending residents are under droplet precautions, a sign was placed by the resident's door, PPE carts are available outside of the resident's room. Staff is wearing PPE before entering the residents room. Pending residents for COVID-19 test results and symptomatic were separated from not pending asymptomatic residents. Interview conducted on [DATE] at 4:40, RN stated that pending residents are under droplet precautions. She stated that she had to wear PPE before entering the resident room. She stated that the facility is providing every shift with a list of all the pending and positive resident for COVID-19. She stated that resident pending for COVID and asymptomatic were separated from asymptomatic and negative residents. Interview conducted on [DATE] at 4:48, ICP stated that every morning the list for positive and pending resident of COVID-19 results was updated and provided to the staff. She stated that in-services were provided to the staff about the 24 hrs. report. She stated that pending resident for COVID-19 test results are isolated and under droplet precaution. Observation conducted on [DATE] at 9:23 a.m. reflected ADON provided an in-service about the 24hrs report to the strike team. Interview with the CNA on [DATE] at 9:15am stated that there are copies available of the 24hrs report that reflected what resident is pending and positive. Observations conducted on [DATE] at 7:42 a.m. revealed staff wearing PPE before entering the resident's rooms. Observations conducted on [DATE] at between 3:41p.m. and 3:54 p.m. reflected facility staff removing the used biohazard bags and placing new ones. Observations conducted on [DATE] at between 7:00 a.m. and 7:00 p.m. revealed, the facility had the 24hrs report available with the list of the pending and positive COVID19 residents at the nurse station. During an interview conducted on [DATE] at 4:24 p.m. ADM stated that they are planning to open a second isolation hall in 400 to transfer the new positive residents. During an interview conducted on [DATE] at 6:17 p.m., DON stated that they had dedicated staff for both Isolation halls. Observations conducted on [DATE] between 4:14p.m to 6: 00p.m, revealed that all positive COVID-19 residents were moved to the new 400 isolation hall. During an interview conducted on [DATE] at 9:48a.m, HK stated that she used the 24hrs report sheet that carries with her to identify the resident who are positive and pending. She stated that she had in-services on how to wear PPE and that she needs to wear it when cleaning the resident's room. ADM was notified on [DATE] at 3:35 PM the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm and a scope identified as widespread due to a need for ongoing monitoring.

Based on observations, interview, and record review, the facility failed to ensure the resident's right to be free from neglect for one of eight residents (Resident # 1) reviewed for neglect. The facility failed to ensure Resident #1's post-surgical care was overseen by specialists including the Vascular Surgeon which resulted in the resident being readmitted to the hospital with [REDACTED]. This failure could place residents at risk of delay of appropriate medical treatment and worsening of a resident's condition. Findings included: Review of the Face Sheet for Resident #1 reflected a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of progress note dated 10/28/19 reflected Resident #1 arrived at the facility in stable condition and was admitted for wound care with reopen surgical site to bilateral AKAs. Further review reflected that resident was getting services from Hospice. Review of the readmission MDS for Resident #1 dated 12/12/19 reflected a BI[CONDITION] of 15 indicating intact/borderline cognition. Further review of the readmission MDS Section M skin conditions reflected Resident # 1 had a surgical wound. Readmission MDS section J health conditions reflected Resident #1 was receiving pain medication and reflected that he was frequently experiencing pain. Review of progress note dated 11/6/19 reflected Resident #1 was in his room poking his leg wounds with a pair of scissors. The wound appearance was more severe than the baseline. Review of progress note dated11/10/19 reflected that the facility called hospice informing them of deteriorating condition of the resident's wounds on his stumps. Hospice advised to send the resident to the emergency room . Review of the hospital progress notes dated 11/10/19, reflected Resident #1 was admitted to the hospital for self-mutilating his left [MEDICAL CONDITION] and resident was complaining of itching. Review of the hospital progress notes dated [DATE], reflected that vascular surgeon had a consultation with the resident. Review of Hospice progress notes dated 11/13/19, reflected Resident revocation of hospice to schedule surgery to repair the leg damage. Resident FM was informed, and she anticipates using Hospice services again. Review of the hospital progress note dated [DATE], reflected a bilateral above knee amputation performed by Resident #1's vascular surgeon. Review of the hospital discharge orders dated 12/05/19, reflected Resident #1 had a post-surgical follow up; stump assessment and a post hospitalization follow up with oncologist on 12/26/19 the order stated, MUST HAVE APPT and be transported for continuation of SPRYCELL. Review of progress notes dated 12/5/19, reflected that resident was readmitted to the facility for wound care in stable condition. Review of progress note for Resident #1 dated 12/9/19, reflected the facility scheduled transportation for a follow up appointment with the oncologist and the vascular surgeon on 1[DATE]. Review of progress noted dated [DATE], reflected wound care was provided to the resident with no sign of infections noticed. Review of Palliative plan of care dated [DATE], reflected Resident #1 and NP signed a consent to receive and provide palliative care services. Palliative plan of care read in part, The care and services the resident receives should continue to meet standards of practice for nursing services, dietary services, social services, and any other care or services necessary for the resident to be in a safe comfortable enviroment. Review of progress notes dated 1[DATE], reflected that resident post-operative follow-up with vascular surgeon and outpatient follow up with oncologist were cancelled because he was under palliative care. Review of progress notes dated [DATE], reflected that resident denies refusing or cancelling his appointment with his oncologist and agrees to attend the next appointment if rescheduled. Review of progress note dated [DATE] reflected Resident #1 again stated that he does wish to attend his oncologist appointment and to continue his related medication. Appointment and transportation was schedule for 1/24/2020. Review of progress notes dated 12/29/19, reflected wound care nurse stated that the left above knee amputation (AKA) surgical wound appears with 100% slough & purulent drainage to wound bed with the bone exposed. Surrounding skin also noted with 100% eschar. Review of progress note dated 12/30/19 reflected transportation for the oncology appointment was cancelled. Review of NP progress notes dated 12/30/19, reflected Resident#1's wound appears infected with [DIAGNOSES REDACTED] and purulent discharge form the incision bed. Further review reflected that resident continues to follow under the services of palliative care with comfort as a goal. Review of the Care Plan for Resident #1 dated 12/31/19 reflected interventions for infection, which included administering antibiotic as per MD orders, follow facility policy and procedures for line listing, summarizing and reporting infections, maintain universal precaution when providing resident care. Further review of the resident care plan reflected intervention for open wounds and picking at scabs, which include administering antibiotic medications as ordered by physician. Further review of resident care plan reflected that resident had no care plan for palliative care services. Review of progress note dated 1/6/2020, reflected a wound care note stating resident left AKA wound is deteriorating. 100% slough to wound bed, peri wound area was covered with eschar, and femur was exposed. Review of progress note dated 1/7/2020, reflected that resident's femur continued to be exposed. NP was notified and ordered to send the resident to the hospital for further evaluation and treatment. Further review reflected that at the time of transfer resident showed intermittent confusion and disorientation, Review of emergency progress notes dated 1/7/2020, reflected that resident was admitted for wound infection. The onset was 8 days before admission with symptoms of redness and purulent discharge and the degree at present is severe. The risk factor consists of immunocompromised resident. Further review of the progress notes reflected that physician stated the following Pt has horrific wound on leg, with necrotic femur protruding through necrotic surrounding tissue. He is surprisingly not febrile or [MEDICAL CONDITION] (though very high WBC). There is a social service note from mid-December that says his hem-oncologist visit was canceled because he is palliative care. I'm not sure if that is true or what current treatment plan is for him. I don't see any document to that effect that were brought with him from the facility. Observations conducted on 1/08/20 at 10:29 a.m., revealed resident receiving wound care at the hospital, resident didn't refuse wound care. Observations conducted on 1/08/19 at 10:40 a.m., revealed the admitting physician explaining the surgery to resident #1. Resident didn't refuse and agreed to have the procedure. During an interview conducted on 1/08/19 at 10:30 a.m., resident stated that he was getting wound care at the facility and added that he is in pain. During an interview conducted on 1/08/2020 at 11:00 a.m. the resident's admitting physician stated that if the vascular surgeon team was not on board or informed about the wound infection then he would have a concern. He stated that when the resident was admitted , resident had dead tissue and bone was sticking out, so the resident is going for surgery to clean the wound. During an interview conducted on 1/8/2020 at 3:30 p.m. wound care, RN stated that she should have notified the NP when the wound was getting worse. She stated that on Friday [DATE], the wound was not that bad and added that the bone was a little bit exposed. She stated that Monday 1/6/2020, when she came back to the facility the wound was worse and resident mental state. She stated that she notified the NP and resident was sent to the hospital. During an interview conducted on [DATE] at 11:30 a.m., DON stated that resident's appointment was cancelled because he was under palliative care. He stated that if the resident requested to reschedule his appointment they would reschedule them, but they wouldn't remove him from palliative care. During a telephone interview conducted on 0[DATE]20 at 2:06 p.m., NP stated that resident was admitted under palliative care and that was the reason that all his appointments were cancelled. NP stated that he explained and resident was completely aware when he took the decision to be under palliative care even knowing that his appointment would be cancelled. He stated that he provided a full advance care talk about what palliative care was before resident signed the consent. NP stated that if the resident was requesting to see his physician, an appointment should be scheduled even if the resident was under palliative care. He stated that resident refused to go to his follow-up appointment and that he will add refusals on his progress notes. During an interview conducted on 0[DATE]20 at 4:20 p.m., resident stated that he never refused any type of treatment or to go to his doctor's appointments and asked who was saying that. He stated that he doesn't have a reason to stop seeing his Vascular Surgeon. He stated that he had requested to see the doctor, but he doesn't know why they cancelled his appointments. He stated that he doesn't know what palliative care was and added that he doesn't remember signing a consent since he had to sign a lot of papers and consents for medications. During an interview conducted on 01/09/10 at 4:28 p.m., Resident's FM stated that resident was under hospice services before being admitted to the hospital. She stated that they removed the resident from hospice, so he can have a surgery. She stated that she thought that resident would be under hospice when readmitted to the facility. She stated that she doesn't know what palliative services were and she wasn't aware that the resident was under those services. During an interview conducted on [DATE] at 4:40 p.m., MDS coordinator stated that hospice is a contract service that comes in and provides services to the resident. She stated that palliative care is end of life care we (the facility) provides to the resident. During an interview conducted on 0[DATE]20 at 12:30p.m., DON stated that in order to cancel an appointment, it must be agreed on between the resident and NP. He stated that he can't say if an appointment must be cancelled because a resident was under palliative care. He stated that he interprets the palliative order to the resident with the instructions of Do not send resident to the hospital except for trauma as sending the resident if something catastrophic happens like a [MEDICAL CONDITION]. He stated that the reason they sent Resident #1 to the hospital on [DATE] was because they discussed the wound situation during the morning meeting and requested the NP to get the order. He stated in an emergency, they would send the resident to the hospital right away. He said that this situation wasn't an emergency and that was the reason why they contacted the NP for directives. DON stated that his expectations from the staff was to document when resident refuses to go to his appointment and to explain the risk of this refusal and to document the resident's response after explaining the risks of cancelation. Review of facility policy revised September 2018 and titled reflected the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mealt anguish, or mental illness.

Based on observations, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one of two residents (Resident #1) reviewed quality of care in that: The facility failed to ensure Resident #1's post-surgical care was overseen by specialists including the Vascular Surgeon which resulted in the resident being readmitted to the hospital with [REDACTED]. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, and inadequate to prevent complications such as infection,[MEDICAL CONDITION], and death. Review of the Face Sheet for Resident #1 reflected a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission MDS for Resident #1 dated 12/12/19 reflected a BI[CONDITION] of 15 indicating intact/borderline cognition. Further review of the readmission MDS Section M skin conditions reflected Resident # 1 had a surgical wound. Re- Admission MDS section J health conditions reflected Resident #1 was receiving pain medication and reflected that he was frequently experiencing pain. Review of progress note dated 10/28/19 reflected that resident arrived at the facility in stable condition and was admitted for wound care with reopen surgical site to bilateral AKAs. Further review reflected that resident was getting services from Hospice Austin. Review of progress note dated 11/6/19 reflected that resident was in his room poking his leg wounds with a pair of scissors. The wound appearance was more severe than the baseline. Review of progress note dated11/10/19 reflected that the facility called hospice informing them of deteriorating condition of the resident's wounds on his stumps. Hospice advised to send the resident to the emergency room . Review of the hospital progress notes dated 11/10/19, reflected that resident was admitted to the hospital for self-mutilating his left [MEDICAL CONDITION] and resident was complaining of itching. Review of the hospital progress notes dated [DATE], reflected that vascular surgeon have a consultation with the resident. Review of Hospice progress notes dated 11/13/19, reflected Resident revocation of hospice to schedule surgery to repair the leg damage. Resident FM was informed, and she anticipates using Hospice Austin service again. Review of the hospital progress note dated [DATE], reflected that during resident admission he had a bilateral above knee amputation revision by his vascular surgeon. Review of the hospital discharge orders dated 12/05/19, reflected that resident had a post-surgical follow up; stump assessment and a post hospitalization follow up with oncologist on 12/26/19 the order stated, MUST HAVE APPT and be transported for continuation of SPRYCELL. Review of progress notes dated 12/5/19, reflected that resident was readmitted to the facility for wound care in stable condition. Review of progress note for Resident #1 dated 12/9/19, reflected the facility scheduled transportation for a follow up appointment with the oncologist and the vascular surgeon on 1[DATE]. Review of progress noted dated [DATE], reflected wound care was provided to the resident and no sign of infections were noticed. Review of Palliative plan of care dated [DATE], reflected that resident and NP signed a consent to receive and provide palliative care services. Review of progress notes dated 1[DATE], reflected that resident post-operative follow-up with vascular surgeon and outpatient follow up with oncologist were cancelled because he was under palliative care. Review of progress notes dated [DATE], reflected that resident denies refusing or cancelling his appointment with his oncologist and agrees to attend the next appointment if rescheduled. Review of ordered summary report dated [DATE], reflected an active order starting on [DATE] that stated, Palliative care: Do not hospitalize except for trauma. Review of progress note dated [DATE] reflected Resident #1 again stated that he does wish to attend his oncologist appointment and to continue his related medication. Appointment and transportation was schedule for 1/24/2020. Review of progress notes dated 12/29/19, reflected wound care nurse stated that the left above knew amputation (AKA) surgical wound appears with 100% slough & purulent drainage to wound bed with the bone exposed. Surrounding skin also noted with 100% eschar. Review of progress note dated 12/30/19 reflected transportation for the oncology appointment was cancelled. Review of NP progress notes dated 12/30/19, reflected Resident#1's wound appears infected with [DIAGNOSES REDACTED] and purulent discharge form the incision bed. Further review reflected that resident continues to follow under the services of palliative care with comfort as a goal. Further review of the progress note reflected that Resident #1 was sent to the hospital on [DATE] where an incision and debridement with closure was performed by the resident's vascular surgeon. Review of the Care Plan for Resident #1 dated 12/31/19 reflected interventions for infection, which included administering antibiotic as per MD orders, follow facility policy and procedures for line listing, summarizing and reporting infections, maintain universal precaution when providing resident care. Further review of the resident care plan reflected intervention for open wounds and picking at scabs, which include administering antibiotic medications as ordered by physician. Further review of resident care plan reflected that resident had no care plan for palliative care services. Review of progress note dated 1/6/2020, reflected a wound care note stating resident left AKA wound is deteriorating. 100% slough to wound bed, peri wound area was covered with eschar, and femur was exposed. Review of progress note dated 1/7/2020, reflected that resident's femur continued to be exposed. NP was notified and ordered to send the resident to the hospital for further evaluation and treatment. Further review reflected that at the time of transfer resident showed intermittent confusion and disorientation, Review of emergency progress notes dated 1/7/2020, reflected that resident was admitted for wound infection. The onset was 8 days before admission with symptoms of redness and purulent discharge and the degree at present is severe. The risk factor consists of immunocompromised resident. Further review of the progress notes reflected that physician stated the following Pt has horrific wound on leg, with necrotic femur protruding through necrotic surrounding tissue. He is surprisingly not febrile or [MEDICAL CONDITION] (though very high WBC). There is a social service note from mid-December that says his hem-oncologist visit was canceled because he is palliative care. I'm not sure if that is true or what current treatment plan is for him. I don't see any document to that effect that were brought with him from the facility. Observations conducted on 1/08/20 at 10:29 a.m., revealed resident receiving wound care at the hospital, resident didn't refuse wound care. Observations conducted on 1/08/19 at 10:40 a.m., revealed the admitting physician explaining the surgery to resident #1. Resident didn't refuse and agreed to have the procedure. During an interview conducted on 1/08/19 at 10:30 a.m., resident stated that he was getting wound care at the facility and added that he is in pain. During an interview conducted on 1/08/2020 at 11:00 a.m. the resident's admitting physician stated that if the vascular surgeon team was not on board or informed about the wound infection then he would have a concern. He stated that when the resident was admitted , resident had dead tissue and bone was sticking out, so the resident is going for surgery to clean the wound. During an interview conducted on 1/8/2020 at 3:30 p.m. wound care, RN stated that she should have notified the NP when the wound was getting worse. She stated that on Friday [DATE], the wound was not that bad and added that the bone was a little bit exposed. She stated that Monday 1/6/2020, when she came back to the facility the wound was worse and resident mental state. She stated that she notified the NP and resident was sent to the hospital. During an interview conducted on [DATE] at 11:30 a.m., DON stated that resident's appointment was cancelled because he was under palliative care. He stated that if the resident requested to reschedule his appointment they would reschedule them, but they wouldn't remove him from palliative care. During a telephone interview conducted on 0[DATE]20 at 2:06 p.m., NP stated that resident was admitted under palliative care and that was the reason that all his appointments were cancelled. NP stated that he explained and resident was completely aware when he took the decision to be under palliative care even knowing that his appointment would be cancelled. He stated that he provided a full advance care talk about what palliative care was before resident signed the consent. NP stated that if the resident was requesting to see his physician, an appointment should be scheduled even if the resident was under palliative care. He stated that resident refused to go to his follow-up appointment and that he will add refusals on his progress notes. During an interview conducted on 0[DATE]20 at 4:20 p.m., resident stated that he never refused any type of treatment or to go to his doctor's appointments and asked who was saying that. He stated that he doesn't have a reason to stop seeing his Vascular Surgeon. He stated that he had requested the facility to see the doctor, but he doesn't know why they cancelled his appointments. He stated that he doesn't know what palliative care was and added that he doesn't remember signing a consent since he had to sign a lot of papers and consents for medications. During an interview conducted on 01/09/10 at 4:28 p.m., Resident's FM stated that resident was under hospice services before being admitted to the hospital. She stated that they removed the resident from hospice, so he can have a surgery. She stated that she thought that resident would be under hospice when readmitted to the facility. She stated that she doesn't know what palliative services were and she wasn't aware that the resident was under those services. During an interview conducted on [DATE] at 4:40 p.m., MDS coordinator stated that hospice is a contract service that comes in and provides services to the resident. She stated that palliative care is end of life care we (the facility) provides to the resident. During an interview conducted on 0[DATE]20 at 12:30p.m., DON stated that in order to cancel an appointment, it must be agreed on between the resident and NP. He stated that he can't say if an appointment must be cancelled because a resident was under palliative care. He stated that he interprets the palliative order to the resident with the instructions of Do not send resident to the hospital except for trauma as sending the resident if something catastrophic happens like a [MEDICAL CONDITION]. He stated that the reason they sent Resident #1 to the hospital on [DATE] was because they discussed the wound situation during the morning meeting and requested the NP to get the order. He stated in an emergency, they would send the resident to the hospital right away. He said that this situation wasn't an emergency and that was the reason why they contacted the NP for directives. DON stated that his expectations from the staff was to document when a resident refuses to go to his appointment and to explain the risk of this refusal and to document the resident's response after explaining the risks of cancelation. Requested Policy and procedure for Quality of care was not provided by the facility.

Based on observation, interview, and record review, the facility failed to ensure each resident received assistance devices to prevent accidents, for one resident (Resident #11) of 22 residents reviewed for proper transfers. The facility failed to ensure Resident #11's wheelchair had foam covering over sharp edges which resulted in the resident sustaining a laceration requiring 26 sutures during a transfer. This deficient practice could affect residents by placing them at risk of serious injury that could have otherwise been avoided. Findings include: Review of the Face Sheet for Resident #11 reflected a [AGE] year-old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS for Resident #11 dated 3/20/19 reflected a BIMS was not conducted. Further review of the Admission MDS reflected Resident #11 was total dependence, two+ persons physical assist for transfers which indicated full staff performance every time during entire 7-day period. Admission MDS reflected Resident #11 was extensive assistance, two+ persons physical assist with bed mobility. Review of the physician's orders [REDACTED]. Review of Emergency Provider Report for Resident #11 dated 5/17/19 reflected Resident #11 had a 12-centimeter subcutaneous flap laceration located on her right lower limb. The wound was closed with five horizontal mattress sutures and 21 simple interrupted sutures. Review of the Care Plan for Resident #11 dated 6/10/19 reflected interventions for ADL self-care to include extensive assistance to turn and reposition, one person extensive to dress, set-up for meals and one person extensive for toilet use. Further review of the care plan reflected transfer needs were not addressed nor did it reflect that a mechanical lift should be used during transfers. Review of the Timeline of events for Resident #11 provided by the facility on 6/14/19 read in part: Resident was non-weight bearing at the time of admit and required a mechanical lift with two-person staff assistance for transfers. On (MONTH) 17, 2019 resident was transferred to bed with the assistance of two staff members. Once the resident was placed in bed the nurse noted a skin tear of 4.5 inches with a curve shape and skin lifted on the right leg. During a telephone interview on 6/12/2019 at 12:58 pm, FM stated on 5/17/19 she was notified about the incident and that Resident #11 was taken to the hospital. FM stated on 5/20/19, she met with the administrator to get more details regarding the incident. FM stated ADM was unaware of the incident and had to consult with the DON. FM stated DON was unaware of the incident and had to refer to nursing progress notes. FM stated DON read nursing notes and stated the incident occurred at 12:14 am and the laceration was described as a scratch. FM stated DON stated nursing staff noticed the laceration when they pulled Resident #11's pants down to change her. FM stated DON called staffing coordinator in to provide more details regarding the incident. FM stated staffing coordinator told her that the injury occurred while the resident was transferred to the bed using a two-person transfer. Staffing coordinator stated the injury was caused by the wheelchair. During an interview on 6/13/19 at 1:10 pm, DON stated RN D and CNA [NAME] noticed a laceration on Resident #11's right leg after transferring Resident #11 into bed using a two-person transfer. DON stated the laceration appeared to have been caused by a sharp edge from the wheelchair. DON stated there was a process in place to inspect wheelchairs to ensure they were in safe condition. DON stated sharp edges should be covered with foam. DON stated nursing staff and therapy staff inspect the wheelchairs once a week. During an interview on 6/13/19 at 2:25 pm, ADON stated staff were transferring Resident #11 and Resident #11 pivoted where you take the footrest off the chair. ADON stated Resident #11 got sutures and an antibiotic order. ADON further stated Resident #11 got [MEDICAL CONDITION] around the same area and was treated for [REDACTED]. Observation conducted on 6/13/19 at 9:00 a.m. revealed multiple residents in similar wheelchairs to that of Resident #11. Further observation revealed the area on the wheelchair alleged to have injured Resident #11 did not have foam covering and left exposed which did not adhere to the facility's weekly wheelchair inspection policy and procedure. During an interview on 6/14/19 at 1:08 pm, PTA H stated if they notice any sharp edges on the wheelchair they do not use it. During an interview on 6/14/19 at 1:44 pm, Staffing Coordinator stated the night of the incident RN D and CNA [NAME] transferred Resident #11 from her wheelchair to the bed. RN D and CNA [NAME] did not notice the laceration until they pulled off Resident #11's pants. Staffing Coordinator stated the footrests were removed exposing two metal disks where the footrests attached. Staffing Coordinator further stated they reenacted the incident and determined that to be the cause of the injury. During an interview on 6/14/19 at 2:12 pm, RN D stated at approximately 9:30 pm she noticed Resident #11 was still up in her wheelchair. RN D stated CNA [NAME] assisted her with transferring Resident #11 into bed. RN D stated they noticed the cut when they got Resident #11 on the bed. During a telephone interview on 6/14/2019 at 2:12 pm, CNA [NAME] stated she assisted RN D with a two person transfer the day of the incident involving Resident #11. CNA [NAME] further stated she did not notice the laceration until Resident #11's pants were removed. During an interview on 6/14/19 4:50 pm, Corporate Therapy Director stated the day of the incident Resident #11 should have used a wheelchair with no footrests. During an interview on 6/15/19 at 3:15 pm, RN D stated her analysis the night of the incident, she figured the blood would not have come from the bed it was probably the wheel chair after taking off the footrest. RN D further stated CNA [NAME] was lifting Resident #11 from the wheelchair by placing her knee in between Resident #11's leg and failed to guard Resident #11's weak right leg. RN D stated Resident #11's leg was weak because she had a cast on it so her skin was more susceptible to injury. RN D further stated that placing the leg between the knees did not provide guarding for the weak leg with fragile skin. RN D stated PT told them they should have placed their leg to the outside of Resident #11's right leg protecting the leg/skin from rubbing up against the wheelchair which would have safe guarded the leg and made it easier for transferring resident.

Based on observation, interview, and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three residents (Resident #1, Resident #2, and Resident #4) of three residents reviewed for Quality of Care. The facility failed to provide ordered [MEDICAL CONDITION] (Continuous Positive Airway Pressure) treatments to two residents (Resident #1 and Resident #2). This failure resulted in Resident #1 being emergently transferred to the hospital, diagnosed with [REDACTED].secondary to malfunctioning of home [MEDICAL CONDITION] machine and aspiration pneumonia .and acute metabolic [MEDICAL CONDITION] (an organic disorder of the brain chemistry): .secondary to hypercapnic respiratory acidosis per hospital records review. The Resident #1 resident was intubated on 1/23/2019 and admitted to ICU, stabilized and extubated on 1/24/2019, and treated and released to home health care on 1/28/2019 per hospital records. This failure resulted in Resident #2 being emergently transferred to the hospital on [DATE] and diagnosed with [REDACTED]. Her respiratory status quickly improved with [MEDICAL CONDITION] therapy and it is clearly stipulated in her discharge to SNF. per hospital records review the resident was admitted to ICU, stabilized, and discharged on [DATE] to the facility with [DIAGNOSES REDACTED]. These failures resulted in an Immediate Jeopardy situation on 3/15/19. While the IJ was removed on 3/16/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective action. The facility failed to provide ordered positioning and mobility support to Resident #4. These failures could affect residents at risk of decline in health status, as well as decline in mental and psychosocial status from not having their needs appropriately addressed as ordered by their physicians. The findings include: Review of the facility face sheet reflected Resident # 1 was a [AGE] year-old male admitted to the facility on [DATE] for treatment of [REDACTED]. The ordered treatment included IV antibiotics, wound care, therapies evaluations, and medications and treatments to support the resident's medical diagnoses. Resident [DIAGNOSES REDACTED]. The resident's 5-day Minimum Data Set (MDS) Basic Inventory of Mental Status (BIMS) dated 1/22/2019 and his discharge MDS dated [DATE] both revealed that the resident was not assessed for his mental status per sections B of the MDS, but he was assessed as independent per sections C of the MDS, Staff Assessment of Mental Status indicating no discerned cognitive impairment. The MDS sections E800 also indicated that the resident had no occasion of refusing care. Review of the admission orders [REDACTED]. Initial facility paperwork dated 1/17/2019 included a specific note that the resident was bringing his own C-PAP/Bi-PAP (Bilevel Positive Airway Pressure) equipment. Review revealed that Resident #1 had orders from the attending physicians for [MEDICAL CONDITION] treatment from his initial admission on 1/17/2019. The only indication that the NP was aware of any problem with the resident's obtaining [MEDICAL CONDITION] was an entry on 1/21/2019 where the NP said he was notified by the resident's wife that the [MEDICAL CONDITION] was not working, and he was told that the [MEDICAL CONDITION] would be delivered that day. At that time, he placed the resident on continuous O2 by nasal cannula. The following day, 1/22/2019, a different physician saw Resident #1 and there was no mention of the resident not having a [MEDICAL CONDITION]. The next provider note was later in the day of 1/22/2019 by the NP, reflecting the resident's emergent transfer to the hospital likely in the setting of acute [MEDICAL CONDITION], OSA (Obstructive Sleep Apnea) and noncompliance with [MEDICAL CONDITION] due to machine breaking. Review of the only care plan in Resident#1''s record was dated 1/18/2019 and revealed that the resident was only care planned for his full code status, his perirectal abscess, and acute care plan for the open boles to R gluteal. No care planning was provided for any of his other admission [DIAGNOSES REDACTED]. Review of the only progress notes in the system for Resident #1 revealed that the intake assessment noted that the resident wears [MEDICAL CONDITION] at night and when napping. There are only four nursing progress notes: two on initial admission/assessment date of 1/17/2019 that do not include all of the admission diagnoses, one on 1/18/2019 that mentions the resident's wound, resident pain, and that the wife is at bedside, and a final entry on 1/23/2019 at 3:00 AM that states that Resident #1 is lethargic, addresses his condition, states that the wife present and states that the resident was sent to the hospital. There are no other records of nursing concerns about the resident's breathing status or Oxygen therapy. Review of Resident#1's wife's (submitted) log of her concerns about Resident#1's status noted that the wife had recorded that [MEDICAL CONDITION] broke on the first day at (the facility). (Resident #1) has a difficult time breathing. I asked to borrow a [MEDICAL CONDITION]. I was told that the facility doesn't have [MEDICAL CONDITION] machines. Her notes continue to address her increasing concern about Resident #1's ability to breathe starting on 1/20/19. Her notes state that I notified the CNA that (Resident #1) is having a difficult time breathing. At this time an oxygen machine was brought into the room. Record review of the facility records revealed no mention of this report, or of the addition of Oxygen therapy due to the wife's concern. The wife's 1/21/2019 notes state that Resident #1 was confused and the 1/22/2019 notes state that he just looks at me blank. Her notes on 1/23/2019 state that {Resident #1) was not responding and wetting himself. I called the CNA and requested to call 911. Skilled nursing notes review revealed no skilled nursing notes 1/17-18/2019. Skilled nursing notes dated 1/19/2019 at 1:48 AM do not indicate [MEDICAL CONDITION]/[MEDICAL CONDITION] or O2 therapy (the resident was measured at 96% on room air at 2:58 AM 1/19/2019). A note was included in the skilled nursing note progress note section uses '[MEDICAL CONDITION]' at hs (sleep) however wife took machine home saying its broken. The resident's cognitive status was documented as alert with no other comments. Skilled nursing notes dated 1/20/2019 at 1:45 AM do not indicate [MEDICAL CONDITION]/[MEDICAL CONDITION] or O2 therapy (the resident was measured at 96% on room air at 1:50 AM on 1/20/2019). A note was included in the skilled nursing note progress note section uses '[MEDICAL CONDITION]' at hs (sleep) however wife took machine home saying its broken. The resident's cognitive status was documented as alert with no other comments. Skilled nursing notes dated 1/21/2019 at 1:06 AM do not indicate [MEDICAL CONDITION]/[MEDICAL CONDITION] or O2 therapy (the resident was measured at 96% on room air at 1:12 AM on 1/21/2019). A note was included in the skilled nursing note progress note section uses '[MEDICAL CONDITION]' at hs (sleep) however wife took machine home saying its broken. The resident's cognitive status was documented as alert with no other comments. Skilled nursing notes dated 1/21/2019 at 5:52 PM stated most recent Oxygen saturations 96% at 2 L per nasal cannula on a continuous and PRN basis at 9:00 am on 1/21/2019. The skilled nursing notes progress note stated O2 per NC and wife at bedside. The resident's cognitive status was documented as alert with no other comments. Skilled nursing notes dated 1/22/2019 at 10:38 AM stated that the most recent O2 saturations level were cited as 96% on NC at 1/21/2019 at 9:00 AM, mentioning Oxygen via nasal cannula, but without any other Oxygen dosage or other documentation of O2 therapy. The skilled nursing notes progress note stated O2 per NC and wife at bedside. The resident's cognitive status was documented as alert with documented short term and long term memory problems, impaired decision making, and disorganized thinking. Review of the NMAR for Resident #1 indicated that the [MEDICAL CONDITION] was signed by nursing as having been checked twice every day from admission on the evening of 1/17/2019 through 1/22/2019. Further review indicated that accu-checks and pain monitoring were not done as ordered on [DATE]. An interview with LVNA was held on 1:45 PM on 3/15/2019. She stated that she had signed the Nurse Medical Administration Record (NMAR) so she must have seen the [MEDICAL CONDITION], but that she never saw Resident #1 using the [MEDICAL CONDITION]. She said she doesn't remember, and that she just signs the NMAR if she sees that there is a [MEDICAL CONDITION] machine in the room. An interview was held at 2:00 PM on 3/15/2019 with the DON. When asked about the disparity in the NMAR records which indicated that the [MEDICAL CONDITION] had been provided to Resident #1 vs the Skilled Nursing Notes which indicated that there was no [MEDICAL CONDITION] machine at the facility, the DON asked to see the documentation. When she was shown the documentation, she stated that she didn't know that there had a been a problem with Resident #1's [MEDICAL CONDITION], that she should have been told, and that she could not explain the discrepancies in the documentation. She stated that her expectation was that all nursing documentation should be consistent and accurate. When shown the NMAR orders that were signed she agreed that the NMAR order entry was confusing, as it did not stipulate the specific documentation of the resident's status, so it was unclear if Resident #1 was receiving [MEDICAL CONDITION] treatment as ordered. Review of the transfer form for Resident #1 dated 1/23/2019 at 4:22 AM from the facility to the hospital revealed that the documented reason for transfer was urinary incontinence and that the resident had been receiving [MEDICAL CONDITION], but the NP order for transfer stated the reason for transfer was notified by nursing staff of patient's unresponsiveness, respiratory distress. Patient is not responding to verbal stimuli. Likely in the setting of acute [MEDICAL CONDITION], OSA and noncompliance with [MEDICAL CONDITION] due to machine breaking. The resident was received by the hospital emergency room at 4:11 AM on 1/23/2019. Review of the facility Admin/Discharge Report revealed that the facility recorded that Resident #1 was discharged on [DATE] Home, when he was discharged to the hospital that date. A phone interview was conducted with the spouse of Resident #1 at 10:05 AM on 3/14/2019. She said that her husband is recovering and appears to be mentally ok. She stated that there has been much expense and suffering. She said that she was always at the facility with her husband. She said that Resident #1 was admitted to facility from the hospital for wound care and intravenous (IV) antibiotics only because their insurance insisted upon a rehab facility instead of home health care. She said she was not with Resident #1 during his admission to the facility as he was sent directly from the hospital, and that she did not remember any paperwork during admission. She said that she told staff (Certified Nursing Assistants, CNAs) that the [MEDICAL CONDITION] broke on the first day at the facility and they shrugged and said that the facility didn't have [MEDICAL CONDITION] machines. She said that she immediately tried to get an authorization from her insurance for a new travel [MEDICAL CONDITION] but had difficulty since she didn't have a PCP because they had new health insurance. She said this went on 4-5 days. She said that the doc is white, and that he just talked, didn't do any exam of Resident #1. She said she never saw any nurses. She referred to her initial report to HHSC that included her ongoing notes, taken during the episode of care by her on her tablet (computer), that told of the decline in Resident #1's status. She stated that she was told by one CNA that she could not stay the night with Resident #1, but she did anyway, and that when Resident #1 became very ill during the night of 1/22-23/2019 she requested that the facility call 911. She said that she didn't remember names of staff. An interview was held at 10:34 AM on 3/15/2019 with the Nurse Practitioner (NP). He said he was told by Resident #1's wife on 1/21/2019 that resident didn't have [MEDICAL CONDITION] over weekend. He said this should have been reported to the on-call provider. The NP said that he was under the impression that the [MEDICAL CONDITION] was being delivered later that day and ordered O2 per NC for Resident #1. He stated that he had no data from 1/17-18/2019 when he looked at his records. He stated that the orders to continue [MEDICAL CONDITION] should have been done, and that he, or the on-call provider, should have been notified if the orders were not done. He said that Resident #1 was always on Oxygen. An interview was held at 1:33 PM on 3/15/2019 with CNAA. He stated that he thought he had seen the [MEDICAL CONDITION] functioning on Resident #1 on 1/18/2019, but he wasn't sure. He said he didn't work again until 1/22/2019. He said that Resident #1's wife didn't say anything to him about the [MEDICAL CONDITION] not working. An interview was held at 1:40 PM on 3/15/2019 with CNAD. She said that she saw the [MEDICAL CONDITION] on Resident #1 on 1/20/2019. She said that the resident's wife told her that the [MEDICAL CONDITION] was making a noise. She said that she told the charge nurse (CN) on duty and the Certified Medical Assistant (CMA) on duty. No record of that report was found in facility record review. An interview was held at 1:56 PM on 3/15/2019 with CNAC. She stated that she didn't see [MEDICAL CONDITION] on resident #1, and that she encouraged him to use Oxygen. She said that the resident's wife didn't say anything to her about the [MEDICAL CONDITION] not working. Review of Resident #2 reflected a [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. per the resident's face sheet. Also noted per the physician history dated 1/30/2019 is a history of chronic [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], type 2 diabetes mellitus with [MEDICAL CONDITIONS](gastro-[MEDICAL CONDITION] reflux disease), vitamin D deficiency, and allergic rhinitis. Review of Resident #2's care instituted on 1/31/2019 and revised 2/13/2019 did not care plan for the resident's [MEDICAL CONDITION] needs. Resident #2 was care planned for falls, open venous stasis ulcers, diabetes, therapy (PT/OT/ST), code status, pain, and skin integrity. Review of the MDS assessment of Resident #2 dated 1/26/2019 revealed that the assessment did not include a BIMS section. The discharge MDS of 2/1/2019 revealed that the resident was not assessed for her mental status per section B of the MDS, but she was assessed as independent per section C of the MDS, Staff Assessment of Mental Status indicating no discerned cognitive impairment. The MDS section E800 also indicated that the resident had no occasion of refusing care. MDS assessment dated [DATE] indicated a BIMS score of 15 indicating no cognitive deficit, and section E800 revealed no occasion of the resident's refusing care. Review of Resident #2's hospital records revealed that hospital discharge orders included [MEDICAL CONDITION] qhs (every night), O2 via NC (nasal cannula), and RT eval and treat. Review of Resident #2's care plan revised 2/13/2019 did not care plan for the resident's [MEDICAL CONDITION] needs as stipulated in the hospital discharge orders. Resident #2 was care planned for falls, open venous stasis ulcers, diabetes, therapy (PT/OT/ST), code status, pain, and skin integrity. Review revealed that Resident #2 was not ordered [MEDICAL CONDITION] by her attending physician at the facility upon her initial admission on 1/26/2019; however, during her initial admission on 1/26/2019 the admitting nurse noted that the resident uses [MEDICAL CONDITION], stated 'I have it at home my family will bring it to me tomorrow'. Review indicted that although the NMAR notes are checked for [MEDICAL CONDITION] after Resident returned on 2/12/2019, there are discrepancies between the NMAR, the O2 saturation documentations, and the skilled nursing notes. For example, NMAR documentation on [MEDICAL CONDITION] application by nursing documented that [MEDICAL CONDITION] was applied every evening in (MONTH) 2019, but every O2 Sats Summary Record for the month of (MONTH) 2019 except 3/1/2019 and 3/5/2019 stated measurement on room air or nasal cannula. Additionally, NMAR documentation for (MONTH) 2019 indicated that O2 at 2L per NC had been discontinued on 3/4/2019 but documented in the O2 Sats Summary Record on two occasions during March, after 3/4/2019. Another example is that he skilled nursing note dated 3/12/2019 and citing measurements on 3/11/2019 documented labored breathing by Resident #1 with treatment by [MEDICAL CONDITION]/[MEDICAL CONDITION] and O2 by nasal cannula (PRN). The O2 Sats Summary Record stated that the resident was on O2 per NC. Review of Resident #2's progress notes dated 2/12/2019-3/15/2019 revealed that there is no note in the initial assessment to ensure that the resident receives [MEDICAL CONDITION], nor are there any notes about the Resident's oxygen therapy orders. Review of Resident #2's NMAR revealed that abnormal blood pressures were recorded on 3/1/2019 and 3/5/2019 with orders to report this data (to the physician) not documented. An interview was held from 6:04-6:28 PM on 3/15/2019 Resident #2. She stated that she owns her [MEDICAL CONDITION]. She stated that the night staff don't help with anything. She said that if there is a problem at night she wouldn't call the staff but would call her sister or her parents as that was her only option. She said she is somewhat confident about the monitoring of the [MEDICAL CONDITION]. She said sometimes the staff doesn't check if it's on. Resident #2 said the staff are unfamiliar with the equipment usage or settings and she has taught at least one CNA (CNAA) how to set up the [MEDICAL CONDITION], and that she trusts him. She said that normally only the CNAs come in and check the [MEDICAL CONDITION], rarely do the nurses come in. An interview was held at 6:47 PM with CNAA. When asked about Resident#1 he stated that Resident#1 didn't ask for much or ask them to do much for him. He then stated he only worked with him very briefly on admission. He said that he was taught by Resident #2 how to do [MEDICAL CONDITION], adding the distilled water or filter and how to turn it on or place it on her. She was the first person to show him how to use it. He then stated if something were wrong with the [MEDICAL CONDITION] he would report it to the nurse and after that if nothing gets done he will go higher up. He also stated that there is no charting for [MEDICAL CONDITION] for CNAs. Anything they find out going on with residents they can set up a new alert that informs administrator and DON. He said that the nurses never check [MEDICAL CONDITION]. He then stated he has never been in-serviced on [MEDICAL CONDITION] or taught about the [MEDICAL CONDITION] machine and that he thought it was a nursing task because of the way it is set up. Usually if it is something a CNA should do they already know of it. He stated that he was never in-serviced on [MEDICAL CONDITION] and that they need training on the rehab hall (200) where both residents with [MEDICAL CONDITION] resided. An interview was held at 11:30 AM on 3/15/2019 with the Director of Nursing (DON). She said that her expectation that residents should be put on O2 as ordered and needed and that the and physician s/b notified immediately of any problems. She stated that all ordered positioning should be done for residents with mobility concerns. She said that all documentation is in their electronic medical records system. A follow up interview was held at 4:15 PM on 3/15/2019 with the DON. When asked what the process is for residents with [MEDICAL CONDITION] machines on admission she stated they want to order their own and if they come in with one they try to use the facility one. That is done in case theirs breaks, the facility would be responsible to replace the [MEDICAL CONDITION] machine. The facility will order a [MEDICAL CONDITION] as soon as they can and do not wait 3 or 5 days. DON then stated as soon as they know a [MEDICAL CONDITION] is broken they replace it. However, the [MEDICAL CONDITION] is ordered through SMS (the facility supply) and she does not know how long it takes to arrive at the facility, but it should be same day. If the [MEDICAL CONDITION] does not arrive the same day, they are to call the physician and get orders and do what he asks them to do in the mean-time. They are to follow all doctor's orders and if nurses know the [MEDICAL CONDITION] is not working, they should call the doctor and they should have let her know. Nurses should address and make sure [MEDICAL CONDITION] is working and can go in the nurse's note and document the care being provided or they can use the MAR (Medication Administration Record) and if a MAR indicated [REDACTED]. When asked about her expectation for nursing documentation, the DON stated, nurses should be documenting accurately and need to be letting her know if something is not right. The staff need to inform the doctor and she also needs to be informed. The DON stated that there had not been specific in-service training on [MEDICAL CONDITION]/[MEDICAL CONDITION] for nursing staff, but that the nursing staff was aware that they should report concerns to her and/or the physician. When asked about her expectation for care plans reflecting resident comorbidities, she stated all comorbidities (patient health concerns/diagnoses) should be specifically addressed on the care plan. She then stated her expectation is that the care plan addresses all things needing attention to. Care plans should reflect doctor's orders and staff are to follow doctor's orders and provide [MEDICAL CONDITION] as ordered and make sure it's working. If it is not they should call the doctor or let her (the DON) know so they can go forward with the process. Care plans should be done on admission and should be updated if changes occur. An interview was performed with RN A on 3/16/2019 at 3:30 PM. She stated that she had not had training on [MEDICAL CONDITION]/[MEDICAL CONDITION] before receiving the Plan of Removal mandated training, and that she appreciated the training and was more clear on how these work. During an interview on 3/15/2019 at 5:23 p.m. with the Administrator, when asked about his expectation for residents who admit with a [MEDICAL CONDITION] he stated the staff are to follow doctor's orders and recommendations from physician. If staff see or know it is broken they need to notify the physician and the DON. If an aide notices it then they tell the nurse and nurses tell the doctor. Staff needs to tell supply, so they can get a [MEDICAL CONDITION] to the facility. They need to contact the physician for what to do in the mean time for something that can be done same day. If there are any issues with care staff are to contact the physician and follow the orders from the doctor. He then stated for admissions, nurses should get report from the hospital and get all info they need to care for the resident admitting and follow up with the physician about the orders received. Anything a resident is admitted for , rehab and anything that arises afterwards his staff will address it. He stated he expects all [DIAGNOSES REDACTED]. Auditing is ongoing, and every month as needed. Discrepancies between records and accuracy are monitored by medical records, a third-party entity, and the corporate person on an annual basis. The way they determine discrepancies is with audits as well as by the Director of Clinical Operations, who audits things. The medical records should be an accurate representation of the resident and you should be able to look at that and know what is going on with the resident. It needs to be accurate and complete. When asked if their facility had a respiratory therapist on site, he stated the respiratory therapist is offsite at a sister community and can be utilized. The ADM stated that he thought that all nursing concerns were being communicated to and addressed by the DON. Review of Resident #4 reflected an 84- year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. vein, urinary tract infection, muscle weakness, and essential hypertension. Review of Resident #4's Annual MDS assessment dated [DATE] revealed a BIMS score of 1 indicating profound cognitive deficit, although review of his progress notes on 2/16/2019 indicate that Resident #4 is his own RP (Responsible Party). Review of section E800 revealed no occasion of the resident's refusing care. Review of the resident's care plans dated 10/12/2018 and 1/16/2019 reveal that orders are not addressed, and that the care plans include out of date orders and do not address the current status of the resident. Resident 4's care plans did not include all of the resident's diagnoses, e.g. his incontinence and history of Urinary Tract Infections, and notations in the care plan included outdated [DIAGNOSES REDACTED]. I have pneumonia) and contradictory care plan items that supported discontinued care modalities in addition to current care modalities, creating confusion about the actual care plan content (e.g. the resident is to be supervised while eating and not required to have supervision while eating related to his [DIAGNOSES REDACTED]. Review revealed that Resident #4 has current active physician orders [REDACTED]. Review of Resident #4's skin status revealed a notation of redness to sacrum on 3/10/2019, but this was not noted on his progress notes nor on requested/provided skin/wound care reports. Observation of Resident #4 on 3/15/2019 at 7:30 AM revealed redness to his sacrum and excoriated skin on the front of his left shoulder/chest, where his contracted hand contacts his chest. Review of Resident #4's NMAR records from 2/2019 and 3/2019 revealed multiple check-offs by nursing indicating that the resident had his left hand splint applied, was out of bed for meals, was provided assistance during meals, and had a pillow placed between his legs (all as ordered) including times where observations did not support the documentation, nor were there notes in the progress notes to explain the discrepancies Additionally, the NMAR dated 2/27/2019 showed three instances of actions not performed with no note in the progress notes to explain the lack of performance. Multiple observations were made of Resident #4 from 3/14/2019-3/15/2019. Resident #4 was always observed to be lying in his bed, on his left side. A brief interview was held with the resident at 10:45 AM on 3/14/2019. He was pleasant and conversant but appeared somewhat confused, lying on his left side with his legs drawn up toward his chest, and his contracted left hand (no splint) was exposed. Broad, angry-appearing red marks were observed on the skin of the front of his left shoulder where his contracted hand laid against his body. No pillow was seen placed between his knees as ordered. He was observed during lunch on 3/14/2019 with a bedside table with food in front of him, but he was not observed eating, nor was there assistance being provided. Note that he had orders to be OOB (out of bed) for all meals and to be provided assistance during all meals. On 3/15/2019 at 4:50 AM the resident was observed on his left side with no pillow between his knees as ordered, nor did he have a splint applied to his contracted left hand as ordered. Additionally, there was a strong urine odor in his room. Resident #4 was noted to have profound bilateral lower extremity contractures. At 7:30 AM on 3/15/2019 CNAD was asked to view the resident with the investigator, and she verbally acknowledged that the pillow should have been placed between the resident's knees. Observation at 8:06 AM on 3/15/2019 revealed that a pillow had been placed between the resident's knees, but he was still lying on his left side. At 8:30 AM on 3/15/2019 Resident#4's light was off in his room, and he was observed lying on his left side. When asked about whether the resident would be eating breakfast, LVN2 stated that he often refused. Review showed that there was no documentation of the resident previously refusing meals until 8:39 AM on 3/15/2019, when the nurse documented the refusal. A phone interview was held with complainant #2 at 12:23 PM on 3/14/2019. She said the last year or two has been bad at the facility, and that she had been there for eight years (she was very recently terminated). She said Resident #4 will fight care and the CNAs won't change him. She said CNAD told her that she doesn't touch them all night. She stated that Resident #4 has skin breakdown and that she showed the nurse that the resident's testicles were purple. Investigator observation/assessment of the resident did not reveal discolored testicles, and an interview with the wound care nurse on 3/15/2019 at 9:30 AM revealed that the facility has been [MEDICATION NAME] treating the resident to avoid scrotal skin breakdown. The complainant stated that Resident #4 is suffering weight loss. Resident #4 was found by record review to be on an ordered supplement to maintain his weight. An interview was performed at 8:44 AM on 3/15/2019 with the COTA. She stated that she started working at the facility on 1/2/2019. She stated that she was aware of problems with the staff, that they didn't like working with (Resident #4) because of his behavior. She said that she had ordered a special wheelchair for Resident #4 to help him get out of bed as ordered for meals since he will sometimes fall out of regular wheelchairs. Review of the facility's undated policy on Quality of Care r

Based on observation, interview, and record review, the facility failed to ensure that each resident was free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. (Resident #14) The facility failed to provide the necessary services required to prevent the elopement of Resident #14, who had a history of [REDACTED].#14 spending the night outside the facility. This failure resulted in Resident #14 sleeping in the grass outside the facility and sustaining numerous ant bites on his back and arms. It placed Resident #14 at risk for further harm due to proximity to a busy street in front of the facility. This failure could have affected 6 out of 6 residents with histories of wandering behaviors. An IJ existed from 7/7/2017 to 7/10/2017. 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. Findings included: Review of face sheet for Resident #14 reflected an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and diastolic [MEDICAL CONDITION], muscle wasting and atrophy, muscle weakness, [MEDICAL CONDITION], and dysphagia. Review of annual Minimum Data Set (MDS) conducted for Resident #14 on 2/7/2017 reflected that a Brief Interview for Mental Status (BIMS) score could not be obtained. Review of progress notes dated 7/8/2017 to 7/10/2017 reflected that Resident #14 was on hourly checks over the weekend and then put on one-to-one supervision at 3:00 p.m. on 7/10/2017. Review of physician's orders [REDACTED]. Review of nurse practitioner orders dated 5/9/2017 reflected that the wander guard was discontinued. No further information was found in the medical record for Resident #14 regarding any justification or planning related to this discontinuation. Surveyor attempted to call the nurse practitioner who discontinued the wander guard on 7/12/2017 at 10:27 a.m. and left a voicemail. Review of most care plan dated 10/7/2016 for Resident #14 reflected a Focus Item created by DON and containing the following information: I have an actual incident of elopement towards Riverside street and have potential for more attempts. During an interview on 7/12/2017 at 1:13 p.m., DON stated that she did not have any documentation of any more recent care plan or any care plan or interdisciplinary discussion concerning the discontinuation of wander guard for Resident #14. Review of nurse's notes for Resident #14 reflected that a late entry was made by ADON on 7/9/2017 at 7:23 p.m., labeled 7/8/2017 at 6:00 a.m., and containing the following: Resident was not in room during rounds. Code Pink called. Resident found outside on facility grounds. No visible injury noted. Head to toe assessment done by (LVN G). POA notified. DON notified. Q1h rounds started on resident. Review of a list contained in the facility investigation report reflected that Resident #14 has a BIMS score of 1, indicating a severe cognitive disability. Review of dermatologist orders dated 7/12/2017 reflected that the dermatologist ordered [MEDICATION NAME] ointment and [MEDICATION NAME] as needed to Resident #14 to treat the [DIAGNOSES REDACTED]. Observation of Resident #14 on 7/11/2017 at 7:32 a.m. revealed that he was laying in bed asleep, and CNA B was providing one-on-one supervision. During an interview on 7/11/2017 at 7:32 a.m., CNA B stated that she was called in to supervise Resident #14 one-on-one, but she thought maybe he was trying to fall, but she did not know exactly why he needed one-on-one supervision. During an interview on 7/11/2017 at 11:15 a.m., responsible party (RP) for Resident #14 stated that she was told, when she called at 10:30 a.m. on 7/8/2017, that the staff noticed at 6:00 a.m. on 7/8/2016 that Resident #14 was not in the building. She stated that the facility had called Hospice about the elopement, and Hospice had called her. She stated that he had already been found by the time she spoke to the facility, and that it was her understanding that he was found in a grassy area in front of the building. She stated that it was her understanding that he had spent the night outside. She stated that the facility called her on Sunday and stated they had noticed a rash on Resident #14's upper arms. She stated that she visited Resident #14 on Monday and saw the rash, which she felt sure were fire ant bites. She stated that she visited the DON on Monday afternoon after viewing the rash and asked the DON what she thought of the rash. RP stated that the DON told her at this time she had not viewed the rash yet. She stated that the DON heard about the elopement at 6:30 a.m. on Saturday, and the RP was angered by the fact that the DON had not assessed Resident #14 herself. RP stated that she and the DON went to look at Resident #14's rash, and, upon viewing it, the DON told her it looked like [MEDICAL CONDITION]. RP stated that she did not get a completely straight answer about how long Resident #14 was outside, but she could not find anyone who could account for him after 9:30 p.m. on 7/7/2017. She stated that Resident #14 was rattled and exhausted by the incident. During an interview on 7/11/2017 at 1:08 p.m., LVN F stated that she had not worked the weekend but had come back on shift on 7/10/2017. When she arrived, she was told that Resident #14 had eloped on Friday night 7/7/2017. LVN F stated that ADON was working as the charge nurse from 6:00 p.m. to 6:00 a.m. on Friday 7/7/2017, Saturday 7/8/2017, and Sunday 7/9/2017. LVN F stated that her understanding of what happened was that ADON had seen Resident #14 on the porch on Friday night 7/7/2017, and that she did not see him again until someone realized at 5:30 a.m. that he might still be sitting there. LVN F stated that she does not know exactly who found resident #14, but LVN G had told her Resident #14 was found laying on the ground outside. LVN F stated she observed the numerous bumps on Resident #14's arms and back, and, when she started reading documentation of the incident, she came to believe the bumps must be ant bites. LVN F stated that all facility staff received in-services for elopement and reporting abuse. During an interview on 7/12/2017 at 8:27 a.m., LVN G stated that he was the oncoming charge nurse for the shift that began at 6:00 a.m. and relieved ADON. He stated that, when he arrived on the morning of 7/8/2017, CNA A came up to him and asked him where Resident #14 was, because she had not seen him on any of her checks that night. LVN G stated that CNA A had told him she had attempted to inform ADON, but she had been busy throughout the night. LVN G stated they went to look for Resident #14, and he was not in his bedroom or the bathroom. LVN G stated that he called a Code Pink at this time. LVN G stated that a Code Pink is the alert for a missing resident. LVN G stated that Resident #14 was found at 6:30 a.m. and brought inside, but LVN G did not remember exactly who found him. LVN G stated that he knows Resident #14 was found in the grassy area. LVN G stated that the staff agreed he had been outside all night. LVN G stated that Resident #14 was in his clothing and his glasses, and they got him undressed and did a skin assessment, and that Resident #14 refused a shower at that time. LVN G stated that all range of motion was normal at that time, and Resident #14's mental state was at its baseline. LVN G stated that he instituted hourly checks for resident #14 immediately, and that Resident #14 spent most of that day asleep in bed. LVN G stated that he did another skin assessment on 7/9/2017 before lunch, and there was still no rash visible on Resident #14, but during the assessment after lunch, Resident #14's arms and back were covered in pustules. LVN G stated that he called the nurse practitioner and Hospice at that point. LVN G stated that ADON did not say anything in particular about Resident #14. LVN G stated he thought that ADON would go see Resident #14 for her own assessment and start an incident report, as that is the usual procedure in an elopement. LVN G stated that facility staff is aware of the residents who have exhibited wandering behavior by presence of their names in a binder at the nurse's station called Happy Feet. During an interview on 7/12/2017 at 9:32 a.m., DON stated that she heard about Resident #14's elopement at 6:30 a.m. on 7/8/2017 from ADON and LVN G via telephone call. She stated that she directed them to do a head to toe assessment of Resident #14 and notify the RP and physician. DON stated she also suggested a shower, but her understanding was that Resident #14 refused a shower. She stated that she directed them to begin hourly checks on the resident. DON stated that it is her expectation that any administrative staff report a reportable incident to Texas Department on Aging and Disability Services within 24 hours of discovery of the incident. She stated that she would have assumed that ADON would complete the incident report. DON stated they did not know he was missing until 6:00 a.m., and he was found at 6:15 a.m. or 6:30 a.m. The DON stated that they did not know for sure until 7/10/2017 that CNA A and ADON had not seen Resident #14 all night and had not done a thorough search for him. DON agreed that Resident #14 was outside all night. DON stated that it is her expectation that the overnight staff check all residents every two hours every shift, and CNA A should have performed these checks and reported any missing residents to ADON. She stated they took disciplinary action towards the ADON and CNA A, and they are both suspended. DON stated that the ADON should have documented something right away about the incident that could be communicated to the staff. After viewing the progress note describing the elopement, the DON acknowledged that it was not entered by the ADON until 7:23 p.m. on 7/9/2017. DON stated that the order for Resident #14's wander guard was discontinued by the physician, because he had not had any elopement attempts since 107/2016. She stated that she did not know if there was any care planning or discussion by the interdisciplinary team related to the discontinuation of that wander guard. During an interview on 7/13/2017 at 10:15 a.m., ADMN stated that she agreed that ADON failed to follow facility policy to care for and supervise Resident #14 and that this resulted in Resident #14 spending the entire night outside the facility. During an interview on 7/13/2017 at 10:31 a.m., CNA D stated that the person who actually found Resident #14 on 7/8/2017 was LVN H. During an interview on 7/13/2017 at 10:33 a.m., LVN H stated he found Resident #14 laying in the grass asleep about 8 feet away from the curb that surrounds the parking lot on the right side of the building front. LVN H stated he did not see any ants or insects on Resident #14 at this time. Review of a written statement submitted to the facility by CNA K reflected the following: I (CNA K) on 7/7/17 Friday the last time I saw (Resident #14) was 7:00 p.m. Review of a written statement submitted to the facility by CNA L reflected the following: I worked on 300 hall in the evening of July 7, 2017 from 2:00 PM to 10:00 PM. The last time I had seen (Resident #14) on that day was around 9:20 PM during my last round. When I was doing my last round, I saw (Resident #14) walking from his room heading to the nurse station. I was surprised with him the next day to be found sleeping outside. (Resident #14) never left his room without coming back and nor confusing his room number on the hall. Review of the written statement submitted to the facility by ADON reflected the following: Friday July 7, 2017 5:30 pm Arrived at building for start of shift. I observed (Resident #14) sitting in rocking chair in front of facility. 9:30 p.m. Entered (Resident #14's room) to do blood sugar check. (Resident roommate) asked me where (Resident #14) was. I left room and asked CNA from Rio to go and check on (Resident #14). I did not hear anything back from her. 12:00 midnight I went outside in front of facility and did not notice any residents outside. 3:00 a.m. I went outside in front of facility and did not notice any residents outside. 5:30 a.m. (LVN G) went to do rounds and asked me where (Resident #14) was. I checked in room/bathroom and proceeded to call Code Pink. All staff searched facility rooms/bathrooms, and grounds. (Resident #14) found on grounds laying down with glasses on. Assisted him back to room. (LVN G) told me he would do head to toe assessment and call POA. No visible injuries. Resident did not have dirt on clothing and stated 'I fell asleep.' This narrative was not signed by ADON. Review of the written statement submitted to the facility by CNA A reflected the following (sic): On Friday 07/07/17 @ 10:30 p.m. I noticed (Resident #14) was not in his room. Thinking he was maybe sent to hospital, 12:40 p.m. did my second round and (Resident #14 was not present in his room so nurse (ADON) was busy on hall's I made an attempt to ask her about him but she actually seen very busy between two halls so it just over come me as I continued my round. At 6:00 am shift change nurse I asked (LVN G) for him @ 6:00 a.m. and (LVN G) got (ADON) attention to look for him. Everyone went on a search to look for him and he was found outside. This narrative was signed by CNA A and dated 7/10/17. During a telephone interview on 7/13/2017 at 10:48 a.m., CNA A stated that she had been the CNA on duty in Resident #14's hall overnight on 7/7/2017. She stated that she came in that evening at 10:00 p.m. She stated that she walked to every room at 10:30 p.m. and did not see Resident #14. She stated that two other residents were asking for as needed pain medication, and she approached ADON to tell her about those two residents and Resident #14. She stated that ADON told her I'm coming, I'm coming. CNA A stated that another resident was waiting on a breathing treatment, and she tried to approach ADON a second time but only reminded ADON of the residents needing medication and a breathing treatment. CNA A stated that ADON did not stop being busy until 1:00 a.m. CNA A stated she checked in Resident #14's room at 10:30 p.m., 12:40 a.m., 3:30 a.m., and 5:00 a.m. CNA A stated she provided incontinent care for Resident #14's roommate at 3:30 a.m. and 5:00 a.m. CNA A stated that Resident #14 was never in the room during her checks. She stated that she never spoke to ADON again through the night. She stated she thought Resident #14 was probably at the hospital, but usually someone tells her if that is the case. She stated that it is facility policy to go through an elopement process when a resident is missing. She stated that the nurses have always listened before when she told them important information about residents, and she did not know how to handle this situation. During an interview on 7/13/2017 at 1:28 p.m., CNA E stated that she was working on another hall the morning of 7/8/2017 and overheard ADON telling CNA A, When they ask you any questions, say you saw him last when you made you 5 o'clock rounds. CNA E stated that she walked away at that point, because she did not want to be involved with that situation. During an interview on 7/17/2017 at 11:54 a.m., ADON stated that she had worked from 6:00 p.m. to 6:00 a.m. at the facility on 7/7/2017. She stated that she was on call that weekend, and two nurses called in, so she came to work as charge nurse. She stated she arrived at the facility at 5:30 p.m. and saw Resident #14 in the rocking chair on the front porch. She stated she was responsible for about 40. At 9:30 p.m., she was checking blood sugar on Resident #14's roommate, and he asked where Resident #14 was. She stated she stopped the first CNA she saw and asked her to check on Resident #14. She stated she never heard back, and then stated, Honestly I was so overwhelmed and busy, and I know that is no excuse. ADON clarified that she meant she did not follow up on the missing resident and did not hear anything from the CNA she had dispatched. She denied CNA A ever coming to tell her Resident #14 was missing. Review of facility policy regarding Wandering/Missing Residents reflected the following At times, the facility admits and retains residents that are confused and have the tendency to wander about the facility. If the facility is equipped with a secured unit, these residents will normally be secured on this unit. However some of the SCC's facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Plan of care will be developed and implemented with specific approaches and goals for the wanderer. Review of facility policy regarding Staff treatment of [REDACTED]. Review of a document dated 7/11/2017 and titled Correction Plan and dated 7/11/2017 reflected the following items: - In-service Staff, CNA, and Nurses to make walking rounds to account for residents on neighborhood on each shift change. Date initiated 7/9/17 - At the start of each shift change the on-going and in-coming Nurse will make walking rounds for Resident accountability and document on audit tool. Date initiated 7/10/17 - Code Alert Book reviewed and updated to include this resident. Date initiated 7/10/17 - Complete midnight census with visible observation of residents and document on audit tool at 6 pm, 6 am, and midnight shift. Date initiated 7/10/17 -100% assessment of residents at risk for elopement. Date initiated 7/10/17 - Nurse in-serviced to lock entry door at 10 pm. Date initiated 7/10/17 - Red River Charge Nurse on 6 pm to 6 am will ensure front entry is lock at 10 pm and residents are accounted for. Date initiated 7/10/17 - Any resident desiring to be outside on the porch after 10 pm must be supervised by staff/family member. Date initiated 7/10/17 - Resident placed on monitoring and 1 on 1. Date initiated 7/10/17 - Wander guard placed on resident. Date initiated 7/10/17 - Review all residents BIM scores, and those residents with a score of below 12 will be accompanied with supervision outside. Date initiated 7/10/17 - List of residents with BIMS below 12 will be identified at the front desk and each nurse's station. This will be updated by SW when a change in BIM score occurs. Date initiated 7/10/17 - Residents with score of below 12 will be added to the POC task for CNAs. Date initiated 7/10/17 - Residents identified will have their care plan updated. Date initiated 7/10/17 Review of an undated document titled Performance Improvement Plan reflected the following: Observation Continuous monitoring for compliance of resident presents in the building.Goal/Objective All residents will be accounted for in the building at the beginning of each shift at 6 AM and 6 PM and 12 midnight each day. Actions Nurse managers, licensed nurses, CMAs and CNAs have been trained and in-servicde on the below process so everyone is aware. Employee will be trained prior to their next day of working for PRN employees. All new employees will receive training in their orientation. At the beginning of each shift walking rounds will be done by the oncoming nurse and the off going nurse to ensure all residents are accounted for. The midnight census of heads in the bed will be given to the ADM each morning/Manager on Duty on the weekend. The audit tool for the charge nurse rounds will be signed by oncoming nurse daily. This will be reviewed in the morning clinical meeting. The weekend Manager on Duty will review on the weekend. If any concerns over the weekend, the ADM and DON will be notified. Identification of noncompliance, a disciplinary action will be documented by DON. All weekly findings will be reviewed at the weekly WAR meeting and monthly at the QAPI Meeting. If any discrepancies of residents being accounted for in the building occurs, the ADM, DON, RVP, and DCO will be notified immediately. Director of clinical operations will review for compliance with each facility visit. Observations of Resident #14 between 7/11/2017 at 8:20 a.m. and 7/13/2017 at 3:18 p.m. revealed a staff person providing one to one supervision at all times and a wander guard on his right ankle under his sock. During an interview on 7/11/2017 at 10:06 a.m., CMA I stated that she had been in-serviced the day before on elopement procedures and abuse and making rounds and they are doing head counts at every shift change now. She stated that she knows Resident #14 was out and was not supposed to be out, and he is now a risk for elopement. She named Residents #40, 41, and 42 on hall 100 who are at risk for elopement. She stated there are no residents on hall 200 at risk for elopement. During an interview on 7/11/2017 at 10:08 a.m., CNA C stated that they received training that morning before their shift for elopement, abuse and neglect, and making rounds. She stated that she works on hall 100, and her residents at risk for wandering are Residents #40, 41, and 42 but that she has to make sure to count all the residents. During an interview on 7/11/2017 at 1:52 p.m., LVN F stated that the charge nurses are now to sign a census sheet accounting for every resident at shift change, and this is given to the ADM and/or the Manager on Duty, depending on the day of the week. She stated that, in the event of an elopement, the administrator should be notified no matter who the manager on duty is. During an interview on 7/12/2017 at 2:40 p.m., CNA J stated that she was in-serviced the afternoon of 7/10/2017 on elopement and resident head counts, and they have a new procedure in place to count residents at every shift change. She stated she knows to contact a charge nurse if there is a missing resident. She stated she works on hall 300, and Resident #14 is her only elopement risk. During an interview on 7/12/2017 at 2:46 p.m., CNA D stated that she received in-servicing on elopement and making head counts and she has had three in-services on abuse/neglect in the last two weeks. She stated that she works on hall 200 and does not have any residents on the elopement list. Review of facility in-service dated 7/9/17 and titled Elopement Monitoring/Rounds reflected the following instruction: All staff should be making rounds to ensure that all residents are accounted for and needs are being met during their shift. In addition, a round should be done by both nurses and CNAs at the beginning of the shift to perform a head count of the residents on the hall to ensure that all residents whereabouts are known. If a resident is unable to be found at this time or any other, a CODE PINK should be called immediately by the charge nurse on duty. All staff should immediately begin to search the building and grounds methodically for the missing resident. The charge nurse on duty must notify the DON and administrator immediately when a CODE PINK is called, as well as when the resident has been located. Charge nurse on duty should complete an incident report for the elopement and the resident should be immediately started on visual monitoring every hour for three days. Review of facility in-service dated 7/10/17 and titled Making Rounds on Resident reflected the following instruction: CNA is to make rounds with oncoming shift. And every two hours during the shift. All residents need to be visualized during the round, any resident sitting outside needs to be communicated to charge nurse for monitoring. Nurses should make rounds at the beginning of the shift, during the middle of the shift and at the end of the shift. P.m. nurses need to do rounds at midnight. Doors are to be locked at 10 PM after all residents are accounted for. Report any changes or unaccounted resident to the charge nurse. Review of facility in-service dated 7/11/17 and titled Binder at Nurses Station and Lobby Desk identifying residents with BIMS less than 12. Asterisk of those residents that enjoy going outside and will need staff/family supervision reflected the following instruction: There is a binder that has been established at the Nurses Station and lobby desk with residents who have triggered below a 12 on their BIMS assessment. The resident with an asterisk are identified as those residence with the BIMS of less than 12, but enjoy going outside on the front porch. The residents with asterisks will require supervision when they go outside. Residents list will be updated with change in condition and MDS. Residents identified will be reported weekly during facility at risk meeting. Observation on 7/13/2017 at 1:15 p.m. reflected binders at the lobby desk and the Nurses Station containing a list of residents with BIMS scores under 12, which indicates a cognitive impairment. Review of this document reflected a list of 41 residents with BIMS scores under 12 and 8 residents with asterisks indicating they enjoy sitting outside with supervision. Observations of the facility front porch between 7/11/2017 at 6:45 a.m. and 7/13/2017 at 4:13 p.m. revealed a staff person present at all times that any resident was sitting outside. Review of facility in-service dated 7/13/17 and titled Reporting any alleged misconduct to facility ADM. Always Follow facility Policy and procedures and local and Federal laws. reflected the following instruction: As I have spent time this week with you here at Riverside I just want to make sure everyone is knowledgeable regarding reporting and sharing concerns, and concerns of misconduct. We all have a responsibility to our residents and coworkers to do the right thing every day. As a facility we must follow our policies and procedures. We also must follow local and federal laws and guidelines. Whether it's your supervisor, another staff or even family member you are asked to do something that you know is not right, you are uncomfortable with, I need you to feel comfortable with questioning what is being asked of you. I encourage you to call your facility administrator, your director of nursing. If you remain uncomfortable still I encourage you to call the compliance hotline [PHONE NUMBER] or you can visit the website. Review of document titled Ad Hoc QAPI included all items described in Correction Plan and reflected signatures from Director of Clinical Operations, Medical Director, Attending Physician, Vice President of Operations, Administrator, and Director of Nursing. Review of facility investigation report reflected written warnings and three-day suspensions for ADON and CNA A. Review of physician progress notes [REDACTED]. The physician also recorded that ant bites are usually immediate reaction. Physician diagnosed Resident #14 with folliculitis/impetigo and treated with Keflex 250 mg. Review on 7/13/2017 of updated care plan for Resident #14 reflected a revised Focus Item created on 7/9/2017 and containing the following information: I need supervision by facility or hospice staff when I have a desire to go outside of all buildings. and one created 7/11/2017 and containing the following information: Wander guard check placement and functioning every shift. Review of the revised care plan refelcetd that the previous Focus Item from 10/7/2016, I have an actual incident of elopement towards Riverside street and have potential for more attempts, remained on the revised care plan. Review of Wandering/Elopement Risk Evaluations for all residents with a history of wandering reflected that Residents #40, 41, 42, 43, and 44 had evaluations completed between 7/10/2017 and 7/13/2017. Observation of Resident #43 on 7/13/2017 at 8:40 a.m. revealed she was in her bed asleep with most of her breakfast still on a tray in front of her. A wander guard was visible on her right ankle, and a wheelchair sat by her bed. A sign hung over her bed with information about the Happy Feet Club. Observation of Resident #40 on 7/13/2017 at 8:45 a.m. revealed that she was asleep under a throw blanket in her bed. A wander guard was visible on her right ankle. A sign hung over her bed with information about the Happy Feet Club. Observation of Resident #42 on 7/13/2017 at 9:10 a.m. revealed that she was seated upright in her wheelchair in the television room. She did not grant permission to observe her ankle. She struggled to reorient her wheelchair and move it forward and made very slow progress. During an interview with Resident #42 on 7/13/2017 at 9:10 a.m., she stated that she cannot stand up on her own and can barely move her own wheelchair. She stated she has never tried to leave the facility without someone attending her. Observation of bedroom for Resident #42 at 9:20 a.m. revealed a sign hung over her bed with information about the Happy Feet Club. Review of a document titled Midnight Census Report and dated 7/12/2017 reflected a list of all residents in the facility with check marks next to each resident name with a space for a head count number and a signature on the bottom of the document. Check marks reflected that all residents were accounted for, and the document was signed by LVN M. Review on 7/13/2017 of a document titled Resident Monitoring Tool reflected a head count on each hall initialed by the outgoing and oncoming charge nurse at 6:00 p.m., 6:00 a.m., and midnight each day starting at 6:00 p.m. on 7/10/2017 through 6:00 a.m. 7/13/2017. Review of CMS-802 reflected that 6 residents with wandering behaviors could have been affected by the facility's failure to provide necessary services.

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. (Resident #14) The facility failed to provide adequate supervision required to prevent the elopement of Resident #14, who had a history of [REDACTED].#14 spending the night outside the facility. This failure resulted in Resident #14 sleeping in the grass outside the facility and sustaining numerous ant bites on his back and arms. It placed Resident #14 at risk for further harm due to proximity to a busy street in front of the facility. This failure could have affected 6 out of 6 residents with histories of wandering behaviors. An IJ existed from 7/7/2017 to 7/10/2017. 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. Findings included: Review of face sheet for Resident #14 reflected an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and diastolic congestive heart failure, muscle wasting and atrophy, muscle weakness, chronic kidney disease, and dysphagia. Review of annual Minimum Data Set (MDS) conducted for Resident #14 on 2/7/2017 reflected that a Brief Interview for Mental Status (BIMS) score could not be obtained. Review of progress notes dated 7/8/2017 to 7/10/2017 reflected that Resident #14 was on hourly checks over the weekend and then put on one-to-one supervision at 3:00 p.m. on 7/10/2017. Review of physician's orders [REDACTED]. Review of nurse practitioner orders dated 5/9/2017 reflected that the wander guard was discontinued. No further information was found in the medical record for Resident #14 regarding any justification or planning related to this discontinuation. Surveyor attempted to call the nurse practitioner who discontinued the wander guard on 7/12/2017 at 10:27 a.m. and left a voicemail. Review of most care plan dated 10/7/2016 for Resident #14 reflected a Focus Item created by DON and containing the following information: I have an actual incident of elopement towards Riverside street and have potential for more attempts. During an interview on 7/12/2017 at 1:13 p.m., DON stated that she did not have any documentation of any more recent care plan or any care plan or interdisciplinary discussion concerning the discontinuation of wander guard for Resident #14. Review of nurse's notes for Resident #14 reflected that a late entry was made by ADON on 7/9/2017 at 7:23 p.m., labeled 7/8/2017 at 6:00 a.m., and containing the following: Resident was not in room during rounds. Code Pink called. Resident found outside on facility grounds. No visible injury noted. Head to toe assessment done by (LVN G). POA notified. DON notified. Q1h rounds started on resident. Review of a list contained in the facility investigation report reflected that Resident #14 has a BIMS score of 1, indicating a severe cognitive disability. Review of dermatologist orders dated 7/12/2017 reflected that the dermatologist ordered triamcinolone ointment and Benadryl as needed to Resident #14 to treat the [DIAGNOSES REDACTED]. Observation of Resident #14 on 7/11/2017 at 7:32 a.m. revealed that he was laying in bed asleep, and CNA B was providing one-on-one supervision. During an interview on 7/11/2017 at 7:32 a.m., CNA B stated that she was called in to supervise Resident #14 one-on-one, but she thought maybe he was trying to fall, but she did not know exactly why he needed one-on-one supervision. During an interview on 7/11/2017 at 11:15 a.m., responsible party (RP) for Resident #14 stated that she was told, when she called at 10:30 a.m. on 7/8/2017, that the staff noticed at 6:00 a.m. on 7/8/2016 that Resident #14 was not in the building. She stated that the facility had called Hospice about the elopement, and Hospice had called her. She stated that he had already been found by the time she spoke to the facility, and that it was her understanding that he was found in a grassy area in front of the building. She stated that it was her understanding that he had spent the night outside. She stated that the facility called her on Sunday and stated they had noticed a rash on Resident #14's upper arms. She stated that she visited Resident #14 on Monday and saw the rash, which she felt sure were fire ant bites. She stated that she visited the DON on Monday afternoon after viewing the rash and asked the DON what she thought of the rash. RP stated that the DON told her at this time she had not viewed the rash yet. She stated that the DON heard about the elopement at 6:30 a.m. on Saturday, and the RP was angered by the fact that the DON had not assessed Resident #14 herself. RP stated that she and the DON went to look at Resident #14's rash, and, upon viewing it, the DON told her it looked like dermatitis. RP stated that she did not get a completely straight answer about how long Resident #14 was outside, but she could not find anyone who could account for him after 9:30 p.m. on 7/7/2017. She stated that Resident #14 was rattled and exhausted by the incident. During an interview on 7/11/2017 at 1:08 p.m., LVN F stated that she had not worked the weekend but had come back on shift on 7/10/2017. When she arrived, she was told that Resident #14 had eloped on Friday night 7/7/2017. LVN F stated that ADON was working as the charge nurse from 6:00 p.m. to 6:00 a.m. on Friday 7/7/2017, Saturday 7/8/2017, and Sunday 7/9/2017. LVN F stated that her understanding of what happened was that ADON had seen Resident #14 on the porch on Friday night 7/7/2017, and that she did not see him again until someone realized at 5:30 a.m. that he might still be sitting there. LVN F stated that she does not know exactly who found resident #14, but LVN G had told her Resident #14 was found laying on the ground outside. LVN F stated she observed the numerous bumps on Resident #14's arms and back, and, when she started reading documentation of the incident, she came to believe the bumps must be ant bites. LVN F stated that all facility staff received in-services for elopement and reporting abuse. During an interview on 7/12/2017 at 8:27 a.m., LVN G stated that he was the oncoming charge nurse for the shift that began at 6:00 a.m. and relieved ADON. He stated that, when he arrived on the morning of 7/8/2017, CNA A came up to him and asked him where Resident #14 was, because she had not seen him on any of her checks that night. LVN G stated that CNA A had told him she had attempted to inform ADON, but she had been busy throughout the night. LVN G stated they went to look for Resident #14, and he was not in his bedroom or the bathroom. LVN G stated that he called a Code Pink at this time. LVN G stated that a Code Pink is the alert for a missing resident. LVN G stated that Resident #14 was found at 6:30 a.m. and brought inside, but LVN G did not remember exactly who found him. LVN G stated that he knows Resident #14 was found in the grassy area. LVN G stated that the staff agreed he had been outside all night. LVN G stated that Resident #14 was in his clothing and his glasses, and they got him undressed and did a skin assessment, and that Resident #14 refused a shower at that time. LVN G stated that all range of motion was normal at that time, and Resident #14's mental state was at its baseline. LVN G stated that he instituted hourly checks for resident #14 immediately, and that Resident #14 spent most of that day asleep in bed. LVN G stated that he did another skin assessment on 7/9/2017 before lunch, and there was still no rash visible on Resident #14, but during the assessment after lunch, Resident #14's arms and back were covered in pustules. LVN G stated that he called the nurse practitioner and Hospice at that point. LVN G stated that ADON did not say anything in particular about Resident #14. LVN G stated he thought that ADON would go see Resident #14 for her own assessment and start an incident report, as that is the usual procedure in an elopement. LVN G stated that facility staff is aware of the residents who have exhibited wandering behavior by presence of their names in a binder at the nurse's station called Happy Feet. During an interview on 7/12/2017 at 9:32 a.m., DON stated that she heard about Resident #14's elopement at 6:30 a.m. on 7/8/2017 from ADON and LVN G via telephone call. She stated that she directed them to do a head to toe assessment of Resident #14 and notify the RP and physician. DON stated she also suggested a shower, but her understanding was that Resident #14 refused a shower. She stated that she directed them to begin hourly checks on the resident. DON stated that it is her expectation that any administrative staff report a reportable incident to Texas Department on Aging and Disability Services within 24 hours of discovery of the incident. She stated that she would have assumed that ADON would complete the incident report. DON stated they did not know he was missing until 6:00 a.m., and he was found at 6:15 a.m. or 6:30 a.m. The DON stated that they did not know for sure until 7/10/2017 that CNA A and ADON had not seen Resident #14 all night and had not done a thorough search for him. DON agreed that Resident #14 was outside all night. DON stated that it is her expectation that the overnight staff check all residents every two hours every shift, and CNA A should have performed these checks and reported any missing residents to ADON. She stated they took disciplinary action towards the ADON and CNA A, and they are both suspended. DON stated that the ADON should have documented something right away about the incident that could be communicated to the staff. After viewing the progress note describing the elopement, the DON acknowledged that it was not entered by the ADON until 7:23 p.m. on 7/9/2017. DON stated that the order for Resident #14's wander guard was discontinued by the physician, because he had not had any elopement attempts since 107/2016. She stated that she did not know if there was any care planning or discussion by the interdisciplinary team related to the discontinuation of that wander guard. During an interview on 7/13/2017 at 10:15 a.m., ADMN stated that she agreed that ADON failed to follow facility policy to care for and supervise Resident #14 and that this resulted in Resident #14 spending the entire night outside the facility. During an interview on 7/13/2017 at 10:31 a.m., CNA D stated that the person who actually found Resident #14 on 7/8/2017 was LVN H. During an interview on 7/13/2017 at 10:33 a.m., LVN H stated he found Resident #14 laying in the grass asleep about 8 feet away from the curb that surrounds the parking lot on the right side of the building front. LVN H stated he did not see any ants or insects on Resident #14 at this time. Review of a written statement submitted to the facility by CNA K reflected the following: I (CNA K) on 7/7/17 Friday the last time I saw (Resident #14) was 7:00 p.m. Review of a written statement submitted to the facility by CNA L reflected the following: I worked on 300 hall in the evening of July 7, 2017 from 2:00 PM to 10:00 PM. The last time I had seen (Resident #14) on that day was around 9:20 PM during my last round. When I was doing my last round, I saw (Resident #14) walking from his room heading to the nurse station. I was surprised with him the next day to be found sleeping outside. (Resident #14) never left his room without coming back and nor confusing his room number on the hall. Review of the written statement submitted to the facility by ADON reflected the following: Friday July 7, 2017 5:30 pm Arrived at building for start of shift. I observed (Resident #14) sitting in rocking chair in front of facility. 9:30 p.m. Entered (Resident #14's room) to do blood sugar check. (Resident roommate) asked me where (Resident #14) was. I left room and asked CNA from Rio to go and check on (Resident #14). I did not hear anything back from her. 12:00 midnight I went outside in front of facility and did not notice any residents outside. 3:00 a.m. I went outside in front of facility and did not notice any residents outside. 5:30 a.m. (LVN G) went to do rounds and asked me where (Resident #14) was. I checked in room/bathroom and proceeded to call Code Pink. All staff searched facility rooms/bathrooms, and grounds. (Resident #14) found on grounds laying down with glasses on. Assisted him back to room. (LVN G) told me he would do head to toe assessment and call POA. No visible injuries. Resident did not have dirt on clothing and stated 'I fell asleep.' This narrative was not signed by ADON. Review of the written statement submitted to the facility by CNA A reflected the following (sic): On Friday 07/07/17 @ 10:30 p.m. I noticed (Resident #14) was not in his room. Thinking he was maybe sent to hospital, 12:40 p.m. did my second round and (Resident #14 was not present in his room so nurse (ADON) was busy on hall's I made an attempt to ask her about him but she actually seen very busy between two halls so it just over come me as I continued my round. At 6:00 am shift change nurse I asked (LVN G) for him @ 6:00 a.m. and (LVN G) got (ADON) attention to look for him. Everyone went on a search to look for him and he was found outside. This narrative was signed by CNA A and dated 7/10/17. During a telephone interview on 7/13/2017 at 10:48 a.m., CNA A stated that she had been the CNA on duty in Resident #14's hall overnight on 7/7/2017. She stated that she came in that evening at 10:00 p.m. She stated that she walked to every room at 10:30 p.m. and did not see Resident #14. She stated that two other residents were asking for as needed pain medication, and she approached ADON to tell her about those two residents and Resident #14. She stated that ADON told her I'm coming, I'm coming. CNA A stated that another resident was waiting on a breathing treatment, and she tried to approach ADON a second time but only reminded ADON of the residents needing medication and a breathing treatment. CNA A stated that ADON did not stop being busy until 1:00 a.m. CNA A stated she checked in Resident #14's room at 10:30 p.m., 12:40 a.m., 3:30 a.m., and 5:00 a.m. CNA A stated she provided incontinent care for Resident #14's roommate at 3:30 a.m. and 5:00 a.m. CNA A stated that Resident #14 was never in the room during her checks. She stated that she never spoke to ADON again through the night. She stated she thought Resident #14 was probably at the hospital, but usually someone tells her if that is the case. She stated that it is facility policy to go through an elopement process when a resident is missing. She stated that the nurses have always listened before when she told them important information about residents, and she did not know how to handle this situation. During an interview on 7/13/2017 at 1:28 p.m., CNA E stated that she was working on another hall the morning of 7/8/2017 and overheard ADON telling CNA A, When they ask you any questions, say you saw him last when you made you 5 o'clock rounds. CNA E stated that she walked away at that point, because she did not want to be involved with that situation. During an interview on 7/17/2017 at 11:54 a.m., ADON stated that she had worked from 6:00 p.m. to 6:00 a.m. at the facility on 7/7/2017. She stated that she was on call that weekend, and two nurses called in, so she came to work as charge nurse. She stated she arrived at the facility at 5:30 p.m. and saw Resident #14 in the rocking chair on the front porch. She stated she was responsible for about 40. At 9:30 p.m., she was checking blood sugar on Resident #14's roommate, and he asked where Resident #14 was. She stated she stopped the first CNA she saw and asked her to check on Resident #14. She stated she never heard back, and then stated, Honestly I was so overwhelmed and busy, and I know that is no excuse. ADON clarified that she meant she did not follow up on the missing resident and did not hear anything from the CNA she had dispatched. She denied CNA A ever coming to tell her Resident #14 was missing. Review of facility policy regarding Wandering/Missing Residents reflected the following At times, the facility admits and retains residents that are confused and have the tendency to wander about the facility. If the facility is equipped with a secured unit, these residents will normally be secured on this unit. However some of the SCC's facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. Plan of care will be developed and implemented with specific approaches and goals for the wanderer. Review of facility policy regarding Staff treatment of [REDACTED]. Review of a document dated 7/11/2017 and titled Correction Plan and dated 7/11/2017 reflected the following items: - In-service Staff, CNA, and Nurses to make walking rounds to account for residents on neighborhood on each shift change. Date initiated 7/9/17 - At the start of each shift change the on-going and in-coming Nurse will make walking rounds for Resident accountability and document on audit tool. Date initiated 7/10/17 - Code Alert Book reviewed and updated to include this resident. Date initiated 7/10/17 - Complete midnight census with visible observation of residents and document on audit tool at 6 pm, 6 am, and midnight shift. Date initiated 7/10/17 -100% assessment of residents at risk for elopement. Date initiated 7/10/17 - Nurse in-serviced to lock entry door at 10 pm. Date initiated 7/10/17 - Red River Charge Nurse on 6 pm to 6 am will ensure front entry is lock at 10 pm and residents are accounted for. Date initiated 7/10/17 - Any resident desiring to be outside on the porch after 10 pm must be supervised by staff/family member. Date initiated 7/10/17 - Resident placed on monitoring and 1 on 1. Date initiated 7/10/17 - Wander guard placed on resident. Date initiated 7/10/17 - Review all residents BIM scores, and those residents with a score of below 12 will be accompanied with supervision outside. Date initiated 7/10/17 - List of residents with BIMS below 12 will be identified at the front desk and each nurse's station. This will be updated by SW when a change in BIM score occurs. Date initiated 7/10/17 - Residents with score of below 12 will be added to the POC task for CNAs. Date initiated 7/10/17 - Residents identified will have their care plan updated. Date initiated 7/10/17 Review of an undated document titled Performance Improvement Plan reflected the following: Observation Continuous monitoring for compliance of resident presents in the building.Goal/Objective All residents will be accounted for in the building at the beginning of each shift at 6 AM and 6 PM and 12 midnight each day. Actions Nurse managers, licensed nurses, CMAs and CNAs have been trained and in-servicde on the below process so everyone is aware. Employee will be trained prior to their next day of working for PRN employees. All new employees will receive training in their orientation. At the beginning of each shift walking rounds will be done by the oncoming nurse and the off going nurse to ensure all residents are accounted for. The midnight census of heads in the bed will be given to the ADM each morning/Manager on Duty on the weekend. The audit tool for the charge nurse rounds will be signed by oncoming nurse daily. This will be reviewed in the morning clinical meeting. The weekend Manager on Duty will review on the weekend. If any concerns over the weekend, the ADM and DON will be notified. Identification of noncompliance, a disciplinary action will be documented by DON. All weekly findings will be reviewed at the weekly WAR meeting and monthly at the QAPI Meeting. If any discrepancies of residents being accounted for in the building occurs, the ADM, DON, RVP, and DCO will be notified immediately. Director of clinical operations will review for compliance with each facility visit. Observations of Resident #14 between 7/11/2017 at 8:20 a.m. and 7/13/2017 at 3:18 p.m. revealed a staff person providing one to one supervision at all times and a wander guard on his right ankle under his sock. During an interview on 7/11/2017 at 10:06 a.m., CMA I stated that she had been in-serviced the day before on elopement procedures and abuse and making rounds and they are doing head counts at every shift change now. She stated that she knows Resident #14 was out and was not supposed to be out, and he is now a risk for elopement. She named Residents #40, 41, and 42 on hall 100 who are at risk for elopement. She stated there are no residents on hall 200 at risk for elopement. During an interview on 7/11/2017 at 10:08 a.m., CNA C stated that they received training that morning before their shift for elopement, abuse and neglect, and making rounds. She stated that she works on hall 100, and her residents at risk for wandering are Residents #40, 41, and 42 but that she has to make sure to count all the residents. During an interview on 7/11/2017 at 1:52 p.m., LVN F stated that the charge nurses are now to sign a census sheet accounting for every resident at shift change, and this is given to the ADM and/or the Manager on Duty, depending on the day of the week. She stated that, in the event of an elopement, the administrator should be notified no matter who the manager on duty is. During an interview on 7/12/2017 at 2:40 p.m., CNA J stated that she was in-serviced the afternoon of 7/10/2017 on elopement and resident head counts, and they have a new procedure in place to count residents at every shift change. She stated she knows to contact a charge nurse if there is a missing resident. She stated she works on hall 300, and Resident #14 is her only elopement risk. During an interview on 7/12/2017 at 2:46 p.m., CNA D stated that she received in-servicing on elopement and making head counts and she has had three in-services on abuse/neglect in the last two weeks. She stated that she works on hall 200 and does not have any residents on the elopement list. Review of facility in-service dated 7/9/17 and titled Elopement Monitoring/Rounds reflected the following instruction: All staff should be making rounds to ensure that all residents are accounted for and needs are being met during their shift. In addition, a round should be done by both nurses and CNAs at the beginning of the shift to perform a head count of the residents on the hall to ensure that all residents whereabouts are known. If a resident is unable to be found at this time or any other, a CODE PINK should be called immediately by the charge nurse on duty. All staff should immediately begin to search the building and grounds methodically for the missing resident. The charge nurse on duty must notify the DON and administrator immediately when a CODE PINK is called, as well as when the resident has been located. Charge nurse on duty should complete an incident report for the elopement and the resident should be immediately started on visual monitoring every hour for three days. Review of facility in-service dated 7/10/17 and titled Making Rounds on Resident reflected the following instruction: CNA is to make rounds with oncoming shift. And every two hours during the shift. All residents need to be visualized during the round, any resident sitting outside needs to be communicated to charge nurse for monitoring. Nurses should make rounds at the beginning of the shift, during the middle of the shift and at the end of the shift. P.m. nurses need to do rounds at midnight. Doors are to be locked at 10 PM after all residents are accounted for. Report any changes or unaccounted resident to the charge nurse. Review of facility in-service dated 7/11/17 and titled Binder at Nurses Station and Lobby Desk identifying residents with BIMS less than 12. Asterisk of those residents that enjoy going outside and will need staff/family supervision reflected the following instruction: There is a binder that has been established at the Nurses Station and lobby desk with residents who have triggered below a 12 on their BIMS assessment. The resident with an asterisk are identified as those residence with the BIMS of less than 12, but enjoy going outside on the front porch. The residents with asterisks will require supervision when they go outside. Residents list will be updated with change in condition and MDS. Residents identified will be reported weekly during facility at risk meeting. Observation on 7/13/2017 at 1:15 p.m. reflected binders at the lobby desk and the Nurses Station containing a list of residents with BIMS scores under 12, which indicates a cognitive impairment. Review of this document reflected a list of 41 residents with BIMS scores under 12 and 8 residents with asterisks indicating they enjoy sitting outside with supervision. Observations of the facility front porch between 7/11/2017 at 6:45 a.m. and 7/13/2017 at 4:13 p.m. revealed a staff person present at all times that any resident was sitting outside. Review of facility in-service dated 7/13/17 and titled Reporting any alleged misconduct to facility ADM. Always Follow facility Policy and procedures and local and Federal laws. reflected the following instruction: As I have spent time this week with you here at Riverside I just want to make sure everyone is knowledgeable regarding reporting and sharing concerns, and concerns of misconduct. We all have a responsibility to our residents and coworkers to do the right thing every day. As a facility we must follow our policies and procedures. We also must follow local and federal laws and guidelines. Whether it's your supervisor, another staff or even family member you are asked to do something that you know is not right, you are uncomfortable with, I need you to feel comfortable with questioning what is being asked of you. I encourage you to call your facility administrator, your director of nursing. If you remain uncomfortable still I encourage you to call the compliance hotline [PHONE NUMBER] or you can visit the website. Review of document titled Ad Hoc QAPI included all items described in Correction Plan and reflected signatures from Director of Clinical Operations, Medical Director, Attending Physician, Vice President of Operations, Administrator, and Director of Nursing. Review of facility investigation report reflected written warnings and three-day suspensions for ADON and CNA A. Review of physician progress notes [REDACTED]. The physician also recorded that ant bites are usually immediate reaction. Physician diagnosed Resident #14 with folliculitis/impetigo and treated with Keflex 250 mg. Review on 7/13/2017 of updated care plan for Resident #14 reflected a revised Focus Item created on 7/9/2017 and containing the following information: I need supervision by facility or hospice staff when I have a desire to go outside of all buildings. and one created 7/11/2017 and containing the following information: Wander guard check placement and functioning every shift. Review of the revised care plan refelcetd that the previous Focus Item from 10/7/2016, I have an actual incident of elopement towards Riverside street and have potential for more attempts, remained on the revised care plan. Review of Wandering/Elopement Risk Evaluations for all residents with a history of wandering reflected that Residents #40, 41, 42, 43, and 44 had evaluations completed between 7/10/2017 and 7/13/2017. Observation of Resident #43 on 7/13/2017 at 8:40 a.m. revealed she was in her bed asleep with most of her breakfast still on a tray in front of her. A wander guard was visible on her right ankle, and a wheelchair sat by her bed. A sign hung over her bed with information about the Happy Feet Club. Observation of Resident #40 on 7/13/2017 at 8:45 a.m. revealed that she was asleep under a throw blanket in her bed. A wander guard was visible on her right ankle. A sign hung over her bed with information about the Happy Feet Club. Observation of Resident #42 on 7/13/2017 at 9:10 a.m. revealed that she was seated upright in her wheelchair in the television room. She did not grant permission to observe her ankle. She struggled to reorient her wheelchair and move it forward and made very slow progress. During an interview with Resident #42 on 7/13/2017 at 9:10 a.m., she stated that she cannot stand up on her own and can barely move her own wheelchair. She stated she has never tried to leave the facility without someone attending her. Observation of bedroom for Resident #42 at 9:20 a.m. revealed a sign hung over her bed with information about the Happy Feet Club. Review of a document titled Midnight Census Report and dated 7/12/2017 reflected a list of all residents in the facility with check marks next to each resident name with a space for a head count number and a signature on the bottom of the document. Check marks reflected that all residents were accounted for, and the document was signed by LVN M. Review on 7/13/2017 of a document titled Resident Monitoring Tool reflected a head count on each hall initialed by the outgoing and oncoming charge nurse at 6:00 p.m., 6:00 a.m., and midnight each day starting at 6:00 p.m. on 7/10/2017 through 6:00 a.m. 7/13/2017. Review of CMS-802 reflected that 6 residents with wandering behaviors could have been affected by the facility's failure to provide adequate supervision.

Based on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); or a need to alter treatment significantly for one of six residents reviewed for lab performance (Resident #4). Resident #4 had physician ordered lab studies for altered mental status to rule out infection. The lab results had critical high levels of white blood cells and critically low blood sugar indicating an infection. Resident #4's physician was not notified of the critical lab results and continued to receive medication ([MEDICATION NAME]) to lower her blood sugar after the lab results were available. Subsequently, Resident #4 became unresponsive and was admitted to a hospital intensive care unit for 3 days with an intestinal infection; and had a total hospital stay of 12 days. This deficient practice could affect a facility census of 40 residents with a [DIAGNOSES REDACTED]. Findings Include: Resident #4 was [AGE] years old with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident #4 dated 01/19/16 reflected she required extensive assistance of two staff for all activities of daily living except eating, which required set up only. Resident # 4 was occasionally incontinent of bladder and bowel and had minimal cognitive impairment. Further review of the admission MDS for Resident #4 reflected in Section I -[DIAGNOSES REDACTED]. Review of a care plan for Resident #4 dated 01/14/16 reflected there were no goals or interventions for Diabetes Mellitus or [DIAGNOSES REDACTED] (low blood sugar). Review of physician's orders [REDACTED]. -Document blood sugars twice daily for Pre-Diabetes in the morning and evening. -[MEDICATION NAME] 2.5 mg. one tablet a day. ([MEDICATION NAME] is an oral medication used to control/lower blood sugars in patients with non insulin type Diabetes). Review of a NP progress note dated 01/22/16 for Resident #4 reflected the following: Patient with episodes of confusion yesterday {01/21/16}. Refused [MEDICAL TREATMENT]. Patient has improved per staff. Will check labs to rule out infection due to altered mental status. Labs ordered CBC, BMP. Ammonia level and urinalysis with culture and sensitivity if indicated. Review of a lab studies report for Resident #4 dated 01/23/16 reflected the following: Critical results called to {Registered Nurse-RN A} at 03:08 AM-results read back correctly. Glucose- 50 (normal range is 70 and 100). White Blood Count- 22.0 (Normal range is 4.0-10.8) There was a notation on the bottom portion of the lab results page that read -faxed to NP 01/23/16 (there was no signature or initials indicating who sent the fax). Review of the January 2016 MAR for Resident # 4 reflected [MEDICATION NAME] 2.5 mg was adminstered on 01/23/16 and 01/24/16. In an interview on 05/26/16 at 2:30 PM, RN A, stated she is the Infection Control Nurse and part of the management team. RN A added she rotates taking weekend call and if someone calls in she works the shift. RN A added she did not recall working the night of 01/22/16 but she could have. RNA A could not recall receiving a call from the lab about Resident #4's critical lab results. RN A reviewed the lab results and stated the notation of the fax to the NP was not her hand writing and denied being aware of the results despite the fact her name was on the results for the person contacted by the lab. RN A added critical labs are called to the facility by the lab and then facility staff are to call the physician no matter what time they are received and faxing is not considered notification. {As of exit on 05/26/16 the facility staff were unable to determine whose writing was on the lab results indicating they were faxed.} Review of the nurses' notes for Resident #4 dated 01/24/16 reflected residents blood sugar was 69 at 0700. Rechecked after 30 minutes and it {blood sugar level} was 56. Patient appears confused and said 'she's in jail.' One tube of glucose given (a medicinal preparation to raise a dangerously low blood sugar) and NP notified. Rechecked at 10:00 AM (2 hours after giving the glucose) and the blood sugar level was 92. Patient becoming less confused. Alert and oriented and having brunch.{the facility offers a small breakfast of cereal, juices and/or milk prior to lunch} Will continue to monitor. In a telephone interview on 05/25/16 at 2:00 PM, LVN M stated on the morning of 01/24/16 she had treated Resident #4 for an episode of low blood sugar and given a tube of glucose. LVN M stated she checked her again at 10:00 AM and her glucose level was 92 and Resident #4 had been served her brunch and was eating. LVN M stated just a few minutes after checking on Resident #4 her sister walked in to the facility and asked how she (Resident #4) was doing. LVN M stated Resident #4's sister was told about the earlier episode of confusion and low blood sugar, but she was fine now. LVN M stated Resident #4's sister went in to the room and came back to the nurses' station and said this is unacceptable! Call 911 now for my sister. LVN M stated she called the nurse practitioner using her cell phone, rather than call 911, to inform him of the sister's request; and gave the cell phone to the sister so they could speak. LVN M stated Resident #4's sister told the NP if you cannot come here immediately, then I want 911 called and my sister (Resident #4) taken to the hospital. LVN stated she called 911, but Resident #4's sister would not allow her in the room to assess her. LVN M stated she thought she told the Medication Aide to hold Resident # 4's [MEDICATION NAME] on the morning of 01/24/16 when the glucose levels were low, but did not check to see if it had been held. LVN M stated the emergency medical services technicians had reported Resident #4's was 20 when they arrived. LVN M added she was unsure of the facility's policy on when to re-check a blood sugar after administering glucose, but thought it was 15 or 30 minutes after administration. LVN M did not have an explanation for rechecking Resident #4's blood sugar at 10:00 AM, when thirty minutes after giving the glucose would have been approximately 8:00 AM. In a telephone interview on 05/26/16 at 3:00 PM, the Nurse Practitioner (NP) for Resident #4's Primary Care Provider stated a facility nurse called him on the morning of 01/24/16 when Resident #4 had a hypoglycemic episode (low blood glucose/sugar) and was given oral glucose; and had responded well according to the nurse. The NP stated he was not on call for the weekend of January 23-24, 2016, but staff sometimes calls him when he is not on call and he responds. The NP stated he was not called regarding any critical abnormal labs for Resident #4. The NP stated he reviewed his notes for Resident # 4 via the electronic record and did not see any notations of the abnormal labs for 01/23/16. The NP stated if he would have been informed of the lab results, and knowing her recent altered mental status and condition, he would have sent Resident #4 immediately to the hospital. In a telephone interview with Resident #4's physician on 05/26/16 at 3:32 PM, she stated she never takes weekend call. The physician stated she would review Resident #4's record when she returned to the office and see if there is any notation of critical lab values for the 01/23/16. But with the lab values being what they were and critical, the person on call should have been called immediately. {The physician did not call the Investigator to provide additional information before or after exit on 05/26/16} In an interview on 05/26/16 at 3:10 PM, the DON stated she would begin in-servicing on the procedures for receiving critical lab values and will do an individual in-service with RN A. The DON added she had spoken with LVN M who was the charge nurse that sent Resident #4 to the emergency roiagnom on the morning of 01/23/16 and she reported she had not been aware of any critical lab values for Resident #4. The DON confirmed the facility's policy for [DIAGNOSES REDACTED] is to recheck the blood glucose 15 minutes after administering glucose. In a telephone interview on 05/23/16 at 11:00 AM, Resident #4's Responsible Party (RP) stated on the morning of 01/24/16 she stopped by the nurses' station to ask how she (Resident #4) had been overnight. The RP stated LVN M told her Resident #4 had an episode of low blood sugar and confusion, but she had recovered. The RP stated she went directly in to Resident #4's room and found her unresponsive with her eyes rolled back in her head, naked, and there was a large amount of diarrhea on her buttocks and upper legs. The RP stated she immediately told LVN M to call 911 and send her sister to the hospital. The RP added when the emergency staff arrived Resident #4's glucose level was in the teens. {meaning somewhere between 13 and 19} Resident #4's RP stated emergency medical services transferred her to the hospital where she was admitted to the intensive care unit for 3 days with [MEDICAL CONDITION] (a bacterial intestinal infection) and remained in the hospital for 12 days. Review of the facility's policy titled Laboratory and dated August 2013 reflected the following: Lab results: Panic/Critical lab values will be called immediately to the physician upon receipt of the Panic/Critical lab value. {As of exit 05/26/16 the facility had not been able to provide information on whose handwriting was on the critical lab results for Resident #4 indicating they had been faxed to the NP. Review of the facility's [DIAGNOSES REDACTED] Management policy dated March 2015 reflected the following: Policy: Facility staff will strive to identify [DIAGNOSES REDACTED] in residents in a timely manner. Procedure: If glucose level is less than 70mg/dl staff will treat the resident's [DIAGNOSES REDACTED]. If the resident is alert and able to eat and drink: 1 e.) give one tube of glucose gel 2. Wait 15 minutes and recheck blood sugar/glucose. 3. If blood sugar/glucose is still less than 70 repeat above. The DON provided a list of 40 residents with a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for quality of care (Resident # 4). Resident #4 had physician ordered lab studies for altered mental status to rule out infection. The lab results had crtital levels of white blood cells and critically low blood sugar indicating a severe infection. Resident #4's physician was not notified of the critial lab results and contiuned to receive medication ([MEDICATION NAME]) to lower her blood sugar for two days after the lab results were available. Subsequently, Resident #4 became unresponsive and was admitted to a hospital intensive care unit for 3 days and had a total hospital stay of 12 days. This deficient practice could affect a facility census 40 residents with a [DIAGNOSES REDACTED]. The Findings Include: Resident #4 was [AGE] years old with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident #4 dated 01/19/16 reflected she required extensive assistance of two staff for all activities of daily living except eating, which required set up only. Resident # 4 was occasionally incontinent of bladder and bowel and had minimal cognitive impairment. Further review of the admission MDS for Resident #4 reflected in Section I -[DIAGNOSES REDACTED]. Review of a care plan for Resident #4 dated 01/14/16 reflected there were no goals or interventions for Diabetes Mellitus or [DIAGNOSES REDACTED] (low blood sugar). Review of physician's orders [REDACTED]. -Document blood sugars twice daily for Pre-Diabetes in the morning and evening. -[MEDICATION NAME] 2.5 mg. one tablet a day. (Glyberide is an oral medication used to control/lower blood sugars in patients with non insulin type Diabetes). Review of a NP progress note dated 01/22/16 for Resident #4 reflected the following: Patient with episodes of confusion yesterday {01/21/16}. Refused [MEDICAL TREATMENT]. Patient has improved per staff. Will check labs to rule out infection due to altered mental status. Labs ordered CBC, BMP. Ammonia level and urinalysis with culture and sensitivity if indicated. Review of a lab studies report for Resident #4 dated 01/23/16 reflected the following: Critical results called to {Registered Nurse-RN A} at 03:08 AM-results read back correctly. Glucose- 50 (normal range is 70 and 100). White Blood Count- 22.0 (Normal range is 4.0-10.8) There was a notation on the bottom portion of the lab results page that read -faxed to NP 01/23/16 (there was no signature or initials indicating who sent the fax). Review of the January 2016 MAR for Resident # 4 reflected Glyberide 2.5 mg was administered on 01/23/16 and 01/24/16. In an interview on 05/26/16 at 2:30 PM, RN A, stated she is the Infection Control Nurse and part of the management team. RN A added she rotates taking weekend call and if someone calls in she works the shift. RN A added she did not recall working the night of 01/22/16 but she could have. RNA A could not recall receiving a call from the lab about Resident #4's critical lab results. RN A reviewed the lab results and stated the notation of the fax to the NP was not her hand writing and denied being aware of the results despite the fact her name was on the results for the person contacted by the lab. RN A added critical labs are called to the facility by the lab and then facility staff are to call the physician no matter what time they are received and faxing is not considered notification. {As of exit on 05/26/16 the facility staff were unable to determine whose writing was on the lab results indicating they were faxed.} Review of the nurses' notes for Resident #4 dated 01/24/16 reflected residents blood sugar was 69 at 0700. Rechecked after 30 minutes and it {blood sugar level} was 56. Patient appears confused and said 'she's in jail.' One tube of glucose given (a medicinal preparation to raise a dangerously low blood sugar) and NP notified. Rechecked at 10:00 AM (2 hours after giving the glucose) and the blood sugar level was 92. Patient becoming less confused. Alert and oriented and having brunch.{the facility offers a small breakfast of cereal, juices and/or milk prior to lunch} Will continue to monitor. The note was electronically signed by LVN M. In a telephone interview on 05/25/16 at 2:00 PM, LVN M stated on the morning of 01/24/16 she had treated Resident #4 for an episode of low blood sugar and given a tube of glucose. LVN M stated she checked her again at 10:00 AM and her glucose level was 92 and Resident #4 had been served her brunch and was eating. LVN M stated just a few minutes after checking on Resident #4 her sister walked in to the facility and asked how she (Resident #4) was doing. LVN M stated Resident #4's sister was told about the earlier episode of confusion and low blood sugar, but she was fine now. LVN M stated Resident #4's sister went in to the room and came back to the nurses' station and said this is unacceptable! Call 911 now for my sister. LVN M stated she called the nurse practitioner using her cell phone, rather than call 911, to inform him of the sister's request; and gave the cell phone to the sister so they could speak. LVN M stated Resident #4's sister told the NP if you cannot come here immediately, then I want 911 called and my sister (Resident #4) taken to the hospital. LVN stated she called 911, but Resident #4's sister would not allow her in the room to assess her. LVN M stated she thought she told the Medication Aide to hold Resident # 4's [MEDICATION NAME] on the morning of 01/24/16 when the glucose levels were low, but did not check to see if it had been held. LVN M stated the emergency medical services technicians had reported Resident #4's was 20 when they arrived. LVN M added she was unsure of the facility's policy on when to re-check a blood sugar after administering glucose, but thought it was 15 or 30 minutes after administration. LVN M did not have an explanation for rechecking Resident #4's blood sugar at 10:00 AM, when thirty minutes after giving the glucose would have been approximately 8:00 AM. In a telephone interview on 05/26/16 at 3:00 PM, the Nurse Practitioner (NP) for Resident #4's Primary Care Provider stated a facility nurse called him on the morning of 01/24/16 when Resident #4 had a hypoglycemic episode (low blood glucose/sugar) and was given oral glucose; and had responded well according to the nurse. The NP stated he was not on call for the weekend of January 23-24, 2016, but staff sometimes calls him when he is not on call and he responds. The NP stated he was not called regarding any critical abnormal labs for Resident #4. The NP stated he reviewed his notes for Resident # 4 via the electronic record and did not see any notations of the abnormal labs for 01/23/16. The NP stated if he would have been informed of the lab results, and knowing her recent altered mental status and condition, he would have sent Resident #4 immediately to the hospital. In a telephone interview with Resident #4's physician on 05/26/16 at 3:32 PM, she stated she never takes weekend call. The physician stated she would review Resident #4's record when she returned to the office and see if there is any notation of critical lab values for the 01/23/16. But with the lab values being what they were and critical, the person on call should have been called immediately. {The physician did not call the Investigator to provide additional information before or after exit on 05/26/16} In an interview on 05/26/16 at 3:10 PM, the DON stated she would begin in-servicing on the procedures for receiving critical lab values and will do an individual in-service with RN A. The DON added she had spoken with LVN M who was the charge nurse that sent Resident #4 to the emergency roiagnom on the morning of 01/23/16 and she reported she had not been aware of any critical lab values for Resident #4. The DON confirmed the facility's policy for [DIAGNOSES REDACTED] is to recheck the blood glucose 15 minutes after administering glucose. In a telephone interview on 05/23/16 at 11:00 AM, Resident #4's Responsible Party (RP) stated on the morning of 01/24/16 she stopped by the nurses' station to ask how she (Resident #4) had been overnight. The RP stated LVN M told her Resident #4 had an episode of low blood sugar and confusion, but she had recovered. The RP stated she went directly in to Resident #4's room and found her unresponsive with her eyes rolled back in her head, naked, and there was a large amount of diarrhea on her buttocks and upper legs. The RP stated she immediately told LVN M to call 911 and send her sister to the hospital. The RP added when the emergency staff arrived Resident #4's glucose level was in the teens. {meaning somewhere between 13 and 19} Resident #4's RP stated emergency medical services transferred her to the hospital where she was admitted to the intensive care unit for 3 days with [MEDICAL CONDITION] (a bacterial intestinal infection) and remained in the hospital for 12 days. Review of the facility's policy titled Laboratory and dated August 2013 reflected the following: Lab results: Panic/Critical lab values will be called immediately to the physician upon receipt of the Panic/Critical lab value. {As of exit 05/26/16 the facility had not been able to provide information on whose handwriting was on the critical lab results for Resident #4 indicating they had been faxed to the NP. Review of the facility's [DIAGNOSES REDACTED] Management policy dated March 2015 reflected the following: Policy: Facility staff will strive to identify [DIAGNOSES REDACTED] in residents in a timely manner. Procedure: If glucose level is less than 70mg/dl staff will treat the resident's [DIAGNOSES REDACTED]. If the resident is alert and able to eat and drink: 1 e.) give one tube of glucose gel 2. Wait 15 minutes and recheck blood sugar/glucose. 3. If blood sugar/glucose is still less than 70 repeat above. The DON provided a list of 40 residents with a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to notify the physician of lab results for 1 of 6 residents reviewed for physician notification of lab results (Resident # 4). Resident #4 had physician ordered lab studies for altered mental status to rule out infection. The lab results had critical high levels of white blood cells and critically low blood sugar indicating an infection. Resident #4's physician was not notified of the critical lab results and continued to receive medication ([MEDICATION NAME]) to lower her blood sugar after the lab results were available. Subsequently, Resident #4 became unresponsive and was admitted to a hospital intensive care unit for 3 days with an intestinal infection; and had a total hospital stay of 12 days. This deficient practice could affect a facility census of 40 residents with a [DIAGNOSES REDACTED]. The Findings Include: Review of Resident #4's Face Sheet reflected Resident #4 was [AGE] years old with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of an admission MDS for Resident #4 dated 01/19/16 reflected she required extensive assistance of two staff for all activities of daily living except eating. Resident # 4 was occasionally incontinent of bladder and bowel and had minimal cognitive impairment. Review of nurses' notes for Resident #4 dated 01/24/16 reflected she was sent to a local hospital via emergency medical services due to being hypoglycemic, unresponsive, and at the family's request. Resident #4 did not return to the facility. Review of a lab studies report for Resident #4 dated 01/23/16 reflected the following: Critical results called to {Registered Nurse-RN A} at 03:08 AM-results read back correctly. Glucose- 50 (normal range is 70 and 100). White Blood Count- 22.0 (Normal range is 4.0-10.8) There was a notation on the bottom portion of the lab results page that read -faxed to NP 01/23/16 (there was no signature or initials indicating who sent the fax). In an interview on 05/26/16 at 2:30 PM, RN A stated she is the Infection Control Nurse and part of the management team. RN A added she rotates taking weekend call and if someone calls in she works the shift. RN A added she did not recall working the night of 01/22/16, or remember receiving a call from the lab about Resident #4's critical lab results. RN A reviewed the lab results and stated the notation of the fax to the NP was not her hand writing. RN A added critical labs are to be called to the physician no matter what time they are received and faxing is not considered notification. In an interview on 05/26/16 at 3:10 PM, the DON stated she would begin in-servicing on the procedures for receiving critical lab values and will do an individual in-service with RN A. The DON added she had spoken with LVN M who was the charge nurse that sent Resident #4 to the emergency roiagnom on the morning of 01/23/16 and she reported she had not been aware of any critical lab values for Resident #4. In a telephone interview on 05/26/16 at 3:00 PM, the Nurse Practitioner (NP) for Resident #4's Primary Care Provider stated a facility nurse called him on the morning of 01/24/16 when Resident #4 had a hypoglycemic episode (low blood glucose/sugar) and was given oral glucose; and had responded well according to the nurse. The NP stated he was not on call for the weekend of January 23-24, 2016, but staff sometimes calls him when he is not on call and he responds.The NP stated he was not called regarding any critical abnormal labs for Resident #4. The NP stated he reviewed his notes for Resident # 4 via the electronic record and did not see any notations of the abnormal labs for 01/23/16. The NP stated if he would have been informed of the lab results, and knowing her recent altered mental status and condition, he would have sent Resident #4 immediately to the hospital. In a telephone interview with Resident #4's physician on 05/26/16 at 3:32 PM, she stated she never takes weekend call. The physician stated she would review Resident #4's record when she returned to the office and see if there is any notation of critical lab values for the 01/23/16; but with the lab values being considered critical the person on call should have been called immediately. {The physician did not call the Investigator to provide additional information before or after exit on 05/26/16} Review of the facility's policy titled Laboratory and dated August 2013 reflected the following: Lab results: Panic/Critical lab values will be called immediately to the physician upon receipt of the Panic/Critical lab value. {As of exit 05/26/16 the facility had not been able to provide information on whose handwriting was on the critical lab results for Resident #4 indicating they had been faxed to the NP.} The DON provided a list of 40 residents with a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to immediately consult with the physician for 1 of 6 residents reviewed for a change in condition (Resident #22). Resident #22, was being treated for [REDACTED]. The resident developed an "open" denuded area on her right gluteal area that deteriorated with alternating periods of improvement and decline from [DATE] to [DATE]. Resident #22 was transferred to the hospital on [DATE] for an unrelated condition at that time the resident was diagnosed with [REDACTED]. The physician was not notified of the change in the deteriorationg skin condition, nor did the staff seek a change in treatment. Resident #22 died on [DATE] in the hospital due to an unrelated medical condition. This deficient practice affected one resident with IAD by not getting the necessary medical treatment and services to prevent pressure ulcer development and infection. Findings include: Review of Resident #22's physician order [REDACTED]. Review of Resident #22's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected she was at risk for developing pressure ulcers and required extensive assistance of two or more persons related to bed mobility and was incontinent of bowel. Review of Resident #22's Quarterly Braden Scale Assessments for predicting pressure sore risks dated [DATE], [DATE], [DATE], and [DATE] each reflected a score of 15 that determined the resident was "at risk" for pressure sore development. Review of Resident #22's Care Plan dated [DATE] reflected a potential for pressure ulcer development related to impaired bed mobility and bowel incontinence and noted interventions to address the risk of pressure ulcers as follows: "Assess/record/monitor wound healing routine. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD/family/wound care nurse. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of Resident #22's Care Plan dated [DATE] reflected a history of chronic denuded skin to buttock/sacral areas and chronic incontinence of bowel. Further review reflected no updated/revised goals or interventions related to pressure ulcer care and treatment had been put into place for the resident. Review of Resident #22's physician's orders [REDACTED]. Review of the ongoing weekly Non-Pressure Condition Reports for Resident #22's right gluteal area assessed by the treatment nurse reflected the following: [DATE] for the right gluteal area reflected that the skin was "intact." [DATE] for the right gluteal area reflected a new "partial thickness" skin loss that measured 6 centimeters (cm) by 4 cm with a depth of 0.2 cm. The area was described as "dark pink/red tissue" that had "deteriorated" with a small amount of drainage of an "open" denuded skin as assessed by the facility's treatment nurse, who documented application of [MEDICATION NAME] Paste to the area. ([MEDICATION NAME] Paste is an over-the-counter zinc oxide-based paste that protects against moisture and minor skin irritation). [DATE] measurements smaller at 5 cm by 4 cm with 0.2 depth "partial thickness" skin loss with "dark pink/red tissue" with gluteal area "denuded from moist incontinence" and "not changed" with continued application of [MEDICATION NAME] Paste to the area. [DATE] no documentation of any measurements, but assessed as "partial thickness" skin loss with "dark pink/red tissue" with gluteal area "denuded" and "not changed" with "[MEDICATION NAME] treatment continued every 8 hours and prn (as needed) following incontinent care." [DATE] measurements smaller at 3 cm by 1 cm with 0.1 depth "partial thickness" skin loss with "dark pink/red tissue" and noted progress "not changed", but area "less red" and "treatment with [MEDICATION NAME] continued every 8 hours and prn after incontinent care." [DATE] measurements larger at 3 cm by 1.8 cm by 0.2 cm depth "partial thickness" skin loss with "dark pink/red tissue" and progress note by treatment nurse of "red [MEDICAL CONDITION], denuded skin, open" with [MEDICATION NAME] treatment continued. Review of Resident #22's Nurses Notes dated [DATE] reflected that she was transferred to a local area hospital emergency room for a condition unrelated to her skin breakdown. Further review of Resident # 22's nurses notes from [DATE] until her transfer to the hospital on [DATE] reflected no documentation that the resident's physician was notified of the resident's skin breakdown that had been initially assessed by the treatment nurse on [DATE]. Review of Resident #22's physician's orders [REDACTED]. Review of the hospital emergency room physician's report dated [DATE], reflected Resident #22 had "increased ulcers and skin breakdown in the sacral, buttock and perineal area. Also note purulent drainage from the vagina," and "Multiple diffuse decubitus ulcers." The Clinical Impression reflected "Multiple pressure ulcers: sacrum, right buttock and left buttock. Stage: 2 and 3 (decubitus/perineal)." This report further noted that the resident had "feces around her vaginal area." Review of the hospital's history and physical (H&P) dated [DATE] by Resident #22's attending physician reflected that the resident had "multiple medical problems", one of which was "...multiple decubitus ulcers over her back side." Review of a hospital consultation report for Resident #22 dated [DATE] by a consulting physician, reflected that the resident had "several sacral decubiti over the pelvis." Review of the hospital's photographic wound documentation for Resident #22 dated [DATE] reflected Stage II, Stage III, and unstageable pressure ulcers to the resident's buttocks, sacrum and thighs. During an interview on [DATE] at 10:00 a.m., the hospital's Registered Nurse (RN) Director of Quality Outcomes and Management stated that it is hospital policy to take photos as evidence and documentation of patients' physical conditions upon arrival at the hospital and prior to admission. She stated that the patient's (Resident #22's) photos clearly show the Stage 2 and 3 pressure ulcers over her sacral area with visible depth and fascia. She also stated that the patient (Resident #22) was seen by at least three hospital physicians who were all in agreement about the pressure ulcers' assessments. During an interview with the Licensed Vocational Nurse (LVN) treatment nurse on [DATE] at 1:15 p.m., she stated Resident #22's wounds were from Incontinence Associated [MEDICAL CONDITION] (IAD), a skin irritation that results from chronic urinary and/or bowel incontinence. She stated the wounds were being treated with [MEDICATION NAME] Paste, an over-the-counter topical ointment and moisture barrier that contains [MEDICATION NAME] and zinc oxide and did not consider the wounds to be pressure ulcers. She stated her understanding of a pressure ulcer is an open wound on a bony area and she did not consider the gluteals bony areas, but did say the areas are exposed to moisture and pressure. She stated that the facility's wound specialist, who is a Wound Ostomy Continence Nurse (WOCN) had told her that if the resident's skin condition failed to improve or got worse, to let her know and she would see the resident. The treatment nurse stated she continued to do weekly assessments of the resident's skin and apply the [MEDICATION NAME] as treatment, but did not consult the facility's WOCN, because the wounds would get better and then worse and get better again. During an interview on [DATE] at 8:30 a.m., Resident #22's physician, who was also one of the facility's two Medical Directors stated that the resident was seen by his Nurse Practitioner (NP) and he had not been informed of any changes to the resident's skin beyond the chronic condition of IAD for which she had been receiving treatment. During an interview on [DATE] at 10:00 a.m., Resident #22's physician's NP stated she last saw Resident #22 in [DATE], before going on maternity leave and at that time the resident's condition "had not progressed beyond denuded, excoriated, superficial breakdown on her buttocks." During an interview on [DATE] at 10:55 a.m., the WOCN stated that facility's procedure should be to consult her when wounds did not progress, when wounds required debridement, when residents had IAD that failed to improve, and she would do an assessment and make treatment recommendations to the physicians. She stated she had previously instructed the treatment nurse to contact her if Resident #22's skin condition failed to progress or worsened. The WOCN stated that the next step after she made an assessment of the resident would have been to notify the physician of her findings and make a recommendation for a change in treatment to prescription-strength [MEDICATION NAME] powder and [MEDICATION NAME]. The WOCN stated she was not informed of any lack of progress in the resident's skin condition or she would have seen her upon request. During an interview on [DATE] at 2:15 p.m., the Director of Nursing (DON) stated she knew that there were open wounds on Resident #22's buttocks, but considered it IAD. The DON thought the WOCN had talked with the treatment nurse about a month ago about the status of the resident's wounds. The DON stated at that time she thought the areas had been diagnosed as IAD. The DON was asked what change in condition would prompt her to call on the WOCN for an assessment of the resident's wounds. She stated that the wounds would get worse, but then seemed to respond to the [MEDICATION NAME] cream and then a few days later returned to red, denuded areas. She stated that because of the periodic improvement of the resident's skin, no one requested an assessment by the WOCN. Review of an article published by a healthcare association Certified Wound Ostomy Continence Nurse (CWOCN) dated [DATE] at www.gnyhaservices.com entitled "Differentiating Incontinence-Associated [MEDICAL CONDITION] from Category/Stage II Pressure Ulcers" reflected the following statement: "Patients with incontinence-associated [MEDICAL CONDITION] can develop a pressure ulcer because excessive moisture reduces the skin's tolerance to excessive pressure!" Review of the facility's undated pressure ulcer protocol reflected under the section "General Preventive Measures" that the assessing nurse should "Immediately report any signs of a developing pressure ulcer to the supervisor." Review of the facility's Incontinence-Associated [MEDICAL CONDITION] Intervention Tool (IAD-IT) dated 2008 (month unknown) reflected an intervention to "Consult WOCN if available." Review of the 'Pressure Ulcer Prevention & Treatment' QUICK REFERENCE GUIDE International NPUAP-EPUAP Pressure Ulcer Classification System Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanginous-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. *Bruising indicates deep tissue injury. Category/Stage III: Full Thickness Skin Loss Partial thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. The CMS form 670 dated [DATE] revealed 5 residents remained in the facility with pressure sores.

Based on interview and record review the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcer development for 1 of 6 residents (Resident #22) reviewed for pressure ulcers. Resident #22 was being treated for [REDACTED]. The resident developed an 'open' denuded area on her right gluteal area that deteriorated with alternating periods of improvement and decline from [DATE] to [DATE]. Resident #22 was transferred to the hospital on [DATE] for an unrelated condition. At that time, the resident was diagnosed with [REDACTED]. The staff did not notify the facility Wound Ostomy Continence Nurse (WOCN) or physician to seek a change in treatment. Resident #22 died on [DATE] in the hospital due to an unrelated medical condition. This deficient practice affected one resident with IAD by not getting the necessary medical treatment and services to promote healing, prevent infection, and prevent development of pressure ulcers. Findings included: Review of the physician order [REDACTED]. Review of Resident #22 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #22 was at risk for developing pressure ulcers. The MDS reflected that she required extensive assistance by two or more for bed mobility and was incontinent of bowel. Review of Resident #22 ' s Quarterly Braden Scale Assessment for predicting pressure sore risk dated [DATE], [DATE], [DATE], and [DATE] each reflected a score of 15, which classified the resident "at risk " for pressure sore development. Review of Resident #22's Care Plan dated [DATE] reflected a potential for pressure ulcer development related to impaired bed mobility and bowel incontinence and noted interventions to address the risk of pressure ulcers as follows: "Assess/record/monitor wound healing routine. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD/family/wound care nurse. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of Resident #22 ' s Care Plan dated [DATE] reflected a history of chronic denuded skin to buttock/sacral areas and chronic incontinence of bowel. Further review reflected no updated/revised goals or interventions related to pressure ulcer care and treatment had been put into place for the resident. Review of Resident #22's physician's orders [REDACTED]. Review of the ongoing weekly Non-Pressure Condition Reports for Resident #22's right gluteal area assessed by the treatment nurse reflected the following: [DATE] for the right gluteal area reflected that the skin was "intact." [DATE] for the right gluteal area reflected a new "partial thickness" skin loss that measured 6 cm (by 4 cm with a depth of 0.2 cm. The area was described as "dark pink/red tissue" that had "deteriorated" with a small amount of drainage of an "open" denuded skin as assessed by the facility's treatment nurse, who documented application of [MEDICATION NAME] Paste to the area. [DATE] measurements smaller at 5 centimeters (cm) by 4 cm with 0.2 depth "partial thickness" skin loss with "dark pink/red tissue" with gluteal area "denuded from moist incontinence" and "not changed" with continued application of [MEDICATION NAME] Paste to the area. [DATE] no documentation of any measurements, but assessed as "partial thickness" skin loss with "dark pink/red tissue" with gluteal area "denuded" and "not changed" with "[MEDICATION NAME] treatment continued every 8 hours and prn (as needed) following incontinent care." [DATE] measurements smaller at 3 cm by 1 cm with 0.1 depth "partial thickness" skin loss with "dark pink/red tissue" and noted progress "not changed", but area "less red" and "treatment with [MEDICATION NAME] continued every 8 hours and prn after incontinent care." [DATE] measurements larger at 3 cm by 1.8 cm by 0.2 cm depth "partial thickness" skin loss with "dark pink/red tissue" and progress note by treatment nurse of "red [MEDICAL CONDITION], denuded skin, open" with [MEDICATION NAME] treatment continued. Further review of Resident #22's nurses notes from [DATE] until her transfer to the hospital on [DATE] reflected no documentation that the resident's physician was notified of the resident's skin breakdown that had been initially assessed by the treatment nurse on [DATE]. Review of Resident #22's physician's orders [REDACTED]. Review of Resident #22's Nurses Notes dated [DATE] reflected Resident #22 was transferred to a local area hospital emergency room for a condition unrelated to her skin breakdown. Review of the hospital emergency room physician's report dated [DATE], reflected Resident #22 had "increased ulcers and skin breakdown in the sacral, buttock and perineal area. Also note purulent drainage from the vagina," and "Multiple diffuse decubitus ulcers." The Clinical Impression reflected "Multiple pressure ulcers: sacrum, right buttock and left buttock. Stage: 2 and 3 (decubitus/perineal)." This report further noted that the resident had "feces around her vaginal area." Review of the hospital's history and physical (H&P) dated [DATE] by Resident #22's attending physician reflected that the resident had "multiple medical problems", one of which was "...multiple decubitus ulcers over her back side." Review of a hospital consultation report for Resident #22 dated [DATE] by a consulting physician, reflected that the resident had "several sacral decubiti over the pelvis." Review of a hospital consultation report for Resident #22 dated [DATE] by a consulting physician, reflected that the resident "notes chronic pain mostly related to her decubitus ulcers." Review of the hospital's photographic wound documentation for Resident #22 dated [DATE] reflected Stage II, Stage III, and unstageable pressure ulcers to the resident's buttocks, sacrum and thighs. Review of the hospital's emergency room Triage Report for Resident #22 dated [DATE] reflected "Pressure sore with shallow crater (Stage II) and damage down to fascia (Stage III) noted; located on sacral area. Present on arrival (buttocks, inner thigh and back of thigh bilaterally, groin area, and unstageable)." During an interview on [DATE] at 10:00 a.m., the hospital's Registered Nurse (RN) A, Director of Quality Outcomes and Management at the hospital, stated that it is hospital policy to take photos as evidence and documentation of patients' physical conditions upon arrival at the hospital and prior to admission. She stated that the patient's (Resident #22's) photos clearly show the Stage II and III pressure ulcers over her sacral area with visible depth and fascia. She also stated that the patient (Resident #22) was seen by at least three hospital physicians who were all in agreement about the pressure ulcers' assessments. During an interview with the Licensed Vocational Nurse (LVN) treatment nurse on [DATE] at 1:15 p.m., she stated Resident #22's wounds were from Incontinence Associated [MEDICAL CONDITION] (IAD), a skin irritation that results from chronic urinary and/or bowel incontinence. She stated the wounds were being treated with [MEDICATION NAME] Paste, an over-the-counter topical ointment and moisture barrier that contains [MEDICATION NAME] and zinc oxide and did not consider the wounds to be pressure ulcers. She stated her understanding of a pressure ulcer is an open wound on a bony area and she did not consider the gluteals bony areas, but did say the areas are exposed to moisture and pressure. She stated that the facility's wound specialist, who is a WOCN had told her that if the resident's skin condition failed to improve or got worse, to let her know and she would see the resident. The treatment nurse stated she continued to do weekly assessments of the resident's skin and apply [MEDICATION NAME] as treatment, but did not consult the facility's WOCN, because the wounds would get better and then worse and get better again. During an interview on [DATE] at 8:30 a.m., Resident #22's physician, who was also one of the facility's two Medical Directors stated that the resident was seen by his Nurse Practitioner (NP) and he had not been informed of any changes to the resident's skin beyond the chronic condition of IAD for which she had been receiving treatment. During an interview on [DATE] at 10:00 a.m., Resident #22's physician's NP stated she last saw Resident #22 in [DATE], before going on maternity leave and at that time the resident's condition "had not progressed beyond denuded, excoriated, superficial breakdown on her buttocks." During an interview on [DATE] at 10:55 a.m., the WOCN stated that the facility's procedure should be to consult her when wounds did not progress, when wounds required debridement, when residents had IAD that failed to improve, and she would do an assessment and make treatment recommendations to the physicians. She stated she had previously instructed the treatment nurse to contact her if Resident #22's skin condition failed to progress or worsened. The WOCN stated that the next step after she made an assessment of the resident would have been to notify the physician of her findings and make a recommendation for a change in treatment to prescription-strength [MEDICATION NAME] powder and [MEDICATION NAME]. The WOCN stated she was not informed of any lack of progress in the resident's skin condition or she would have seen her upon request. During an interview on [DATE] at 2:15 p.m., the Director of Nursing (DON) stated she knew that there were open wounds on Resident #22's buttocks, but considered it IAD. The DON thought the WOCN had talked with the treatment nurse about a month ago about the status of the resident's wounds. The DON stated at that time she thought the areas had been diagnosed as IAD. The DON was asked what change in condition would prompt her to call on the WOCN for an assessment of the resident's wounds. She stated that the wounds would get worse, but then seemed to respond to the [MEDICATION NAME] cream and then a few days later returned to red, denuded areas. She stated that because of the periodic improvement of the resident's skin, no one requested an assessment by the WOCN. The DON also stated that the resident was non-compliant with care and refused to be turned and she had addressed that in the care plan. During an interview on [DATE] at 3:00 p.m., Certified Nurse Assistant (CNA) G stated that the resident was usually cooperative with care, but at times was hurting and didn't want to move because of pain. The CNA stated when this happened she reported the pain to the nurse and the nurse would give pain medication to the resident. Further Review of Resident #22's Nurses Notes from [DATE] through [DATE] reflected: [DATE]- " Applied [MEDICATION NAME] to peri and bottom area. " [DATE]- " Resident with excoriated bottom-treatment given Calazyme ([MEDICATION NAME]), turned side to side. " [DATE]- "Per the shower aide, resident is not doing well during showers. Continues to cry and has less endurance of the pain. Complains of pain to her bottom." [DATE]- "Resident on stretcher to go to doctor's office, crying continuously for pain to bottom area." [DATE] - "Resident in bed crying complaining of pain to bottom. Check bottom has [MEDICATION NAME] cream on it. Appears red but intact. Informed resident will get help and be right back. Asked treatment nurse for assistance to reposition resident. Family at bedside at this time. Resident called daughter to come to facility, resident complained of not being changed & cream is not being applied to bottom." [DATE] - " The resident's buttock continued open, [MEDICATION NAME] and dressing applied due to bowel incontinence and the resident wanting [MEDICATION NAME] for the pain on her bottom. Review of an article published by a healthcare association Certified Wound Ostomy Continence Nurse (CWOCN) dated [DATE] at www.gnyhaservices.com entitled "Differentiating Incontinence-Associated [MEDICAL CONDITION] from Category/Stage II Pressure Ulcers" reflected the following statement: "Patients with incontinence-associated [MEDICAL CONDITION] can develop a pressure ulcer because excessive moisture reduces the skin's tolerance to excessive pressure!" Review of the facility's undated pressure ulcer protocol reflected under the section "General Preventive Measures" that the assessing nurse should "Immediately report any signs of a developing pressure ulcer to the supervisor." Review of the facility's Incontinence-Associated [MEDICAL CONDITION] Intervention Tool (IAD-IT) dated 2008 (month unknown) reflected an intervention to "Consult WOCN if available." Review of the 'Pressure Ulcer Prevention & Treatment' QUICK REFERENCE GUIDE International NPUAP-EPUAP Pressure Ulcer Classification System reflects: Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanginous-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. *Bruising indicates deep tissue injury. Category/Stage III: Full Thickness Skin Loss Partial thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. The CM form 670 dated [DATE] revealed 5 residents remained in the facility with pressure sores.