Every finding on record at San Antonio West Nursing and Rehabilitation

Based on observation, record review and interview, the facility failed to be administered in to maintain the highest practicable well-being of each resident reviewed for administration.Administration failed to notify staff and residents that a tree had fallen during the storm the night of 08/28/2026 and was blocking the exit door at end of Corridor E and walkway.This failure could place residents at risk for delayed exit or prevent safe evacuation during an emergency, which could cause smoke or fire related injuries to residents. Findings included: Observation on 08/30/2026 at 12:19 p.m., upon exterior inspection of the facility revealed there was a fallen tree near the E Hall Emergency Exit. Further observation of the area revealed there were three tree branches blocking the emergency door. The fallen tree and several branches were blocking the walkway from the outdoor courtyard to the public way. The entire walkway was blocked by the tree and several branches. Interview on 08/30/2026 at 12:24 p.m., Agency Nurse A stated she did not receive any notification regarding the exit being blocked by management. Telephone interview on 08/30/2026 at 12:27 p.m., the Administrator stated she was aware on 08/28/2026 of the fallen tree blocking the E Hall Emergency Exit. She stated the tree had fallen on Friday night, during the storm, and had been there since. She stated she had sent a message to all staff members at the facility through a group chat on a third-party messaging system notifying staff of the blocked exit. She stated all facility staff should be aware of the blocked exit. When asked about the Agency Staff Member not knowing the exit was blocked, the Administrator stated that the Agency Staff Member was a third-party staff member and was not a part of the group message. Observation on 8/30/2026 at 12:32 p.m. of the Evacuation Route posted on Corridor E revealed the door at end of the hall was still to be used for evacuation. Interview on 08/30/2026 at 12:54 p.m. CNA B stated she had not received any message or notification from management that the exit was blocked. CNA B opened her cellphone with the group message and there were no messages from management regarding the blocked E Hall Emergency Exit. Interview on 8/30/2026 at 12:54 p.m. CMA C stated she was not made aware of a tree blocking the Corridor E exit door by management. Interview on 8/30/26 at 12:56 pm with Resident #1, who resided in Hall E revealed he was not notified the exit door was blocked. Interview with weekend RN D on 8/30/26 at 1:11 p.m. revealed she was not aware of any damage form the storm and did not know Exit door at end of Hall E was blocked. RN checked her phone and stated she did not receive any text messages from management. RN D further stated the app was predominantly used to share staffing needs. Interview on 8/30/26 at 1:20 p.m. with CNA E stated she was not notified by management of the Corridor E door being blocked. Interview on 08/30/2026 at 1:45 p.m., the Maintenance Director stated he was unsure if any of the staff were notified. He stated he did not know if all staff were informed about the fallen tree. Maintenance Director further stated failure to keep emergency exits free of all obstructions could cause a delay or prevent safe evacuation in the event of an emergency. This could affect the health and safety of individuals in the facility during a fire by exposing individuals to smoke or fire related injuries. Interview with NFA on 08/30/2026 at 2:15 p.m. with NFA revealed she was not sure why message was not received and she will have to conduct training. Record review of policy titled, Planning for Evacuations, revised August 2018 revealed under the section titled Evacuation Routes: 4. Customized maps or diagrams depicting specific evacuation routes, driving instructions, and projected travel times to pre-designated alternate facilities (computerized mapping programs, etc.) are established and updated as needed.

Based on observation, record review and interview facility failed to ensure the resident environment remained as free of accident and hazards as is possible for 1 of 5 corridors, corridor E impacting 6 residents who resided in that corridor.Exit corridor E was obstructed by a fallen tree that fell night of 08/28/2026, blocking the door from opening and blocking the walkway.This failure could place residents at risk for delayed exit or prevent safe evacuation during an emergency, which could cause smoke or fire related injuries to residents.Observation on 08/30/2026 at 12:19 p.m., upon exterior inspection of the facility revealed there was a fallen tree near the E Hall Emergency Exit. Further observation of the area revealed there were three tree branches blocking the emergency door. The fallen tree and several branches were blocking the walkway from the outdoor courtyard to the public way. The entire walkway was blocked by the tree and several branches. Interview on 08/30/2026 at 12:24 p.m., Agency Nurse A stated in the event of a fire she would evacuate the residents in Hall E through the E Hall Emergency Exit. When asked if she was aware that the E Hall Emergency Exit was blocked by a fallen tree, she stated she was unaware of the fallen tree. She stated she did not receive any notification regarding the exit being blocked. Telephone interview on 08/30/2026 at 12:27 p.m., the Administrator stated she was aware of the fallen tree blocking the E Hall Emergency Exit. She stated the tree had fallen on Friday night 08/28/2026, during the storm, and had been there since. She stated she had sent a message to all staff members at the facility through a group chat on a third-party messaging system notifying the staff of the blocked exit. She stated all facility staff should be aware of the blocked exit. When asked about the Agency Staff Member not knowing the exit was blocked, the Administrator stated that the Agency Staff Member was a third-party staff member and was not a part of the group message. Observation on 8/30/2026 at 12:32 pm of Evacuation Route posted on Corridor E revealed the door at the end of the Corridor was to be used for evacuation.Interview on 08/30/2026 at 12:54 p.m. CNA B revealed she became aware of the tree blocking the door on Saturday morning (08/29/2026). CNA B further stated she had not received any message or notification from management that the exit was blocked. CNA B opened her cellphone with the group message and there were no messages from management regarding the blocked E Hall Emergency Exit.Interview on 8/30/2026 at 12:54 pm with CMA C, she stated she saw the tree blocking the door on Saturday (08/29/2026) between 10:30- 11:00 a.m. She further stated she was not made aware by management of the blocked tree. CMA C revealed Resident #1 was the only interviewable resident in E Hall.Interview on 8/30/26 at 12:56 pm with Resident #1 who resided in Hall E revealed he was not aware that the exit door was blocked.Interview on 08/30/2026 at 1:10 p.m., Agency Nurse A revealed there were a total of 7 residents residing in E Hall 6 of which required assistance transferring to wheelchair, of those 6 only 2 can self-propel.Interview with weekend RN D on 8/30/26 at 1:11pm revealed she was not aware of any damage from the storm and did not know the Exit door at end of Hall E was blocked. RN D checked her phone and stated she did not receive any text messages from management informing her of the blocked door.Interview on 8/30/26 with CNA E revealed that she became aware of a tree blocking the exit door and walkway yesterday (08/29/2026) morning by a resident. CNA E further stated she was notified by management of door being blocked.Interview on 08/30/2026 at 1:45 p.m., the Maintenance Director stated he had been working at the facility for about 4 months. He stated that when the storm happened on Friday (08/28/2026), he arrived at the facility and assisted with other issues. When he arrived, he was made aware of the fallen tree outside of E Hall. He said that since Saturday (08/29/2026) morning he had been cleaning up fallen branches from other trees on the property. When asked why the tree and the branches had not been cleaned up near E Hall, he stated he had been cleaning branches around the property and had been working his way to E Hall. He stated he had started cleaning up the branches around E Hall at 1:00 p.m. and would have it all cleaned up as soon as possible. When asked if staff were notified about the blocked emergency exit, he stated he was unsure if any of the staff were notified. He stated he did not know if all staff were informed about the fallen tree. When asked who was responsible for maintaining emergency exits free of obstructions, he stated he was responsible. After further discussion he stated that failure to keep emergency exits free of all obstructions could cause a delay or prevent safe evacuation in the event of an emergency. This could affect the health and safety of individuals in the facility during a fire by exposing individuals to smoke or fire related injuries. Record review of policy titled, Planning for Evacuations, revised August 2018 revealed under the section titled Evacuation Routes: 4. Customized maps or diagrams depicting specific evacuation routes, driving instructions, and projected travel times to pre-designated alternate facilities (computerized mapping programs, etc.) are established and updated as needed.

Based on interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Residents #3) reviewed for medication administration. The facility failed to ensure Resident #3 received his anti-seizure medication as ordered by the physician on 8/4/2026 at 9:00 AM. This failure could place residents at risk of not receiving the intended therapeutic effects of medications, including seizures.Findings included: Record review of Resident #3's admission Record, dated 8/13/2026, reflected a [AGE] year-old male who re-admitted to the facility on [DATE] and initially admitted to the facility on [DATE]. Relevant diagnoses included epilepsy, unspecified, not intractable, without status epilepticus [a chronic neurological disorder characterized by unprovoked seizures caused by abnormal electrical activity in the brain; the seizures are able to be treated with medication and are not continuous]. Record review of Resident #3's Comprehensive MDS Assessment, dated 6/15/2026, reflected a BIMS score of 15, which indicated he was cognitively intact. Section I5400 (Active Diagnoses) of the MDS reflected Resident #3 had a diagnosis of seizure disorder or epilepsy. Record review of Resident #3's Order Summary Report, dated 8/13/2026, reflected an order, dated 6/6/2025 for Lamotrigine oral tablet 100mg to be administered orally two times a day for seizures. Record review of Resident #3's undated Medication Administration Record reflected Resident #3 did not receive the morning or evening doses of Lamotrigine on 8/4/2026, documented by CMA A. In an interview on 08132026 @ 1:35 PM, Resident #3 stated that he received his 7:00 AM medication but did not receive his 9:00 AM medication. In an interview on 8/14/2026 at 5:55 PM, CMA A stated that she worked the 7 AM to 7 PM shift on 8/4/2026 on Halls B and C. She stated that she did not provide Resident #3's morning lamotrigine medication because he was at the doctor's office when she went to his room. She said she left a blank on the MAR because she was waiting for Resident #3 to return so she could administer his medication. She said the protocol she followed when a resident could not be found was to let the nurse know so they could locate the resident. She stated she let the charge nurse know and did not administer any medications to Resident #3 on 8/4/2026 at 9:00 AM. In an interview on 8/13/2026 at 6:30 PM, the Maintenance/Driver confirmed the transport record was accurate and that he transported Resident #3 to an offsite doctor's appointment 8/4/2026 at 10:30 AM. In an interview on 8/14/2026 at 12:30 PM, the DON stated that Resident #3 should have received the ordered lamotrigine on 8/4/2026 at 9AM. She stated that missing a dose could cause his medication level to decrease over time and could result in seizures. In an interview on 8/14/2026 at 1:04 PM, the Attending Physician stated that he could not know the effect of missing a medication without labs but that the facility should ensure residents received their scheduled medications before leaving for an appointment when possible. Record review of the undated facility policy titled, Medication Administration, revealed: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records: The facility failed to document wound care treatment on the TAR for Resident #1 on 07/26/2026. This failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings included: Record review of Resident #1's face sheet, dated 08/05/2026 revealed a [AGE] year-old female with an initial admission on [DATE] and a readmission on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (insulin resistance leading to elevated blood sugar levels). Record review of Resident #1's quarterly MDS, dated [DATE] revealed BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Record review of Resident #1's July TAR dated 08/06/2026 revealed the following order: Cleanse site with NS, pat dry, apply TAO, and cover with dry dressing until resolved, one time a day for skin tear with a start date of 07/26/2026. Record review of Resident #1's July TAR dated 08/06/2026 indicated no documentation of wound care treatment for 07/26/2026. During an interview on 08/06/2026 at 12:03 p.m., LVN A stated they were the treatment nurse for the facility. LVN A stated the floor nurse was responsible for doing wound care on residents on the weekend. LVN A stated nurses should be documenting wound care on the residents TAR. LVN A confirmed that there was no documentation of wound care on Resident #1's TAR on 07/26/2026 but had stated that day was a weekend and the floor nurse would have been responsible for documentation. LVN A stated the risk of not documenting wound care could be that it could look like the treatment was not done. During an interview on 08/06/2026 at 3:45 p.m., the DON stated nurses should be documenting wound care on the residents TAR. The DON stated it was important to document wound care on the TAR in order to show that the wound care was done. During an interview on 08/06/2026 at 4:30 p.m., RN B stated they worked the day of 07/26/2026 and was the nurse for Resident #1. RN B stated they were responsible for providing wound care on the weekends. RN B stated they document wound care on the TAR whether the resident received the wound care or refused it. RN B stated they did provide wound care for Resident #1 on 07/26/2026 but must have forgotten to fill out the TAR. RN B stated if the TAR is not completed it could look like the wound care was not done. Record review of the facility's policy titled, Documentation of Wound Treatments, with no date, revealed: 3. Wound treatments are documented at the time of each treatment.

Based on 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 1 of 5 residents (Resident #1) reviewed for care plans: The facility failed to ensure Residents #1's Care Plan reflected she was a smoker. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #1's face sheet, dated 08/05/2026 revealed a [AGE] year-old female with an initial admission on [DATE] and a readmission on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (insulin resistance leading to elevated blood sugar levels). Record review of Resident #1's quarterly MDS, dated [DATE] revealed BIMS score of 15 out of 15, which indicated the resident's cognition was intact and there was not a section that recorded tobacco use on the MDS. Record review of Resident #1's smoking evaluation dated 07/29/2025 stated Resident #1 was a smoker. Record review of Resident #1's care plan initiated on 07/29/2025 has no mention of Resident #1 being a smoker. During an interview on 08/06/2026 at 12:16 p.m., LVN C stated they were responsible for creating and revising care plans when needed along with the IDT team. LVN C confirmed Resident #1 was a smoker and that their care plan did not reflect so. LVN C stated they did not know why Resident #1's care plan did not reflect Resident #1 having been a smoker. LVN C stated Resident #1's care plan should have had that Resident #1 was a smoker to ensure the safety of the resident. During an interview on 08/06/2026 at 3:45 p.m., the DON stated it was important Resident #1's smoker preference be reflected on their comprehensive care plan. The DON stated they were not aware of Resident #1's care plan not including the resident was a smoker. The DON stated the risk of not documenting on the comprehensive care plan could be that they were not identified as a safe or not safe smoker and that their interventions would not be documented. Record review of the facility's policy titled, Comprehensive Care Plans, with no date, revealed: It is policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on record review and interview, the facility failed to maintain policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and the smoking safety that also takes into account nonsmoking residents for 1 out of 5 residents (Resident #2) reviewed for accuracy of records: The facility failed to ensure Resident #2 received a quarterly smoking evaluation. This failure could place the residents at risk of errors in care and treatment.The findings include: Record review of Resident #2's face sheet, dated 08/05/2026 revealed a [AGE] year-old male with an admission on [DATE] with diagnoses of nicotine dependence, cigarettes, uncomplicated, major depressive disorder, recurrent, unspecified (persistent feelings of sadness, loss of interest in activities) and schizophrenia (affects how a person thinks, feels, behaviors, often leading to hallucinations, delusions, and disorganized thinking). Record review of Resident #2's annual MDS, dated [DATE] revealed BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Further review of Resident #2's MDS in Section J - Health Conditions J1300. Current Tobacco Use revealed the assessment documented the resident was a current tobacco user. Record review of Resident #2's care plan initiated on 01/07/2020 revealed: [Resident #2] is a smoker with interventions that include instruct [Resident #2] about the facility policy on smoking: locations, times, safety concerns last revised 09/07/2022. Record review of Resident #2's smoking evaluations revealed the last evaluation was completed on 03/15/2026. During an interview on 08/06/2026 at 12:39 p.m., the SW stated residents who smoked received an initial admission smoker evaluation and quarterly smoker evaluations. The SW stated they were responsible for completing quarterly smoker evaluations. The SW stated they knew when smoker evaluations were due when they were triggered in their system. The SW stated the last smoker evaluation completed for Resident #2 was completed on 03/15/2026 and that Resident #2 should have received a quarterly smoker evaluation on 06/15/2026. The SW stated they were unsure why they missed it and was unaware it had not been done. The SW stated the risk of residents not receiving quarterly smoker evaluations could be that the other staff would not be able to determine if the resident was a safe smoker. During an interview on 08/06/2026 at 3:45 p.m., the DON stated residents who smoked received an initial admission smoker evaluation, quarterly smoker evaluations, and if they had a change of condition an additional smoker evaluation would be completed. The DON stated the SW was responsible for completing resident's quarterly smoker evaluations. The DON stated the SW knew when the quarterly smoker evaluations were due because they would trigger in their system. The DON stated the risk of residents not receiving quarterly smoker evaluations could be not reevaluating residents to determine if they are safe or not. Record review of the facility's policy titled, Smoking Policy - Residents, revised July 2017, revealed: 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by staff.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care and catheter care, in that: While providing incontinent care for Resident #2, CNA B used a back to front motion to clean Resident #2. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #2's face sheet, dated 07/07/2026, revealed an admission date of 09/25/2025, with a diagnosis of Hemiplegia (severe paralysis on one side of the body. Record review of Resident #2's Quarterly MDS assessment, dated 06/14/2026, revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment, and he was always incontinent of bowel and bladder. Record review of Resident #2s care plan, dated 10/29/2025, with a problem of Incontinent of bladder related tofunctional incontinence. and an intervention of Provide proper perineal care and use barrier creams to protect the skin from urine/feces exposure. Observation on 07/08/2026 at 9:56 a.m. revealed CNAs A and B provided incontinent care for Resident #2. During care CNA B used a back and forth motion to wipe the resident instead of a front to back motion. She wiped Resident #2's penis from base to tip instead of tip to base. During an interview with CNA B on 07/08/2026 at 10:10 a.m., CNA B stated the proper motion to clean a resident's penis was front to back or tip to base. She did not realize she was using the wrong motion and stated she was nervous. She stated she received training in incontinent care within the year from the DON and ADON. During an in interview with the DON on 07/08/2026 at 2:30 p.m., she stated the correct motion to clean a resident was front to back to prevent the contamination of the urinal tract with fecal matter and prevention of infection. She stated the staff was provided incontinent care training, and their skills were checked annually and as needed. Record review of facility's policy titled, Perineal care, dated 2018, revealed, For a male resident:a.Wet washcloth and apply soap or skin cleansing agent.b.Wash perineal area starting with urethra and working outward.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #7) reviewed for infection control, in that: The facility failed to ensure CNA B changed her gloves and sanitized her hands after cleaning Resident #2 and before touching the clean brief and used the proper technique to sanitize her hands. These failures could place residents at-risk for infection due to improper care practices. The findings were: Record review of Resident #2's face sheet, dated 07/07/2026, revealed an admission date of 09/25/2025, with a diagnosis of Hemiplegia (severe paralysis on one side of the body), osteoarthritis (joint pain that comes with wear and tear. Record review of Resident #2's Quarterly MDS assessment, dated 06/14/2026, revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment, and he was always incontinent of bowel and bladder. Record review of Resident #2s care plan, dated 10/29/2025, with a problem of Incontinent of bladder related tofunctional incontinence. and an intervention of Provide proper perineal care and use barrier creams to protect the skin from urine/feces exposure. Observation on 07/08/2026 at 9:56 a.m. revealed while providing incontinent care for Resident #2, CNA B did not sanitize between her fingers while using the sanitizer between change of gloves after cleaning Resident's genitals. CNA B did not change her gloves and sanitize her hands after cleaning the resident's buttocks and before touching the clean brief. During an interview on 07/08/2026 at 10:10 a.m. with CNA B, she stated she did not realize she was not sanitizing between her fingers when using the sanitizer and thought she was. Further interview revealed she stated she did not change her gloves and sanitize her hands after cleaning Resident #2's buttocks and before touching the clean brief. She said she was nervous and forgot. She stated she received infection control training within the year. Interview on 07/08/2026 at 2:30 p.m. with the DON, revealed she stated the staff needed to sanitize between their fingers when using the sanitizer and, needed to sanitize hands between change of gloves and change gloves between cleaning a resident and touching something clean for the prevention of infection to the residents but also the staff. The DON stated infection control training was provided and skills were checked annually. Review of facility's policy, titled Handwashing/Hand Hygiene , dated 2018, revealed Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to [ .] after removing personal protective equipment [ .] Use an alcohol=base hand rub [ .] before moving from a contaminated body site to clean body site during resident care [ .] after contact with bodily fluid [ .] Using alcohol-Based hands rubs 1. Apply generous amount of product to palm of hands and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 2 residents (Resident #2) reviewed for resident rights, in that: CNAs A and B did not completely close Resident #2's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents who received incontinent care at-risk of loss of dignity, embarrassment, and a decline in quality of life.Findings include: Record review of Resident #2's face sheet, dated 07/07/2026, revealed an admission date of 09/25/2025, with diagnoses that included: Aphasia (disorder of language because of injury to the brain), Hemiplegia (severe paralysis on one side of the body), osteoarthritis (joint pain that comes with wear and tear), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's Quarterly MDS assessment, dated 06/14/2026, revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment, and he was always incontinent of bowel and bladder. Record review of Resident #2s care plan, dated 10/29/2025, with a problem of Incontinent of bladder related tofunctional incontinence. and an intervention of Provide proper perineal care and use barrier creams to protect the skin from urine/feces exposure. Observation on 07/08/2026 at 9:55 a.m. revealed CNAs A and B provided incontinent care for Resident #2. During care CNAs A and B did not completely pull the curtain at left side of the bed to offer privacy to the resident because the privacy curtain was too short to surround the bed. Further observation revealed Resident #2 could have been seen by someone opening the room's door and his genitals were fully exposed. During an interview with CNAs A and B on 07/08/2026 at 10:10 a.m., CNAs A and B stated the privacy curtain was not closed while they provided care for Resident #2 but should have been. The stated they had reported the curtain was too short. CNAs A and B stated they had received resident rights training from DON and ADON. During an interview with the DON on 07/08/2026 at 2:35 p.m., she stated privacy must be provided during nursing care and Resident #2's privacy curtain should have been closed completely. They stated Resident rights training had been provided for the staff within the current year. Record review of the facility's policy titled, Quality of life - Dignity dated 2018, revealed, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedure.

Based on observations, interviews, 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 ensure the facility was free from flies. These failures could lead to cross contamination and/or decreased quality of life. Based on observations, interviews, 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 ensure the facility was free from flies. These failures could lead to cross-contamination and/or decreased quality of life. Findings included: Record review of the facility's pest control invoice, dated 1/2/26, revealed that single bulb for fly light was replaced. During observation and interview on 6/17/26 beginning at 11:24 am, seven flies were observed in the kitchen, flying over the hot table where the lunch meal was being prepared. The DM said pest control went to the facility every couple of weeks and PRN. The DM further stated that there was an electric fly swatter in the office. The DM said the residents went in and out to the patio for smoke breaks and flies kept entering the facility. The DM said there was also an air curtain on the back door of the kitchen, but the front door kept opening and closing allowing flies to enter the kitchen, especially after it rained. The DM said if flies touched the food it had to be tossed because it could make somebody sick. During observation and interview on 6/17/26 at 12:53 pm, a fly was observed in Resident #5's room. Resident #5 said he had killed 3-4 flies. Resident #5 further stated it bothered him when flies landed on his food. During observation on 6/17/26 at 12:55 pm, a fly was observed on the B hall. During observation and interview on 6/17/26 at 12:59 pm, nine flies were observed on three plates of leftover food on a table in the dining room. Resident #10 was observed swatting flies away from her face. Resident #10 said the flies bothered her, especially when she was trying to eat. Resident #9 said the flies bothered her when they got in her face. Resident #9 further stated that the flies got on the food. During observation on 6/17/26 at 1:04 pm, 3 flies were observed on the D hall. During an interview on 6/17/26 at 1:06 pm, Resident #8 was sitting in the dining room. He said the flies were in his face. During observation on 6/17/26 at 1:56 pm, 2 flies were observed in Resident #4's room. During observation and interview on 6/17/26 at 2:30 pm, a fly was observed in Resident #2's room. During an interview on 6/17/26 at 2:55 pm, Resident #6 said flies came into the facility now and then. During an interview on 6/17/26 at 3:48 pm, Resident #1 said sometimes flies landed on his food, so he had to eat quickly. Record review of the facility's pest control invoice, dated 6/17/26, revealed that the fly boards in all fly light stations were changed out. During observation and interview on 6/18/26 at 8:17 am, six flies were observed on dirty dishes on a cart outside the kitchen. Further observation revealed four flies on dirty dishes on a second cart outside the kitchen. LVN A confirmed there were flies on the dirty dishes on the carts outside the kitchen. During an interview on 6/18/26 at 8:30 am, LVN B said she had recently noticed that flies had been an issue. During an interview on 6/18/26 at 8:48 am, the MS said pest control was scheduled to go to the facility once a week, and they checked all the fly traps. During an interview on 6/18/26 at 11:39 am, the Administrator said she was responsible for ensuring the facility was free of flies. The Administrator further stated pest control went to the facility every two weeks and PRN. Record review of the facility's policy titled Pest control, revised May 2008, revealed: .Our facility shall maintain an effective pest control program.1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects. Record review of the facility's policy titled Safe and Homelike Environment, Copyright 2025, revealed: .In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.

Based on observation, interview, and record review the facility failed to, in accordance with accepted professional standards of practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 3 of 6 residents (Resident #6, Resident #7, and resident #8) reviewed for clinical records. The facility failed to accurately document on 28 medication administrations for Resident #6, Resident #7 and Resident #8 the holding of a blood pressure medication due to residents' blood pressure being out of parameters. The documentation shows the medication was administered despite parameter orders stated to hold the medication. This failure could place residents at risk of not receiving care and services needed or alteration to medication dosing by physicians due to inaccurate information being documented.The findings include: 1. Record review of Resident #6's admission Record, dated 04/28/2026, revealed a [AGE] year-old male that admitted to the facility 02/10/2026 with diagnoses that included Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients), Congestive Heart Failure (chronic, progressive condition where the heart muscle cannot pump blood efficiently, causing blood to back up and fluid to build up in lungs, legs, and other tissues), Hypertension (chronic condition where blood pressure constantly measures 130/80 or higher, forcing the heart to work too hard), and history of Cerebral Infarction (type of stroke which is the death of brain tissue caused by a sudden lack of oxygen and nutrients due to obstructed blood flow, usually from a clot). Record review of Resident #6's Annual MDS dated [DATE] revealed a BIMS score of 03, reflecting a severe cognitive impairment. Record review of Resident #6's Care Plan, dated 04/17/2026, revealed risk for falls related to balance issue with use of hypertensives, impaired physical and cognitive function related to past heart attacks, potential for decreased cardiac output related to heart failure, and potential for altered tissue perfusion related to hypertensive heart disease. Record review of Resident #6's Order Summary Report, dated 04/28/2026, revealed active orders for Lisinopril 20mg 1 tablet by mouth one time a day, HOLD for SBP less than 110 and Pulse less than 60; Carvedilol 6.25mg 1 tablet by mouth two times a day, HOLD for SBP less than 110 and Pulse less than 60. Record review of Resident #6's April MAR, dated 04/28/2026, revealed improper documentation of Carvedilol 6.25mg on 04/07/2026 for the 5:30pm medication pass on 04/07/2026, that despite the blood pressure being recorded at 109/57, the medication was marked as administered. MAR revealed parameters for hypertensive medication were Hold for SBP less than 110. Record review of Resident #6's Progress Notes, dated 04/28/2026, revealed no nurse note related to the SBP being 109 and out of parameters. 2. Record review of Resident #7's admission Record, dated 04/28/2026, revealed a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses that included Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients), Cerebral Infarction (type of stroke which is the death of brain tissue caused by a sudden lack of oxygen and nutrients due to obstructed blood flow, usually from a clot), and Hypertensive Heart Disease (heart damage caused by long-term blood pressure, leading to thickened heart muscles, heart failure, and arrythmias). Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 99 indicating that the cognitive test could not be performed. Record review of Resident #7's Care Plan, dated 02/26/2026, revealed communication problem related to history of heart attack, fall risk related to balance concerns due to hypertension issues, and ADL self-care deficits due to history of heart attack. Record review of Resident #7's Order Summary Report, dated 04/28/2026, revealed active orders for Carvedilol 6.25mg 1 tablet by mouth two times a day, HOLD for SBP less than 100 or Pulse less than 60; Hydralazine HCl 100mg 1 tablet by mouth two times a day, HOLD if SBP less than 100 or Pulse less than 60; Losartan Potassium 50mg 1 tablet by mouth two times a day HOLD if SBP less than 110 or Pulse less than 60. Record review of Resident #7's March MAR, dated 04/28/2026, revealed improper documentation of Carvedilol 6.25mg, Hydralazine 100mg, and Losartan Potassium 50mg for the 9:30am medication pass on 03/18/2026 by LVN C, that despite the Pulse being recorded at 54, the medication was marked as administered. MAR revealed parameters for hypertensive medications were HOLD for Pulse less than 60. Record review of Resident #7's Progress Notes, dated 04/28/2026, revealed no nurse notes related to the Pulse being 54 and out of parameters. 3. Record review of Resident #8's admission Record, dated 04/28/2026, revealed a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients), Hypertension (chronic condition where blood pressure constantly measures 130/80 or higher, forcing the heart to work too hard), and Other Chest Pain (symptom requiring immediate medical attention if it is severe, crushing, or accompanied by dizziness, nausea, or shortness of breath). Record review of Resident #8's admission MDS, dated [DATE], revealed a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #8's Care Plan, dated 04/20/2026, revealed potential for altered tissue perfusion related to Hypertensive Heart Disease. Record review of Resident #8's April MAR, dated 04/28/2026, revealed active orders for Lisinopril 5MG 1 tablet by mouth one time a day, HOLD for BP less than 110/60 and Pulse less than 60; Nifedipine ER 60mg 1 tablet by mouth one time a day HOLD if BP less than 110/60 and Pulse less than 60; Metoprolol Tartrate 25mg 1 tablet by mouth two times a day HOLD if BP less than 110/60 and Pulse less than 60 until Resident #8 was discharged to the hospital on [DATE] related to UTI. Record review of Resident #8's April MAR, dated 04/28/2026, revealed improper documentation of Lisinopril 5mg, Nifedipine ER 60mg, and Metoprolol Tartrate 25mg for the 7:00am and 9:00am medication pass on 04/02 despite Pulse 57; 04/13 despite Pulse 59; 04/15 despite Pulse 58; 04/16 despite BP 130/59 and Pulse 59; 04/17 despite BP 138/58 and Pulse 58; 04/21 despite BP 133/58; 04/22 despite BP 111/58; and 04/23 despite BP 132/59 Pulse 58. MAR revealed parameters for hypertensive medications were HOLD for BP less than 110/60 and Pulse less than 60. LVN C was nurse who administered medications. Record review of Resident #8's Progress Notes, dated 04/28/2026, revealed no nurse notes related to the BP or Pulse being out of parameters. During an observation on 04/29/2026 at 8:17am, CMA A was observed obtaining the blood pressure and pulse of an unknown resident before administering medications. CMA A entered the blood pressure and pulse into PCC before opening medication cart to pull the unknown residents' medications out for administration. When the blood pressure and pulse were entered into PCC, CMA A checked the parameters before selecting each medication for hypertension to be administered. This process follows professional guidelines for medication administration. During an observation on 04/30/2026 at 7:28am, CMA B was observed obtaining the blood pressure and pulse of an unknown resident before administering medications. CMA B entered the blood pressure and pulse of the unknown resident into PCC before opening the medication cart to pull the unknown residents' medications out for administration. When the blood pressure and pulse were entered into PCC, CMA B checked the parameters before selecting each medication for hypertension to be administered. This process follows professional guidelines for medication administration. During an observation on 04/30/2026 at 7:36am, CMA C was observed obtaining the blood pressure and pulse of an unknown resident before administering medications. CMA C entered the blood pressure and pulse of the unknown resident into PCC before opening the medication cart to pull the unknown residents' medications out for administration. When the blood pressure and pulse were entered into PCC, CMA C checked the parameters before selecting each medication for hypertension to be administered. This process follows professional guidelines for medication administration. During an observation on 04/30/2026 at 8:24am, LVN B was observed obtaining the blood pressure and pulse of Resident #6 before administering medications. LVN B entered the blood pressure and pulse of Resident #6 into PCC before opening the medication cart to pull Resident #6's medications out for administration. When the blood pressure and pulse were entered into PCC, LVN B checked the parameters before selecting each medication for hypertension to be administered. This process follows professional guidelines for medication administration. During an observation on 04/30/2026 at 8:31am, LVN C was observed obtaining the blood pressure and pulse of Resident #8 before administering medications. LVN C entered the blood pressure and pulse of Resident #8 into PCC before opening the medication cart to pull Resident #8's medications out for administration. When the blood pressure and pulse were entered into PCC, LVN C checked the parameters before selecting each medication for hypertension to be administered. This process follows professional guidelines for medication administration. During an observation on 04/30/2026 at 8:32am, LVN C was observed obtaining the blood pressure and pulse of an unknown resident before administering medications. LVN C entered the blood pressure and pulse of the unknown resident into PCC before opening the medication cart to pull the unknown residents' medications out for administration. When the blood pressure and pulse were entered into PCC, LVN C checked the parameters before selecting each medication for hypertension to be administered. During an interview on 04/29/2026 at 8:17am, CMA A revealed that she had been a medication aide for 40 years, 11 years at this facility. CMA A stated that she always checks the blood pressure and pulse of a resident before giving the medication. CMA A stated that she also notifies the charge nurse if she sees a medication that should have parameters without any and if a residents' blood pressure or pulse is outside of parameters she will notify the nurse and not give the med. CMA A confirmed that she has had training at the facility for blood pressure medications and checking parameters before administering. During an interview on 04/29/2026 at 1200pm, LVN A stated that when a new resident admits, or a previous resident readmits or returns from the hospital to the facility, they go over their medication list with the physician. If blood pressure medication is on the list the nurse asks the physician for parameters. If the physician does not want parameters, then that is put into the order that shows on the MAR in PCC. LVN A confirmed training at the facility regarding blood pressures and following physician orders for parameters. During an interview on 04/30/2026 at 7:28pm, CMA B stated that she had been a CMA B for 37 years and will never give blood pressure medication without checking that residents' blood pressure first. CMA B stated that she understands the importance of checking their blood pressure first, as not checking could lead to injury or death. CMA B confirmed training for parameters and stated I will not cut corners period. These are MY people. If the blood pressure or pulse is out of parameters then I will not give the medication and will let the nurse know. During an interview on 04/30/2026 at 7:36am, CMA C stated that she always checks blood pressure to input into PCC for parameters. CMA C stated that she will put the blood pressure pills into a separate medication cup and combine them if the blood pressure is good per the order. CMA C stated that the majority of the parameters in the facility are to hold the medication for SBP less than 110 and Pulse less than 60. If it is less than those numbers I hold the medication and tell the nurse. During an interview on 04/30/2026 at 8:24am, LVN C stated that she always checks the blood pressure to see if it meets the parameters. LVN C stated she never gives blood pressure medications outside of parameters. LVN C stated that if the medications are at separate times but both on her shift she will recheck the blood pressure and pulse before administering. LVN C stated that even if the MAR may say it was given, she always holds for parameters, she just may have clicked the wrong box. LVN C stated that she knows that that leads to incorrect documentation. During an interview on 04/30/2026 at 11:42am, DON stated that they do not have a process to verify that staff gave or held medications per the MAR for vitals outside of parameters. DON stated that staff know, and are expected, to hold medications that do not meet parameters for administration. For CMA's the nurse for that hall will verify or check that everything looks okay, but if a nurse is passing medications, they are responsible for themselves. DON also stated that they do not have a policy requiring parameters, it is just best practice. Their medication policy does cover holding per parameter if there are any. Record Review of Medication Administration policy dated 05/2025, revealed that staff are to obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside of physicians prescribed parameters. Policy review also revealed that staff should correct any discrepancies and report to nurse manager.

Based on observations and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there was an incident involving the resident and has the potential for requiring physician intervention; a need to alter treatment for 2 of 17 Residents (Resident #1 and #2) reviewed for incident reporting. 1. The facility failed to report to Resident #1's Representative and Resident #2's Representative an incident of Resident #1 found partially disrobed in Resident #2's room on 4/14/26.2. The facility failed to report to Resident #1's Physician and Resident #2's Physician an incident of Resident #1 was found partially disrobed in Resident #2's room on 4/14/26. This failure could place residents at risk for delayed responsible party and physician's intervention.The findings included: Resident #1:A record review of Resident #1's admission record dated 4/22/2026 revealed an admission date of 11/15/2024 with a diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted into the memory care unit (MCU) for long term care safety related to her cognitive impairment. Resident #1 was assessed with the inability to complete a BIMS exam but was able to make herself understood and could usually make herself understood. Resident #1 Was assessed with adequate hearing and vision and did not use glasses or hearing aids. A record review of Resident #1's care plan dated 4/22/2026 revealed Resident #1 was cared by hospice services related to senile (characteristics of old age, often referring to mental confusion, memory loss, and reduced cognitive function resulting from aging) degeneration of the brain with an intervention for staff to Keep family informed of change and condition . notify Hospice of any change in condition . Is dependent on staff for activities . social interaction . needs assistance / escort activities and functions . Has impaired physical functioning related to cognitive impairment difficulty in walking muscle weakness and lack of coordination will remain well-groomed dressed and assisted by staff as needed lower body dressing requires supervision or touching assistance. A record review of Resident #1's physicians' orders dated 4/22/2026 revealed the physician prescribed hospice services on 1/5/2025, and for nursing staff to contact hospice services to report any changes or concerns. A record review of Resident #1's nursing progress note written by RN B dated 4/14/2026 at 3:30 PM revealed an incident on 4/14/2026 at 3:30 PM During nursing shift change rounds, patient (Resident #1) was found in room (Resident #2's room) in bed A with no pants or diaper on, nude from waist down and covered with a blanket. Patient that resides in that room was sitting on his walker on the other end of the room looking out the window. Asked both patients what was going on, both said they don't know. (Resident #1) orientated x 1 to person only. Male patient stepped out of room at this time, and Resident #1 was dressed and checked, no abnormal findings noted, she denies anything happened and feels fine. Patient was re-orientated and shown where her room is. Will continue to monitor patient's behavior. A record review of Resident #1's medical records for the period of 4/14/2026 through 4/22/2026 revealed no report to the resident's physician or families for the 4/14/2026 incident where Resident #1 was discovered semi-nude in Resident #2's room. During an interview on 4/22/2026 at 12:10 PM Resident #1's Representative stated Resident #1 had dementia and lived in the MCU and was very confused. Resident #1's Representative stated on 4/21/2026 he received a report from the hospice RN that on 4/14/2026 Resident #1 was found in Resident #2's room nude from the waist down. Resident #1's Representative stated he was upset to learn of the incident a week later and felt he should have been given a report immediately. Resident #1's Representative stated he was in the facility after 4/14/2026 and had met with the SW and the ADON on 4/15/2026, a day after the incident and they did not report the incident Resident #2:A record review of Resident #2's admission record dated 4/22/2026 revealed an admission date of 2/10/2026 with a diagnosis of severe dementia (a general, umbrella term for a progressive decline in mental ability, including memory, thinking, and reasoning, severe enough to interfere with daily life) and anxiety. A record review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for LTC in the MCU. Resident #2 was assessed with adequate hearing without a hearing aid and adequate vision with the use of glasses. Resident #2 was assessed with the ability to have clear speech, could usually understand others and could usually make himself understood. Resident #2 was assessed with a BIMS score of 3 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #2's medical records for the period of 4/14/2026 through 4/22/2026 revealed no report to the resident's physician or families for the 4/14/2026 incident where Resident #1 was discovered semi-nude in Resident #2's room. During an interview on 4/22/2026 at 4:08 PM Resident #2's Representative stated she had not received a report from the facility for an incident on 4/14/2026. During an interview on 4/22/2026 at 1:13 PM RN B stated on 4/14/2026 she worked the 2:00 PM to 10:00 PM shift in the MCU and was receiving a report from LVN D who had worked the 6:00 AM shift to 2:00 PM shift in the MCU. RN B stated during the report LVN D could not locate Resident #1 and they began looking for Resident #1. RN B stated they located Resident #1 in Resident #2's room semi-nude from the waist down. RN B stated she assessed both residents without injuries and assisted Resident #1 to dress and redirected her back to her room. RN B stated she reported the incident to the DON and the ADON During an interview on 4/22/2026 at 12:00 PM the ADON stated she was the supervisor for the MCU. The ADON stated she worked on 4/14/2026 and had received a report from RN B that Resident #1 was found in Resident #2's room semi-nude. The ADON stated she and the SW met with Resident #1's Representative on 4/15/2026 to discuss moving Resident #1 out of the MCU but had not reported to Resident #1's Representative the incident on 4/14/2026 where the resident was found semi-nude in Resident #2's room. The ADON stated that because it was a sensitive subject, they had not gone over the details with Resident #1's Representative, and because their belief was RN B had already reported the incident to Resident #1's and resident #2's respective representatives. The ADON further stated she believed RN B had also reported the incident to the residents' physician but had not verified if they had done so. During an interview on 4/22/2026 at 1:10 PM Hospice RN C stated she spoke with Resident #1's Representative on 4/21/2026 at 11:40 AM and gave a report of the 4/14/2026 incident where Resident #1 was semi-nude in another male resident's room. Hospice RN C stated she believed Resident #1's Representative had received a report from the facility's RN who discovered Resident #1 In the male resident's room. Hospice RN C stated she visited Resident #1 weekly on Thursdays and on 4/16/2026 she learned of the 4/14/2026 incident from staff. Hospice RN C stated when she spoke to Resident #1's Representative on 4/21/2026 and she realized Resident #1's Representative had not received a report of the incident. During an interview on 4/24/2026 at 3:00 PM the Administrator and the DON stated the expectation for nursing staff was to report all unusual incidents to the Residents' representatives and physicians as soon as an incident occurred. The Administrator and the DON stated the potential negative outcome for residents could be not being informed of their health status and not having the interventions of their physicians. A record review of the facility's policy titled Notification of Changes dated 6/23/2025, revealed, Policy: the purpose of this policy is to ensure the facility promptly informs the resident, consult the residence physician: and notifies, consistent with his or her authority, the residence representative when there is a change requiring notification. Circumstances requiring notification include: . residents incapable of making decisions: the representative would make any decision that have to be made. The resident should still be told what is happening to him or her.

Based on interviews and record reviews the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 2 of 17 (Residents #1 and #2) residents reviewed for reporting. The facility failed to report to the state agency alleged incident of Resident #1 found partially disrobed in Resident #2's room. This failure could place residents at risk for not having allegations of ANE reported.The findings included: Resident #1:A record review of Resident #1's admission record dated 4/22/2026 revealed an admission date of 11/15/2024 with a diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted into the memory care unit (MCU) for long term care safety related to her cognitive impairment. Resident #1 was assessed with the inability to complete a BIMS exam but was able to make herself understood and could usually make herself understood. Resident #1 Was assessed with adequate hearing and vision and did not use glasses or hearing aids. A record review of Resident #1's care plan dated 4/22/2026 revealed Resident #1 was cared by hospice services related to senile (characteristics of old age, often referring to mental confusion, memory loss, and reduced cognitive function resulting from aging) degeneration of the brain with an intervention for staff to Keep family informed of change and condition . notify Hospice of any change in condition . Is dependent on staff for activities . social interaction . needs assistance / escort activities and functions . Has impaired physical functioning related to cognitive impairment difficulty in walking muscle weakness and lack of coordination will remain well-groomed dressed and assisted by staff as needed lower body dressing requires supervision or touching assistance. A record review of Resident #1's physicians' orders dated 4/22/2026 revealed the physician prescribed hospice services on 1/5/2025, and for nursing staff to contact hospice services to report any changes or concerns. A record review of Resident #1's nursing progress notes revealed an incident on 4/14/2026 at 3:30 PM where Resident #1 was found in male Resident #2's room, sitting on his bed nude from the waist down while fully clothed Resident #2 was in the room with the door closed. RN B documented, During nursing shift change rounds, patient (Resident #1) was found in room (Resident #2's room) in bed A with no pants or diaper on, nude from waist down and covered with a blanket. Patient that resides in that room was sitting on his walker on the other end of the room looking out the window. Asked both patients what was going on, both said they don't know. (Resident #1) orientated x 1 to person only. Male patient stepped out of room at this time, and Resident #1 was dressed and checked, no abnormal findings noted, she denies anything happened and feels fine. Patient was re-orientated and shown where her room is. Will continue to monitor patient's behavior. Resident #2:A record review of Resident #2's admission record dated 4/22/2026 revealed an admission date of 2/10/2026 with a diagnosis of severe dementia (a general, umbrella term for a progressive decline in mental ability, including memory, thinking, and reasoning, severe enough to interfere with daily life) and anxiety. A record review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for LTC in the MCU. Resident #2 was assessed with adequate hearing without a hearing aid and adequate vision with the use of glasses. Resident #2 was assessed with the ability to have clear speech, could usually understand others and could usually make himself understood. Resident #2 was assessed with a BIMS score of 3 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #2's nursing progress notes written by LVN F documented on 3/31/2026 at 7:42 PM that, Resident #2 was verbally aggressive towards when (Resident #1) was taken to room for care resident states She is mine and will do whatever i say Nurse redirected resident that care needed to be provided as (Resident #1) started to cry. Nurse reassured (Resident #1) she was safe and everything was okay. A record review of the Texas Unified Licensure Information Portal (TULIP) website database; accessed 4/22/2026; for the period between 3/1/2026 and 4/22/2026, revealed no reported suspicions / allegations regarding Resident #1 and Resident #2's suspected ANE. During an interview on 4/22/2026 at 12:00 PM the ADON stated she was the supervisor for the MCU. ADON stated she worked on 4/14/2026 and had received a report from RN B that Resident #1 was found in Resident #2's room semi-nude. The ADON stated she had reported the incident to the DON and the Administrator who was the abuse prevention coordinator. During an interview on 4/22/2026 at 1:13 PM RN B stated on 4/14/2026 she worked the 2:00 PM to 10:00 PM shift in the MCU RN B stated during the report LVN D could not locate Resident #1 and they began looking for Resident #1. RN B stated they located Resident #1 in Resident #2's room semi-nude from the waist down. RN B stated she assessed both residents without injuries and assisted Resident #1 to dress and redirected her back to her room. RN B stated she had reported the incident to the DON and the ADON. During an interview on 4/22/2026 at 1:20 PM LVN D and CNA E stated they were on duty from 6:00 AM - 2:00 PM on 4/14/2026 when around 2:00 PM LVN D recognized Resident #1 was not in the Livingroom where she usually sat and LVN D went to Resident #1's room and discovered Resident #1 was not in her room. LVN D immediately suspected Resident #1 was in Resident #2's room and directly went to Resident #2's room where Resident #1 was found nude from the waist down seated on the side of Resident #2's bed. LVN D called out to CNA E who entered the room and observed Resident #2 coming out of the bathroom dressed and asking, what's going on. During an interview on 4/24/2026 at 3:00 PM the Administrator and the DON stated they had not received a report of the 3/31/2026 incident of Resident #2 being verbally aggressive towards Resident #1 but had received a report of the 4/14/2026 incident in the MCU where Resident #1 was semi-nude in Resident #2's room. The Administrator and the DON stated they had not reported the incidents to the state agency and regarding the 4/14/2026 incident they believed it was normal behavior for residents who are confused to wander about the MCU and could be confused and disrobe. The Administrator and the DON stated they believed that nothing happened between Resident #1 and Resident #2 and therefore did not consider the incident a suspicion of ANE. A record review of the facility's policy undated abuse, neglect, and exploitation policy revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Reporting / response: the facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, adult Protective Services and to all other required agencies within specified time frames: a) immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, orb) not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. A record review of the facility's policy, undated, abuse, neglect, and exploitation policy revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of alleged abuse, neglect, and exploitation; an immediate investigation is warranted when suspicion of abuse, neglect, for exploitation, poor reports of abuse, neglect, or exploitation occur.

Based on interviews and record reviews the facility failed to have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, for 2 of 17 Residents (Resident #1 and Resident #2) reviewed for facility investigations. The facility failed to investigate allegations of incident of Resident #1 found partially disrobed in Resident #2's room. This failure could place residents at risk for not having allegations of ANE investigated and summary reported.The findings included: Resident #1:A record review of Resident #1's admission record dated 4/22/2026 revealed an admission date of 11/15/2024 with a diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted into the memory care unit (MCU) for long term care safety related to her cognitive impairment. Resident #1 was assessed with the inability to complete a BIMS exam but was able to make herself understood and could usually make herself understood. Resident #1 Was assessed with adequate hearing and vision and did not use glasses or hearing aids. A record review of Resident #1's care plan dated 4/22/2026 revealed Resident #1 was cared by hospice services related to senile (characteristics of old age, often referring to mental confusion, memory loss, and reduced cognitive function resulting from aging) degeneration of the brain with an intervention for staff to Keep family informed of change and condition . notify Hospice of any change in condition . Is dependent on staff for activities . social interaction . needs assistance / escort activities and functions . Has impaired physical functioning related to cognitive impairment difficulty in walking muscle weakness and lack of coordination will remain well-groomed dressed and assisted by staff as needed lower body dressing requires supervision or touching assistance. A record review of Resident #1's physicians' orders dated 4/22/2026 revealed the physician prescribed hospice services on 1/5/2025, and for nursing staff to contact hospice services to report any changes or concerns. A record review of Resident #1's nursing progress notes revealed an incident on 4/14/2026 at 3:30 PM where Resident #1 was found in male Resident #2's room, sitting on his bed nude from the waist down while fully clothed Resident #2 was in the room with the door closed. RN B documented, During nursing shift change rounds, patient (Resident #1) was found in room (Resident #2's room) in bed A with no pants or diaper on, nude from waist down and covered with a blanket. Patient that resides in that room was sitting on his walker on the other end of the room looking out the window. Asked both patients what was going on, both said they don't know. (Resident #1) orientated x 1 to person only. Male patient stepped out of room at this time, and Resident #1 was dressed and checked, no abnormal findings noted, she denies anything happened and feels fine. Patient was re-orientated and shown where her room is. Will continue to monitor patient's behavior. Resident #2:A record review of Resident #2's admission record dated 4/22/2026 revealed an admission date of 2/10/2026 with a diagnosis of severe dementia (a general, umbrella term for a progressive decline in mental ability, including memory, thinking, and reasoning, severe enough to interfere with daily life) and anxiety. A record review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for LTC in the MCU. Resident #2 was assessed with adequate hearing without a hearing aid and adequate vision with the use of glasses. Resident #2 was assessed with the ability to have clear speech, could usually understand others and could usually make himself understood. Resident #2 was assessed with a BIMS score of 3 out of a possible 15 which indicated severe cognitive impairment. During an interview on 4/22/2026 at 12:00 PM the ADON stated she was the supervisor for the MCU. ADON stated she worked on 4/14/2026 and had received a report from RN B that Resident #1 was found in Resident #2's room semi-nude. The ADON stated she had reported the incident to the DON and the Administrator who was the abuse prevention coordinator. During an interview on 4/22/2026 at 1:13 PM RN B stated on 4/14/2026 she worked the 2:00 PM to 10:00 PM shift in the MCU and was receiving a report from LVN D who had worked the 6:00 AM shift to 2:00 PM shift in the MCU. RN B stated during the report LVN D could not locate Resident #1 and they began looking for Resident #1. RN B stated they located Resident #1 in Resident #2's room semi-nude from the waist down. RN B stated she assessed both residents without injuries and assisted Resident #1 to dress and redirected her back to her room. RN B stated she had reported the incident to the DON and the ADON. During an interview on 4/24/2026 at 3:00 PM the Administrator and the DON stated they had not received a report of the 3/31/2026 incident of Resident #2 being verbally aggressive towards Resident #1 but had received a report of the 4/14/2026 incident in the MCU where Resident #1 was semi-nude in Resident #2's room. The Administrator and the DON stated they had not provided the state agency an investigation summary report for the 4/14/2026 incident they believed it was normal behavior for residents who are confused to wander about the MCU and could be confused and disrobe. The Administrator and the DON believed that nothing happened between Resident #1 and Resident #2 and therefore did not consider the incident a suspicion of ANE. A record review of the facility's policy, undated abuse, neglect, and exploitation policy revealed, . Investigation of alleged abuse, neglect, and exploitation; an immediate investigation is warranted when suspicion of abuse, neglect, for exploitation, or reports of abuse, neglect, or exploitation occur.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the following; the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the services provided or arranged by the facility, as outlined by the comprehensive care plan, must be culturally-competent and trauma-informed, for 2 of 17 Residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. The facility failed to have interventions care planned in regard to Resident #2's unwanted focused attention towards Resident #1. These failures could place residents at risk for not having their highest practicable physical, mental, and psychosocial well-being needs care met. The findings included: Resident #1:A record review of Resident #1's admission record dated 4/22/2026 revealed an admission date of 11/15/2024 with a diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted into the memory care unit (MCU) for long term care safety related to her cognitive impairment. Resident #1 was assessed with the inability to complete a BIMS exam but was able to make herself understood and could usually make herself understood. Resident #1 Was assessed with adequate hearing and vision and did not use glasses or hearing aids. A record review of Resident #1's care plan dated 4/22/2026 revealed Resident #1 had no specific interventions regarding Resident #2's unwanted focused attention. A record review of Resident #1's physicians' orders dated 4/22/2026 revealed the physician prescribed hospice services on 1/5/2025, and for nursing staff to contact hospice services to report any changes or concerns. During an interview on 4/22/2026 at 12:10 PM Resident #1's Representative stated Resident #1 had dementia and lived in the MCU and was very confused. Resident #1's Representative stated he visited Resident #1 often usually 5 times a week if not daily. Resident #1's Representative stated he learned, over Resident #1's stay, that Resident #2 had become fond of Resident #2 and had developed a habit of having Resident #2 sit next to him. Resident #1's Representative stated the staff had reported this behavior to him and he had observed the same behavior. Resident #1's Representative stated he had often visited and physically removed Resident #1 from Resident #2's area. Resident #2:A record review of Resident #2's admission record dated 4/22/2026 revealed an admission date of 2/10/2026 with a diagnosis of severe dementia (a general, umbrella term for a progressive decline in mental ability, including memory, thinking, and reasoning, severe enough to interfere with daily life) and anxiety. A record review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for LTC in the MCU. Resident #2 was assessed with adequate hearing without a hearing aid and adequate vision with the use of glasses. Resident #2 was assessed with the ability to have clear speech, could usually understand others and could usually make himself understood. Resident #2 was assessed with a BIMS score of 3 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #2's care plan dated 4/22/2026, revealed Resident #2 had socially inappropriate behaviors Resident #2's care plan revealed generic interventions to Document specific instances of inappropriate behavior, including the context, duration, an impact on others, 4/16/2026. Further review revealed there was no care plan specific for Resident #2's focused attention towards Resident #1. A record review of Resident #2's nursing progress notes revealed LVN F documented on 3/31/2026 at 7:42 PM documented, Resident verbally aggressive towards when (Resident #1) was taken to room for care resident states She is mine and will do what ever I say Nurse redirected resident that care needed to be provided as (Resident #1) started to cry. Nurse reassured (Resident #1) she was safe and everything was okay. During an interview on 4/22/2026 at 4:08 PM Resident #2's Representative stated she had received a report from the facility for an incident where Resident #2 had been aggressive towards peer residents and believed these aggressive incidents were being addressed by staff to redirect Resident #2 to safety. During a joint interview on 4/22/2025 at 1:20 PM LVN D and CNA E stated LVN D stated Resident #2 had been admitted about 3 months ago and Resident #1 had been a resident for longer. CNA E and LVN D stated Resident #2 had become increasingly focused on Resident #1 over the last month and had a behavior of scolding Resident #1 when he perceived she was not fast enough and had been known to cuss at Resident #1. LVN D and CNA E stated they monitored Resident #2 and Resident #1 and would intervene for safety by redirecting Resident #1 or Resident #2 away from each other. LVN D stated Residents #1 and Resident #2 did not have a revised care plan to detail the staffs' interventions to monitor and redirect Resident #1 and Resident #2 away from each other. During an interview on 4/24/2026 at 3:00 PM the Administrator and the DON stated the expectation for nursing staff was to report all unusual incidents and their monitoring and interventions to the IDT as soon as the interventions occurred so that a revised care plan could be developed. The Administrator and the DON stated the potential negative outcome for residents could be not having an accurate care plan. A record review of the facility's undated care plan policy revealed, The facility will 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. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings.The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and .The residents' goals for admission and desired outcomes.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents' medical, physical, mental and psychosocial needs.

Based on interviews and record reviews, the facility failed to provide or obtain laboratory services that meet the needs of its residents, for 1 of 3 residents (Resident #4) reviewed for laboratory services, in that: LVN G failed to obtain a urinary analysis for resident #4 as prescribed by NP H. This failure could place residents at risk for delayed treatment.Based on interviews and record reviews, the facility failed to provide or obtain laboratory services that meet the needs of its residents, for 1 of 3 residents (Resident #4) reviewed for laboratory services, in that;. LVN G failed to obtain a urinary analysis for resident #4 as prescribed by NP H. This failure could place residents at risk for delayed treatment. The findings included: A record review of Resident #4's admission record dated 4/24/2026 revealed an admission date of 1/8/2025 and a discharge date of 4/18/2026 with diagnoses which included history of falling, hemiparesis following cerebral infarction affecting left side (left side paralysis after a stroke), and type II diabetes (long term disease where the body cannot produce enough insulin or cannot use the insulin it does produce). A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was a [AGE] year-old female admitted for LTC and was assessed with a BIMS score of 3 out of a possible 15 which indicated sever cognitive impairment. A record review of Resident #4's care plan dated 4/24/2026 revealed Resident #4 was incontinent of bladder and had nursing interventions to monitor for signs and symptoms of urinary tract infections (UTI) as well as a history of falls and had interventions for urinary analyses, Resident #4) has actual fall 04/07/2026 Actual Fall no injury . Date Initiated: 04/07/2026. Labs and UA to be collected Date Initiated: 04/08/2026. A record review of Resident #4's Physician's orders dated 4/24/2026 revealed no orders for a urinary analysis for the period reviewed 4/1/2026 through 4/24/2026. A record review of Resident #4's nursing progress note written by LVN G documented on 4/8/2026 at 11:20 AM that NP H Ordered CBC (a blood laboratory report for blood cells) and UA (a laboratory report for urine) per (NP H) as part of action plan for recent fall. During an interview on 4/22/2026 at 5:17 PM NP H stated she was the nurse practitioner for Resident #4 and had been following her for a history of UTI's and cardiac disease. NP H stated she could not recall the report from LVN G about Resident #4's fall but could state it would be reasonable for her to order a CBC and UA laboratory report to assess Residents for potential infections and possible rational for falls. During an interview on 4/22/2026 at 6:00 PM LVN G stated she had spoken with NP H when Resident #4 was reviewed for her fall on 4/8/2026. LVN G stated NP H requested a CBC laboratory report and LVN G coordinated and secured the lab draw. LVN G stated although her note documented that nurse practitioner wanted a blood draw and a urinary analysis her note was not complete and stated the note should have read NP H wanted the blood draw, however, the urinary analysis was only to take place if Resident #4 had signs and symptoms of a potential UTI; for example, confusion, pain with urination, foul smelling urine, and therefore the order for UA was never in place and it was never completed. During a joint interview on 4/24/2026 at 11:07 AM the DON and the Administrator stated the expectation was for nurses to support and implement prescribers' new orders for residents and stated LVN G was responsible for coordinating NP H's order for a urinary analysis and had not done so. The DON stated the potential negative outcome could be prescribers would be NP's and physicians would be denied the opportunity to intervene by not having laboratory services reported. A policy was requested for the incident, and the DON and the Administrator stated the facility followed HHSC guidelines.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of 5 residents (Residents #95 and #89) reviewed for medication administration. The facility failed to ensure Resident #95 received his anti-seizure medication as ordered by the physician on 4/9/2026. The facility failed to ensure Resident #89 received the correct dose of insulin on 4/10/2026. These failures could result in residents not receiving the intended therapeutic effects of medications, including seizures or low blood sugar levels.Findings included: 1. Record review of Resident #95's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included epilepsy, unspecified, not intractable, without status epilepticus [a chronic neurological disorder characterized by unprovoked seizures caused by abnormal electrical activity in the brain; the seizures are able to be treated with medication and are not continuous]. Record review of Resident #95's significant change MDS submitted 3/2/2026 reflected a BIMS score of 11, which indicated moderately impaired cognition. Section I5400 of the MDS reflected Resident #95 had a diagnosis of seizure disorder or epilepsy. Record review of Resident #95's Order Summary Report dated 4/10/2026 reflected an order dated 8/29/2025 for Lacosamide oral tablet 100mg to be administered orally two times a day for seizures. Record review of Resident #95's Medication Administration Record dated 4/10/2025 reflected Resident #95 did not receive the morning or evening doses of Lacosamide on 4/09/2026, documented by CMA F. In an observation and interview on 4/10/2026 at 8:07 AM, MA F was observed preparing Resident #95's morning medications for administration. She could not locate Resident #95's Lacosamide, and she said the medication was re-ordered the day prior from the pharmacy and should have been delivered in the evening. She said Resident #95 did not get the medication yesterday because it was out of stock, and she was unsure why it had not been reordered previously because she had not been scheduled to work during that time. She said if Resident #95 did not receive his medication, it could result in him having seizures. MA F was able to locate the medication in a different cart, and Resident #95 received the ordered dosage as ordered. In an interview with the DON on 4/10/2026 at 10:00 AM, she said all medication should be reordered when the stock has 7 days remaining. She was unsure why Resident #95's medication had not been reordered, and she was unaware that he had not received the medication on 4/09/2026. She said Resident #95 had not experienced any seizures on 4/9/2026 or 4/10/2026. 2. Record review of Resident #89's admission Record dated 4/10/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included type 2 diabetes mellitus with hyperglycemia [when the body develops resistance to insulin, leading to elevated blood sugar levels]. Record review of Resident #89's significant change MDS submitted 3/17/2026, reflected a BIMS score of 08, which indicated moderately impaired cognition. Section N0350 of the MDS reflected Resident #89 received insulin injections for 5 days of the 7-day assessment period. Record review of Resident #89's Order Summary Report dated 4/10/2026 reflected an order dated 3/13/2026 for Lantus subcutaneous solution 100 unit/mL (Insulin Glargine) Inject 8 unit [sic] subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA [sic]. In an observation and interview on 4/10/2026 at 7:34 AM, LVN C was observed preparing to administer the insulin to Resident #89. The insulin was drawn into a syringe, and LVN C approached Resident #89 to notify him of the medication administration. She told Resident #89 she was going to administer the medication into his left arm, and she cleansed the upper arm with an alcohol pad to prepare the site for administration. The surveyor requested to see the syringe immediately prior to administration, and the syringe was observed to contain 10 units of insulin. LVN C was asked how many units Resident #89 was ordered to receive, and she said 8 units. She inspected the syringe and said the syringe contained 8 units. She then left Resident #89's room and inspected the syringe in the hall, and said she needed to expel 2 units. She said the writing on the syringe was difficult to see. In an interview with the DON on 4/10/2026 at 10:00 AM, she said insulin should be double-checked prior to administration, and the potential risk of not checking was administering the wrong dosage of insulin to a resident and possible hypoglycemia (low levels of blood sugar that require treatment). Record review of the facility provided a policy titled Administering Oral Medications did not contain guidance related to injections or insulin.

Based on observations, interviews, and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for four (4) of seven (7) residents (Resident #5, Resident #11, Resident #57, and Resident #86) reviewed for resident rights. 1. The facility failed to obtain signed consent for psychotropic (a medication that affects brain function and used to treat psychiatric conditions) mood stabilizer medication, Divalproex Sodium (Depakote) which was administered to Resident #5. 2. The facility failed to obtain signed consent for psychotropic antidepressant medication, Sertraline HCl (Zoloft) prior to initial administration on 01/06/2026, to Resident #57. 3. The facility failed to obtain signed 3713s for Risperdal and Depakote for Resident #11. 4. The facility failed to obtain signed Form 3713, [Nursing Facility Consent for Antipsychotic or Neuroleptic] for Ziprasidone for Resident #86. These failures could place residents at risk of receiving medications without their, or that of their responsible party's prior knowledge or consent and could place the residents at an increased risk for adverse reactions to the medications. The findings included: 1. Record review of Resident #5's admission Record, dated 04/09/2026, indicated Resident #5 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #5 was listed as a contact and did not have a listed guardian. Record review of Resident #5's Diagnosis Report, dated 04/09/2026, revealed diagnoses including bipolar disorder (a mental illness characterized by alternating periods of elation and depression), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #5's Annual MDS assessment, dated 03/10/2026, indicated Resident #5 had a BIMS score of 15, which indicated she was cognitively intact. The MDS indicated Resident #5 had not exhibited behavioral symptoms, including rejection of care. The MDS indicated Resident #5 had an active diagnosis of bipolar disorder. Under high-risk drug classes, mood stabilizer was not listed as an option for documenting if Resident #5 had taken a medication under the drug class and if an indication was noted. Record review of Resident #5's Care Plan Report, dated as last care plan review completed 04/02/2026, indicated Resident #5 had focus [Resident #5's name] has the Potential [sic] for drug related complications associated with use of psychotropic medications, date initiated 03/25/2025 and revised 04/10/2025, with an intervention, Obtain consent from patient/responsible party for use of psychotropic medications, date initiated 03/25/2025. Record review of Resident #5's Order Summary Report, dated 04/09/2026, revealed the order Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD, noted as an active order with an order and start date of 01/17/2026 and no end date. Record review of Resident #5's Order Audit Report for order Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD with order date 01/17/2026, revealed under Medication/Supply and Directions the medication had been dispensed three times and reordered two times. The initial date dispensed was noted as 01/18/2026 with the medication noted as exhausted on 02/09/2026 and reordered. The second date dispensed was noted as 02/09/2026 with the medication noted as exhausted on 04/01/2026 and reordered. The third date dispensed was noted as 04/01/2026. Record review of Resident #5's CMA MAR, dated 04/01/2026- 04/30/2026 and printed 04/10/2026 at 11:00 a.m., revealed the order Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD was scheduled for administration at 0900 (09:00 a.m.), 1300 (01:00 p.m.), and 2100 (09:00 p.m.). Of the 29 scheduled administrations possible prior to the document reviewed, Resident #5 had been administered Divalproex Sodium seven (7) times (at 09:00 a.m. on 04/03/2026, 04/07/2026, and 04/08/2026; at 01:00 p.m. on 04/09/2026, and at 09:00 p.m. on 04/05/2026, 04/07/2026, and 04/08/2026) and refused the medication 22 times. Record review of Resident #5's electronic medical record under Misc tab, undated and accessed 04/10/2026 at 10:58 a.m., did not reveal a consent form for Divalproex Sodium. A document titled Informed Consent for Psychoactive Medications, dated as signed 09/29/2025 was identified in Resident #5's EMR; however, the document did not include a medication name. During an observation and interview on 04/10/2026 at 01:57 p.m., LPN J stated the facility protocol for medication consents was for the nurse to call the resident's representative or speak to the resident to get approval for medication administration. She stated if the approval was over the phone, there had to be a witness to the approval, and two staff members would have to sign the consent form indicating approval. She stated the nurse would have to follow that protocol when they receive a new order from the physician or when a prior order had changed, such as the dosage or amount of medication administered. She stated the consents were checked quarterly and the ADON was responsible for following up to make sure the consents are done. LPN J was observed looking through Resident #5's EMR and stated she did not see a consent for Divalproex Sodium. LPN J stated the impact of a resident having received a medication without consent was that the medication administration would be stopped immediately and only resume once the facility received consent.During an interview on 04/10/2026 at 02:14 p.m., ADON E stated the facility protocol for medication consents was for as soon as a medication was noticed to require one, the facility staff would get it. She stated the facility staff could not give the medication without the consent. She stated either the ADON or nurses on the floor were responsible for getting the consent signed by the resident or resident's family member. She stated the ADONs encourage the floor nurses to get the consent, but the ADONs were responsible for following up and getting it. She stated she had not audited the residents' charts for medication consents. She stated that she looked in Resident #5's EMR and found a consent document where the front page was not uploaded. During an interview on 04/10/2026 at 05:21 p.m., Resident #5 stated she was currently refusing her psychotropic medications because she wanted to try to wean from them. She stated she did recall signing the consent for Divalproex Sodium but could not recall when. 2. Record review of Resident #57's admission Record, dated 04/08/2026, indicated Resident #57 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #57 was listed as a contact and did not have a listed guardian. Record review of Resident #57's Diagnosis Report, dated 04/08/2026, revealed diagnoses including Alzheimer's disease (a progressive disease that affects memory and other important mental functions) with early onset, bipolar disorder, and mood disorder (a mental health condition characterized by persistent disturbances in a person's emotional state that is more intense or prolonged than typical) due to known physiological condition with depressive features. Record review of Resident #57's admission MDS assessment, dated 01/11/2026, indicated Resident #57 had a BIMS score of 11, which indicated he was moderately cognitively impaired. The MDS indicated Resident #57 had not exhibited behavioral symptoms, including rejection of care. The MDS indicated Resident #57 had an active diagnoses of depression (other than bipolar) and mood disorder. Under high-risk drug classes, Resident #57 was documented as haven taken antidepressant medication during the last seven (7) days or since admission/entry or reentry with an indication noted. Record review of Resident #57's Care Plan Report, dated as last care plan review completed 01/23/2026, indicated Resident #57 had focus .Has potential for alteration in mood state r/t chronic disease process, mood disorder due to physiological condition with depressive features., date initiated and revised 01/18/2026, with an intervention, Administer medications as ordered by physician, date initiated 01/18/2026. An intervention to obtain a medication consent was not identified. Record review of Resident #57's Order Recap Report, dated order date 01/01/2026- 01/31/2026 and printed 04/09/2026, revealed the orders:- Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Mood/anxiety/executive function related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES, noted as discontinued with an order date of 01/05/2026, a start date of 01/06/2026, and an end date of 01/09/2026. The reason for discontinuation was blank.- Sertraline HCl Oral Tablet 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES, noted as discontinued with an order date of 01/09/2026, a start date of 01/10/2026, and an end date of 03/26/2026. The reason for discontinuation was not noted.Record review of Resident #57's CMA MAR, dated 01/01/2026- 01/31/2026 and printed 04/09/2026 at 11:33 a.m., revealed- the order Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Mood/anxiety/executive function related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES was scheduled for administration at 0900 (09:00 a.m.) and discontinued on 01/09/2026 at 02:41 p.m. Resident #57 had been administered Sertraline HCl four (4) times, at 09:00 a.m. on 01/06/2026 to 01/09/2026. - the order Sertraline HCl Oral Tablet 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES was scheduled for administration at 0900 (09:00 a.m.) and discontinued on 03/26/2026 at 12:45 a.m. Resident #57 had been administered Sertraline HCl 22 times, at 09:00 a.m. from 01/10/2026 to 01/31/2026. Record review of Resident #57's CMA MAR, dated 02/01/2026- 02/28/2026 and printed 04/09/2026 at 11:31 a.m., revealed- the order Sertraline HCl Oral Tablet 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES was scheduled for administration at 0900 (09:00 a.m.) and discontinued on 03/26/2026 at 12:45 a.m. Resident #57 had been administered Sertraline HCl 28 times, at 09:00 a.m. from 02/01/2026 to 02/28/2026. Record review of Resident #57's Order Summary Report, dated 04/08/2026, revealed the order Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to ADJUSTMENT DISORDER WITH DEPRESSED MOOD, noted as an active order with an order and start date of 03/26/2026 and no end date. Record review of Resident #57's CMA MAR, dated 03/01/2026- 03/31/2026 and printed 04/09/2026 at 11:30 a.m., revealed- the order Sertraline HCl Oral Tablet 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH DEPRESSIVE FEATURES was scheduled for administration at 0900 (09:00 a.m.) and discontinued on 03/26/2026 at 12:45 a.m. Resident #57 had been administered Sertraline HCl 25 times, at 09:00 a.m. from 03/01/2026 to 03/25/2026. - the order Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to ADJUSTMENT DISORDER WITH DEPRESSED MOOD was scheduled for administration at 0900 (09:00 a.m.). Resident #57 had been administered Sertraline HCl six (6) times, at 09:00 a.m. from 03/26/2026 to 03/31/2026. Record review of Resident #57's electronic medical record under Misc tab, undated and accessed 04/10/2026 at 11:07 a.m., did not reveal a consent form for Sertraline HCl.During an interview on 04/10/2026 at 01:27 p.m., Resident #57 stated he did not recall giving medication consent or having a discussion regarding his prescribed psychotropic medications. He stated the facility staff gave him his medications and he took them. He stated he did not see a problem with his being given and taking Sertraline HCl, but stated he did not have outbursts, referring to mood disorder diagnosis.During an observation and interview on 04/10/2026 at 02:05 p.m., RN K stated the facility procedures for psychotropics, sleepers, or mood alteration medications was to let the resident know about the medication order and to call the resident representative. She stated the nurse would talk to both the resident and the resident representative about the side effects, uses, why it was being used for the resident, and the benefit. She stated the nurse would discuss how long the medication was to be used and why it was important to continue. She stated that this discussion was to be done after the medication was ordered but before the medication was started or administered. She stated the consent forms were to be completed after explaining the medication to the resident. RN K stated Resident #57's medication consent should be in the EMR and if it was not, she would have to let the doctor of the resident know that the facility had been administering medication without consent. She stated the facility staff would have been checking for harm as part of the administration protocols, but they would be required to communicate the lack of consent to the resident's physician. She stated the nurse that received the initial medication order was responsible for obtaining the resident or resident's representative consent. RN K was observed reviewing Resident #57's EMR, under Miscellaneous tab and stated she did not find a consent signed or uploaded around the time of his Sertraline HCl order, 03/26/2026. During an observation and interview on 04/10/2026 at 03:53 p.m., ADON L stated the facility procedure for medication consents was that nursing staff were supposed to get consent prior to giving medication. She stated the nurse upon admission or the nurse that received the order was responsible. She stated the following day, she or the other ADON would review the order and identify if additional consent was required. She stated for new medications, the nurse was to call the resident's family or let the resident know about the new order and get either in-person signatures or approval over the phone. For Resident #57, she stated she might have his consent. She stated she would scan completed consents to her work email and then upload it to the resident's EMR. ADON L was observed going through a box of paperwork under her desk but did not locate Resident #57's consent for Sertraline HCl. She stated she might have scanned the form but forgot to upload the form. She stated the facility was not supposed to be administering the medication if they did not get the consent. She stated she was not sure of the resident impact if the consent was taken but not available on the resident's EMR but stated the consent should be uploaded. During interview and record review on 04/10/2026 at 05:14 p.m., ADON L stated Resident #57's Sertraline HCl consent was in her email, dated 03/26/2026. Record review of Resident #57's Informed Consent for Use of Psychotropic Medication, dated and signed 03/26/2026, revealed Sertraline was consented for administration by Resident #57 for depression on 03/26/2026. ADON L stated the form was not uploaded to the resident's EMR. She stated the nursing staff should not administer the medication until the actual consent was in hand and was not sure how other nursing staff would know the consent was given if the document was not in the resident's EMR. She stated the nursing staff were not trained to look for completed consents but were supposed to hold the medication until the consent was completed. She stated there was not a consent completed for Resident #57's Sertraline HCl order in January because the order was being modified. During an interview on 04/10/2026 at 04:40 p.m., the DON stated the facility procedure for medication consents was for when the facility received an order, the staff were to get consent. She stated the medication should not start until the facility had received consent. She stated, once the facility staff received consent, the ADONs were to give the consent document to the receptionist to upload to the resident's EMR. She stated the impact of not having medication consent was that the facility would not know if the family or resident agreed to the medication. She stated it was the nurses' responsibility to obtain the resident or resident representative's consent, and the ADONs were responsible for running an order list each morning and ensuring a consent was obtained for each order. She stated there was not a standard timeline of when the consent should be uploaded to the resident's EMR. She stated the impact of Resident #5 and Resident #57 not having consents for their medications was that the facility was administering medications to the residents without obtaining their consent or knowing if the resident consents. During an interview on 04/10/2026 at 05:28 p.m., the ADMIN stated the nurse managers or ADONs for the hall the resident resides in, and ultimately the DON, were responsible in ensuring medication consents were obtained. She stated the impact of not obtaining a consent was not knowing if the family was onboard with the residents plan of care. She stated the consent showed transparency with the residents plan of care and indicated agreement with the medications provided to their loved ones. 3. Record review of Resident #11's admission record, dated 04/07/2026, reflected resident was a [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE] with diagnoses to include schizoaffective disorder and generalized anxiety disorder.Record review of Resident #11's annual MDS assessment, dated 03/23/2026, reflected that he had a BIMS score of 05 out of 15, indicating severe cognitive impairment.Record review of Resident #11's care plan, undated, reflected focus of [Resident #11] receives antipsychotic medications r/t behavior management, schizoaffective disorder, bipolar type, behaviors hallucinations., initiated 10/05/2017.Record review of Resident #11's order summary report, dated 04/07/2026, reflected Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG. Give 1 capsule by mouth two times a day related to GENERALIZED ANXIETY DISORDER, SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE., dated 03/04/2026. It further reflected Risperdal Oral Table 0.5 MG. Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, dated 06/11/2025, Risperdal Oral Table 2 MG. Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, dated 06/11/2025, Risperdal Oral Table 2 MG. Give 2 mg by mouth in the morning related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE.During an interview on 04/08/2026 at 11:41 AM, Resident #11 revealed the facility managed his medication. He revealed he had no concerns about the medication he received and the facility was good about giving him his medication on time.During an interview on 04/10/2026 at 03:20PM, the DON revealed Resident #11 did not sign form 3713 for Risperdal and Depakote. She revealed he did sign a medication consent form but not a 3713. She revealed it was important to have a 3713 signed because it was a state regulation. 4. Record review of Resident #86's admission Record, dated 04/08/2026, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Resident was not listed as his own responsible party with his [family member] listed as Emergency Contact #1.Record review of Resident #86's Medical Diagnoses, undated and access on 04/08/2026 at 6:02 p.m., revealed diagnoses including seizures (a sudden surge of abnormal electrical activity in the brain that temporarily affects awareness, behavior, or muscle control), bipolar disorder (mental health condition characterized by significant mood swings), and schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking).Record review of Resident #86's quarterly MDS, dated [DATE] and signed 03/15/2026 as completed, reflected a BIMS score of 03, indicating moderate cognitive impairment. Resident #86 was documented as having not exhibited any behavioral symptoms. Resident #86's functional abilities were documented as requiring partial/moderate assistance to set up or clean-up assistance.Record review of Resident #86's care plan, undated, and accessed on 04/08/2026 at 6:10 p.m., revealed Resident #86 had been identified as having PASRR positive status related to an intellectual disability.Record review of Resident #86's order summary report, dated 04/08/2026, reflected Ziprasidone HCl Oral Capsule 40 MG, Antipsychotics/Antimanic Agents, ordered 01/13/2024.Record review of Resident #86's Psychotropic Medication Consent., undated, and accessed on 04/08/2026 at 6:05 p.m., revealed consent was not signed by physician and was not the appropriate form for psychotropic medication required, Form 3713, Nursing Facility Consent for Antipsychotic or Neuroleptic.During an interview on 04/07/2026 at 12:00 p.m., Resident #86 revealed the facility managed his medication. He revealed he had no concerns about the medication he received and the facility was good about giving him his medication on time.During an interview on 04/10/2026 at 2:20 p.m., LVN C stated the charge nurses are expected to obtain psychotropic medication consents during new admissions of a resident. She stated psychotropic medications need consents from the responsible party or resident if they are their own responsible party. She stated she will notify the physician of consent form that needs to be completed. She stated charge nurses are expected to obtain psychotropic medication consent prior to medication administration. She stated, realistically psychotropic medication cannot be administered without a consent. She stated she is expected to notify NP W that Form 3713 is required. LVN C stated that administering psychotropic medications without the required consent form can be harmful to a resident.During a subsequent interview on 04/10/2026 at 2:42 p.m., LVN X stated psychotropic medications cannot be administered or ordered without consent forms being signed by RP. She said she was not familiar with Form 3713 requiring a physician signature for specific medications. She stated Nursing Facility H has a psychotropic medication form and she will obtain consent prior to medication administration. LVN X stated that without accurate consent form being completed prior to medication administration can be harmful to the residents and she would need to check their vitals and monitor them.During an interview on 4/10/2026 at 3:36 p.m., ADMIN revealed she was not familiar with psychotropic consents to provide information on compliance.During an interview on 4/10/2026 at 5:20 p.m., ADON E revealed she, ADON L and the DON are responsible for ensuring psychotropic medication consents including Form 3713 are signed and completed. She noted that the impact of not having completed Form 3713 could negatively impact residents as medications would be delayed, and this could impact their behaviors, cause them stress, anxiety, and delay in their overall care.During an observation and interview on 4/10/2026 at 5:20 p.m., ADON L revealed that Resident #86 was admitted with psychotropic medications, start date unknown, and a psychotropic medication form had been secured for him. ADON L was observed to review Resident #1's EMR and psychotropic medication consent hard copy binder and stated Form 3713 should have been there, but she could not find it. She noted there was a consent form completed, but it was not the required form and was not signed by NP W. She noted that she would start working on the accurate psychotropic medication form for Resident #86 and submit to NP W for a signature.On 04/10/2026 at 07:01 p.m., an emailed request for a facility policy on Medication Consent was sent. A policy was not received.

Based on observation, interview and record review the facility failed to maintain a sanitary, orderly, and comfortable interior by housekeeping and maintenance services, which were necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 8 resident rooms (room [ROOM NUMBER], 6, 11, and 13) and 1 of 1 hallway of the secured unit reviewed for homelike environment. The facility failed to ensure resident room [ROOM NUMBER] in the secured unit had repaired the door frame with dents, cracks, black scuff marks, wall with peeled paint, worn out paint, torn furniture, chipped baseboard trim lifting from the wall, light fixture with plastic border loose and hanging, windowsill cracked, peeling paint, missing caulking.The facility failed to ensure resident room [ROOM NUMBER], resident room [ROOM NUMBER], and resident room [ROOM NUMBER] located in the secured unit, repaired the door frame with dents, cracks, black scuff marks, with peeled pain, baseboard trim lifting from the wall.The facility failed to ensure resident rooms [ROOM NUMBERS], which was connected by a bathroom, located in the secured unit, repaired both door frames with dents, cracks, black scuff marks, broken ceiling vent fixture, baseboard trim lifting throughout the bathroom, missing caulking around the toilet bowl and sink, missing tile around the toilet bowl, sheetrock cracked above the sink, peeling paint, and used brief was left on the floor.The facility failed to ensure the secured unit hallway ceiling adjacent to room [ROOM NUMBER]'s, EXIT sign fixture was not loose and hanging from the ceiling, floor plan signage was not separating from the wall, and the walls did not have numerous black scuff marks. These failures could place residents at risk of diminished self-worth.The findings include: During observation of the secured unit on 04/07/2026 1:30 p.m. to 04/09/2026 5:40 p.m., revealed the following: a. Resident room [ROOM NUMBER], located in the secured unit, had a door frame with dents, cracks, black scuff marks, wall with peeled paint, worn out paint, torn furniture, chipped baseboard trim lifting from the wall, light fixture with plastic border loose and hanging, windowsill cracked, peeling paint, missing caulking. b. Resident room [ROOM NUMBER], resident room [ROOM NUMBER], and resident room [ROOM NUMBER] located in the secured unit, the door frame had dents, cracks, black scuff marks, with peeled paint, and baseboard trim was lifting from the wall. c. Resident room [ROOM NUMBER], located in the secured unit, the door frame had dents, cracks, black scuff marks, peeled paint, and baseboard trim was lifting from the wall.d. Resident room [ROOM NUMBER], located in the secured unit, the door frame had dents, cracks, black scuff marks, peeled pain, and baseboard trim was lifting from the wall. e. Resident rooms [ROOM NUMBERS] which were connected by a bathroom, located in the secured unit, both door frames had dents, cracks, black scuff marks, broken ceiling vent fixture, baseboard trim was lifting throughout the bathroom, missing caulking around the toilet bowl and sink, missing tile around the toilet bowl, sheetrock cracked above the sink, peeling paint, and a used brief was left on the floor. f. On the secured unit hallway ceiling adjacent to room [ROOM NUMBER] the EXIT sign fixture was loose and hung from the ceiling, the floor plan signage was separating from the wall, and the walls had numerous black scuff marks. During an observation and interview on 04/09/2026 at 1:45 p.m., CNA R revealed resident room [ROOM NUMBER] that had warped paint and stains would be a maintenance issue and noted he was not sure if a maintenance request was submitted previously. CNA R was observed repairing the loose and hanging light fixture. He stated if the light fixture was to worsen it could pose a danger to the residents in the room and he was observed repairing it immediately.During a subsequent interview on 04/09/2026 at 1:52 p.m., CNA R revealed there had been no maintenance staff at the facility for almost two weeks and a temporary maintenance staff from corporate was onsite this week. He stated, to be honest he had not submitted maintenance repair requests for resident rooms requiring minor repairs and paint touchups and had no reason for not following up.During an observation and interview on 04/09/2026 at 2:07 p.m., Housekeeping revealed she had only been employed for two weeks at the facility. She said she had not made any reports for repairs and said she believed staff were already aware of the condition of the hallway and resident rooms. She said she could go in and take a rag and clean the walls, she could not make repairs, and she was not aware of how to submit a maintenance request. Housekeeping was observed entering resident room [ROOM NUMBER] and wiping brown stains off the walls.During an interview on 04/09/2026 at 2:20 p.m., LVN X revealed she had not submitted a maintenance request for the secure unit's condition of chipped paint, black marks on hallway walls and doorways and broken blinds. She said the facility did not have maintenance staff to submit requests to at this time.During an interview on 04/09/2026 at 2:40 p.m., CNA S revealed she notified the charge nurse on the unit of maintenance concerns in specific rooms and said several resident rooms looked like they were falling apart. She said she reported maintenance concerns to the charge nurse who was responsible for submitting requests to maintenance staff. She stated you could only report the concern a few times without follow-up, and you must move on.During an observation on 04/09/2026 at 2:47 p.m. Resident of room [ROOM NUMBER] was not present in his room for an interview. During an observation on 04/09/2026 at 2:47 p.m. Resident of room [ROOM NUMBER] was not present in his room for an interview.During an observation on 04/09/2026 at 2:47 p.m. Resident room [ROOM NUMBER] was vacant and did not have a resident assigned to the room. During an interview on 04/09/2026 at 3:00 p.m., the ADMIN revealed the maintenance director resigned from his position about two weeks back as he became overwhelmed with the plumbing issues at Nursing Facility H. She noted she was aware of the need for repairs, minor maintenance, touch ups, walls, and sprucing up the secured unit, but her focus since she started in her role as ADMIN was to get Nursing Facility H up to code to pass inspections. She stated she planned to work on the secured unit touchups next as this was the resident's home and it should feel and look comfortable and homelike. She stated she planned to take a walk through the rooms in the secured unit with corporate staff to note the minor repairs.Record review of the facility's policy titled, State of Resident's Rights in Texas, dated 08/2022, revealed .You have a right to: 2. Safe, decent, and clean conditions.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 10 residents (Resident #10, Resident #15, Resident #82) reviewed for care planning. The facility failed to ensure Resident #10's comprehensive care plan included safety interventions related to the use of an electronic cigarette (vape).The facility failed to ensure Resident #15's comprehensive care plan included elopement risk and safety interventions related to placement in a secure unit.The facility failed to ensure Resident #82's comprehensive care plan included elopement risk and safety interventions related to placement in a secure unit. This failure could place residents at risk of inappropriate use of the device resulting in injury or not receiving appropriate care and services.Findings included: 1. Record review of Resident #10's admission Record dated 4/10/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included paraplegia (the loss of sensory and/or motor function in the lower extremities). Record review of Resident #10's quarterly MDS submitted 1/28/2026 reflected a BIMS score of 15, which indicated intact cognition. Section J1300 reflected Resident #10 was a smoker.Record review of Resident #10's Smoking Evaluation dated 9/23/2024 reflected Resident #10 was identified as a smoker, and no safety issues were identified. Record review of Resident #10's Care Plan Report, undated/ printed 4/08/2026, did not reveal care planning related to smoking. Record review of Resident #10's progress notes revealed the following entry dated 3/19/2026 at 11:30 AM by LVN C:This nurse went to room to inform resident that had got footrest for his wheelchair, noted smoke in room asked resident if could show what he was smoking, resident showed this nurse a vape machine, asked resident if could have it, resident stated no, mentioned to resident that cannot be smoking in his room, resident stated that he did not get a chance to go outside, again encouraged resident not to be smoking in his room and mentioned to DON and social worker of resident smoking in room and was advised not to smoke in room.In an interview with Resident #10 on 4/07/2026, he denied that he was a current smoker. In an interview with LVN C on 4/10/2026 at 12:15 PM, she said Resident #10 routinely used a vape and was allowed to keep the device in his possession. She said she had caught Resident #10 using the vape in his room on several occasions and had reported the findings to the DON. She said Resident #10 knew not to use the vape in his room, and the facility policy was to remind him that he could use the vape only in designated smoking areas. She said there were no other safety concerns regarding using the vape. In an interview with the MDS nurse on 4/10/2026 at 12:35 PM, she said she was also responsible for updating care plans after completing MDS assessments. She said Resident #10's should contain care planning related to smoking and any safety concerns. She said the potential harm of not including this information in the care plan was the resident or someone else could get injured. Record review of the facility policy Smoking Policy- Residents dated 2001, revised October 2023, revealed the following: .10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . 2. Record review of Resident #15's admission Record dated 04/08/2026 reflected a [AGE] year-old female admitted [DATE]. Resident #15 was not listed as her own responsible party.Record review of Resident #15's Medical Diagnoses, undated and accessed 04/08/2026 at 6:38 p.m., revealed diagnoses including Alzheimer's Disease (a progressive disease that affects memory and other important mental functions), vascular dementia (cognitive impairment caused by reduced or blocked blood flow to the brain, leading to memory, thinking, and behavioral problems), cognitive communication deficit (condition where impairments in cognitive processes, rather than language or speech mechanics, disrupt a person's ability to communicate effectively), altered mental status (broad term describing any change in a person's normal cognitive function, awareness, or behavior, ranging from mild confusion to complete unresponsiveness), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and depression (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems). Record review of Resident #15's significant change Minimum Data Set (MDS), dated [DATE] and signed 02/27/2026 as completed, reflected a BIMS score of 03, indicating severe cognitive impairment. Resident #15 was documented as having exhibited physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. Resident #15 was documented as not having exhibited wandering behaviors. Resident #15's functional abilities were documented as requiring supervision or touching assistance to set up or clean-up assistance.Record review of Resident #15's care plan, undated and accessed 04/08/2026 at 6:45 p.m., did not reveal mention of secure unit placement, risk for elopement, or wandering interventions. The care plan revealed Resident #15 had impaired cognitive function/dementia/though process related to Alzheimer's, Dementia. The care plan focus was created and initiated on 10/16/2025. The care plan focus included PAL [Prefeence Based Living] Cards created and placed in memory care unit to assist with fostering relationships by identifying important preference information across departments by implementing a person-centered quality improvement initiative. She loves to sing Spanish. The care plan focus was created and initiated on 10/16/2025 and the interventions were initiated 04/08/2026.Record review of Resident #15's Elopement Risk. assessment, dated 10/01/2025 revealed yes was selected for .the resident is at risk for elopement and yes was selected for .has the care plan been initiated/updated to reflect interventions?Record review of Resident #15's progress notes, dated 10/01/2025 (day of admission) to 10/05/2025 (day of transfer to secure unit), indicated no documentation about why a room change to the secure unit was made.During an observation of Resident #15 on 04/07/2026 at 3:19 p.m., was noted to be lying down in her bed eating a cookie. She yelled at the surveyor and said she was sick not to enter her room.During an observation and interview of Resident #15 on 04/09/2026 at 1:30 p.m., she was noted to be standing in the doorway of her room. She was communicating in Spanish, she was dressed well, groomed appropriately, and no odors. She stated she is fighting against the cold, she wants coffee with milk. She interacted well with staff moving throughout the unit. She said the black male staff is her friend, but he is serious. She said staff treat her well, she has fallen in her room from all the water on the floor that is falling from the ceiling. Her bed was in a low position, no water observed on the floor or coming from the ceiling. She said staff have a tough time understanding her because they speak little Spanish and she speaks primarily Spanish. She said there are usually three staff members in the unit. Resident #15 said the staff do not let her exit her room and she does not know why. Resident was noted struggling to find the right words, following the conversation, expressing her thoughts, and confused.During a subsequent observation of Resident #15 on 04/09/2026 at 2:05 p.m., she was noted to be participating in karaoke in the dining room with numerous residents watching her perform. Resident was singing a Spanish song from memory, she was loud, smiling, and excited from her performance.During an interview on 04/09/2026 at 7:05 p.m., Resident #15's [family member] and responsible party stated this is a good facility, Resident #15 is well taken care of, she is always treated well and with respect, staff care for her with kindness and love and she eats well. Resident #15's responsible party said she transferred from another nursing facility at the beginning of October 2025 because she had behaviors of wandering and several elopement attempts. She said the former nursing facility did not have an open bed in the secure unit and she was admitted to this nursing facility with the expectation for Resident #15 to be moved into the secure unit for her safety. She said she has no concerns with Resident #15's care at this facility.During an interview on 04/09/2026 at 7:26 p.m., the DON revealed Resident #15 transferred from another facility. She noted that Resident #15 was having elopement behaviors at her prior facility and the party responsible was requesting a secure unit upon admission. 3. Record review of Resident #82's admission Record dated 04/08/2026, reflected a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #82 was not listed as her own responsible party with her (family member) listed as Emergency Contact #1.Record review of Resident #82's Medical Diagnoses, undated and accessed 04/08/2026 at 4:48 p.m., revealed diagnoses including Alzheimer's Disease (a progressive disease that affects memory and other important mental functions), cognitive communication deficit (condition where impairments in cognitive processes, rather than language or speech mechanics, disrupt a person's ability to communicate effectively), muscle weakness (condition in which muscles are unable to generate the expected amount of force, resulting in reduced strength or difficulty performing normal movements), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems).Record review of Resident #82's annual Minimum Data Set (MDS), dated [DATE] and signed 03/23/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #82 was documented as having exhibited physical and behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. Resident #82 was documented as not having exhibited wandering behaviors. Resident #82's functional abilities were documented as requiring supervision or touching assistance to independent.Record review of Resident #82's care plan, undated and accessed 04/08/2026 at 5:05 p.m., did not reveal mention of secure unit placement, risk for elopement, or wandering interventions. The care plan revealed Resident #82 had Cognitive impairment as evidenced by Impaired decision making, and Alzheimer's dementia. The care plan focus was created and initiated on 05/16/2025 and revised on 03/21/2026.Record review of Resident #82's MD, NP Progress Notes, dated 06/16/2025 and written by NP W documented PT [Resident #82] IS SEEN IN SECURE UNIT FOR THE FOLLOWING MEDICAL CONDITIONS: ALZHEIMER'S DISEASE: PT [Resident #82] RECENTLY MOVED FROM D HALL TO SECURE UNIT, DUE TO WANDERING IN THE ROOM OF OTHER RESIDENTS. PT [Resident #82] IS CONFUSED AND NEEDS FREQUENT REDIRECTING BY STAFF. NO EXIT-SEEKING, AGGRESSION OR AGITATION.During an observation of Resident #82 on 04/07/2026 at 2:08 p.m., she was noted to be lying down in her bed with her eyes wide open. Her bed was noted to be in a low position. Resident #82 was dressed well, groomed appropriately, no odors, call light within reach, and a few personal items were noted in her room. Attempted interview with Resident #82 revealed she was not interviewable.During an observation on 04/08/2026 at 5:19 p.m., Resident #82 was noted to be asleep in bed. Her bed was noted to be in a low position.During an observation and interview of Resident #82 on 04/09/2026 at 1:35 p.m., she was noted to be lying down in her bed facing the window. Her bed was in a low position, and a crossword book was lying beside her. She sat up on her bed and began speaking in Spanish. She was noted to have a large hematoma with bruising to the right side of her forehead. She said she was a new resident in the facility, she did not know what happened to her forehead, stated she recalls going to the hospital, and does not take medications, she eats a little because this is her preference. Resident #82 was noted to be dressed well, groomed appropriately, no odors. Resident struggled to find the right words, to follow the conversation, express her thoughts, recalling details, and was confused.During an observation of Resident #82 on 04/09/2026 at 2:04 p.m., she was noted as alert and walking out of her room, ambulated without a device, walking up and down the hallway searching for the music she heard playing throughout the unit.Attempted interview on 04/09/2026 with Resident #82's [family member] and responsible party at 7:04 p.m. but they did not return the call.During an observation and interview on 04/09/2026 at 7:26 p.m., the DON revealed Resident #82 was transferred to the secure unit on 06/19/2025 because she had behaviors with a roommate. She said on 05/08/2025 and 05/09/2025 Resident #82 was making statements of wanting to leave and go home, she was angry, and she packed her belongings and headed for the door. She said on 05/19/2025 a care conference to discuss Resident #82's behaviors and if she would benefit from a WanderGuard transpired. She said Social Services was having difficulties with Resident #82's placement. She stated the exit seeking behavior determined the resident's need for secure unit placement. The DON was observed to review Resident #15's care plan, 06/17/2025 IDT, care plan summary, social service progress notes and nursing progress notes from 05/07/2025 (admission date) to 06/19/2025 (transfer to secure unit) and stated she could not find documentation of IDT discussion for secure unit placement, responsible party consenting of transfer to secure unit, and interventions for secure unit placement. She stated Social Services would have been responsible for documenting the transfer to secure unit, updating the care plan, and progress notes with follow up discussion of Resident #15's care; however, she [Social Services] was new to her role so she would not have documented well. She said the appropriate consent for Resident #82 was obtained prior to her transfer to the secure unit and interventions were in place for this resident; however, not documented in Resident #82's EMR. She said the facility is not in compliance with documentation requirements and the team will work on this moving forward. During an interview on 04/09/2026 at 1:52 p.m., CNA R stated care plans provide staff with specific information of care a resident requires and not being updated or accurate can be harmful to a resident.During an interview on 04/09/2026 at 2:20 p.m., LVN X stated care plans give the staff vital information on resident care and are necessary to provide interventions needed for behaviors.During an interview on 04/09/2026 at 2:40 p.m., CNA S stated care plans will list interventions needed to separate residents who have behavior issues and updated care plans are necessary as staff rely on interventions in the secure unit.During an interview on 04/10/2026 at 2:00 p.m., Social Services said she was responsible for psychosocial assessments, checking on the emotional well-being of each resident, assisting with IDT, sending referrals to psych services, participating in PASRR meetings, quarterly meetings, new admission meetings, and to follow-up on resident-to-resident incidents. She stated the importance of documenting and updating resident care plans was to provide nursing staff with interventions to help avoid resident behaviors and to de-escalate incidents. She stated the impact of not updating care plans or inaccurately documenting care plans would be that staff may not have the required information to help a resident de-escalate behaviors and potential of incidents occurring.During an interview on 04/10/2026 at 1:35 p.m., CNA, V stated he utilized care plans as they communicate vital information on how to care for a resident to be well and thrive, maintain a healthy lifestyle. He stated that inaccurate care plans could keep a resident from receiving the necessary care and thereby cause a decline of their health.During an interview on 04/10/2026 at 1:47 p.m., CNA U stated she received daily reports during shift change and the expectation is to review the care plans daily to provide the best care possible to the residents assigned to her hallway. She stated inaccurate care plans can cause a delay in care.During an interview on 04/10/2026 at 2:20 p.m., LVN C stated she and the aides she oversees rely on the care plans and their accuracy to provide specific care for a resident. She stated if care plans are not updated or inaccurate a resident could negatively suffer.During an interview on 04/10/2026 at 3:00 p.m., the MDS revealed that care plans should be updated every quarter and as needed. She noted that a change of condition would require the care plan to be updated. She stated mental health services are documented in the care plan along with determination of PASRR services. The MDS stated care plans are to alert the nursing staff, residents, and families of specialized services being provided. She stated if care plans are not updated or inaccurate could cause harm to residents and those around them. The MDS noted that residents residing in the secured unit would require IDT discussion to ensure all staff involved in resident's care are on the same page with their care. She noted that ADON E, ADON L, DON, Social Services, and herself make up the IDT. She noted that she could not say the IDT discussed secured unit placements quarterly but noted that there are verbal discussions constantly taking place and cannot say that the discussions are documented in the resident EMR.During an interview on 4/10/2026 at 3:36 p.m., the ADMIN revealed at times she will participate in more challenging care plan meetings. She noted that residents placed in the secured unit should have information documented in their care plan. She noted that she is aware that secured unit resident care plans do not reflect their status in the secured unit or their interventions. She noted that the IDT does discuss secured unit placements but would need to verify if these discussions are being documented in the resident EMR as she could not recall at this time. The ADMIN noted that care plans should be person-centered and describe the services that are to be provided to attain or maintain the resident's physical, mental, and psychosocial well-being. She noted that not developing and implementing person-centered care plans could negatively impact the social and mental well-being of a resident.During an interview on 4/10/2026 at 5:20 p.m., ADON E revealed the nursing staff rely on the resident's EMR task bar and care plan for specific care to provide to a resident. She noted that if a care plan is not updated or accurate it could have a negative impact on a resident as staff would not be informed of interventions to redirect their behaviors. Record review of policy titled, Care Planning - Interdisciplinary Team, dated Qtr. 3, 2018, revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.Record review of policy titled, Comprehensive Care Plans, date revised 05/05/2025, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASRR recommendations. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and when a resident experiences a status change 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . Record review of policy titled, Secure unit placement, date revised 06/10/2025, revealed .3. Written findings and the factual basis for the placement are documented in the health information record.5. The IDT team to evaluate place of a resident in a secure environment.6. The evaluation team shall re-evaluate as needed.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 7 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his right stage 3 heel wound on 10/16/25. Resident #1 refused an ER referral when the maggots were found and was sent to the emergency room a day after the maggots were discovered. An IJ was identified on 10/23/25. The IJ template was provided to the facility on [DATE] at 3:25 p.m. While the IJ was removed on 10/25/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. This failure could place residents at risk of experiencing a diminished quality of life, infections and/or death. The findings include: Record review of Resident #1's face sheet, dated 10/21/25, reflected a 32 -year-old male who was admitted to the facility on [DATE] and discharged AMA on 10/20/2025. Resident #1 had diagnoses which included: osteophyte, right foot (bone spur) ,osteophyte (a bony outgrowth) right ankle and left foot and ankle, pressure ulcer to left buttock stage 3, pressure ulcer left hip stage 3, paraplegia (loss of impairment in both lower limes), amputation at level between elbow and wrist, open wound of lower back and pelvis, pressure ulcer to left buttock stage 3, pressure ulcer of right buttock stage 4, and pressure ulcer right heel stage 3. The RP was listed as the resident. Record review of Resident#1's admission MDS, dated [DATE], reflected a BIMS score of 12, indicative of moderate impairment in cognition. The ADLs for: B/B was catheter for blader; bowel was incontinent. Transfer was total assistance; and bed mobility was supervision. Assistive device was listed as motorized W/C. ROM was documented as impairment to lower body. Record review of Resident #1's skin assessment on admissions, dated 10/3/25, reflected a right heel pressure ulcer with measurements of 3.5 x5.5x08 full thickness stage 3 20% slough (puss) serosanguinous (mix of blood and serum) and drainage. Record review of Resident #1's NP A' skin assessment on 10/13/25 of the right heel reflected the following measurements: 3.5 Length by 5.5 Width by 0.8 Depth.Record review of Resident #1's CP, dated 10/16/25, reflected .Reports of having live maggots in his right heel wounds. Interventions listed in the CP included: education to the residents, MD notified, sent to ER on [DATE] for any treatment, and daily wound treatment and weekly skin assessments. The CP documented to notify the physician as needed when resident refused wound care.Record review of Resident #1's physician orders, dated 10/15/25, read: . Wound care to right heel stage 3 pressure injury, cleanse with normal saline, pat dry, apply medihoney, (calcium) alginate, cover with dry dressing daily. Record review of Resident #1's Nurse Note, dated 10/16/25 at 6:00 a.m., authored by RN A, reflected: Multiple wounds with purulent drainage. Record review of Resident #1's SBAR note, dated 10/16/25 at 9:23 p.m., authored by LVN D, reflected .Wound to right heel is noted with live maggots falling from wound site. Resident is noted with history of refusing wound care and non-compliance of staying outdoors in wheelchair for long periods of time. Wound site is cleaned and wound care provided. [MD call center] on call notified of finding and recommendation to send to ED for eval (evaluation) and treatment.Record review of Resident #1's SBAR noted, dated 10/17/25 at 12:17 p.m., authored by the DON, reflected .maggots noted to patient wounds on feet [right heel] .wound care provided. persuaded patient to go to hospital with education of the outcome if not getting treatment for maggots in his wounds [right heel] . [arrived at hospital at 2:44 p.m.] Record review of Resident #1's Nurse Note, dated 10/17/22 at 12:22 p.m., authored by the DON, reflected .Resident (#1) stated ' I know my body and I don't really need to go to the hospital, I'm used to having maggots and they come whenever [I] skip wound care, I should have told y'all that happens.' Record review of Resident #1's Hospital records reflected Resident #1 was sent to the hospital for refusing care and now has maggots on 10/17/25. Record review of Resident #1's AMA sheet, dated 10/20/25, reflected the signed resident sheet with 3 witnesses present (DON, LVN C and RN K). Reason for AMA: resident wanted to be independent.Observation on 10/22/25 at 10:20 a.m., revealed some flies in Resident #2's room while observing wound care given to Resident #2 by LVN C. [flies in the room had the potential of landing on the resident's wound or laying eggs throughout the room and later infecting the resident's wounds] Observation of Resident #1's room on 10/22/25 at approximately 12:15 p.m. reflected that the screen was not fully adjusted to the frame, potentially allowing for flies/gnats to enter. There were no flies or gnats observed. During an interview on 10/21/25 at 12:30 p.m., the DON stated: Resident #1 was discovered with maggots tohis right wound heel on 10/16/25 by LVN D. The DON stated the timeline was as follows: ---10/2/25-resident was admitted with 9 pressure ulcers to include stage 3 to the right heel. No maggots were present in the wounds. MD Orders for daily wound care.---10/3/25- to 10/13/25 daily wound care done.---10/14/25 skin assessment: no change to wounds and no maggots in any wound.---10/15/25-resident refused wound care all day. ---10/16/25 during the day shift (6:00 a.m. to 2:00 p.m.) resident refused wound care.---10/16/25 at 9:23 p.m. maggots were observed by LVN D in the right heel dressing. The resident refused to go to the ER. LVN D attempted to remove the maggots.---10/17/25 at 6:00 a.m. resident refused wound care.---10/17/25 around 8:30 a.m., Resident accepted wound care from the DON and maggots were again found in the right heel. MD was again notified and order given to send resident to the ER for an assessment.---10/17/25-DON convinced resident to be assessed at the ER and DON accompanied the resident.---10/17/25-ER note: [Right] lower extremity with a lateral [well] healing ulcer, no maggots. discharged to facility in a stable condition.---10/20/25- wound care given by NP PP in the morning. Resident signed out AMA around 2:00PM [MD had given new orders for IV daptomycin (wound infection) and Levaquin (wound infection) prior to the resident going out AMA.] During an interview on 10/21/25 at 4:26 PM, the DON stated Resident #1 received daily wound care and was seen by the NP [A] Wound Nurse Weekly but had a history of refusing wound care. The DON stated NP PP was aware Resident #1 at times refused wound care. During an interview on 10/22/25 at 9:55 AM, the DON stated Resident #1's right heel wound was covered when the resident was up and about based on observations by nursing staff to include the DON. During an interview on 10/22/25 at 10:04 a.m., the DON stated the resident 's dressing was clean and dry except on 10/16/25 at 6:00 a.m., when the dressing was soiled and the resident refused wound care. The DON stated maggots were discovered on 10/16/25 around 8:30 a.m. and cleaned by the DON and LVN C (wound nurse) were present. The DON added, she saw 3-4 maggots on the right heel. The DON stated the resident still had maggots on 10/17/25 around 9:00 a.m. located on the right heel and the toe of the right foot (no wound); and several maggots on the right foot. The DON stated, other staff who saw the maggots were the Administrator on the wound (right heel) and LVN C on the bed. During an interview on 10/22/2025 at 10:20 a.m., LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. During a telephone interview on 10/22/25 at 11:05 a.m., NP PP stated rubbing could kill the maggot eggs on a wound. NP PP stated heat, and the smell of dry blood could lead to flies laying eggs on a resident and develop into maggots within 8-20 hours. NP PP stated Resident #1 had the habit of going out on pass and refusing wound care. NP PP stated there were no issues with the wound care given to residents by facility nursing staff. NP PP stated Resident #1 skipping wound care for 2 days or more could result in maggots being present. NP PP stated she never saw maggots in the resident's wounds, but the resident could be infected with maggots given his habit of refusing care and spending hours outside the facility in the heat. During an interview on 10/22/25 at 11:15 a.m., the Administrator stated the last pest control spraying was done on 10/10/25 and the next spraying was scheduled for every two weeks (10/24/25). The Administrator stated the Pest Company sprayed all the common interior areas and exterior for occasional insects; no issues noted on the spraying on 10/10/25. During a telephone interview on 10/22/25 at 12:07 p.m., the MD stated the skipping of wound care could lead to maggots developing within 8-12 hours especially if the wound was soaked, there was heat, and the dressing was uncovered. The MD added some cleansing wound care solutions could kill maggots. The MD stated there were standing orders when the resident missed wound care. The MD stated she first became aware of the maggots when reported on 10/16/25 by LVN D. During a telephone interview on 10/22/25 at 3:25 p.m., the Pest Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. The Vendor added, flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids. The Vendor stated he had not seen an infestation of flies in the facility, but flies could be present in the facility from doors opening. During an interview on 10/22/25 at 3:35 p.m., the Administrator stated the facility had not identified a fly problem. The Administrator stated no fly lights had been installed in the facility to include the kitchen, and no request had been made to the pest control vendor for special spraying and wiping down surfaces for fly prevention. During an interview on 10/22/25 at 5:08 p.m., LVNC stated: when Resident #1 allowed wound care per physician orders was completed. LVN C stated she saw no issues with the wound care provided by other nursing staff. LVN stated she never saw maggots in Resident#1's wounds. On 10/17/25 while assisting the DON, LVN C stated she saw maggots on the resident's bed on 10/17/25 and removed the maggots from the bed. During an interview on 10/22/25 at 6:02 p.m., the Administrator stated she saw a few maggots on the resident's heel on 10/17/25 at 9:30 a.m. The Administrator stated the DON cleaned the maggots and disposed of them. During a joint interview on 10/22/25 at 6:15 p.m., the Administrator and DON stated the sheets were removed on 10/17/25 and Resident #1's room was cleaned and sanitized/bleached. The DON did not know whether the sheets were changed, and room cleaned on the 10/16/25 night shift when LVN D saw maggots. During a telephone interview on 10/22/25 at 6:24 p.m., LVN D stated, he saw maggots on Resident #1's right heel on 10/16/25 around 9:30 p.m. and called the MD for guidance. LVN D stated the MD gave an order to send the resident to the ER for an assessment; but the resident refused to go to the ER. LVN D stated he could not remember whether the sheets were changed, and the room cleaned and sanitized/bleached. During an interview on 10/23/25 at 9:12 a.m., the Housekeeping Manager stated: housekeeping was not on done the night of 10/16/25 when LVN D saw maggots on Resident#1 heel wound. The Housekeeping manager stated Resident #1's room was not cleaned or bleached or the linen changed because no housekeeping staff were on duty the night of 10/16/25. The Housekeeping Manager stated she assumed nursing staff at night was responsible for housekeeping. The Housekeeping Manager started around 2:00-3:00 p.m. on 10/17/25 housekeeping services were provided to Resident #1's which included: cleaned, sanitized and bleached; and linen was changed. The Housekeeping Manager stated the linen was discarded; no maggots were seen. The Housekeeping Manager stated housekeeping services were provided again when the DON saw maggots in the afternoon on 10/16/25. The Housekeeping Manager stated the effective method for maggot control was deep surface cleaning, bleaching, and discarding affective linen and materials. During a telephone interview on 10/23/25 at 1:30 p.m., LVN D (night nurse) stated: he only focused on wound care for the right heel where the maggots were present. LVN D stated he only visually looked at the other wounds and saw no maggots. LVN D stated he saw the maggots on 10/16/25 around 9:30 p.m. LVN D stated he had not seen maggots in the resident's wounds in the past. LNV D stated Resident #1's gown was changed and there was a brief change. LVN D stated there was no linen changed, and he was not aware of the room being cleaned and sanitized. During a telephone interview on 10/24/25 at 10:30 a.m., LVN D stated: the resident had a right heel pressure ulcer at admissions (10/2/25). LVN D stated there were no maggots on the 9 PU sites upon admission. LVN D stated, the skin condition was awful at admissions. The resident was total assistance for transfer. LVN D stated there were no flies or gnats in the room where the assessment was conducted on 10/16/25 at 9:23 p.m. of the right heel with maggots. LVN D stated the right heel dressing was intact the days he saw the resident. LVN D stated the dressings to the right heel were sometimes moist, and the resident sometimes refused care. LVN D stated Resident #1 was always outside in a gown and would have blankets on the motorized W/C. LVN D stated the resident enjoyed spending time outside. LVN D stated he called the MD around shift change after seeing the maggots. Record review of pest control logs reflected pest control visit on 10/10/25 with no noted issues. Record review of facility's grievance log for the past 90 days (August-October 2025) reflected no grievances involving pests. Record review of the facility's Cleaning and Disinfection of Environment Surfaces policy, dated revised June 2009, read, .Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Pathogens Standard. Record review of the facility's Pest Control policy, dated revised May 2008, read, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents. This was determined to be an Immediate Jeopardy (IJ) on 10/23/25 at 3:25 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 10/23/25 at 3:25 p.m. The following Plan of Removal submitted by the facility was accepted on 10/24/25 at 12:43 a.m. [Facility] respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on 10/23/2025. Plan submitted on 10/23/2025 at 6:30pm The facility allegedly failed to maintain an effective pest control program so that it is free of pests and rodents. On 10/16/25, Resident #1 was found with maggots in his right stage 4 heel wound. On 10/16/2025, when maggots were discovered in Resident #1's heel wound, the Director of Nursing (DON) and LVN C. immediately cleansed the wound per wound protocol. Resident #1's room [was] thoroughly cleaned and sanitized in accordance with the facility's cleaning and disinfection policy.Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not fully adjusted to the frame, potentially allowing for flies/gnats to enter. However, no flies or gnats were observed. Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not Fully adjusted to the frame, potentially allowing for flies/gnats to enter. However, no flies or gnats were observed. Surveyor and Administrator confirmed that the window was sealed appropriately, and that the screen's previous misalignment would not [allow] any insects or pests to enter the facility. A facility-wide environmental inspection was completed on 10/22/2025 by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure. No issues noted. Observation on 10/22/25 at 10:20 a.m.flies were observed in Resident #2's room while observing wound care given to Resident #2 by LVN C. [Not Resident #1] During an interview on 10/22/2025 at 10:20 AM, LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. Record review of pest control logs reflected pest control visit on 10/10/25 with no noted issues. During interview on 10/22/25 at 3:25 p.m., [Pest] Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. He said flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids [not sure if done at the facility]. Record review of facility's Pest Control policy, dated revised May 2008, reflected, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents The Administrator confirmed the facility currently utilizes three fly zap lights as part of its pest control prevention program. These devices are strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. In addition, the facility employs three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building. On 10/22/2025, the Administrator contacted Pest Control and placed an order for three additional fly zap lights to further enhance pest prevention coverage throughout the facility. The Zap lights were delivered and installed on 10/23/2025 by Pest Prevention Technician [.] in the following locations. B Hall Dining Room, C Hall Dining Room and E Hall dining room. The effectiveness of the newly installed Zap Lights will be monitored utilizing the environmental daily check list. The Housekeeping Supervisor and Maintenance Director and or designee will be responsible for Zap Light Effectiveness. On 10/23/2025 the Pest Prevention Technician assisted the facility utilized the wipe down method in rooms of residents with treatment orders. This method entails wiping down surfaces and walls. Observation of Resident #1's room at approximately 12:15 p.m. on 10/22/25 revealed the screen was not fully adjusted to the frame, potentially allowing flies/gnats to enter. However, no flies or gnats were observed. Surveyor and Administrator confirmed that the window was sealed appropriately, and that the screen's previous misalignment would not allow any insects or pests to enter the facility. A facility-wide environmental inspection was completed on 10/22/2025 by the Maintenance Director to ensure all windows, screens, and entry points were intact and secure. No issues noted Observation on 10/22/25 at 10:20 a.m., revealed some flies in Resident #2's room while observing wound care given to Resident #2 by LVN C. [Note-this is part of the facility's POR]During an interview on 10/22/2025 at 10:20 AM, LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. Record review of pest control logs show pest control visit on 10/10/25 with no noted issues. [Note-this is part of the facility's POR]During interview on 10/22/25 at 3:25 p.m., the Pest Control Vendor stated flies were controlled by checking for room sanitation, checking dumpsters, and spraying. He said that flies could be controlled by fly lights [not present in the facility] and wiping down surfaces with special liquids [not sure if done at the facility].[Note-this is part of the facility's POR] Record review of the facility's Pest Control policy, dated revised May 2008, reflected, .Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents. [Note-this is part of the facility's POR] The Administrator confirmed that the facility currently utilizes three fly zap lights as part of its pest control prevention program. These devices are strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. In addition, the facility employs three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building.Residents with the potential to be affected by the alleged deficient practice: A comprehensive skin and wound audit was completed for all residents with pressure injuries on 10/23/25 by the nurse managers to ensure no other residents were affected. No other maggots or pests were found. This assessment was documented in a progress note. No other issues were discovered. All Staff were in serviced on the facilities Pest Control Program. The training was completed on 10/23/25 and was conducted by the Administrator and Director of Nurses. Resident identified to have been affected by the alleged deficient practice: On 10/16/2025, after providing additional education and multiple attempts to encourage compliance with medical care, Resident #1 agreed to be transported to the emergency room for further evaluation and treatment. The Director of Nursing (DON) personally accompanied the resident to the hospital. Prior to transfer, the DON, Administrator, Social Worker, Treatment Nurse, Charge Nurse, and Certified Nursing Assistant (CNA) were all involved in efforts to educate and persuade the resident regarding the importance of receiving medical attention. Resident stated, I get maggots when I refuse care, and I had them before coming here. Resident was [educated] on multiple occasions by providers. Progress notes [input] on 10/9, 10/13, 10/14 and 10/20. Care Plan on 10/15 also references history of refusal of care. Systemic Measures:[all staff]Training provided to all staff on the Pest Control Policy and protocols for pest prevention, environmental inspection, and staff reporting. This was completed on 10/23/25. 100% completed. This was completed by the Administrator and Director of Nurses. [Housekeeping]Training provided to all staff on the cleanliness of resident rooms to ensure rooms remain as free as possible of items that may attract pests. The staff [were] educated on cleaning procedures in the event pest are identified. Housekeeping Cart is available in E hall housekeeping closet for after-hour [use]. This was completed on 10/23/25. 100% completed. This was completed by the Administrator and Director of Nurses. The facility increased pest control vendor visits from biweekly to weekly and added three additional fly light installations in key areas. Weekly vendor visits initiated on 10/22/25 for 4 weeks. The three additional Zap Lights were installed on 10/23/25 by by Pest Prevention Technician. Maintenance initiated a weekly environmental inspection log for all window seals, screens, and potential pest entry points. This will be completed by the Maintenance Director and [/] or designee. The facility began utilizing this log on 10/23/25. Environmental Services implemented a daily cleaning checklist focusing on food debris and sanitation in resident rooms and dining areas. This will be conducted by the Housekeeping Supervisor and or [/] designee. The facility began utilizing this log on 10/23/25. Nurses received re-education on wound care refusal documentation, physician notification, and resident education procedures. 100% completed. The training was completed on 10/23/2025 and was conducted by the Director of Nurses. Quality Assurance Performance Improvement: On 10/23/2025 the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The facility will review the pest control log daily for any pest control issues. The Admin/ DON/designee will review and observe. In addition, the Admin/DON/designee will complete 5 observations per week. If any pest control issues or deficient practices are discovered the Admin/ DON/designee will provide additional training [for] staff. Training to include. Pretest, Inservice, Post Test and Return Demonstration. The results of the Admin/ Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction:10/23/2025 Monitoring of the POR included the following: Observation and interview on 10/24/25 at 4:30 p.m. Housekeeping Staff GG was observed involved in the deep cleaning of the facility wall edges. Housekeeping Staff GG stated she was instructed on the wipe down method by the Pest Control vendor. Also, Housekeeping Staff GG stated she did deep cleaning and wall frame rubbing down of rooms where residents had orders for pressure ulcer wound care; the room assignments were given by the Housekeeping Manager. Observation on 10/24/25 from 4:25 p.m. to 4:35 p.m., of all window screens reflected no holes and properly fitted to the window frames. Also, windows of 6 residents receiving wound care were sealed. During an observation on 10/24/25 from 5:00 p.m. to 5:10 p.m., of the facility reflected, there were three fly zap lights as part of its pest control prevention program present. These devices were strategically located at the facility entrance, kitchen area, and along A Hall and B Hall to minimize insect activity. The facility employed three high-velocity door fans, positioned at the E Hall exit, B Hall exit, and kitchen exit, to deter flying insects from entering the building During an observation on 10/25/25 at 11:00 a.m. revealed 6 fly zaps were all working. During an interview on 10/24/25 at 1:25 p.m., RN G stated she attended in-service on Pest Control policy and the highlights were to report any insects or rodents found anywhere in the facility through the system TELS. RN G stated Prevention included keeping the residents clean and food out of the room. During an interview on 10/24/25 at 1:32 p.m., LVN H stated the highlights of the in-service included: increased pest control spray and install fly lights. LVN H stated Environmental inspection involved checking on hoarding of food by residents. LVN H stated Reporting involved making an entry in TELS and notifying the Administrator. During an interview on 10/24/25 at 1:41 p.m., RN K stated the training highlighted to prevent insects and rodents by checking for cleanliness of rooms and food in the room. RN K stated Prevention also included changing of linen. RN K stated Reporting involved notifying the to the Administrator and documenting in TELS. During an interview on 10/24/25 at 1:56 p.m., CNA N stated the training included: prevention of pests by fly lights and fans blowing out. CNA N stated the environment was to be kept clean During an interview on 10/24/25 at 2:04 p.m. CNA O stated: prevention of pests included the use of zap lights. Prevent CNA O stated food was to be discarded in trash cans and rooms kept clean. CNA O stated to report any COC to Nursing staff. During an interview on 10/24/25 at 2:07 p.m., CNA P stated: prevention of pests involved by keeping areas Cleaned and keep residents bathed. CNA P stated to Report to nurse and Administration any room changes. During an interview on 10/24/25 at 2:10 p.m., LVN Q stated prevention involved keeping the area clean, the residents clean and take out trash. LVN Q state Reporting involved documenting in TELS. During an interview on 10/24/25 at 2:25 p.m., Staff R (Social Worker) stated the highlights were: prevention by cleanliness and Resident rooms should not have leftover food. Staff R stated, Report by documenting in the maintenance binder and notify management.,During an interview on 10/24/25 at 2:27 p.m., Staff S (Rehab) stated: highlights of the training involved shutting windows and keeping rooms cleaned. Staff S stated residents were to be kept clean and received incontinent Care; and report any COC on wounds to nursing staff. During an interview on 10/24/25 at 2:30 p.m., Staff T (Maintenance) stated prevention training included: maintain the facility and seal any openings in screens or windows. Staff T stated Notify nursing staff if insects or rodents were seen in the facility and document in the maintenance log. During an interview on 10/24/24 at 2:35 p.m. the Maintenance Director stated he received no W/O to seal windows or screens during the time of the incident on 10/16-10/17/25. The Maintenance Director added prior to the incident the facility did not have fly lights. During an interview on 10/24/25 at 2:38 p.m. Staff U (Kitchen) stated: highlights of the training included to keep kitchen and facility clean and practice hygiene; and Report W/O to management. During an interview on 10/24/25 at 2:39 p.m. Staff V (kitchen) stated: prevention of pests through cleaning and checking; and Reporting of pests through W/O. During an interview on 10/24/25 at 2:40 p.m. Staff W (kitchen) stated training involved keep the kitchen clean and the facility and throw out trash and inspect dumpsters. Staff W stated Report to the administrative staff about any issues with insects. During an interview on 10/24/25 at 2:41 p.m. Staff X (kitchen) stated: in-service stressed to keep the facility and kitchen clean as a prevention measure against pests. Staff X stated to check on the appearance of residents.and Report immediately if insects were on ceiling lights During an interview on 10/24/25 at 1:42 p.m., LVN I stated the highlights of training included: prevention through spraying and keeping rooms clean. LVN I stated Reporting involved to report to the DON and put in the maintenance log. During an interview on 10/24/25 at 1:43 p.m., CNA J stated the highlights were: check rooms for food and drinks. CNA J stated the environment involved to make sure it was kept clean. CNA J stated Reporting to the charge nurse and any COC and to document. During an interview on 10/24/25 at 1:52 p.m., CNA L stated the highlights of training included: prevention by keeping the facility clean. CNA L stated Check that residents were bathed as a prevention measure. CNA L stated to Report to housekeeping and the Administrator any room change. During an interview on 10/24/25 at 1:54 p.m., CNA M stated the training emphasized prevention of pests by having the resident cleaned and showered; and ensuring trash was removed. CNA M stated Report on TELS and report to DON and COC. During an interview on 10/24/25 at 2:50 p.m., Staff Y (Rehab) stated highlights of training included: cleanliness in rooms and no clutter and no food. Staff Y stated check on resident odors and cleanliness as prevention. Staff Y added to Check on wound dressings; and inform the nursing staff if the residents appear dirty and unkempt. During an interview on 10/24/25 at 2:51 p.m., Staff Z (Rehab) stated: prevention of pests included rooms needed cleaning and windows sealed; and Residents should be clean and kept clean. Staff Z stated Report issues to the nursing staff. During an interview on 10/

Based on interviews and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. The facility failed to implement treatment orders for Resident #1's wounds for 5 of 9 wounds for 12 to 13 days; did not document on the TAR if treatment was provided to 5 of 9 wounds for 13 days; and did not complete a weekly wound assessment on 10/09/2025 for 5 of 9 wounds. This failure could hinder the healing of the residents' existing pressure ulcers or lead to the development of additional skin injuries. The findings included: Record review of Resident #1's admission Record (face sheet), dated 10/24/2025, revealed he was [AGE] years old, admitted to the facility on [DATE] with diagnoses which included osteomyelitis (infection of the bone marrow), pressure ulcers (bed sores), paraplegia (partial paralysis), intracranial injury (injury to part of the brain), peripheral vascular disease (narrowing of the blood vessels in the arms and legs due to plaque buildup); and was discharged on 10/20/2025. Record review of Resident #1's MDS, an admission assessment dated [DATE], revealed a BIMS score of 15 out of 15 which indicated his cognitive skills for daily decision making were not impaired; had not rejected care and he was admitted with six stage 3 pressure ulcers (severe form of skin breakdown that involves full-thickness tissue loss, extending into the subcutaneous fat layer), one stage 4 pressure ulcer (severe form of skin breakdown that extends through the skin and underlying tissues, exposing muscle, tendon, and bone) and one unstageable deep tissue injury (condition that affects the underlying layers of skin and soft tissues, often resulting from sustained pressure or shear forces, leading to tissue damage and tissue death). Record review of Resident #1's care plans dated 10/17/2025, revealed a care plan for the focus area of Pressure ulcer actual or at risk due to admitted with pressure ulcers, paraplegia that was initiated 10/03/2025 for the following wounds: sacrum (bottom area) stage 4, right heel stage 3, right hallux (big toe) abrasion (wound caused by rubbing or scraping the skin), left lateral (outer) thigh stage 3, left lateral foot (outer side of the foot) stage 3, left hallux deep tissue injury, right lateral malleolus (outer bony prominences on the ankle) stage 3 and left groin stage 3. Under interventions was to conduct weekly wound assessments and treatments as ordered. Record review of Resident #1's admission Weekly Head to Toe Skin Check, dated 10/03/2025 completed by Treatment Nurse LVN C, revealed he had 9 wounds on:1. Left rear thigh stage 3 pressure ulcer with 30% slough (type of dead tissue that forms in a wound bed) that measured 9 cm x 5 cm x 2 cm.2. Left lower rear leg stage 3 pressure ulcer with 20% slough that measured 1.5 cm x 3.5 cm x 1.5 cm.3. Right heel stage 3 pressure ulcer with 20% slough that measured 3.5 cm x 5.5 cm x 0.8 cm.4. Sacrum stage 4 pressure ulcer with serosanguinous drainage (light pink, thin watery fluid that is common in stages of wound healing) that measured 26 cm x 29 cm x 7 cm.5. Groin stage 3 pressure ulcer that measured 1 cm x 1.5 cm x 0.8 cm.6. Left hallux deep tissue injury that measured 1 cm x 2 cm x 0.8 cm.7. Left lateral foot stage 3 pressure ulcer with 20% slough that measured 3.2 cm x 2.5 cm x 0.8 cm.8. Right hallux that measured 4 cm x 2 cm x 0.8 cm. 9. Right lateral malleolus stage 3 pressure ulcer that measured 1 cm x 1 cm x 0.8 cm. Record review of Resident #1's Physician Order Summary Report, dated 10/24/2025, revealed there were treatment orders with a start date of 10/03/2025 for the wounds on his left rear thigh, left lower rear leg, sacrum and left lateral foot. The treatment orders for the wounds on the groin and right hallux had a start date of 10/14/2025; and the wounds on the right heel, left hallux, and right lateral malleolus had a start date of 10/15/2025. An antibiotic, Levaquin oral 750 mg tablet, was ordered on 10/20/25 and was to be administered once daily for osteomyelitis. Record review of Resident #1's October 2025 TARs revealed it was not documented that he received wound care to the wounds on his right heel, groin, left hallux deep tissue injury, left hallux abrasion and right lateral malleolus until 10/15/2025. Record review of Resident #1's Wound Assessments dated 10/09/2025, completed by Treatment Nurse LVN C, revealed there was an assessment for the wounds on his left lower rear leg, sacrum, left hallux, and left lateral foot; but there was no assessment for the wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus. Record review of Resident #1's Wound Assessments dated 10/13/2025, completed by Treatment Nurse LVN C, revealed there was a wound assessment for all 9 wounds which had the following measurements:1. Left rear thigh stage 3 pressure ulcer with 20% slough that measured 9 cm x 5 cm x 2 cm.2. Left lower rear leg stage 3 pressure ulcer with 20% slough that measured 1.5 cm x 3.5 cm x 1.5 cm.3. Right heel stage 3 pressure ulcer with 20% slough that measured 3.5 cm x 5.5 cm x 0.8 cm.4. Sacrum stage 4 pressure ulcer with serosanguinous drainage that measured 26 cm x 29 cm x 8 cm.5. Groin stage 3 pressure ulcer that measured 1 cm x 1.5 cm x 0.8 cm.6. Left hallux deep tissue injury that measured 1 cm x 2 cm x 0.8 cm.7. Left lateral foot stage 3 pressure ulcer with 20% slough that measured 3.0 cm x 2.5 cm x 0.8 cm.8. Right hallux abrasion that measured 4 cm x 2 cm x 0.8 cm. 9. Right lateral malleolus stage 3 pressure ulcer that measured 1 cm x 1 cm x 0.8 cm. Record review of Resident #1's Wound Nurse Practitioner's progress note dated 10/13/2025, revealed his 9 wounds were assessed by Wound NP OO with the following measurements:1. Left rear thigh stage 3 pressure ulcer with 20% slough that measured 9 cm x 5 cm x 2 cm.2. Left lower rear leg stage 3 pressure ulcer with 20% slough that measured 1.5 cm x 3.5 cm x 1.5 cm.3. Right heel stage 3 pressure ulcer with 20% slough that measured 3.5 cm x 5.5 cm x 0.8 cm.4. Sacrum stage 4 pressure ulcer with serosanguinous drainage that measured 26 cm x 29 cm x 7 cm.5. Groin stage 3 pressure ulcer that measured 1 cm x 1.5 cm x 0.8 cm.6. Left hallux deep tissue injury that measured 1 cm x 2 cm x 0.8 cm.7. Left lateral foot stage 3 pressure ulcer with 20% slough that measured 3.0 cm x 2.5 cm x 0.8 cm.8. Right hallux abrasion that measured 4 cm x 2 cm x 0.8 cm. 9. Right lateral malleolus stage 3 pressure ulcer that measured 1 cm x 1 cm x 0.8 cm. Record review of Resident #1's Wound Nurse Practitioner's progress note dated 10/20/2025, revealed his 9 wounds were assessed by Wound NP OO with the following measurements:1. Left rear thigh stage 3 pressure ulcer with 20% slough that measured 9 cm x 4 cm x 1.5 cm.2. Left lower rear leg stage 3 pressure ulcer with 20% slough that measured 1.4 cm x 4 cm x 1 cm.3. Right heel stage 3 pressure ulcer with 20% slough that measured 3.5 cm x 5.5 cm x 0.8 cm.4. Sacrum stage 4 pressure ulcer with serosanguinous drainage that measured 26 cm x 30 cm x 7 cm.5. Groin stage 3 pressure ulcer that measured 1 cm x 1 cm x 0.8 cm.6. Left hallux deep tissue injury that measured 1 cm x 2 cm x 0.8 cm.7. Left lateral foot stage 3 pressure ulcer with 20% slough that measured 4.0 cm x 2 cm x 0.8 cm.8. Right hallux abrasion that measured 2 cm x 1 cm x 0.8 cm. 9. Right lateral malleolus stage 3 pressure ulcer that measured 1 cm x 1 cm x 0.8 cm.Record review of Resident #1's Nurse's Note, dated 10/02/2025, by LVN OO revealed approached resident for assessment and he asked to be left alone and did not want to be touched. Nurse advised resident that it was important to do assessment. 'I said, I do not want to be touch (sic).'Record review of Resident #1's Nurse's Note, dated 10/06/2025, by Treatment Nurse LVN C revealed [Resident #1] refused to be seen by Wound NP OO for initial evaluation. He stated he did not want to get back in bed and was happy being outside enjoying the sun.Record review of Resident #1's Nurse's Note, dated 10/10/2025, by RN NN revealed [Resident #1] refused meds and wound care this shift, attempted x6 and [Resident #1] continued to refuse.this nurse asked another nurse to accompany for one last effort to ask [Resident #1] if he would take [his] medication and allow wound care to be complete[d] he continues to refuse at this time. Record review of Resident #1's Nurse's Note, dated 10/12/2025, by RN B revealed [Resident #1] was outside the facility the whole shift 1400-2142 (2:00 p.m. - 9:42 p.m.). He was asked politely multiple times by different staff to come inside the facility to have his wounds dressed but he refused.He was reminded on multiple occasions that he has to come inside to eat, take his medications and have his wounds dressed which were already weeping, oozing fluid mixed with blood.but he again refuses and was calling staff names.Record review of Resident #1's Nurse's Note, dated 10/14/2025 by Treatment Nurse LVN C, revealed upon arriving to my shift [Resident #1] up in his chair outside in patio area, I asked if I could do his wound care he stated 'No, I am staying outside'. I then asked when, he shrugged his shoulders.Record review of Resident #1's Nurses Notes from 10/02/2025 to 10/15/2025 revealed there was no documentation if wound care was provided to Resident #1's wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus.Record review of Resident #1's SBAR note, dated 10/16/25 at 9:23 p.m., authored by LVN D, reflected .Wound to right heel is noted with live maggots falling from wound site. Resident is noted with history of refusing wound care and non-compliance of staying outdoors in wheelchair for long periods of time. Wound site is cleaned and wound care provided. [MD call center] on call notified of finding and recommendation to send to ED for eval (evaluation) and treatment.Record review of Resident #1's SBAR noted, dated 10/17/25 at 12:17 p.m., authored by the DON, reflected .maggots noted to patient wounds on feet [right heel] .wound care provided. persuaded patient to go to hospital with education of the outcome if not getting treatment for maggots in his wounds [right heel] . [arrived at hospital at 2:44 p.m.]Record review of Resident #1's Nurse Note, dated 10/17/22 at 12:22 p.m., authored by the DON, reflected .Resident (#1) stated ' I know my body and I don't really need to go to the hospital, I'm used to having maggots and they come whenever [I] skip wound care, I should have told y'all that happens.'Record review of Resident #1's Hospital records reflected Resident #1 was sent to the hospital for refusing care and now has maggots on 10/17/25.Record review of Resident #1's Social Services note, dated 10/20/25, revealed she had Followed up with resident regarding refusal of care. Resident stated he is not currently refusing care and is allowing them to do wound care. Discussed refusal of lower extremities and resident stated he is allowing wound care to bottom but dressings were done the day before on the lower extremities. Educated and discussed with resident following doctors' orders and verbalized understanding of the risks of noncompliance.Record review of Resident #1's Nurse's Note, dated 10/20/25 at 12:45 p.m. by RN K, revealed Resident stated he wanted to go to ER related to sacral itching. This nurse educated resident that his wound had been treated by the wound NP and wound nurse and new healthy tissue was noted and that is why he was having more sensation. Resident acknowledged but continued to request ER visit. This nurse called for transport but resident refused to go by stretcher. This nurse educated resident on EMS policy of stretcher transport for ER visits. Resident refused transport and stated he would leave AMA. This nurse informed administration. Resident was educated on leaving AMA and risk associated with be unable to receive care from facility. Resident acknowledged and stated he still would be going AMA.Record review of Resident #1's Nurse's Note, dated 10/20/2025 at 1:24 p.m. by Treatment Nurse LVN C, revealed .[Resident #1] stated he would just leave AMA, I educate[d] [Resident #1] on the importance of wound care and medication management. He states he knows and understands any risk he is taking, he signed the AMA form, thanked me for helping him but he wants to be able to come and go as he wants. He signed form, I called DON and informed [his] Primary Care Provider.Record review of Resident #1's AMA sheet, dated 10/20/25 at 12:45 p.m., reflected the resident signed the sheet with 3 witnesses present (DON, LVN C and RN K). Reason for AMA: resident wanted to be independent.During an interview on 10/22/25 at 10:04 a.m., the DON stated the resident 's dressing was clean and dry except on 10/16/25 at 6:00 a.m., when the dressing was soiled and the resident refused wound care. The DON stated maggots were discovered on 10/16/25 around 8:30 a.m. and cleaned by the DON and LVN C (wound nurse) were present. The DON added, she saw 3-4 maggots on the right heel. The DON stated the resident still had maggots on 10/17/25 around 9:00 a.m. located on the right heel and the toe of the right foot (no wound); and several maggots on the right foot. The DON stated, other staff who saw the maggots were the Administrator on the wound (right heel) and LVN C on the bed. During an interview on 10/22/2025 at 10:20 a.m., Treatment Nurse LVN C stated while doing wound care to Resident #2, she observed some flies in the resident's room. Treatment Nurse LVN C stated, He is really messy with food, and he [NAME] on food and spills it everywhere, so he does get flies sometimes. We try to clean it up quickly, but there's never been any infestation or anything. During a telephone interview on 10/22/25 at 11:05 a.m., NP PP stated Resident #1 had the habit of going out on pass and refusing wound care. NP PP stated there were no issues with the wound care given to residents by facility nursing staff. NP PP stated Resident #1 skipping wound care for 2 days or more could result in maggots being present. NP PP stated she never saw maggots in the resident's wounds, but the resident could be infected with maggots given his habit of refusing care and spending hours outside the facility in the heat.During a telephone interview on 10/22/25 at 12:07 p.m., the MD stated the skipping of wound care could lead to maggots developing within 8-12 hours especially if the wound was soaked, there was heat, and the dressing was uncovered. The MD added some cleansing wound care solutions could kill maggots. The MD stated there were standing orders when the resident missed wound care. The MD stated she first became aware of the maggots when reported on 10/16/25 by LVN D. During a telephone interview on 10/22/25 at 6:24 p.m., LVN D stated, he saw maggots on Resident #1's right heel on 10/16/25 around 9:30 p.m. and called the MD for guidance. LVN D stated the MD gave an order to send the resident to the ER for an assessment; but the resident refused to go to the ER.During a telephone interview on 10/23/25 at 1:30 p.m., LVN D (night nurse) stated: he only focused on wound care for the right heel where the maggots were present. LVN D stated he only visually looked at the other wounds and saw no maggots. LVN D stated he saw the maggots on 10/16/25 around 9:30 p.m. LVN D stated he had not seen maggots in the resident's wounds in the past. In a telephone interview on 10/24/2025 from 10:33 a.m. to 10:54 a.m., LVN D stated he completed a skin assessment on Resident #1 on the first day he cared for Resident #1, which was the resident's second day in the facility because the resident had refused to let the nurses do an assessment the previous day. LVN D said Resident #1 was very noncompliant with letting the nurses complete skin assessments and wound care despite encouragement from the nurses.In a telephone interview on 10/24/2025 at 11:05 a.m., RN B stated he would provide wound care to Resident #1's sacrum wound when incontinent care was provided and would try to do wound care on his other wounds, but Resident #1 would frequently refuse care to his other wounds despite encouragement and education. RN B said Resident #1 did allow the nurse to provide wound care to his right heel, but RN B could not remember when that was. In a telephone interview on 10/24/2025 from 12:16 PM to 12:48 p.m., Treatment Nurse LVN C stated she would complete a skin assessment and wound assessment when a resident was admitted to the facility and then a weekly assessment would be completed. Treatment Nurse LVN C said Resident #1's skin was pretty bad.he had nine wounds, he was seen weekly by the Wound NP A, but Resident #1 had refused to let the Wound NP A assess him on 10/06/2025 when she was in the facility because he was outside because if he was up [in his wheelchair] that was it, there was no going back [to bed to do wound care]. Treatment Nurse LVN C stated she thought there were orders for all of Resident #1's wounds when he was admitted but could not remember without looking at his chart. The Treatment Nurse said she was responsible for entering resident's wound orders into their clinical record and the harm of not having a wound treatment order was . the wound could become infected; it could get bigger.In an interview on 10/24/2025 from 1:34 p.m. to 1:45 p.m., CNA F stated she remembered the nurses would provide wound care to Resident #1 when he was in bed and when he allowed them to do so but he would be combative or refuse at times. In an interview on 10/24/2025 at 1:48 p.m., RN G stated she cared for Resident #1 only on 2 days and she did not provide wound care to him because the facility has a Treatment Nurse. RN G said she remembered seeing Treatment Nurse LVN C provide wound care to Resident #1 one day in the hallway to his heels because that was the only place the resident would allow the treatment nurse to do it, and because he did not want to be put back into bed and the wound dressings needed to be changed.In a follow-up telephone interview on 10/25/2025 from 11:34 a.m. to 11:41 a.m., Treatment Nurse LVN C stated she could not remember why orders were not written for Resident #1's wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus. She said the reason why a weekly wound assessment was not done on 10/09/2025 for his wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus was because she might have been interrupted during her wound assessments and forgot to go back to finish the assessment on those wounds. LVN C stated with Resident #1, Once you start, you can't stop and if you stop, he won't let you go back to him.In an interview on 10/25/2025 at 11:55 a.m., the Regional Clinical Resource (corporate nurse), stated Resident #1 was assessed by Wound NP OO before he left the facility AMA.In an interview on 10/25/25 at 3:34 p.m., the Regional Clinical Resource stated she reviewed Resident #1's clinical record and could not find any admission treatment orders for his wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus; and the orders for those wounds were started on either 10/14/2025 or 10/15/2025. The Regional Clinical Resource said when she spoke to the DON, the DON stated the treatment nurse provided wound care to Resident #1's wounds when he would let her. In an interview on 10/24/2025 at 2:57 p.m., the DON stated when she would do her daily rounds in the facility, she had observed that Resident #1 had wound dressings on both of his feet which were dated with that day's date, so she knew the wound care nurse was providing the wound care. The DON stated wound care was to be documented on the resident's TAR, but it was not documented on Resident #1 because it looked like there was an error due to orders that were not in the chart for the wounds. The DON reviewed Resident #1's wound assessments completed on 10/09/2025 and stated there were only 4 wound assessments done for the sacrum, left lower rear leg, left lateral foot and left hallux wounds. The DON stated the Treatment Nurse was responsible for ensuring the weekly wound assessments were completed and the harm of not completing a weekly wound assessment was that it would be difficult to determine if the wound was healing or deteriorating. The DON said the procedure for ensuring admission treatment orders were transcribed for wounds was the treatment nurse's responsibility; and the harm of not having a treatment order could result in wound care not being provided to the resident.In an interview on 10/24/2025 at 3:38 p.m., the Administrator stated the treatment nurse, or the admitting nurse was responsible for entering the treatment orders for wounds into the resident's clinical record upon admission; and not having a treatment order for wounds could result in the resident's plan of care not being followed. The Administrator said the treatment nurse was responsible for completing the weekly wound assessments and not having it completed could result in not following the plan of care and cause a decrease in the skin's integrity.Record review of the facility's policy Wound Care, dated 2021, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident.Documentation. The following information may be recorded in the resident's medical record, if applicable: 1. The type of wound care given. 2. The date and time the wound care was given.

Based on observations, interviews, and record reviews the facility failed to protect the residents right to be free from physical abuse by Resident #83 and #55, for 3 of 13 residents (Residents #55, #61, and #83) reviewed for physical abuse and neglect. 1. On 1/11/2025 on or about 11:00 AM Resident #61 was physically battered by Resident #83, to include a face punch, his hair pulled, and drug by his foot across the floor. 2. On 4/9/2024 Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. 3. On 4/22/2024 Resident #61 was punched in the nose by Resident #55. 4. On 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. An IJ was identified on 1/29/2025. The IJ template was provided to the facility on [DATE] at 3:15 PM. While the IJ was removed on 1/30/2025 at 9:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm. These failures placed residents at risk for physical abuse. The findings included: 1. Resident #61 A record review of Resident #61's admission record dated 1/27/2025, revealed an admitted [DATE] with diagnoses which included dementia with moderate agitation (a group of symptoms affecting memory, thinking and social abilities. further review revealed Resident #61 resided in the facility's secured Memory Care Unit (MCU). A record review of Resident #61's annual MDS assessment dated [DATE] revealed Resident #61 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 4 out of a possible 15 which indicated severely impaired cognition. Resident #61 was reviewed for the 6 days prior to the assessment and Resident #61 was assessed with a history of wandering, has the Resident wandered? Behavior of this type occurred 1 to 3 days. does the wandering place the Resident at significant risk of getting to a potentially dangerous place? Yes Resident #61 was diagnosed with cataracts (a gradual progression of vision problem, eventually, if not treated, may result in vision loss.) Further review revealed Resident #61 was 5 foot and 5 inches tall and weighed 129 lbs. A record review of Resident #61's care plan dated 1/29/2025 revealed, Behavioral Complex Care Plan Physically Abusive Behavior, Socially Inappropriate Behavior, Wandering, verbally abusive and/or resisting care. 12/24/24 pacing back/forth ready to go to work attempted to go out-door pushing bar. 1/11/25 Another Resident (Resident #83) entered this Res room. Staff heard yelling other resident was found dragging (Resident #61) by the hair as per CNA, then that resident began to drag Resident (#61) by the legs . revision 1/16/2025 . Resident move to different room. Date Initiated: 01/14/2025 Refer to behavioral health Date Initiated: 08/13/2024 Revision on: 8/14/2024 Separate Residents. Date Initiated: 01/11/2025 . Resident #61 uses anti-anxiety medications r/t agitation. Resident #61 is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor every shift for safety A record review of Resident #61's physicians orders, dated 6/10/2024, revealed the physician prescribed for staff to have Frequent monitoring throughout the shift staff to attempt to anticipate some of residents needs as tolerated. A record review of Incident reports indicated the following: A record review of the facility's incident report dated 4/9/2024 revealed Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. Further review of the report revealed the previous administrator and the previous DON had been notified. A record review of the facility's incident report dated 4/22/2024 revealed the previous DON documented Resident #61 was punched in the nose by Resident #55. Resident #61 was presented to the nurse with a bloody nose after exiting Resident #55's room. Resident #61 took the nurse to Resident #55 room and stated, this is the bathroom, and he won't let me use it. He hit my nose. Resident #55 stated, He came in here to take a shit. I told him to get out. He peed in the corner, so I hit him on the nose. A record review of the facility's incident report dated 8/12/2024 revealed the LVN C documented on 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. Resident #55 stated, I hit him because he came into my room. Resident # 83 A record review of Resident #83's admission record dated 1/30/2025 revealed an admitted [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a cluster of symptoms, not an illness. It's sometimes described as losing touch with reality), mood disturbance, and anxiety. Further review revealed Resident #83 resided in the MCU. A record review of Resident #83's admission MDS assessment dated [DATE] revealed Resident #83 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. Resident #83 was reviewed for the 6 days prior to the assessment and Resident #83 was assessed with a history of behavioral symptoms, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . behavior of this type occurred 1 to 3 days. verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . behavior of this type occurred 1 to 3 days. impact on others? Put others at significant risk for physical injury? Yes Further review revealed resident #83 was six foot tall and weighed 179 lbs. A record review of Resident #83's care plan dated 1/29/2025 revealed, Behavioral Complex Care Plan Physically Abusive Behavior, Verbally Abusive Behavior 1/1/25 noted standing in doorway of another resident, both residents with raised voices. 1/11/25 Another Resident went into his room this resident. This resident is kept separated from other resident and redirected as necessary Date Initiated: 11/06/2024 Revision on: 01/28/2025 . Look for alternative placement. Date Initiated: 01/14/2025 Residents were separated. Date Initiated: 01/01/2025 Staff to explain cares to resident prior to and during process of cares. Date Initiated: 11/07/2024 Revision on: 11/14/2024 A record review of Resident #61's provider investigation report dated 1/20/2024 revealed the operations manager documented an incident on 1/11/2025 at 11:00 AM, where Resident #83 physically battered Resident #61. The operations manager documented Resident #83 as the perpetrator and identified CNA A and RN S as witnesses. The operations manager documented, Resident was hit by another Resident, dragging by his hair and his leg per CNA. Resident stated he accidentally walked into wrong room. after interviewing staff and Resident(s) it was found Resident wandered into wrong room and was the cause of the altercation and we moved residents' room to avoid future issues. (Resident #61) is extensive supervision and needs constant redirection due to dementia diagnosis During an observation and interview on 01/26/25 at 3:55 PM revealed the MCU where Resident # 61 was asleep in room [ROOM NUMBER] (which was not his assigned room.) CNA A was the only staff in the MCU. CNA A was alerted by the surveyor that Resident #61 was not in his assigned bedroom. CNA A discovered Resident #61 in another bedroom and redirected him to his bedroom. CNA A stated on 1/11/2025 at 11:00 AM she heard screams from the end of the hall and ran to the sounds and witnessed Resident #83 in his room and had Resident #61 by his hair and was dragging him to the floor. CNA A attempted to separate them but Resident #83 was a large man and CNA A was herself threatened so she ran down the hall, exited the MCU to gather emergency assistance, and upon her return to the MCU, she witnessed Resident #83 had Resident #61 by his foot and drug him out of Resident #83's room and into the hallway. CNA A stated, I am often alone in the MCU, the nurse works this MCU and another hall outside of the MCU. CNA A stated Resident #83 was very aware of his room and becomes violent when anyone was in his room. Resident #61 was very confused and often goes into different rooms and Resident #83 becomes aggressive towards Resident #61. During an interview on 1/30/2025 at 5:35 PM RN S stated she was a nurse who worked at the facility as needed and could work the MCU during the 10P-6A shift. RN S stated she had received the in-service for the MCU which included the addition of 2 CNAs would staff the MCU. RN S stated she appreciated the addition of 2 CNAs for the MCU since she was on duty on 1/22/2025 at 11:00 AM when Resident #61 was battered by Resident #83 and CNA A had to leave the residents and the MCU to alert her to the resident-to-resident abuse. RN S stated she was on the adjacent hall providing care when CNA A exited the MCU and called out for help in the MCU. RN S stated she ran after CNA A and entered the MCU to the end of the hall to Resident #83's bedroom and witnessed Resident #83 dragging Resident #63 by his legs out of the room into the hall. RN S stated the residents were separated for safety and assessed head to toe, no injuries were assessed for Resident #83, and Resident #61 was assessed with a right cheek redness, slight swelling, and discoloration. The physician received a report and Resident #61 was supported with x-rays which revealed no deep injuries. RNS stated residents were monitored frequently and ultimately Resident #61 was relocated to a bedroom away from Resident #83's bedroom. During an interview on 1/27/2025 at 4:05 Resident #61's emergency contact stated Resident #61 was a full code and would often visit him. Resident #61's emergency contact stated she often observed the MCU was staffed by 1CNA and 1 nurse and was not aware the nurse would leave the MCU to care for residents outside of the MCU. Resident #61's emergency contact stated she received a report from Resident #61's Representative that Resident #61 was punched in the face by Resident #83 but was not aware Resident #61 was left alone with Resident #83 while the CNA left to get help. During a joint interview on 1/28/2025 at 11:47 AM Resident #61's representative and emergency contact stated they had not received a full report for the Resident-to-Resident aggression on 1/11/2025 when Resident #61 wandered into a different bedroom, I only knew that another Resident had hit Resident #61 in the face and he had received x-rays. Resident #61's representative and emergency contact stated they were unaware the MCU was staffed by one CNA and were unaware Resident #61 was left alone while Resident #83 was beating Resident #61, (Resident #61) is profoundly confused and needs redirection to his bedroom . he often goes to lay down . and needs to be monitored for safety and never left alone During a joint interview on 1/28/2025 at 8:55 AM the DON and the operations manager stated the facility operates 3 shifts: 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM to include the MCU. The operations manager stated she investigated an incident of Resident-to-Resident aggression between Resident #61 and Resident #83 on 1/11/2024 at 11:00 AM when CNA A witnessed Resident #83 pulled Resident #61 out of his room when Resident #61 wandered into the bedroom. The DON stated currently 13 residents resided in the MCU to include Residents #61 and Resident #83. The DON stated the MCU was staffed by 1 CNA and 1 nurse during every shift. The DON stated the nurse was also assigned another set of residents to care for outside of the MCU and stated, she would leave the MCU to care for residents in the C hall. The administrator stated the facility provided for Resident #61's safety, post the aggression incident, by moving Resident #61 to a different bedroom away from Resident #83 and continued with the 1 CNA to monitor and redirect the MCU residents. The operations manager and the DON stated the IDT met Monday - Friday mornings and they were responsible for leading the meeting. The DON and the operations manager stated the previous day's care was reviewed and the team would be responsible for developing and implementing any further care to keep residents healthy and safety. The operations manager stated on 1/13/2025 the IDT met and decided to move Resident #61 to a different bedroom and continue with the level of supervision for the MCU. During an interview on 01/28/2025 at 3:00 PM, the MDS nurse stated she was responsible for updating Residents care plans to include Resident #61's care plan on 01/14/2025. The MDS nurse stated the IDT met during the morning meeting on 01/13/2025 and again on 01/14/2025 and reviewed the aggression incident on 01/11/2025 for Residents #61 and #83 and decided to add interventions for Resident #61 to be moved to a different bedroom and for Resident #83 to be safely discharged to another facility. The MDS nurse stated residents in the MCU had a history of Resident-to-Resident physical aggression and prior to the 01/13/2025 and 01/14/2025 meetings, there were no interventions for monitoring for wandering safety for residents #61 and #83 to include the history of physical aggression between the two. Resident #55 A record review of Resident #55's admission record revealed an admitted [DATE] with diagnoses which included corneal ulcer of the right eye, generalized anxiety disorder, dementia with behavioral disturbance. A record review of Resident #55's annual MDS assessment dated [DATE] revealed Resident #55 was a [AGE] year-old male admitted for long term care and resided in the MCU. Resident #55 was assessed with a BIMS score of 00 which indicated severe cognitive impairment as evidenced by his inability to participate in the assessment. A record review of Resident #55's care plan dated 1/28/2025 revealed, (Resident #55) has a behavioral concern of increased agitation physical and verbal aggression with the possibility of throwing things. 1/8/25: yelled and cursed at SW Date Initiated: 12/22/2022 Revision on: 01/09/2025 Intervene as needed to ensure resident safety. Date Initiated: 12/22/2022 Leave additional activities to keep resident engaged. (psych provider) eval/tx for psychological services. Refer to behavioral health. Date Initiated: 08/13/2024 Revision on: 08/13/2024 . Staff to redirect resident to other activities Date Initiated: 12/22/2022 Revision on: 12/22/2022 2. During an interview and observation on 01/26/25 at 4:00 PM revealed LVN C entered the MCU and to exit the MCU and attended residents in the C-hall. LVN C stated she was assigned to work the MCU and the c-hall (rooms 34-46) which were located outside of the MCU. LVN C stated the MCU was also staffed by 1 CNA, who would stay in the MCU. During an observation and interview on 1/27/2025 at 3:32 PM revealed CNA B exited the MCU, continued observation revealed the MCU was unattended. At 3:54 PM revealed CNA B returned to the MCU. CNA B stated he was the only staff in the MCU and had left the MCU briefly to return a meal tray to the kitchen. CNA B stated he was the CNA for the MCU and there was no nurse until 4:30 PM. CNA B stated the current nurse on duty was the DON and he was not in the MCU. CNA B stated if a Resident had aggression, he would be by himself, he would attempt to separate residents and then leave the MCU to go get help. CNA B stated if a Resident was discovered unresponsive, he would have to leave the unit to ask for help because he would not know who was a full code and/or a DNR. CNA B stated it was routine to be by himself due to the routine schedule which had a nurse to work 2 halls to include the MCU. CNA B stated his concern for aggressive and confused residents was for Resident #61 and Resident #83 history of physical aggression. During an interview with DON and Administrator on 01/28/2025 at 4:10 PM, their plan for keeping residents safe was for staff to monitor wandering residents, separate aggressive residents, and leave the memory care unit to call for help. A record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed, Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The Administrator was notified on 1/29/2025 at 3:15 PM an IJ was identified on 1/29/2025 due to the above failures. The IJ template was provided to the facility on [DATE] at 3:15 PM and was accepted on 1/30/2025 at 9:00 PM. Plan of removal Date 1/29/2025 (the Facility) PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 1/29/2025 sic(1/26/2025) annual survey was initiated at (The Facility). On 1/29/2025, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to residents' health. The notification of the alleged immediate jeopardy states as follows: F600 Abuse and Neglect The facility neglected to have measures in place to keep residents in the memory care unit free from abuse. Problem On 01/11/2025 at 11 AM, Resident #61 wandered into Resident #83's room on the memory care unit. Resident #83 punched Resident #61 in the face, pulled Resident #61's hair, and dragged Resident #61 across the floor by his foot. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Once the facility was made aware of the deficient practice, the Director of Nursing/ designee immediately ensured a second team member would be staffed in the memory care unit as of 1/28/2025. The facility Director of Nursing/designee completed a 100% in-service for nursing staff over ensuring two staff members need to be in the memory care unit at all times, that one staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. Walkie Talkies will be held by nursing staff member, as emergency communication back up, in the unit and the second by the licensed nurse that is floating between two units. Identification of Others: Residents identified at risk for deficient practice are the resident population residing in the memory care unit. Systemic Changes The Director of Nursing/ designee initiated immediate education with all licensed/certified nursing staff over staffing requirements for memory care unit, that one facility staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. These educations are at 100% completion as of 1/28/2025. Staff who are on leave or off-site have been notified and provided education via phone call. The Director of Nursing /designee initiated immediate education, by neuropsychologist, with all licensed/certified nursing staff over managing difficult behaviors, de-escalation strategies, and wandering/elopement on 1/29/2025. This education will be at 100% completion by 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. The Director of Nursing/designee initiated immediate education with all facility staff over the Abuse, Neglect, Exploitation or Misappropriation Prevention Program on 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. Administrator/designee will conduct monthly all-staff meetings, beginning on 2/12/25, during monthly in-service a specific aspect of behavioral care will be addressed: focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities. All education and training was sic(were) started on 1/28/2025 and will continue until all nursing staff have received training prior to the start of their work shift. The facility Director of Nursing, Corporate Clinical Director and Administrator met on 1/28/2025 to evaluate the facility's staffing schedules and requirements regarding the memory care unit and general population. All residents have access to behavioral health services. Residents with increased behaviors are identified by staff and provided with comprehensive behavioral health services to include medication management, counseling services, cognitive behavioral therapy, and neuropsych sic(neuropsychic) therapy. The Director of nursing/designee will complete education and training with all licensed/certified nursing staff and newly hired licensed/certified nursing staff over facility's memory care unit staffing requirement. The education will be provided by DON or designee and be kept in the employees' HR file. The Director of nursing/designee will complete Preferences for Activity and Leisure (PAL) Cards for all residents in the memory care unit to assist in managing challenging behaviors and de-escalation strategies such as providing triggers, providing comfort and familiarity, offering calming strategies, encouraging positive redirection, supporting non-verbal communication, building trust and rapport, etc. By integrating PAL Cards into daily care, staff can proactively prevent agitation and respond effectively when challenging behaviors arise, fostering a person-centered care environment. PAL Cards will be completed for all residents in memory care unit by 1/29/2025. All nursing staff will receive education on purpose and utilization of PAL Cards by 1/29/2025. The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600. Monitoring will include a system to ensure deficient practice is prevented and residents in the memory care unit will have sufficient supervision. The monitoring and oversight system will gather measurable data for review of patterns or trending. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all residents especially in the memory care unit are under appropriate supervision. This monitoring system will begin 1/29/2025. All concerns identified during the monitoring process will be addressed timely and staffing will be adjusted appropriately. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 3 months for this plan of correction. The administrator will be responsible for monitoring DON compliance with the system weekly. System compliance will be documented and discussed. Administrator/designee will monitor use of walkie talkies every shift x 7 days then random audit daily x 3 months. Sign out log will be completed every shift to validate staff responsible for carrying and utilization of walkie talkies. The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600, to include monitoring of PAL card use and compliance with utilization and updating as appropriate. Clinical Director of Operations will in-service Admin and DON over deficient practice F600 Abuse and Neglect on 1/29/2025. Monitoring will be conducted weekly for 4 weeks to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. Social Services/designee will attend daily meeting Monday - Friday to be made aware of any newly identified behaviors or concerns. Social Services/designee will assure necessary notification to behavioral health services are in place or make necessary appointments to have residents in need seen as soon as possible. The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented. Ad Hoc QAPI meeting will be held on 1/29/2025 with the Medical Director, Administrator and Director of Nursing to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on 1/29/2025. The Administrator will be responsible for implementation of ensuring the adequate process regarding staffing requirements for increased supervision and minimize to support accident management. The new process/systems were initiated on 1/29/2025. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 1/29/2025. Plan of Removal Verification Intermittent observations on 1/26/2025, 1/27/2025, 1/28/2025, and 1/29/2025 from 8:00 AM to 10:00 PM revealed 13 residents resided in the MCU to include residents #55, #61, and #83. During an observation and interview on 1/29/2025 at 1:30 PM it was revealed that CNA D and MA E were staffing the MCU. MA E and CNA D stated they were assigned to the MCU and if they needed help, they would stay in the MCU and call via the 2-way radios provided. MA E stated LVN C had the radio while she was out of the MCU providing care for other residents. Observation on 1/30/2025 at 5:25 PM in the memory care unit had 2 CNA's and 1 nurse/CNA. Observation and interview on 1/30/2024 at 5:26 PM revealed LVN R had the other walkie talkie and could use to communicate with the CNAs in the MCU. Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU, they can use the walkie talkie for emergency as well. Dr. x During an observation on 1/29/2025 at 10:40 AM revealed Dr. X provided the in-service topic Understanding Dementia to staff in the facility's living room. During an interview on 01/29/25 at 11:09 AM, Dr. X revealed he conducted an in-service to the facility staff on helping residents with dementia. He revealed some interventions he taught to include getting to know residents, getting to know their triggers, and adjusting resident care accordingly. Record review of in-service/sign in sheet, dated 1/29/2025, reflected in-service topic Understanding Dementia with Facilitator Dr. X. further review revealed 54-staff signed the document. Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU can use the walkie talkie for emergency as well. During an interview on 1/30/2025 5:29/2025 the DON stated he would hold an all-staff monthly meeting, beginning 2/12/2025, to cover aspects of behavioral care with a focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities. During an interview on 1/30/2025 at 5:38 PM the DON stated all the in-services have been completed for all staff and stated any staff who had not received the in service i.e., new staff, no one would be able to accept a work shift until they received the in service. During an interview on 01/30/25 at 07:00 PM, the Administrator revealed he informed the DON will ensure 2 CNAs will be always staffed back in MCU. They revealed when a staff member did not come in as scheduled, they would make sure to fill this position in. They further revealed they were actively hiring and searching for new staff members to be adequately staffed. Record reviews of facility schedules, from 1/26/2025 to 1/30/2025, revealed the following staff usually worked the following shifts: 6:00 AM - 2:00 PM LVNs RNs: DON ADON LVN C CNAs: CNA G CNA F CNA A MA E CNA H CNA I 2:00 PM - 10:00 PM LVN J RN K LVN L LVN W CNAs CNA B CNA M CNA N CNA O CNA P CNA Q 10:00 PM to 6:00 AM Nurses LVN R RN S CNAs CNA T CNA U During an observation on 1/30/2025 at 1:55 PM of the MCU revealed CNA B and CNA U staffed the MCU. It was observed CNA B had on his person the 2-way radio and RN K had the other 2-way radio while she documented at the nurse's station located outside of the MCU. Record review of Resident - to Resident Altercations (2022) and unmanageable residents (2010) policy, in- service, dated 1/11/2025, indicated there is to be 2 CNA's on A hall at all times. If there is an emergency, 1 aide needs to always stay with the resident /residents, while the other aide goes to help, there will be a walkie talkie to communicate with A hall nurse and A hall CNAs in case of emergency. The Walkie talkie needs to always stay with the employee during their shift. Walkie talkies will be checked every shift to ensure they are working properly. There will be a walkie talkie log to be initialed by nurses and CNA documenting they are working properly every shift signed by 53 staff, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in- service dated 1/29/2025 titled Abuse and Neglect had 89 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in- service dated 1/29/2025 titled Understanding Dementia had 44 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in-service dated 1/29/2025 titled PAL (preference for activity and leisure) had 28 staff signatures. Observation on 1/30/2025 at 7:03 PM revealed the MCU nurse station where the PAL (preference for activity and leisure) binder was located. The PAL (preference for activity and leisure) binder revealed 12 residents had their preferences, likes, dislikes, and plan for redirections and included triggers for behaviors. A Record review of the undated PAL for Resident #55 revealed, Resident is a smoker, likes to eat in dining room. A Record review of the undated PAL for Resident #61 revealed, he has been married [AGE] years. He worked as a driver. He has 2 children. A Record review of the undated PAL for Resident #83 revealed, he was a body work. In jail for [AGE] years causing him to struggle with confinement and others in his space. During an interview on 1/30/2025 at 1:58 PM LVN C stated she had the PAL documents in a binder kept at the nurse station which aided in preferences and redirections for residents. A record review of the facility's in-service dated 1/29/2025 titled monitoring weekly x4 weeks to determine compliance is being sustained had 2 staff signatures to include the DON. During an interview on 1/30/2025 at 05:34 PM the DON stated he received the in service from the regional operations manager on 1/28/2025 to include the new policy to have 2 CNA staff in the MCU during all 3 shifts, to provide the MCU nurse and 1 CNA each a 2-way radio to facilit [TRUNCATED]

Based on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. 2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for serious harm, disability, or death. The findings included: Observations 1/8/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. Observation on 1/9/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. Observation on 1/10/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. 1. Record review of Resident #1's Admission Record dated 1/7/2025 revealed he was admitted on [DATE] with diagnoses of vascular dementia ( type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), epilepsy ( chronic brain disorder that causes seizures, which are brief episodes of involuntary movement.), language deficits, unsteady on feet, anxiety, major depressive disorder, and psychotic disorder with hallucinations (severe mental illnesses that can cause hallucinations and delusions). Record review of Resident #1's Admission Record revealed he was discharged on [DATE]. Record review of Resident #1's consolidated physician orders for January 2025 revealed he had an order for wander guard dated 7/2/2024, device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering. Record review of Resident #1's MAR (medications administration record) revealed device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering and monitoring every 15 minutes. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 4 (severely impaired cognition), epilepsy, behaviors of rejecting care and has a walker. After elopement the new interventions for Resident #1 was placed on q 15 minutes, visited by psychological MD and moved to a secure unit. Record review of Resident #1's care plan (initiated 6/12/23 and prior to 5/25/24 incident) revealed he was at risk for elopement with interventions including Assess for distress; Contact family to sit with resident or deescalate situation; Device alarm change every 90 days; Visual check wander guard to left wrist q shift due to elopement risk; Wander guard check via electronic check every day due to elopement risk; Encourage resident to stay in common areas of building for observation if needed; Provide resident with safe place to wander if necessary. Following the elopement on 5/25/24, new intervention for Resident #1 was Monitor resident closely for signs/symptoms of increased wandering and desire to keep walking. New interventions were Resident #1: Resident will be monitored every 15 minutes until evaluated by psych on 5/29/24 (5/28/24); Redirect patient from doors (5/28/24); Involve patient in decision making regarding daily choices (5/28/24); Involve patient in preferred activities (5/28/24); Assess for risk of elopement per living center policy (5/28/24); Use wander guard placed on right ankle (6/11/24); Wander guard place on bottom of wheelchair seat as tolerated (7/12/24). Record review of Resident #1's Wandering assessment dated [DATE] revealed he was forgetful/short attention span, mobility was independent, known wanderer/history of wandering and had a wander guard- scored a 12.0- high risk. Record review of Resident #1's head to toe assessment dated [DATE] revealed no skin issues. Record review of Resident #1's Pain assessment dated [DATE] revealed he was resistant to care/medication aggressiveness/physically or verbally abusive and had no pain. Record review of Resident #1's progress note Interdisciplinary Team dated 5/25/2025 revealed elopement, due to Resident #1's diagnosis of dementia and baseline cognitive status resident #1 is a poor decision maker with poor impulse control resident can ambulate and likes to walk and venture around facility. Resident #1 stated he was trying to take a walk with no distress or agitations noted prior to exiting. intervention were abuse/neglect in service, and elopement in services. The MD and family were notified by DON, ADON, MDS staff. Record review of Resident #1 psychological consult dated 5/2/2024 stated he was oriented to person, time, impaired to place and was to assess Resident #1's safety and comfort with no concerns of any type. Record review of intake 506765, on 5/25/24 at 5:45 PM revealed, Resident #1 left the building. An off-duty staff member informed the facility the resident was seen outside. The resident was found at a bus station (less than a mile away) stating he was going to work. Staff were able to get the resident to come back to the facility. Resident #1's responsible party, ADM, DON, ADON and physician were notified. Record review of intake 506765 had a provider investigation and staff were in-serviced on abuse/neglect, elopement. Record of in-services was completed by all staff on 5/26/2024. Record review of Resident #1's intake, on 5/26/24 at 7:30 PM revealed, Resident #1 attempted to leave the building, and his wander guard sounded. Staff responded to the alarm and found resident outside of the facility. They were able to redirect him back inside, and there were no injuries. 2. Record Resident #2's Admission Record dated 1/8/2025 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), major depressive disorder (a serious mental illness that causes a persistent low mood, loss of interest, and other symptoms that can affect daily life), cognitive communication deficit, dementia (a general term for a group of diseases that cause severe memory and thinking loss), and asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways.). Record review of Resident #2's physician orders dated 6/7/2024 for resident to wear a wander guard at all times due to elopement risk. visual check wander guard to right ankle every shift due to elopement risk. Record review of Mar (medication administration record revealed this was completed. Record review of Resident #2's optional state assessment MDS dated [DATE] revealed she had a BIMS score of 5 out of 15 (severely impaired), she mobilized with walker. Record review of quarterly MDS dated [DATE] revealed she had a wander/elopement alarm. Record review of Resident #2's care plan (initiated 10/10/18 and prior to 6/6/24 incident) revealed she was at risk for elopement with interventions including Distract resident from wandering by offering structured activities; Wander guard alarm: Change every 90 days and as needed. New intervention was Resident #2: Check placement and function of safety monitoring device every shift; Visual check wander guard to right ankle every shift due to elopement risk (6/10/24); Wander guard check via electronic machine every day due to elopement risk (6/10/24). Record review of intake # 509407, Per facility self-report, on 6/6/24 between 4 and 5 PM, Resident #2 had family visiting and was attending an activity. The resident's [family member]informed staff she was missing. Resident #2 was found down the street in front of a church (less than a mile away) and said she was looking for her [family member]. The temperature was 93 that day. Resident #2 was given a head-to-toe assessment upon return to the facility and was sent to the ER for further assessment. Resident #2's ER paperwork revealed heat exhaustion, unspecified, and no other injury. She returned to the facility the same night. Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed she scored an 8-high risk and care plan was initiated/updated to reflect interventions. Record review of Resident #2's 6/6/2024 and 6/12/2024 Head to toe Assessment revealed no injuries. Record review of in-services dated on 6/6/2024 revealed in was on Abuse/Neglect/Explotation, Elopement, Front door, and Resident Rights with all staff. Observation on 1/9/2025 at 2:25 PM revealed Resident #2 had her wander guard on her ankle. Interview on 1/7/25at 1:14 PM with LVN F stated they kept a binder of residents that were wander/elopement for staff to check, but most staff know which resident have wandering behaviors. Resident #1 would sundown at night and be more confused. Staff monitored him, but she was not sure how he eloped out of facility. LVN F stated she was not sure how Resident #2 eloped, maybe a family member let her out. LVN F stated no other residents had eloped. Staff try to re-direct residents that wander towards the exits, now they have a staff person near the front door. Interview with previous DON G stated #1 was found at the bus stop and not sure how he left the facility and was not gone more than 15-20 minutes. The previous DON G stated they started the elopement protocol to find Resident #1, he was not injured when they found him. Resident #1 was discharged to another facility that could be more appropriate for his aggressive behaviors and a secure unit. The previous DON G stated Resident #2 had left the building and the family had alerted them, the staff started the elopement protocol, they found Resident #2 less than a mile, at a church. The previous DON G stated they conducted a head to toe and decided to take her to the local clinic, she had heat exhaustion with no other injuries. The previous DON G stated her new interventions was a wander guard bracelet to wear in her ankle. Resident #2 had not had any previous elopements. The previous DON G stated she did conduct in-services with all staff for elopement. Interview 1/8/2025 at 11:19 AM with the previous Maintenance supervisor H stated he found Resident #1 at the church nearby. He was trained on the elopement protocol. Maintenance supervisor H stated Resident #2 had no injuries and offered her water due to a warm day. Maintenance supervisor H stated he tested the wander guard monitors frequently and documented Interview 1/9/2025 at 1:46 PM with the previous Administrator A stated Resident #1 was aggressive, so they worked with family/Ombudsman to get him transferred to a safe facility, since it was not safe for him at this facility. The Administrator stated she had reported the elopements to the STATE and trained staff on elopements. Administrator A stated there were new interventions in place for Resident #1 and #2. The new interventions for Resident #1 was to transfer him to a secure unit q 15 minute checks, and psychological MD visit Intervention for Resident #2 was a wander guard. Interview 1/8/2025 AT 1:32 pm with Resident #2's family stated Resident #2 was found in 30-45 minutes and they took her to the local clinic for evaluation, she was dehydrated. The Family stated the facility acted immediately to Resident #2 missing, she had dementia and felt safer with her wander guard. Interview 1/10/2025 at 4:29 PM with the medical director stated she was aware of the elopements and facility discussed in AD Hoc meeting. Record review of in-services dated 5/26/2024 on Wandering/Elopement, Abuse/Neglect protocol/door alarm/ Resident Rights were completed with all staff. Record review of check operations of door monitoring and resident, and test for doors and locks dated the week of 5/27/2024 and 6/7/2024. Record review of Policy Wandering and Elopement dated 2019 revealed the facility will identify residents who are a t risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation l. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f document relevant information in the resident's medical record. Record review of the Policy Wander guard (no date) revealed: Identification: Identify residents who are at risk of wandering Consent: Obtain consent from residents, family members. Monitoring: Regularly check on residents to ensure they are safe Response Facility Protocol: Staff is to respond to alarms immediately. Ensure resident is Safe. Redirect Resident to safe environment. Maintenance: Ensure the monitoring system works properly, even during power outages Wander guard devices Wristbands: Electronic bracelets Door controllers: Devices that monitor doors and send alerts if they are opened without authorization were completed, before surveyor entered the facility. The AIT-Administrator was notified on 1/10/25 at 4 PM, an PNC IJ situation had been identified due to the above failures. The PNC IJ template was given to the administrator on 1/10/24 at 4 PM. Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 1/10/2025. Interventions: Interviews with staff total was 35 all staff were in serviced on Elopement/Wandering, Abuse/Neglect, Door Alarms and to check resident devices (wander guards every shift) and understood the elopement protocol. Interviews on 1/8/2025 at 1:21 PM-5pm and 1/9/2025 at 1 PM-6 PM. Scheduled shift were 6-2 PM, 2-10 PM. 10pm-6 AM. 1. CNA J, 2. LVN F 3. CNA K 4. CNA L 5. CNA M 6. LVN N 7. CNA O 8. CNA P 9. CNA Q 10. CMA R 11. MDS 12. LVN S 13. LVN T 14. DOR (director of rehabilitation) 15. CNA U 16. CNA V 17. ADON 18. Maintenance Director 19. CNA Y 20. CNA Z 21. CNA AA 22. CNA BB 23. RN CC 24. CNA DD 25. LVN EE 26. CNAFF 27. [NAME] GG 28. Dietary HH 29. Hsk II 30. Hsk JJ 31. HSK KK 32. Laundry LL Record review of the facility Elopement Binder had 7 current residents for wandering behavior, it contained face sheet and care plans for wandering. Observations on 1/10/2025 at 10am of residents in the elopement binder were checked for wander guard and were randomly checked at the door alarm throughout the day. Observations and interview with the Maintenance Supervisor on 1/9/25 at 745 am-8:05 am stated he began employment in October at the facility; he stated that all of the facility doors were alarmed but the front door and the exit door for C-hall needed more attention for better security and are working properly now; the Maintenance Director stated that he checks all facility exit doors for security purposes twice a day-at the beginning of his shift and the end of his shift; all of the facility exit doors were observed by Surveyor with the Maintenance Director as noted: Facility Front door-alarmed and working D-hall exit door-alarmed and working; the Maintenance Director stated that a new mag lock was installed and he will provide paperwork for Surveyor E-hall-exit door at the end of the hallway was alarmed and worked; door in lounge on hallway was alarmed and opened to outside open smoking area with two locked gates that were checked and secure. A-hall-the door leads to a small courtyard area and was alarmed; the MD stated that the alarm is turned off and back on when he enters for the day and leaves at night and stays on during the w/c; the door stays locked without the alarm being on; the MD stated that the door stays alarmed on the w/e. B-Hall- the exit door was alarmed; the MD stated he plans to purchase another mag lock for this door; he stated that he had been also turning this alarm on/off during his work hours to allow for multiple deliveries thru out the day and the door stays locked; Surveyor suggested that he keep this door alarmed at all times. C-Hall-exit door alarmed and working.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for one of six residents (Resident #5) reviewed had a change of condition. The facility failed to notify the wound care physician, primary care physician, and Resident #5's resident representative of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough(debris that appears tan, yellow, green or brown in color) and eschar (hard plaque that is tan, brown or black in color). An Immediate Jeopardy (IJ) situation was identified on 09/17/2024 at 4:57 p.m. While the IJ was removed on 09/19/2024 at 6:05 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diabetes mellitus (a chronic disease that affects how the body uses insulin and glucose), end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and hypertension (high blood pressure in the arteries that carry blood from the heart to the resident of the body). Record review of Resident #5's quarterly MDS, dated [DATE], reflected Resident #5 had short-term and long-term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired. Section GG Functional Abilities and Goals reflected Resident #5 used a wheelchair for mobility and required partial to moderate assistance with rolling left and right in bed and transferring from bed to wheelchair. Section H Bladder and Bowel reflected Resident #5 was frequently incontinent of bowel and bladder. Section M Skin Conditions reflected Resident #5 was at risk for developing pressure ulcers and had moisture associated skin damage (MASD; incontinence-associated dermatitis, perspiration, drainage). Record review of Resident #5's care plan, initiated 05/22/2024 and revised 05/30/2024, reflected Resident #5 had a pressure ulcer or potential for pressure ulcer development related to needing assistance with repositioning, diabetes, end stage renal disease and dialysis, 3 days a week. The goal was Resident#5 would have intact skin, free of redness, blisters or discoloration by/through review date, 09/12/2024. The intervention was Resident #5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #5 had an additional care plan, initiated on 08/01/2024 and revised on 08/02/2024, stating Resident #5 had altered skin integrity, non-pressure related to MASD on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). The goal was for the affected area to heal without complications, target date 09/21/2024. Interventions included: a) evaluation for pain prior to cleansing or dressing changes b) monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor and notify physician of significant findings c) notify practitioner if symptoms worsen or do not resolve d) nutritional and hydration support e) provide thorough skin care after incontinent episodes and apply barrier cream f) skin assessment to the complete per living center policy g) treatments as ordered - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing as needed if soiled or removed at every day shift every Tuesday, Thursday and Saturday. Record review of Resident #5's progress note, written by LVN A on 07/28/2024, reflected resident has skin breakdown to sacrum, will have wound care evaluate, notify doctor, daughter, and DON, per [nurse name] with [physician name], she ordered cleanse with n/s pat dry apply hydrocolloid change q 72 hours, add vitamin c 500 mg bid x 30 days. MVI with Mineral 1 tab daily, zinc sulfate 220mg 1-tab daily x 14 days. Record review of Resident #5's progress note written by the Treatment Nurse, dated 08/01/2024, reflected the treatment nurse rounded with the wound care physician and the area is MASD to sacrum, new orders are to apply Medi honey, alginate, dry foam dressing T. TH. S, prn if soiled. Record review of Resident #5's weekly head to toe skin check, completed by the treatment nurse, dated 08/01/2024, reflected Resident #5 had a MASD - 3.0 x 1.4 x .2, pink, serous, moderate drainage on the sacrum. Wound documentation reflected Medi honey, alginate, dry foam dressing. Record review of Resident #5's August 2024 treatment administration record revealed an order for MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. Resident #5 also had an order MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly head to toe skin check, dated 08/12/2024 written by the treatment nurse, reflected Resident #5 had non pressure wound to sacrum- 1.5 x 0.4 x 0.1cm, moderate serous drainage, open areas with exposed dermis. Record review of Resident #5's initial wound evaluation and management summary, dated 08/12/2024 by the wound care physician, reflected Resident #5 was seen for a wound on her sacrum. The focused wound exam listed etiology as moisture associated skin damage. Duration was documented as less than 50 days. The objective was healing/maintaining healing. The wound size was documented as 1.5 x 0.4 x 0.1 cm and surface area was 0.60 cm. Exudate (fluid released by an organism through pours or a wound) was documented as moderate serous (clear or pale-yellow water fluid that is found in the body especially in the spaces between organs and membranes) and dermis (middle layer of skin) was documented as open areas with exposed dermis. Record review of Resident #5's progress note, by the treatment nurse, dated 08/12/2024, reflected Resident #5's wound care orders remained the same for non-pressure wound to sacrum. Record review of Resident #5's weekly wound review by the treatment nurse, dated 08/19/2024, reflected Resident #5 had a non-pressure wound on her sacrum measuring 2 x 1 x .2 cm. Resident #5 had 30% slough and 0% eschar and serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's daughter was notified. Record review of Resident #5's wound care physician progress note, dated 08/19/2024, revealed signing off without visit- in house. Record review of Resident #5's wound care physician progress note, dated 08/26/2024, reflected Resident #5's weekly visit was rescheduled due to Resident #5 being gone from the facility at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 08/28/2024, reflected Resident #5 had a non-pressure wound on the sacrum measuring 2 x 1 x .03 cm. Resident had 30% slough and 0% eschar with scant serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's family notification was blank. Record review of Resident #5's September 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. MASD on sacrum-cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/04/2024, reflected Resident #5 had a non-pressure wound to the sacrum measuring 2 x 2 x 0.2cm. The slough and eschar percentages were blank, and drainage was marked as scant. The physician and family notification sections were blank, and the treatment plan was blank. Record review of Resident #5's progress note, dated 09/04/2024, by the treatment nurse, reflected resident continues with non-pressure wound to sacrum. Area remains the same at this time. Resident continues to attend dialysis and have extended time sitting in wheelchair. Will continue to encourage and offload and reposition throughout shift. Record review of Resident #5's weekly wound review completed by treatment nurse, 09/09/2024 at 1:41 p.m., revealed Resident #5 has MASD to the sacrum measuring 2 x 0.6 x .2 and had 20% slough and 10% eschar with no drainage. The physician notification was checked as completed but there was no name of physician or date and time of notification. The family notification section was blank. The treatment plan was Medi honey, alginate, board gauze. Record review of Resident #5's wound care physician progress note, 09/09/2024, reflected the patient's visit has been rescheduled. She is at dialysis. Record review of hospital photos reflected a sacrum wound, dated 09/09/2024 at 11:20 p.m. that revealed a wound bed covered in slough and black eschar necrotic tissue, and a left heel purple wound, dated 09/09/2024 at 11:30 p.m. Record review of Resident #5's hospital wound care note, by the hospital wound care RN, dated 09/11/2024 at 1:47 p.m., reflected a wound assessment located on the coccyx, classified as an unstageable pressure injury. The description of the wound was large, foul-smelling wound with dark, boggy necrotic tissue covering wound bed. Necrotic tissue extends down to the perirectal area. Wound measurement is 12.4cm x 8.0cm. A second wound located on the left heel was classified as a deep tissue injury. The wound was described as dark purple, but intact tissue overlying heel and measured 2.5 x 2.3cm. The hospital wound RN stated patient will likely need debridement to this wound but unsure if she is an ideal surgical candidate. Patient with leukocytosis, likely due to wound. Patient was not responsive during assessment and did not wake to movement. Patient being offloaded on specialty bed with bilateral heel protectors. Record review of Resident #5's hospital consult notes, dated 09/11/2024 at 2:19 p.m., reflected Resident #5 presented with leukocytosis and found to have unstageable sacral decubitus ulcer and a general surgery consult for possible debridement. The note also stated Resident #5 had an unstageable sacral decubitus ulcer with necrotic tissue and concern for infection. Under Medical Decision Making the consult note reflected will take her to the operating room tomorrow in the morning for debridement of the area with possible wound vac placement. Patient is a very poor surgical candidate for any other intervention. Will take cultures intraoperatively. Continue neurological workup. Consider hospice discussion. Record review of hospital physician progress note dated 09/11/2024 at 10:05 p.m., reflected Resident #5 had significant metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood that effects to brain) in the context of an acutely infected ulcer. The note also reflected the patient has a significant wound on her buttocks, which is black with foul odor, suggestive of necrosis or infection. Record review of the hospital operative surgeon note, dated 09/12/2024 at 1:01 p.m., reflected Resident #5's surgical procedure performed was incision, drainage and debridement of sacral decubitus ulcer, sacral bone biopsy, substitute skin graft product placement and negative pressure wound VAC therapy (a device that removed pressure over the area of the wound that can help a wound heal and gently pulls fluid from the wound). Post Operative diagnosis stated, unstageable infected sacral ulcer, abscess, concern for osteomyelitis. Findings documented were 9 x 7 x 3cm unstageable infected sacral decubitus ulcer with associated abscess and significant necrotic tissue. Record review of Resident #5's physician progress note, dated 09/15/2024 at 11:41 a.m., reflected Resident #5's sacral decubitus ulcer wound culture collected on 09/12/2024 was positive for E coli, a type of bacteria that can cause diarrhea, vomiting and kidney failure. During an interview with Resident #5's family member on 09/14/2024 at 1:57 p.m., Resident #5's family member stated she was notified by hospital staff when Resident #5 arrived at the hospital and Resident #5 was unresponsive and had one wound on her heel and a bad one on her bottom. Resident #5's family member said she was never notified by the facility that Resident #5 had a wound on her heel or bottom. The family member stated she was told by the facility Resident #5 had a diaper rash. Resident #5's family member said she was told by the hospital the wound on her bottom was black, and the hospital was checking to see if the infection went to her bone. During an interview with Hospital RN Z on 09/14/2024 at 3:20 p.m., Hospital RN Z said Resident #5 admitted with a diagnosis of metabolic encephalopathy (alteration in consciousness) and sepsis. Hospital RN Z said Resident #5 had a DTI to her left heel and she had a very bad sacrum wound and was now on a wound vac. Hospital RN Z stated the hospital took pictures of the wounds upon admission. During an interview with the facility Treatment Nurse on 09/15/2024 at 12:54 p.m., the treatment nurse revealed she began doing treatments at the facility at the beginning of August 2024. She stated her role as the treatment nurse was to assess skin, round with the wound care physician, take orders, notify the doctors and family of changes with the wound and provide wound care daily. The treatment nurse stated wound treatments were documented on the resident TAR and she was notified of changes in the resident skin by the direct care staff and also received copies of the resident shower sheets. The treatment nurse stated she performed skin assessments weekly and the last time she completed a skin assessment for Resident #5 was on the morning of 09/09/2024 around 5am-6am prior to Resident #5 going to dialysis. The treatment nurse described Resident #5's wound on the morning of 09/09/2024 as pink with scant amount of drainage and close to her sacrum. She said Resident #5 had no eschar and the skin was pink and moist. The Treatment Nurse said she did not look at Resident #5's heels that morning and was not aware of Resident #5 having a wound on her left heel. The Treatment Nurse stated she did a treatment on Resident #5 on the morning of 09/09/2024 and said she did not know why it was not documented on Resident #5's TAR as being completed. The Treatment Nurse revealed the Wound Care Physician rounded at the facility weekly and should have seen Resident #5 weekly but stated the Wound Care Physician often rounded while Resident #5 was at dialysis. The Treatment Nurse stated she thought it had been a couple of weeks since the wound care physician had assessed Resident #5's wound. The Treatment Nurse described the wound as MASD and the wound was around 2.0 x1.0 x0.4cm. During an interview with the facility Treatment Nurse on 09/15/2024 at 2:30 p.m., the treatment nurse stated when the wound care physician missed observations of Resident #5 each week she, just told her it was the same each time and she said if it gets worse to send her a picture. The Treatment Nurse stated the wound assessments she completed on 08/12/2024 was the original date the wound care physician assessed the wound so the treatment nurse would write down that date on each of the assessments. The treatment nurse said she did not have any documentation to prove she made notifications each time the wound was assessed and noted to be changing. During an interview with the facility Wound Care Physician on 09/16/2024 at 11:39 a.m., the physician stated she began assessing residents at the facility at the beginning of August 2024 and the facility would request the consult and the resident would get added to her list of residents to assess each week. The Wound Care Physician stated she observed Resident #5 sacrum wound on 08/12/2024 and said the wound measured 1.5 x 0.4 x 0.1cm and looked like dermis and classified as MASD. We do not assign a stage to MASD and cannot really measure a depth less than .1. It was superficial and looked like irritation. The Wound Care Physician stated she was supposed to assess Resident #5 weekly but Resident #5 was always gone to dialysis when she would come by to make rounds. She stated she relied on the treatment nurse to guide her to tell her which patients needed to be seen, if they were not at the facility from her previous visit, then she tried to make accommodations to see the resident. The Wound Care Physician stated she received updates on resident progress if she did not see them, she communicated very closely with [treatment nurse name]. We also have an option to do a telemedicine visit, because I am new, I have not mastered that, but it is something we can do in the future. The Wound Care Physician said there was a discussion about changing Resident #5's dialysis treatment days because I go to multiple facilities and my schedule is not flexible. The Wound Care Physician stated the Treatment Nurse mentioned she noticed some changes on Resident #5's wound on 09/09/2024 but did not say what type of changes. The Wound Care Physician stated she was not notified of the slough and eschar tissue documented on the treatment nurse assessment on 09/09/2024 and said if she was notified of she would have known the wound needed a debridement. The Wound Care Physician said I would have expected to be notified immediately that there is necrotic tissue and slough, that is a big change. I was just notified by [treatment nurse name] that she wanted me to come by and look at the wound sometime that week and we were talking about me coming on 09/11/2024. She did not tell me the current status of the wound. The Wound Care Physician stated she would have changed the treatment order if she was notified about the slough and eschar development on the wound and stated my suspicion is there is tissue that needed to be removed. That is not optimal that it was not removed. Without seeing the wound, I can only say that I think that the non-viable tissue needed to be removed. The Wound Care Physician stated she would have expected to be notified about the change in the wound and she said the facility treatment nurse did not notify her of necrotic tissue The wound care physician was shown a photo of Resident #5's sacrum wound taken at the hospital on 09/09/2024 at 10 p.m. and said that is very different than what I have seen or been notified of. I had no idea it looked like that. Oh geez, that is bad. If I knew it looked like that, I would have come in on a Saturday. I am a surgeon by training, I can smell the wound, I know how it is supposed to look and not look. We do have patients that are more complicated. If I knew it looked even 10% of that I would have debrided it. The Wound Care Physician also stated The honey and alginate did not make it worse; it just would not have done anything to heal it. It needed further treatment. The Wound Care Physician was asked how long it could take a wound to get to that stage and she said It could not happen in 8 hours. People on dialysis and diabetic progress pretty quickly. It could have been a week or 3 weeks but would not develop like that. Yeah, given her diagnosis, I would say a week to 2 weeks. During an interview with the facility Treatment Nurse on 09/16/2024 at 1:00 PM, the Treatment Nurse stated Resident #5 did not have necrotic tissue on her sacrum when she assessed her. The Treatment Nurse was shown her assessment from 09/09/2024 that reflected the Treatment Nurse documented Resident #5 had 10% necrotic tissue and 20% slough and she said yes, there may have been some eschar in there, I told the wound care physician it had gotten larger on 09/09/2024. The Wound Care Physician knew there was slough, I don't know if I mentioned the eschar. When asked if she had any documentation to support her notification, she said no but knew she called her and told her the wound was bigger on 09/09/2024 and she should have told her about the eschar. The Treatment Nurse was asked if she notified the Wound Care Physician about Resident #5 wound changes and slough from her 09/04/2024 assessment and she said I text The Wound Care Physician all the time, we just haven't been able to get together. I guess we could have gotten together and did a video chat. No, I don't have anything documented that I notified her, just verbally and I know I should have documented it. The Treatment Nurse said it was important to notify the physician of changes so we can change something and go in a different direction. Just the size was concerning, and I know she sits up a lot, but we could have changed the order, frequency or done something different. The Treatment Nurse stated she should have also notified Resident #5's primary physician if the wound was changing and Resident #5 was not being assessed by the Wound Care Physician. During an interview with Resident #5's primary facility physician on 09/16/2024 at 2:12 p.m., the Physician stated he last observed Resident #5 approximately two weeks prior to 09/16/2024. The Physician stated he did not see the sacrum wound and a wound care physician followed Resident #5. The Physician stated the Wound Care Physician should be notified of changes in wounds so the treatment orders could have been changed to address the changes in the wound and said I would hope the wound care physician would know about it because it is their responsibility. The physician stated he was not notified of Resident #5's wound having slough or eschar and stated I would expect the wound care doctor to be notified of that. I would be notified if the patient needs other things like antibiotics. If there was no wound care doctor I would want to be notified. The Physician was asked if he was notified of any change in condition with the resident and he said lethargy and altered mental status was not new for Resident #5 and she was declining for the last few months. The Physician was asked what should have been done if the Wound Care Physician was not able to see Resident #5 weekly and he said That is a question for the facility, what do they do when a provider doesn't come? I don't see the patient wounds because the wound care nurse should be following orders from the wound care doctor. During an interview with the facility DON, on 09/16/2024 at 4:07 p.m., the DON said the facility had a treatment nurse Monday - Friday and charge nurses were responsible for wound care on the weekends if the treatment nurse was not there. The DON said the facility had a clinical meeting daily and the charge nurses went to the meeting and gave report on the residents and the facility had a weight and skin meeting weekly on Wednesdays. The DON stated wound care was validated and monitored for wound healing through communication between the DON, Treatment Nurse and Wound Care Physician, and the Treatment Nurse kept a log of wounds which was reviewed weekly by the Corporate Nurse. The DON stated the Treatment Nurse was responsible for notifying the Wound Care Physician of wound changes, documenting the notification in the medical record and following new orders. The DON stated her expectation was for the Treatment Nurse to identify any changes in a resident wound and report those changes immediately so an appropriate treatment was implemented. When asked what harm can happen to a resident if the physician is not notified of changes in their wounds, the DON stated if the intervention is not working and you are not getting the results that you need, a lot of factors can effect wound healing including nutrition or other comorbidities and the physician should be notified so the physician could make a clinical judgement on what to do. The DON said she knew Resident #5 had MASD on her sacrum but never observed the wound. The DON said she was not informed Resident #5's wound had changed or developed slough and eschar and said she would have expected to be notified of these changes immediately. During an interview with the Hospital Wound Care RN on 09/17/2024 at 10:13 a.m., the Hospital Wound Care RN stated she assessed Resident #5 on 09/11/2024 and observed an unstageable pressure ulcer with full eschar, necrotic tissue covering the wound and could not see the depth. The Hospital Wound Care RN said the sacrum wound had a foul odor and Resident #5's laboratory results reflected a high white blood cell count that indicated the wound needed an urgent surgical debridement the Hospital Wound Care RN stated she submitted a surgery consult request and Resident #5 was taken for surgery on 09/12/2024 and received a debridement, skin graft and bone biopsy. The Hospital Wound Care RN also revealed Resident #5 had a wound vac placed on the sacrum wound and an order to leave it on for one week. The Hospital Wound Care RN stated slough usually appeared on a stage 3 wound and if Resident #5 had 10% eschar documented prior to hospitalization , the wound would not have been classified as MASD and should have been classified as a pressure ulcer. The Hospital Wound Care RN also stated Resident #5's wound, in her opinion would take at least a week to develop on a patient who was never turned or repositioned and about 2- 3 weeks for a patient who was repositioned and had other comorbidities. During an interview with the Wound Care Physician on 09/17/2024 at 11:32 a.m., with the DON, Treatment Nurse, Administrator and Corporate RN present, the Wound Care Physician was asked about her assessing Resident #5 on 08/12/2024 and not receiving any updates on Resident #5 until 09/09/2024 and the wound care physicians said, that is because there were no changes with the wound until 09/09/2024. The Wound Care Physician said when she spoke to the Treatment Nurse on 09/09/2024, the treatment nurse told her there were changes in the wound, but she did not remember exactly what the changes were because they discussed so many wound when she was rounding. The Wound Care Physician said whatever the change that occurred prompted her to change her schedule and make a plan to go see Resident #5 outside of her regular schedule, but the resident was sent to the hospital. The Wound Care Physician hung up the call at 11:40a.m. and the other members stayed in the room. The Treatment Nurse was asked where she documented the physician notification of the wound changes, and she said it was not documented. The treatment nurse said she did not call any other physicians, did not notify the DON and did not add any additional interventions to prevent the wound from worsening. The Treatment Nurse states she was responsible for notifications. The Treatment Nurse and DON stated they did not know what N/A meant and the DON stated it was a process she was working on This was determined to be an Immediate Jeopardy (IJ) on 09/17/2024 at 4:55 p.m. The Administrator and the DON were notified, The Administrator and the DON were provided with the IJ Template on 09/17/2024 at 4:57 p.m. The following Plan of Removal submitted by the facility was accepted on 09/18/2024 at 4:52 p.m.: [Facility Name and Address] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On September 14, 2024 an investigation was initiated at [Facility Name and Address]. At approximately 5:00 p.m. on September 17, 2024 a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [the facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F580 - Notice of Changes Immediate Corrections Implemented for Removal of Immediate Jeopardy. On September 9, 2024 Resident #5 was transferred to the hospital after becoming unresponsive at dialysis. Action: Through review of hospital record, facility identified Resident #5 was at baseline upon being received to dialysis center and became unresponsive during treatment. Intake to emergency department reveals physician plan to address the following diagnosis: seizure-like activity, leukocytosis, ESRD on dialysis On September 17, 2024, at approximately 7:00am the following action was taken: Action: 100% skin sweep of 85 of 85 residents to identify and ensure no new skin pressure areas were observed. Any resident identified to have a skin pressure area had documentation updated in facility electronic medical record system. Responsible party and physicians were notified. Resident care plans were reviewed to ensure care plan was up to date. Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: DON Action: All licensed nursing staff were provided education and in-servicing on requirement to notify responsible party and physician of new or worsening skin pressure conditions. Nursing staff were educated on what conditions constituted a change included but not limited to change in size, color, appearance and smell. Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: DON Action: Facility implemented Stop and Watch notification process. All staff were educated on identification, notification and utilization of stop and watch process. The stop and watch process will utilize a predetermined questionnaire, accessible by all staff, to identify any potential change in condition to include but not limited to, cognition, skin condition, ADL assistance, etc. The questionnaire form will have a carbon copy attached to the original form being completed. Upon staff identification of potential change in cognition, skin condition, ADL assistance, etc., the form will be completed and given to the charge nurse. The charge nurse will review documentation on the Stop and Watch form and follow facility protocol to address any potential change. The carbon copy of the form will be provided to ADON/designee to ensure daily, Monday through Friday, timely follow up, documentation and notification has been completed. ADON/designee will bring copies to daily clinical meetings, Monday through Friday, and provide update to Director of Nursing. Start Date: 9/17/2024 Completion Date: 9/18/2024 Responsible: DON Action: Ad hoc QAPI meeting held with IDT team and MD to review Plan of removal/response to Immediate Jeopardy Citation on 9/17/2024 Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: Administrator IDENTIFICATION OF OTHER AFFECTED: All residents experiencing a change in condition have the potential to be affected. Action: Facility conducted 100% skin sweep of 85 of 85 residents to identify and ensure no new skin pressure areas were observed. Any resident identified to have skin pressure area had documentation updated in facility electronic medical record system. Responsible party and physicians were notified. Resident care plans were reviewed to ensure care plan was up to date. Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility nursing staff regarding the process for residents who have been identified as having new or worsening pressure skin conditions. In-service and education was provided to facility staff on utilization of stop and watch notific [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #5) for pressure ulcers. 1. The facility failed to ensure Resident #5 received services and treatment orders to prevent sacral and left heel pressure ulcers from developing. 2. The facility failed to notify the wound care physician or primary care physician of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough [debris that appears tan, yellow, green or brown in color] and eschar [hard plaque that is tan, brown or black in color]). An Immediate Jeopardy (IJ) situation was identified on 09/17/2024 at 4:57 p.m. While the IJ was removed on 09/19/2024 at 6:05 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diabetes mellitus (a chronic disease that affects how the body uses insulin and glucose), end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and hypertension (high blood pressure in the arteries that carry blood from the heart to the resident of the body). Record review of Resident #5's quarterly MDS, dated [DATE], reflected Resident #5 had short-term and long-term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired. Section GG Functional Abilities and Goals reflected Resident #5 used a wheelchair for mobility and required partial to moderate assistance with rolling left and right in bed and transferring from bed to wheelchair. Section H Bladder and Bowel reflected Resident #5 was frequently incontinent of bowel and bladder. Section M Skin Conditions reflected Resident #5 was at risk for developing pressure ulcers and had moisture associated skin damage (MASD; incontinence-associated dermatitis, perspiration, drainage). Record review of Resident #5's care plan, initiated 05/22/2024 and revised 05/30/2024, reflected Resident #5 had a pressure ulcer or potential for pressure ulcer development related to needing assistance with repositioning, diabetes, end stage renal disease and dialysis, 3 days a week. The goal was Resident#5 would have intact skin, free of redness, blisters or discoloration by/through review date, 09/12/2024. The intervention was Resident #5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #5 had an additional care plan, initiated on 08/01/2024 and revised on 08/02/2024, stating Resident #5 had altered skin integrity, non-pressure related to MASD on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). The goal was for the affected area to heal without complications, target date 09/21/2024. Interventions included: a) evaluation for pain prior to cleansing or dressing changes b) monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor and notify physician of significant findings c) notify practitioner if symptoms worsen or do not resolve d) nutritional and hydration support e) provide thorough skin care after incontinent episodes and apply barrier cream f) skin assessment to the complete per living center policy g) treatments as ordered - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing as needed if soiled or removed at every day shift every Tuesday, Thursday and Saturday. Record review of Resident #5's progress note, written by LVN A on 07/28/2024, reflected resident has skin breakdown to sacrum, will have wound care evaluate, notify doctor, daughter, and DON, per [nurse name] with [physician name], she ordered cleanse with n/s pat dry apply hydrocolloid change q 72 hours, add vitamin c 500 mg bid x 30 days. MVI with Mineral 1 tab daily, zinc sulfate 220mg 1-tab daily x 14 days. Record review of Resident #5's weekly head to toe skin check, dated 07/28/2024, by LVN A, reflected Resident #5 had skin breakdown quarter size on the sacrum. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's July 2024 treatment administration record reflected an order which stated, cleanse skin breakdown on sacrum with normal saline, pat dry, apply hydrocolloid, change q 72 hours for skin breakdown to sacrum, start date 07/28/2024. Record review of Resident #5's progress note written by the treatment nurse on 08/01/2024, reflected the treatment nurse rounded with the wound care physician and the area is MASD to sacrum, new orders are to apply Medi honey, alginate, dry foam dressing T. TH. S, prn if soiled. Record review of Resident #5's weekly head to toe skin check completed by the treatment nurse, 08/01/2024, reflected Resident #5 had a MASD - 3.0 x 1.4 x .2, pink, serous, moderate drainage on the sacrum. Wound documentation reflected Medi honey, alginate, dry foam dressing. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's August 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. Resident #5 also had an order which reflected MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly head to toe skin check, 08/08/2024 by the treatment nurse, reflected Resident #5 had MASD 1.5 x 0.4 x 0.1cm, pink, no slough, no odor, scant drainage to the sacrum. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's weekly head to toe skin check, 08/12/2024 by the treatment nurse, reflected Resident #5 had non pressure wound to sacrum- 1.5 x 0.4 x 0.1cm, moderate serous drainage, open areas with exposed dermis. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's initial wound evaluation and management summary, dated 08/12/2024 by the wound care physician, reflected Resident #5 was seen for a wound on her sacrum. The focused wound exam listed etiology as moisture associated skin damage. Duration was documented as less than 50 days. The objective was healing/maintaining healing. The wound size was documented as 1.5 x 0.4 x 0.1 cm and surface area was 0.60 cm. Exudate (fluid released by an organism through pours or a wound) was documented as moderate serous (clear or pale-yellow water fluid that is found in the body especially in the spaces between organs and membranes) and dermis (middle layer of skin) was documented as open areas with exposed dermis. Record review of Resident #5's progress note, by the treatment nurse, dated 08/12/2024, reflected Resident #5's wound care orders remained the same for non-pressure wound to sacrum. Record review of Resident #5's weekly wound review by the treatment nurse, dated 08/19/2024, reflected Resident #5 had a non-pressure wound on her sacrum measuring 2 x 1 x .2 cm. Resident #5 had 30% slough and 0% eschar and serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's daughter was notified. Record review of Resident #5's wound care physician progress note, dated 08/19/2024, reflected signing off without visit - in house. Record review of Resident #5's wound care physician progress note, dated 08/26/2024, reflected Resident #5's weekly visit was rescheduled due to Resident #5 being gone from the facility at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 08/28/2024, reflected Resident #5 had a non-pressure wound on the sacrum measuring 2 x 1 x .03 cm. Resident had 30% slough and 0% eschar with scant serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's family notification was blank. Record review of Resident #5's September 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. MASD on sacrum-cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/04/2024, reflected Resident #5 had a non-pressure wound to the sacrum measuring 2 x 2 x 0.2cm. The slough and eschar percentages were blank, and drainage was marked as scant. The physician and family notification sections were blank, and the treatment plan was blank. Record review of Resident #5's progress note, dated 09/04/2024, by the treatment nurse, reflected resident continues with non-pressure wound to sacrum. Area remains the same at this time. Resident continues to attend dialysis and have extended time sitting in wheelchair. Will continue to encourage and offload and reposition throughout shift. Record review of Resident #5's foot check assessment completed at the dialysis clinic, dated 09/06/2024, reflected Resident #5 presented with left heel dressing noted. Dressing clean, dry and intact. Record review of Resident #5's progress note, by LVN C, dated 09/09/2024 at 11:44 a.m., LVN C documented received a call from [name] RN from resident's dialysis center. As per [name] RN resident was transferred to [hospital name] ER for altered mental status as per nephrologist. [Name] RN notified residents daughter prior to transferring resident. Called ER but did not get an answer. Record review of Resident #5's wound care physician progress note, 09/09/2024, reflected the patient's visit has been rescheduled. She is at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/09/2024 at 1:41 p.m., reflected Resident #5 has MASD to the sacrum measuring 2 x 0.6 x .2 and had 20% slough and 10% eschar with no drainage. The physician notification was checked as completed but there was no name of physician or date and time of notification. The family notification section was blank. The treatment plan was Medi honey, alginate, board gauze. Record review of Resident #5's dialysis report, dated 09/09/2024 at 11:13 a.m., reflected treatment early due to clotting with minimal blood loss. Post treatment patient hard to arouse and MD order to refer to [hospital name] ER per EMS: AMS. Record review of hospital photos reflected a sacrum wound, dated 09/09/2024 at 11:20 p.m. that revealed a wound bed covered in slough and black eschar necrotic tissue, and a left heel purple wound, dated 09/09/2024 at 11:30 p.m. Record review of Resident #5's hospital admission H&P, dated 09/09/2024 at 7:30 p.m., reflected Resident #5 was admitted due to AMS during dialysis and Resident #5 was dialyzed for 3 hours and went unconscious. Resident #5 was acting normal prior to the start of dialysis. When Resident #5 arrived at the hospital, Resident #5 was completely obtunded (a state of reduced alertness or consciousness) with inability to answer any questions with some deviated gaze as well as significant facial droop. The assessment/plan reflected: 1) seizure-like activity 2) leukocytosis (elevated white blood cell count indicating an infection, inflammation or injury) - treat this patient for possible episode of sepsis (chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body that can damage multiple organs, leading them to fail, sometimes resulting in death) due to pronounced leukocytosis with neutrophilia (caused when a body produces too many neutrophils which are a type of white blood cells). No clear source at this point. Record review of Resident #5's hospital wound care note, by the hospital wound care RN, dated 09/11/2024 at 1:47 p.m., reflected a wound assessment located on the coccyx, classified as an unstageable pressure injury. The description of the wound was large, foul-smelling wound with dark, boggy necrotic tissue covering wound bed. Necrotic tissue extends down to the perirectal area. Wound measurement is 12.4cm x 8.0cm. A second wound located on the left heel was classified as a deep tissue injury. The wound was described as dark purple, but intact tissue overlying heel and measured 2.5 x 2.3cm. The hospital wound RN stated patient will likely need debridement to this wound but unsure if she is an ideal surgical candidate. Patient with leukocytosis, likely due to wound. Patient was not responsive during assessment and did not wake to movement. Patient being offloaded on specialty bed with bilateral heel protectors. Record review of Resident #5's hospital consult notes, dated 09/11/2024 at 2:19 p.m., reflected Resident #5 presented with leukocytosis and found to have unstageable sacral decubitus ulcer and a general surgery consult for possible debridement. The note also stated Resident #5 had an unstageable sacral decubitus ulcer with necrotic tissue and concern for infection. Under Medical Decision Making the consult note reflected will take her to the operating room tomorrow in the morning for debridement of the area with possible wound vac placement. Patient is a very poor surgical candidate for any other intervention. Will take cultures intraoperatively. Continue neurological workup. Consider hospice discussion. Record review of hospital physician progress note dated 09/11/2024 at 10:05 p.m., reflected Resident #5 had significant metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood that effects to brain) in the context of an acutely infected ulcer. The note also reflected the patient has a significant wound on her buttocks, which is black with foul odor, suggestive of necrosis or infection. Record review of the hospital operative surgeon note, dated 09/12/2024 at 1:01 p.m., reflected Resident #5's surgical procedure performed was incision, drainage and debridement of sacral decubitus ulcer, sacral bone biopsy, substitute skin graft product placement and negative pressure wound VAC therapy (a device that removed pressure over the area of the wound that can help a wound heal and gently pulls fluid from the wound). Post Operative diagnosis stated, unstageable infected sacral ulcer, abscess, concern for osteomyelitis. Findings documented were 9 x 7 x 3cm unstageable infected sacral decubitus ulcer with associated abscess and significant necrotic tissue. Record review of Resident #5's hospital MD progress note, dated 09/13/2024 at 10:57 a.m., reflected the resident received a decubitus ulcer debridement, substitute skin graft and wound vac placement on 09/12/2024. The disposition planning note stated continue wound care with negative pressure wound therapy. Wait at least 5 to 7 days for dressing change due to presence of skin graft substitute in the area. Very poor prognosis due to medical comorbidities and location of wound. Record review of Resident #5's physician progress note, dated 09/15/2024 at 11:41 a.m., reflected Resident #5's sacral decubitus ulcer wound culture collected on 09/12/2024 was positive for E coli, a type of bacteria that can cause diarrhea, vomiting and kidney failure. Record review of Resident #5 shower sheets provided by the DON for the month of August and September 2024 reflected one shower sheet marked refused on 09/07/2024, one shower sheet reflected mark on butt/red dated 08/12/2024. All other shower sheets were marked N/A. During an observation in Resident #5's room with hospital RN [NAME] 09/14/2024 at 3:25 p.m., RN A removed Resident #5 left heel dressing to reveal a quarter size purple DTI. Resident #5 did not arouse during the observation. During an interview with Resident #5's family member on 09/14/2024 at 1:57 p.m., Resident #5's family member stated she was notified by hospital staff when Resident #5 arrived at the hospital and Resident #5 was unresponsive and had one wound on her heel and a bad one on her bottom. Resident #5's family member said she was never notified by the facility that Resident #5 had a wound on her heel or bottom. The family member stated she was told by the facility Resident #5 had a diaper rash. Resident #5's family member said she was told by the hospital the wound on her bottom was black, and the hospital was checking to see if the infection went to her bone. During an interview with Hospital RN Z on 09/14/2024 at 3:20 p.m., Hospital RN Z said Resident #5 admitted with a diagnosis of metabolic encephalopathy (alteration in consciousness) and sepsis. Hospital RN Z said Resident #5 had a DTI to her left heel and she had a very bad sacrum wound and was now on a wound vac. Hospital RN Z stated the hospital took pictures of the wounds upon admission. During an interview with LVN A on 09/15/2024 at 10:56 a.m., LVN A stated she was the charge nurse for Resident #5 on the 2 p.m. -10 p.m. shift on 09/08/2024. LVN A stated she observed Resident #5's wound around 9 p.m. on 09/08/2024 when she provided wound care. LVN A stated she provided wound care to Resident #5, 2-3 times a day. LVN A stated treatments were documented on the resident treatment administration record. LVN A stated it was not documented on the TAR for 09/08/2024 and said she did not know why it was not documented. LVN A stated Resident #5 had PRN orders for wound care and said, well it was done, and I do it daily. LVN A said, on 09/08/2024 around 9pm, Resident #5's wound appeared red with greyish area and larger than quarter size and it was deep. LVN A said she would instruct staff to rotate Resident #5 when in the bed and said Resident #5 was not up and in her wheelchair long at all on her shifts but she did not work on Resident #5's dialysis days. During an interview with CNA A on 09/15/2024 at 11:21 a.m., CNA A said the last time she provided care for Resident #5 was approximately 2 weeks ago. CNA A stated Resident #5 had a quarter size red area on her bottom and said she was not aware of any other wounds. During an interview with CNA B on 09/15/2024 at 11:32 a.m., CNA B stated she had not worked in the last 2-3 weeks. CNA B stated when she observed Resident #5's wound about 3 weeks ago, it was small and I think it hurt her, maybe quarter size. She complained that it hurt every time we changed her. CNA B said she would reposition Resident #5 during the shift and said she thought Resident #5 was scheduled for baths three times a week but didn't know often she was getting them. During an interview with LVN C on 09/15/2024 at 12:28 p.m., LVN C stated she worked for a staffing agency and was the charge nurse on 6 a.m. - 2p.m. shift on 09/09/2024. LVN C said she did not assess Resident #5 prior to her leaving for dialysis on the morning of 09/09/2024. LVN C said she received a call from the dialysis clinic around noon and the nurse said Resident #5 was sent to [hospital name] ER because she had altered mental status after the dialysis procedure. During an interview with the facility Treatment Nurse on 09/15/2024 at 12:54 p.m., the treatment nurse revealed she began doing treatments at the facility at the beginning of August 2024. She stated her role as the treatment nurse was to assess skin, round with the wound care physician, take orders, notify the doctors and family of changes with the wound and provide wound care daily. The treatment nurse stated wound treatments were documented on the resident TAR and she was notified of changes in the resident skin by the direct care staff and also received copies of the resident shower sheets. The treatment nurse stated she performed skin assessments weekly and the last time she completed a skin assessment for Resident #5 was on the morning of 09/09/2024 around 5am-6am prior to Resident #5 going to dialysis. The treatment nurse described Resident #5's wound on the morning of 09/09/2024 as pink with scant amount of drainage and close to her sacrum. She said Resident #5 had no eschar and the skin was pink and moist. The Treatment Nurse said she did not look at Resident #5's heels that morning and was not aware of Resident #5 having a wound on her left heel. The Treatment Nurse stated she did a treatment on Resident #5 on the morning of 09/09/2024 and said she did not know why it was not documented on Resident #5's TAR as being completed. The Treatment Nurse revealed the Wound Care Physician rounded at the facility weekly and should have seen Resident #5 weekly but stated the Wound Care Physician often rounded while Resident #5 was at dialysis. The Treatment Nurse stated she thought it had been a couple of weeks since the wound care physician had assessed Resident #5's wound. The Treatment Nurse described the wound as MASD and the wound was around 2.0 x1.0 x0.4cm. During an interview with the facility Treatment Nurse on 09/15/2024 at 2:30 p.m., the treatment nurse stated when the wound care physician missed observations of Resident #5 each week she, just told her it was the same each time and she said if it gets worse to send her a picture. During an interview with the DON on 09/15/2024 at 2:50 p.m., the DON revealed the facility had not spoken to Resident #5's family since Resident #5 went to the hospital on 09/09/2024 and had not received any updates or medical records from the hospital since Resident #5's admission to the hospital on 09/09/2024. During an interview at Resident #5's dialysis clinic with the Clinical Manager and Social Worker on 09/16/2024 at 9:15 a.m., the Social Worker revealed Resident #5 was arriving at dialysis with an altered mental status for about a month but significantly improved once she was dialyzed. The Social Worker said Resident #5 received treatment at the clinic since 08/15/2023 and usually arrived at dialysis around 7 a.m. and left around 2 p.m. to return to the facility. The Clinical Manager said on 09/09/2024, Resident #5 became unresponsive to stimuli and very lethargic toward the end of her dialysis treatment, the nurse notified the physician, and the physician gave an order for Resident #5 to be sent to the ER. The Clinical Manager said Resident #5 had a foot check on 09/06/2024 and was observed to have a dressing to her left heel. The Clinical Manager stated it was not facility proctive to remove the dressing to look at the wound and Resident #5 arrived dressed to her treatments each week and clinic staff would not have observed a sacrum wound. The Clinical Manager stated Resident #5 arrived on 09/09/2024 around 7:30 a.m. and was picked up by EMS at 11:23 a.m. to be transported to the ER. During an interview with the facility Wound Care Physician on 09/16/2024 at 11:39 a.m., the physician stated she began assessing residents at the facility at the beginning of August 2024 and the facility would request the consult and the resident would get added to her list of residents to assess each week. The Wound Care Physician stated she observed Resident #5 sacrum wound on 08/12/2024 and said the wound measured 1.5 x 0.4 x 0.1cm and looked like dermis and classified as MASD. We do not assign a stage to MASD and cannot really measure a depth less than .1. It was superficial and looked like irritation. The Wound Care Physician stated she was supposed to assess Resident #5 weekly but Resident #5 was always gone to dialysis when she would come by to make rounds. She stated she relied on the treatment nurse to guide her to tell her which patients needed to be seen, if they were not at the facility from her previous visit, then she tried to make accommodations to see the resident. The Wound Care Physician stated she received updates on resident progress if she did not see them she communicated very closely with [treatment nurse name]. We also have an option to do a telemedicine visit, because I am new, I have not mastered that, but it is something we can do in the future. The Wound Care Physician said there was a discussion about changing Resident #5's dialysis treatment days because I go to multiple facilities and my schedule is not flexible. The Wound Care Physician stated the Treatment Nurse mentioned she noticed some changes on Resident #5's wound on 09/09/2024 but did not say what type of changes. The Wound Care Physician stated she was not notified of the slough and eschar tissue documented on the treatment nurse assessment on 09/09/2024 and said if she was notified of she would have known the wound needed a debridement. The Wound Care Physician said I would have expected to be notified immediately that there is necrotic tissue and slough, that is a big change. I was just notified by [treatment nurse name] that she wanted me to come by and look at the wound sometime that week and we were talking about me coming on 09/11/2024. She did not tell me the current status of the wound. The Wound Care Physician stated she would have changed the treatment order if she was notified about the slough and eschar development on the wound and stated my suspicion is there is tissue that needed to be removed. That is not optimal that it was not removed. Without seeing the wound, I can only say that I think that the non-viable tissue needed to be removed. The Wound Care Physician stated she would have expected to be notified about the change in the wound and she said the facility treatment nurse did not notify her of necrotic tissue The wound care physician was shown a photo of Resident #5's sacrum wound taken at the hospital on 09/09/2024 at 10 p.m. and said that is very different than what I have seen or been notified of. I had no idea it looked like that. Oh geez, that is bad. If I knew it looked like that, I would have come in on a Saturday. I am a surgeon by training, I can smell the wound, I know how it is supposed to look and not look. We do have patients that are more complicated. If I knew it looked even 10% of that I would have debrided it. The Wound Care Physician also stated The honey and alginate did not make it worse; it just would not have done anything to heal it. It needed further treatment. The Wound Care Physician was asked how long it could take a wound to get to that stage and she said It could not happen in 8 hours. People on dialysis and diabetic progress pretty quickly. It could have been a week or 3 weeks but would not develop like that. Yeah, given her diagnosis, I would say a week to 2 weeks. During an interview with the facility Treatment Nurse on 09/16/2024 at 1:00 PM, the Treatment Nurse stated Resident #5 did not have necrotic tissue on her sacrum when the treatment nurse assessed her. The Treatment Nurse was shown her assessment from 09/09/2024 which reflected the Treatment Nurse had documented Resident #5 had 10% necrotic tissue and 20% slough and she said Yes, there may have been some eschar in there, I told the wound care physician it had gotten larger. The Wound Care Physician knew there was slough, I don't know if I mentioned the eschar. The Treatment Nurse stated she did not have any documentation to support her notification but knew she called The Wound Care Physician r and told her the wound was bigger and said she should have told her about the eschar. The Treatment Nurse was asked if she notified the wound care physician about Resident #5's wound changes and slough from her 09/04/2024 assessment and she said I text her all the time, we just haven't been able to get together. I guess we could have gotten together and did a video chat. No, I don't have anything documented that I notified her, just verbally and I know I should have documented it. The Treatment Nurse said it was important to notify the physician of changes so we can change something and go in a different direction. Just the size was concerning, and I know she sits up a lot, but we could have changed the order, frequency or done something different. The Treatment Nurse stated she should have notified Resident #5's primary physician if the wound was changing and Resident #5 was not being assessed by the Wound Care Physician. She stated I could have notified him too. The Treatment Nurse stated the sheets were completed by the direct care staff who provided the shower and then turned into the Charge Nurse and to the Treatment Nurse to review. The Treatment Nurse stated she assumed that N/A marked on the shower sheets meant Resident #5 did not get a shower. The Treatment Nurse was asked about Resident #5 having N/A on the majority of her shower sheets in August and September and the treatment nurse said we just implemented the sheets in August. If someone refuses, we should be documenting refusals on it so those must be on her dialysis days so they should have been changed and given to her before she leaves for dialysis or on the opposite days. During an interview with Resident #5's primary facility physician on 09/16/2024 at 2:12 p.m., the Physician stated he last observed Resident #5 approximately two weeks prior to 09/16/2024. The Physician stated he did not see the sacrum wound and a wound care physician followed Resident #5. The Physician stated the Wound Care Physician should be notified of changes in wounds so the treatment orders could have been changed to address the changes in the wound and said I would hope the wound care physician would know about it because it is their responsibility. The physician stated he was not notified of Resident #5's wound having slough or eschar and stated I would expect the wound care doctor to be notified of that. I would be notified if the patient needs other things like antibiotics. If there was no wound care doctor I would want to be notified. The Physician was asked if he was notified of any change in condition with the resident and he said lethargy and altered mental status was not new for Resident #5 and she was declining for the last few months. The Physician was asked what should have been done if the Wound Care Physician was not able to see Resident #5 weekly and he said That is a question for the facility, what do they do when a provider doesn't come? I don't see the patient wounds because the wound care nurse should be following orders from the wound care doctor. During an interview with the facility DON on 09/16/2024 at 4:07 p.m., the DON said the facility had a treatment nurse Monday - Friday and charge nurses were responsible for wound care on the weekends if the treatment nurse was not there. The DON said the facility had a clinical meeting daily and the charge nurses went to the meeting and gave report on the residents and the facility had a weight and skin meeting weekly on Wednesdays. The DON stated wound care was validated and monitored for wound healing through communication between the DON, the Treatment Nurse and the Wound Care Physician, and the Treatment Nurse kept a log of wounds which was reviewed weekly by the corporate nurse. The DON stated the treatment nurse was responsible for notifying the Wound Care Physician of wound changes and documenting the notification and following new orders. The DON stated her expectation was for the treatment nurse to identify any changes in a resident wound and report those changes so an appropriate treatment was implemented. the DON stated if the intervention is not work [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 Residents (Resident #1) and from 1 staff member (CNA A) reviewed for quality of care in that: CNA A used Resident #1's arm to pull the resident back into position to move Resident #1, which resulted in a right arm fracture. This failure resulted in the identification of an IJ on 7/7/21. While the IJ was removed on 7/9/21, the facility remained out of compliance at an actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This failure placed residents at risk for improper care, injury, pain, decreased quality of life, worsening health conditions, and even death. The findings were: Record review of Resident #1's face sheet dated 7/8/21 he was a [AGE] year old male revealed with an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan dated 1/25/19 revealed Resident #1 had an ADL self-care deficit and required extensive staff assistance with ADLS (transfers, moving in bed, showers, eating). Record Review of Resident #1's MDS dated [DATE] revealed he needed extensive and physical help with ADLs (transfers, moving in bed, showers, eating), and Resident #1 had a functional limitation in his arms (shoulder, elbow, wrist, hand). Record review of the facility's incident and accident report dated 6/1/21 to 7/7/21 revealed no concerns related to positioning resident's in bed. Record review of the facility's resident's ADL review dated 7/7/21 revealed she facility discussed all residents who needed any assistance in bed or other care. Record review of Resident #1's incident report dated 6/8/21 revealed Resident #1 complained of right shoulder pain after being repositioned by CNA A, Resident #1 was able to move his arm with facial grimacing and stated he could not lift his right arm. Further review revealed Resident #1 moaned in pain during the nurse assessment. Record Review of Resident #1's care plan dated 6/8/21 revealed he had an acute closed middle right Humerus fracture and dislocation with interventions which included acetaminophen (Tylenol) as ordered, initiated on 6/25/21, keep brace on except for bathing, allow elbow to hang in a seated position or with the head of the bed raised, initiated on 6/18/21, and monitor right shoulder skin for swelling or breakdown and keep elevated at all times, initiated on 6/8/21. Record review of Resident #1's progress notes written by LVN D dated 6/8/21 at 6:12 a.m. revealed he complained of pain to his right shoulder during incontinence care on the night shift, Resident #1 was able to move his right arm but not lift it, and was observed grimacing when he was asked to lift his arm. Record review of Resident #1's progress note by the NP on 6/8/21 at 3:59 p.m. revealed he was seen by the NP for right shoulder pain and had decreased mobility, pain with movement/touch, poor strength, and was unable to extend his right arm because of pain. The NP ordered Resident #1 a rushed right shoulder Xray. Record Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Xray to his right shoulder dated 6/8/21 revealed an acute, comminuted and displaced (bone was broken into 2 or more pieces and moved out of alignment) fracture to the middle of Resident #1's right Humerus. Record review of Resident #1's progress note completed by his primary care physician dated 6/9/21at 6:00 p.m. revealed he was seen in the facility by his doctor who reviewed an Xray completed at the facility on 6/8/21 which showed Resident #1 had a fracture to his right arm. Review of Resident #1's care plan dated 6/11/21 revealed he had right arm pain related to a fracture with interventions which included anticipate the resident's [Resident #1] need for pain relief and respond immediately to any complaint of pain. Record review of Resident #1's SBAR communication completed by LVN B dated 6/14/21 revealed Resident #1 had a change in status of his right arm fracture which seemed to worse with increased swelling, coldness to touch, decreased ROM, and increased pain. Further review revealed Resident #1 was transferred to a local emergency room for an evaluation. Record review of Resident #1's emergency room visit notes dated 6/14/21 revealed Resident #1 needed an evaluation because the injury to his right arm worsened, Resident #1 presented to the emergency with swelling, redness, and poor circulation to his right arm, the radiologist reported Resident #1's right arm fracture was unchanged and he was sent back to the facility with a splint and a sling to his right arm. Further review revealed Resident #1 appeared uncomfortable, and the emergency room doctor recommended a follow up with an orthopedic surgeon (bone surgeon) and Tylenol for pain. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's BIMS assessment dated [DATE] revealed a score of 5 of 15, which meant Resident #1 had a severe cognitive impairment (unable to understand the meaning/ importance of something, trouble remembering, trouble concentrating, and the inability to make decisions affecting his everyday life). Record review of Resident #1's progress note completed by his primary care physician dated 7/2/21 revealed he was seen by his doctor in the facility. Further review revealed Resident #1's skin was normal temperature, no bleeding under his skin and Resident #1's skin was normal colored. Record review of Resident #1's SBAR assessment completed by LVN B dated 7/5/21 revealed he had a change to his right upper arm with a puncture near his fracture site, and Resident #1 reported pain to his right arm. Record review of Resident #1's head to toe skin assessment completed by LVN B dated 7/5/21 revealed he had an open area over the fracture to his right arm which measured 1.5 cm by 1 cm. Record review of Resident #1's progress note written by LVN B dated 7/5/21 revealed he was transferred to a local hospital for a punctured area to the skin over his right upper arm/ shoulder fracture. Record review of Resident #1's hospital note dated 7/6/21 revealed Resident #1 was sent to the hospital on 7/5/21 after the facility noted protruding bone from Resident #1's right upper arm and it was unclear how it happened. Record review of Resident #1's care plan changes dated 7/7/21 revealed for bed mobility Resident #1 needed extensive assistance from one staff member up until 7/6/21 when it was changed to Resident #1 needed extensive assistance from two staff members to turn and reposition in bed. Record review of Resident #1's order audit report dated 7/8/21 revealed he had an order dated 6/25/21 for mechanical Lift: use Hoyer (lift) for all transfers every shift. In an interview on 7/6/21 at 2:05 p.m. the Administrator revealed on 6/8/21 CNA A was repositioning Resident #1 in his bed when she reported to LVN D she heard a pop sound while moving Resident #1 in bed. The Administrator revealed Resident #1 had an x-ray to his right arm on 6/8/21 and it showed a fractured right Humerus (the long bone of the upper arm). In an interview on 7/6/21 at 2:10 p.m. DON confirmed CNA A had been trained in proper positioning of residents in bed as she reviewed he competency checklist in her employee file. The Administrator revealed CNA A was trained by the PT in proper positioning of residents in bed. In an interview on 7/6/21 at 2:34 p.m. ADON C revealed she was the nurse manager for Resident #1's hall. ADON C revealed on 6/8/21 CNA A reported to LVN D, during care and changing Resident #1's gown, she heard a pop from his arm. LVN D on duty got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON C revealed the Xray showed a fracture to the long bone of the right upper arm, and Resident #1 was sent to a local emergency room (ER) to confirm the fracture, which confirmed there was a fracture to Resident #1's's right upper arm. ADON C revealed there was no documented staff training with return demonstrations regarding safe handling of residents during care after the incident on 6/8/21, and she was not aware if CNA A had any formal training before she was allowed to continue working with Resident #1 and other Residents. In an interview on 7/7/21 at 10:05 a.m. the Administrator revealed LVN D provided re-education to CNA A immediately after CNA A reported the incident with Resident #1. Further interview revealed the Administrator did not have documentation of LVN D's education or any return demonstrations with CNA A. In an interview on 7/7/21 at 11:00 a.m. LVN D revealed she was the nurse for Resident #1 on the early morning of 6/8/21. LVN D reported CNA A checked on her assigned residents and noticed Resident #1 was on the edge of his bed, CNA A reported to LVN D that she put her arm under Resident #1's right arm and pulled him by his right arm to reposition him when CNA A reported she heard a pop sound. LVN D revealed she pulled CNA A to the side to remind her to call for help for resident repositioning when needed and use a bed pad to move residents in their bed, LVN D stated she did not document her conversation with CNA A. LVN D revealed during her assessment of resident #1 at 2:00 a.m. he complained about right shoulder pain, she gave him Tylenol per his orders. LVN D revealed Resident #1 complained of increased pain to his right shoulder towards the end of her shift at 6:30 a.m., she notified his doctor and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN D revealed she had no facility training on Resident #1's sling or splint to his right arm. In an interview on 7/7/21 at 11:32 a.m. ADON C revealed she received a recommendation from the PT to change Resident #1 from a one-person extensive assistance transfer to a mechanical lift total assistance with 2 staff members on 6/25/21. ADON C could not explain why Resident #1 had his transfer status changed 17 days after his fracture, and stated he needed increased help because his right arm was immobilized due to the fracture on 6/8/21. ADON C could not remember any specific staff training on Resident #1's right arm splint or sling. In an interview on 7/7/21 at 1:27 p.m. the Administrator confirmed CNA A reportedly grabbed Resident #1 under his right arm to reposition him in bed on 6/8/21 which led to the finding of a fracture to Resident #1's right upper arm. The Administrator revealed the expectation was staff were never to use resident's arms or legs for repositioning and CNA A had been checked off as competent. In an interview on 7/7/21 at 1:56 p.m. the PT revealed she was responsible for training/ and checked staff competencies for resident repositioning. The PT revealed there was no reason any of the staff should use resident's arms or legs to move them in bed. Revealed she trained CNA A in January of 2021 and CNA A provided a return demonstration in the area of reposition residents and passed the competency. In an interview on 7/7/21 at 2:35 p.m. CNA A confirmed she was the nurse aide assigned to care for Resident #1 on 6/8/21. CNA A revealed she was walking down the hall and noticed Resident #1 was lying close to the edge of his bed, so she went into his room to reposition Resident #1 in his bed. CNA A confirmed she interlocked her right arm under Resident #1's right arm and grabbed the bed pad with her left hand, then used Resident #1's right arm to pull him up and over in bed at which time CNA A reported Resident #1 yelled out, Ow! My Arm! CNA A revealed she notified LVN D who responded immediately. CNA A stated LVN D had not re-educated her on repositioning after the incident. CNA A revealed she usually would use Resident #1's bed pad to reposition him in bed and she did not know why she pulled his arm. CNA A revealed she spoke with the Administrator on 6/8/21 about transfers and repositioning but did not recall being trained or checked off before that. CNA A revealed if there were two nurse aides together, they would use resident's underarms/ arms to pull them up in bed, but CNA A could not name any other residents or staff members. CNA A revealed she did not ask for assistance with repositioning Resident #1 on 6/8/21 because the other nurse aide on duty was too far away in the facility, and she saw LVN D at the nurses station but did not think to ask her. CNA A confirmed she could continue working with Resident #1 and other assigned residents after the incident. In an interview on 7/7/21 at 2:45 p.m. the Staffing Coordinator confirmed CNA A was never removed from the schedule on or after 6/8/21 for additional competency checkoffs in repositioning residents in bed. Record review of CNA A's skill checklist dated 1/20/21 revealed she was checked off as competent in resident bed mobility and turning/ repositioning by the Wound Care Nurse. Record review of the facility's training attendance form dated 6/8/21 revealed nursing staff were trained on [CONDITION(S)], [CONDITION(S)], safe transfer, the Kardex, and care plan. Further review revealed not all direct care staff were trained and had been allowed to work with residents (Wound Care Nurse, OTA). CNA A attended the training. Further review revealed no knowledge checks or return demonstrations were completed to ensure competence in repositioning residents in bed. Record Review of CNA A's disciplinary action record dated 6/8/21 revealed she received a verbal warning and was inserviced on bed mobility and repositioning by LVN D, and the corrective action was CNA A was to attend additional training. Further review revealed no documented evidence LVN D inserviced CNA A on bed mobility or repositioning. The disciplinary action record was not signed by CNA A. Record review of the facility's lift and transfer guide (page 11) dated 2010 revealed when repositioning residents direct care staff should use gait belts or slip sheets to assist with repositioning when necessary and repositioning must be done with 2 or more people for residents who were unable to assist. Record review of the facility's abuse and neglect prohibition policy dated 7/2018 revealed each resident had the right to be free from abuse, neglect, and mistreatment. Further review revealed the facility would report all allegation/substantiated occurrences of neglect to the State Survey Agency and events which caused serious bodily injury would be reported no later than 2 hours after facility notification. The facility Administrator was notified an IJ had been identified on 7/7/21 at 5:45 p.m. The IJ Template was provided and the POR was requested. The facility's POR was accepted on 7/8/21 at 11:33 a.m. and included: Record review of the Plan of Removal read: (quoted as written in Administrator's format and wording). - The facility immediately completed a 100% review of all incident and accidents from 6/1/21 up to 7/7/21 to ensure no other injuries were caused by bed repositioning. None discovered. Completed 7/7/21. Direct Care Staff were in serviced on properly repositioning of residents in bed. Pre- test, Inservice, Post Test and Return Demonstration completed. CNA A (Out of the Country) or any other staff members will not return to work until skills validation is completed. An ADL report was generated to identify residents requiring limited to total assisted with bed mobility. Residents identified were reviewed and no concerns were discovered. - Administrator submitted self-report on 7/5/21. Intake # 7 and immediately started an investigation. Licensed Nurses were in serviced on resident pain assessments/ pain management on 7/7/2021. Licensed Nurses will not return to work until training is completed. - CNA A (out of the country) will not return to work until additional training is completed. Training to include: Pretest, Inservice, Post Test and Return Demonstration. - Resident Council meeting held on 6/1/21 and 6/28/21, no nursing concerns voiced. No issues voiced during daily rounds. 10% additional residents interviewed regarding staff handling during bed mobility. Completed on 7/7/21. No issues voiced. - Incident & Accidents: The facility will review all incident report and 24-hour reports daily for injuries. The DON/designee will review and investigate any injuries to ensure the residents were repositioned properly. If any injuries are discovered the DON/designee provide addition training to staff. Training to include. Pretest, Inservice, Post Test and Return Demonstration. The results of the daily reviews will be reported to the QAPI committee for no less than 90 days. Reposition Monitoring: The DON/designee will complete 5 observation per week. The results of the daily reviews will be reported to the QAPI committee for no less than 90 days. On 7/8/21 the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The facility will review all incident report and 24-hour reports daily for injuries. The DON/designee will review and investigate any injuries to ensure the residents were repositioned properly. In addition, the DON/designee will complete 5 observation per week. If any injuries or deficient practices are discovered the DON/designee will provide addition training to staff. Training to include. Pretest, Inservice, Post Test and Return Demonstration. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. POR Verification Monitoring from 7/8/21 to 7/9/21: - Interviews on 7/8/21 at 3:15 p.m. with the DON and the Administrator confirmed nursing staff had been trained on safe transfers, Kardex and Care plans- Resource Material: The Facilities Lift and Transfer and Repositioning Policy. In an interview on 7/9/21 at 12:00 p.m. the PT confirmed she had checked off nursing staff on 7/7/21 and 7/8/21 on proper positioning of residents in bed and transfers, and staff provided a returned demonstration of resident transfers, positioning in bed and use of a gait belt (cloth belt used to assist with resident movement and transfers from one surface to another). In an interview on 7/9/21 at 12:45 p.m. the Wound Care Nurse confirmed she helped check off nursing staff on positioning residents in bed and the nursing staff had to provide a proper return demonstration of bed mobility and turning and repositioning before they could work with residents on the floor. Interviews with staff members (CNA G, ADON F, PT, DON, OTA, CNA H, Staffing Coordinator, RN, ICP, Wound Care Nurse, Activities Manager, ADON C, LVN I, ADON J) on 7/8/21 from 11:30 a.m. to 5:30 p.m. and 7/9/21 from 9:00 a.m. to 2:30 p.m. revealed they were told they could not work the floor if they had not been checked off on repositioning residents in bed. Record review of an in-service dated 7/7/21 revealed more than 90% direct care staff had been trained on proper positioning of a resident in bed and had to provide a return demonstration and be checked off. Record review of the facility's staff return demonstrations dated from 7/7/21 to 7/9/21 revealed staff passed the skills check of for repositioning residents (CNA G, ADON F, PT, DON, OTA, CNA H, Staffing Coordinator, RN, ICP, Wound Care Nurse, Activities Manager, ADON C, LVN I, ADON J). In an interview on 7/8/21 at 4:00 p.m. the DON confirmed he had in-serviced all nurses who worked in the facility except for one as needed nurse. In an interview on 7/8/21 at 4:00 p.m. the Administrator confirmed she submitted a self- report regarding Resident #1's broken arm. Interviews on 7/9/21 from 11:00 a.m. and 2:00 p.m. revealed nurses (ADON C, DON, RN, Wound Care Nurse, LVN I) had been trained in pain assessment and pain management and demonstrated knowledge in those areas. - Record review revealed a message sent by the Staffing Coordinator to CNA A on 7/8/21 at 10:57 a.m. which informed her she could not return to work the floor until she was re-trained and found to be competent in repositioning of residents, CNA A confirmed her understanding. - Interviews on 7/8/21 from 11:30 a.m. to 12:00 p.m. and 7/9/21 from 10:00 a.m. to 1:00 p.m. Residents (#2, #3, #4, #5, #6, #7, #8, #9) revealed they had no negative reports about how the direct care staff/ therapy staff positioned them in their bed or wheelchair. Further interview revealed they had never been injured during or after being positioned by the staff. - Interviews on 7/9/21 at 12:30 p.m. the facility's nurse managers (the Staffing Coordinator, Wound Care Nurse, ADON C, ADON F) revealed they were made aware they were to review the incident reports and the 24 hour nursing report daily, and report any injuries to the DON who will ensure concerns were reported in QAPI meetings monthly. Record review of the facility's Pretest (for understanding of proper positioning of residents), In-service, Post Test (for understanding of proper positioning of residents) and Return Demonstration (for understanding of proper positioning of residents) forms revealed compliance. - Interviews on 7/9/21 at 12:30 p.m. the facility's nurse managers (the Staffing Coordinator, Wound Care Nurse, ADON C, ADON F) revealed they were made aware 5 resident position tasks observations needed to be watched per week and they were to report any concerns to the DON, and keep a record for QAPI meetings. In an interview on 7/8/21 at 4:10 p.m. the Administrator and the DON confirmed a QAPI meeting was held on 7/8/21 via conference to address the training concerns, the administrator provided a copy of the QAPI meeting for the investigation. Observations on 7/9/21 from 9: 00a.m. to 11:45 a.m. revealed Residents #7, #8, and #9 were positioned in bed without complaints and per policy and regulation. Staff (CNA H, ADON C, CNA K, CNA L, LVN B) demonstrated proper technique and knowledge of why positioning residents needed to be safe. Record review of the facility's QAPI tracking tools/ forms revealed no concerns for compliance. In an interview on 7/9/21 at 10:20 a.m. the Administrator revealed CNA A had not properly positioned Resident #1 in bed even after she was instructed by the PT and ADON J how to do so placed residents at risk for injury. In an interview on 7/8/21 at 10:45 a.m. LVN B confirmed Resident #1 had a closed fracture to his right upper arm which changed to an open fracture on 7/5/21. LVN B was unable to explain how Resident #1's fracture went from closed to opened. LVN B revealed she called in Resident #1's condition to a local hospital nurse when he was transferred there on 7/5/21. LVN B revealed she reported to the nurse Resident #1 had an existing fracture to his right arm, which had changed because it had an opened where it was closed before. LVN B revealed she could not remember if she reported Resident #1 had bone showing in the opening on his right upper arm. In an interview on 7/8/21 at 10:50 a.m., the NP, revealed she last saw Resident #1 on 6/15/21, but he started to complain of pain to his left shoulder when she saw him on 6/8/21. The NP revealed she had ordered a rushed Xray of Resident #1's right shoulder on 6/8/21. Further interview revealed the NP read Resident #1's Xray as (NP looked at her notes) a rotator cuff tear, [CONDITION(S)] joint disease, and a closed right Humerus fracture (no broken skin). The NP revealed her assessments of Resident #1's right arm on 6/8/21 and 6/15/21 showed a little redness, and mild swelling, but no bruising. The NP stated, it is clear another injury [to Resident #1] happened after 6/8/21 because his arm was negative for any open areas. In an interview on 7/8/21 at 12:18 p.m. the Staffing Coordinator revealed she had not been instructed by the Administrator to make sure staff had the in-service training dated 6/8/21 on transfers and repositioning before they worked the floor. In an interview on 7/8/21at 12:45 p.m. the Wound Care Nurse confirmed she had not signed the in-service training form dated 6/8/21 and she had not been checked off on resident positioning in bed since 6/8/21. In an interview on 7/8/21 at 12:53 p.m. the OTA, confirmed his signature was not on the staff in service training form dated 6/8/21 which covered transfers/ repositioning of residents in bed, and could not explain why he was not trained. On 7/9/21 at 5:00 p.m. the Administrator was notified the IJ was removed. The facility remained out of compliance at a level of actual harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. Record review of the facility's training attendance record dated 7/9/21 revealed nursing staff were trained on Resident #1's sling/brace care and draw sheet positioning care. Further review revealed no documented training on Resident #1 was provided before 7/9/21. In an interview on 7/12/21 at 10:05 a.m. the Administrator confirmed the facility had no specific policy on quality of care, the expectation was to follow best practices.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse and neglect for 2 of 14 residents (#16 and #33) reviewed for abuse, in that: 1. PT S told Resident #16 she would not get anything to drink unless she finished therapy. 2. HK R told Resident #33 to urinate in her brief and someone would clean her up afterwards. This deficient practice could place residents who were dependent upon staff for care at risk for abuse. The findings were: 1. Review of Resident #16's face sheet dated 2/10/20 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #16's Care Plan initiated 11/29/19 revealed the resident had [MEDICAL CONDITION] and required adequate fluid intake. Further review of the Care Plan revealed Resident #16 had a potential for fluid volume overload related to kidney failure and required a fluid restriction of 1500 ml in a 24-hour day. Observation on 2/11/20 at 2:15 PM two surveyors were sitting in the conference room, which was located across the hall from the rehabilitation room. At that time the door to the conference room was open and a conversation could be heard outside the door. A voice from outside the door was heard saying, I walked, and I want my tea and a response from another person replied, No Ma'am you did not. The two voices could be heard several times. The first voice stated she did her therapy and the second voice told her she did not. The second voice got louder and abruptly told the first voice, No Ma'am (stating Resident #16's name) you did not! and then crying was heard. When the surveyors stepped into the hall PT S was observed pushing Resident #16 in her wheel chair as she continued to cry. Further observation revealed NP T was in the room adjoining to the conference room with the door open and was looking out the door into the hall. Interview on 2/11/20 at 2:24 PM PT S confirmed she was the one talking to Resident #16 in the hall. PT S stated the staff encouraged Resident #16 to do therapy by offering to give her something to drink if the resident participated. The therapist confirmed Resident #16 was on a fluid restriction. Interview on 2/11/20 at 2:27 PM Resident #16's private caregiver stated some staff would give Resident # 16 fluid when she performed specific tasks. Interview on 2/11/20 at 2:28 PM Resident #16 was crying and stated she worked with therapy and was supposed to get her tea her. Resident # 16 stated they were being mean and not giving her the tea her family brought her. Interview on 2/11/20 at 3:05 PM PT S stated Resident #16 was told she could have tea when she successfully completed therapy. PT S reported, well she (Resident #16) didn't complete therapy so she didn't get her tea. Interview on 2/11/20 at 3:20 PM, NP T she revealed she overheard the conversation between PT S and Resident #16. NP T stated the conversation sounded, Like a mother talking to her child. Interview on 2/11/20 at 4:00 PM, OTA U stated she would give Resident #16 a soda as an incentive to work with her in therapy. OTA further stated if Resident #16 does not do the work then she does not get the soda. OTA U revealed she was aware Resident #16 was on a fluid restriction. 2. Review of Resident #33's face sheet dated 2/11/20 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #33's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, severely impaired, and required supervision with ambulation and extensive assistance with toileting. Attempted to interview Resident # 33 on 2/9/2020 at 11:45 AM, she was non-interviewable. Interview on 2/9/20 at 11:59 AM, Resident #33 walked up to this surveyor, mumbled some words, then stated, Pee Pee. HK R was standing near by and asked this surveyor what the resident had said. Surveyor informed HK R Resident #33 stated she had to go to the restroom. HK R stated to Resident #33, Just go in your diaper and someone would clean you up. Surveyor then notifed another staff member of Resident #33's request to go to the restroom and they took her. Interview on 2/9/20 at 1:13 PM with the Housekeeping Supervisor and HK R, HK R confirmed she instructed Resident # 33 to go in her diaper. The Housekeeping Supervisor instructed HK R that she was not to say anything to the residents and to get the aide if the residents needed something. Interview on 2/9/19 at 1:30 PM with the Administrator and Housekeeping Supervisor revealed HK R walked out of the facility after her supervisor spoke to her about the incident and had not returned. During an interview on 2/9/19 at 1:30 PM the Administrator and Housekeeping Supervisor revealed HK R walked out of the facility after her supervisor spoke to her about the incident and had not returned. Review of the facility's policy, Abuse and Neglect Prohibition, revised (MONTH) (YEAR), revealed, Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation and Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to others regarding the resident, or within the resident's hearing distance regardless of their age, ability to comprehend, or disability.

Based on observation, interview and record review the facility failed to treat each resident with respect, dignity and care in a manner and in an environment that promoted enhancement of his/her quality of life, while protecting the rights of the resident for 2 of 14 residents (#16 and #33) reviewed for residents rights, in that: 1. PT S told Resident #16 she would not get anything to drink unless she finished therapy. 2. HK R told Resident #33 to urinate in her brief and someone would clean her up afterwards. These failures could affect the residents who receive therapy services and residents that require assistance with their ADL's by placing them at risk for social isolation, loss of dignity, and self-worth. The findings were: 1. Review of Resident #16's face sheet dated 2/10/20 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #16's Care Plan initiated 11/29/19 revealed the resident had [MEDICAL CONDITION] and required adequate fluid intake. Further review of the Care Plan revealed Resident #16 had a potential for fluid volume overload related to kidney failure. Observation on 2/11/20 at 2:15 PM two surveyors were sitting in the conference room, which was located across the hall from the rehabilitation room. At that time the door to the conference room was open and a conversation could be heard outside the door. A voice from outside the door was heard saying, I walked and I want my tea and a response from another person replied No Ma'am you did not. The two voices could be heard several times. The first voice stated she did her therapy and the second voice told her she did not. The second voice got louder and abruptly told the first voice, No Ma'am (stating Resident #16's name) you did not! and then crying was heard. When the surveyors stepped into the hall PTA S was observed pushing Resident #16 in her wheel chair as she continued to cry. Further observation revealed NP T was in the adjoining to the conference room with the door open and was looking out the door into the hall. Interview on 2/11/20 at 2:24 PM PT S confirmed she was the one talking to Resident #16 in the hall. PT S stated the staff encouraged Resident #16 to do therapy by offering to give her something to drink if the resident participated. The therapist confirmed Resident #16 was on a fluid restriction. Interview on 2/11/20 at 2:27 PM Resident #16's private caregiver stated some staff would give Resident # 16 fluid when she performed specific tasks. Interview on 2/11/20 at 2:28 PM Resident #16 was crying and stated she worked with therapy and was supposed to get her tea her. Resident # 16 stated they were being mean and not giving her the tea her family brought her. Interview on 2/11/20 at 3:05 PM PT S stated Resident #16 was told she could have tea when she successfully completed therapy. PT S reported, well she (Resident #16) didn't complete therapy so she didn't get her tea. Interview on 2/11/20 at 3:20 PM, NP T she revealed she overheard the conversation between PT S and Resident #16. NP T stated the conversation sounded, Like a mother talking to her child. Interview on 2/11/20 at 4:00 PM, OTA U stated she would give Resident #16 a soda as an incentive to work with her in therapy. OTA further stated if Resident #16 does not do the work then she does not get the soda. OTA U revealed she was aware Resident #16 was on a fluid restriction. 2. Review of Resident #33's face sheet dated 2/11/20 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #33's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, severely impaired, and required supervision with ambulation and extensive assistance with toileting. Attempted to interview Resident # 33 on 2/9/2020 at 11:45 AM, she was non-interviewable. Interview on 2/9/20 at 11:59 AM, Resident #33 walked up to this surveyor, mumbled some words, then stated, Pee Pee. HK R was standing near by and asked this surveyor what the resident had said. Surveyor informed HK R Resident #33 stated she had to go to the restroom. HK R stated to Resident #33, Just go in your diaper and someone would clean you up. Surveyor then notifed another staff member of Resident #33's request to go to the restroom and they took her. Interview on 2/9/20 at 1:13 PM with the Housekeeping Supervisor and HK R, HK R confirmed she instructed Resident # 33 to go in her diaper. The Housekeeping Supervisor instructed HK R that she was not to say anything to the residents and to get the aide if the residents needed something. Interview on 2/9/19 at 1:30 PM with the Administrator and Housekeeping Supervisor revealed HK R walked out of the facility after her supervisor spoke to her about the incident and had not returned. Review of the facility's policy, Resident Rights, revised (MONTH) (YEAR), revealed, Facility staff will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and This policy applies to all employees.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to be free from neglect for 1 of 25 residents (Resident #11) whose care was reviewed in that: The facility failed to implement orders for treatment of [REDACTED]. after he returned from the hospital, and update the resident's care plan. Nursing Staff did not refer Resident #11 to the orthopedic after being released from the hospital for follow up from a fracture due to a fall. Thirty-nine days from day of discharge from the hospital had elapsed with no orthopedic follow up. There were no orders by the physician to address the resident's soft cast or care plan in the 39 days following discharge from the hospital. Nursing Staff did not monitor Resident #11 after sustaining a fracture due to a fall. Resident # 11 had a soft cast to lower right leg with no doctor's order on how to monitor or treat the fracture or injury. Because of this fracture, Resident #11 lost the ability to walk, where he had been able to walk with assistance prior to the fall and fracture. These deficient practices and failures resulted in identification of an Immediate Jeopardy (IJ) on 02/22/2019. While the IJ was removed on 02/23/2019, the facility remained out of compliance at a level of actual harm with a scope identified as isolated. This deficient practice could affect residents who required follow up treatment through referral or specialty consultant to monitoring their level of care for injury or fractures from falls. The findings were: Review of Resident #11's face sheet, dated 2/20/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The Fracture of Upper and Lower End of Left Fibula, Fracture of Shaft of Right Tibia was added to this list on 1/13/19. Review of Resident #11's Transfer Evaluation dated 10/31/18 revealed Full Weight Bearing status and unsteady gait. Review of Resident #11's Physical Therapy Evaluation & Plan of Treatment dated 11/2/18 revealed full weight bearing status to bilateral lower extremities. Review of Resident #11's Occupation Therapy Evaluation & Plan of Treatment dated 11/2/18 revealed clinical impression: strength deficit, balance, function endurance, coordination, and cognition impacting ADL performance and overall negative mobility. Review of Resident #11's Nursing Daily Skilled Charting dated 1/12/19 revealed transfers should be supervised, independent toileting, impaired balance, impaired gait and partial weight bearing status. Review of Resident #11's Nursing Note dated 1/13/19 at 5:18 p.m., written by the DON, revealed Resident #11 had a fall this morning, X-Ray completed reportedly showed a right femur fracture, and nurse on duty received orders to immobilize and follow up with ortho in AM from MD. This nurse contacted MD and requested to have resident transferred to ER for evaluation and treatment. Review of Resident #11's hospital discharge report dated 1/13/19 at 6:46 p.m. revealed he fell [DATE]. X-rays revealed fracture of proximal right fibula involving fibular neck. Review of Resident #11's hospital discharge report dated 1/13/19 at 6:46 p.m. revealed recommendation to follow up with Orthopedic Specialist in clinic next week. Pain control administered at hospital, splint placed and discharged with instructions to follow-up. Review of Resident #11's Nursing Daily Skilled Charting dated 1/14/19 revealed transfers with limited assistance, however weight bearing status was not assessed. Review of the Specialist Referral Form, provided by the Social Worker Q, dated 1/16/19, revealed that Resident #11 was referred to the Orthopedic specialist for evaluation and treatment due to a right ankle fracture by the facility Medical Director for follow up. Review of the Disciplinary Action Record in RN EE's personnel file, dated 1/18/19, revealed that RN EE was terminated due to failure to follow protocol managing falls. Further review of the personnel file revealed that RN EE had been counseled on 11/8/18 for no documentation on the assessment of a fall. Review of Resident #11's Physical Therapy Evaluation & Plan of Treatment dated 1/29/19 revealed casting of ankle . no weight bearing precaution noted in chart, will treat as NWB (non-weight bearing) until cleared by MD: Location= Right side. Further clinical impressions indicate decreased balance, decreased strength, decreased flexibility, increased pain, poor motor plan, poor sequence of task, poor safety awareness, poor functional activity tolerance. This puts patient at increased risk for falls, further decline. Review of Resident #11's Occupational Therapy Evaluation & Plan of Treatment dated 1/30/19 revealed Pt presents with significant decline in his ADLs due to current R tib/fib fracture that is NWB (non-weight bearing). He is unable to sit edge of bed at this time due to pain when sitting upright. Pt is unable to complete LB (load bearing) ADLs (Activities of Daily Living) at this time and risk for further decline in his self-care abilities. Review of Resident #11's physician's orders for (MONTH) 2019 and (MONTH) 2019 did not include an order for [REDACTED]., to include non-weight bearing, or the use of the soft cast. During an interview on 2/22/19 at 6:47 p.m., RN Z confirmed that there were no treatment orders for Resident #11's fracture to his right leg. During an interview on 2/22/19 at 6:47 p.m., LVN Treatment Nurse S confirmed that she did not have treatment orders for Resident #11's fracture to his right leg. LVN Treatment Nurse S further revealed that Resident #11 kept the soft cast to the right lower extremity on at all times and that when he showered it was covered with a plastic bag. Record review of Resident #11's clinical record revealed that there was no documentation on how to treat the soft cast worn by the resident when showering. Further review of the record revealed no documentation regarding skin integrity issues in relation to the use of the soft cast. Review of Resident #11's most current Significant Change MDS, dated [DATE], which was incomplete, revealed the Staff's assessment for Resident #11's mental status was consistent and reasonable for daily decision-making skills. Further review of the MDS revealed that the resident required 1-person physical assist for bed mobility, transfers, and toilet use, and did not include that the activity for ambulation had occurred. The Significant Change MDS did not include that the resident used a soft cast, or include weight bearing status. Review of Resident #11's Care Plan, dated 2/20/19, revealed that the resident was at risk for falls related to gait impairment, [MEDICAL CONDITIONS] disorder, and an actual fall that occurred on 1/13/19 that resulted in [MEDICAL CONDITION] leg. Interventions included safe environment, bed in low position, handrails on the wall, personal items within reach, and appropriate footwear when ambulating or mobilizing in the wheelchair. Further review revealed that the soft cast, or weight bearing status was not care planned and there were instructions for cast care. Review of the Nursing progress note, dated 2/23/19, time stamped 3:48 p.m., revealed that Resident #11 was transferred back from the ER for evaluation of status [REDACTED]. Observation on 2/22/19 at 6:22 p.m. revealed, Resident #11 was seen sitting up in a wheelchair with a bandage wrapped on the right lower extremity covered with a soft cast. Observation on 2/22/19 at 6:47 p.m. Resident #11 was assessed by RN Z and LVN S who removed the residents bandage and soft cast to the right lower extremity and macerated skin was observed under the cast from mid foot to approximately 2-3 inches above the ankle. Minimal non-[MEDICAL CONDITION] to the right lower extremity was observed. Interview on 2/22/19 at 6:22 p.m. Resident #11 revealed that he had pain to the back of his right knee and reported that he got a splint when he returned from the hospital on [DATE]. Resident #11 further revealed that he had used the call light to try to get assistance to the bathroom and when nobody came he transferred himself from the bed to the wheelchair and propelled himself to the restroom, grabbed the bar on the wall to a standing position and revealed that his right leg gave out and he fell . Resident said that he then used the call light in the bathroom for assistance and stated that a staff member (RN EE) came into the bathroom and found him on the floor. Resident #11 revealed that the nurse (RN EE) came back into the room with a female staff and assisted him back to his wheelchair. Interview on 2/22/19 at 6:47 p.m., Resident #11 revealed that no one (nurse, doctor, therapist) had checked his right leg or foot since the time he came back from the hospital (39 days). During an interview on 2/22/19 at 5:46 p.m. CMA DD revealed that on 1/12/19 at approximately 7:00 p.m. she was summoned by RN EE to assist him with Resident #11 because the resident had fallen. CMA DD revealed that Resident #11 was on the floor in the bathroom and that she and RN EE assisted the resident off the floor. CMA DD further stated that she then returned to finish her break when approximately 15 minutes later RN EE summoned her because Resident #11 had fallen again. CMA DD revealed that she told RN EE she would come help him once she clocked back from break but that RN EE told her that he had already had someone else assist him with the resident. CMA DD revealed that she received a phone call from the DON the following day on 1/13/19 and was asked if RN EE had summoned her the night before to assist him with Resident #11 after having a fall. CMA DD revealed that she had and did not inform the DON of the second fall that the resident had because she didn't ask me. During an interview on 2/22/19 at 5:27 p.m. the DON revealed that she received a call from ADON K that Resident #11 had a fall on 1/13/19 and that he had a fracture. The DON revealed that she was told by ADON K that there was rumors that Resident #11 had not fallen on 1/13/19 but had fallen the night before on 1/12/19. The DON revealed that she then contacted RN EE and asked when the resident had fallen. The DON revealed that RN EE told her that the resident had fallen on the morning of 1/13/19 and that he had witnessed it. The DON revealed that she asked RN EE to leave because she needed to investigate the incident with Resident #11. The DON revealed that after the investigation, RN EE was terminated. Review of the facility policy titled Fall Management, revision date 7/2017, revealed in part .The facility assists each resident in attaining/maintain his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review .When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred . Review of the facility policy titled Truly Listening to Our Customers (TLC) Program, revision date 5/2017, revealed in part .The facility actively resolved concerns submitted orally or in writing to any member of the facility's staff .This policy applies to all employees .The Administrator acts as the Grievance Official and is responsible for : Overseeing the grievance/concern process .Coordinating with State and Federal agencies as necessary .3. If the concern relate to nursing care or alleged abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and/or misappropriation of property, the concern should be forwarded immediately to the Abuse Coordinator for response, and reported in accordance with the Abuse and Neglect Prohibition policy .The resolution is documented on the Concern Form . During an interview on 2/22/19 at 5:59 p.m., the DON revealed that Resident #11 had been referred to the orthopedic since release from the hospital on [DATE] and confirmed that he had not seen the orthopedic as of today (2/22/19). The DON stated that an appointment with the orthopedic could not be made because the resident needed a referral but that the facility physician was not on the insurance provider list. The DON further revealed that she was not aware if Resident #11 was wearing a cast. During an interview on 2/22/19 at 6:22 p.m., the Administrator confirmed that Resident #11 had a fall in (MONTH) and that nursing staff were managing his pain. The Administrator confirmed that the resident had a referral to see the orthopedic for a follow-up to the fracture but had not seen the specialist as of today (2/22/19) due to insurance non-coverage. The Administrator further revealed that Resident #11 had an insurance that did not include the facility physician as the primary. The Administrator further revealed that the resident continued to be non-weight bearing and wore a soft cast. During an interview on 2/22/19 at 6:32 p.m. Rehab Manager W revealed that Resident #11 sustained a fracture on 1/13/19 and had obtained orders from the facility physician for a rehabilitation therapy evaluation. During an interview on 2/22/19 at 7:19 p.m., with CNA AA revealed that he had showered Resident #11 on more than one occasion and that each time the right leg was wrapped with a plastic bag. During an interview on 2/23/19 at 12:27 p.m., the Medical Director revealed that he had unofficially visited with Resident #11 while in the facility. The Medical Director stated that Resident #11 was sent to the emergency room (on 2/22/19) and then recommended a follow up in a week with the orthopedic. During an interview on 2/23/19 at 5:30 p.m., the Nurse Practitioner revealed that Resident #11 had transferred himself from the wheelchair and slipped and fell . The Nurse Practitioner further revealed that she could not recall if the resident had a soft or hard cast on his right leg. The Nurse Practitioner revealed that since the resident was referred to the Orthopedic that a follow up x-ray would have been recommended to ensure that the fracture had healed properly. The Nurse Practitioner stated that she was not aware that the resident had not been seen by the orthopedic. During an interview on 2/23/19 at 6:05 p.m., MDS Director A revealed that a Significant Change MDS was in the process of being completed based on recommendations from an IDT meeting held on 1/26/19 (8 days after Resident #11 was confirmed with a fracture) in which it had been determined that Resident #11 had a decline in ADL's and was non-weight bearing. Review of the facility's Abuse and Neglect Prohibition policy, revision date 7/2018, revealed in part .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Neglect means a 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. Injuries of unknown origin may occur as a result of neglect . The Administrator was notified on 2/22/19 at 8:14 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 2/23/19 at 12:30 p.m. and included: Retama Manor respectfully submits this plan of removal (v.2) to abate the allegations of immediate jeopardy identified on (MONTH) 22, 2019. Plan submitted on 2/23/2019 at 11:00am Immediate action taken for resident affected: The resident was sent to the emergency room (2/22/19) for an evaluation and returned with no new orders. The resident has pain medication ordered and is receiving this as needed. The primary care physician was contacted and arranged for the resident to be seen by an orthopedic for follow on 2/25/2019 at the Orthopedic Clinic. Resident identified to have been affected by the alleged deficient practice: The facility immediately completed a review of all residents with falls, X-rays completed in house and emergency room visits to ensure residents that had orders for follow up consults with specialist were scheduled and completed and the resident received timely assessment and treatment for [REDACTED]. Falls: The facility immediately reviewed 5 residents with falls with fractures in the last 6 months. The RN reviewed the 3 residents that had ordered follow up consults with orthopedic specialists and found all consults were scheduled and completed as ordered. The facility immediately reviewed 110 residents with falls in the last 3 months and the RN determined that all residents received timely assessment and treatment at the time of the fall. Completed 2/22/2019 X-rays: The (facility) immediately reviewed the 17 residents with X-rays in the last 3 months and found 1 resident with fracture identified on X-ray. The RN reviewed all X-rays with identified fractures and reviewed the orders for follow up found that orders were completed. Completed 2/22/2019 ER Visits: The facility immediately reviewed 10 residents with emergency room visits in the last 3 months. The RN determined there were no residents with orders for consults to specialist and all residents had discharge orders transcribed and completed. Completed 2/22/2019 Residents with the potential to be affected by the alleged deficient practice: During the above thorough review of the entire facility population the facility identified 5 residents with falls resulting in a fracture in the last 6 months,110 residents with falls in the last 3 months, 1 resident with an X-Ray identifying a fracture in the last 3 months and 10 residents who had an ER visit within the last 3 months. Systemic Measures: 1. Falls: The facility will review all incident report and 24 hour reports daily for falls. The DON/designee will review and investigate all falls to ensure the resident received timely assessment and treatment of [REDACTED]. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days 2. X-Ray: The DON/designee will review physician orders and 24 hour report daily for X-ray orders. The DON/designee will review all residents with X-ray reports identifying a fracture to ensure all physician orders for consults for orthopedic follow up are scheduled and completed. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days 3. ER Visits: The DON/designee will review 24 hour reports daily for all residents with a transfer to the ER to ensure all orders for consults to specialists are scheduled and completed. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days. 4. Training: Will be completed as follows: a. All licensed nursing staff will be trained on completing Incident Reports and timely assessment and treatment of [REDACTED]. b. All licensed nursing staff will be trained on scheduling and completing of consult orders received from the attending physician for fractures identified on x-ray reports or noted on discharge instructions received from ER transfers. Further training on the facility process for notification of the Medical Director if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult. Will be completed 02/23/2019. c. All licensed nursing staff will be trained on entering discharge or new orders for consults and follow up in the physicians order section of PCC, including information on appointment needed, name of and contact information of physician to follow up with and date and time of appointment. d. All licensed nurses will be trained to enter discharge instructions and consult orders, falls, xrays results and transfers toER on the 24 hour report. Status of the resident post fall, xray results and any orders or referrals will carry over each shift until 72 hours post fall and/or appointment has been set or orders received and entered into PCC. e. Facility Director of Nursing will be trained on using the Clinical Morning Meeting Tool designed to monitor and track falls, X-rays and transfers to the ER to ensure timely assessment, treatment of [REDACTED]. Further training on facility process to notify the Medical Director if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. This training will be provided by Jill Gutierrez, RN District Director of Clinical Services on 02/22/2019. f. Facility administrator will be trained on using the Clinical Morning Meeting Tool designed to monitor and track falls, X-rays and transfer to the ER to ensure follow up on timely assessment, treatment of [REDACTED]. This training will be provided by RN District Director of Clinical Services on 02/22/2019. Quality Assurance Performance Improvement: On 02/22/2019 the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: 02/23/2019 On 2/23/19 the Survey Team confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. Interviews were conducted with 6 CNA's, 2 RN's, 6 LVN's, 3 Med Aides, Social Worker, PT Manager, Nursing Staff Scheduler, the DON, and the Administrator. Interviews revealed that facility staff were able to identify the procedure to follow when a fall occurred. Interviews revealed that staff were able to identify the process for follow up with specialty consultants and obtaining appointments for follow up after an injury was identified and/or discharge from the hospital. Staff interviewed were able to identify types of abuse/neglect and the process for reporting. An in-service dated 2/22/19, concerning ensuring incident/accident and follow up on the 24-hour report was reviewed and contained 29 signatures. On 2/23/19 the Immediate Jeopardy was removed, however, the facility remained out of compliance at the scope of isolated and severity potential of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to be free from neglect for 1 of 25 residents (Resident #11) whose care was reviewed in that: The facility failed to implement orders for treatment of [REDACTED]. after he returned from the hospital, and update the resident's care plan. Nursing Staff did not refer Resident #11 to the orthopedic after being released from the hospital for follow up from a fracture due to a fall. Thirty-nine days from day of discharge from the hospital had elapsed with no orthopedic follow up. There were no orders by the physician to address the resident's soft cast or care plan in the 39 days following discharge from the hospital. Nursing Staff did not monitor Resident #11 after sustaining a fracture due to a fall. Resident # 11 had a soft cast to lower right leg with no doctor's order on how to monitor or treat the fracture or injury. Because of this fracture, Resident #11 lost the ability to walk, where he had been able to walk with assistance prior to the fall and fracture. These deficient practices and failures resulted in identification of an Immediate Jeopardy (IJ) on 02/22/2019. While the IJ was removed on 02/23/2019, the facility remained out of compliance at a level of actual harm with a scope identified as isolated. This deficient practice could affect residents who required follow up treatment through referral or specialty consultant to monitoring their level of care for injury or fractures from falls. The findings were: Review of Resident #11's face sheet, dated 2/20/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The Fracture of Upper and Lower End of Left Fibula, Fracture of Shaft of Right Tibia was added to this list on 1/13/19. Review of Resident #11's Transfer Evaluation dated 10/31/18 revealed Full Weight Bearing status and unsteady gait. Review of Resident #11's Physical Therapy Evaluation & Plan of Treatment dated 11/2/18 revealed full weight bearing status to bilateral lower extremities. Review of Resident #11's Occupation Therapy Evaluation & Plan of Treatment dated 11/2/18 revealed clinical impression: strength deficit, balance, function endurance, coordination, and cognition impacting ADL performance and overall negative mobility. Review of Resident #11's Nursing Daily Skilled Charting dated 1/12/19 revealed transfers should be supervised, independent toileting, impaired balance, impaired gait and partial weight bearing status. Review of Resident #11's Nursing Note dated 1/13/19 at 5:18 p.m., written by the DON, revealed Resident #11 had a fall this morning, X-Ray completed reportedly showed a right femur fracture, and nurse on duty received orders to immobilize and follow up with ortho in AM from MD. This nurse contacted MD and requested to have resident transferred to ER for evaluation and treatment. Review of Resident #11's hospital discharge report dated 1/13/19 at 6:46 p.m. revealed he fell [DATE]. X-rays revealed fracture of proximal right fibula involving fibular neck. Review of Resident #11's hospital discharge report dated 1/13/19 at 6:46 p.m. revealed recommendation to follow up with Orthopedic Specialist in clinic next week. Pain control administered at hospital, splint placed and discharged with instructions to follow-up. Review of Resident #11's Nursing Daily Skilled Charting dated 1/14/19 revealed transfers with limited assistance, however weight bearing status was not assessed. Review of the Specialist Referral Form, provided by the Social Worker Q, dated 1/16/19, revealed that Resident #11 was referred to the Orthopedic specialist for evaluation and treatment due to a right ankle fracture by the facility Medical Director for follow up. Review of the Disciplinary Action Record in RN EE's personnel file, dated 1/18/19, revealed that RN EE was terminated due to failure to follow protocol managing falls. Further review of the personnel file revealed that RN EE had been counseled on 11/8/18 for no documentation on the assessment of a fall. Review of Resident #11's Physical Therapy Evaluation & Plan of Treatment dated 1/29/19 revealed casting of ankle . no weight bearing precaution noted in chart, will treat as NWB (non-weight bearing) until cleared by MD: Location= Right side. Further clinical impressions indicate decreased balance, decreased strength, decreased flexibility, increased pain, poor motor plan, poor sequence of task, poor safety awareness, poor functional activity tolerance. This puts patient at increased risk for falls, further decline. Review of Resident #11's Occupational Therapy Evaluation & Plan of Treatment dated 1/30/19 revealed Pt presents with significant decline in his ADLs due to current R tib/fib fracture that is NWB (non-weight bearing). He is unable to sit edge of bed at this time due to pain when sitting upright. Pt is unable to complete LB (load bearing) ADLs (Activities of Daily Living) at this time and risk for further decline in his self-care abilities. Review of Resident #11's physician's orders for (MONTH) 2019 and (MONTH) 2019 did not include an order for [REDACTED]., to include non-weight bearing, or the use of the soft cast. During an interview on 2/22/19 at 6:47 p.m., RN Z confirmed that there were no treatment orders for Resident #11's fracture to his right leg. During an interview on 2/22/19 at 6:47 p.m., LVN Treatment Nurse S confirmed that she did not have treatment orders for Resident #11's fracture to his right leg. LVN Treatment Nurse S further revealed that Resident #11 kept the soft cast to the right lower extremity on at all times and that when he showered it was covered with a plastic bag. Record review of Resident #11's clinical record revealed that there was no documentation on how to treat the soft cast worn by the resident when showering. Further review of the record revealed no documentation regarding skin integrity issues in relation to the use of the soft cast. Review of Resident #11's most current Significant Change MDS, dated [DATE], which was incomplete, revealed the Staff's assessment for Resident #11's mental status was consistent and reasonable for daily decision-making skills. Further review of the MDS revealed that the resident required 1-person physical assist for bed mobility, transfers, and toilet use, and did not include that the activity for ambulation had occurred. The Significant Change MDS did not include that the resident used a soft cast, or include weight bearing status. Review of Resident #11's Care Plan, dated 2/20/19, revealed that the resident was at risk for falls related to gait impairment, [MEDICAL CONDITIONS] disorder, and an actual fall that occurred on 1/13/19 that resulted in [MEDICAL CONDITION] leg. Interventions included safe environment, bed in low position, handrails on the wall, personal items within reach, and appropriate footwear when ambulating or mobilizing in the wheelchair. Further review revealed that the soft cast, or weight bearing status was not care planned and there were instructions for cast care. Review of the Nursing progress note, dated 2/23/19, time stamped 3:48 p.m., revealed that Resident #11 was transferred back from the ER for evaluation of status [REDACTED]. Observation on 2/22/19 at 6:22 p.m. revealed, Resident #11 was seen sitting up in a wheelchair with a bandage wrapped on the right lower extremity covered with a soft cast. Observation on 2/22/19 at 6:47 p.m. Resident #11 was assessed by RN Z and LVN Treatment Nurse S who removed the residents bandage and soft cast to the right lower extremity and macerated skin was observed under the cast from mid foot to approximately 2-3 inches above the ankle. Minimal non-[MEDICAL CONDITION] to the right lower extremity was observed. Interview on 2/22/19 at 6:22 p.m. Resident #11 revealed that he had pain to the back of his right knee and reported that he got a splint when he returned from the hospital on [DATE]. Resident #11 further revealed that he had used the call light to try to get assistance to the bathroom and when nobody came he transferred himself from the bed to the wheelchair and propelled himself to the restroom, grabbed the bar on the wall to a standing position and revealed that his right leg gave out and he fell . Resident said that he then used the call light in the bathroom for assistance and stated that a staff member (RN EE) came into the bathroom and found him on the floor. Resident #11 revealed that the nurse (RN EE) came back into the room with a female staff and assisted him back to his wheelchair. Interview on 2/22/19 at 6:47 p.m., Resident #11 revealed that no one (nurse, doctor, therapist) had checked his right leg or foot since the time he came back from the hospital (39 days). During an interview on 2/22/19 at 5:46 p.m. CMA DD revealed that on 1/12/19 at approximately 7:00 p.m. she was summoned by RN EE to assist him with Resident #11 because the resident had fallen. CMA DD revealed that Resident #11 was on the floor in the bathroom and that she and RN EE assisted the resident off the floor. CMA DD further stated that she then returned to finish her break when approximately 15 minutes later RN EE summoned her because Resident #11 had fallen again. CMA DD revealed that she told RN EE she would come help him once she clocked back from break but that RN EE told her that he had already had someone else assist him with the resident. CMA DD revealed that she received a phone call from the DON the following day on 1/13/19 and was asked if RN EE had summoned her the night before to assist him with Resident #11 after having a fall. CMA DD revealed that she had and did not inform the DON of the second fall that the resident had because she didn't ask me. During an interview on 2/22/19 at 5:27 p.m. the DON revealed that she received a call from ADON K that Resident #11 had a fall on 1/13/19 and that he had a fracture. The DON revealed that she was told by ADON K that there was rumors that Resident #11 had not fallen on 1/13/19 but had fallen the night before on 1/12/19. The DON revealed that she then contacted RN EE and asked when the resident had fallen. The DON revealed that RN EE told her that the resident had fallen on the morning of 1/13/19 and that he had witnessed it. The DON revealed that she asked RN EE to leave because she needed to investigate the incident with Resident #11. The DON revealed that after the investigation, RN EE was terminated. Review of the facility policy titled Fall Management, revision date 7/2017, revealed in part .The facility assists each resident in attaining/maintain his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review .When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred . Review of the facility policy titled Truly Listening to Our Customers (TLC) Program, revision date 5/2017, revealed in part .The facility actively resolved concerns submitted orally or in writing to any member of the facility's staff .This policy applies to all employees .The Administrator acts as the Grievance Official and is responsible for : Overseeing the grievance/concern process .Coordinating with State and Federal agencies as necessary .3. If the concern relate to nursing care or alleged abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and/or misappropriation of property, the concern should be forwarded immediately to the Abuse Coordinator for response, and reported in accordance with the Abuse and Neglect Prohibition policy .The resolution is documented on the Concern Form . During an interview on 2/22/19 at 5:59 p.m., the DON revealed that Resident #11 had been referred to the orthopedic since release from the hospital on [DATE] and confirmed that he had not seen the orthopedic as of today (2/22/19). The DON stated that an appointment with the orthopedic could not be made because the resident needed a referral but that the facility physician was not on the insurance provider list. The DON further revealed that she was not aware if Resident #11 was wearing a cast. During an interview on 2/22/19 at 6:22 p.m., the Administrator confirmed that Resident #11 had a fall in (MONTH) and that nursing staff were managing his pain. The Administrator confirmed that the resident had a referral to see the orthopedic for a follow-up to the fracture but had not seen the specialist as of today (2/22/19) due to insurance non-coverage. The Administrator further revealed that Resident #11 had an insurance that did not include the facility physician as the primary. The Administrator further revealed that the resident continued to be non-weight bearing and wore a soft cast. During an interview on 2/22/19 at 6:32 p.m. Rehab Manager W revealed that Resident #11 sustained a fracture on 1/13/19 and had obtained orders from the facility physician for a rehabilitation therapy evaluation. During an interview on 2/22/19 at 7:19 p.m., with CNA AA revealed that he had showered Resident #11 on more than one occasion and that each time the right leg was wrapped with a plastic bag. During an interview on 2/23/19 at 12:27 p.m., the Medical Director revealed that he had unofficially visited with Resident #11 while in the facility. The Medical Director stated that Resident #11 was sent to the emergency room (on 2/22/19) and then recommended a follow up in a week with the orthopedic. During an interview on 2/23/19 at 5:30 p.m., the Nurse Practitioner revealed that Resident #11 had transferred himself from the wheelchair and slipped and fell . The Nurse Practitioner further revealed that she could not recall if the resident had a soft or hard cast on his right leg. The Nurse Practitioner revealed that since the resident was referred to the Orthopedic that a follow up x-ray would have been recommended to ensure that the fracture had healed properly. The Nurse Practitioner stated that she was not aware that the resident had not been seen by the orthopedic. During an interview on 2/23/19 at 6:05 p.m., MDS Director A revealed that a Significant Change MDS was in the process of being completed based on recommendations from an IDT meeting held on 1/26/19 (8 days after Resident #11 was confirmed with a fracture) in which it had been determined that Resident #11 had a decline in ADL's and was non-weight bearing. Review of the facility's Abuse and Neglect Prohibition policy, revision date 7/2018, revealed in part .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Neglect means a 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. Injuries of unknown origin may occur as a result of neglect . The Administrator was notified on 2/22/19 at 8:14 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 2/23/19 at 12:30 p.m. and included: Retama Manor respectfully submits this plan of removal (v.2) to abate the allegations of immediate jeopardy identified on (MONTH) 22, 2019. Plan submitted on 2/23/2019 at 11:00am Immediate action taken for resident affected: The resident was sent to the emergency room (2/22/19) for an evaluation and returned with no new orders. The resident has pain medication ordered and is receiving this as needed. The primary care physician was contacted and arranged for the resident to be seen by an orthopedic for follow on 2/25/2019 at the Nix Orthopedic Clinic. Resident identified to have been affected by the alleged deficient practice: The facility immediately completed a review of all residents with falls, X-rays completed in house and emergency room visits to ensure residents that had orders for follow up consults with specialist were scheduled and completed and the resident received timely assessment and treatment for [REDACTED]. Falls: The facility immediately reviewed 5 residents with falls with fractures in the last 6 months. The RN reviewed the 3 residents that had ordered follow up consults with orthopedic specialists and found all consults were scheduled and completed as ordered. The facility immediately reviewed 110 residents with falls in the last 3 months and the RN determined that all residents received timely assessment and treatment at the time of the fall. Completed 2/22/2019 X-rays: The (facility) immediately reviewed the 17 residents with X-rays in the last 3 months and found 1 resident with fracture identified on X-ray. The RN reviewed all X-rays with identified fractures and reviewed the orders for follow up found that orders were completed. Completed 2/22/2019 ER Visits: The facility immediately reviewed 10 residents with emergency room visits in the last 3 months. The RN determined there were no residents with orders for consults to specialist and all residents had discharge orders transcribed and completed. Completed 2/22/2019 Residents with the potential to be affected by the alleged deficient practice: During the above thorough review of the entire facility population the facility identified 5 residents with falls resulting in a fracture in the last 6 months,110 residents with falls in the last 3 months, 1 resident with an X-Ray identifying a fracture in the last 3 months and 10 residents who had an ER visit within the last 3 months. Systemic Measures: 1. Falls: The facility will review all incident report and 24 hour reports daily for falls. The DON/designee will review and investigate all falls to ensure the resident received timely assessment and treatment of [REDACTED]. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days 2. X-Ray: The DON/designee will review physician orders and 24 hour report daily for X-ray orders. The DON/designee will review all residents with X-ray reports identifying a fracture to ensure all physician orders for consults for orthopedic follow up are scheduled and completed. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days 3. ER Visits: The DON/designee will review 24 hour reports daily for all residents with a transfer to the ER to ensure all orders for consults to specialists are scheduled and completed. The Medical Director will be notified if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. The results of the daily reviews will reported to the QAPI committee for no less than 90 days. 4. Training: Will be completed as follows: a. All licensed nursing staff will be trained on completing Incident Reports and timely assessment and treatment of [REDACTED]. b. All licensed nursing staff will be trained on scheduling and completing of consult orders received from the attending physician for fractures identified on x-ray reports or noted on discharge instructions received from ER transfers. Further training on the facility process for notification of the Medical Director if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult. Will be completed 02/23/2019. c. All licensed nursing staff will be trained on entering discharge or new orders for consults and follow up in the physicians order section of PCC, including information on appointment needed, name of and contact information of physician to follow up with and date and time of appointment. d. All licensed nurses will be trained to enter discharge instructions and consult orders, falls, xrays results and transfers toER on the 24 hour report. Status of the resident post fall, xray results and any orders or referrals will carry over each shift until 72 hours post fall and/or appointment has been set or orders received and entered into PCC. e. Facility Director of Nursing will be trained on using the Clinical Morning Meeting Tool designed to monitor and track falls, X-rays and transfers to the ER to ensure timely assessment, treatment of [REDACTED]. Further training on facility process to notify the Medical Director if the follow up appointment cannot be scheduled due to payment, insurance or other issues and arrange for the resident to be seen at the Centric Nix clinic for evaluation and consult with orthopedics. This training will be provided by Jill Gutierrez, RN District Director of Clinical Services on 02/22/2019. f. Facility administrator will be trained on using the Clinical Morning Meeting Tool designed to monitor and track falls, X-rays and transfer to the ER to ensure follow up on timely assessment, treatment of [REDACTED]. This training will be provided by RN District Director of Clinical Services on 02/22/2019. Quality Assurance Performance Improvement: On 02/22/2019 the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: 02/23/2019 On 2/23/19 the Survey Team confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. Interviews were conducted with 6 CNA's, 2 RN's, 6 LVN's, 3 Med Aides, Social Worker, PT Manager, Nursing Staff Scheduler, the DON, and the Administrator. Interviews revealed that facility staff were able to identify the procedure to follow when a fall occurred. Interviews revealed that staff were able to identify the process for follow up with specialty consultants and obtaining appointments for follow up after an injury was identified and/or discharge from the hospital. Staff interviewed were able to identify types of abuse/neglect and the process for reporting. An in-service dated 2/22/19, concerning ensuring incident/accident and follow up on the 24-hour report was reviewed and contained 29 signatures. On 2/23/19 the Immediate Jeopardy was removed, however, the facility remained out of compliance at the scope of isolated and severity potential of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse or neglect for 3 of 25 Residents (Resident #11, #67, #261) whose care was reviewed in that: 1. The facility did not report when Resident #11 was discovered with a fracture to right lower extremity. 2. The facility did not investigate and report when Resident #67 complained of another resident's inappropriate sexual behavior in her room. 3. The facility did not investigate and report when Resident #261 alleged that she had been neglected by staff when requesting assistance to change a leaking [MEDICATION NAME] bag. This failure could place residents who resided at the facility at risk for abuse, neglect, exploitation. The findings were: 1. Review of Resident #11's face sheet, dated 2/20/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The Fracture of Upper and Lower End of Left Fibula, Fracture of Shaft of Right Tibia was added to this list on 1/13/19. Review of Resident #11's most recent Significant Change MDS, dated [DATE], revealed that the Resident had clear speech and clear comprehension. Further review of the MDS revealed that the residents decision- making skills were consistent and reasonable. Review of Resident #11's physician's orders for (MONTH) 2019 did not include an order for [REDACTED]., to include non-weight bearing, or the use of the soft cast. Observation on 2/22/19 at 6:22 p.m. revealed, Resident #11 was seen sitting up in a wheelchair with a bandage wrapped on the right lower extremity covered with a soft cast. Observation on 2/22/19 at 6:47 p.m. Resident #11 was assessed by RN Z and LVN S who removed the residents bandage and soft cast to the right lower extremity and macerated skin was observed under the cast from mid foot to approximately 2-3 inches above the ankle. Minimal non-[MEDICAL CONDITION] to the right lower extremity was observed. Interview on 2/22/19 at 6:22 p.m. Resident #11 revealed that he had pain to the back of his right knee and reported that he got a splint when he returned from the hospital on [DATE]. Resident #11 further revealed that he had used the call light to try to get assistance to the bathroom and when nobody came he transferred himself from the bed to the wheelchair and propelled himself to the restroom, grabbed the bar on the wall to a standing position and revealed that his right leg gave out and he fell . Resident said that he then used the call light in the bathroom for assistance and stated that a staff member (RN EE) came into the bathroom and found him on the floor. Resident #11 revealed that the nurse (RN EE) came back into the room with a female staff and assisted him back to his wheelchair. During an interview on 2/22/19 at 5:27 PM the DON revealed that she had received a call from ADON K informing her that there was a rumor that Resident #11 had fallen on 1/12/19 and not on 1/13/19 as RN DD had first reported. The DON further revealed that she had to investigate the fall and as a result RN DD was terminated for not reporting the incident the day that it happened. 02/22/19 06:22 PM Interview with the Administrator confirmed that Resident #11 had a fall in January. We did not report it to state because the fall was witnessed. The RN did not do his due diligence and was fired. Looking back at the situation, RN EE was neglectful and should have reported the fall as soon as it happened. Resident had not seen an orthopedic because PCP's were not part of the insurance provider that the Resident was on. Administrator was asked what was being done for the Resident and she said managing his pain. PCP has been into the facility to see the resident since the fall. The resident was discharged with follow up orders from the hospital to see an orthopedic but had not seen one because of an insurance glitch. The resident had a PCP that was on his insurance of resident's insurance but they wanted him to change to facility physicians, but both facility physicians credentials had lapsed with resident's insurance and so now the resident waits until facility physicians get credentialed with resident's insurance. Resident continued to be non-weight bearing and wears a soft cast as of today. During an interview on 2/23/19 at 5:30pm, the Nurse Practitioner revealed that Resident #11 was in the bathroom and had transferred himself from his wheelchair and slipped and fell . The Nurse Practitioner further revealed that the Resident was by himself when the fall occurred. 2. Review of Resident #67's Face Sheet, dated 2/22/19, revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #67's Annual MDS assessment, dated 1/15/19, revealed Resident #67 had a BIMS score of 15 indicating cognitive status intact for daily decision making. Further review of the MDS revealed Resident #67 required extensive assistance with ADL's. Record review of Resident #67's physician's orders, dated 2/22/19, revealed Resident #67 was receiving [MEDICATION NAME] for Major [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], Trazadone for Major [MEDICAL CONDITION], [MEDICATION NAME] as needed for pain, Trazadone for depression, Tylenol with [MEDICATION NAME] as needed for pain, and [MEDICATION NAME] for Major [MEDICAL CONDITION]. Interview on 2/20/19 at 3:01p.m. with Resident # 67 revealed that approximately 2 weeks ago, Sunday (2/10/19) a man, name unknown, came to Resident #67's room and asked whether he could watch TV. Resident #67 allowed the man to watch TV as she had seen the man in the hallway and knew he was a resident at the facility. Resident #67 was watching through her window people passing by after church. When Resident #67 looked to the other side, she realized that the man's pants were down to his ankle and was masturbating in his wheel chair. Resident #67 said she was shocked and turned on the call light. A CNA, name unknown, came and took the male out of the room. Resident #67 also said nurse did not check on her after the incident that day. Resident #67 further revealed that she had seen the man in his wheel chair in her hallway but he had never come in to her room. The next day Resident #67 informed LVN O of the incident. Administrator and DON talked to the resident and the Administrator told Resident #67 that this was not the first time this had happened but Resident #67 was not sure of what that meant. Resident #67 also stated I am afraid of him, afraid he would come when I am asleep and touch or something. Interview on 2/20/19 at 3:18 p.m. with Resident # 67's roommate confirmed that she couldn't remember the day of the incident but a man came into the room and pulled his pants down. Record review of Progress notes, dated 2/11/19 at 12:07 p.m. by LVN O revealed that Resident #67 informed that a male resident asked if could come into her room to watch TV, this resident stated yes, male resident sat beside her watching TV, stated she did not realized that resident did not have any pants on and when she turned around male resident was masturbating, resident then put call light on and male resident, staff come into room and male resident was asked to leave room. After resident telling this nurse that this happen resident stayed in therapy in good spirits, male residents nurse informed along with DON and administrator. Interview on 2/22/19 at 3:35 p.m. with DON revealed that she came to know about the incident on 2/11/19 and stated that the DON and administrator had a meeting with Resident #67 but was not sure of the date. DON also confirmed an investigation had not been completed. DON revealed identity of the male Resident as Resident #81 and said Resident #81 had a lot of sexual behaviors. DON further revealed that in the past the facility had provided Resident #81 with a 30 day notice; however, was unable to discharge resident to any other facility. DON also confirmed facility did not have any additional interventions in place and asked Resident #67 not to allow Resident #81 in her room. Review of Resident #81's MDS dated [DATE] revealed a BIMS score of 13 indicating cognitively intact for daily decision making. Interview on 02/20/19 at 3:54 p.m. with Social Worker revealed that Resident #81 had a lot of sexual behavior and at times they were able to redirect. In (MONTH) (YEAR), Resident #81 was moved to an all male residents hall, referred to mental health for his behavior, and contacted family member. Social Worker further revealed that she was not aware of this incident and usually Social Worker was involved in incidents like this. Observation on 2/20/19 at 4:04 p.m. revealed Resident #81 wandering the Hall B. Interview on 02/21/19 at 7:57 a.m. with Administrator revealed that she was aware of the incident between Resident #67 and Resident #81. Administrator also confirmed that no incident report was initiated since Resident #67 did not tell administrator that she was afraid of Resident #81. Administrator also said a 30 day discharge notice was initiated on 2/20/19 after the surveyor had talked to the DON and Social worker regarding the incident. Further interview revealed that Social Worker would talk to Resident #67 and refer to Psychiatric services if needed. Administrator also stated that Resident #81 was monitored closely; however, administrator could not provide any documentation of monitoring or how monitoring was done. Interview on 2/21/19 at 8:29 a.m. with LVN O revealed that Resident #67 informed her of the incident on 2/11/19 at 11:07 a.m. while resident was in therapy. LVN O immediately informed DON. LVN O also said she knew that the DON had spoken to Resident #67. LVN O also confirmed the incident took place on 2/10/19 on 2-10p shift. LVN O further revealed that if an incident like this happened on her shift she would immediately let the DON and administrator aware. If a CNA found out the incident first the CNA was to report to the charge nurse. Interview on 2/21/19 9:13 a.m. with RN P the charge nurse for C wing the day of incident revealed that a female CNA, name unknown, informed RN that Resident #81 went in to Resident #67's room and CNA got Resident #81 out of there. RN was not aware of anything else and RN didn't think of anything since Resident #81 had a habit of wandering up and down the hallways. Further interview revealed that Resident #81 had behavioral issues like coming out of the room without clothes and being verbally aggressive. Staff redirected Resident #81 when behaviors occurred. Observation on 2/21/19 at 1:34 p.m. revealed Resident #67 was in rehab on Hall E. Observation on 2/21/19 at 1:45 p.m. revealed Resident #81 going down Hall E in his wheel chair. Observation on 2/21/19 at 1:55 p.m. revealed Resident #81 going down to the front hall in his wheel chair. Observation on 2/21/19 at 2:10 p.m. revealed Resident #81 entering C Hall in his wheel chair and turned around. Interview on 2/21/19 at 2:16 p.m. with Resident #67 revealed that she was not afraid of anyone in the facility except the man who came to my room, he made me paranoid. Resident #67 also revealed that on 2/20/18 afternoon (after the surveyor left Resident #67's room) Resident told DON that she was scared of that man. Interview on 02/21/19 at 2:26 p.m. with DON revealed that Resident #67 told DON that she felt safe in the facility. DON also confirmed that she did not inform Social Worker Q regarding this incident. Interview on 2/21/19 at 2:28 p.m. with Social Worker revealed that she was not aware of the incident till 2/20/19. Further interview indicated that the incident was definitely a self-report. Social Worker further revealed that she believed the incident caused emotional distress to Resident #67. Social Worker also revealed that she received a call from the Ombudsman regarding this incident. Ombudsman revealed that she received a call from a family member of a resident in the facility who liked to remain anonymous, regarding this incident. Social Worker also admitted that she hasn't had a chance to talk to the resident yet; however, Resident #67 was under psychiatric care and last visit was on 2/11/19. Social Worker further confirmed that to her knowledge there was no investigation regarding this incident and felt that this should have been something that the Social Worker should have been informed of. When asked what would be a Social Worker's role in an investigation, she stated that she would talk to the residents involved to see whether they are ok and would refer to appropriate people/agency like psychiatry, etc. if needed. Interview on 02/22/19 at 10:20 a.m. with DON revealed that she did not think the incident was reportable since Resident #81 had only a BIMS score of 10, moderately impaired cognitive status and had not willfully done this act to Resident #67; also, Resident #81 did not ask Resident #67 to look at him. Also said facility followed the HHSC provider letter to decide whether an incident was reportable or not. DON further said in the meeting with Resident #67, she did not express any distress. Interview on 2/22/19 10:24 a.m. with Administrator revealed that the HHSC provider letter was what the facility used to determine reportable incidents and she did not report this event after reviewing the HHSC provider letter for reportable abuse and neglect. Administrator also said in the meeting with Resident #67, she did not express any distress. Administrator further revealed that she did not call or follow up with the charge nurse on duty or the CNA who was involved in the incident once Administrator came to know about the incident. Administrator also stated the CNA was no longer employed at the facility. Review of Resident #81's Significant change MDS assessment dated [DATE] revealed a BIMS score of 13 indicating cognitively intact. Interview on 2/22/19 at 4:52 p.m. with Social Worker confirmed that Resident #67's Responsible Party was not notified of this incident and confirmed there was no documentation. Interview on 2/22/19 at 4:55 p.m. with DON confirmed facility had not contacted RP and Resident #67 informed her Responsible party. 3. Record review of Resident #261's face sheet, dated 2/21/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #261's most recent Admission MDS, dated [DATE], revealed the resident had clear speech and clear comprehension. Further review of the MDS revealed that the residents decision- making skills were consistent and reasonable. Record review of Resident #261's physician's orders for (MONTH) 2019 revealed an order to change wafer to [MEDICATION NAME] every other day and PRN (due to) lifting or leakage. Record review of the facility document titled Concern Form, dated 1/15/19 written to the DON, revealed that Resident #261informed LVN CC that she needed a shower because her [MEDICATION NAME] bag was leaking. Further review of the Concern Form revealed that the resident had seen this as neglect, breakdown of communications, misunderstanding or just being ignored. During an observation on 2/22/19 at 9:25 a.m., LVN S provided [MEDICATION NAME] care to Resident #261. The area surrounding the [MEDICATION NAME] stoma appeared pink and slightly dry and measured approximately 7 X 6 in diameter. No open areas were observed. During an interview on 2/20/19 at 11:58 a.m., Resident #261 revealed that she was unsure if the facility had investigated the incident in which her [MEDICATION NAME] bag was leaking. Resident #261 revealed that on the day of the incident she had asked for a shower at around 3:30 p.m. but did not receive a shower until 5 ½ hours later and that the leaking [MEDICATION NAME] caused the skin around the stoma to become irritated. During an interview on 2/21/19 at 8:00 a.m., the Administrator revealed that Resident #261's concern regarding not having her [MEDICATION NAME] bag changed due to leaking had been investigated by the facility and since the incident did not cause harm it had not been reported to the State Survey Agency. The Administrator was asked if she could interpret what Resident #261 had written on the Concern Form dated 1/15/19. The Administrator stated that the resident was probably alleging neglect. During an interview on 2/21/19 at 9:06 a.m. the DON revealed that the incident in which Resident #261 had complained about her leaking [MEDICATION NAME] bag was not reported to the State Survey Agency because there was no neglect, abuse, or failure to treat. The DON was asked if she could interpret what Resident #261 had written on the Concern Form dated 1/15/19. The DON stated that there was a neglect with the breakdown of the communication is the way I read her concern form. During an interview on 2/21/19 at 10:04 a.m., LVN S revealed that Resident #261 had complained of a leaking [MEDICATION NAME] bag and was informed about the incident the following day by the DON. LVN S revealed that the resident had already been treated for [REDACTED]. LVN S further revealed that after the incident with the leaking [MEDICATION NAME] bag, Resident #261's skin surrounding the [MEDICATION NAME] stoma was inflamed and red requiring oral medication to treat the infection. LVN S revealed that this incident should have been reported to the State Survey Agency because it was considered neglect. Review of the facility policy titled Abuse and Neglect Prohibition, revision date 7/2018, revealed in part, .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .Prevention .3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk of occurring .Reporting and Response .1. STATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency .in accordance with Federal and State law through established procedures . 2. Review of Resident #67's Face Sheet, dated 2/22/19, revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #67's Annual MDS assessment, dated 1/15/19, revealed Resident #67 had a BIMS score of 15 indicating cognitive status intact for daily decision making. Further review of the MDS revealed Resident #67 required extensive assistance with ADL's. Record review of Resident #67's physician's orders, dated 2/22/19, revealed Resident #67 was receiving [MEDICATION NAME] for Major [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], Trazadone for Major [MEDICAL CONDITION], [MEDICATION NAME] as needed for pain, Trazadone for depression, Tylenol with [MEDICATION NAME] as needed for pain, and [MEDICATION NAME] for Major [MEDICAL CONDITION]. Interview on 2/20/19 at 3:01p.m. with Resident # 67 revealed that approximately 2 weeks ago, Sunday (2/10/19) a man, name unknown, came to Resident #67's room and asked whether he could watch TV. Resident #67 allowed the man to watch TV as she had seen the man in the hallway and knew he was a resident at the facility. Resident #67 was watching through her window people passing by after church. When Resident #67 looked to the other side, she realized that the man's pants were down to his ankle and was masturbating in his wheel chair. Resident #67 said she was shocked and turned on the call light. A CNA, name unknown, came and took the male out of the room. Resident #67 also said nurse did not check on her after the incident that day. Resident #67 further revealed that she had seen the man in his wheel chair in her hallway but he had never come in to her room. The next day Resident #67 informed LVN O of the incident. Administrator and DON talked to the resident and the Administrator told Resident #67 that this was not the first time this had happened but Resident #67 was not sure of what that meant. Resident #67 also stated I am afraid of him, afraid he would come when I am asleep and touch or something. Interview on 2/20/19 at 3:18 p.m. with Resident # 67's roommate confirmed that she couldn't remember the day of the incident but a man came into the room and pulled his pants down. Record review of Progress notes, dated 2/11/19 at 12:07 p.m. by LVN O revealed that Resident #67 informed that a male resident asked if could come into her room to watch TV, this resident stated yes, male resident sat beside her watching TV, stated she did not realized that resident did not have any pants on and when she turned around male resident was masturbating, resident then put call light on and male resident, staff come into room and male resident was asked to leave room. After resident telling this nurse that this happen resident stayed in therapy in good spirits, male residents nurse informed along with DON and administrator. Interview on 2/22/19 at 3:35 p.m. with DON revealed that she came to know about the incident on 2/11/19 and stated that the DON and administrator had a meeting with Resident #67 but was not sure of the date. DON also confirmed an investigation had not been completed. DON revealed identity of the male Resident as Resident #81 and said Resident #81 had a lot of sexual behaviors. DON further revealed that in the past the facility had provided Resident #81 with a 30 day notice; however, was unable to discharge resident to any other facility. DON also confirmed facility did not have any additional interventions in place and asked Resident #67 not to allow Resident #81 in her room. Review of Resident #81's MDS dated [DATE] revealed a BIMS score of 13 indicating cognitively intact for daily decision making. Interview on 02/20/19 at 3:54 p.m. with Social Worker revealed that Resident #81 had a lot of sexual behavior and at times they were able to redirect. In (MONTH) (YEAR), Resident #81 was moved to an all male residents hall, referred to mental health for his behavior, and contacted family member. Social Worker further revealed that she was not aware of this incident and usually Social Worker was involved in incidents like this. Observation on 2/20/19 at 4:04 p.m. revealed Resident #81 wandering the Hall B. Interview on 02/21/19 at 7:57 a.m. with Administrator revealed that she was aware of the incident between Resident #67 and Resident #81. Administrator also confirmed that no incident report was initiated since Resident #67 did not tell administrator that she was afraid of Resident #81. Administrator also said a 30 day discharge notice was initiated on 2/20/19 after the surveyor had talked to the DON and Social worker regarding the incident. Further interview revealed that Social Worker would talk to Resident #67 and refer to Psychiatric services if needed. Administrator also stated that Resident #81 was monitored closely; however, administrator could not provide any documentation of monitoring or how monitoring was done. Interview on 2/21/19 at 8:29 a.m. with LVN O revealed that Resident #67 informed her of the incident on 2/11/19 at 11:07 a.m. while resident was in therapy. LVN O immediately informed DON. LVN O also said she knew that the DON had spoken to Resident #67. LVN O also confirmed the incident took place on 2/10/19 on 2-10p shift. LVN O further revealed that if an incident like this happened on her shift she would immediately let the DON and administrator aware. If a CNA found out the incident first the CNA was to report to the charge nurse. Interview on 2/21/19 9:13 a.m. with RN P the charge nurse for C wing the day of incident revealed that a female CNA, name unknown, informed RN that Resident #81 went in to Resident #67's room and CNA got Resident #81 out of there. RN was not aware of anything else and RN didn't think of anything since Resident #81 had a habit of wandering up and down the hallways. Further interview revealed that Resident #81 had behavioral issues like coming out of the room without clothes and being verbally aggressive. Staff redirected Resident #81 when behaviors occurred. Observation on 2/21/19 at 1:34 p.m. revealed Resident #67 was in rehab on Hall E. Observation on 2/21/19 at 1:45 p.m. revealed Resident #81 going down Hall E in his wheel chair. Observation on 2/21/19 at 1:55 p.m. revealed Resident #81 going down to the front hall in his wheel chair. Observation on 2/21/19 at 2:10 p.m. revealed Resident #81 entering C Hall in his wheel chair and turned around. Interview on 2/21/19 at 2:16 p.m. with Resident #67 revealed that she was not afraid of anyone in the facility except the man who came to my room, he made me paranoid. Resident #67 also revealed that on 2/20/18 afternoon (after the surveyor left Resident #67's room) Resident told DON that she was scared of that man. Interview on 02/21/19 at 2:26 p.m. with DON revealed that Resident #67 told DON that she felt safe in the facility. DON also confirmed that she did not inform Social Worker Q regarding this incident. Interview on 2/21/19 at 2:28 p.m. with Social Worker revealed that she was not aware of the incident till 2/20/19. Further interview indicated that the incident was definitely a self-report. Social Worker further revealed that she believed the incident caused emotional distress to Resident #67. Social Worker also revealed that she received a call from the Ombudsman regarding this incident. Ombudsman revealed that she received a call from a family member of a resident in the facility who liked to remain anonymous, regarding this incident. Social Worker also admitted that she hasn't had a chance to talk to the resident yet; however, Resident #67 was under psychiatric care and last visit was on 2/11/19. Social Worker further confirmed that to her knowledge there was no investigation regarding this incident and felt that this should have been something that the Social Worker should have been informed of. When asked what would be a Social Worker's role in an investigation, she stated that she would talk to the residents involved to see whether they are ok and would refer to appropriate people/agency like psychiatry, etc. if needed. Interview on 02/22/19 at 10:20 a.m. with DON revealed that she did not think the incident was reportable since Resident #81 had only a BIMS score of 10, moderately impaired cognitive status and had not willfully done this act to Resident #67; also, Resident #81 did not ask Resident #67 to look at him. Also said facility followed the HHSC provider letter to decide whether an incident was reportable or not. DON further said in the meeting with Resident #67, she did not express any distress. Interview on 2/22/19 10:24 a.m. with Administrator revealed that the HHSC provider letter was what the facility used to determine reportable incidents and she did not report this event after reviewing the HHSC provider letter for reportable abuse and neglect. Administrator also said in the meeting with Resident #67, she did not express any distress. Administrator further revealed that she did not call or follow up with the charge nurse on duty or the CNA who was involved in the incident once Administrator came to know about the incident. Administrator also stated the CNA was no longer employed at the facility. Review of Resident #81's Significant change MDS assessment dated [DATE] revealed a BIMS score of 13 indicating cognitively intact. Interview on 2/22/19 at 4:52 p.m. with Social Worker confirmed that Resident #67's Responsible Party was not notified of this incident and confirmed there was no documentation. Interview on 2/22/19 at 4:55 p.m. with DON confirmed facility had not contacted RP and Resident #67 informed her Responsible party. 3. Record review of Resident #261's face sheet, dated 2/21/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #261's most recent Admission MDS, dated [DATE], revealed the resident had clear speech and clear comprehension. Further review of the MDS revealed that the residents decision- making skills were consistent and reasonable. Record review of Resident #261's physician's orders for (MONTH) 2019 revealed an order to change wafer to [MEDICATION NAME] every other day and PRN (due to) lifting or leakage. Record review of the facility document titled Concern Form, dated 1/15/19 written to the DON, revealed that Resident #261informed LVN CC that she needed a shower because her [MEDICATION NAME] bag was leaking. Further review of the Concern Form revealed that the resident had seen this as neglect, breakdown of communications, misunderstanding or just being ignored. During an observation on 2/22/19 at 9:25 a.m., LVN S provided [MEDICATION NAME] care to Resident #261. The area surrounding the [MEDICATION NAME] stoma appeared pink and slightly dry and measured approximately 7 X 6 in diameter. No open areas were observed. During an interview on 2/20/19 at 11:58 a.m., Resident #261 revealed that she was unsure if the facility had investigated the incident in which her [MEDICATION NAME] bag was leaking. Resident #261 revealed that on the day of the incident she had asked for a shower at around 3:30 p.m. but did not receive a shower until 5 ½ hours later and that the leaking [MEDICATION NAME] caused the skin around the stoma to become irritated. During an interview on 2/21/19 at 8:00 a.m., the Administrator revealed that Resident #261's concern regarding not having her [MEDICATION NAME] bag changed due to leaking had been investigated by the facility and since the incident did not cause harm it had not been reported to the State Survey Agency. The Administrator was asked if she could interpret what Resident #261 had written on the Concern Form dated 1/15/19. The Administrator stated that the resident was probably alleging neglect. During an interview on 2/21/19 at 9:06 a.m. the DON revealed that the incident in which Resident #261 had complained about her leaking [MEDICATION NAME] bag was not reported to the State Survey Agency because there was no neglect, abuse, or failure to treat. The DON was asked if she could interpret what Resident #261 had written on the Concern Form dated 1/15/19. The DON stated that there was a neglect with the breakdown of the communication is the way I read her concern form. During an interview on 2/21/19 at 10:04 a.m., LVN S revealed that Resident #261 had complained of a leaking [MEDICATION NAME] bag and was informed about the incident the following day by the DON. LVN S revealed that the resident had already been treated for [REDACTED].